Another open letter to clinical clerks

If your preceptor asks if you want to stay and see patients, the answer is always yes. Especially if it's not even noon yet.

When ER docs chat

"ya, my brother and I are both boys"

Thanks for clearing that up Tom.


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Just decoration

Nurse: patient has a fixed dilated pupil
Me: oh no!
Patient's wife: is that the glass or eye his own eye?

Laughter.


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My concentration is poor when I am observed

Ichibod Crane in Tim Burton's Sleepy Hollow pushes everyone out of the OR so he can perform his autopsy alone.

I wish I'd thought of that.

Instead, I bumble through my procedures with my preceptor looking over my shoulder, making me ill at ease, waiting for them to take over whatever I'm working at.

It's happened so many times now that all I do now is ensure that the patient isn't harmed when the scalpel or other implement is snatched away.

For someone who thinks she is strong at self critique and awareness, it's ridiculous that I didn't notice. Fortunately though, my new preceptor is much more in tune with learning. He pointed out that he makes me nervous and will, from now on, stay outside the room until and if I need him.

I'm so very lucky. And most importantly, about to get much better at my procedures!

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Am I really this cold hearted?

We get prepped in med school for dealing with the patient who for religious reasons refuses blood products. It's a scenario we discuss with each other and practice dealing with the anger we may potentially feel. Anger to what though? To a religion? To parents? To spouses? To Jehovah? Or even, heaven forbid, to our patient?
I'm not sure how this happened, but as a rule, as long as it is what my patient truly wants, I'm ok with it. You want to avoid pain meds because you want the chance to say good bye to your kids? No problem. You don't think going for a chest X-ray is worth your time? Your choice.
You don't want any blood products whatsoever, even if it means you may die within the week? Got it. Let me help you with some meds that will reduce your inevitable air hunger.
Speaking with some nurses today, I had the impression I'm not as affected as I should be by patients' choices. It seemed to me though, that they may be projecting their own belief systems and choices they would make for their own lives onto their patients'.
These nurses clearly care and give their patients compassionate, intuitive care. Because they care so much though, they are frustrated when the care plan they would have for a family member is not the one chosen by a patient.
I still cry with patients over beautiful moments and sad news. I touch them and try to make them laugh when appropriate. I respect their choices.




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How to annoy Dr. Impostor

I was asked to scrub in for a c section being done by two obstetricians. There is nothing for me to do in a case like this except keep sterile, which is what I did. It's frustrating.

During the surgery, Dr. Vulva asked Dr. Uterus what they should be teaching family medicine residents.

Dr. Uterus didn't understand.

"He means, what are the things that family doctors screw up all the time and annoy you."

"Exactly!" said Dr. Vulva.

He then went on to list everything that a family doc has ever done that annoyed him.

Why consultants feel a need to dump all they see wrong with other specialties onto the residents is honestly beyond me. I had the same experience in pediatrics and in the ED.

Implicit is that the complainer has never made a mistake that the other specialist has had to deal with, such as a consultation note that was illegible or so brief that it was useless.

They also tend to assume that the patient they are sharing with a colleague was in the same state as what they see in front of them. Illness is a changeable thing that presents differently during its course. The patient I saw in the ED last night may look quite different the next morning or even 2 hours later. We need to trust each other when we share our clinical opinions with one another.

It's time to stop the propagation of the gap between specialties. They make me too cranky.


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Oh. Boy.

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Exercise is fun

Spotted on my way to work: woman in her late 70's wearing a trucker hat and turquoise pajamas, cycling on the sidewalk with a huge toothy grin.
Wish she was slow enough to get a photo.

Now I'm wondering if she was a code yellow...

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Shirt seen in fracture clinic on a 78 year old man

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Doctor speak

"there's a lot of complexity there" - patient has a personality disorder +\- an addiction.

"this is an interesting presentation" - bask in my glory for I have diagnosed something Dr. House would have missed.



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Kids who are injured should be allowed to heal

Parents who are pushing them to get back to football, baseball, soccer, etc. need to hush.


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July 1

Good luck to all the new residents just getting started!

Best. Job. Ever.


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Patients are safe with residents

http://www.eurekalert.org/pub_releases/2012-06/bc-pcb062612.php

I'd still be careful on July 1.


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Patients say the funniest things

Oh no, I'm very happy to get my STI testing done so I don't feel like such a dirt bag.

Me: See you later alligator!
7 year old boy: (moves his arms like a big crocodile mouth snapping shut) RAWR!!!!

Things aren't right down there. I think I need the finger. You know - to make sure I don't have prostate cancer.

With the Nuva ring an everything else, I'm starting to feel like my vagina is a storage locker.





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Words to live by

After I feigned exasperation that my patient, like most others who are much older than me, wasn't able to provide a sample because (understandably) they'd gone before leaving home, he replied:
When you get past 60 years old, never pass a urinal; never ignore an erection.

