All I need to know about being a doctor I learned from Buffy

1. We all need friends. Even when we're called, chosen if you will, to enter the medical profession. Probably even more so. We need our Scoobie gang, the people who will keep us grounded, take us toboganning, help us get drunk and dish about sex. Our cheerleaders who make us feel invincible when we need it.

2. Keep your head when everyone is losing theirs. It's up to me to have a plan of attack. I need to slay the demons run the code, even if it's on my friend and neighbour. Even if it's the vampire man I love.

3. Magic and medicine don't mix. Follow evidence based practice, accept no substitutes.

4. Always carry a beeper in case the apocalypse comes. That's fairly '90s though isn't it. Now I make sure that my cell phone is charged and the ringer is on. My colleagues may need help at the hospital, my nurses may have questions about patients. Unless I'm post call, I need my beauty sleep.

5. Get your beauty sleep or you get cranky.

6. Love makes you do the wacky. If you love your patients, you won't have perspective. I'm not saying don't continue to love them, just be aware your brain is wacky.

7. Be confident, even when you're not, or you your patient may get dead.

8. Plan ahead like the good slayer. Faith went dark without a plan. Docs without a plan, without friends, who don't listen will also go to the dark side. They become TOO confident and patients die then too.

9. Wear lipgloss.

10. While not everyone will notice what I am doing, treading like mad under the surface, saving lives, when they do they can be quite gracious. And sometimes will give you a toy surprise.

Things no one tells you about your first year of practice

I've disappeared for a while again. A couple of reasons why. One is that BlogPress's iPad app isn't working. I'm not able to blog on the go like I used to be able to.

The bigger reason is that my practice is getting up and running. By running, I mean running over me while I desperately try to keep breathing, completely giving up on keeping up.

I expected that I would end up with a larger than usual number of patients with personality disorders. I've been shocked though at how many there are. Most of the time in our "meet and greet" appointment is spent putting their supplements, meds, and "medical problems" into my EMR.

Something I hadn't counted on, were the high number of patients who are incredibly unwell but haven't seen a doc in 20 years. These are patients who have had their illnesses slowly progressing so they didn't notice how unwell they were. Some come into my office stating they've never felt better, but I can hear water on their lungs from across the room. Determining the cause of their illness and treating it takes time and all my training.

I've been giving all my new patients questionnaires to fill in before we get started. It helps to guide our first meeting and has been really helpful IF the patient isn't coming in already broken. Rather than being able to be on top of what is happening right away, I've had to hire someone with some clinical smarts to enter all the answers to my questions for me so that I can spend our first appointments dealing with acute medical issues.

Something else I wasn't expecting was needing to put a hold on my new patients while I get the ones that I already have a solid plan. I don't know who half my patients are. I've met them, I have notes in the chart about them, but have no idea what face goes with what name. I wish there was a photo component to the chart to help me with that.

I still think I have the best job in the world, just surprised by how overwhelmed I've been.

Talking to people who are chronically ill

Those with cancer wish that they could spend time feeling carefree. Their entire lives seem to resolve around hospital appointments, medications and their side effects, support groups, and planning for their family's future without them in it.

This is why when I'm around those with chronic disease, all I seem to talk about are silly, frivolous, light hearted things; my kittens tearing my house apart, the recent adaptation of a children's book into movie, the way pink and purple make me feel happy, whatever moment is captured in photos around the room. Not just for the one with the disease but for their family too. Leave space for all of them to talk about seriousness, but give the give of pretending it doesn't exist, if only briefly.

Remind your friends, patients, family what it's like to be care free.

You may be a country doc if

You've been late because you pulled over to help a farmer get his sly sheep off the road. They are damn cute though.


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Oh the pity I felt for this patient

Allergic to bacon!! AND chocolate!! I'm not sure I'd be able to go on living.




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Can I possibly improve my blog? Maybe.

For kicks, I decided to look on PubMed to see if there was any research done on blogging. There is. Actual research done on how docs blog. Cool. But it's Saturday, so I'm only going to look at 2 of them.

First of all, did you know about Web 2.0?? I sure didn't but I've been using it like a mad person for years. Web 2.0 describes web sites that use technology beyond the static pages of earlier web sites.

This article makes a point I've been considering for a while - making my blog searchable in a way that will make it easier to match experiences I've had with my progress in my training and any applicable social aspects. They propose that bloggers use the usual tags they use (my favourite seems to be 'note to self''), they call these folksonomy - plus a diagnostic code from the ICD-11. The blogs that the researchers suggest these tags be used include WebMD, Kevin MD, and CasesBlog. My blog has little to do with these blogs - it's just me, I'm trying to learn more about myself as a physician not necessarily educate others (though I hope that's a happy bonus), and, for the most part, I hide my patients' true diagnosis. If I choose to follow the proposed system in this paper, which frankly isn't terrible, it makes it more difficult to hide my patients' identity. Unless, I use the ICD codes only for my rants on specific topics like suicide and HIV, and ignore the diagnoses of the cases I dissect. Which certainly is something worth looking at.  While I won't follow their algorithm to the letter, I will try to remember to tag liberally.

