Pimpin ain't easy

I feel like now that this blog has kind of transformed into a med student blog (ok, well actually has, overnight), I have to comment on pimping.

Pimping is basically what attending physicians do to students in order to "teach."  There are many different styles, and everyone has their own opinion, but here's mine.

There are essentially three types of doctors: those who don't pimp at all, those who pimp but really want you to learn (nice-pimping), and those who pimp because they can/hate students/have identity issues/hate people in general/hate their job (angry-pimping). I thought I'd prefer the non-pimpers, but you honestly don't learn anything on those rotations.  I still feel like a complete idiot during constructive (nice) pimping, but I definitely remember that stuff.

You can pretty much predict what kind of pimping to expect by the service.  Psychiatrists and family medicine docs tend to be more nurturing and point interesting things out (which I appreciate immensely, but promptly forget).  This, however, is good to have every few months to allow neuronal healing.  Surgeons tend to be on the other side of that spectrum.

As a med student, you also get really used to answering "I don't know."  The first few times are painful, as most of us are type A perfectionists, but after a few times it becomes second nature.  So, really the difference between being nice-pimped and angry-pimped is how embarrassed and humiliated you feel when you say "I don't know."

The worst kind of pimping is when it's not even related to medicine, like when that CT surgeon pimped me for 7 hours during a surgery about what band sang each song on his iPod (I got one right, total).  That's by far the biggest ego deflation, as you don't feel worthy enough to even get angry-pimped.

So thank your lucky stars when you get nice-pimped, or even angry-pimped.  At least they're acknowledging your role as a student.

Addendum 1/9/2012:

Troponinitis (Law 10 of The House of God)

If you've ever met me, you know that my calling my neuroticism regarding cardiology "pathologic" would be a huge understatement.

Well, after two and a half years, I'm finally on a cardiology rotation.  Not medicine, not find-the-heart-patient-in-OBGYN, not a summer research program where I got to hang out on cards rounds- I've finally made it to the bona fide third year selective of INPATIENT CARDIOLOGY!

Needless to say, I've been looking forward to this for a very, very long time.  But boy, I was in for a big surprise.

I've seen like 30 patients this week on the cardiology service.  And NONE of them were in the hospital for HEART problems!!!  So far I've seen gastroenteritis, cholecystitis, personality disorders, immune disorders, poisonings, you name it.  And they all have some sort of cardiac problem, but that's not their immediate problem.

So really, this is just a glorified internal medicine rotation.  But I started thinking...I've got three years of medicine before cardiology fellowship!  AND three years of cardiology fellowship with patients just like these!  Then who knows after that.  So really, this has just been a bit of an eye-opener about what the rest of my life is going to be like.

I don't love cardiology any less, but I'm 5 days "less naive" about my career choice.

One of the most useful lessons I've learned this week (well, saw put into practice) was jokingly referred to today as troponinitis.  The layman's description is best describe by one of the laws of The House of God which is one of the best books ever written about being a resident (the details are a bit outdated but the concepts are timeless):

IF YOU DON’T TAKE A TEMPERATURE, YOU CAN’T FIND A FEVER.

From a patient's perspective, this sounds terrible.  But clinically, it's an essential part of medicine.  If you do an MRI on every patient, you'll find something in every patient.  As cliche as it is, it's so important because you may be worsening an outcome by finding something (what if the patient dies in the OR, but otherwise would have lived another 5 happy, relatively healthy years?).

So troponinitis is fairly specific to cardiology- troponins are a marker of muscle death, which is part of the diagnosis during a heart attack.  It's easy to jump the gun and order the test on every patient on the cardiology service- these patients have a higher risk, so why run the chance of missing a heart attack, right?

Wrong.  For explanation's sake, the cutoff of normal is less than 0.06 (hospital-specific, for you picky people).  People having heart attacks typically have levels over 5, and sometimes much higher.  But what happens when you get a number just above normal, but isn't really suggestive of a heart attack??  Today my patient's was 0.07.  She was obviously not having a heart attack.

Then the problem shifts from "how to save the patient" to "how to save the hospital."  As horrible as it is, a lot of medicine these days is focused on how to prevent malpractice suits.  (This is another soapbox of mine which I would NEVER blog about.  But I honestly wonder how morbidity and mortality rates would change if there were no lawyers.)  The appropriate thing is to do a full, expensive, time-consuming, potentially-damaging workup on a patient who doesn't need it.

So this is a good example of how medicine is more of an art than it is a science, and what clinical years of med school and residency are about, rather than the details of physiology and things like that.

PS. "Troponinitis" is medical jargon, not an actual term (although many doctors would understand the reference), in case that wasn't clear.  It's basically a complaint that the levels came back elevated even though heart attack is EXTREMELY unlikely, leaving a clinical predicament.

Analogous explanations of my life

So, rotations are a very interesting time in your life where you really have to confront your fears and insecurities and values and morals.  The only word I can think of is VIVID. I feel like I'm having to get to know myself in a way that's super uncomfortable- you have to know your strengths and weaknesses like the back of your hand in order to succeed in the field of medicine.  Anyway for some reason when I'm on a rotation these analogies dominate my thoughts, and they're pretty hilarious when you think about them (although I'm dead serious, they are about as true as I can get).  And I think they paint a picture worth a thousand words for each of the rotations I've done so far.

