If this is an emergency...

This month, I've been working at a smaller, community hospital affiliated with the large academic center where I mainly spend my time as a Urology resident.

It's really different here -- everyone knows everyone, the ancillary staff takes a ton of initiative to solve problems before running them up the chain, there is less paperwork, the nurses take verbal orders, the patients are less sick...it's a pretty sweet deal all around.

I discovered one of my favorite aspects of this smaller hospital late one night when I was on call.  I had a medication question and I asked the switchboard to connect me with the pharmacy.

The phone greeting went like this:  "You have reached the overnight Pharmacy line.  Please listen to the following list of telephone options; however, if this is an emergency or you are a physician, please dial 1 now to speak with a pharmacist immediately."

I have never felt more important in my life.

Curiosities at the Hospital

I am continually fascinated by just how fat Americans are able to become.

Like, people can get so fat, that Medicine had to come up with a word for the extra gut that hangs down and makes a fold over your lower torso--that 'body part' is called a pannus.  I'm pretty sure that word didn't exist 100 years ago, because No One Was That Fat.

I recently discovered that our equipment room on the Urology floor has a bin full of "retracted penis pouches".  Now, I am a doctor, training in Urology, but even I had to read the package insert to figure out what the heck these were.

I'll spare you the gory details, but it's basically a urine collection device that can be used on a man who is so fat, that his fat has actually mounded up and completely obscured his man-parts.  (This problem is so common that someone actually had to invent a device to address it...?!?!?!)

All I'm saying is, if you are So Fat that your fat starts engulfing other parts of your body--such that they cannot be seen or recognized any longer--you need to put down the chicken strips, the french fries dipped in mayonnaise, and your bucket of Mountain Dew and go for a walk.

PS.  Yes, the 'retracted penis pouches' are next to the 'large scrotal supports'.  Let me just say that being a Urologist is a very *interesting* job, and there is really no limit to how large a scrotum can become.

Managing Expectations

A lot of being a successful doctor is managing the expectations of your patients.

It is important to say things like:
"after your surgery, you will have pain."
"after your surgery, you will have to get out of bed and work with Physical Therapy."
"after your surgery, you will not be allowed to eat Bojangles Atomic Chicken strips on post-op day 1."

Despite our best efforts at expectation management, patients all too often seem to arrive to the hospital thinking they are about to go on the health-care equivalent of a 7 day cruise.

We hear a lot of things like:
"Can I have another drink?  A Sprite?  No, a Ginger Ale.  Wait, definitely a Ginger Ale, but if it isn't Canada Dry, then actually I want a Diet Coke."
"Do you guys have a long-distance code in here?  I have to call my cousin in Albuquerque.  I haven't talked to that guy in months."
"Would you trim my toenails.  They are nasty."

Given this apparent confusion, all I'm saying is, Do We Really Need TOWEL ANIMALS!?????!?!??!

Sometimes Patients Make You Feel Bad

At the hospital, I meet many new patients every day.  Sometimes, I introduce myself as "J" and other times, I'm "Dr. Llo."  There's not clear rhyme or reason to when I pick which title, but I tend to use "J" with the very young, the very old, people who look like they might be fun to get a drink with were we meeting under different circumstances, and always with patients who are themselves physicians.  In contrast, I make sure to use "Dr. Llo" with patients who are angry, unruly, or have already called me "Nurse" (these patients are usually talking loudly about inane stuff into their cellphones and say things like 'hey, hang on, my nurse just walked in'...um, yeah, I didn't go to 4 years of medical school, pass three national licensing exams, and give up my twenties to be called "nurse"). 

Tonight, a patient came up from the Emergency Department after breaking his tibia falling off of a ladder.  He was a relatively healthy, middle-aged guy who had been painting his house prior to putting it up for sale.

So, after putting in a few orders for pain medicine and a meal tray, I went to the patient's room.  All new arrivals to the service need to be checked out by a doctor following admission, plus I figured a little TLC would smooth over what I'd heard was a long wait in the ED.

As it so happens, this patient did something sort of boldly obnoxious that had not yet happened to me in my almost-10 months of being a doctor.  And he really, really irritated me in doing it.

