It was only a matter of time....

I think I just became a coffee-drinker.

For the first 23 years of my life, I never drank coffee, minus the occasional sip at a wedding or other occasion (followed by dislike of the taste and continued non-consumption). But this year, as med school continues unrelentingly, I began to think it was time I learned to like coffee. So far, I've been able to maintain my 8 hours of sleep nearly every night, but there are still days that I feel sleepy and in need of caffiene. Plus, I know my future holds many a night of on-call or other long shifts, so I doubted I'd be able to handle that lifestyle with caffiene from tea or Coke alone, as I had done so far.

So a couple of months ago, I bought a cup of coffee at the coffee cart at school, on a day when I was literally falling asleep in lecture. And I choked down about one-third of it (black, because I don't want the hassle or calories of cream and sugar). ANd, again, about a month or so after that, I bought another cup on an afternoon when I was tired and having trouble focusing. Both times, the coffee had the desired effect, and kept me up, but I really didn't like it.

But today...I got another cup, and I actually enjoyed the taste. I mean, it's not my favorite thing in the world (that would be chocolate), but I've finished almost the whole cup, and I really don't mind it at all.

Check. One more milestone on the road to becoming a doctor achieved.

Pop quiz!

My throat was numb for the better part of this afternoon because:
A. I drank too much ice water
B. It was sprayed with lidocaine
C. Of a weird side effect of my allergy nasal spray
D. Strange things like that just happen sometimes

If you guessed B, you win the prize! Now, you may ask, why did I have lidocaine in my throat? For the laryngoscopy, of course! That probably doesn't clarify much, so here's the story:

For my Doctoring class, we were learning about how to do an ENT exam, so we were assigned to a couple hours with ENT residents to learn about their exams. And instead of using standardized patients (ie actors), they had us do it with student volunteers. So for the laryngoscope exam, I volunteered to be the patient. No one else really wanted to, and our class gunner was trying to volunteer a different girl, so I said I'd do it so she didn't have to. I really didn't mind, actually, it was pretty cool to see my own throat up close, and it really didn't hurt or anything (thanks to the lidocaine, of course). And now I know what it feels like, in case I ever get the chance to do it on a patient!

Which one am I?

I think this is fitting, since for some reason I've been thinking more lately about what specialty I want to pursue once medical school is finally over (if that ever happens...) Which category am I in?



From Movin' Meat

What have I gotten myself into?

I die a little bit inside every time I see doctor bloggers complain that the 80 hour per week limit for residents is not enough time for them to learn everything.

Is is just me, or does 80 hours a week seem like too many hours already? I mean, I can see that 40 hours is really not a lot, so I'm okay with more than that. Plus, I understand that in residency, they push to get more experience in in a shorter time. And I know there is a LOT to learn, so it takes time to learn it all.

But hearing about what's coming at a time when I feel like I am already spending every waking minute studying or thinking about how I should be studying, makes me feel like the next 6 years of my life are going to be more of the same.

I guess it's good that I'm teaching myself to like coffee now, because it looks like I'm going to need it...

First post! (for me)

This is my first post here, so I figure I should probably introduce myself. I'm Abby's sister, Dr. Liz ... except, I'm a Doctor of Pharmacy, versus being a medical doctor. I work in the retail setting (at a store I'm going to be referring to as Rx's R Us ... and, of course, all patient names and identifying information will be changed for patient privacy reasons), and I graduated from college a few years ago. I've been working in pharmacy, though, for a half-dozen years or so by now, though, so I definitely have plenty of stories to share. I generally won't bore you with old stories, but if something interesting happens at work, I'll definitely pass it along.

And, it just so happens that I have a story about a "special" patient of mine to pass along.

Last night, a patient calls in a refill for her Diazepam 10mg. Directions: 1 tablet three times daily. She received 90 pills 10 days ago. I flag it as being too soon to fill, and call the patient to tell them that I will not have it ready for them that evening. The doctor's office is closed, so I can't check about getting an early refill.

But, wait, it gets better.