Another set of researchers looked specifically at learners' blogs. It's like they were looking over my shoulder. They found that learners used their blogs to reflect on their experiences. Their table 2 looks at the analysis of the blogs and what is covered and offers a few suggestions. My absolute favourite is the suggestion to share coping strategies with peers. Personally, I would have put it under "emotional distress" not "interaction with peers". I think that many learners are looking for other learners' blogs to find out how they deal with the big stuff in their lives - exams, residency matching, patient death... Having a fairly anonymous way of talking about things we are afraid of telling each other face to face would be helpful. There are many conversations taking place on twitter and in medical journals about burnout. It seems to me that using each other via the anonymity of Web 2.0 is one way to seek help without worrying about repercussions.

They also found that blogging learners were likely to preach the benefits both of collaborative learning and having a solid support system. Of course they do. Blogging learners rock.

Pinilla et al also makes some suggestions about how medical educators can use their students' blogs to enhance their learning. One suggestions is that the educators look for where their learners are having problems with exams, etc. This creeps me out. If I had any inkling that my teachers were looking at my blog I would have stopped writing. Or at least edited my posts to the point of ruining the point I was trying to make. Random, unknown educators would have been welcome to peruse, but not my own teachers. Looking at broad themes and concerns of the bloggers in general is a great idea. That it might even be an option makes me happy that I've stayed the Imposter.

So, to recap what I've learned:
1. Tag my blog liberally so that finding information in the future will be easy, both for me and for my readers.
2. Encourage the use of blogs as a way to share coping strategies.
3. Blogging learners rock.
4. Educators should not follow their own learners' blogs. It's creepy. But I'm all for qualitative research. Especially when it's done by someone else.

A True Love Story

First things first. Go get some tissue. Sincerely.

Next, watch this video. It's beautiful. Seriously. Watch it.

Did you love it? Of course you did. Daily love letters? Planning for a partner's life after you die?

Now you may continue.

This is a love story that I first learned about more than 10 years ago. They were one of my favourite couples who came to my restaurant when I was serving. They came from India during a time when you did not date outside your caste. Especially not the untouchables, but love goes beyond these invisible borders when you are good people.

They went to school and were educated in medical fields. One became a brilliant researcher and teacher, the other a fantastic clinician working to save lives. I have had the honour of hearing stories from the students and patients of these couples. They are well loved by those they serve.

The love they feel for each other was obvious in their dealings with each other - the tenderness they showed one another over their table through touch and words, the way they shared their meals, Mrs. would always bring home a treat for Mr. when he wasn't able to make it to dinner. They would tell me stories of their courting and their move from India to Canada. I would often end in happy tears with the two of them. (by the way, can you see why Family Medicine had to be where I'd end up?)

Fast forward over my medical training.

I am doing a hospital elective in the town I used to live in, where I first met the brilliant couple.

We are paged to see a patient who is not doing well. There is a long history of cancer and chemo complications. I'm shocked to recognise my Mr. Love Story on the hospital bed. He looks unwell. Very unwell. I can tell immediately that he's actively dying.

We catch up, I learn the course of his metastatic prostate cancer over the past year. About all the treatments he has been through for the past year. About how Mrs. LS has never left his side, sleeping many nights by his hospital beds. The entire time, they are holding hands, looking at each other with the doe eyes I didn't even know I had missed. Mrs. LS tells me that the love she feels for Mr. LS is only growing stronger through all of this. Mr. LS's biggest concern is that he is leaving Mrs. LS with unfinished business. And how will she continue without him around? Their children will be some comfort but, as with all families, they are busy.

Next comes the part I hate the most. The goals of care talk.

They think they are in the ED for a quick fix so they can go home together. I tell them I think that Mr. LS is dying. They aren't surprised but they are sad. Mr. and Mrs. LS want to have a few more months together. I'm hoping for a week. Mostly I'm annoyed that the colleagues of the LS's didn't let them know (or at least ensure they understood) during their treatments that Mr. LS was dying. I know it's hard to have perspective when the patient is someone you know. I learned that it is even harder when it's someone you love.

My colleague came to see the LSs and did the evaluation. My visit was to determine goals of care and ease the conversation for the next doc to evaluate and admit Mr. LS. The next doc came and told me that my week was overly optimistic and that Mr. LS would not have more than a day.

The funeral service was beautiful. Both communities came out to celebrate the life of Mr. LS and the love between him and Mrs. LS.

As with most of these painful encounters. I want to learn.

Lessons learned here:
1. Love stories are important. They are everywhere and give us something to hold onto when everything else is crappy. Ask patients and find out what their love story looks like.
2. Having perspective with patients who you are emotionally attached to is impossible. Ask for help. Know where the boundaries are.
3. Find out patient expectations early in the interaction to best help your patient.
4. Serving others provides your emotional self with great nourishment and can allow a love to grow exponentially through adversity. I served food as a waitress but now I serve my patients. I am constantly overwhelmed by the lives my patients live and their willingness to share these lives with me.

Pill Rolling Tremor

I'm on vacation while I wait for the FHT to sort out the red tape in me joining the practice. This is giving me time to sort through questions that have come up during residency. 

One was after a disagreement I had with a doc about what a pill rolling tremor is. The doc I was working with insisted it was a fine movement of the wrist. I was really sure it was a fine movement between the thumb and index finger. 

I love being right. 

You see pill rolling in some folks with Parkinson's disease. It's often a tip off for me that I need to look for other symptoms to determine if I should be worried or if its just a nervous tic. Because its a resting tremor it's one that is often difficult for the patient to hide and will present itself during the Q&A portion of our visit. 

