The First Breath of Autumn

I love mornings like this, early fall maple muffin mornings, with fog as thick as a cloud bank hovering over the hayfield. Freddie the Freeloading porcupine sneaking breakfast under the apple tree, unaware I'm watching. Dew on the grass that will be frost soon enough and air already cool enough to faintly see your breath. It won't last long, the mid-morning sun will see to that.

The first breath of autumn always goes fast.

Kind of like third year rotations. When you're in the starting gate, gazing down the track toward the clubhouse turn (the first curve in horse racing), six weeks appears endless. Before you know it, you're in the home stretch and the written exam lies ahead at the finish line and you're wondering what madness possessed you to think you were too weary to study after a day on the wards. Surely, you didn't need sleep that badly, did you? Yet, somehow, like Seabiscuit, you dig deep, pulling a passing grade or better out of your hat like a magician's rabbit. A weekend of freedom passes like a thief in the night and the process starts all over again

But not this time. At least not with internal medicine. IM is a twelve week test of endurance, though broken into several subgroups you get a wide glimpse at the field. Thus far, I've been on the residents' teaching service, spent eight days with a hospitalist, and Monday heralds rehab medicine. Two weeks later comes two weeks of night float and assuming I'm still afloat after that, my final two with the residents. It's not as long as it sounds, like the first breath of autumn, it goes fast.

At first, the twelve hour days are exhausting and you wonder how the residents do it, how you'll do it when you're one of them. A week and they're familiar, another and they're commonplace while you're hustling to get all your patients seen, clinical notes written and patients seen once more before evening report. If you've had an admission or accompanied a patient to a procedure, you realize this is what cranberries feel like when they're tossed into a blender at Thanksgiving and the switch clicked on.

The good thing is, it's only week six. Instead of feeling like you've just gotten accustomed to finding your way before it's time to move on, you have a chance to actually practice what you've been learning. The context in which you'll see patients will change, but it's still internal medicine. It's not as though you've been doing well-child visits, diagnosing colds, ear aches, and strep throat, and suddenly have to distinguish between major depression and an acute grief reaction. Racing to a code blue cardiac emergency is a bit different from rushing to intervene with a telephone wielding patient who checked self-control at the door to the locked psych unit.

You get used to it, we all do, but it's nice once in a while when you don't have to. When you can to get close to a patient without having say goodbye before hello has barely passed your lips. When you've grown confident walking into a hospital room without a resident holding your hand because you've done it thirty or forty or fifty times and lived to tell the tale. When you can step into the doctors' dictation room, sit down at a computer and do your business because you have business to conduct, just like the other doctors. Don't get too comfortable, though, because it won't last, it can't -- you have other things to learn, other patients to see, and like the first breath of autumn, it all goes fast.

It always does.

(Creative Commons image of autumn colors by franzikus garten via Flickr)

Doctor's Notes

Before going much further, I feel like I should apologize for not having written anything lately. The past seven and a quarter days I've been working with the hospitalist service and that includes the weekend. It's probably self-indulgence, but truthfully, our work as students doesn't end with a punch of the time clock. Anyway, thanks, as always, to any and all who've come by to see if there's anything new. I've got the next four days off and I'll try my best to make up for my laxity of late.

What's that? Oh, the hospitalist service refers to physicians who are employed by a hospital for the sole purpose of providing inpatient care. My current rotation entails spending a week to ten days working with one of them -- it's a bit like an apprenticeship -- and learning internal medicine under their tutelage. The two weeks prior were spent with family medicine residents seeing their assigned patients and it's to their service I'll report once again this coming Monday.

As healthcare delivery has changed over the years, it's pretty rare to see a family doctor or any kind of doctor, for that matter, admitting and then following their own patients in the hospital. There are still a few, mostly family practitioners in the hinterlands of upstate Maine or other remote locations, who do it the old-fashioned way, but they're a vanishing breed. For the most part, patients are evaluated in the ER and then transferred to the responsibility of a hospitalist who oversees their hospital stay.

And that's where my fellow students and I come in. We'll report to the Emergency Room, take a detailed history from the patient and/or their family members, complete a physical exam in the company of a resident or attending physician, and then become a member of their treatment team as long as they're inpatient. Sometimes the H & P (history and physical) has already been done when we arrive for rounds (morning report) and we just go on from there.

