Society has an obsession with age, and using the term "old" is controversial. Despite the almost universal fear of the aging process, there is no universal definition.
My own personal definition of "old" is: always 10 years from where you are now. A decade always seems like such a long time, and the great thing about this definition is that the cut point is moving with you. I can only assume my grandmother had a similar policy, as even at the age of 88 she absolutely refused to consider moving to a nursing home or assisted-living facility because "that's for OLD people."
This made me start thinking about how different medical specialties see "old."Most literature I've seen uses 65 as the definition for elderly.
Here are my impressions for what each specialty thinks of as old:
Medicine: When the patient develops an obsession with describing their bowel movements
Cardiology: 65 - when your age is enough to bump up your risk even without other medical conditions
GI: 50 - colonoscopy time!
OB/GYN: 35. the point at which you're automatically high risk in pregnancy due to age.
Anesthesia: 65, your age puts you at greater risk with sedation
Surgery: When you include the word elderly in your note
Pediatrics: 19. Time to find a new doctor.
Geriatrics: Is geriatrics consulted? If yes, patient is old.
Radiology: When any finding can be attributed to "age-related"
Thursday, August 8, 2013
Monday, July 22, 2013
GAAAAA!
As the intern, there are so many things I know that I don't know. Some things, however, just don't feel right. I'm used to double- or even triple-checking my work just to make sure nothing's slipped through the cracks, but sometimes things slip through. Sometimes, however, it's not me who's missing something.
After seeing a patient for a relatively simple consult. I called the primary team to give our recommendations. "okay", was the reply, "what about transfer to medicine?"
"Excuse me?," I said, "you didn't mention that when you called for the consult."
"Maybe I didn't communicate that clearly, but there's also a question about transfer to medicine" the surgical resident replied.
"Okay, but the patient has no active medical conditions," I said
"We're not going to do surgery, so we can't keep her and she can't stay in the observation unit past 24 hours"
"I know that, but she doesn't meet admission criteria for medicine"
"She has MULTIPLE medical problems!!!!!"
"That's true, but none of them are active. medicine can't accept the transfer."
At this point, sensing I wasn't getting anywhere, I told the resident I would talk to my senior and get back to them.
My senior resident agreed with my assessment but suggested I run it by the attending just to prevent too much pushback from the surgical team.
I went by the patient's room to check on his condition and to make sure I hadn't missed anything. I ran into the surgical resident and went another round as he insisted the patient needed admission to medicine and I explained that we couldn't do that, the patient did not meet criteria for admission, and that I had included recommendations for home medications and care in my note.
The resident clearly wasn't happy, but I did what I could and gave my senior resident the heads up. It was a good thing too, as she then got an extraordinarily angry call from the surgery chief resident about it.
This was one of two cases that day where surgery requested an inappropriate transfer that we turned down. My senior resident and my attending had my back, and it was a really good feeling when they told me I was correct and had done the right thing. I know I'll miss things and make plenty of mistakes, but it's nice to know I can do things right sometimes too.
After seeing a patient for a relatively simple consult. I called the primary team to give our recommendations. "okay", was the reply, "what about transfer to medicine?"
"Excuse me?," I said, "you didn't mention that when you called for the consult."
"Maybe I didn't communicate that clearly, but there's also a question about transfer to medicine" the surgical resident replied.
"Okay, but the patient has no active medical conditions," I said
"We're not going to do surgery, so we can't keep her and she can't stay in the observation unit past 24 hours"
"I know that, but she doesn't meet admission criteria for medicine"
"She has MULTIPLE medical problems!!!!!"
"That's true, but none of them are active. medicine can't accept the transfer."
At this point, sensing I wasn't getting anywhere, I told the resident I would talk to my senior and get back to them.
My senior resident agreed with my assessment but suggested I run it by the attending just to prevent too much pushback from the surgical team.
I went by the patient's room to check on his condition and to make sure I hadn't missed anything. I ran into the surgical resident and went another round as he insisted the patient needed admission to medicine and I explained that we couldn't do that, the patient did not meet criteria for admission, and that I had included recommendations for home medications and care in my note.
The resident clearly wasn't happy, but I did what I could and gave my senior resident the heads up. It was a good thing too, as she then got an extraordinarily angry call from the surgery chief resident about it.
This was one of two cases that day where surgery requested an inappropriate transfer that we turned down. My senior resident and my attending had my back, and it was a really good feeling when they told me I was correct and had done the right thing. I know I'll miss things and make plenty of mistakes, but it's nice to know I can do things right sometimes too.
Tuesday, July 16, 2013
Medicine Consult is an excuse for surgeons to not use their brains!
I'm currently on the medicine consult service. We manage medical issues in surgical patients, but I've found it to be primarily used by surgeons as a way of getting out of dealing with ANY non-surgical issues.
The frustrating thing is, most of our consults are from Orthopedics and Neurosurgery - these are very competitive fields, so I find it hard to believe people who got 280 on their USMLE Steps1 and 2 all of a sudden are completely clueless when it comes to medicine. Perhaps picking up a bonesaw kills brain cells?
Here are actual consults I've gotten
1) Diabetes management - in a patient that had well-controlled glucose at home. They didn't even consider putting him back on his home dose of insulin
2) Syncope, in a patient that had not, in fact, fainted. Don't know why it didn't occur to them to actually ask the patient this very important question before calling.
3) STD check. At least the neurosurgery resident was apologetic, saying "sorry for the consult but I wasn't sure what to order", but they couldn't be bothered to look it up on uptodate themselves?
We've gotten dozens of consults for simple problems with basic management, where it just seemed they just had no interest in dealing with the problem. If there's one thing I've gotten from this rotation, it's a loss of respect for the surgery profession in general.
The frustrating thing is, most of our consults are from Orthopedics and Neurosurgery - these are very competitive fields, so I find it hard to believe people who got 280 on their USMLE Steps1 and 2 all of a sudden are completely clueless when it comes to medicine. Perhaps picking up a bonesaw kills brain cells?
Here are actual consults I've gotten
1) Diabetes management - in a patient that had well-controlled glucose at home. They didn't even consider putting him back on his home dose of insulin
2) Syncope, in a patient that had not, in fact, fainted. Don't know why it didn't occur to them to actually ask the patient this very important question before calling.
3) STD check. At least the neurosurgery resident was apologetic, saying "sorry for the consult but I wasn't sure what to order", but they couldn't be bothered to look it up on uptodate themselves?
We've gotten dozens of consults for simple problems with basic management, where it just seemed they just had no interest in dealing with the problem. If there's one thing I've gotten from this rotation, it's a loss of respect for the surgery profession in general.
Saturday, July 6, 2013
Just the Beginning
Memorable moments of my first week of residency:
1) Repressing the urge to do a double take when addressed as doctor
2) Having to counsel a patient against cocaine use
3) Getting paged for the first time, only to have to repeat orders that were already perfectly clear in my note.
It's a surreal experience, to put on the long white coat, be called doctor, to be able to put in notes and orders. I'm not sure I'll ever get used to that. It still feels like I'm getting away with something.
1) Repressing the urge to do a double take when addressed as doctor
2) Having to counsel a patient against cocaine use
3) Getting paged for the first time, only to have to repeat orders that were already perfectly clear in my note.
It's a surreal experience, to put on the long white coat, be called doctor, to be able to put in notes and orders. I'm not sure I'll ever get used to that. It still feels like I'm getting away with something.
Tuesday, June 18, 2013
Monday, June 3, 2013
That's a perfectly cromulent word!
I experience a little bit of a reentry phenomenon whenever interacting with nonmedical friends or family members. I spent the last four years learning to communicate in medicalese and surrounded by people who encouraged or even demanded that we stick to the proper clinical terms when discussing anything medical, even in the presence of patients.