Hear hear.




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"I said I loved you when we got married..."

"I'll let you know if it changes."
~ male patient describing his marriage

So many of my older female patients complain about not being sure if their husbands still love them. These couples have fallen into routines that make intimacy a tiny part of their lives. I ask what things he does for her doing the day - it'll be things like bringing coffee to her or killing spiders. I remind my patient that her husband is doing these things because he loves her.

It would be so much easier though if he just said it.

My advice to all these couples getting married this summer - please ACTUALLY tell each other you love each other regularly. Just do it. Please.




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Grief

People try so hard to be helpful with those dealing with the loss of a loved one. They hate to someone they care about in pain.

My advice to anyone in this situation - "should" is a bad word. You mean well, I know, but telling someone they should take dance lessons or should get out more or should lay down and cry is only adding to any guilty feelings they already have.

Instead, if you know of someone who found dance lessons helpful, "I know my friend Sally found dance lessons got her out of the house and gave her a chance to talk with people who didn't know Stanley. I don't know if that's the sort of thing you like, but I know it made Sally happy." Now your friend Sue doesn't feel she's letting you down if she doesn't want to tango.


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Overwhelmed

At least once a week, I look at what I don't know but feel I should know to be a "good doctor" and am completely paralyzed by the volume. I "read around" my cases and try to get ahead but feel like its an uphill battle.
I know uncertainty is something family docs need to be comfortable with. I wish there was a way for that to be taught in residency. Seeing older docs who have all the answers is not very good for this fragile ego.



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An open letter to clinical clerks

I've recently been thinking a lot about medical education again. There are some clerks who really seem to get it - why they are in the hospital rather than sitting at home learning from books. This post isn't for them.

I don't expect much from a clerk, but I make my expectations clear on the first day. Please read it. You know what, if your resident sends you any email, read it.

Don't argue with your resident about these expectations, especially to suggest that the staff physician should have already done the tasks that belong to you. Yes, some of these tasks are time consuming, but by fulfilling your obligations to the service you are practicing your clinical skills, solidifying knowledge and finding things you don't already know. What's Celestone? You can leave the obstetrical service without ever knowing if you don't recognize the medication in the patient's history.

Pretend to have fun. Even if you hate the rotation you are on, it's a big deal to the patients, nurses, staff and your residents that you at least appear interested. You'll be surprised at how much more you will learn when you feign interest. Residents will be more likely to drag you to the cool case they saw last night. Nurses will include you in their patients' care. You will see more and learn more as you dig in and pay attention to the facets of various illnesses and how they present. Pregnant women get cholecystitis. Pediatric patients fracture limbs. Geriatric patients are like petri dishes for all aspects of medicine. Pay attention. Something you find interesting will show up every day when you pay attention.

If you think your resident is over reacting, you may not be paying enough attention. Ask his or her thoughts.

Respect the hierarchy. If you respect your junior residents, they will protect you and keep you in the loop when fun things are happening. Basically, you are at the bottom of the totem pole. The guy cleaning floors is above you. Show respect to everyone you work with. They all have something to teach you - even the guy cleaning the floor.

Respect your fellow clerks. Backstabbing is not cool.

Be available. Don't turn off your pager or cell phone. Don't hide.

Get to know your patients. Very often, only the clerk knows the full story about a patient.

Unless you have the evidence to back your statement don't contradict your resident. Really.

You don't know enough to start looking for short cuts through your clinical and interviewing skills. Follow the guidelines you have.


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Car

I had my first car accident this week. After it happened my initial thought was to make sure the other driver was ok. He was.

I am very surprised at how my mind and body responded to the accident so I want to have a record to remind myself later.

Once it was established we were both walking and talking, I looked at the damage to my car.


My initial thoughts were about how late I'd be for class. Then how much money it was going to cost to fix my precious LuLu. Then - wow, my chest is sore. I realized I'd slammed into the steering wheel with the right side of my chest. The air bag hadn't deployed.

Day of the accident, I was overwhelmed by how kind everyone was. Things with insurance, towing, police and repair went much more smoothly than I could have anticipated. I was sore. It was reachable by Tylenol and Advil but really sore. Adrenaline was definitely the hormone du jour.

The next day, was much worse. As predicted by my clever, concerned little brother. I was stiff, sore, had a crazy headache when i woke up that wouldn't go away and now nausea added to the whole thing. I actually considered seeking medical advice. I hate going to the doctor. Doctors freak me out.

I had to take quite a bit of the second day off because I was very much afraid of vomiting, the room was spinning, I was sore and honestly, I just wanted gravol and my bed.

The third day was the most surprising to me.

My headache was gone, the nausea remained. My entire body was stiff. My heart was racing. I had a feeling of impending doom. No matter how much I stretched or drank water and ate bananas, my entire body felt like it had run a marathon. I think this is from lactic acid release post collision but I'm just guessing.

