Today was good. Slow but good. I learned a lot from my two residents who took time to point out the finer details of the neuro exam to me. They have a lot of patience. We also had an unusual consult today on someone with an odd mix of psychological and lower motor neuron problems. Maybe. We’ll round on him tomorrow with the attending and probably have a better answer.
Today my family was having a conversation about local politics and I wanted to have an opinion but I didn’t know anything that was going on. Not that I knew a whole lot before about politics but it just showed me how out of the loop I am with everything happening in society. On the whole though, I’m pretty okay with trading in my knowledge of pop culture and politics for a better understanding of medicine.
I studied all day and then my friend Apple came over and I showed him the demos I had been working on. He’ll be co-producing this Year Two record with me. Luckily, he liked the demos and seems to have plenty of ideas to flesh them out. I’m excited about the direction we’re going to take it in.
It was a slow day in neurology right up till the end when things got exciting.
We got a consult for a man with vertigo and possible stroke that may have occurred several weeks ago.
Five minutes into the exam I got the distinct feeling that he was faking it. I felt like a jerk. I put my suspicions aside and really tried to ensure the resident and I gave him a thorough exam. And we did. Later, the attending came and he gave him an even more rigorous exam. In the hallway afterward he told us all he was suspicious as well. We went back in the room. My attending asked about stress in the man’s life. He revealed that four months ago his wife had died and lately he had been having suicidal thoughts.
Earlier, the attending had taught us that sometimes patient’s will embellish symptoms that they really do have in order to get the attention/treatment they think they deserve. A lot of this is a reaction to being blown off by other physicians who didn’t make them feel like they really cared about their condition.
What I’ve learned from all of this, from this whole week really, is that just because a patient is pretending to have an illness that they don’t have, it doesn’t make them any less your patient and it doesn’t give you the right to be any less compassionate than you would be if they would have had the disease. They are still suffering, just in a different way than they seemed to be at first. Of course it feels like the patient is working against you, making it harder to do your job, or stealing time and resources away from patients who really need it. That is obvious. But I have found myself asking, “can a really thorough exam be just the treatment they need?”. We are giving them more than CT scans and testing reflexes. In a round about way, we are giving them love. A kind of love they are lacking or maybe never received in the first place. An unconditional open ear and a patient, kind heart for them to speak into. I think we can talk all day about having compassion in a classroom but until you’ve seen a physician actually disperse compassion to someone who the rest of the world would think twice about, I don’t think it is really instilled in you. It’s the kind of thing you have to see to believe exists and to believe that you will be capable of one day. At times it is a love that goes against logic but as I’ve learned this week, even in neurology, matters of the heart often take precedence over those of the brain.
After I was released from my duties I went back to see a patient I had checked on earlier in the day. He had said he felt lonely so I figured I should see how he was doing. I sat and talked with him for about 20 minutes. He reminded me of my grandfather who I rarely get to see. I guess in a way I hope someone would do the same for my grandfather if he was lonely in the hospital. Sometimes, the medicine most needed is friendship.
I had my first real encounter with a patient who was clearly faking his illness today. There is a little loss of innocence involved with an experience like this I think because it proves that you can’t always believe patients 100% of the time like you hope you can. But don’t think I am getting jaded in a new way now. Probably the biggest thing I learned today is that these situations are quite complicated. As my attending emphasized emphatically this morning to all the residents and myself, psychogenic illness is the very last diagnosis you explore. It is a diagnosis of total exclusion. The problem is, people with mental illness get sick too and you have to be able to figure out the biological illnesses from the fictitious ones. You could have a boy who cried wolf scenario but the guilt will be with you if the boy gets eaten by the wolf. So of course myself, two residents, and the attending all conducted as thorough exams as possible on this guy. We ended up just diagnosing him with a complicated headache by default. Not the stroke he was going for but he still got treated.
I ended up not having to do the neuro exam in front of my attending today. I think because we were a bit rushed for time during rounds.
When I thought about our possible stroke patient later, I still felt bad for the guy. Not for his “illness” but for his being in a situation in which he felt that being a person with stroke like symptoms was better than being his relatively healthy self. I don’t know how a person gets to a place like that but I’m pretty sure it’s not an enjoyable journey.
