Not actually like death panels at all

Hello there! It has been pointed out to me by, uh, all 2 people who read this blog, that I have not posted a new entry in quite some time. Well, I am now studying (“studying”) for Step 2 CK (more on that later), so clearly this will cause an exponential increase in the number of blog entries! I mean, I can’t study all the time. And since I’ve gone through 3rd year, I’ve developed some sort of medical ADHD/narcolepsy, where I fall asleep if I’m sitting quietly for more than 10 minutes at a time, but also try to do 13 different things at once. I’m a medical marvel!

Anyway. A few weeks ago, Tim asked me about my opinion on universal healthcare (or the expansion of healthcare coverage, whatever you want to call it, because the current bill making its way through the Senate is not what I envision universal healthcare to be), so here it is!

A few months ago, I was talking to someone else — a Canadian! — and she was talking about how dumb American Senators get it all wrong when they’re talking about Canadian universal healthcare because they don’t even KNOW about it, and who are they to slam universal healthcare when they’ve never even had it themselves, etc. And that’s true, people twist the issue of universal healthcare and say dumb things they don’t know about. But, I think that’s true in both ways — my liberal friends and those in the universal healthcare camp oftentimes are very single-minded about the universal healthcare system, and talk up the Scandinavian/Canadian/British health systems like they are the greatest things on earth, with no problems. And you know what, I think they are better systems in a utilitarian sense (more on that later), but I have to say that no system can be flawless, or else every country would have adopted it by now. Great Britain is still a constitutional monarchy, which to me seems CRAZY because obviously democracy is the way to go, RIGHT? Or not, because the monarch still fulfills some sort of role that is needed. Where was I going with this? Not to a political science or international affairs discourse, that’s for sure.

Right, so I wanted to talk about healthcare, and I wanted to talk about my experiences with it, both from a theoretical point of view and from an anecdotal point of view. My theoretical background comes from a summer working full-time and a year working part-time (extracurricularly) on research for writing a universal healthcare plan for America. My anecdotal background comes from being my mother’s child (you’ll see) and being a medical student, soon-to-be-oh-please-please-say-it’s-over-soon doctor.

Let me start off by saying that I am a proponent of a universal healthcare plan for America. (Wow, that sounded very politico!) Call it whatever you want, either the true meaning of universal coverage for everybody, or the newer, less “scary liberal”-sounding “quality, affordable healthcare for all,” it’s all the same to me and I’ll agree with it, whatever you label it. I think all people living in this country should get the same basic coverage for medical care. What do I mean by basic? Basic is anything you need, especially primary care and oh my GOD, VERY MUCH SO preventive care.

Single-payer
Who pays for it? I think it should be single-payer. If you want to set up a private company that handles it (don’t do it!), I’d be for it as long as it was VERY ACCOUNTABLE for the money, and we’ve all seen how well private companies have done with accountability lately (answer: not at all). Obviously, the single “company” that has the most stake would be the federal government. Some people make the argument for state-based single-payer, but I’m not interested in talking about that because it feels like discussing the trees and forgetting the forest (not to mention, well, it’s a hassle and difficult if you move states, or if you’re like me and are a permanent resident of one state but go to school in another), because I just want it to be publicly paid and publicly accountable.

Also, guess what? Success in healthcare should be measured in illnesses prevented, or lives saved, or morbidity/lasting ill-effects avoided, or increased life span. Success in healthcare should not be measured by money earned. The profit of healthcare is people, not pennies. (Hey, I should make that a bumper sticker.)

Privately provided
I think it’s best, for this country, for the healthcare to be privately provided. What do I mean? I mean that you don’t have to go to your neighborhood hospital to see the doctor that is assigned to you, like the way public school is done. I think that Americans are used to getting to pick, rightly or wrongly, which doctors they see. If it means they doctor shop until they find a doctor willing to use that prescription pad, then so be it. I’m not interested in those people. I’m not interested in Senators who can buy their own healthcare and concierge medicine right after buying another Porsche. I’m interested in the most common denominator: getting people to see the doctor before and when they need to.

That’s it. That’s my ENTIRE REASON for wanting this very complicated system. I want my patients to see a primary care doctor to screen for high blood pressure, heart disease, diabetes, cervical and prostate cancer. I want my patients to grow up learning good dietary and exercise habits. I want my patients to get immunized in a timely manner (actually, immunization programs are the one well-run aspect of primary care medicine that I’ve seen in my working at the general hospital clinic; them and prenatal care for the pregnant ladies) and screened for early childhood developmental problems. And when there’s a problem, I want my patients to get to see a doctor, and get the medication/treatment/surgery they need so that it doesn’t get worse. Because you know what? Untreated medical problems tend to get worse. Whoops. And if it takes private physicians to make people happy, and people don’t want to wait in a hospital clinic for a hospital’s resident physician (or, ahem, let’s face it, sometimes a 3rd year medical student), I totally don’t blame you. I hate working at clinic, anyway, and I wouldn’t go to a general medical clinic, either.

But you know what else? It’s SO HARD to get everybody to see the doctor when they need to. People don’t have time, people don’t care, people can’t figure out the healthcare system, people don’t have money, people don’t have a lot of things. I just think people should be able to have a doctor to see when they are sick. It’s not a lot to ask, and it seems like a reasonable right to ask for, to me.