Geriatric Psych: treading water, without feet, in an ocean with no land in sight.

Fam Med: having to pick ALL the daisies in a very big but beautiful field.

Surgery: facing a firing squad while sitting in an electric chair.

Obstetrics: giving your bank PIN number to a crack addict.

Introducing Bayle!

Happen to one day be surfing the net and ran across this picture of a dog waiting to be adopted near Charleston:

I am Bubbles- my names tells you all about my personality. My family left me and moved. I am about 1 1/2 years old and have a ton of love to give you. I am spunky and love to play with tennis balls. I get along with all other dogs and children. i am spayed, microchipped and up to date on all vaccinations.

 I found out that she had been found in an abandoned house about a year ago, and has been in a shelter ever since, waiting for a "forever family."  Well, long story short, we ("we" is used loosely- Patrick can still "opt out") brought her home.

Her name is now Bayle (it's a medical reference but that's another story).  She hadn't seen stairs or elevators or beds or couches before, having lived in a shelter most of her life.  So it's been wonderful experiencing all of these new things with her.  As far as we can tell, she's extremely happy to join the family, and Bandaid is absolutely thrilled to have a new partner in crime.

 Bayle (above)

 Bandaid, left; Bayle, right

Bandaid, left

Bandaid, left

Best bet is that Bayle's got the bone...

What's in a name?

So this isn't 100%, but it looks like I might have found Bandaid's sister and *may* adopt her.  Yes, it's crazy.  Whatever, that decision is not the point of this posting and isn't up for discussion.

So I'm looking for dog names ("Bubbles" is not going to work) and was trying to find something heart-related.  I'm thinking about naming her after a pioneer in cardiology, and the closest to a girl name I've found so far is Adrian (the guy who did the first heart transplant in the US) because no woman has pioneered anything in the field yet (leaving the door open for me).

So anyway I came across this picture, and if you think about it, it's pretty downright stupid. Like three amazingly brilliant surgeons pointing to a really dumbed-down model of a heart.  AND they're looking at the back of the heart, which is much less interesting than the front.

It's such an unlikely scenario and kind of makes you question what they actually knew when they did the first bunch of these surgeries (just fyi, the first bunch were all "considered" successes but died within weeks...but you can judge for yourself).  FOUR DAYS AND IT'S OVER.  Anyway....cheers.

new theory

So my new theory is that being severely obtunded secondary to chronic sleep deprivation during the cardiothoracic surgery rotation is actually a protective mechanism.

I'm exhausted, but I can't remember what I got yelled at for this week.

Empathopenia

A brief commentary on empathy in medical school.

So I keep hearing that empathy dips to the lowest of lows during third year of med school.  I really couldn't figure that one out.  I definitely went through a phase as a paramedic after a few years of 3am paper cuts and back pain for 3 weeks.  So I know what it's like and how to mentally combat it (I was prepared this time!).

Well it hasn't happened yet.  What I HAVE lost is a lot of respect for the medical field.  How freaking sad is that??  I'll have to be unconscious and dying before I show up at a hospital now.

It's definitely not the patients.  Even my most bitter patients still make me smile and laugh; they are a challenge that I honestly enjoy taking on.

Really I think it's seeing my superiors not doing all those things they tell us to ALWAYS do- taking complaints seriously, addressing pain, listening rather than talking, being open-minded.  I know in a lot of cases it's a time constraint (which boils down to a lack of resources) but just as often it's not.  Even if I'm dead on my feet and have been awake for 40 hours, I still put the rest of my energy into making sure I'm being a good med student for my patient.

I think that I now define "successful doctor" (my personal end goal) is one who can put everything else aside and still be 100% committed to the patient's best interest.  When did that stop happening??

You can never practice enough

So my first official surgery that I scrubbed into last week was actually pretty thrilling.  I actually got to participate; I was given opportunities that are usually reserved for residents.  It was tough standing there for 7 hours (mostly because I was preoccupied for most of it worrying about what I would be orally grilled on), but it was amazing to stand there- opposite the surgeon- looking at a man's beating heart.  Although I can't look back and say that I made an "impressive impression" on the surgeons, I feel like I at least gained a little respect.

One thing my mentor taught me is that silence is often the biggest compliment a doctor can give a student.  Handing me the instruments during the surgery, allowing me to help open the patient's chest, was one of the biggest compliments I've gotten so far in my career.

I even got to suture!  Ok, it definitely wasn't my first time.  I'm still pretty slow but it's a skill that I've put some time into developing.  After the surgery one of the surgeons handed me an instrument used for suturing and told me, "you can never get enough practice."

And I'll honestly never forget that, especially since it can apply to everything in medicine.

So for a laugh, I'll share a picture of one of the poor washcloths that has fallen victim to my practicing.  It's hard to see, but all edges are closed! (Plus there are a few aberrant stitches and knots for fun.)