Because my body was in a state of disrepair and the imbalances were affecting my heart rate, I spent most of the day rehydrating and attempting to convince myself that I wasn't going to die. The panic was really overwhelming. I'm grateful that my preceptor gave me the day to take care of myself.

While not my favorite way to spend a week, I'm glad for the experience and hope it will help give me insight into the reactions that my patients have to trauma in their lives. Mine was tiny compared to most. I am, as ever, impressed with what we can put up with.

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Facebook and medicine

(814): Wow, im gonna be a great doctor..."hi let me save your life but first check out this pic of me deep throating a handle of grey goose"
From TFLN

To avoid that awkward moment when a pt says "right! I saw you tagged in my cousin's sister-in-law's bachelorette party photos on Facebook!", I'm tempted to delete my account. The truth is though that it's how I'm able to contact family and friends.

Maybe I'll jump on the band wagon and change my name into something less recognisable.

Or just continue to keep my Facebook Mom and child safe.

These are definitely the kinds of decisions my preceptor didn't have to make before he set up practice.


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Last day on L&D

I'm a little sad. The team here has been so much fun to work with.


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Triage nursing

I was chatting with some of my nurses about patients who push to get to the front of the line at the emerg triage. There are many with unreasonable expectations, either based on what telehealth has told them, a misunderstanding of their own illness, and, or an inflated sense of self worth.

One nurse told a story about when she was working triage in Detroit. A patient stood up and started yelling that he needed to be seen and he was being discriminated against. The nurse also stood up, looked at the patient, and said "that bullet wound is in your leg, no where near your heart. You can wait."

Wow.


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Freudian autocorrect?

Today while updating my patient's chart I typed bariatric. It autocorrected to barbaric.

That's exactly how the patient feels about the bariatric clinic.


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You can't take the nurse out of the patient

Without fail, every nurse I treat (whether they be retired or active) will change the paper on the exam table before they leave.

Ding dongs.



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NCB

Natural child birth is seen as a badge of honor for many women. Some do it very well. They quietly moan and sigh. When it's time to push they push with all their might.

One woman I heard about had a small twitch in her cheek with really bad contractions. Quietly, without fanfare, she went through her entire labour with minimal noise. Suddenly, she looked at her nurse and said "baby is here". When she looked, the nurse saw that yes, the baby's head was ready to emerge.

We don't have many NCBs at this hospital. As much as many women come in thinking they'll go through labour without medication, they are very happy when we ask them if they'd like to change their minds. Then they go on and on about how much they love the drugs.

Some nurses as well act as though they are better nurses for encouraging her patient to go without an epidural. That's an argument for another day.

We have several tours of pregnant moms and dads who come through the L&D. One weekend, a NCB patient was being encouraged by her partner to moan through her contractions. These were loud moans. Very very loud moans.

You see where I'm going I'm sure.

The group of soon to be parents clustered together in the hallway giggling and swearing to use meds. Which made me giggle.




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Residency has tough moments

Telling a medical student what they need to do to pass. Encourage them to do what needs to be done, but let them make the decision to not fulfill any real objectives. Watching someone choose to fail at medicine is very hard to do.


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Quiet day on call

So I tried making some flowers that I'll use as decorations at a party we're throwing next year.


All recycled fabric from the final scene of our fourth year skit.

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In a nutshell, my worst nightmare

http://m.youtube.com/#/watch?desktop_uri=%2Fwatch%3Fv%3D3pbKRc-0mSs&v=3pbKRc-0mSs&gl=CA

Watch it.


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Fertilizer

As I stood, covered in a meconium and amniotic fluid shower, holding a very large baby, I wondered, did this child grow so large from being fertilized by the large amount of baby manure he had been swimming in?

It's been said before, but worth repeating, meconium happens.


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Happiness is...

Diagnosing a women with nausea of pregnancy then helping her stop vomiting.

8 months later helping her deliver a beautiful baby.

Then 1 day later having them come find me to give me a hug and thank me before they went home.

It's also getting a hug from a brand new grandma.


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Klepto vs. tattletale

Kids are pretty funny.

The children of one of my post partum patients were visiting while I was doing rounds. They were, as expected, adorable.

Thing 2: Dr Impostor!
Me: yes Thing 2?
Thing 2: my grandpa took home a thousand straws and a box of gloves!
Me: he sure is clever!
Thing 2 nods
Mom tries to crawl under her bed to get away from the embarrassment.

She really shouldn't care though. This is going to be something they can tease grandpa about for years!!


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Not a real doctor

My partner has a PhD. He constantly teases me that he's the real doctor since he's done novel research and I haven't. It's all in good fun.





Of course momma rat wants a vet. No comment about whether or not they're real doctors....