Now I've gotten to the point where many of the terms I've been using have become so second nature that I use them in nonmedical settings or sometimes forget the 'mundane' terms, thus creating a great deal of confusion among friends, family and acquaintances who have not been trained this way.
For example: Using 'proximal', 'distal' or 'lateral' to refer to objects or places, and using terms such as anticoagulant, orthostatic hypotension, or endocrine that I find easy to say and understand but a layperson might not.
Now I've gotten to the point where many of the terms I've been using have become so second nature that I use them in nonmedical settings or sometimes forget the 'mundane' terms, thus creating a great deal of confusion among friends, family and acquaintances who have not been trained this way.
For example: Using 'proximal', 'distal' or 'lateral' to refer to objects or places, and using terms such as anticoagulant, orthostatic hypotension, or endocrine that I find easy to say and understand but a layperson might not.
Thursday, May 30, 2013
Liar!
Patients lie. We all know that sometimes it's more obvious than others, but for one reason or another patients will lie to us about history, drug use, etc. I understand and accept that to a certain degree. What I don't understand is why lie about getting imaging done? You won't get your procedure or prescription any faster. You WILL waste an hour of my time while I try to track down your doctor or the hospital or facility where you supposedly had it done only to find they have no record of it. And you get to sit in our cold exam room for another hour instead of simply getting the order for your MRI and getting to leave.
Friday, May 10, 2013
Life on Pain (not in pain)
I'm currently on pain management and while a lot is what I expected, there are a lot of surprises.
Most people know that we use the pain scale from 1-10 to assess severity.
I learned this week that there is also a scale for the amount of pain medication a patient is taking.
This scale ranges between a "scosh" and a "shitload".
For example:
Mrs. Stenosis is doing much better after her surgery but she could use just a scosh as needed when the pain flares up.
Mr. Suboxone has a long history of opioid use and is still NPO after his emergency laparotomy, so he is getting a shitload of IV Dilaudid.
While learning about the use of the medications and procedures is great, by far the most useful part of this rotation is in how to deal with pain patients. They are a notoriously difficult population to work with because you cannot just treat the pain, you also have to address the physical and psychological toll that pain takes. I think coming out of this rotation, I will feel a lot more comfortable dealing with pain and pain patients. How you approach the patient and his or her pain can make the biggest difference in how your interaction goes.
Most people know that we use the pain scale from 1-10 to assess severity.
I learned this week that there is also a scale for the amount of pain medication a patient is taking.
This scale ranges between a "scosh" and a "shitload".
For example:
Mrs. Stenosis is doing much better after her surgery but she could use just a scosh as needed when the pain flares up.
Mr. Suboxone has a long history of opioid use and is still NPO after his emergency laparotomy, so he is getting a shitload of IV Dilaudid.
While learning about the use of the medications and procedures is great, by far the most useful part of this rotation is in how to deal with pain patients. They are a notoriously difficult population to work with because you cannot just treat the pain, you also have to address the physical and psychological toll that pain takes. I think coming out of this rotation, I will feel a lot more comfortable dealing with pain and pain patients. How you approach the patient and his or her pain can make the biggest difference in how your interaction goes.
Tuesday, April 9, 2013
Hello from Dublin!
I'm at the halfway point on my trip through Europe at the moment. Myself and four of my med school friends are doing a post-match/pre-graduation trip to celebrate they joy and freedom that a fourth year has before reality sets in and intern year begins.
We started out in Italy. We were exhausted the first day and didn't do a whole lot our fist day. We landed fairly early and our hotel wouldn't let us actually check in until 2 pm. Unfortunately, it was rather rainy, so each of us shelled out 3 euro apiece for cheap umbrellas from one of the street vendors. Oddly, even once you have an umbrella, the vendors still come up to you trying to sell one.
Our second day we went to the pantheon and did a guided tour of the Vatican and St. Peter's Basilica. It cost more than twice admission would have but we got the skip the line and we learned a lot. Our last day we went to see the colosseum. We turned down the guided tour this time and had a lot of fun taking pictures all around. The tickets in included admission to the roman forum and the palatine. We went to see the forum but without a guide we weren't sure what we were looking at. We still aren't sure or we saw the forum or not.