The patient proceeds to tell me that she talked to the nurse, and the nurse said that she was going to call in a new script with the right directions. And what directions were these, you might ask? 30mg of Diazepam three times daily. Because the patient was in so much pain, that's how the doctor told her to take it. (my mental response: riiiiiiiiiiiiiight)

I tell the patient that I don't have any way to get ahold of the doctor, but they're willing to try if they'd like to do so. I say that I cannot fill the prescription until I hear back from the doctor giving me new directions and/or an authorization to fill the medication early.

This morning, I call over to the doctor's office - they do a lot of orthopedic stuff and deal with a lot of patients in pain, but I'm pretty sure that the nurse will not be confirming the patient's story.

RPh: Patient Susie Smith --

Nurse: *audible sigh*

RPh: I take it you talked to her this morning?

Nurse: Last night, actually. She called to have the doctor call in a new presciption for her Valium (brand name for Diazepam), saying that she's had to take more of the medication because of her pain. I told her last night that the doctor was already gone when she called in, so it would have to wait until today. He won't be in until after lunch since he's in surgery this morning.

The nurse said she'd call back once she talked to the doctor about the patient, but I didn't hear anything back before I left work this afternoon.

And, to top things off, the patient finally realized that I wasn't going to fill her RX without doctor authorization (which didn't appear to be forthcoming), so she had the prescription filled at a different pharmacy. I told the other RPh about the too soon issue, but it's their problem now ...

One of these things is not like the other...

Many time since I've started medical school, I've gotten the feeling that I don't quite fit in. I don't mean that in a whiny, "nobody likes me" way, just that in the course of typical medical school activities, I sometimes realize a new way that I am different than the my classmates. There are lots of these examples, but this post is about one that happened today, in one of the million small group sessions we have for our Respiratory course.

I forget why, but for some reason the conversation landed on "back-up plans", what we would do if medical school didn't work out. I don't think any of us are actually expecting to need these, but it's kind of nice to fantasize about an alternate life when the pressure of medical school gets too high. But after today, I'm starting to think that I need to get a new back up plan...

The other people in my group had back up plans like "wedding planner" or "librarian". Guess what mine is: Pharmacist. No, seriously, it is, and I tell people that all the time. Way less time in school than medical school, but killer compensation when you are done. (Not that I'm in it for the money, but still.)

What does it say about me that my back up is so similar to my current plan? Obviously, the fact that I have a sister who's a pharmacist has something to do with it, I think, but I can't even think of a non-medical fallback career I'd be interested in. I think I need to work on that...maybe alpaca farmer? (Come to think of it, I do think that would be a pretty sweet gig. They're so cute!)

New world order

I think one of the hardest things about medical school (besides, you know, being really hard work) is that the standards of measurement change so drastically. Medical students all come from a background of academic success; otherwise we wouldn't have gotten into medical school in the first place. But once you are actually IN medical school, it's just not possible for all of us overachievers to keep being the best.

So it's been an adjustment to try to be satisfied with managing to be merely average, and trying to be happy with "above average" when that means an 86%, when the average was 84%. I told myself this year that (after pass/fail grading last year), I wasn't going to get caught up in always trying to be the best; I was going to try to be reasonable with my expectations. But I don't think it's worked. Maybe the worst thing is that I feel like I spend every waking moment studying, but it's still not enough. I'm not really sure what I could have done that would have pushed that 86% up to the 88% it would have taken to get an A in CV (which has a massive curve, if you couldn't guess).

But I felt this way last year, too, especially at the beginning. So, I'm still holding out hope, that as I get used to the new rhythm, I'll inch closer to the top of the heap. But, really, in a class of all stars, middle of the heap's probably not so bad.

After all, what is it they say? "What do you call the person who graduates last from medical school? Doctor. " One day, I'm sure, I won't care what grades I got, but right now, it hurts a little not to be the best.

Today we had a small group discussion for on of my classes, and were instructed to talk about possible causes for a patient's heart failure. We came up with the usual ones, like myocardial infarction or congenital abnormalities, but the case description was not totally straightforward, so we tried to come up with some of the more obscure ones as well. In the course of our continual brainstorming, one of my classmates declared: "It could be all in his head. Psychosomatic is always in my differential!"

