Food Chain

Medical student : plankton :: attending physician : Great White shark

And I guess resident physicians would be...barracudas?

Medical school is 4 years. You get your M.D. and then train some more in residency, where you are called a resident. Your first year in residency is called your intern year, and you are called an intern. All interns do the same thing no matter what field you want to go into. They take care of the patients in the hospital, making phone calls, calling consults, nagging the nurses, and writing notes in the charts. Sometimes they have to go to clinic to see patients, which they hate (especially the surgery interns, who prefer their patients anesthetized).

When you are a third year medical student as I am, you are the bottom of the totem pole. Nobody is below you on the ladder. Even the lady sweeping the floors knows more about the hospital than you do, at least geographically. The nurses know the protocols better than you. The attendings know the medicine better than you, and half the time you are terrified of them. The interns are so damn happy to not be at the bottom (though they are only one rung up) and are generally kind to the students.

The residents are the wild cards on the medical team. Some residents love to teach and help students learn. We looove this kind of resident.

Other residents are like the overlords. They feel they are getting some knowledge under their belts, and love bossing the interns around. They also love to lecture medical students in the most irritating pedantic fashion. This is my new resident, and needless to say, he sucks.

Yesterday we saw a patient together--a new medical admission from the clinics downstairs. He told me before we went in that he had only 20 minutes to talk to the patient and do the physical exam, and that he wanted me to do it. Fine, although 20 minutes is not really sufficient, but I get it, he's busy. I went along and asked the man the typical questions--where does it hurt? when did it start? how did it feel? how long did it last? have you had this before? did you take anything for it? what makes it better/worse? I also asked him questions about his past medical history and family history, since this patient was new to me and I didn't know anything about him yet.

After we took the history, my resident was checking his watch and looking annoyed, so instead of completing the physical head-to-toe as I normally would, I just rolled up the guy's pants leg to look at his leg (he had a possible blood clot). I figured the resident could get the info he needed to start his admission note and that I would come back later and get a more detailed physical and history.

Later my resident took me aside and the lecturing began. "Your history was a little too detailed; you don't need to ask too many questions here. We know what's going on, so don't bother asking about family history right now. We don't care about that." Hmm. News to me. I read that 80% of medical diagnoses can be made from history alone. And many important medical problems are related to family history. Since when is that unimportant?

"And furthermore, your physical exam should be more systematic. You need to go head-to-toe. Don't just jump to the leg right away." Ok dude. If you weren't breathing down my neck, glancing at your watch and shifting your weight from foot to foot for the last 10 minutes I wouldn't have felt pressured to skip half the exam. "And I didn't see you check for Homan's sign, so go back and do that later."

In patients with blood clots in the calf, they can have pain when you push their foot up towards their knee (so their toes point to the ceiling). This is called a positive Homan's sign. Unfortunately the sign is practically meaningless; you can have a clot and not have the sign, and you can have the sign and have no clot, and it doesn't help at all.

So I went back and did the Homan's sign, being an obedient medical student. I reported a positive Homan's sign this morning to my attending physician, to whom I must present the new admissions during rounds with the team. "You did a Homan's?! You know you can dislodge the clot by doing that maneuver..." Dislodging a leg clot can cause it to float through the veins back into the right side of the heart and into the lungs, meaning pulmonary embolism and possible death for the patient.

Thanks, resident!

Just a thought

This afternoon I was reviewing some guidelines and standards for my Family Med shelf tomorrow. One of them is to counsel any woman of childbearing age to take 0.4 milligrams of folic acid daily to decrease the incidence of neural tube defects should they become pregnant. (By the time a woman realizes she's missed a period or suspects she is pregnant, it is too late for additional dietary folic acid to play a part in reducing NTDs.)



Why not put that 0.4 milligrams into the birth control pills that most of the young women I know are taking? Not everyone who gets pregnant on the pill wants an abortion. Half of pregnancies carried to term are unplanned. That would be such a great idea...



Since cereal started getting fortified with folic acid the incidence of NTDs has decreased by 50% in Canada (probably similar rates in the US, but I'm too lazy to find the studies). There's some controversy about the fortification; some studies suggest a link between folic acid consumption and increased incidence of colon cancer. Others complain that fortifying with folic acid masks B-12 deficiency in the elderly. Why not throw a little B-12 in the cereal too?

Bless me, Doctor, for I have sinned

The more experience I get with patients, the more parallels I see between doctors...and religious clergy.

1. Patients are often afraid that their doctor will judge their bad habits.

Probably one out of three patients makes some snarky comment when I ask them to step on the scale in clinic. "Oh, I've been bad this week!" or "Can we skip this part?" or "It's my shoes, these shoes are soooo heavy!". Similarly, when I ask patients if they smoke, or how much alcohol they drink, I'm met with a series of comments. "Only when I'm stressed" or "Sometimes I need a break for myself" or "You have to have a little fun!".

I know many of them are afraid, as I ask my questions and jot down a note occasionally, that I am forming judgments about them and their lifestyle habits. My job is to find out everything I can about their health and habits so that we can work together to make that patient the healthiest individual possible. I don't spend time judging people; most of us are guilty of the same bad habits, so it's hard to point fingers at others who overeat or overdrink.

But I can't blame them. It makes me remember Confession Day in my Catholic elementary school. I was so terrified that the priest would remember me and my sins when he saw me walking in the hall the next day at school. Even though the head priest told us that he was only a "conduit to the Lord" for our sins to be heard, I had a hard time believing they didn't get together later at the rectory to talk about all of us :)

2. Patients tell their doctors things they don't tell their friends, family, or even spouses.

While I myself didn't have any salacious tidbits to impart to my priest at age 10, nor would I be honest enough to do so if I went to confession these days, many of my patients share very intimate and sometimes shocking details of their lives with me. This to me is especially strange, since I am not functioning as anyone's personal physician. I am merely the medical student rotating through that clinic or hospital service for 2 months maximum; I find it hard to believe that anyone could trust me enough or feel comfortable enough with me to share some of the things they do. Things about husbands' affairs, or their sexual habits, or their drug and alcohol abuse. Stories about reforming their lives after years of abusing themselves and their children.

Sometimes when I am listening to patients, it feels like I have 2 separate brains. One brain is thinking about what the patient is telling me, how it applies to their health, and what else I can possibly do to help them if I can (sometimes they just need a listener, and that's fine too). The other brain is busy going "Holy crap, holy crap, holy crap, I can't believe I'm hearing this" -- not in a judgmental way, but in utter disbelief that I am privvy to such secrets. More than once I've left a patient's room feeling more like their priest than their doctor.


3. We both wear costumes to work.

Maybe priests and other clergy have more costume-y wardrobes for work, but doctors come in a close second. Surgeons roam around in what basically amount to pajamas with pockets all day. The pediatricians all have little stuffed animals attached to their (teeny tiny) stethoscopes, or wear scrubs with little cartoons on them, pockets bulging with stickers and lollipops. The rest of us wear these ridiculous white coats with all manner of papers, instruments and pocket manuals jammed into the myriad pockets. I subject my coat to a hot wash with bleach every week, but still the cuffs look a little dingy and that bloodstain from trauma surgery refuses to budge. I wonder who the hell came up with white as the color for our coats?