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Laughing the baby out

Today I got to help a patient laugh her baby out. Part of the success was through video clips of movies and trailers of comedies we wanted to watch. Funnest day ever.

Shattered dreams

I wonder if this is what my partner thought of me when I watched Scrubs to study for so many exams.

(803): My girlfriend is studying for the MCAT by watching The Magic Schoolbus. There go my dreams of being a househusband.

(from TFLN)


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C spine

We had a workshop today on how to read c spine films. When I saw this image of a 23 yo male who had been in a motorcycle accident, all I could think was, Gold chain on x-ray. Is that a positive Guido sign?


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Education about breast cancer

A while ago, I saw a brilliant image shared on Facebook. I haven't seen it since so today I went looking for it.


This easily, visually describes many of the types of breast cancer. According to a small study the group did, using lemons was less sexualized. I guess that makes it more palatable to some women. I'm just happy the resource exists.

The top right lemon shows hardening of the lemon - I wish that this was a bit more obviously Paget's disease, one that few women know to be on the lookout for.



Despite the few number of women that I see in my family medicine clinic, I have many who come in with their own concerns about breast cancer. I'll be sharing this resource with them. http://www.worldwidebreastcancer.com/


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New yarn!!

On vacation last week I picked up quite a few skeins of merino wool in very yummy colours.

I'm excited to get working with it but first I need to get it into a workable form.

My upside down, rotating bar stool is working really well as an impromptu niddy noddy.


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Poster on the diner wall

In a bacon and egg breakfast, the chicken is involved but the pig is committed.



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Hurry hard!!

One of my tasks in L&D is to coach the woman in labour. This involves me looking her in the eye, saying "are you ready?" then "OK go go go go go go push push push push push!". Repeat. A lot. I also encourage good pushes that make baby move further down the canal. It sounds pretty goofy while I'm doing it. Even more goofy to anyone not directly involved in the pushing.

One dad who looked like he was stuck in an surreal movie scene started laughing. He said he felt like we were at the Briar and that he expected me to start saying "hurry hard!".

I was laughing too hard to help with the next push.

You can laugh the baby out right?

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I'm loving my Obs Gyne rotation

After having such a terrible experience in clerkship it's great to finally get what all the fuss is about. The nurses in town are amazing. They are teaching me tons and helping make this rotation a lot of fun. Now I know that I want to include some obstetrics in my future practice. That was something I hadn't considered until this rotation. This is what residency should be about.




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Lessons from the don't file

I'm thinking of album names for a friend. Something catchy, memorable, and that will make their album stand out.




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Just call me butt face

There are always what appear to be strings of similar cases in medicine. They work out to be a great way to learn, then solidify the learning by practicing it over and over again.

Recently, it was the skill of artificially rupturing membranes. This involves inserting a plastic hook through the internal cervical os and tugging at the amniotic sac enough to make a small hole. We always check to make sure that there is a hard head well applied. If not, we could end up with a cord prolapse. A very scary obstetrical emergency.

There was one particularly difficult ARM that I did. The internal os was a fingertip open and very posterior. I really wanted to do a touchdown dance when I got the gush of fluid. But that would have been wrong.

Heaven forbid I be allowed to enjoy being so clever and doing so well with my new skill.

During one of our busiest days, I ruptured membranes for an adorable woman quite easily. Later that night, her clever nurse noticed that labour had slowed down and had a strange contraction pattern. Her doc went in to double check the cervical dilation. According to the patient, he was up to his elbow and making a funny face. She was, to be fair, hopped up on nitrous gas. You can't deny though that her baby was breech. I ruptured the membrane over a bum. The patient was kind to me. She said she was sure baby had flipped since I ruptured the membranes. Sweet white lies.

The new skill I'm working on is applying to gel to cervixes to make them appropriate for induction of labour. But I've learned. All these moms are getting Leopold maneuvers and an ultra sound to make sure junior is head down.


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Dear OR nurses,

While I generally have nothing but respect for nurses, I was very disappointed in your behaviour the other night. Usually nurses remind physicians that we need to be respectful of our patients. Hopefully you will understand why I was so upset with you, the small group of nurses in our OR on shift while I was on call.

To begin with, acknowledge that emergency surgeries are just that. When we put these on the board, we aren't trying to ruin your night. I know you prefer to sleep through the last part of your shift instead of having to work it. I also enjoy sleep. Patients don't want to have emergency surgery in the middle of the night. Please remember that sometimes our work is about the patient, not us.

Also, your stage whispers can be heard by everyone who is conscious in the OR including the patient undergoing awake surgery. I'm ok with you talking about me in the disparaging way you enjoy so much. I'm not ok with you talking about the patient while they can hear you, especially about how awful things look while we are desperately trying to calm them down.

I can't express how disappointed I was in your behaviour, or how grateful I am that your attitude is so rare among your colleagues.