Have a look at this article on how pills used to be made to get an idea of where the name came from. My favourite quote is:

Pharmacists could coat pills to disguise the flavour of the medicine, making them easier to swallow.  Depending on how much the client was willing or able to pay, thin gold or silver leaf, calcium carbonate (to achieve a pearl finish), sugar, or gelatin could be used. Many of these coatings made the pills indigestible. As a result, they would pass through the digestive system whole, without delivering medication.

My online appearance is more important than my physical appearance

I had a great time today reading posts and comments on Twitter about physicians' appearances.

Things I've learned:
1. Some docs really like this article from 2005 (!!!!) on the importance of dressing well for your patients. Remember it can take up to 3 years to publish an article so this data is from 2003 at the latest. Think track suits and Queer Eye for the Straight Guy.

2. The BBC would really like doctors to generally judge everything about their outward selves. This article looks at "scruffy doctors", overweight doctors, and doctors who smoke. They also acknowledge that many patients are expecting the white coated doctor to be male. 

Which brings me to...

3. A separate discussion has been playing out today on Twitter about how young female physicians are perceived spurred by this blog entry. Female docs are often (VERY often) mistaken for nurses. Even after introducing themselves as Doctor SoandSo. I know I've blogged on this before but I can't find it. We are also assumed to be the assistant, the secretary. As an older than average resident, I was usually mistaken for the social worker or my pediatric patients' mother DESPITE wearing an ID badge and my stethoscope. One intelligent staff member asked me 6 times during my 2 month pediatric rotation to fill out the insurance forms for "my child". She was shocked every time that I was *still* a physician. I was once blocked from a code by the nurse who called me to it because she thought I was a family member (again, with stethoscope and badge). 

While I was on rotations in other hospitals, I would carry a small bag with my "pocket" stuff. Pens, a Drug Pocket, my phone. Most "professional" women's clothing prohibits actually using pockets if they do exist. This teeny satchel was usually the scape goat in my mis-identification. 

This is one of those issues that makes me a bit cranky. Have I told you yet about the preceptor who told me that it was perfectly reasonable to be mistaken for the social worker since "doctors don't have long curly hair, you can't expect to be taken seriously"? It makes me see red. 

If, in real life, I'm mistaken for another profession or not a professional at all, based on my hair and my satchel, what must the medical world think of me based on my online profile? 

Some argue that our online presence allows others to see our "true selves" (it's the basis for many relationships that start online). Social media (SoMe), plays a big part in my life. I'm in a tiny rural town, most of my friends are in different provinces. Without my online presence, I would be entirely isolated. My professional online presence is split between The Imposter and Dr. SoandSo. Maintaining my anonymity on this blog is important to my being able to use it as a sandbox for trying out ideas and ways of dealing with patients in a safe environment. As Dr. SoandSo, I have opinions on family medicine and its role among the specialties. As just me, I am on Facebook with my friends and family so I can watch my family grow up from a distance. 

I'm seeing guidelines and suggestions about how docs (and everyone else) should behave online. It's true, many docs are illiterate in the ways of SoMe, but I think that they are aware of how to behave in a crowded mall. The same rules we learned in kindergarten apply. 

1. Share everything. Post your references so others can also be as smart as you.
2. Play fair. Don't overload your online profile so that your friends aren't also visible. 
3. Don't hit people. Don't call them names. Maybe they have had a really bad day.
4. Clean up your own mess.  Untag any photos that you wouldn't want your mother to put into the family Christmas card. 
5. Don't take things that aren't yours. Credit any source that you use. You wouldn't want someone else prancing around in the sweater you took 3 years to make claiming they knitted it themselves. Our intellectual property is just as important. 
6. Say you're sorry when you hurt somebody. Apologise when you make a mistake and correct those mistakes.
7. Wash your hands before you eat. MRSA y'all. 
8. Live a balanced life - learn some and think some and draw and paint and sing and dance and play and work every day some. Your online friends are interested in the new bottle of wine you found just as much as they are the new journal article that you found so fascinating. Share. But please don't overshare. 

Truthfully, first impressions are just that. The patients who mistook me for a social worker trusted my ability to care for their medical needs. First impressions don't matter nearly as much as who we as health professionals truly are. How many times have you heard from your patients the story about the surgeon in his million dollar suit with no bedside manner? Could you possibly sleep well at night knowing that you had treated your patients in a way that would have put you in the corner during kindergarten? My online presence is as close as it comes to knowing the real Imposter and how she speaks with her patients. 

Dress respectfully for your patients but act respectfully (online and face to face) for yourself as much as them. 

Changes are coming in residency training

The CMA posted this morning that residency expectations will be changed by 2017. It will be competency based  rather than time and exam based. In theory, this is already going on. You need to be recommended to sit your licensing exam by your program. If your program sees you as a resident at risk, they should not recommend you. From what I understand, this rarely happens, what Dr. Jason Frank in the article calls "failure to fail". Medicine in general has a tendency to pass students who should be re-mediated, or, kicked out. People are shocked that my school kicked 3 people out of our program, despite being a pass/fail school. So, sub-par residents can make it through to their exams missing essential skills.

My clerkship program was quite focused on our actions - for example, we all needed to deliver one baby vaginally, place 5 peripheral IVs, etc. etc. Students were not always able to complete the activities though because their residents scooped them all, their consultants didn't have time, or there just weren't enough patients. Fake signatures abounded, our teachers were willing to sign off when we were able to describe what we would do if given the opportunity. My exam in IM was meant to be hands on, but ended up being a  seated conversation between me and my preceptor.

In my experience, preceptors who are not in academic centers are not great teachers and can be even worse at giving feedback. Many I've met choose to stay away from academic centers to keep away from the extra workload of teaching and research. For residency programs to have such a strong focus on competency and the improvement of those competencies, there needs to be a significant improvement in the training of preceptors, especially those who are based in the community and in rural settings. 4 years is an optimistic turn over time. Many of the docs I've worked with this year are holding me to the same standards they were held to 15 years ago in their training in a specialty other than family medicine. Getting those docs into this decade, into my specialty, will take some effort. It will take much more to get them in line with an entirely new way of completing residency.

If however, this is based on objective observations by a small number of mentors/preceptors who can watch the resident progress from tadpole to frog, it will be a step in the right direction. These observers will need to have their own mentors to help them differentiate where a new resident should be versus a senior. The proposed evaluation program assumes that those evaluating residents will be able to make these distinctions. Unless you have experience with many residents at various levels, knowing how a resident is performing can be tricky.

Most concerning to me though, is the dependency of this type evaluation on numbers of patients. I've been worrying about this since I noticed the rising number of learners coming behind me while we are rushing patients out of hospitals. Despite taking on extra call shifts, totally ignoring PAIRO's rules about hours working, and leaving my cell number for all attendings to call me with juicy cases, at the end of my residency I have spaces in my skills log that are empty, experiences my residents told me I would get after clerkship. If I was graduating from residency in 2020 with the bad luck that I've had for catching cases that are on the relegated list of "must do's", it would take me extra time to finish. Which is fine. But it also means that I'd be taking those vaginal deliveries from junior residents and clerks, because shit does flow downhill.

In an ideal world, this is a great proposition. I try to be optimistic but  my experience with community docs having something extra to do makes it hard. I expect the community and rural programs to lose preceptors when their responsibilities change.

Ask your doc

Chances are he/she will have an opinion.

I recommend you don't get your doc started on Dr. Oz.

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More from the rural hospital

Direct from my rural hospital cafeteria, Real Fruit! And yes that's a local strawberry.


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Learning radiology on your own

Check out the radiology channel on you tube. It includes such BRILLIANT gems as the ossification centres of the paediatric elbow. Awesome.

And don't forget the Wheeless Orthopadics text book. It gives advice on doing the physical exam and management.


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Why cats are not doctors

Good to know.



But somewhat patient centred right?




This is unfortunately not species specific.

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OMG I passed.

Be afraid.


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Choke weed is a jerk

It looks so pretty, hanging out in the sun, making me feel guilty for pulling it out of my garden.



Then I see it taking over the rest of the plants and makes me all cranky. Especially because it's so tricky to pull off my perennials.




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Bias from preceptors

I've experienced so much bias an prejudice during my training. I plan on writing more about this soon, but until then, here's my favourite "constructive criticism".

Of course no one is going to think you're a doctor. People don't take women with long curly hair seriously.


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Yay!

My very own orange book!!




Boo!! A huge stack of dictations!!



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You may be working in a rural hospital if...

You may be working in a rural hospital if your cafeteria

• Is only open to the public between 11 and 2
• Makes real scones
• Serves the same lunch they serve the patients
• Is available 24/7 to all staff with a swipe card
• Lets you run a tab by writing down your eats on a sheet of paper
• Has employees that smile and call you by name

I love this wine

Feel free to send cases. It reminds me of Brie and yummy cosy nights.



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My thought process when choosing where I would practice

In my first year of residency I started to look for where I wanted to practice. I needed to know there was going to be a light at the end of this very long dark tunnel. Seeing how some practices ran, I had a better idea of what I needed in my own and things I wanted to avoid.

I wanted a team that acted like a team. Secretaries and nurses who felt empowered to deal with fires and update me later. Fellow docs who worked together and seemed to have each others' backs. An office manager who was excited about what was happening in the clinic. If the team wasn't able to at least fake this on my visit, they didn't get considered.

A clinic across the street from the hospital. I want to have inpatients and need to feel that I can run across during the day if one starts to decompensate, or starts pushing out a baby.

Hospital nurses who didn't glare at me. If they feel that poorly about a new doc, what must they think of their old ones?

A town within an hour-ish of friends and family. Not too close of course.

An office of my own with a door.

A clinic that allows docs to choose how quickly they'll see pts. Double booking two every ten minutes was not to going to work for me.

A clinic that doesn't need much fixing to make it amazing. I spent quite a bit of my med school career fixing curriculum and have no intention of doing the same while trying to figure out how to run a practice.

I want to teach so having learners regularly was important.

I want to be taught, so having fellow docs who are willing to guide me along was essential. I didn't want to be with docs that are burned out or just as new as me.

Finding a clinic where the docs love their job means that they will be good examples of how to set up my practice to avoid burnout.

I wanted a practice where I could work in the Emerg, deliver babies, help in the OR, see inpatients, and have a diverse group of patients in my out patient practice.

I want to be able to walk to work.

Having a town where housing prices weren't ridiculous was a bonus. Access to nature - hiking trails, water - was essential.

I'm blown away that my wish list was fulfilled. I'm truly looking forward to beginning practice (assuming I pass the damn test - only ten ish more days waiting).

Anything you would have added to your wish list?



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I gave the program two years of my life

And all I get is this stinking water bottle.