For all?
When I was in Sweden, 3 Americans and 3 Swedes (sounds like the start of a joke…) got to talking about “rights” that the government must provide its citizens. Did you know that in Sweden, apartment buildings must, by law, have free washers and dryers for its tenants? Because everybody needs clean clothes! Did you know that in Stockholm, you as a citizen can go into one of three “vaccine” clinics and get checked up and get vaccinations, including costly travel vaccinations and malaria prophylaxis, for free, because you need it? THAT SOUNDS CRAZY to me. Crazy awesome.

But the problem with this awesomeness is that it costs money. Your money. 30% taxes, to be exact. So, if you are a retail manager, as one of the Swedes was, you make upwards of $60,000 a year! That’s so much money, you say! But most people are paid about the same amount. And you all pay 30% of that to taxes, for your free laundry and your travel vaccines. And you know what, that is a super set-up for us all, but it’s not a better set-up for me, myself.

This brings me to talking about the utilitarian aspect of universal healthcare. Getting everybody to see the doctor when they need to see the doctor, and to prevent problems because of not seeing the doctor, is beneficial for everybody. It’s beneficial in the number of workdays not lost to sickness, beneficial in the amount of money saved because diuretics for treating high blood pressure is cheaper than embolization or rehab for responding to uncontrolled high blood pressure that causes a stroke, beneficial in that the average lifespan of our countrymen will increase. It’s good for all of us. But it’s bad for me, singly. It means that I can’t get my appointments when I want to, because I have to wait in line. It means that I’ll have to pay more to get more-than-basic care. (I can’t even think of more examples of how it’s bad for the individual, it’s such a stupid argument against universal healthcare.) Oh, right: most importantly, it means that I am not a special little snowflake.

Honestly, I think that this is sometimes the root of the biggest hump (mixed metaphor, ahoy!) in getting Americans to come around to the idea of universal healthcare. Americans have this idea that healthcare is something they buy, so they comparison shop and price shop (for real!) and demand certain privileges like they were shopping at a Target. And doctors have responded: the last two offices I was in were private orthopedic surgeons’ offices, and they all had websites touting what they could do for you and fancy business cards and pens to give out. And multiple doctors have pulled me aside and discussed how they’ve had to become businessmen in order to stay being doctors. I did not sit through 23948 hours (appx.) of biochemistry to end up in sales.

It has also been mentioned that the American Senators who were talking about fearing universal healthcare cited the point that universal healthcare (or, to scare us, opponents now call it “socialized medicine”) might mean we have to wait a long time, or never get surgeries/procedures unless the situation is dire, that it means the end for elective or semi-elective procedures. I think this is true, in that there will be longer waiting lists, because oh, now everybody who needs a procedure is going to get it, instead of just the ones who can afford it/have insurance (see: above paragraphs regarding what’s best for us versus what’s best for me). This is why I think that any universal healthcare system setup in this country has to give an optional buy-out clause for people who want to and are willing to buy elective procedures, or buy a private doctor to do their surgery next week instead of next month. Fine, go ahead. If it means that everybody can still get the care they need, you go and buy-out all you want. Essentially, I want a buy-out system where you pay for extra care, instead of our current buy-in system where you pay for any care.

What really makes this argument for universal coverage, for me, is that something like 75% of personal bankruptcies that are declared, are in the wake of medical emergencies or expenses. (There was a study that came out in like, 2006, and I could find it, but I’m lazy and I know you wouldn’t slog through it). You know why? Because for all we bitch about waiting for the doctor or not getting appointments fast enough, when you are in a car accident, you get care. You get care, pronto. There is not a single ER or trauma doctor worth his salt who wouldn’t follow the same protocol for you, insured or not, if you came in through those ER doors strapped to a c-spine collar and on a gurney. We don’t even know your freakin’ name when you come in (traumas at my hospital are labeled in some theme per trauma, as in, the people in the same accident get labeled Alpha, Beta, Delta, etc., and the next trauma situation will be named Denver, Tucson, Portland, etc.), much less your insurance coverage. Family members of our patients don’t say to us, “Well, how much does it cost to reattach the finger? How about just one of them?” (which is why I smelled something fishy when this scenario was relayed in Sicko, but I can’t prove it). They say to us, “Please do what you can.” And we say to them, “We will try.” Nowhere does money come into play, and I have to say, this is probably why (if the study is true) 75% of our patients then go bankrupt — they spent the money because they had to.

My mom gets most of her healthcare in Taiwan. Taiwan has some sort of universal coverage with some buy-out options (honestly, I’m not too clear on the details). She had a ganglion cyst that wasn’t dangerous, just painful and annoying. When she went to her doctor last time, she wanted it surgically removed. They were like, “Well, it’s not absolutely necessary, so we can’t do it and have the government pay for it. But you could pay [insert large fee here] for optional removal.” And my mom was like, “HA! That’s what I’d pay in the States. Thanks, but no thanks.” Um. I forget where I was going with this story because it’s late and I’m tired, but I think it had to do with an acknowledgement that universal healthcare is not going to solve all our problems. Just our biggest problem.

The end. *curtsy*

Not actually like Grey’s Anatomy

It occurs to me now that I never wrote about my obstetrics/gynecology (ob/gyn) rotation that happened in November and December of 2008, in a different borough of New York City The ob/gyn rotation is a 6-week rotation about… babies and vaginas. Um, basically. I did my rotation at a school-affiliated community hospital that is in a borough of New York City, but feels like a world away.