You see, I walked in and--based on my split-second assessment of his posture, his age, his mood, etc--decided that I would be "Dr. Llo" in my interactions with him, because he just looked a little bit surly. 

"Hi Mr. SoandSo.  My name is Dr. Llo.  I'm one of the night doctors on Orthopedics" [aside:  I'm covering Ortho this month].

"Who are you?"  he asks.

"I'm Dr. Llo.  I'm one of the night doctors on Orthopedics."

"And what is your first name?"

Obviously, I don't love this question since I'd already decided that I wanted him to call me Dr. Llo, but I answered, hoping my ever-so-slightly reluctant tone of voice would clue him in to the fact that I've not invited him to refer to me by my first name--especially since I was referring to him as 'Mr. SoandSo'.  "My first name is J," I told him.

And then we talk...about his long wait in the ED, the 10 feet of his house he has left to paint, the plan for his operative tibial repair.  And the whole time, he's calling me J, in a way that feels simultaneously aggressive and dismissive.  I was so mad...and what kills me is, if he was just a little less threatening to begin with, I probably would have introduced myself as J in the first place!

How Good Life Is

For those of your who are medically inclined (or economically inclined, perhaps), this NYT article about hemodialysis is food for thought.

Freudian Slip

I was in the Emergency Department recently, and treated a young female patient who came in with discharge and odor...of a female nature.

When you come in with this problem, your doctor (in this case, me) is obligated to perform a pelvic exam.


Joy.

So, I'm doing my exam and the smell is, in fact, quite potent. Sometimes, Matt leaves old Tupperware containers in his car during the summer, with old food bits and juices inside, that bake and congeal for days...yeah, the smell was sort of similar to those.

Now, to make women more comfortable during the pelvic exam process, I always tell them what I'm going to do before I do it. "You're going to feel my hand on your thigh. Now I'm going to look on the outside. I'm going to insert the speculum," etc, etc.

I'm getting ready to do the bimanual portion of the exam, which I always preface by saying "Alright, now I'm going to press on your belly to examine your uterus and ovaries".

Except, this time, I said, "I'm going to press on your belly to examine your uterus and odor-ies".

Oops!

The Only Thing I Enjoy at the VA

The only thing I enjoy about working at the Durham VA is interacting with these hilarious robots. (They perform a job carried out by human "pharmacy techs" at most hospitals--that is, delivering medications from the pharmacy to the wards, where the patients are.)


It's almost like working at the hospital of the future...or, the hospital of some dystopian future, where there are mildly recalcitrant electronic helpers; a computer system whose glitches make order-entry feel like two-steps-forward, one-step-back; and a cadre of nurses/ancillary staff who are well-acquainted with the business-end of a pack of Virginia Slims.

New Low

Working at the Durham VA is a lot like practicing medicine in the 3rd world...or in the 1970s...or in the 3rd world in the 1970s.

In any case, today, I reached a new low.

Yes, that's right. I trimmed a patient's toenails.

Good thing I went to 4 years of medical school for that.

Fire Drill

I heard the following story on the radio recently.

In brief, a high school math teacher who motivates inner city students by teaching them chess was being interviewed. He himself learned chess as a kid in the Ukraine, before he moved to America at age six.

So, the six-year-old future math teacher moves to America and his parents enroll him in first grade. The school year has already started, so he tries to fit in as best he can. Problem is, he does not speak English. At all. No English.

School is hard -- not the material, but the not-understanding-what's-going-on-because-I-don't-understand-the-language part.

Then, the school hosts a fire drill. Apparently, there are no fire drills in Ukraine, and the kid doesn't really know what's going on. Plus, he's in the bathroom--alone--so he can't see everyone filing out to the school yard. It turns out, while they don't have fire drills, the Ukrainians do have faulty equipment, so the kid just assumes that something has broken in the school building's wiring and is making a strange noise.