My first two weeks I spent learning how to write a clinical note. That may not sound like much, but really, it's huge. The clinical or chart or progress note -- they're all basically the same thing -- is how doctors talk to one another about a patient's condition, symptoms, and so forth. Even though I got the basic format down during my psychiatric rotation, writing a note for internal medicine takes practice and I practiced a lot. I didn't have nearly as many patients to follow as I did this past week, so I had time to write and rewrite my notes over and over to make sure I had something worth leaving in the chart.

This past week my task was slightly different. Having gotten accustomed to writing notes that were legible and covered all the clinical bases, now I had to figure out how to turn them out faster in order to keep up with my attending. But you can only write so fast before legibility gets tossed out the window and a student's note has to be readable in order for a supervisor to evaluate our thinking process. So, you learn the art of brevity, writing what is truly necessary, and generating a plan of treatment that specifically addresses a patient's symptoms that particular day. Pragmatics take precedence over literary perfection.

It's a matter of taking one step after another, one step at a time. That's really how a rotation like this one unfolds. To be of any value at all, you've got to be able to communicate about patients and since your note is a critical element in the process, you start there. It's not dramatic, no one's going to page you at the end of the day with an offer of a guest spot on Gray's Anatomy. But once in a while, an attending reads what you've got to say, decides you have a good idea, and adds the medication you suggested or obtains the consult you recommended. And right then, you got to do something good for someone. And that's really cool.


(Creative Commons image entitled "Doctor's Note" by keitamiyoshi via Flickr)

Internal Medicine: One Week Down

Third year clinical rotations are great opportunities to discover what you don't know. For instance, I thought, like many other well-intentioned medical students, that "internal medicine" was concerned with illness conditions too severe for the family practitioner to manage. You referred to an internist when the waters were swirling and you didn't want your patient going under a third time. Oops, there goes another of my misconceptions. Internal medicine means simply the practice of adult medicine. Family docs treat families, pediatricians are all about kids, OB/GYN's manage women and babies, and psychiatrists -- well, they try to keep everything on an even keel, how's that? Except family docs treat adults and pediatricians may treat young adults, so that throws simplicity out the window.

Once upon a time, internal medicine would have been my first rotation, but as it stands, I've spent time in a rural family practice (loved it), pediatrics (really loved that), and psychiatry ("you make me feel like dancing, I wanna dance the night away" ~ Leo Sayer). I've also done a stint in osteopathic manipulative medicine (a wonderful experience) which, for us DO types, ties pretty much everything together. I guess I've come back to where I might have started.

So, what kinds of things can you encounter in IM? The same ones you do in kids, the kids are just bigger, is all. And there are some you don't as much. Heart disease is more common in adults, hypertension and the effects of lifestyle -- alcohol, drugs, overwork. Cancer, clearly something the world would be far better off without, is there, too. Adults have responsibilities and being sick means being under stress, which only complicates the healing process. Internal medicine (and pediatrics and family medicine and...) is one part physical and two parts psychological and spiritual. People who are sick need hope. Come to think of it, so do the rest of us.

Where do I see my assigned patients? Since this is a hospital-based rotation, the inpatient unit, ICU, and rehab. If one of them is undergoing a procedure, I'll follow along to observe and learn and provide moral support. You see, students possess in relative abundance, something the residents and attending physicians have in short supply, i.e. time. We also have some measure of freedom about how we choose to use it. Talking to patients, forming a relationship, is one of the best uses of our time. If you've never been a patient yourself, or even if, like me, you have, this is a chance to find out what it's like for them to be in their shoes. Moral support may seem small in comparison to writing treatment orders, but from the patient's perspective, it's huge.

It's also important to spend some of that "abundance" talking to nurses and not simply about the patients you have in common. Nurses know things, things you want (and need) to know, too. When you're trying your heart out to do well, to develop some measure of competence, and to avoid doing anything that should never be done in the first place, having staff members who watch your back is priceless. Besides, it makes life more pleasant and we can all use some of that.

I mentioned in a previous post how I wanted to learn more psychiatry in the course of learning internal medicine. One week down, I think it's impossible not to. Osteopathic physicians are intent upon finding the person in the midst of their illness. Patients aren't problems to be solved, though their condition may pose many, nor are they incidental to what we do like a spot on an X-Ray that turns out to be a clasp on a hospital gown. They're the why for all of medicine and any occasion to work them teaches something about why they tick the way they do. I suppose you could say I'm learning how to keep them ticking as healthily and hopefully, as long as they can, before the clock strikes twelve.