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Airway management class

Again.
But at least I got to play with the Gum Bougie for the first time. Fun.

Cozy Sunday

By the fireplace with kitty. Re-reading my favourite book - Good Omens.

Exam done. Course work done. Enjoying the dreary, rainy, couldn't possibly weed the garden, day.

Bliss.



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How far can you push your status?

(347): I just used my med student white coat as ID to buy beer at 9 in the morning

- TFLN


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Ornge crash

This is devastating and hits close to home. We thankfully rarely need the services from Ornge, but when we do, things are already going south. They are a fabulous team that make a huge difference, if only to my piece of mind. I can't imagine how the rest of the Ornge team, the receiving hospital and the patient they were flying to carry feel.


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Waiting on exam results is painful

"The mountains of madness have many little plateaux of sanity" - Terry Pratchett, The Truth.

Our exam began May 3. We should expect results by mid June. MID JUNE. ARE YOU EFFING KIDDING ME.?????

I swear I'm having more, and scarier, nightmares now that I've written. All I can do is rethink everything I did during those three days. I'll see a patient with chronic renal disease and remember a test that I ALWAYS do but forgot to mention. Or, I'll see someone who reminds me of the fake patients in the SOOs and almost burst out crying. Unreal.

If, as my mommy thinks, I passed, at least this will be the last round of exams.

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Residency blues. Again.

I'm lucky enough to not have lost any colleagues to suicide...yet. In the US, physicians are the profession with the highest rate of suicide. Pamela Wible has described three scenarios that I know have at least flitted past my consciousness. The idea that we are supposed to take on as much responsibility as we do and not be allowed to address our own distress is appalling. We shouldn't be afraid to ask for help for fear of losing malpractice insurance.

I know I've blathered on about the stress associated with residency, but honestly feel that I just can't do it enough justice. The words to describe the emotional roller coaster just don't exist. Instead, I'll give you a list of events that I have experienced, usually many in the same day.

Received lab results back that confirm invasive breast cancer in my neighbour.
Been so overwhelmed at work I haven't cleaned my poor kitty's box in well over a week.
Delivered a beautiful baby girl to a mom and dad who couldn't stop kissing each other or the baby to let me congratulate them.
Delivered a beautiful baby boy to a mom who because of her own brain injury will not be allowed to keep him.
Revive a patient during a code blue and have him go on to living a healthy happy life.
Help a young woman suffering from a painful cancer sleep away her last week of life. And then help her parents cope with their daughter's decision.
Lost track of so many emails and Facebook messages from friends I'm surprised they still answer me when I do send a note.
Been told that I'm an incompetent physician who needs to do at least 6 months of remedial training.
Been told I'm a brilliant physician and that my preceptor is excited to have me as a future colleague.
Had patients hug me for telling them about their cancer, their lack of cancer, that I'm leaving a practice, that their mom just died.
Newborn baby exams. Smelling newborn babies.
Helping moms learn to breast feed when they've given up hope.
Missed my nephews special events for work.
Finding my own worrisome lumps.
Had my vacation time continually denied until I just gave up and have weeks of vacation at the end of each residency year left over.

The ups and downs never end. It can be absolutely exhausting. My blog has provided me with some outlet for what I'm doing. I also have a fabulous partner who is extra supportive and a BFF who is going through the same crap. But even with all of the help, residency is incredibly isolating.

This doesn't make sense to me.

Residency is supposed to be preparing us for practice. We should be learning the coping mechanisms now that will keep us from planning a 03:00 dive off a bridge.

Which I suppose leads to the question, what prevents us from becoming hopeless? How do we keep our light shining when we barely have the energy to wash our hair?

Zakari Tatasuggests monthly counselling sessions for residents to address the extra stress that residency incurs. She also says "The idea is not to find a perfect solution but to openly discuss and accept that physicians are vulnerable. The current culture that presents physicians as always being in control of their psychological health should be discarded."

I know an attempt was made in my med school to encourage self care, but it wasn't given as much attention as the importance of knowing how to write a clinical note or avoiding embarrassing the school. Lip service from the chosen few lovey dovey types that isn't also reflected in regular practice is soon lost.

Next week is resident wellness day at my institute. Events will be held in a city I try to visit and will include a speech and yoga. One day a year doing something I could do at home by watching a Ted talk while stretching.

As with most other behaviours, I argue that we need to learn and be taught by example. After breaking bad news, do a debrief and check in on one another. A preceptor who is willing to admit to difficulty dealing with everything on their plate and going through the options of dealing with said overflowing plate teaches a valuable lesson. We are trained to recognize depression and anxiety in our patients but rarely ask our colleagues about it. I've seen a doc whom all his colleagues stated was burned out but none were willing to talk to him or ask how to help him slow down and recharge. The lesson I learned is that my own mental health doesn't matter in my profession.

That can't be right.



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Making patients responsible for their own health

Something we talk about a lot at our hospital is that we expect our patients to take control of their own health.

You're out of breath and coughing like crazy? You should choose to stop smoking.

You've had a headache for three weeks and haven't tried Advil yet? Seriously? I have no words for you.

There are ads everywhere reminding patients that they need to be screened for various cancers. Patients should take responsibility for initiating contact.

Once you make contact, Advil didn't work or want to quit smoking? I'd LOVE to help. But honestly, if I'm pulling you by your nose to take care of yourself, you're not going to like it and I'm going to lose interest. Patients who come in wanting to find out what they can do to prevent constipation or to lower their cholesterol make me glow. I love teaching my patients.

