Thursday, May 24, 2007

Medicine upside down

Sometimes in medicine, the hierarchy breaks down. Our etiquette, which rivals the military’s in its degree of structural rigidity, fails to inform our behavior in particular situations. It happened to me the other night in fact: I had a physician as a patient. That may sound trivial, but here’s how I ended up introducing myself to him: “Hi Dr. Lambert, I’m Wyatt, and I’ll be the medical resident handling your admission this evening.” Of course, he loved it, instinctively raising his chin and straightening out his posture in the gurney. By my addressing him as doctor and myself by first name, I had just indicated that I was planning on giving him the full respect that I would afford one of my own attendings. Not only would he receive the utmost politeness and consideration, but his opinion would be given a very heavy weight. From my few words of greeting, he knew that the full VIP treatment was his.

Myself, I felt more ambivalent about the tone I had set for our interactions. By addressing him as a superior, I had just conceded my power as the doctor over to him. This would be one warped doctor-patient relationship: he would be calling the shots and I would simply be carrying them out. In fact, in all actuality he would be his own doctor. The implications of this were still unclear to me, but I figured that basically I would run all of my orders by him while avoiding any uncomfortable questions or elements of the examination that I might otherwise have performed.

Directing your own medical care may sound nice, but I can testify that in reality, it’s not. For one, it’s impossible to see yourself objectively. To verify this, simply take a stroll around the hospital ward counting the number of bare buttocks that you see. Those nice hospital gowns that cover everything up so neatly in the front, it so happens, leave gaping holes in the back if even a single renegade string goes untied. Moreover, doctors are notorious hypochondriacs. When you know the constellation of symptoms for hundreds of rare diseases and see people sick with them on a daily basis, you forget that rare diseases are actually rare. If left to yourself, you’d likely cause your own drawn out death from bleeding due to excessive lab testing. Alaskans, already familiar with the concept of death by mosquito bite, know what I'm talking about.

Fortunately, this doctor was much cooler than expected, and he pretty much let me run the show. Having an attending physician asking and caring about my opinion felt really great and restored the standing that I had abdicated earlier. It turned out that he actually wanted to have a doctor, rather than be one, so we both ended up satisfied. In fact, the experience was so positive that next time not only will I keep the same introduction, I won’t even skip out on the rectal exam.

Sunday, May 13, 2007

Saturday Night Syndrome

One of my least favorite things about residency is the one-day weekends. If it wasn’t bad enough already, the one day off is marred by the certainty of work the next day. Most people are familiar with this feeling on Sunday evenings – knowing that a long and hard work week is about to begin and being unable to fully enjoy the evening because of it. To have Sunday Night Syndrome on a Saturday, though, is particularly painful. Everyone else is out living up the prime night of the week, staying out after hours with the comfortable knowledge of a late sleep-in and casual brunch coming the following day. You on the other hand are at home, stressed out about the next day and going to bed depressingly early. It’s hard to get used to.

The holiday season, they say, is the most active for suicide because seeing others happy and together intensifies loneliness. I know, I am supposed to be grateful to belong to this profession and to have an opportunity to serve. It’s just that sometimes that gift of service feels like a double-edged sword when it demands that you serve even when you’re not yet rested and ready.

Wednesday, May 09, 2007

Question and answer

Attending: How does heparin work?

It prevents clot formation by enhancing the action of anti-thrombin III. . . wait, heparin’s not a thrombolytic, it’s not supposed to break up clot, it just prevents more clot from forming. . . anti-thrombin III breaks up clot that’s already there so that can’t be right. . . wait, where the hell does anti-thrombin III actually act? . . it must inhibit thrombin. . . maybe it doesn’t break up clot after ---

Someone else: It activates anti-thrombin III.


Attending: Right. And how does plavix work?

It inhibits platelet aggregation. . . but how? . . . can’t be a IIb-IIIa inhibitor because integrillin and reopro are the IIb-IIIa inhibitors. . . but IIb-IIIa is the way that platelets crosslink so it must act somewhere on those receptors. . . hmm, could it act on fibrin or fibrinogen?. . . that doesn’t sound ---

Someone else: It impedes platelet aggregation.


Attending: Very good.

Thursday, May 03, 2007

Petits morceaux de France

I spent this last week in France, dividing time between Paris and Monaco, which explains why I haven't posted anything on my blog in awhile, and which led to these morsels of thought.


The yogurt in France is so creamy and delicious that it's no wonder they feel the need to ease their guilt by studding it with cholesterol medication. I'm just wondering what happens to a foolish American tourist who downs four cartons of the stuff all at once.


It's a good thing they don't have Coca-Cola Light in this country. I’m having a hard enough time controlling my Diet Coke addiction as it is without them throwing that dangerously tasty brew into the mix.


Beautiful old buildings that give Paris its characteristic charm and evoke the early 20th century: great for city ambience, scary as hospitals.


Getting rid of all public toilets in fact does not eliminate the human need to urinate.


I don’t understand the foie gras controversy. You could force-feed me baguettes all day long without a whimper of complaint.


The contrast between French waiters, whose tips are for the most part already included in the bill and who often seem annoyed to serve, and American waiters, who work for tips and really try to satisfy their customers, really speaks to the power of positive incentive. It makes me think that more positive encouragement and feedback in the over-critical world of medicine could go a long ways.


Smoke-free DC was a great idea. Air never felt so breathable.


Please tell me that fruit tarts count as one of my recommended daily servings of fruit.


It's possible to forget an awful lot of medicine in one week.