Lessons from a n00b - The end of the beginning

12 months of clinical rotations has swept by in the blink of an eye, and here I am, approximately 8 weeks away from taking the biggest exam of my life so far (my first licensing exam). It's a somewhat nostalgic time, and thus a good time for reflection. A few more lessons I've picked up along the way:

Lesson 1:
A lot of times, attendings say words that I try to avoid. For instance: the word titrate. Do most people understand what titrate means? I mean, even I have only dull memories of the word from my chemistry classes in high school. I've heard attendings and residents often tell a patient that we'll start them on a low dosage of a particular medication, then titrate the dose as we see how the patient responds. I suppose this isn't such a bad usage, since it's the physician side that does the titration. But sometimes they'll tell patients to "titrate" the dosage of over the counter medications, based on their response, and I always have to wonder if patients understand what they're telling them to do. It's interesting what words we do and don't use in various situations, and sobering to think how important words are in a field like this.

Lesson 2:
Neurology is kind of boring to me. Maybe that's because I don't understand the basics well enough, or maybe that's because it really is boring to me. Whatever the cause, I know for sure that it's not the field for me.

Lesson 3:
On a related note, I often felt, on neurology, that if we didn't know the exact reason a patient presented with particular symptoms, we'd chalk it up to a psychogenic etiology--which means that their brain, for some reason, believed that they were weak, or felt tingly and numb, or couldn't walk, or whatever, and so they experienced those symptoms--but there was no physical abnormality causing them. I had SO many patients who we concluded had psychogenic causes for their neurological symptoms, that now I'll always wonder if a person's neurological problems are psychogenic.

Lesson 4:
Contrary to what I believed at the beginning of this year, shelf exams really do get easier to perform on and study for as you take more and more. This is great news. The key, at least for me, was to repeatedly do practice questions until I got them all right...then rinse and repeat.

Lesson 5:
It's amazing how often you'll hear interesting stories from your patients, especially when you're treating outpatients. Almost every day when I was on family medicine, I'd meet a patient or two who had had interesting life experiences, had cool goals for the future, or were interesting in various other ways.

Lesson 6:
A year's worth of clinical rotations definitely teaches you a thing or two. It's amazing how much my confidence has grown, along with my knowledge base. This is a good thing.

Lesson 7:
Shingles comes in many shapes and sizes. So does mono.

Lesson 8:
I still have a lot to learn in terms of handling patients, especially those I would call "difficult." I was impressed by my family medicine attending's ability to entertain even the wackiest of patient requests without missing a beat. And she did it all while maintaining the patients' respect and trust. Hopefully this is a skill I'll gain with time and experience.

Lesson 9:
It's surprising how many people are vehemently opposed to the flu shot. It's also surprising how many people think that the flu shot "injects the flu into you" (not quite), a belief that implies they don't realize that most other vaccines also inject the disease-causing entity into you. For the record: the flu vaccine, and the majority of other vaccines, inject a dead virus, or an inert part of a bacterium, into you. The point is to teach your body to react against the disease-causing entity, without giving you the disease itself. However, since your body is supposed to launch a counter attack (which is what you're experiencing when you feel "sick:" fever kills bugs and helps the body fight infection better; runny noses are meant to flush out bugs living inside your nose, and so on), you often do end up feeling a bit sick after getting a vaccine, any vaccine. It sounds like more people get sick after getting the flu vaccine than after getting other vaccines, but that's probably because more people get the flu vaccine, more often, than any other vaccine. Basically, my point is that if I had to choose between getting sick after getting the flu shot, but never truly getting the flu, and actually getting the flu--I'd choose the shot every time. You should too. Just saying.

Lesson 10:
Time flies. I've said it before, and I'll say it again. Forgive me for the repetition. But these 12 months flashed by in an instant, and I'm sure the next 18 will do the same. At that point, I'll just be Dr. n00b.

