Wednesday, March 17, 2010

Snapshots from Week 1 on the Wards

I had so much to reflect on from my first week of inpatient medicine, so much I wanted to capture and document here in a format that I could look back on, a format that would keep me honest. But I didn't. Instead, I ranted to my roommates (I'm living in a dorm with four other med students, right across from the hospital), I ranted to my boyfriend. And I emailed my preceptor at the clinic.

I'll paste those emails here, more raw than I'd be able to re-create. His responses were what was epic about the exchange - but I think it's probably poor form to post someone's emails on the Internet, unbeknownst to him or her. But here's at least my end, for me to remember.

Thursday, March 11, 2010 -23:31.

Life is ok here. Slightly less disoriented as the days go by. Getting pretty good at writing notes, functioning on little sleep, and mildly to moderately competent at presenting without sounding like an idiot. Oh, and yesterday I found out that I passed my Boards.

I started my first rotation on Monday. Renal. Everything very interesting but exhaustingly sad and frustrating. Even the people who “get better” don’t actually really get better. It's almost like there is a drop-down menu: 1) dialysis now, 2) dialysis later, 3) death.

My first patient is the sweetest, nicest old man. I spend most of my day with him and his wife (a nurse), translating all the minutiae of his treatment plan (they totally care, and nobody ‘gets’ that they really, truly want to know every single thing that’s going on). They’re so scared, and they experience a greater sense of control by having specific data points to track. But all the data gets worse every day. Prior to a few months ago, he had no renal problems at all – and suddenly, he’s days away from dialysis. Diagnosis is still undetermined (repeated a biopsy today) – but he might actually have Wegener’s. I didn't know people actually got that. His renal function gets progressively worse, his sugars are skyrocketing from all the steroids he’s getting, and he has incidental lung findings that might be consistent with IPF (you taught me about how bad that on my last day at clinic; my first patient wasn’t supposed to actually have it…)

Most nights, I dream about him dying.

While I was at a lecture today, he had an ischemic cardiac episode (ST depression on ECG, initial biomarkers were negative but it was probably too early). I later found out he had to call 3x before anyone came to him. He had told me about overnight chest pain on pre-rounds this morning (which he later explained felt exactly the same as this episode), and my team unanimously concluded this was anxiety when I presented to them. Then, this happened. I felt horrible. I was too wimpy to advocate for him; I merely reported facts and didn’t dare express my differing opinion – even though, technically, this is an environment where I could have.

My residents frequently comment on what a great case this is for me to see as a student – an ANCA-positive vasculitis with possibly related lung findings (my one useful contribution to life was to suggest testing for anti-GBM antibodies, since that commonly but unfamously can show up ANCA-positive). But it doesn’t feel great. It feels awful. Every time he asks me if he’s going to get better and stop getting infused with all the poisons we’re giving him, and I have to find some horrible way to balance realism with whatever we’re waiting on for x day, it’s just awful. Important learning experience and preparation for what is to come, of course, but awful nonetheless.

Saturday,March 13, 2010 -11:30

Yesterday was a good opportunity to focus on all the non-"know how" parts of medicine, and to feel useful that way. It was a really scary day for my patient -- tunnel cath placement and start of plasmaphoresis and dialysis (all of which were decided last-minute, so he hadn't psychologically prepared for it). I had time to spend the whole day with him and talk about his fear, intervening/translating when various characters communicated sub-ideally (including eeeeeevery resident here, who all either spout nonstop jargon or deliver all news at the level of a first-grader; no middle ground). I hope I'm not naïve in thinking that piss-poor communication skills are not soley the result of time pressures that I don't yet have.

It's good that I'm literally forced, all day long, to practice educating him and his family at appropriate levels for all of them, and framing horrible test results and horrible treatment options (my new gripe that may prove to top "compliance" the longer I'm here, is the whole "we're going to do x to you today" without bothering to create even an illusion of perceived control).

I've been spoiled in spending so much time watching you communicate about difficult issues so expertly. But I forgot how instructive to watch how NOT to handle something, too - and attaching what I learn to this emotional memory, I hope will last. For example, we were recommending cyclophosphamide (communicated as "we're going to start you on cyclophosphamide" without a discussion of what it is or its risks) -- and the wife's eyes bulged out of her head. She clearly recognized the drug name and assumed her husband had cancer and that we weren't telling them, so started asking vague questions so as not to alarm her husband. The resident could have cleared this up so quickly, but didn't pick up on what the issue was instead was awkward and vague and ending up scaring the hell out of them. I don't think I'll ever forget that, the importance of inhabiting people's responses to be able to anticipate future response. I've been able to ask these folks all sorts of questions about their reactions to various events and interactions. I won't ever be able to spend an hour on that after clerkship - but hopefully I'll remember to ask at all.

I'd like to be at a place where I don't get tearful when I come home every night and show up to the hospital rehearsing my coping mechanism for finding him dead. Does this get easier?

In other news, today I saw the chalky blue-grey skin changes of amiodarone that I memorized and regurgitated for Boards but had never even seen a photo of. Seriously not ok.

Monday, March 15, 2010 -- 20:12
Today I pissed my supervising intern off by asking if I could call for a (free) dietary consult to teach my patient (who is actually getting better!!!) about how to adjust to his new restrictive diet. "It's too much information." A complete misread on who this guy is. He wants information. He wants to understand. He gets anxious without being able to have any expectations, or at least accurate ones (bonehead covering attending over the weekend told him he could go home today, without determining that plasma exchange isn't done as an outpatient here - Imagine his disappointment to learn that it's actually an entire week extra).

On the flipside, I'm now helping to take care of a new patient who's at a totally different level of what she understands and wants to understand. 78 year old woman, very much of the "doctors do no wrong, I entrust myself completely in all of your hands" mindset. I'm sure that I'll learn a lot about how differently I'll likely communicate with her than with the first guy. It's a tricky balance between making people feel comfortable and safe vs minimizing the fact that their kidneys are shutting down. It's entry-level "giving bad news" practice.

In other news, I independently diagnosed a real person for the first time. It was a result of relying on a flawed heuristic (I'd read someone's memoir a few weeks ago about missing ischemic colitis in a little old lady with a GI bleed) instead of legitimately knowing that the other potential causes I did know about were more common. It was the first time I had an original intelligent contribution within the borders of the state of Maine, and it didn't even earn a "good thought" (universal validation of medically intellectual legitimacy, of course). It was more "let's order a lactate to humor the silly medical student to make her feel like part of the team." I was kind-of furious at myself about how proud I was to be right, especially since I arrived at it completely unscientifically. But as a wise man once told me: "tis better to be lucky than to be good." I probably butchered that, sorry.

No comments: