Highs and lows, and seeing what we expect to see

I’m back!  Where did September go? The dearth of posts has been the result of a period of ample time to write but lack of inspiration followed by a period of ample inspiration and lack of time, in the midst of the constant struggle to strike the right balance in my life.

Residency is a time of highs and lows.  At times, one feels surprisingly confident and competent, almost proficient, but then foolish and amateurish in the next moment.  Here is one of the lows.

I saw one of my clinic patients a few weeks ago who presented with a sore throat, cough,  and runny nose for a little over a week.  My impression from his history was that he had a cold, but  I dutifully checked him over from head to toe, looking in his ears, nose, and throat, listening to his lungs and heart. After finding nothing of interest, I concluded that he did indeed have a common cold.  I stepped out of the exam room to discuss the case with the attending (supervising) physician to whom I presented my findings and impression.  As a routine measure, she accompanied me back in the room to verify some of the key elements of the history and exam.  Feeling that this was more than a little unnecessary for such a benign problem, I stood by confidently as she also looked, listened, and felt. But as she listened to the lungs, she tilted her head to the side, and looked far off in the distance, obviously listening very intently over one particular area of the lung field.  ”He has some wheezing and crackles in the right base, don’t you think?”

Were I practicing alone, missing these lung sounds would not have harmed this patient.  Although the presence of this finding suggested a diagnosis of bronchitis rather than viral upper respiratory infection, and although we did give him antibiotics, there’s little evidence that antibiotics are necessary and people with bronchitis essentially always get better without them. Certainly, he would not have died without antibiotics.  But listening to the lungs is, as you might imagine, one of the most basic skills that even a first year medical student possesses, so missing such an obvious finding was humbling to say the least.

I could swear his lungs were clear when I listened to them the first time, but just minutes later, I too could quite clearly hear the abnormal sounds.  Did I just not listen hard enough the first time?  Maybe I just missed putting my stethoscope over the area where they were most audible? Or, maybe the patient coughed just prior to my listening and cleared out the secretions?  All of these are definite possibilities and unfortunately I don’t get to know the answer.  But, I have to assume that they were there and that I somehow failed to hear them.

More troubling, I was not entirely sure what to learn from this.  Listen harder next time?  It’s not as though I had made a  less than adequate effort or was rushed or careless with the exam.  No, instead I believe I fell victim to the most human of errors, seeing only what we expect to see.

In science we call this confirmation bias.  Confirmation bias is the tendency to search for and accept evidence that supports our pre-conceived beliefs and to ignore or reject evidence that opposes those beliefs.  Humans are susceptible to this in all aspects of our lives from our political views and religious beliefs to our favorite foods and movies.  Scientists take extraordinary means to avoid this bias by conducting experiments designed to disprove their own theories.  The practice of medicine, although not a perfect experimental science, can be approached in a similar way.  I thought this patient had a cold, and I performed my exam with the expectation of not finding anything.  If I had approached this patient with the belief that he had pneumonia, might I have been more thorough and deliberate when listening to his lungs, searching for evidence to support that belief? I’m pretty certain the answer is yes.

Having a healthy dose of skepticism about the beliefs of others is one thing, but being skeptical of your own beliefs is far more challenging and unnatural.  When taking care of patients, being your own devil’s advocate is exactly what is required.  In this case, there would have been no serious consequences to my missed diagnosis, but that will not always be the case.  Sometimes, rarely, it may be a difference of life or death.

Goals updated

Goals for July were updated.  Visit the Goals page to view them.

Surgery

I’m on the verge of completing my second rotation of residency: general sugery.  ”Why do you have to do a surgery rotation?” I’m often asked, not only by friends and family, but by residents in other specialties as well.  Family medicine is not a “surgical specialty,”  and my colleagues in other primary care residencies like internal medicine and pediatrics do not complete a surgery rotation, so why does family medicine?

1. Procedural skills.  Unlike internal medicine or pediatrics, the scope of family medicine training includes office procedures.  Many (if not most) internists and pediatricians will not sew up a laceration, open up an abscess, cut out a cyst or lipoma, or perform vasectomies, but these are all things that family physicians commonly do right in the office.  None of these procedures are very difficult, but they do require some basic skills such as suturing, familiarity with some basic surgical instruments and surgical techniques.

2. Recognition of surgical disease.  Many diseases can be managed without a knife.  But for some, the healing power of steel is needed.  Knowing when to consult a surgeon is an important skill for any provider who is on the front line.  Some common diseases that demand surgical intervention include:

• Pus. Abscesses must be drained of pus.  They will not heal with antibiotics alone.  There is a lot of pus out there.
• Hernias.  A weakness in the abdominal wall allows guts to protrude through it.  No drugs to fix that.  Usually the defect is sewn closed and a flat synthetic mesh is placed for reinforcement.
• Gallstone disease.  ”Bread and butter” for the surgeon (they keep them in business), gallstones can be completely benign, or seriously life-threatening.  Lots of people have them (1 out of 5) and they have the potential to cause disease or injury in 4 different organs (gallbladder, liver, pancreas, intestine)!  The treatment is generally always the same–go to the source and take out the gallbladder.
• Appendicitis.  The little vestigial worm hanging off your colon can kill you.  Almost 1 in 10 people will develop acute appendicitis at some point in their life.  Cutting it out is the only effective treatment (and is extremely successful).
• Cancer.  Eespecially breast and colon, because these cancers are often detected before they have spread, and therefore, cutting them out is often curative.  Other common cancers, such as lung, are often discovered long after they have already spread and surgical removal of the tumor doesn’t help.

3. Familiarity with common surgical procedures.  It is unlikely that I will ever perform an appendectomy, cholecystectomy (gall bladder removal), or an open breast biopsy, but I will undoubtedly have many patients who will undergo these procedures.  Although most surgeons do an excellent job of explaining and addressing patient concerns, patients invariably have more questions that often get brought to their primary care provider.  Having some familiarity with the risks, benefits, and complications of common procedures is part of the scope of knowledge a family physician should possess.

Hard working

I’ve never worked this hard.  It’s only been one month, but it is already apparent just how much harder I will be working over the next few years than I have ever worked before.    As a medical student, I had spent 2 years pretending to be an intern, and I thought I had it down.  But there are at least 3 key differences between being an intern and being a student.

1. No one double checks your work.  As a student, 99% of everything you do is repeated by someone else.  Whether it’s your history, your physical exam, the orders you write, the documentation, almost all of it is duplicated by a supervising physician.  Of course I still have supervision as a physician-in-training, but as opposed to 99% duplication, it seems like there’s only about 10%.  That means extra vigilance on my part and an added layer of responsibility if I miss something.
2. Volume.  As a student, you are typically assigned a small number of patients to follow.  As a resident, you are expected to be a work horse.  My first month was in the emergency department, often evaluating and working up four or five patients simultaneously (the more senior ER residents frequently carry seven or eight or more at a time, boggling my mind).
3. Real responsibility.  As a student, you may write notes, orders, see patients, but if you don’t, someone else is responsible for covering what you don’t get done.  Not anymore.  If I don’t do it, it simply doesn’t get done.  That means zero slacking off, delivering 100% on commitments that I make.

I’ve quickly become to feel like a machine at work, powered not by my own volition, but simply by the demands of the environment.  This leads to a certain sense of disembodiment, as though I am watching all of my actions from above, but not directly motivating them.  It almost makes the work easier, as I don’t feel the need to exert willpower to get the job done. I can just watch myself get it done.  But with that comes a degree of depersonalization, and I hate to say that I now can understand the vacant stares I’ve seen on residents’ faces over the last two years.  They weren’t deliberately ignoring me, uninterested, or rude, they were just working hard.  I hope that my realization of this will allow me to fight back against such mechanization and help me to continue to be a human being throughout this process.

Goals

Pauline Chen, MD  had an interesting piece in the New York Times a couple weeks ago about residency training.  She recounts a story of how she lost control and snapped in grocery store line under the stress of her training.  Experiences like this are not uncommon, she explains, and are often the result of burnout caused by the imbalance of personal and professional life that residency often demands.  She speaks with Dr. Neda Ratanawongsa, lead author of a recent study on resident burnout from Johns Hopkins.

“The [residents] who are happier,” Dr. Ratanawongsa observed, “are the ones who have held on to one or two things and have said, ‘I’m not just another resident. I play the guitar, I run races, or I go home to family.’ They don’t do these things to the same extent as they did before residency, but they do them enough to maintain a sense of self.”

Robert Centor, MD offered his advice over at DB’s Medical Rants:

While in training, I always had 3 priorities for my off time.  I played basketball most every off day – even post call.  As an addicted basketball player during that time, I knew that i need the sweat.

I always read fiction.  For some reason I did not feel guilty that I did not just read medicine.

I always listened to music.  Music made me happy then, and makes me happy now.

And my major priority was my wife, and during residency my daughter.

All of this talk of burnout and balance has gotten me a little worried myself.  Our chief residents advised us during orientation that if we could survive this year just with our personal relationships intact, we should consider it a success.

Though I have just barely begun to experience the stress of training, it is clear to me that establishing priorities for my personal life is going to be key to maintaining some happiness.  Setting a few concrete goals seems to be a reasonable way of establishing those priorities (and someone has told me many times that writing down your goals goes a long way towards achieving them).  Here are my goals:

1. Staying close with loved ones.
- I will call my family at least once a week.
- I will talk to my girlfriend in some form at least every other day.
- I will talk to old friends at least once a month (blog comments count!)

2. Fitness/health
- I will do some form of exercise at least 3 times a week, even if only a short jog.
- I will cook at least two meals a week

3. Personal enjoyment/entertainment
- I will  read at least 4 books for pure pleasure this  year
- I will watch Lost, The Office, and 30 Rock
- I will watch one or two movies  each month
- I will write something on this blog at least once every two weeks (hopefully more frequently)

4. Recreation

- I will do something fun outdoors at least once a month
- I will try one or two new recreational activities each year

I will be creating a Goals page to track these goals and keep myself accountable.  Wish me luck!

Day one, as easy as ABC

“HELP! We need a doctor in triage now!”

I glanced up from the computer where I was fumbling my way through the electronic medical record (EMR).  I’d heard this kind of panicked beckon dozens of times before, as a medical student, and I’d learned to calmly look around and make sure that the nearest doctor was hopping out of her chair to run in and save the day.  But as I turned my head from side to side, I realized that the back side of fast track was completely empty, save for myself and the flushed-in-the-face nurse, staring me square in the eyes, and pointing towards triage.

This can’t really be happening, I told myself.  It’s an intern’s worst nightmare: your first day on the job, there’s a catastrophe, and you’re the only “doctor” around.  Except this wasn’t a nightmare.  It was my first day, just a few hours into my first ER shift, there was a catastrophe, and I was the only doctor to be found.  I stuttered as I stood up from my seat, considering whether I should log off the EMR as we were so persistently reminded always to do during orientation just a few days earlier.  In retrospect, it’s clear where my priorities should  have been, but as you might imagine, I was a little nervous.

I ran down the hallway, following the nurse who had fetched me.   What am I doing? I asked myself as I rounded the corner.  Is this really happening? Do they really think that I’m a doctor? The thought amused me and I smiled as I fought back the urge to laugh out loud at the absurdity of my being called in to help.

In triage, writhing on the floor in pain was a young man, perhaps a few years older than me.  ”Oh, God, it hurts!” he screamed out.  I knelt down beside him, introduced myself, and asked him his name.

“What’s the matter?” I asked.

“I feel like I’m going to die!”

There are not many things that a patient can say that truly scare you, but in medical school you are taught that this is one of them.  When a patient says this, you listen and pay attention.  But pay attention to what? I wondered as I sat there beside him.  How do you approach a chief complaint of “I feel like I’m going to die!”?  Do you ask questions like, “When did you start to feel this way?” or  ”Do you feel this way all the time, or does it come on go?” or the dreaded, “On a scale of 1-10, how much do you feel like you’re going to die?”  Of course, a detailed history of the present illness is completely inappropriate in this setting.I glanced around the room.  Several other patients and family members had gathered around.  They were all staring at me.  Holy crap! They all think that I actually know what I’m doing! What am I doing?

The approach to medical emergencies almost invariably starts with an assessment of the “ABCs”–a handy acronym that tells you in a prioritized fashion, how to approach an emergent situation.  Fortunately, I remembered these three letters before I launched into a series of questions about the patient’s family history.  Oxygen is food for your tissues.  Without it, they die rather quickly.  It is the first order of survival.  The ABCs assess a patient’s ability to get oxygen from the air into the blood and circulated to the tissues.  A is for Airway, which is most important.  You can have a perfect set of lungs and a perfectly beating heart, but if you can’t get oxygen into your lungs, it doesn’t matter.  To do this, you need an airway.  This gentleman clearly had an airway as he was screaming at me.  This also meant that he had the B, which is Breathing.  If your airway is open but you don’t inflate your lungs, you don’t pull any air into your body.  Your heart can pump to its heart’s content (excuse the pun), but again, if no oxygen reaches the blood vessels in the lungs, it’s no use.  The C is for Circulation.  If A and B are in place, but blood can’t circulate, it does no good. Circulation is quickly assessed by checking a pulse.  This gentleman had a strong pulse.

By this time the nurse had started to take the patient’s vital signs, which provided a little bit more information.  His heart rate was accelerated, but not dangerously so.  His blood pressure was normal–another confirmation that his circulation was good.  And his oxygen saturation–a measure of how much oxygen is in the blood–was very high.  Although I had no idea what was wrong with this gentleman, I relaxed a little bit, knowing that he was unlikely to expire in the next few minutes.  But the patient was still screaming in pain.

