Hallowe'en!!

Two for the kiddos... One for me.




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Unmet Objectives

Yesterday was my last day in the emergency department. It was a day of mixed feelings.

I didn't feel at home in this ED. They weren't familiar with having learners in the department and tended to make me feel uncomfortable and sometimes unwelcome.

The few preceptors who were enthusiastic to teach were a lot of fun to work with and I appreciated their caring and the cake they provided to say good bye with.

Despite my personal enthusiasm to learn, I only met a few of my many learning objectives. Part of this was from the volume we saw in the ED - I can't practice inserting central lines when there is no need for it. The preceptors were not comfortable with me taking the lead in cases where I could use my ACLS. It may be that they didn't realise that I was certified to help a patient whose heart had stopped.

I did however get very good at diagnosing UTIs, sinus headaches and sciatica as well as suturing almost any body part you can think of.

While I don't want to add an extra year of learning to my residency, I do want to be proficient enough to feel comfortable being the only doc in a small ED. I may need to either add learning through simulations or electives.

I really hope that my Internal Medicine rotation that I start next will be more fruitful.

Ouch.

One reason to not attempt kooky sports without training.


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Sometimes, I hate my patients

Like, really, really hate them. Want to punch them in the nose, squish their toes with the base of the gyne lamp, tell them they're stupid-dummy-heads, hate them.

I know that there are higher psychological reasons for why I hate them, that there is transference from someone else in my life, countertransferance of someone else in their life, personality disorders, weird smells, ..... It's just that sometimes I really don't care.

It takes quite a bit of effort for me to still treat them well. I find it hard to make my clinical decisions with these patients. Before I choose a test, a treatment or a referral to someone else, I need to check in with my conscious to make sure I'm not basing any choices solely on my hatred for the patient. Is that enema really necessary? Am I trying to ditch this patient into someone else's service so that I don't have to worry about it any more? Emotionally, it takes much more out of me. It also takes more of my time because I'm second guessing why I am making the decisions I am.

Even though I know I'm not the only one who feels this way about patients, it's nice to know that there is evidence to back that up.

I also know that I will spend more time with the patients that I like. This is something that I don't spend as much time thinking about but wonder if I should start. It would be just as wrong for me to not order invasive tests because I like the patient or spend time that should be spent on other activities.

These patients are going to more likely to lie to me to make me like them more. I have a patient who has been fibbing to me since day one because she didn't want to disappoint me. I finally called her out on it and we are going to start a different therapeutic alliance. I hate that it had to come to that. I liked being lied to and feeling like I was the best doctor ever because my patient was doing so well.

I swear, every time I think I have a handle on this whole doctor thing, something new pops up to let me know I've never had any form of competence.

It's Flu shot season!!

The traveling RN team is shooting up the staff. She's a floozy.



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Apps and PodCasts for CaRMS

It seems like most of the random traffic I get to my blog comes from those looking for info on CaRMS, especially those wondering what will happen if they don't match. This post is for you guys. It's intended for the CaRMS tour, but if I wait until then to post it you won't be able to procrastinate now from writing personal letters.

Pod Casts can be a wonderful way of getting ready to speak with interviewers before you head in. The speakers are using doctor words eloquently and may bring up points that are interesting to you and could inspire a tangential chat between you and your interviewer. They can help you pass the time while waiting outside the interview room and since they require headphones, ensure the other candidates won't freak you out. To be honest, I just had a graphic novel with me that I read while waiting. That kept other candidates far away from me because they figured I was a weirdo.

White Coat Black Art is a fantastic pod cast that often gets at the things that we often think about but rarely talk about, in particular the errors that get made in medicine and how we deal with them and with our patients. These are downloadable from the CBC website or through iTunes.

You can also download the app ReachMD for free. This contains a large selection of pod casts ranging from short 10 minute clips to 3 part lectures that are over an hour long. They have a table of contents based on CME, programming series, specialties (you name it, it's there), Listener's favourites, new programming this week. It's an American radio station on XM satellite but they often have Canadian content experts speaking. This may give you an idea of some of the current topics in the specialty you are applying to that you hadn't thought of yet.