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Things that made me smile this morning

1. A huge Irish setter that out of the corner of my eye, and with the sunrise just so, looked like Clifford the Big Red Dog.
2. Hearing Stereo Hearts by Gym Class Heroes on the radio (It's ok if you judge.)
3. Finished my presentation in time for rounds.
4. A chipmunk running around the parking lot of the hospital.
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Words that always give me chills

Please don't let me die.

I hope I never become so callous that these words don't give me goosebumps. What an awesome amount of trust my patients put in me and my colleagues.


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I'd rather be delivering babies

None seem to want to join us in the L&D. Instead, I quilt.


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Have you ever noticed

...when L&D staff get chatting and gesturing wildly, they keep their index and middle fingers together?

Risk of the job I suppose.


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I may have a new crush

There was a baby stuck in mom's pelvis this morning. It was pretty tense. Baby was OP, so instead of looking left or right she was facing the ceiling. After a failed attempt to reposition baby's head, one of the older docs came in. He brought his forceps.

It was like magic.

The tension in the room dropped. Baby was out in a very short time. It was one of the most amazing things I've ever seen.

I think I have a little crush on forceps. They're shiny an everyone was in awe of what they can do.

Amazing.


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Dealing with disappointment

Seeing so many of my colleagues get their first choice in the match this year made me excited for them. It also made me regret my decisions that let to me not getting my first choice of resident.

It was devastating last year when I didn't get my first choice, I tried to pretend I was happy with my placement but I truly wasn't. It took over a month to convince myself that residency, in a town I didn't want to be in, wouldn't suck.

I made my partner and I a home so we would be comfortable where we were going to live for (at least) the next 2 years. It's a comfy house that has a great patio in a nice neighbourhood. We're close to all amenities and less than 5 minutes from the hospital, perfect.

When I met my fellow residents, I was happy. This was as great group to be with.

My home base, a family health team, was welcoming and lovely. I felt like I was a part of the team.

But it still wasn't where I wanted to be.

This is why I did site visits in my first year of residency. No one that I know of was doing visits this year. I needed to remind myself of the happiness that was to come. It really helped keep me centered.

It also encouraged me to change the site I was at to one that would better suit my lifestyle and learning needs.

I start in a new town in July.




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My new definition of gross

Parents who kiss their freshly born baby after they've marinated in meconium full amniotic fluid.
Yes we wipe the kids off first, but still....Ew.




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OMG it's match day!!!

I woke up this morning in a cold sweat before realizing its not my match day.

As is said about another well known, life changing lottery, may the odds be ever in your favour.


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Making friends

It's well known that the best way to get cozy with obstetrical nurses is to feed them.
When one of my nurses was a bit grumpy, I bought some candies and left them at her desk. Minutes later they were put on the doctors desk.
I found out later that this nurse was on a strict diet.
Because the best thing I can do to make friends is poke the bear with a pointy stick.
Oops.
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Not a busy night on call

I've seen only 3 women on my 24 hours of obs call. In between number 2 and 3 I went home, had roast beef dinner and a very long nap.

Going back in to see number 3, I was a bit groggy having just fallen into a good sleep.

When I went to introduce myself, I slurred my words "hi, I'm Dr. Impostrrrrrraaaaa..." and let it trail off. Quickly rebounded with, "so, what's going on with you?"

After much reassurance baby was ok, I get to go back bed.

Next time I'll practice speaking out loud after a good nap before chatting with a terrified patient.

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Guess which room the jaundiced baby is in

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I delivered a baby!!!!

First one ever. Little tyke grabbed my hand on her way out.

Squeee!


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How do they do it?

I forgot how painful a surgical rotation is. I'm expected to be at the hospital and up on all current cases before 7. AM!!!!

My partner was a huge help this morning in making the transition from a 9:00 start. He brought me coffee in bed, changed the temperature in the room to make it more appealing to leave the covers, and bugged me q5 minutes to get my lazy bones out of bed.

I have no idea how residents without partners survive. Though truth be told I'm too spoiled to even be able to think about any other way o life.


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First day of obs

I finally found the cervix!!! Today was my third attempt ever in life. My first two tries to determine a pregnant woman's dilation failed. I had no idea what I was doing.

Today however ... 1 cm! 50% effaced! Mid way! And I was right.

I had been coached by a friend the night before and one of the nurses just before going in. They made it so easy for me!

I'd almost forgotten how joyful medicine can be.




This was a good day.


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Doctors choose less care compared to their patients

I've talked before about how I feel about end of life care. I want my patients to be comfortable. I want to avoid any interventions that are not going to improve quality of life. Patients and their families don't always agree with what I want. That's their prerogative. End of life is a scary time for people and involves decisions we hope to never have to make.

Patients who are doctors tend to choose end of life care with the least interventions.