An issue that comes up, as it does with so many patient centred practices, is time.

I try to get around this by building up an idea then giving my patients homework. Next visit, we review what happened. Getting patients to buy in is sometimes tricky but I find it gives us a goal to work towards in our visits, especially those with chronic disease.

I wonder if preparing a journal for patients with a specific disease to work through might work better. This article suggests journaling to improve compliance for exercise in the depressed, and offers suggestions for topics after walks such as "how do the trees around you look?" Maybe having a set list of mini goals to achieve would improve compliance.


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Youngman's Death

Where has this poem been all my life??
Now that I know Roger McGough exists my life means so much more.
Let Me Die A Youngman's Death

Let me die a youngman's death
not a clean and inbetween
the sheets holywater death
not a famous-last-words
peaceful out of breath death
When I'm 73
and in constant good tumour
may I be mown down at dawn
by a bright red sports car
on my way home
from an allnight party
Or when I'm 91
with silver hair
and sitting in a barber's chair
may rival gangsters
with hamfisted tommyguns burst in
and give me a short back and insides
Or when I'm 104
and banned from the Cavern
may my mistress
catching me in bed with her daughter
and fearing for her son
cut me up into little pieces
and throw away every piece but one
Let me die a youngman's death
not a free from sin tiptoe in
candle wax and waning death
not a curtains drawn by angels borne
'what a nice way to go' death 

Roger McGough

All of Life's Important Lessons

Everything you need to know comes from the movie Princess Bride.

Here, Buzzfeed shows us some of the funnier lessons.

A mom blogs about what Princess Bride taught her about autism. I love her take on it and think it's applicable to everyone, not just those who love someone with autism.

My favourite lesson is the first:

1.  Affection doesn’t have to mean saying I love you

Reading a story to someone who’s sick in bed, saying “as you wish” or playing rhyming games that annoy your boss... there are many more ways to show love than just those three little words.

I've found a new reason why this is important. Many patients that I have are stubborn. Shocking I'm sure. Today I told a woman that because she refuses her daughters' help, it's like she's not letting them show her how much they love her.

I may have just taken the guilt trip to a whole new level.

Med Students are Biased Against Obese Patients

I want to pull out the original study, but from this article it looks fairly well done.

Essentially, 3rd year medical students in North Carolina were shown drawings of a thin or obese person and the time to associate positive traits was measured. 1/3 were moderately to severely biased against the obese diagram.

This isn't shocking - we've seen it before with practicing docs.

When planning my education objectives in residency, I often hear warnings about recognizing that there are things I know I don't know, things I know I know, things I don't know I already know and things I don't know that I know

Something I like here is that they point out that we need to find a way for students to be aware of their bias. This is a tricky thing to teach since it often falls into the category "what we don't know we don't know".

Teaching students to recognize bias must be a lot like doing psycho therapy - challenging the thoughts that go on behind our actions. It may be that teachers acknowledging their own biases during case presentation may make it second nature for students to include acknowledging bias in their own work. Providing a positive role model to med students is important. We know that clerks are sponges for behaviours they see on the ward. It seems reasonable that positive behaviours can be picked up this way as well. Possibly, we need to devote class time to learning about distorted thinking. We discuss the biases which are inherent in most medical research but often miss the bias we bring to our everyday life.

"If doctors assume obese patients are lazy or lack willpower, they will be less likely to spend time counseling patients about lifestyle changes they could make," he said. "Doctors also may be less likely to recommend formal weight loss programs if they assume their patient is unlikely to follow through. "

Miller said bias might also make doctors less effective. "If a patient senses his or her doctor doesn't like them or doesn't respect them," he said, "that will damage the trust that is key to an effective patient-physician relationship."

This is an issue for more than just obesity. We see this in substance abuse and alcoholism as well. If we don't ask, don't offer help for change, we are cheating our patients.

More importantly, if we allow our biases to lead us, we are teaching the next generation of docs to do the same.
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Suicidal Ideation

We are taught to screen for patients who want to kill themselves. Mnemonics such as SAD PERSONS offer us structure for listing risk factors that put us on high alert.


Often I hear things like "what's the point in taking my medication when it's only prolonging the inevitable?", or "I'd rather have hair than live the extra year that chemo will buy me." We call this passive suicidal ideation. People who do not plan to kill themselves but wouldn't mind if they were dead.


Shocking to me today, was the patient who calmly told me his plan for suicide. He has spent months researching a clean, pleasant way to die which he believes will not scar his family. He has even invited his brother to sit with him as he goes. This is a man who may not have long to live and wants to leave the world on his own terms, in the manliest way possible. Being eaten alive by wild animals would be preferable to the slow death his COPD promises.


More shocking to me, was the way I dealt with this news. I didn't miss a beat and continued to ask him to explore the idea.


Now that his plan is in the open, psychiatry needs to be involved to prevent him from preemptively taking his own life. I find myself questioning the futility of that, but will honor my oath and do all I can to keep my patient comfortable and alive as long as I can.


The psychiatrist may lift the Form One because the patient is reasonable.


In the mean time, I'm researching how to get an angry grizzly bear into the Resp unit with no one noticing.
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The patients you think about

Have a look at this article. I've been following the blog on twitter and learning quite a bit. This case in particular raised my shackles a bit.