Bump is kind of awesome and fun. It's a way to share data between iPhone users. All I use it for is contacts but it has function for photos, apps, music, calendar and social networks. When you are on tour, you'll be meeting some fantastic people you will want to keep in touch with. Bump lets you share your contact information quickly by bumping your 2 phones together so you can text and meet for a beer after interviews. These are your future colleagues, not your enemies, get to know them. Free app!

Starbucks will be in every city you are applying to. Knowing how to get your coffee in the morning or find a place to chill out the night before will make you a much happier applicant. This app has a mapping feature that will help you find directions to the nearest store and includes valuable information such as hours, if they have wireless, if they're drive through and if they will warm your apple fritter for you. Also free!

There will be times when you are preparing for an interview that you want to know some specific information about the city you are applying to. WolframAlpha is the multi trivia app for you. If you ask about the population of the city in question, it has that info plus graphs on the growth of the city in the past 20 years. It will tell you what is nearby to avoid geographical errors in interviews and allows you to compare to other cities. It also has a scientific calculator, information on weather, people and history, music, words and linguistics, information on the local athletic teams. Everything you could possibly want to know to schmooze with the interviewers. $1.99

You want to have your personal letters and CVs with you at all times on the CaRMS tour. It's likely that at some point you will leave the stack of paper in your car or hotel or at home. Emailing it to yourself is a brilliant idea, but what if you can't get access to the internet in the dungeon the interviews are being held in? Am I the only one who plays out these disaster scenarios in my head? I uploaded all my info to Office2Plus. It lets me keep local files on my phone, create word documents there too while I'm feeling creative and connect with my GoogleDocs Cloud folder. You can keep everything in folders that work best for you. The ability to organize everything and the fact that it mimics my PC make me like this app most of all. The original app is free, but you need to purchase within the app for the kinds of files you are using.

The night before your first interview and your interview at your number one school can be brutal for sleep - relaxation is not going to happen. Still, try Andrew Johnson's Relax. This

is a guided relaxation that can make you feel rested. I love his accent. I used this during clerkship too when I had 20 minutes until handover and didn't get any sleep. It helped keep my going just a little bit longer. There's a free version, not sure about that one, but the one for $2.99 lets you choose if you want to wake up or go to sleep at the end of the relaxation time and has different options for the relaxation itself. If I'm extra wired, I go through the meat of the guide 2x.

xkcd has an app. This will keep your humour high during interviews. These are brilliant comics! omg it's free!

Need to put your life into perspective? FML (f my life) has stories of teenage woe that are rarely worth the curse in the title (free). I prefer TFLN (texts from last night), a series of texts that were sent that likely should not have been, more often than not under the influence of alcohol. This one is $0.99 and infinitely entertaining.

Fat Bias in medicine

It happens all the time. You'll hear comments like slob and stupid associated with obese patients. Surgeons in particular have a reputation for commenting about their patients girth in a less than kind manner. I've heard of one patient who, before her surgery, wrote across her abdomen "no fat jokes". It was written so that it was legible from her feet - no easy feat for a pt in hospital. Clearly this is something she was worried about. And she should be. If we don't like our patients or feel that there is something unpleasant about them, we are less likely to treat them well. It's well documented that our psychiatric patients are less likely to have their routine care up to date compared to their counterparts with no mental health concerns.

I did a quick pubmed search looking for obesity discrimination by health care providers. There is a definite dearth of information on the topic. All I know is what I hear. As a larger than average resident, I don't hear as much as what others might, but what I do hear is concerning. In a perfect world, all patients would be seen as equal, no wackiness based on how a patient looks.

We know that role modelling plays an incredibly important part in every medical student's education. Given that medical students start with a bias, it's even more important that those acting as mentors to their students be aware of how their own prejudices can shape attitudes.

"A total of 76 clinical-level medical students were randomly assigned to interact with a digital, virtual female patient who was visibly either obese or non-obese."

The students looked at the virtually obese patient less often and anticipated poor compliance from her. In general they displayed negative stereotyping towards the obese "patient".

Our world is not entirely dim though. Another study has shown that a brief intervention providing anti-bias teaching about obesity is effective in decreasing these negative stereotypes. I worry though that if it's this easy to change an attitude, will the off handed comment of a consultant cause the patient to change back to their previous biases?