Because it’s pretty far from Manhattan and the hours are long (6 AM to 6 PM, plus 6 24-hour calls), the department of ob/gyn rents out a nice apartment for the students. The apartment is about 6 blocks from the hospital, and it’s free housing for the rotation. The apartment is a 3 bedroom (well, 2 bedroom converted into a 3 bedroom), 1 bathroom place on the second floor of a house that was converted into apartments. During my rotation, there were 4 of us: 2 boys and 2 girls. I took pictures of the place to show my parents, who turned out to not even be interested. But here are pictures, anyway!

Our apartment is the one occupying the upper right 1/4 of the house.

This is the living room, which the front door opened into. Notice the tv hooked up to random illegal cable tv… courtesy of whichever medical students had been in the house prior to our arrival. On the wall, the white plastic thing with the blue border is a guide for cervical dilation. Someone had decided that that was what the house needed as its wall decorations, apparently.

Here’s the nearly-fully stocked kitchen. Med students from before our time have probably stocked it with random kitchen essentials like pots and pans and silverware (actually, I think the dinnerware and silverware were supplied by the ob/gyn director, from her own pocket). Interestingly, there was no cutting board and no soup ladles. But there were fondue forks. I mean, I guess that shows you other people’s priorities?

Here’s the bedroom that I had to share with Aubrey. We tossed a coin, and the winners got to have their own bedrooms. The boys were relieved because they didn’t really know each other that well, and Aubrey and I have been roommates since first year. At least, this is what they tried to say to explain why it was a better idea that we share the room instead of them — I say that it sucks to share a room with anybody, no matter how long you’ve known them. We’re in our mid- to late-twenties, for crying out loud. The curtains on the left are my addition to the house. I think you can also guess which side of the room is mine.

Anyway, it was like living in The Real World house (but less fashionable and more utilitarian), or living in the Grey’s Anatomy house (but without the random hookups). Since one of us was usually on call, it meant that mornings consisted of 3 of the 4 of us rushing around trying to get ready. I won’t lie to you — neither Aubrey nor I are morning people, so we both would lie around waiting until the last possible moment to start getting ready for the day. (I mean, when your day starts at 5 AM, you want to delay it as much as possible.) Since Aubrey and I shared a room, the boys never knew if we had gotten up or if we had slept through our alarms. But, our room was in the hallway between the bathroom and the kitchen, so eventually the noise would wake me up and convince me that I did need to get up.

I found out a few weeks into the rotation just how much I’d been depending on the random morning noises from the boys as a barometer for when to get up. That morning, both boys were out of the house — Jamie was still on call and Josh was driving in from Manhattan that morning. I nearly overslept (and Aubrey would have, too, because she was using me as a barometer of when she should get up) and had to run around more than usual just to get to work slightly late. When I told Jamie that I hadn’t realized that I needed them banging pots and microwaving stuff and generally being loud in the kitchen to wake me up, he confessed that some mornings when he was getting concerned about the lateness of the hour, he would stomp a little louder in the hallways and even wiggle the doorknob of our room, to make extra noise. How cute is that? Too cute.

Living in a house with my classmates during the same rotation also led to some pretty fun movie/tv-like moments. We would cook dinner and talk about our day, while standing in the kitchen and wearing green scrubs. We would talk about how much we hated our lives and how cold we were while walking to work at 5:45 AM. There were some very minor living arrangement squabbles, but not that many, and not any that any of us cared about, since we were all just sleep-deprived and only bunking together for 6 weeks, anyway (and 1 of those weeks was Thanksgiving, which doesn’t count as a real work week). Watching Grey’s Anatomy in the house was hilarious, as well, because of how unrealistic it was. During one episode, Cristina and Derek sit in the kitchen on a weekday morning and have a conversation. They sit in the kitchen while the beautiful morning sun streams in through the kitchen window. Some other episode had Meredith’s alarm clock going off at 6 AM (I think it was supposed to mean it was very early to be awake). You guys. The life of a surgeon, especially one in late fall, does not involve sunshine. It does not involve leisurely breakfasts and conversations in the post-sunrise morning. It’s one of running around in the dark, eating on the run, and morning conversations consisting mostly of grunts and clipped sentences. Of all the things I’ve seen on Grey’s Anatomy (uh, treating Clostridium difficile with fecal transfer? Didelphic uterus?), this was the most inaccurate representation of surgery and surgeons, like, ever. I was offended.

All in all, I really liked my ob/gyn rotation. About two weeks into the rotation, I concluded that I totally had some sort of natural Baby Repellent, and babies simply didn’t like to be born while I was on call. I also despaired of ever getting to catch or deliver a baby. Fortunately, though, the Baby Repellent must have worn off, because I did end up catching a baby and delivering two. It was awesome. It was even awesomer when the mom of one of the babies thanked me for not dropping her baby. You’re welcome, lady. You’re welcome.

The future looks… cloudy. With a chance of meatballs.

Claire has accused me of spending approximately 95% of my time since I’ve been on vacation, talking about Twilight. This is a patent lie, since I have clearly spent at least 30% of my time talking about David Cook, making people listen to David Cook, or singing David Cook songs in my newly allergies-induced sore throat-induced hoarse voice. When I’m not hacking up phlegm or blowing snot out of my nose, it’s quite becoming. You’ll just have to take my word for it, I guess.

Anyhoodle, today’s work involved so little Twilight or David Cook that it was appalling. I spent the day filling out dumb forms that we need in preparation for 4th year of med school. We received these forms earlier in December, during one of the few class-wide meetings that everyone is expected to attend. Mostly, the meeting sent me into a panic, because I had only asked, but not yet received, one letter of recommendation from my Internal Medicine rotation. I hadn’t even asked Dr. D from my Psychiatry rotation (maybe I was waiting to see my grade before I asked). This meant that when the Dean told us we should get at least 3 letters of recommendation in our files, I had… none. Cue the panic.