Similar aged woman presents late at night to my ED with a week of deep, dull chest pain. No risk factors. Her ECG was beautiful. D-dimer was negative. OE viral URTI. No improvement with ibuprofen. I was reassured and sent her home to follow up with her family doc ASAP.

Even now, seems reasonable.

I recognize though that I'm someone who suffers from "Nah, it can't be." I know in this case I did all the investigations I would have done for a 45 year old except calling radiology to get a CXR.

Having cases like the one described in the ECG teaching help me to keep perspective. I think we need to share. These odd cases so we remember that not everything we learned in med school was true.

The trick, as ever, is protecting patient privacy while expanding the knowledge base we have available.
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This is NOT a 2 am consult

I'm always afraid of being wrong and making a stupid mistake in front of colleagues. I think it's fairly common, we all want to be seen as competent care givers. We never want to admit that we don't something but when our patients need us to 'fess up about our lack of knowledge, we will, and call a friend.

Working in a small ER means that rather than having in house specialists I can bounce questions off of in the middle of the night, all my specialists are elsewhere in hospitals where they are expected to be allowed to sleep from 11pm on because they'll be on call all weekend. It takes a lot of guts to call after midnight.

I'm sure you can see where this is going.

I've seen a lot, but I haven't come close to seeing everything. I try to extrapolate from what I do know to what I'm seeing in front of me. Given what I saw the other night, and what I know from other similar structures, I was going to need help. Apparently I should have known better and that I didn't need help.

I still feel like I did the right thing. I had a patient in front of me with unbearable pain. The resources in front of me where not at all helpful, though I could have looked for the procedure on youtube... I called. I got snarked at. I also got the info I needed and my patient left free of pain.

Since this blog is about making me a better a doctor, what would I do differently next time?
1. look in even more basic books than I was, something like Tintanelli's.
2. YouTube the procedure.
3. Start my consult (if I still decide to call) with "I'm not sure this is a 2am consult, but my pt is in quite a bit of pain...".
4. Take a breath and put everything in context. I frequently let my nurses guide my care. I trust them to know what to do and very often, that's a good call. But sometimes, I need to listen to my own brain and cut them out.
5. Work out how I would do what I need to do - get the patient into position, get the equipment I need in position. There's something about going through the steps first that makes a procedure easier to do and less scary as well.

Eeyore

I convinced a 5 year old girl this week that Eeyore isn't sad, he's dysthymic. Hearing a wee girl without front teeth say "dysthymic" is awesome.


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Cards Against Humanity

Today was the first of three days of my family medicine licensing exam. It was the short answer management problem day, 3 hours in the morning, 3 hours in the afternoon with an hour for lunch in between.

I had room in my bag for either my notes or my box of cards against humanity game.

I made the right choice.

Playing a silly, irreverent and occasionally dirty game was the perfect mid exam break.


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My partner isn't immune

My partner is incredibly supportive. Like ridiculously supportive. To the point that he is also having exam nightmares.

What a good fellow.


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Exam nightmares

Last night, I was senior resident on call in a teaching hospital. I'd never done this before so it was acknowledged that it was a favour.

My consultant was my grade one teacher. I was still anxious about talking on the phone with her. Not knowing I was on call, I was drunk, and had to speak with her. Mrs. Grade One didn't seem to notice but it was mortifying.

There was also a lot of explaining my age and still being a resident. Also explaining that I'm used to emergencies coming in drips and drabs at my wee hospital.

No actual medicine, just feeling fully out of place and not at all ready.

That's what nightmares ate for though right? To show you what your insecurities are so you can analyse them in the cold light of day and kick them to the curb?

Rawr. I've got this.

Our Worst Enemies

My Facebook Newsfeed has been covered with the Dove Beauty Debate.

It's a fairly powerful video for those who have every felt ugly. Most of us recognize this is untrue, but it's a message that is deeply ingrained. It is unacceptable in many cultures to be confident in one's looks. Our superficial self is less important than how we act "beauty is only skin deep".

Women learn to go to the washroom in groups and complain about our appearances. I remember being so proud of myself for dancing with a boy for the first time in 7th grade but feeling an overwhelming need to put myself down while in the washroom with the grade 8s. It's not like I was tied up and told that I was unattractive. Since I was able to pay attention I was susceptible to all the messages about what beauty is. I was not beautiful.

Speaking of these messages, what about those Ax ads? You know, the ones where women go running after boys who spray themselves with Ax body spray? Yuck. Unfortunately, Ax is owned by Unilever, the same company that owns Dove. Does it matter? I don't think so. The message of the Dove ad is just as valid.

A counter ad has also been making the rounds. Personally, I don't think they get it. It's about how guys are self confident and women try to make them feel bad about themselves. Thanks for supporting the previous ad.

Why does this matter? So what if women secretly think they are pretty but are afraid to admit it in public? There are thousands of articles on pubmed looking at the correlation between low self esteem and health, they speak for themselves. Women in my office have a hard time telling me what it is that is actually bothering them because they don't consider themselves important enough to take up my time. I'm astounded by the number of women I've seen in my very short career who have ignored the signs of cancer until it is too late to do anything.

We are taught in med school to address the patient as a whole. Is there a link between feeling beautiful and caring for one's health? There may be. Honestly though, I didn't find as much evidence as I expected. There are many studies on eating disorders and body image, as well as self esteem and cancer and sexual dysfunction.