So, he washes up and traipses back to his classroom. He finds it empty. 'Strange,' he thinks. He wanders to the next-door classroom, and finds, curiously, that it is empty as well.
In a moment of true problem-solving, the kid decides, 'it's almost lunch time, I guess everyone just went to lunch early.' He wanders to the cafeteria. No one is there, but there are plenty of lunches lined up on the counter. He reaches to take one, and, at that exact moment, a hairnetted lunch-lady runs out from the kitchen, shouting, "THIS IS A FIRE DRILL. YOU MUST GO OUTSIDE. WHY ARE YOU IN HERE???? PUT DOWN THAT LUNCH AND LEAVE RIGHT NOW."

As the math teacher/chess play is relating all this, the radio host interrupts him and says, "That must have been so confusing. It must have been exhausting never knowing what was happening and being so disoriented all the time. I bet you went home that afternoon and thought to yourself 'I can't take this anymore. I never want to go back.'"

At that moment, I couldn't help but think that the kid's experience was a lot like being an intern. Things happen in the hospital, and you don't know why. Patients have bad outcomes, and you don't know why. Tests get ordered, but not completed. Patients refuse blood-draws. Medical students fail to learn simple concepts. Physical Therapy doesn't come. Surgeries are done in the OR, and you don't know what they are. And at the end of the day, some metaphorical-lunch-lady is always yelling at you, for reasons you can't really make out.

The Glow of Good Health

If you Google "glowing with good health," you will find this image:

Now, this isn't really what I had in mind...so, I tried another option-- "fine physical specimen" -- which I feared might veer into the realm of pornography...but, as an intrepid blogger, I carried on.

Porn it was not, but still not what I wanted:

You see, this photo is of a fat guy, and what I wanted was an image to demonstrate "the glow of good health" and being "a fine physical specimen".

I wanted these images to contrast with the picture I'm about to paint of the typical resident-in-training.

Throughout my years as a medical student, I used the following terms to describe the physical appearance of most residents: 'soft,' 'doughy,' 'pale.'

'How do they let themselves go like this?' I thought. 'I won't be like that,' I thought.

Hmmmmmmmmmmmmmmmm.

(pot, meet kettle)

The jury is in: I've been a resident for the past 8 weeks, and I've already developed a bloom of subtle flabbiness. What once were (slightly) rippling muscles now sag wanly. There are divots where divots weren't before, and bulge-y peaks that I hadn't seen during my carefree days as a medical student.

Oh well... Chalk up my physical well-being to the cost of medical training... It can go on the same tab as 1) all my free time, 2) reading for pleasure, 3) staying up past 9pm, 4) sleeping past 5am, 5) my 20s, 6) etc.

Someone steal my pager...I'm begging you.

Got the following hilarious page from my Chief Resident on Vascular Surgery, regarding a patient whose operation I was scheduled to assist with:

JLlo -- unfortunately, your patient presented to preop with confusion and new o2 requirement -- case cancelled. sorry! (it wasn't because he heard you would be operating on him)

This page was obviously more entertaining than some other electronic gems I received today, such as:

So-and-so, rm ####: Pt also is complaining of indigestion following lunch. XXXX, RN.

or

Rm ####, Pt So-and-so. patient states that his Right foot hurts worse than it did prior to surgery. he states that "the doctor didn't fix anything!" thanks, XXXX, RN.

Obviously, I hate my pager.

What Does an Intern Do?

New doctors in the first year of their residency training are referred to as 'interns' and much of modern academic medicine is built on their backs.

Certainly, internship has a steep learning curve. It is the moment of transition from 'medical student' to 'doctor' and many, many competencies must be mastered.

It is a privilege to have access to all this learning, and the cost of that privilege is scutwork.

Scutwork (also known as 'scut'): Monotonous work or menial tasks that--while not pleasant or fulfilling--have to be done, usually as part of a large complex job or project, often by an underling.

Scut is, by definition, neither direct patient care nor clinically-relevant learning. Unfortunately, all residents (all doctors, for that matter) must manage some degree of scut, but--at least in academic settings--a large portion falls on the intern.