Kangaroo Kitty Cat

I met a new patient yesterday, a 30-something year-old dad. He was coming in with an upper respiratory illness that involved a mild sore throat and a pretty nasty dry cough. While taking the social history, I asked him if he had any animals at home. The patient chuckled then, and his laugh suggested there was a story there, but all he told me was that he had one cat, though he's allergic to cats, and two dogs.
Later, when I re-entered with my preceptor, I noticed that the patient's cough sounded mildly wheezy, not unlike the cough I get when I'm around cats (I, too, am allergic). Our patient had been sick for a little over a week, and I wondered if maybe the cat wasn't responsible for his symptoms. "How new is this cat?" I asked. "Two months," he told us. "I guess getting the cat was your wife's idea?" we asked. Well, it's a handicapped cat, he told us. Its back legs are normal, but the front legs are stunted, so that the cat walks on its hind legs or scoots around on its bottom. The very idea was both comical and precious. "So your wife rescued this cat, I guess?" my preceptor ventured. Well, not quite. Our patient had seen the cat on a ranch while he was away for business. He took a picture of the funny little creature and sent it to his wife, saying "It's too bad they'll have to kill this cat." Of course, he received an immediate, vehement response: "You bring that cat home immediately!"
So now our patient lives at home with his wife, daughter, two dogs, and a malformed, adorable kitty, to which he's allergic. He showed us pictures of the thing. It looked like a feline velociraptor. "Look at how the silly thing sleeps!" he told us, showing more pictures. We told him to use an inhaler as needed, pop antihistamines regularly, and learn to live with the cat. His fate was sealed.
Funny the people you'll meet and the stories you'll hear.

Past Medical History

This morning I did an initial History and Physical on a patient who was new to my preceptor's practice. Before I went in to meet him, I learned his chief complaint (rash), and his name: Wilbur. Funny, I remarked to my preceptor. That's a pretty old-fashioned name.

When I walked into the room, I was greeted by a sandy-haired balding gentleman in a crisp white shirt, khakis, and boots. He was wearing too much cologne, which portended sleaziness, but his manner was respectful, professional. We talked about his rash for some time. It had been around for about 5 days, he was developing new spots every day, and they were slightly painful. I think it might be shingles, he said, Or Ramsay-Hunt Syndrome. Usually, patients with shingles complain of terrible pain, I told him. Have you been taking any medication for the pain? No, he said. I've dealt with a lot of really bad pain before, took extra strength Vicodin (Vikodayn, with his Texan accent) for a long time, and now I'm off all that stuff. My eyebrows raised at this hint of a significant medical history. Yeah, he said, I was taking morphine IV and everything, because of a plane crash I was in, but I'm getting off topic. Yes, I told him. We'll get to all that later.

A few questions later, we arrived at the Past Medical History, that fateful part of the initial H&P. Finally, he could tell me what had happened. It was a plane crash, he said, in the mid '90s. Right femur broken. Right arm nearly amputated. Right ulna lost proximally, right radius lost distally. Both shoulders dislocated, sticking out "right here," he told me, indicating his mid-clavicular region bilaterally. He was in the hospital for months, out of work for over a year, underwent 27 surgeries in that time and many more for the reflex sympathetic pain syndrome he developed as a result. He underwent intensive psychiatric therapy and rehabilitation to wean himself off of the megadoses of narcotics required to manage his neuropathic pain. Nearly twenty years later, he was fully functional, working and traveling without any hitches.

The most remarkable thing in all of this was that I never would have guessed at this incredibly traumatic history until he rolled back his shirtsleeves. The scars on his right hand were barely visible, and the hand was stupendously functional, considering the trauma it had undergone. The man sitting before me was shockingly unscathed, at least outwardly.

The interview over, I examined his rash, listened to his heart and lungs, and felt his distal pulses (To my surprise, the right radial pulse was intact). Then I smiled at him and said I'd be back soon with my preceptor.

In the hallway, I gave her a quick rundown of his rash and his storied medical history. A plane crash? she asked. Wow.

When we re-entered the room, after some cursory questions about the rash, she asked what I hadn't: So tell us about this crash. You've gotta tell us the whole story.