When we got the the airport and were checking in, the lady at the ticket counter convinced two of my friends that the plane was so full there wouldn't be room and they had to check their bags. The ticket lady tried to convince me too but I absolutely refused. Of course we get on the plane and not only was there more than enough bin space, there were several empty seats.
Our next stop was barcelona. We noticed in Italy just about everyone spoke English to some degree but they tended to be very rude. I suppose being constantly surrounded by tourists might do that to you. In Barcelona, English was less widely spoken but the people were more friendly. We got in late, but the gentleman in charge of the apartment where we were staying was very friendly and wanted to tell us about getting around in Barcelona and the sights to see despite the late hour. We got to see some of Barcelona's georgeous architecture and I took lots of pictures, but for some reason I can't post them on here.
One unfortunate thing about Barcelona, and Europe in general, it is very difficult to find vegetarian food. In Spain I couldn't even eat cheese. Some people in my group are less understanding than others, and I don't enjoy feeling like a burden when my presence restricts where we can go eat. Having five people decide what to do and where to go is cumbersome and we found splitting into two smaller groups made things go a lot smoother for our last couple days in Barcelona.
We are currently in Dublin. We got a free walking tour this afternoon which was a lot of fun and very informative. Our guide apologized for all the walking but compared to all the walking we did in Rome and Barcelona, it was nothing. My friends are out on the highly recommended Pub Crawl now while I'm at the hostel reading. I don't really me joy drinking and since I've been headache-y at nights here I figured I'd better not risk it. I also skipped the night they went out in Barcelona but it didn't sound like I missed much and I don't regret the extra sleep.
Tomorrow we're planning on more sightseeing and some shopping, preferably all indoors given the cold and rainy weather we're expecting.
After that we have 4 days in London and then 2 days each in Frankfurt and Berlin.
We started out in Italy. We were exhausted the first day and didn't do a whole lot our fist day. We landed fairly early and our hotel wouldn't let us actually check in until 2 pm. Unfortunately, it was rather rainy, so each of us shelled out 3 euro apiece for cheap umbrellas from one of the street vendors. Oddly, even once you have an umbrella, the vendors still come up to you trying to sell one.
Our second day we went to the pantheon and did a guided tour of the Vatican and St. Peter's Basilica. It cost more than twice admission would have but we got the skip the line and we learned a lot. Our last day we went to see the colosseum. We turned down the guided tour this time and had a lot of fun taking pictures all around. The tickets in included admission to the roman forum and the palatine. We went to see the forum but without a guide we weren't sure what we were looking at. We still aren't sure or we saw the forum or not.
When we got the the airport and were checking in, the lady at the ticket counter convinced two of my friends that the plane was so full there wouldn't be room and they had to check their bags. The ticket lady tried to convince me too but I absolutely refused. Of course we get on the plane and not only was there more than enough bin space, there were several empty seats.
Our next stop was barcelona. We noticed in Italy just about everyone spoke English to some degree but they tended to be very rude. I suppose being constantly surrounded by tourists might do that to you. In Barcelona, English was less widely spoken but the people were more friendly. We got in late, but the gentleman in charge of the apartment where we were staying was very friendly and wanted to tell us about getting around in Barcelona and the sights to see despite the late hour. We got to see some of Barcelona's georgeous architecture and I took lots of pictures, but for some reason I can't post them on here.
One unfortunate thing about Barcelona, and Europe in general, it is very difficult to find vegetarian food. In Spain I couldn't even eat cheese. Some people in my group are less understanding than others, and I don't enjoy feeling like a burden when my presence restricts where we can go eat. Having five people decide what to do and where to go is cumbersome and we found splitting into two smaller groups made things go a lot smoother for our last couple days in Barcelona.