My daily scut work looks about like this:
-enter nursing/medication/diet/imaging/PT/etc orders on the computer
-talk to the ward social worker (now called a "patient resource manager") to make sure that patients' insurance companies will pay for their necessary care
-call Radiology to make sure that all the imaging studies I've ordered will actually be performed
-call the clinical laboratory to find out why missing blood test results aren't back
-make 1289746166739509 follow-up appointments for the patients who are soon-to-be discharged
-write 23891612876498793877466 prescriptions, because every patient goes home on a full pharmacy's worth of medications
-type discharge instructions for the patients who are leaving the hospital
-call Radiology again to inquire why the studies they said would would get done haven't been done yet
-answering plenty of pages from the nursing staff
-change wound dressing, stick fingers in surgically-created orfices, put tubes into various bodily openings

Nonetheless, there are still upsides of being an intern:
1. Painful though it may be, you are still a doctor. You wouldn't have gotten this far if that wasn't important to you.
2. Sometimes (rarely, since you don't know anything) you can actually help people.
3. In one year, you won't be the intern anymore, and you will have an intern of your own to carry out all the necessary but painful tasks of the modern medical center.

White Coat Pockets

As an intern, you must travel light but be prepared for anything.

Thus, our white coat pockets are jam-packed with all kinds of essentials.

Here is what I found when I unpacked the 3 pockets of my white coat:

-Resident Survival Guide
-Maxwell's Pocket Medicine
-'Important Numbers' memo book
-Alcohol swabs
-Scissors
-Blood draw tourniquet
-Silk tape
-Prescription pad
-Stethoscope
-Vasoactive drugs reference card
-Diabetes management reference card
-Laminated Duke phone directory card
-Size small gloves (1 pair)
-Patient list
-Note paper with random patient info
-ID Card
-3 paper clips
-2 pens
-1 highlighter
-Penlight
-4x4 gauze pads
-2x4 gauze pads
-Sweet note Matt wrote for me
-Bandaids
-Post-It notes
-Dunkin' Donuts sugar packet
-One dime

Shelter

I've been taking a lot of shelter lately in 1) my long white coat and 2) the fact that I can now call myself "Dr. JLlo".

You see, as the intern, you spend much of your time managing patients on 'the floor' who are either waiting for their operation or recovering post-op....and these patients have a lot of questions.

Fortunately, as a new doctor, I know a lot of stuff.

Unfortunately, most of the things I know are either irrelevant (all the enzymes involved in glycolysis), really irrelevant (how much detergent is left in our jug of Tide at home), or crazy (the entire dialogue of the 2000 Hollywood 'mega hit' Love & Basketball).

Thus, it is hard when patients and families look to me and want (need) answers that I don't have. My policy is to only say what I know and otherwise, defer defer defer. I spend a lot of time explaining the hierarchy of a teaching hospital, and how, as an intern, I have the least amount of experience and the least decision-making clout.

It is easier to say, "That decision is best left to Dr. So-and-so (the boss) because he has much more experience" than to say, "I have no idea." Really, though, these explanations go hand-in-hand.

I worry that patients will give up on me because I often can't answer their questions, but I'm realizing that they don't.... A lot of this has to do with the two things I mentioned at the beginning: the letters M.D. after my name and the white coat I wear. These are powerful symbols that earn new doctors trust and credibility in the eyes of our patients. They make up for our lack of practical knowledge. In these early weeks of my residency training, I feel lucky to have them -- and I hope to become continually more deserving of the authority they give me.

What Does a Urologist Do?

As a recent medical school graduate, I will be starting my residency this July. Residency is the period of specialty training that follows medical school, during which new physicians are closely supervised while gradually developing the skills necessary for independent clinical practice.

I have chosen to specialize in Urology.

What does a Urologist do, anyway?

Urology is a surgical subspecialty that treats a variety of diseases affecting the urinary tract, pelvic floor, and reproductive system in men, women, and children. Commonly-seen conditions include genitourinary (GU) malignancies (kidney cancer, prostate cancer, bladder cancer, testicular cancer, etc), kidney stone disease, incontinence, and male infertility. Urologists also perform GU reconstruction following surgery or trauma and repair congenital GU anomalies.

Urology involves a blend of surgical and medical (i.e. non-surgical) disease management.

One side benefit of practicing Urology are the numerous opportunities for bathroom-humor when people ask "what kind of doctor are you?", and then invariably hear "I am a Neurologist," when you say "I am a Urologist." (humor that goes along the lines of "oh, a little farther South...but a lot of thinking goes on down there as well")