It's a long story, he started. (And long it was; we probably ended up listening to him for 30 or so minutes; at one point, his wife called the receptionist and asked why his appointment was taking so long.) Little by little, the details came out. A private plane, a complete engine failure right after take-off. 78 seconds from take-off to hitting the ground again in a terrifying crash. The other passenger 76 years old, hurt, but not as badly as our patient. Our patient lost a lot of blood. His blood pressure was 40 over nothing, a first responder said. Our patient, declared dead on the scene. Our patient viewing the entire scene from above, in an out of body experience.

And there were three people there, he went on. I remember them so vividly, but I couldn't possibly tell you if they were male or female. I just know they were there. One placed my head in their lap, another held up my feet, and a third held my left hand and fed me some cool water. Later, I saw those three people move the other crash victim's gurney into the life flight helicopter.

Once he arrived at the hospital, my patient remembers being wheeled down a cavernous hallway, with a white sheet covering him. He saw fluorescent lights and ceiling tiles flash past as his gurney progressed, until finally he passed through a set of double doors large enough for all of humanity to enter at the same time. On the other side, he saw his wife in her wedding dress, his kids in their Easter clothes, and his father in his coveralls lined up along the right wall. As he began sitting up to speak to his family, my patient felt a hand on his left shoulder, pushing him back down. A voice said, "Lie back down. There will be time to talk to them later."

Next thing my patient knows, he sits straight up in his hospital bed, lines and tubes coming out of many natural and artificial orifices. "Holy shit, God's hand was just on me," he says. From her chair to his left, his mother turned to him and said, "There you are, son. I was wondering when you'd come back."

In bits and pieces, my patient learns that he's been unconscious for days. The doctors and his family had no idea if he would regain consciousness, no idea if he would be the same man he was before. But he has and he is. Over the next year, our patient is "put back together" by a brilliant surgeon who gave him back full function of his right arm, hand, and leg. He suffers from reflex pain syndrome, taking megadoses of Vicodin and other opioids, just trying to stave off the pain. Eventually, he undergoes intensive inpatient rehab and gets off the narcotics for good. Years pass, and now he sits before us, mildly distressed by shingles.

By this time, over half an hour has passed, and my preceptor and I have exchanged many a quick glance communicating anxiety over the increasing length of this patient encounter. There are other patients out there waiting for us. But our patient says, "I'll just tell you one more thing, and then I'll finish the story, even though there's much more to it," and we say all right. He needs to tell this to us.

A couple years ago, our patient entered a local grocery store in search of a squeegee for his shower. "I know, you're wondering where I'm going with this," he assured us as our eyebrows raised skeptically. "But don't worry." After searching the store himself with no luck, our patient asked a little old man working at the store if he could help him find the squeegees. Why sure, the little old man said. But, he said, glancing at our patient's scarred right arm, what happened to that arm there? A plane crash, our patient said stoically. I bet that's a good story, the little old man said gamely. Why don't you tell me about it while we walk? And so our patient related the whole tale to this perfect stranger. By the time they reached the squeegee aisle, the tale was nearing its end. The little old man cleared some space on a low shelf, and they sat together while our patient told the part that bugs him the most. "Whenever people hear this story, they look at me (and here, he squinted his eyes in a way that said goshdarnit I'm sure of it) and say, God saved you for a reason. You have a purpose in this life. But that's the whole problem. I don't know what my purpose is. Here I am over 10 years later and I still don't know what I'm supposed to be doing. God never told me what He wanted me to do," our patient bemoaned. The little old man put his hand on the patient's shoulder, said "Yes I did, son," and walked off.

Here our patient choked up for the first time, and my preceptor and I exchanged a look altogether different from the ones before. This was a special moment, a moment neither of us was likely to forget. Moments like these remind me how lucky I am to be in the medical field. Being a physician means being let in on the most intimate details of strangers' lives. People trust you immediately, and tell you things they don't tell others, even those they love and know well. It's a position of immense power, and one that keeps me in touch with my own humanity. For this I am grateful.