Fortunately, we then had exams and then I had to move and then I came home for break (and promptly picked up Twilight and did not emerge from my reading chair for two days), so I kind of forgot to panic. Today, though, I opened up the big scary manila envelope containing all the forms, and started filling them out. One of the forms is a “ballot” (their word, not mine) for academic advisors in your intended field. The form had three blank spots for possible fields, and three blank spots for preferred advisors. I filled in the three spots, and then added my own fourth line for possible fields. I KNOW. I’m just all over the place, and I don’t know what I’m doing. Anyway, the four specialties I filled in were radiology, surgery, ob/gyn, and pathology. I guess that now constitutes my Short List for Residency Possibilities. For this week, at least. My potential advisors included two professors who’d taught us, one I’d seen in action at the hospital, and some guy I’ve never even heard of. This can’t turn out worse than academic advising in college, though: in college, I bounced from advisor to advisor for 4 consecutive semesters until I put my foot down and started signing up at the department head’s office even though I wasn’t his advisee.

I’m also supposed to fill out a four-page “worksheet” providing my pertinent background information to the Deans. My favorite question on the first page is, “List your current hobbies and non-medical interests.” It’s interesting, the responses that this question evokes. My friend Adam’s reaction: “Who has time for hobbies? They pretend like when they were in med school they had all this free time. AND when they were in med school there was a lot less to know! Med school kinda blows.” (Do you now see the inherent danger in asking your local medical student how med school’s going? You risk getting this long, kind of angry, defeated rant that basically ends with, “med school sucks.” So, don’t ask, so that we don’t have to lie, okay? My favorite evasive response lately has been, “Well, it’s too late to quit now.” Wow, we are such downers.) My reaction: “As of now, my interests include cleaning my apartment so it’s not a dump, except that’s not a real hobby, because real hobbies are what you do after you’re done doing what needs to get done. Oooohhhh, what if I put down Twilight?!?!” Look, the question did specify “current” hobbies — Twilight is certainly the most current thing I’m into, unless you count eagerly anticipating the day David Cook songs are available on Rock Band, which I’m also currently doing.

Page 4 of the worksheet asks about college education, which sent me into peals of laughter, because I barely remember the things I did last week, much less up to eight(!) years ago. I’m so old.

This is what not-racism looks like

Thanksgiving vacation was great, except for the traveling parts. On the way to LA, I missed my flight because of ridiculous near-misses on public transportation (the Staten Island ferry, then the subway). Actually, I didn’t even miss my flight; I got to the airport at 6:02 for a 6:30 flight. Had I been able to check in online and print out my boarding pass from the hospital, I probably could have edged my way through security and onto the plane, especially since I had only carry-on luggage. But, the hospital has recently shut down Internet access at all the computers I could find, even in the library. I found one computer that had access, but no printer. I even had a flash drive and saved my boarding pass as a jpg, meaning to print it from a different computer, but literally could not find a computer that would recognize my flash drive. When I asked the librarian what was going on, all she said was, “Oh, that’s been happening.” And that was it.

Sometimes I wonder what would happen if I acted in a similar way to my patients. You say that you’re passing out all the time? Well, that happens. You say you’re throwing up blood? Oh, I’ve heard of that. I love that other people are allowed to not care about things not working, but doctors are not allowed to not care about things not working in people. I mean, that’s the whole basis of medicine: things don’t work and somebody’s supposed to fix them. Actually, now it just feels like customer service, albeit customer service with 16-hour workdays and, you know, actual solving of problems.

Anyway, public transportation is not as awesome as people like to pretend it is, things don’t work at hospitals, and I missed my flight. Luckily, there was another flight 2 hours later, and I was able to get a seat on it for the low, punishing rate of $50. Whatever. At that point, I went to the airport bar to get chicken fingers and lots of beer.

On the trip back to New York, my mom packed my carry-on luggage with a lot of food. A LOT of food. The idea was that I would eat some of it over the next few days, and the rest would keep well in the freezer. But, since I was taking it all as a carry-on, I had to go through security. When my bag went through the scanner, they called for a bag check. Fine, whatever. I had 30 minutes before boarding began on my flight, so I wasn’t too worried. The TSA bag check guy, however, took his sweet time going through every container of food, and asking me what was in each container. It was taking forever, but I was still nice about it, since I was pretty sure nothing was over 4 ounces of liquid, and also, it was FOOD, and I was about to take out a plastic fork and encourage him to taste test everything if it meant he would stop pawing through my stuff.

The kicker came, though, when he kept saying, “I’m just doing my job, ma’am. I have to do this.” I was like, “I know, it’s fine, just please hurry because my flight is boarding soon.” Then he goes, “I promise you, this isn’t discrimination against you because of your race, and I’m not judging you for the food you eat.” And I said, “I didn’t even think of that until you said it.” And you know what? It’s true. I live in a privileged world where I don’t usually encounter racism or prejudice in the bad way. The worst that happens is that people assume I play musical instruments (which I do) and that I’m good at math (which I’m not). Nobody is actually outright racist, so I generally don’t assume people are being racist. (There is much more to say about latent sort-of prejudice, like when people ask me if I “eat Chinese food every night,” to which I reply, “Yes, but at home, we just call it ‘food,’ [you dumbass].”)