"In a 2003 article, Joseph J. Gallo and others looked at what physicians want when it comes to end-of-life decisions. In a survey of 765 doctors, they found that 64% had created an advanced directive—specifying what steps should and should not be taken to save their lives should they become incapacitated. That compares to only about 20% for the general public."

It may be worth including these stats when discussing end of life care with our patients and their families. We are always told to use evidence based medicine, and to not ever answer "what would you do if you were me" with a straight answer. This seems like an ethically sound way to answer this question.

Kiddie food

I have a cute 11 month kiddo whose religion dictates that she not eat animal flesh. Milk and eggs are ok.

The kitchen in the hospital keeps sending her plain cod for almost every meal. No matter how many times the unit clerk has re-entered the order to be appropriate for the patient, we get plain cod.

Finally, I called dietary myself to get to the bottom of this. When I told them that my patient was strict vegetarian, I was told that was a vegan. He kept telling me that vegetarian meant fish. Strict vegetarian meant no milk.

I gave up and asked the kitchen to not bother with titles and just send yogurt and anything else they wanted as long as it never had a face.


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Bear

When I travel, go on call, sleep on my couch or in my bed, I have bear.

I've had him since my second year of university. Without him, I have difficulty sleeping and end up using scrunched up towels as a poor substitute.

It's nice to know I'm not alone. 25% of British adults sleep with bears, though, most of that number are men. http://ca.news.yahoo.com/blogs/daily-buzz/survey-says-teddy-bears-accompany-many-british-adults-183611597.html

No matter how my day has been spinning out of control, Bear makes me feel grounded and helps me remember that sleep time is precious. Some days, feeling that my day is over is impossible until I am snuggled with Bear. There are no questions or expectations, no judgements or advice, just calm and softness.


Sigh.


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Thank goodness Buffy didn't find out...

A teacher called CAS and they arranged to have a father arrested for possession of a firearm. He is a PSW, the people who do much of the dirty work in medicine. http://www.thestar.com/iphone/news/canada/article/1136659--kitchener-dad-arrested-at-school-after-daughter-draws-picture-of-gun

This started because his daughter had drawn a picture of her dad holding gun. He doesn't own a gun. Though even if he did, it would not necessarily be against the law in Canada.

I once drew a picture of my father as a vampire. I'm very glad Buffy the vampire slayer didn't see it.


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The strippy quilt is coming together

I'm almost done sewing the quilt top together. Once I find a quilting needle for my machine I'll be able to finish putting it together.


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See one...

Usually in medicine, especially in the ED, you hear "see one, do one, teach one". This refers to seeing a procedure or technique done, doing it yourself then teaching someone else how.

In paediatrics however, it appears to be see one, see one, see one, see one, see one.....



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Sunday morning at its finest

Chilling in bed with post secret, kitty, and my online news. If only I could magically make a coffee appear.


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My friend is having a bad day. We live in different provinces so I can't give her a hug. Instead, I have these cute photos, mostly from cute overload.






























Hope you're feeling better sweetness!!!

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Location:Bad days

Medicine in Art

Take a look. Come to your own conclusions. Share if you like.

Frontier Surgery by Randy Steele

A tribute to a doctor by Sir Luke Fildes

Madness

Hope II by Gustav Klimt

Residency Blues

Starting around 4-6 months into residency, almost universally, residents everywhere get hit with the blues. It is soul sucking and demoralizing to work every day, for what feels like millions of hours, at something that you are never really that good at.

We rotate through different specialities and disciplines every few weeks to every month or two. Our advisers change daily or weekly. Just when we think we're starting to get the hang of how this guy likes to see his notes written, or how she will think about making orders, we're thrown into a brand new situation.

Actual mastery of any domain is difficult to achieve because Family Medicine residents are meant to be exposed to as much as is possible so we get little time to hone our skills before moving on.

I'm in a community based program. This means that I'm in a small hospital which is great for being the only resident on and getting more chance for exposure to cases as they come through the door. It also means I'm the only resident who understands what I'm going through. Even though there are technically 4 of us in the hospital right now, we never see each other because we are never on service together. When we do see each other in the halls there is a flood of conversation, sympathetic smiles, and general advice from our experiences with the rotation before we need to move on.

I came from a large, very close class in med school. I miss them like crazy. We would frequently run into each other in the halls of the hospital while on clinical rotation and give each other pep talks before running on. We had small groups where we could all commiserate and hug and eat chocolate. We didn't feel alone. I knew that more than 140 other med students had my back, and they knew I had theirs.

I feel alone now.

Residency can be very isolating. I love my partner dearly, but he has no idea. He has always been my cheerleader and believes that I'm a rock star no matter how badly I mess up. Other residents get that we do make mistakes and they're horrible and say things like, "Well, you still have a good outcome...", or "No no no. THIS is a terrible mistake." We work through what went wrong and try to learn from it. Residents know how the teams in hospitals work and the questions to ask such as "wasn't there a note in the chart about the patient being diabetic?" This can really help to put things in perspective.

