Dec 24, 2010

A Doctor's Christmas Dinner

I'm stuffed. Christmas dinner with my family, a happy time spending time with grandparents, cousins, aunt and uncles, and all the good Swedish food I remember having as a kid. It's bittersweet; I'm worried that next year I'll be an intern and won't get to be home for Christmas. It's my last year on an academic schedule, the last year that I can depend on someone to protect my time. And as I was thinking about being a doctor during Christmas, my mind drifted to the many foods I learned about in medical school. Not really foods exactly; doctors seem to like to name various pathologies after the dishes they abstractly resemble. So here is my idea of a Christmas dinner for doctors, a menu of pathology.

To drink:
Rice water

Anchovy paste
bread and butter with red currant jelly
caseous (cheese) necrosis
Grape clusters
Olive sign

Main dish:
Pizza pie with onion skin
Hamburger sign

Red cherry
Strawberry tongue
sugar coated spleen
chocolate cyst
Apple core
Banana sign with nutmeg

Here is what we are really serving:

To drink:
Port-wine stain: hemangioblastoma
Coffee-grounds: upper GI bleed emesis
Cafe-au-lait spots: neurofibromatosis
Rice water: cholera diarrhea

Anchovy paste liver: amebic liver abscess
bread and butter with red currant jelly: pericarditis, klebsiella pneumonia
caseous (cheese) necrosis: tuberculosis
Grape clusters: hydatidiform mole
Olive sign: pyloric stenosis

Main dish:
Pizza pie with onion skin: cytomegalovirus retinitis and hypertensive arteriosclerosis
Hamburger sign: uncovered vertebral articular facet
Millet: spread of tuberculosis

Red cherry: Tay-Sachs disease
Strawberry tongue: Kawasaki disease
Sugar coated spleen: chronic spleen serositis
Chocolate cyst: hemorrhagic ovarian cyst
Apple core: colon tumor
Banana sign with nutmeg: hypertrophic cardiomyopathy and alcoholic hepatitis

These are all signs and symptoms that are clinical language to describe the diseases mentioned. Doctors just seem to describe these clinical signs in terms of a better known entity: food. Everyone knows what bread on butter looks like. So when you see a heart with pericarditis, it's a frame of reference for something you see. But it is an unappetizing way to characterize disease.

My advice: don't have holiday dinner in the doctor's lounge.

Dec 17, 2010

It's Not Easy Being Green

No, I’m not talking about Kermit the Frog or even about the environment. I’m talking about medical school. Now that I am a few months from graduating (after nearly four years) I have decided that it’s never easy to be the "greenest" person in one’s profession with little knowledge and a lot of demands. The following account is really true; it is way too bizarre to have been made up.

Month 1: A group of medical students listens to a robot simulation-patient with a heart murmur. It's the same murmur for every student. We must describe said murmur to teacher. Each student proceeds to listen to the patient with their brand new stethescope and echoes the previous student's assessment. In my anxiety and eagerness, I press my stethescope bell to his chest and repeat the same findings. Teacher points out stethescope is hung around my neck and not in my ears.

Month 3: We study anatomy of the lower extremity, and find a cadaver leg with painted toenails. Group of students abandons study and instead discusses whether the person the leg belonged to painted her toenails then died, or if sick student painted them postmortem. Argue about whether formaldehyde would act as nail polish remover or preserver. Never reach conclusion. I still kind of wonder about it.

Month 5: Study the thorax and abdomen. Work hard to learn muscles of chest wall and back. Anatomy professor (retired surgeon) points to a muscle and asks what it is. I blurt out "pec major! its pectoralis major!" He looks at me and says "that would be true...if he were laying on his BACK!" It was the trapezius (similar looking muscle, opposite side of body)! He took the opportunity, not unkindly, to remind us to first orient ourselves to the patient's position and anatomy in all visits and operations. Very sound advice indeed.

Month 10: School pays unfortunate woman to serve as a "standardized" patient for the purposes of us learning to do a well-woman exam. We take turns examining her breasts and learning to do a pelvic exam. As it turns out, opening the speculum is nearly impossible and requires at least three hands. Who knew?

Also Month 10: Same patient is exposed to little docs learning how to professionally communicate. A male classmate completes the breast exam, looks at her and says, "Your breasts feel great to me!" I think what he meant to say was, "Your breast exam is normal." It just came out wrong.

Month 13: I rotate through my first half day in clinic doing pediatrics. Secretly think newborns look like little aliens. Am horrified when little one cries when I touch him because my hands are so cold. I want to cry too.

Month 15: Man comes under my care after cardiac arrest. I ask how he was resuscitated. Wife cuts in and says she punched him in the chest, saying "You're not going to die on me, you son of a bitch!" The punch restarted his heart into sinus rhythm.

Month 16: Watch attending (physician) distract hospitalized patients and then eat food off of their trays.