The TSA guy was so awkward, too. He kept putting containers to the side and telling me I could start to repack them in their plastic bags. Then when I would reach for the containers, he would suddenly decide I couldn’t touch anything yet until he was done. This happened twice. The TSA guy decided that one of the containers that had a meat sauce was “too much liquid” and was suspiciously cold for food. When I explained that it was frozen because a 5-hour flight with frozen meat sauce makes it less likely to spoil, he very patiently told me that “when frozen things melt, they turn into liquid.” GENIUS. He wanted to throw it away, but I asked if I could leave security to hand it over to my parents, who were on their way back to the airport after they called wondering if I was at the gate yet. By the way, when they called me, I asked if I could pick up my phone while he was still searching my bag. His response was something like, “Of course. Why wouldn’t you be able to?” Oh, I don’t know, maybe because you freak out anytime I do something besides sit in the chair with my hands in my lap.

The TSA guy then called over his supervisor, and he says this to him right in front of me: “She says all this food is just for her, but I don’t believe her. This is way too much food for just one person.” The mind reels with snappy comebacks and questions in response to that statement. 1) Really, it’s all just for me. I’m just a total foodie and a fatty, seriously. 2) There is this much food because my parents really, really love me. 3) Who else could it be for? The tiny kitten hiding in my pockets? 4) What awful things could I do to the other passengers? Feed them delicious homemade Chinese food? That would be a new breed of terrorist. 4) You’re just jealous.

In order to give my parents the “unsafe” food, I had to leave security and would have to go through the screening again. And when I said that I hoped it didn’t take too long, the TSA guy said, “You could throw the food away. I have people throw away stuff all the time,” as though that would make matters better. As I was finally allowed to repack my things, I was saying that I hoped I didn’t miss my flight because this TSA search had taken a good 30 minutes, and it was now 8:55 and my flight was at 9:25. This dipshit’s response? “Well, you were already late.” UM, NO. Showing up at 8:30 for a 9:25 flight when you have no luggage and have a boarding pass is not late, it is on time. AND YOU KNOW WHAT, you are not helping.

I repacked my bag, and he says, “Follow me out — I can’t touch your bag once you’ve repacked it.” I haul my suitcase off the table, and stand there waiting for him. He then says, “GO! You need to walk in front of me!” SERIOUSLY, WHAT THE HELL? It’s not that I can’t follow directions, it’s that I can’t follow directions that are exactly opposite of each other. Repack your bag, don’t touch your stuff; follow me, walk in front of me; you’re on time, you’re already late.

I don’t hate security measures. I don’t begrudge TSA for trying to make flying safer. I like that they screen bags and scan people. But I cannot countenance incompetence that is made to seem like my fault.

In the end, my parents met me curbside and I handed over the “unsafe” food. I went through security again, went to a different line, and that bag checker did not even stop my suitcase this time. She didn’t even blink. I boarded my plane as the last person on board, crawled into my seat, and passed out for 4 hours before landing in New York. The only good travel-related encounter I had happened at 6 AM at JFK, when the guy behind the ground transportation counter saw my reaction to the $55 flat rate for taxis to Manhattan, and came out to the curb to find me and tell me about $21 SuperShuttle rides, then escorted me back inside the airport, called the shuttle for me, and kept an eye out for the shuttle driver when she arrived. It was amazing: in that busy of an airport at that inhumane a time with my people skills completely depleted and brain cells nearly all comatose, something efficient happened. That guy totally deserves a gold star. I think I thanked him, like, 5 times.

Psychiatry summary

I meant to write more last month when I was on my psychiatry rotation, so here’s a summary of those 6 weeks. Psychiatry felt a lot like being a camp counselor. It didn’t help that I didn’t wear my white coat, and instead had a long lanyard with my hospital ID, keys to the ward (it was a locked ward, you know), a pen, and a flash drive clipped onto it, and everything would jangle as I walked around on the psych unit. Oh, and I had a clipboard with notes in it, and one of my patients drew me pictures during an art therapy session, and I stuck the pictures in the outer window. Between the art groups, the recreational walks, and then interpersonal drama between patients, it was like camp for adults. Involuntary camp. With ID bracelets and big security guards watching your every move. But still, kind of like camp.

I had a patient who told me that the tv talked to him directly, that newscasters could see him through the tv, and then he confessed his masturbatory habits to me (it made me so uncomfortable that he, even through his social awkwardness and um, psychiatric psychosis, actually said to me, “I can tell I’ve made you uncomfortable, sorry,” and I was like, “UM… Yeah, okay, you’ve made me really uncomfortable, um… yeah.”). It was actually a hopeful story, because he responded really well to medications and psychotherapy, and was committed to continuing therapy, and had a family that was supportive, which are not things that other patients tend to have going for them. So, anyway, even though I had to sit through a really weird conversation about marijuana and masturbation, he ended up being one of my favorite patients on the rotation.

Only on a psych rotation can your patient tell you that he’s with the CIA and the Israeli government. Or, a patient can freak out on you and tell you she’s bisexual and wants you to hit on her. (That conversation, by the way, really did make me freak out until I told one of the nurses, and the nurse was like, “Oh honey, that’s just Janie* — she asks everybody that.” That was… oddly comforting.) I ended up liking psychiatry a lot more than I thought I would, as much as I feared I would, and now it’s on the short list of specialties that I would consider doing my residency in. Yikes. I have some issues with becoming a psychiatrist (mainly: the total lack of medical respect that other doctors give psychiatrists, and the idea of going to med school to become “just” a psychiatrist), even though pharmacological treatment of psychiatric diseases is a lot more medical/science based than I would have suspected AND treatment often involves the psychological and social aspects of patients and overlaps a lot with public health and public policy, and even law.