While I love that my partner thinks that no one is smarter than me and that everything will be perfect, it's difficult to believe after being raked over the coals by a preceptor for not knowing the full differential of rash in a 2 year old. It's not that I'm not willing to explain all the ins and outs of the interactions I have at work, but most days when I need to blow up, I just don't have the energy.

The problem with residents though is that they never really have time to chat. It takes forever to set up a good time for us to actually spend time together.

I'm looking for a good solution.

The most terrifying words I've ever heard

"Dr. Imposter we need you in the special care nursery STAT. RUN!"

I ran. And was terrified. I haven't learned paediatric resuscitation yet. Terrified.

Once I got there I was pretty much furniture. The RT and the nurses ran everything and made the baby go from yucky looking to feisty. These guys rock.

Once I could feel my feet again I asked the RT a million questions about what had happened, and I learned.

I also learned that I was not as calm in the face of a critically ill patient as I thought I'd be. That was eye opening.

I need more practice in dealing with scary situations. It's difficult to convince patients to let me make them critically ill so I can learn. (jokes)


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Everything I need to know about being a doctor I'm learning from Terry Pratchett: Cackling

I love the Disc World series by Terry Pratchett. It is just silly enough to be a great distraction after work and just serious enough to make me feel like an adult while reading it.

There are many witches in the series who act as the health providers in this world - there are doctors too, but those are usually men who are in the city rather than in the mountains where illness is actually happening.

In the stories of Tiffany Aching, an up and coming witch from a sheep farm, we get introduced to the culture of witching and what is expected of witches. These books are rich with, what I consider to be but could very well be far too self centred, analogies to being a physician in a rural setting.

A good example of this is "cackling" which is mentioned in several books and warned against, lest you turn into a Black Aliss and get stuffed in your own oven.

In "Wintersmith", page 17, Pratchett explains cackling:

'When you got right down to it, it was all about cackling. No one ever talked about this, though. Witches said things like "You can never be too old, too skinny, or too warty," but they never mentioned the cackling. Not properly. They watched out for it, though, all the time.

....

"Cackling," to a witch, didn't just mean nasty laughter. It meant your mind drifting away from its anchor. It meant you losing your grip. It meant loneliness and hard work and responsibility on other people's problems driving you crazy a little bit at a time, each bit so small that you'd hardly notice it until you thought that it was normal to stop washing and wear a kettle on your head. It meant you thinking that the fact you knew more than anyone else in your village made you better than them. It meant thinking that right and wrong were negotiable. And, in the end, it meant you "going to the dark," as the witches said. That was a bad road. At the end of that road were poisoned spinning wheels and gingerbread cottages. '

The witches of the Disc World visit each other to keep an eye on each other. Physicians work in similar circles and hear stories about one another though they are frequently not as forceful as Pratchett's witches who will tell a sister witch that they are beginning to cackle. Physicians tend to hope that their fellow docs will figure it out.

We have the CPSO for patients and doctors to report inappropriate or self destructive behaviour. I don't know, because I can't imagine how one would go about doing this research, but it seems that we are likely missing quite a few docs who have begun to cackle.

Looking at the back pages of the Dialogue magazine you see many examples of physicians who have let their minds "drift away from it's anchor". A compassionate person can look at the examples of narcotics mis-prescribing as easy to fall into. It can start with someone who is having a bad time and needs help with pain and with escaping their reality. You've done it once, why not do it again? Bit by bit this can escalate to trafficking - thugs on the street are doing it, why can't I?

Self prescription and self doctoring is extremely easy to fall into. I know enough to take care of these 2000 patients, of course I know enough to take care of myself! I can prescribe just what I need. But, we need someone else to keep us honest. Having a doctor as a physician is essential and I think works very well to keep our thoughts on track - if this doctor will treat us as a patient who is a doctor, not as a doctor who is a patient, by which I mean will take the time to explain a thought process and why they suggest a treatment rather than simply asking what medication the patient wants and dutifully writing a script. If you haven't seen the movie "The Doctor", it's worth checking out for this. There's a scene where the hero has hoarseness and his physician isn't worried because his patient isn't worried.

Taking care of patients without reflecting on what a wonderful privilege this is or how much they give back may leave some docs feeling empty and spent and looking for a way to fill their lives again. It may make them feel entitled to certain allowances such as not keeping proper records, charging extra fees not acceptable by their college or possibly, unfortunately, taking advantage of patients. There are far too many stories in the back pages of the Dialogue about sexual abuse of patients by doctors. To be honest, one story would be too many.