Month 17: Watch a classmate diagnose twins based on fetal doppler tones. Laugh when attending tells him he did indeed find two heartbeats: Mom's and Baby's.

Month 21: Write out a prescription and attending signs it. Spend entire lunch staring at it, admiring my handwriting on prescription pad.

Month 24: Halfway through medical school, and still have to imagine myself sitting as the patient to know which side is their left and right.

Month 25: See infertility consult with attending. Assist with intrauterine insemination procedure. Attending approves my work by saying, "Between you and me, we should be able to get this lady pregnant."

Month 26: Greeted by new rotation attending: "Do you know how many millequivalents per hour to raise a hyponatremic patient's sodium level to prevent central pontine myelinolysis?" Um, no. I think I just forgot what sodium is.

Month 27: Greeted by new rotation attending: "Who the hell are you?"

Month 30: Greeted by new rotation attending: "The s*** has hit the fan!" Um, am I the s*** on your fan? Or is it something else? In any case, can I please, please run away?

Month 31: Realize between my tuition and my husband's salary (we work at the same place), we owe the health center eight thousand dollars for us to both work there full time.

Month 33: See patient with the back of my skirt tucked into my underwear.

Month 34: Do hernia exam on old, fat, hairy, bald man. He jovially warns me to be careful, don't get turned on. Realize, almost too late, that it is not professional to say "Ewwww!"

Month 35: Wear new dress. Attending asks if I am pregnant. Never wear dress again.

Month 36: Must get size medium scrubs from scrub machine at hospital as smalls do not fit over my hips. Mediums huge on bottom, even bigger on top. Curse misogynist freak that designed machine to only dispense atomic booger-colored men's scrubs in sets, not separates.

Also Month 36: Examine patient who has a toddler in tow. Toddler pulls on the drawstring of my too-big scrub pants while I am examining mother. Pants fall down. Complete examination in pink polka-dot panties.

Month 37: Eat at doctor's lounge with attending. Take last turkey sandwich. Attending gets ham, wants turkey. Takes my turkey sandwich. Opens both sandwiches. Removes cheese, changes his swiss for my cheddar. Proceeds to enjoy turkey and cheddar sandwich.

Month 38: Do rotation at a new hospital. Get slapped on the hand (literally) for harmless mistake. Watch another student get grabbed by the back of the scrubs and thrown across the OR. Fondly miss my sandwich-stealing attending.

Month 40: Almost seize with happiness when patient argues with reception that she wants to make her follow-up appointment with me instead of the real doctor.

Month 42: Realize I am graduating in 6 months. Start reflecting on stories. Decide some are pretty funny, and almost certainly universal for medical students.

Month 43: Write them down. More to come.

Board and Restless

I switch my computer on, open up a webpage, stare at it blankly, and shut my laptop. I go unload the dishwasher, clean the catbox, and put away my shoes. I return to the computer, mindlessly opening it back up. With a frown, I shut it again. I open a book, then shut it. I stare at my dog. He stares back. I'm not sure what to do now.

I took my boards yesterday. I am so used to doing practice tests online, to using every spare moment to open a book and do a practice question, that I forgot what it's like to not do that. It's become a habit, a compulsion, to take free moments and turn them into study time. Now the test is over, but I feel no different than I was day before yesterday. I have to adjust to the new, test-free me. It's very disorienting.

I remember this sensation after I took my Step 1 board exams. I wandered around the house restlessly for a few days, turning my computer on and off, cleaning, hovering around my husband until he finally suggested that I go to the gym (a good idea). Eventually I settled down, into a new routine that didn't include 200 daily practice questions, each with a 2 paragraph question stem and answer choices a through j. But now I'm back to this post-board restlessness after Step 2. You think it would be relieving, to have the test over with. But with the test's completion, a significant effort in your life is over. And you are left with the residual habits and anxiety that have unknowingly become part of your daily routine, without anywhere to direct them.

I think anyone in intense academia can relate. I remember the end of my dad's dissertation, when he would dazedly relinquish the Apple Mac (high tech with a 7" screen) to a six year-old me to play Shuffle Puck and McGee. Even though he had a diploma on the wall and cap on the desk, it didn't feel right that he didn't need the computer anymore. Even to me, the house was strangely quiet without the sound of the dot-matrix printer. It had been my bedtime lullaby for as long as I could remember.

I imagine this will happen in the days following my Step 3 boards and written/oral specialty boards. Each time I'm a little more prepared for this strange inner restlessness. It's something that was new for me in medical school, yet another course in the unwritten curriculum. And on many levels it tests doctors in other ways than the questions. It asks you to devote your entire thought process to something, then leave it and be able to shift focus. The test demands all your effort, with no immediate result to show for it. It makes you think quickly, so you have time for every problem. It doesn't take excuses, only answers.

Such is the daily practice of medicine. And these lessons are probably even more valuable information than the actual questions asked.