Whoa. To me, that was an incredibly insensitive thing to say. Yes, I know that these cases do exist, where there is no identifiable medical cause for a patient's symptoms. But to say it's always one of the main possibilities you think of? No way, not for me.

I think as doctors we owe it to the patient to assume that whatever he is describing is real and based on something we can help with. Several years ago, when my mom was going through a period of major medical distress, she was basically told by one of her doctors that she was crazy and to go talk to a psychologist about it. (She wasn't; a different doctor identified the real cause and treated her successfully.) To this day, when she tells me about it, I can tell it was such a hurtful experience. In reality, I doubt that doctor was trying to be mean; he probably did feel like he had exhausted his diagnostic options. Still, I know there must have been a better way to present that conclusion, including keeping options open for a second opinion.

When I am in practice, I will include psychosomatic cause on my differential, but I never want to consider it until I'm sure we've ruled out any other possibilities. Of course, this may change as I get more clinical experience; many of these sort of "when-I'm-a-doctor-I'll..." convictions have already been overturned in the short time I've been in medical school. I hope that this one, at least, will stick with me as I can imagine nothing more devastating to a patient in distress that his doctor has given up on finding out the cause. I'd rather say, "I'm not sure what's going on, but we'll work through it together."

I think my new favorite word is "Candesartan". Doesn't it just roll right off the tongue? It reminds me of so many lovely things all at once: candles, satin, candy; and it just has an exotic ring to it. If I didn't know what it was I would think it was a kind of fancy foreign sweets, like they sell in really nice candy stores. It just sounds smooth and creamy and delicious.

However, the reality is far less interesting. It's a lowly blood pressure pill, an angiotensin receptor blocker, to be specific. But it sounds like it could be something so much sweeter...

You know you're studying too much when...

...it feels more unusual to be biking without a backpack than without a bike helmet.

More than once in the past couple weeks I've absentmindedly forgotten to put on my bike helmet before heading home from school, only noticing right about when I was arriving home. On the other hand, when I left the library for a little while today, leaving my backpack behind (intentionally), I noticed something seemed different before I even left the parking lot. How did I ever survive before I had a 20+ lb weight permanently strapped to my back?

Can you blame me?

So my medical school, like most medical schools (I assume), has a class to teach doctoring. You know, all the stuff a doc needs to know and do that doesn't get covered in anatomy and physiology and those sorts of courses. Stuff like interviewing patients and doing physical exams. And even though most of us treat this as sort-of a not-class, in that it's not as intellectually demanding as, say, pharmacology, I actually quite like it. Don't get me wrong, I like hard science too, but it's nice to have a class to think about the people side of medicine.

Anyway, this year (year 2 of med school), in Doctoring, they are starting to stress differential diagnoses, so that's what we were working on at our first small group session a couple of weeks ago. And as part of this practice, I was performing a physical exam on a standardized patient who (fictitiously) had pain in his right elbow. We learned basic physical exam skills last year, but not really any focused skills. In this case, apparently, I needed to do a joint exam, and in my original attempt to pinpoint the location of the patient's pain, I gently touched his elbow and said, "Is this about where the pain is?" And he replied, "Well, it doesn't hurt now; you're being so gentle." So I laughed and replied smilingly, "Well, I don't want to make the pain worse," thinking that this must be the right sort of thing to say and do.

But no! I got mildly scolded by our group leader (an Internal Med resident), who told me "It's okay to cause pain." Which, I guess I understand. After all, we've already gotten the lecture on how Hippocrates' "First, do no harm" couldn't possibly be followed literally by any doctor, or surgery (and may other fields) would not exist. I guess I felt that in this case, there was little reason for me to even come close to causing this man pain, since I was not going to be offering him any sort of treatment based on my findings anyway. Furthermore, he was a standardized patient (an actor, basically, for those not familiar), so I didn't think I would have been able to find anything interesting even if I did examine more thoroughly.

Thinking about this episode, I hope this is the kind of doctor I end up being. I don't mean it literally, as I'm sure I will end up being more aggressive with physcial exams like this. But I hope I stay the kind of doctor who errs on the side of not causing more pain, the kind of doctor who can't put out of her mind that the physical exam may be uncomfortable for the patient, the kind of doctor who remembers what it's like being a patient.