Helping parents to raise men and women who are strong, who love themselves, and who will treat their bodies well is important to me as a family doc. I'm happy to see my colleagues, family, and friends debating the topic.

Not even the end of second year

And already my colleagues from medical school who have chosen other specialties are dissing family medicine docs.

We are not just a dumbed down version of your specialty, or even all the specialties.

We are a specialty of our own. We deserve your respect. I guarantee, no matter what you think, you could NOT do my job for a day. I couldn't do yours. And that's ok. It's why we chose different specialties to match to.

I know we need to be cocky to do our jobs well, but it should never, ever, be at the expense of another specialty.


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You might be a rural resident if...

You've used the phrase "the antibiotics I usually use for manure spreader injuries are..."

You need to avoid the horse plop when running between the clinic and hospital.

Your nurses are just nurses, not OR nurses and ER nurses and post surgical nurses. They do it all. And rock.

You ask all patients how they heat their homes and what kind of flooring they have. I have several patients who use wood exclusively to heat their homes and others with dirt flooring.

You've diagnosed ORF.

When screening for suicidality, checking for firearms in the home is a real concern. As is rope in the barn to hang from.

Your grocery buying habits have greatly improved because the store is full of your patients who are watching your cart.

Almost none of your patients are full code "I wouldn't treat my horse like that, why would I treat myself that way?".

Happiness is...

Having a giggle fit at one in the morning with a five year old boy who bumped his head while being silly.


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STI testing

There are pros and cons to testing. One con is that your results may not match your partner's.

TFLN

(214): Nothing says love like couples STD testing
(972): Nothing says breakup like the results


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And the exam nightmares begin

Even in my dreams, I would rather hunt zombies than study for the exam.

Right now I'm regretting not doing the MCCQE part 2, if only because it would have forced me to start studying a heck of a lot sooner. It also wouldn't have been so shocking to me to find out there is a day of OSCEs as well as the day of SOOs.

This is the second time they're running the CCFP exam this way. It was run in the fall, no problems from what I can tell from my friends who wrote. That gives me hope that it won't be the gong show that the first computer based MCAT was.

So, this nightmare was one of those that make you feel totally helpless. The usual high school crap. I have been studying, but for some reason, haven't written any exams for the past two years and even miss the final exams. I'm looking at never being a doctor again, ever. Not only have I not written exams, I seem to have entirely missed several classes and was never able to find the text books. And, for some reason, I've moved back into my parents' home, along with all my siblings. There is no place for me to study and too many chores to get any studying in. Then, out of nowhere, zombie apocalypse. And I'm relieved? WTF.

I've been interested to see how different residents are choosing to study for this exam.

Some are studying at least 12 hours a week. Coming together in groups weekly and preparing their 99 problems to discuss with each other. Others aren't studying at all.

I'm just trying to stay on top of my clinic work, study when and if I get time.

I've stocked up on herbal tea. I've set up 3 study areas in the house. I have a back up cafe I can use plus the clinic when it's shut.

I've got this.

How can someone who moves as quickly as you do be so big?

It's hard not to be offended when patients make comments about my body size. It's something that I am incredibly self conscious about, like most folks who struggle with their weight. 

So far, most comments have been fairly benign, but some patients are unwilling to discuss their concerns about their weight with me because they don't believe that I am a valuable source of advice. I think more than most of my colleagues, I'm on top of this information.

The Obesity Society publishes a monthly journal which I read and pull out the most relevant information for my patients. I'm looking at what may and may not work for my patients' health. That I'm not doing the same for myself is, well, it's hard to talk about.

When NJ Governor Chris Christie was considering running for president, he received considerable criticism about his ability to run a country when he couldn't control his own weight. The Obesity Society published this statement about fat bias.

This statement resonates with me.

A person’s body weight provides no indication of an individual’s character, credentials, talents, leadership, or contributions to society. To suggest that Governor Christie’s body weight discounts and discredits his ability to be an effective political candidate is inappropriate, unjust and wrong.
Caution should be taken in making assumptions about a person’s lifestyle behaviors based on physical appearance alone. Individuals who are not struggling with their weight are not necessarily healthy. A lean body does not reveal whether or not a person smokes cigarettes, drinks excessive alcohol, eats a balanced diet, exercises regularly, or wears a seat belt. To single out a political candidate on the basis of body weight is discriminatory. 
The criticism of Governor Christie is an unfortunate example of the weight bias and stigmatization that is pervasive in North American society. The prevalence of weight discrimination in the United States has increased by 66% in the past decade, and is now on par with rates of racial discrimination.

I think that a large part of why it provokes an emotional response in me is because I have just as much weight discrimination against myself as anyone else does.

Good dictation words

I use the word nefarious as often as possible in dictations.



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Half day back

Many of the family medicine residency programs now have half days back to our home clinic. It's a way for us to integrate the learning we're doing in the specialties to regular practice. It also let's us follow our treatment plans and know if we've made good decisions with our patients.

Today was a half day back for me. I followed up on three treatment plans. All going well. All on course. All getting better.

It's one of those days when I feel like I'm doing what I should be.


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Taking a break

It's been a while since I gave myself permission to just chill out. There have been some intense, busy, yucky stuff going on up in here. But today, for the long weekend, I used the afternoon to colour.

So worth it.

I haven't done this since first year of university. It clears my mind, keeps me focused on something silly.

This will come in handy as I prep for exams. Again.




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You May Be Working in an Old OR

If this sign is posted ...


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More Art and Medicine

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