While I never expect to see a doc wearing a kettle on her head, I have seen docs who are a little bit lax on rules, guidelines, and expectations. I have yet to let these docs know that they are beginning to cackle. I hope this is because of my position as a lowly resident without any authority rather than not having the back bone to keep my colleagues from "going to the dark".

It would be awful to lose a friend to being shoved in an oven by a couple of kids.

My poor freaked out partner

We talk about stuff I've seen at work all the time. For the survival of my partner's tender sensibilities, I try to avoid topics that will upset him. These usually involve genitals and anything involving poop.

While he was listening to the Unbelievable Truth, a British comedy radio show, he learned some obstetrical facts that interested him.

The first was that newborn babies cry in the key of A.

The second had to do with episiotomy repairs. In particular, fourth degree tears and what outcomes one might expect. A very difficult topic to cover without discussing genitals or poop.


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Princess Peach

Kids love iPhones. They play games on them, watch YouTube, and take great photos.

Many of my patients play Super Mario. They have Wii machines in the hospital for them to use. I'll make these kids puppets from tongue depressors with Mario, Luigi, and Princess Peach. It's a cheap distraction that lets me examine bellies without voluntary guarding from the patient.

One of the patients had an iPhone with Super Mario on it. Watching him I was shocked at how quickly he was moving through the level. And ashamed of how poor I am at playing the game compared to a 4 year old.

Then his mom told me he was watching videos on YouTube of someone else playing the game.

D'oh.


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Obese Physicians

The January web volume of the journal Obesity contained an article "Impact of Physician BMI on Obesity Care and Beliefs".

It found that physicians with normal BMI were more likely to engage their overweight and obese patients in conversations about weight loss than their obese colleagues. These docs also had greater confidence in their ability to counsel obese patients about exercise and diet. These docs also felt that the patients of doctors who are themselves obese would not trust those obese docs to give advice about their patients' obesity.

They also found that 93% of the docs would only diagnose a patient with obesity if they were confident that the patient weighed more than they did.

There are a couple of implications to these findings that I find concerning.

The first is that obese docs don't trust themselves to help their patients with obesity. It makes sense. Obese docs may feel ashamed that they are unable to control their own weight. I see it more like an AA sponsorship though. A doc who has dealt with weight issues may be better able to share their experiences and help patients avoid pitfalls. There may be less judgement. Though in AA, a sponsor has achieved sobriety. With obesity, it may be the doc who reaches a normal BMI who is best able to provide this support. One study showed that the patients of obese docs are more likely to have a normal BMI than the patients of doctors with normal BMIs. The Cardiac Exercise Research Group compared this to smoking doctors who are less likely to counsel their patients to stop smoking.

The second is that docs with normal BMIs have so little faith in their obese counterparts. Given the squeals of "ew" when images of MRIs of obese patients were shown in class during med school, I shouldn't be so surprised. I wonder what it would take to change these beliefs?

A third is that docs are most comfortable diagnosing obesity in patients who weigh more than them. The implication here is that even docs who have a normal BMI are judging their weights against that of their patients. That's sad.

What I find most disturbing about this article though is how other media have been presenting its findings. E.g. "Fat Doctors Can't Help Fat Patients"

While I wasn't able to find articles on patients' perceptions of fat doctors, the comments on some of the articles I looked at speak volumes. Essentially that they wouldn't give a fat doctor's advice on weight loss much weight, if you pardon the pun. I wonder if this would be different though if they actually met the doctors and developed a relationship with the doc.

When you learn about the ways to help a patient lose weight, we learn about motivation and goals. It may be my goal to be a doctor with a normal BMI, but my motivation is to be a doctor who will earn the trust of her patients. Further motivation for me to follow my New Year's resolution of following the advice I give to my patients.

Where's your ring?

With newborns we end up doing lots of calculations - total fluid intake needed, percentage weight loss, left shift of neutrophils, etc.

When working out weight loss out loud, a dad finished my thought with the answer "about 3.2%". Impressive.

I asked him where his ring was. He was very flattered because he assumed I wanted to know if he was available to be married since I was so impressed with his mad arithmetic skills. He was disappointed that I was looking for his engineers' iron ring.

For the record, I guessed correctly that he was an engineer, he just doesn't wear a ring.

Win!


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Are you kidding me?

The ongoing joke right now on the post partum floor is that if a baby doesn't have a Sofi giraffe to go home with, children's aid society should be called immediately. These are the goofiest things I've seen. The claims that they are so good for teething, implication that they're better than other toys, is amusing to me. Kids love them. They're very cute. I'm sure they help with teething. Just don't know why everyone is compelled to buy them.



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My newest diversion from studying

Learning to spin my own yarn. I'm not brilliant at it but I guess that's what practice is for right?



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Nursery wackiness.

Why is it that once one baby in the nursery starts crying, they all start crying?

We were desperate for a soother. Couldn't find them. Disaster.


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