Psychiatry is just very exhausting, and moreso than in Internal Medicine or Ob/Gyn, you can’t always hold your patients accountable for their actions. Psychiatry can be even more paternalistic than Internal Medicine, given that the physician always has to maintain the therapeutic relationship and basically rise above any immature stunts or behavioral issues in order to preserve a good treatment relationship. And whatever the patient expresses is supposed to be encouraged so that we have an idea of what’s going on in their lives. And you know what, maybe I’m not a big enough person to rise above it and listen to some of my patients who cannot let shit go or stop being such whiners, and one day I would give in to the urge to yell, “OHMYGOD, WHATEVER, OKAY?” Maybe that’s one point for medicine — you don’t have to be exceedingly patient with people who just don’t get it, over and over. In Ob/Gyn, if your patient refuses to come in for pre-natal care, you don’t go find them and drag them into the hospital, and a lot of the time, the baby turns out okay anyway. In Internal Medicine, you try your best and at some point you can wash your hands of a competent adult patient, but in psychiatry, part of the reason these patients are in the hospital is because they literally are not allowed to make decisions for themselves and need people who won’t give up on them. So maybe what I’m saying is that I’d like to be a quitter. But then I think about how fun it was every day to go to work, to play mental chess with the overtly hostile patients, to talk with the cooperative patients who understood that psychiatric help is a type of healthcare need, to hang out with nurses who have seen and heard the craziest things, and I think maybe it’s worth it. And you know, the hours can’t be beat.

*Names changed to protect patients… and me.

Excuse me, your issues are showing

The things that people say or the way people react can give you little clues about what their lives are like. Sure, it’s possible that our conclusions are totally untrue and come from baseless extrapolation, but I prefer to think of it as secret peepholes into other people’s issues. Here, have some vignettes:

1. In our pharmacology lecture one day, Professor P started talking about the mechanism of action of Viagra. This was probably our 2nd or 3rd time learning the mechanism of action of Viagra, since starting med school. For some “unknown” [sacasti-quotes] reason, the professors in med school really love talking about how Viagra works and why it’s awesome. But Professor P’s quote during lecture really was the best of the bunch. Paraphrased, he basically said something like [you have to think of this being said in a Tennesseean, Al Gore-esque accent]: “Now, as men get older, the reproductive equipment doesn’t work as well as it used to. And it’s not anybody’s fault, it just happens, and it’s perfectly natural and Viagra really gives those people that function back.” Of course, those of us sitting in the audience (well, those of us who are awake) are a bit taken aback, and kind of looking down at our notebooks thinking, Um, awk-ward…

2. Last week in a lecture on psychotherapy, Dr. D started telling us about what couples therapy is. He says, “You would not believe the number of couples who do not have sex.” We’re nodding our heads in understanding and writing notes. He continues, “You would. not. believe. They are in committed relationships and they are partners, but when the lights go out at night, [sound effect that basically means, "nothing"].” We’re still nodding our heads, and he says one last time, “So many people. So many.” Gotcha, Dr. D. A lot of people, even the people we would least suspect. Ahem.

3. This week, one of my patients slapped another patient in annoyance and anger. My patient is a 30-year-old, autistic and mildly mentally retarded man who doesn’t actually have a mental illness, just difficulty coping with his emotions and expressing his feelings. In a sequence of events that feels like gentle irony, I ended up being assigned to this patient to work with him on verbally expressing himself, and helping him deal with feeling emotions in a healthy manner. I KNOW, you guys are totally laughing at the idea of me doing that, right? It’s like the blind leading the blind, you guys. Anyway, we were doing just fine, until I started talking to him about the difference between an “acceptable touch” and an “unacceptable touch,” meaning that hitting people in unacceptable, but shaking hands or high fiving is acceptable. And my patient says that hugging is also an acceptable touch. My response was, “Sometimes we have to ask permission to hug, before we just give a hug.” He didn’t understand and kept asking, “But WHY?” Without really thinking (but definitely in mild tones, because this guy is so sensitive I have to be really careful), I said, “Well, not everybody likes being hugged.” And he gave me this sideline look and said, “Sue, I am gonna hug you one day.” I’m a dead woman walking, you guys.

I know kung-fu

This is my favorite story from my Internal Medicine rotation, and it didn’t even happen to me. But, the hilarity and the moral of the story make it worthwhile to pass around.

The paramedics and EMTs often drive around our parts of the city, responding to calls or just looking out for people in trouble. One very hot mid-morning in July, they brought in an 80-something-year-old Korean man who we will call Mr. Kim (I never actually knew his real name). The EMTs found Mr. Kim looking unkempt and disheveled, diaphoretic (sweating), and leaning against a really fancy-looking apartment building. They brought him into the hospital, thinking he had dementia and heat stroke or dehydration. He had no ID or wallet, just a pair of keys. He spoke no English, only Korean. While in the ER, he kept trying to get off his bed and leave the hospital, and all he could say in English was, “I teach kung-fu!” All the doctors and nurses and ER techs were like, “Whatever, silly demented Asian dude who keeps trying to leave the hospital and doesn’t know what’s good for him,” and slapped on some arm restraints to keep him stuck to the bed. So, all afternoon he was sitting cross-legged and strapped to his ER bed, telling anybody who would listen that he taught kung-fu, and pantomiming random kung-fu movements at passers-by.