On my way to morning report today, my friend tells me some horror stories about the surgical rotation a lot of my classmates just went through. Apparently, it’s the only rotation where the atmosphere is highly “malignant”. Morning report reminds me a lot of CPS in 2nd year. Attendings, residents, and med students sit around as one resident presents a current case to everyone for teaching purposes. An attending asks the resident questions and writes on a white board. Then, all the attendings ask everyone questions about what is important in the case. The senior resident knows almost everything. The younger residents know a decent amount. The med students, like myself, stay pretty quiet. Papers are cited, differentials are kicked around, labs are proposed. Then, everyone from my team goes on rounds. An attending, three residents, myself, and an undergraduate who’s shadowing. The attending speaks with authority to patients. He is very decisive. Sure of himself. Not cocky but confident. When the patient hears from him, it is the conclusion of a long string of examinations by residents and med school students. He delivers the final diagnosis. And suddenly all parts of a typical patient’s hospital experience come together for me. I realize that over the past two days I’ve been privy to what exactly goes on during those gaps of time when someone sits in their bed watching TV and eating lackluster food. At a teaching hospital, as your jello is sliding through your esophagus, residents and medical students are pouring over your history, labs, and scans again and again trying to get a complete picture for what is going on with you. While you keep being woken up by nurses who want to draw your blood, attendings are trying to understand that picture before they even meet you. I think this is what makes being treated at a teaching hospital so great. Quality control. While it may be a pain being given the same routine physical exam five separate times, you’ve gotta take some comfort in the fact that if there is something that the med student misses, the residents will pick it up and if there’s something they miss, the attending will find it. That chain works in reverse as well occasionally. It creates a web where very little slips through the holes. So you see, it’s probably better to be treated by a team than a single knowledgeable yet fallible human being.
Did I mention how awesome the residents are? Because they’re fantastic people really. I’m enjoying spending time with them. They nearly always know what they’re doing and they also have sympathy for med students since they recently were one themselves. I did a neuro exam on a patient today by myself. The physical exam went pretty well but I stupidly forgot to take even a mediocre history of present illness which I feel like is equivalent to forgetting how to put your clothes on in the morning. So I gave my all too forgiving resident a “naked” and sparse patient presentation while she sweetly corrected me.
Later I was told to administer a MOCA test to the same patient. It consists of simple writing, logic, and memory exercises to asses cognitive function. The patient did poorly and I was somewhat concerned until I reported my findings to the residents who postulated that he was probably faking things a bit. Looking at all the facts of the case, it’s probably true. But I still felt bad for the guy. He recently separated from his wife and became essentially homeless.
I feel like at this point I can bond with patients pretty well and I have a decent competency for the physical exam, my history taking could get a lot better and I need to tighten the screws on everything. Tomorrow I have to perform a neuro exam on a patient in front of the attending. Let’s all pray I don’t screw this one up too badly.
The first real day of neuro was a slow but fun one. The first thing I learned was how to tell if a patient is really having neurological symptoms or just faking it. That’s the kind of stuff you wont find in textbooks; it only comes from residents who have experience. Speaking of residents, so far they are pretty awesome. And my attending, who I only see for a small part of the day, seems super nice. As I’ve mentioned before, I think neurologists are some of the smartest docs. They deal with some pretty complicated stuff on a regular basis. I only saw two patients all day. One of them was quite talkative and asked for my name so she could pray for me. I was really thankful for that. Here I am, trying to figure out why she’s had falling spells for several decades and she wants to make sure I’m okay. Amazing. Patient’s see me as being there to help them when in reality I’m the one who needs them the most. I am tired intermittently throughout the day now. Last night I couldn’t seem to fall asleep. But I can’t tell you how much better it feels to be walking around the wards all day instead of sitting in a room for 14 hours studying a review book. Actually, I can tell you. It’s SO MUCH BETTER!
The first day of the neuro-psych clerkship was mainly orientation plus some practice we got to do on standardized patients. I actually knew a lot more than I thought I did about giving a neuro exam. Lets hope I still think that tomorrow when I start training for real.
And now as a last hurrah before year three really escalates, I present to you a demo. The first demo for the Year Two album (it’s actually the 4th track on it). This song is the least important out of all the songs on the new album so I don’t feel bad revealing it in its bare bones demo form. As a kind of exercise in aesthetics, I sometimes reduce the meaning of my songs down to a single word. Last week, I went through the Year Two songs and did this.
The one word meaning of this song is “Sacrifice”.