Fortunately, at this time the attending physician (the experienced, supervising physician) had arrived and took over the assessment.  I had survived my first disaster, which of course, ended up not being much of a disaster at all (though the patient ended up being quite sick, he will likely do well).  Later on, as I went back to my charting, I realized that I had actually handled the situation more or less appropriately.  When I needed it, my training kicked in and told me what to do.  Not too bad for my first day, I thought.  But I quickly reprimanded myself; I may have done well this time, but there are still many mistakes to be made.

The “doctor” will see you now

One month ago, I became a doctor. Officially, at least.  Until my name was read aloud, with the appropriate title, and I walked across the stage and grasped my diploma, I was only a lowly medical student.  I expected to feel immediately different, as though simply having the letters “M. D.” bestowed upon the end of my name would instantly transform me into the sharp-witted yet compassionate, quick yet contemplative, tall and devilishly handsome doctor I always hoped I would be.  But at the end of the day when I looked in the mirror, I was the same average statured, average looking, too often too slow or too fast, sometimes crass and not nearly witty enough guy that I was that morning.  Sure, I was a “doctor” technically speaking, but I resembled nothing of the seasoned, experienced, and proficient Doctor (capital D) that I had envisioned when I started medical school four years ago.

Of course, as one might expect, the transition to becoming a Doctor does not happen in an instant, or even over a year, many years, perhaps even a decade (I’ll let you know when I get there).  It certainly bears no correlation with the appearance of “Dr.” in front of your name or the sudden lengthening of your white coat.  You realize this long before graduation, perhaps as early as the first year of medical school when you begin to get a sense of the seemingly infinite amount of knowledge and skills to be mastered.  Although four years in medical school sounds like a long time, you often feel that you have barely scraped the iceberg.  Still, a part of me was holding out some hope that a magical Cinderella transformation would take place on graduation day.  But, alas, my fairy godmother disappointed.

All of this would be rather trivial if it weren’t for one small problem: in a matter of days, I will have to walk into a patient’s room, stare him square in the eye, and tell him with a straight face, that I am his doctor.  And although that will be true in the technical, legal sense, I can’t help but feel like I’m going to be pulling the wool over his eyes, just a little bit.  Because even though I will be his doctor, he will most likely be thinking that I am his Doctor–something that I assure you I am entirely unprepared to be.

Contrary to what you might expect, medical school does not teach you how to practice medicine.  Rather, it dispenses to you much of the raw knowledge that forms the foundation that is drawn upon in the practice of medicine.  And although you do learn the skills of patient interviewing, examination, diagnosis, and treatment, and often play make-believe and pretend you are a doctor, you seldom if ever have any real responsibility.  The closest you get comes during your fourth and final year of medical school when you spend a month doing a “sub-internship” in your chosen specialty (sub meaning below, internship, referring to the first year of residency).  During this month, you make-believe that you are an intern (first year resident) and are generally treated as such.  By the end of the month, you actually feel borderline competent to start residency.  The problem is that for most medical students, that month happens early in the senior year and is followed by the long process of residency application and interviews.  By graduation, it’s been many months since the sub-internship, and while you accomplish a lot during that time (passing boards, graduating, getting a job),  it’s had relatively little to do with learning more medicine or sharpening your doctoring skills. Considerable brain atrophy is usually the result.  On my first day of residency, it will have been nine months since I had anything close to real responsibility for a patient.

And so I can’t help but a feel some degree of fear and trepidation as I will soon be put on display to demonstrate just how unprepared I am for the responsibilities awaiting me.  My fumbles, foibles, and frustrations will be impossible to hide from my teachers, colleagues, the nurses, nursing assistants, medical students, technicians, and even the housekeeping staff.  This I have to accept; it’s unavoidable.  My real fear is that I will reveal my inadequacies to my patient and lose his confidence.   More than anyone else, I want my patient to believe in me and trust me, even if he probably shouldn’t.  At the end of the day, his assessment of me is the only one that matters.

Allow myself to introduce…myself

After years of mulling it over and a couple of false starts, I’ve finally convinced myself to start a blog, for real this time.  I’m a 27 year-old, newly minted medical doctor (MD), who will be starting my family medicine residency training in just a few days.  Here I plan to blog about my experiences as a physician-in-training and any other personal or professional issues that happen to interest me.  The demands of residency will probably keep me from posting more than once a week, if even that often, but, I figure something is better than nothing!