Finally, one of the interns on a different team was down in the ER to pick up his own new patient, and looked over and said, “Hey! That’s Master Kim! He taught me kung-fu when I was a kid!” Everyone went, “FOR REAL?!” And the intern said, “Oh yeah, he’s really famous — he teaches at West Point and stuff like that. His kung-fu studio is nearby. And actually, I think his apartment is close to here, too, because I went there once as a kid when he had a big party for our class.” So, of course, everybody is freaking out because maybe he’s not so demented and not so silly and didn’t need to be rescued.

Cut to a few hours later, when Mr. Kim’s daughter comes into the ER in search of him. She’d been looking all over town for him when he didn’t show up for his afternoon class at the kung-fu studio. She had called our hospital’s ER, but we didn’t have him listed as a patient because we’d spelled his name in some ridiculous way (this is the same hospital that gave me a nametag that read “Sue Change,” so it is not so surprising). She came in anyway, because she figured a name difficulty might have come up.

And the truth? The truth was, he had been disheveled and sweaty because he had just finished teaching his morning kung-fu class. That really nice building he’d been leaning against was his own apartment building. He couldn’t tell us any addresses because he just walked every day from his apartment building to his kung-fu studio and back. He had been trying to leave because he knew he had an afternoon class to teach.

The only thing that made it slightly less embarrassing for us and the profession of medicine was that he really was dehydrated on a disgustingly hot and humid day, and really did have some dementia that had gotten him in some trouble before. His daughter was very understanding and nice and our ER department was really apologetic, but still.

What I love most about this story is that he didn’t need us at all, but that health care people, in an act of hubris, patronizingly took him to the hospital to “protect” him and dismissed his talking as rambling crazy talk. This will forever be known as the time we kidnapped a patient from in front of his own apartment building, then restrained him when he rightly kept trying to leave. Whoops.

Psych out!

This post comes to you from scenic Valhalla, New York. For my 6-week rotation in psychiatry, I have temporarily relocated back to Westchester. I’m living in a sublet at a friend’s off-campus apartment, about 10 minutes away from school and the psych hospital.

The psych hospital (technically, the Behavioral Health Center) is a separate building from the main hospital. It has its own ER, and 3 floors with 1-2 units each (for a total of 5 units). Since each adult unit can hold about 22 people, and each child & adolescent unit can hold about 16 people, that means the capacity of the hospital is approximately 98 people (not counting the ER, where people can supposedly languish for up to 3 days while waiting for a bed). That’s a pretty impressive number of people.

I am on unit B2, which is an adult unit. For good and bad, we do not rotate through different floors or units during our 6 weeks. Instead, the unit you get assigned to is the unit you stay with the entire team. Similarly, the two attending physicians you get at the beginning are the same ones for all 6 weeks. One of my attending physicians is Dr. D, the same person who ran the Behavioral Science course from my first year, and he’s now the clerkship director for the psychiatry rotation. This is… a mixed bag. On the one hand, I specifically chose this hospital to do my rotation because I’d learned so much during my first year. On the other hand, I really didn’t want to actually be on Dr. D’s unit — he expects a lot from his students. I didn’t want to directly work on his team — I just wanted to be adjacent to the team, and reap the benefits by being at his lectures. I mean, on the first day, Dr. D asked us what the definitions of psychosis and delusion were! The nerve! I don’t remember things I learned over a year and a half ago! I barely remember Internal Medicine, and that was 3 weeks ago! And now he expects us to read and learn and answer questions, God, I am so put upon. (Ha, now you all are hoping I don’t become your doctor in the future.)

So, obviously, the bad parts of being on Dr. D’s team have to do with being forced to learn and work, which is anathema to other students’ experiences on other psychiatry teams. The good part is that I will learn a lot of psychiatry. Dr. D truly loves his job, and basically spends those 6 weeks trying to convert people to psychiatry. Dr. D himself started out at an obstetrician/gynecologist, and then realized that he’d rather do psychiatry.

One point in favor of psychiatry? On Friday morning, we went to court! We had some patients who took us to court, to petition for release because they were being held involuntarily in the psych ward. Not to be mean, but some of the best times come from when patients prepare statements or speak out of turn, because then the judge gets to see just how RIDICULOUSLY CRAZY they are. For real, one of our patients prepared a long statement that started off with, “I am with the Israeli government. I am also with the CIA. I am a lawyer, and I taught special education for [redacted] County for 7 years.” The judge interrupted and said, “Wait a minute… the Israeli government and the CIA?” The patient said, “Yes.” And the judge, bless his heart, replied, “Okay.” The patient’s request to be released was, thankfully, not granted. Court was really, really interesting. It’s not so much that I love lawyers or confusing law-speak (sorry, Erika, but I do not), but rather that this specialty of health care interacts so much with other parts of the world. You have judges and lawyers and social workers and doctors and patients and their families and the police who maybe were called to the scene, all working together to try to help the patient. It’s enormously gratifying to be part of this overall plan, and not just work in a vacuum of the hospital, where we release our patients after they are mostly better and hope they continue to heal. I suspect, though, that the recidivism (is that even the right term? probably not) of our sicker patients is very high, and that this chronicity of mental illness would start to bring me down over the years.

Liar liar, pants on… Oh wait, nevermind.