We are currently in Dublin. We got a free walking tour this afternoon which was a lot of fun and very informative. Our guide apologized for all the walking but compared to all the walking we did in Rome and Barcelona, it was nothing. My friends are out on the highly recommended Pub Crawl now while I'm at the hostel reading. I don't really me joy drinking and since I've been headache-y at nights here I figured I'd better not risk it. I also skipped the night they went out in Barcelona but it didn't sound like I missed much and I don't regret the extra sleep.
Tomorrow we're planning on more sightseeing and some shopping, preferably all indoors given the cold and rainy weather we're expecting.
After that we have 4 days in London and then 2 days each in Frankfurt and Berlin.
Friday, March 15, 2013
Bittersweet Victory
I matched! I absolutely will be an anesthesiologist. I will be at a great hospital with huge clinical volume, great facilities and awesome faculty. I spent this monday floating on a little cloud up until I learned some good friends of mine had not matched. The SOAP ended today and they remain unmatched. Another friend is dealing with family misfortune(s), and I've had some unpleasant family drama of my own. It certainly has not been the match week I had expected. I found out where I had matched this friday and am happy with the placement, but it's hard to feel like celebrating when surrounded by so much despair.
By far the hardest thing for me about match day is that it makes this whole thing so much more REAL. Change is scary, and in a few short months I will be moving to a different state, and starting a whole new life, far from family and friends. I am going to be a real doctor with real responsibilities. I am going into the field I wanted. Perhaps in time, my excitement will grow greater than my anxiety, but right now this all feels like a bittersweet victory.
One of the scariest moments of my life was after the move here for medical school, I was driving "home" after dopping my Dad off at the airport when it hit me that I was driving to a home that I just moved into, with a roommate I had met less than 24 hours before, in a city I had never been to, far from anywhere I had been before. My whole life had changed and I had never felt so alone. But soon medical school started, and I met people who have become some of my closest friends and I'm going to miss them terribly come June. I look forward to being able to repeat that process for residency, meeting new people who may become lifelong friends and taking the next step on my journey.
By far the hardest thing for me about match day is that it makes this whole thing so much more REAL. Change is scary, and in a few short months I will be moving to a different state, and starting a whole new life, far from family and friends. I am going to be a real doctor with real responsibilities. I am going into the field I wanted. Perhaps in time, my excitement will grow greater than my anxiety, but right now this all feels like a bittersweet victory.
One of the scariest moments of my life was after the move here for medical school, I was driving "home" after dopping my Dad off at the airport when it hit me that I was driving to a home that I just moved into, with a roommate I had met less than 24 hours before, in a city I had never been to, far from anywhere I had been before. My whole life had changed and I had never felt so alone. But soon medical school started, and I met people who have become some of my closest friends and I'm going to miss them terribly come June. I look forward to being able to repeat that process for residency, meeting new people who may become lifelong friends and taking the next step on my journey.
Monday, February 11, 2013
Life on the other side
Last February, a year ago now, I had a procedure - radiofrequency ablation of my greater occipital nerves.It changed my life. For the first time in almost 4 years I was at a zero out of ten on the pain scale. Since then, and this is the most amazing thing ever, when I get a headache I can make it go away with just some OTC medicine. No more caffergot or ergotamine needed!
This is something I would not have understood before I experienced chronic pain: the opposite of pain is not pleasure, it is No Pain. All of a sudden, not having a headache is the most amazing thing in the world. Before this all started, not being in pain isn't something to be noticed or noteworthy, isn't something 'good', it just is. Now, the absence of pain, ever day that I have it, is something to celebrate.
I still live with the fear of what if it comes back, what if next time it can't be fixed, but that is just more reason to enjoy what I have now, every ounce of it.
The other thing that's changed since I last posted - I'm an MS4 now. I've applied to residency, gone on interviews and submitted my rank list. One month (exactly four weeks) from today I found out if I've Matched. I'm afraid of not matching, though statistics suggest I've got a good chance.The hardest part is always the waiting. There's nothing for me to do now, except close my eyes, cross my fingers and pray for a good outcome. All the same, I'd much rather be where I am now than where I was a year ago!
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