(Public Domain image of Downtown Bangor, ME via Wikipedia)

It's Called Direction

How does it feel, having completed my psychiatric rotation? Satisfying -- especially since a scheduling shift allowed me to tack on another week at the end -- and I think I may have learned something about ordinary living that I hadn't anticipated. Henry David Thoreau wrote, "I went to the woods to live deliberately...to live deep and suck all the marrow out of life." I've endeavored to do likewise, drinking at the fountain of each day. knowing the rotation I've waited four years to experience, would pass like a thief in the night, whether I left the front door unlocked or not. Though it may not seem like much, when you're trying to be fully aware, feeling each moment, allowing it to fill you up and splash over like water overflowing a bottle, five days can equal five lifetimes.

And that's what I tried to do with every weary night's walk from A-3 (adult psychiatry) through the behavioral intensive care unit, down the hallway of the Center for Joint Replacement, then up the stairs to the chemical dependency unit to return the key I'd checked out that morning. The key that gave me ready access to office space for interviewing patients. The key that spelled independence, freedom to spend my time going, doing, accomplishing, instead of watching it trickle through my fingers, waiting. The key like one carried by staff members, by doctors, that signified I was one of them and my work meant something. And not just to me.

A quick goodnight, see you in the morning later, and it's down four and a half flights to the ground floor, past Dunkin' Donuts and out the sliding glass doors marking the main hospital entrance. My car is parked two blocks away and in the heat, it's a long two blocks. People I've never seen glance at my tie and smile in greeting. Nurses, assuming one of the doctors is heading home. An internist, driving by in his Thunderbird convertible, waves. It might be late, it might be early, but I look right at the stoplight and see the hexagonal wooden tower that houses the A-3 dining hall framed against the western sky. I'll see you tomorrow, I whisper.

But Monday's tomorrow, I won't. Instead, I'll be preparing to drive north once again, past the familiar turnoff leading to the tiny burg that was my home for rural medicine, and on to Bangor where Internal Medicine begins in another week. I've got a context now that I didn't have seven weeks ago. Rather than simply learning more medicine, gaining skill like a professional Monopoly player, I'll be learning about the underpinnings of psychiatry in the guise of you name it. I'll exchange my shirt and tie for blue-green scrubs, tennis shoes, and a white coat. Conditions like delerium that I've helped diagnose, now I'll help treat.

But not with a questioning mind uncertain of its goal -- that ship has sailed. Five minutes on the psych unit, I was standing on the dock, waving a hankie and bidding it bon voyage. Everything that is to come is training to be a better psychiatrist, one who can keep a patient alive until the code team arrives if he has to, one whose stethoscope sits on the desk next to a dog-eared copy of Freud's Psychopathology of Daily Life. One whose patients aren't hesitant to call their doctor. More than a context, it's called direction.


(Public Domain image of Henry David Thoreau via Wikipedia; citation from Walden)

The Lucky One

I'm home again after another amazing week in rural Maine. I gave my first tetanus shot yesterday and identified, if not actually diagnosed, my first case of outpatient pneumonia. The latter was a biggie for me since we didn't have a chest x-ray to rely on; instead, it was a matter of taking a careful history and listening to our patient's breathing, then asking what was the most likely explanation for their presentation. As I've mentioned previously, I can't get over how much more akin to internal medicine this rotation is turning out to be.

In part, this is due to the fact that my preceptor's patient population is, by and large, an older one, so the colds, flu, measles, and chickenpox that show up in family medicine don't walk through his door too often. It also stems from his comfort level, dealing with difficult and challenging cases. He won't admit it -- something I admire about him -- but he's a careful and astute diagnostician. He takes his time with patients and encourages me to do likewise and make certain I offer well-reasoned and thorough explanations for what we're doing and why.

More than accurate explanations, he wants to make sure we provide ones that are comprehensible. This appeals to me strongly because it's the same principle my friend Dr. Lynn Smith and I followed when writing our book. We wanted to communicate effectively, not impress readers with the extent of our vocabulary, something that often characterizes academic writing. "It's not what you say or do," my preceptor reminds me over and again, "it's what people think you said," that matters. For this reason, you want to make certain what they think is the closest approximation of what you actually said, as possible.

So, for example, when urging a patient to take a complete course of antibiotics and not stop once they begin feeling better, he'll say, "It's like wolves who attack the weak and sickly in a herd of deer and then go after the strong." An antibiotic kills off the weaker members of a bacterial population in the initial few days of taking it, but you've got to finish the prescription in order to get the ones that remain after you've started to improve. Makes a lot of sense, doesn't it?