During my Internal Medicine rotation, I had a patient who was picked up by EMS after he fell down and couldn’t get back up. He was pretty bruised and incoherent, so the ER people went through his bags and found discharge papers from a different hospital in New York, dated 2 days prior. The point of discharge papers from the hospital is to summarize why the patient was hospitalized, what was done (test, imaging, surgeries), what was found, and medications that the patient has to continue taking (and for how long). The patient gets a copy of their discharge summary and is supposed to bring it to their primary care doctor. (There are, of course, plenty of patients who don’t have the means to have primary care doctors or who have to use the ER as their primary care doctor, but that is a rant for another time.) The listing of the “admitting diagnosis” is generally listed in order of importance, and can contain other existing medical conditions. For example, if a patient came in for a heart attack, but also had pre-existing hypertension and then was found to have early type II diabetes mellitus and high cholesterol, all of those would be listed in the discharge summary after the diagnosis of a heart attack. My point is, other medical professionals (oooh, I just got a tiny thrill when I realized I am part of that group) read the discharge papers and depend on them as a succinct and honest summary of what happened.

So anyway, we read the discharge summary from the other hospital, and the leading diagnoses were “ethanol intoxication” and “mechanical fall,” which is just a fancy way of saying he was drunk and fell down. Well, that would explain the falling down and incoherence, right? It would be consistent with his liver function enzyme tests, which basically said that he had alcoholic liver disease and some liver failure. Because alcohol withdrawal can cause seizures, the ER is pretty aggressive about medicating any signs of alcohol withdrawal. So, they started this guy on a higher dose of medications, but it meant that he was even more out of it, and more incoherent. After a lot of time, we finally figured out what he was trying to say, which was that he was visiting New York from Scotland, and was trying to get in touch with old friends and family members he hadn’t seen in a long time. Further, he didn’t know where they were, or where he had been in the 2 days between when he was discharged from the other hospital and when he was brought to our hospital. Some of the details that he gave sounded pretty incredible, like how he used to be a musician in a band, and in the British Royal Navy after that as a longshoreman, and that he hadn’t seen these family members in over 30 years, and that he was friends with some kind of famous people. We asked if he had had any alcohol to drink, and he said no. But, given the discharge papers and his liver enzyme profile, we were kind of like, “Yeah, right,” and kept medicating like he would go into alcohol withdrawal.

A few days of treatment later, we tapered him off the medications and his speech cleared up. Once it cleared up, the patient was really able to give more details about where he’d been while in the US, and then gave us phone numbers so that we could check out his story with friends and family in Scotland. He also swore that he hadn’t had alcohol in two years, but did say that he used to drink “a lot,” which, in Scottish terms, must mean a LOT a lot. Anyway, I also called the other New York hospital and got in touch with the physician whose name was signed at the bottom of all the discharge papers. When I got him on the phone, I asked about the course of the hospital stay. The last question I wanted to ask was if the patient had actually come in with “ethanol intoxication” as the cause of his falls. And the physician was like, “Um. No.” I said, “Oh, really?” And he said, “Actually, we did a urine toxicology screen, and he was clean for everything; no alcohol, no drugs.” Understand that the discharge summary is not written until the day the patient leaves the hospital. So I said, “Well, then why did you write that the primary diagnosis was ethanol intoxication?,” which came out a bit rude, but I think a fair question, given that he flat-out said that they’d written a diagnosis that the patient didn’t have, and which also led us think that the patient had been lying to us for days.

We also finally got in touch with the patient’s friends, who told us the patient’s stage name from his days in the band. And lo, Google search turned up plenty of proof, including photos and interviews and discographies of the band. So, in the end, here was the tally:
1. Patient says he was in a band: true.
2. Patient says he hasn’t had anything to drink: true.
3. Patient says he is in town to see family and friends he has not seen in years: also true.
4. Patient says he is childhood friends with semi-famous actor: true, and they were raised in the same town.
5. Patient says he was a longshoreman: well, I stopped checking facts at this point, because he was up 4 points to our 0 points, and there was no way we were going to make up this deficit.

Anyway, the moral of this story is, people might lie about the little things, but I think they don’t tend to make up hugely untrue stories about who they are, and what they’ve been doing for the last 2 weeks. Maybe this way, I won’t get jaded about how “all patients lie” and will listen to their stories, no matter how outlandish the stories seem. But then again, my next rotation is in psychiatry, so perhaps not for this next set of patients who say they are Batman or psychically connected to Oprah.

My hypochrondriasis is incredibly prescient

Hey, remember when I told everybody that an insulinoma would explain my Insta-Bitch? Well, all that self-awareness made me actually pay attention to insulinoma as a disease, even though it is very rare. It paid off, though, because it was the answer on my exam last week! The question was a case presentation of a woman brought in by her friend, because the woman had been eating tons and gaining weight suddenly, acting generally irritated and anxious, and had a headache lasting weeks. I was reading it and not understanding what the question was trying to hint at, and thought, “Huh, that sounds like me when I’m hungry…. OH HEYYYY, insulinoma is an answer choice!” Very exciting. Good job, unfounded paranoia!

For the record, though, I did not see an insulinoma while on my Internal Medicine rotation. So really, the exam was not representative of my actual Internal Medicine rotation at a certain Manhattan hospital. Had the test been truly representative, the patient in the question would have been a 50-something-year-old male, probably homeless, with hypertension or high cholesterol or poorly-controlled diabetes (or all three), current or former smoker/drinker, coming in for shortness of breath or chest pain after drinking all weekend/doing cocaine/losing his medications (all things that happened). It’s like a really tedious and frustrating game of Mad Libs.