I'm three weeks down in what's usually a four week rotation but I've been offered the chance to extend it by another two, and that's what I'm doing. I'm learning too much and having too much fun in the process to turn down the opportunity. Of one thing I'm certain, when I graduate, whatever kind of physician I'll become, it will be strongly colored by the weeks I've spent with this guy and his gal Friday in north central Maine. Am I ever the lucky one.


(Creative Commons image of the Kennebec River Valley by jimmywayne via Flickr)

Wearing Yoiur Own Skin

Whoever invented the concept of putting captions on T-shirts has got to be lying beneath an umbrella -- on their own beach -- on their own island -- off the coast of Tahiti, wearing one that reads, "Made in the Shade." I don't know where all this got started (probably California) but there are some phrases I dearly love.

"Don't trust anyone under 14,000 feet" is a quote I've worn, and worn out T-shirts bearing it, for years. The words surround a map of Colorado with all of the peaks marked that meet or exceed altitudes of 14,000 feet. It's a humorous way of calling attention to one of the assets of which we are most proud.

Here's another: "It's not the pace of life that bothers me, it's the sudden stop at the end," from a No-Fear T-shirt. I think that's great and it's perfect for medical students. It reminds me of the lyric from an old country song, "going 90 miles an hour down a dead-end street."

"Wear Your Own Skin," a piece of sound advice offered by a T-shirt-clad stranger standing on a street corner, reminds me of a chance encounter last night at dancing class. I've been sick the past two weeks, as you know, and didn't think it was right to show up, coughing, hacking, sneezing, and passing along virus particles to anyone who had the misfortune of being my partner. So, I've stayed home, hoping I wouldn't forget everything I'd learned in the meantime.

There were several new members present, two of which, it turns out, are doctors in the area. What tipped me off to one was the fact that she kept checking a pager at her waist -- doctors are wedded to their pagers, even when they're supposed to be having a good time. While she and I stood talking in the middle of the floor, oblivious to the fact that the music would be starting momentarily, the other, a physician-in-training, came up and introduced herself. In a matter of seconds, we were chatting like we'd known each other for years.

I love medicine and this is one of the reasons why. It creates an instant community among persons who might ordinarily have little to say to one another. Both of them had studied internal medicine, and of course, my area is psychiatry, but they valued the role of psychology in patient care and I'd had experiences that paralleled theirs with medical patients. I imagined we must have looked funny to the rest of the dancers, our little circle of animated conversation moving to its own unique rhythm. But it made my night and we all made new friends. Dancing class has been fun and I expect it to be a lot more, now that there are three of us, learning together and wearing our own skin.


(Creative Commons image by swan-t via Flickr; 90 Miles an Hour by Hank Snow, also covered by Bob Dylan)

'Monk' In Tights

My life has been filled with terrible misfortunes -- most of which never happened. ~ Michel de Montaigne

Montaigne was a 17th century writer with 21st century angst -- and delivery. His massive volume of essays (the equivalent of the blog in his time) culminates with one entitled, On Experience, in which he talks about how he knows his body better than any physician. It's hard to say, but he may have been just a tad OCD --sort of like Monk in tights. But you have to give him credit, he could see the irony in his thinking and make a joke of his own fears.

Still in all, he must have been very good at sensing the slightest unusual feeling and associating it with illness, if not impending disaster. Medicine being what it was in Renaissance Europe, there were no doubt limitations on what he could find (he probably found enough anyway). But turn him loose with Harrison's Textbook of Internal Medicine and I can imagine him associating a simple headache with a cerebral aneurysm, a blister signaling melanoma, and a swollen gouty big toe the onset of gangrene.

If things are fine, you'd best be careful, if things are bad, they'll get worse. Fate is lurking round the next corner, lying in wait with doom at its heels. Always on the lookout, never quite able to let down his guard, another hundred years and he'd have been like the Minutemen, ready to fight or flight at a moment's notice. Chicken Little seems tame in comparison.

Fortunately for him, he was wrong more often than not and the catastrophes of which he was certain, avoided him like the plague. His watchfulness may have helped, but life bit less than it barked and it may have barked far less than it wagged its tail (tip of the hat to dogs everywhere). As with most of us, the worst thing he had to survive was his own doubt that he would.