I don’t have time to go into a full explanation and most of you probably wouldn’t read it anyway so I thought I’d just explain the song in list form and if you want to you can look things up. I recommend listening to the song first and then going back and reading this list and the lyrics. “White Mass” is the sister song to “Silhouettes in Smoke” from the Year One album. It has the same structure and both are inspired by my experiences on my LCE rotations.
The title - a double meaning - parathyroid adenoma and a special mass given by the Catholic church for physicians
1st verse - the pressures of a surgical rotation, the stomach/communion
2nd verse - pathology, speaking medical jargon to the patient’s relatives, parathyroid adenoma, scrubbing in
Refrain - Cosmas and Damian (two of many patron saints of physicians), a triple layered reference to their miracle of limb reattachment(according to legend), Mathew 5:30, and gangrene caused by Clostridium perfringens. also a comment on sacrafice
Caught in the cathedral
Early in the morning
Under the fluorescent glow
Praying for forgiveness
From the hired healer
For the names that I don’t know
Hands folded together
Walking toward an altar
I could maybe make my home
The bread and the wine
The holiest chyme
The King on his chloride throne
The confession of sins
Through a microscope lens
When the stain speaks as loud as your heart
Talking in tongues
To the daughters and sons
To the husbands and wives in the dark
The calcium stripped
From the bones of believers
The devil inside of your neck
A sacrament given
I’m washing my hands of the death
Then Cosmas and Damian said,
“What good is a leg if you’re in the grave?
To earn our patronage
Sever yourself, amputate
Everything that makes you trip
If the autoclave’s proven ineffective.
‘Cuz ambulating with a limp
Isn’t half as bad as the infection.”
Baptism at the Beach
I nearly finished all the demos today minus the vocal tracks. Productivity is awesome.
Ahhhh. The start of a good weekend doing the things I love best.
Number one: Reading fiction.
Today I finished The Chicago Way by Micheal Harvey. Outstanding. This guy is the Dashiell Hammett of the 21st century. No joke. Of course I’m a sucker for a good detective novel. I’m really fond of the genre for some reason. The dialog was quick, smart, clean and laced with sarcasm. The plot was ingenious and kept building in intricacy till the very end. An absolute page turner. In some respects, Harvey isn’t doing anything dramatically new for this genre but what he’s done is create a immaculate example of how a story like this should be told.
Number two: I started really recording the demos for Year Two.
And number three: I saw a nice piece of cinema.
Harry Potter. The final Harry Potter. Probably the finest job anyone could have done translating that book into a film. It was great but a weird movie to watch because it doesn’t have a real beginning or middle. The whole thing is one giant climax. It’s understandable though since its the culmination of about 20 hours worth of story on film. A mighty swell way to close out the series. In a word: Epic.
Well, that was rough. I feel like I may have not passed. Outside of saying that there were some crazy questions involving the DMV and what not, I don’t really feel like talking about it. It was extremely difficult. End of story.
Well, my father has been discharged with a generally clean bill of health! Hooray!
I got to sit in on the endoscopy via my short white coat powers and I have to say everything looked beautiful. Textbook actually. Now I can say I know my father inside and out.
The GI doc concluded that the pain must be coming from a spasm of the lower esophageal sphincter. Of course we have no hard evidence for this but I suppose it’s a diagnosis of exclusion.
Prior to this, my car broke down on the other side of town. Not comforting on the day before the biggest test of my life. But I have to thank my parents for keeping things in perspective for me. Wonderful folks those two. I will say I have been a little anxious off and on today for the exam. Not so much my mind as my body. I can feel my sympathetic nervous system kick in prematurely. My stomach feels topsy turnvy.
It’s been interesting seeing my dad as a patient these past few days. The difference in our perspectives. Me teaching him something for once in my life. My mother has a medical background and understands quite a bit more. My dad, a master of language, the written and spoken word, an engineer of arguments, is paralyzed by the sight of needles and vaguely knows where his vital organs are located. Explaining to him, on the previous day, the anatomy of his upper GI track and what possible pathology would exist, I assumed he was as comfortable with the aspects of his medical issue as I was. Coming out of the endoscopy however, he expressed a relief at the fact that no terrible cancer was found. I was really surprised at his surprise, even after my endless reassuring. It made me realize the stigma medical procedures carry in society. For me, this endoscopy was routine, a sister procedure to the countless bronchoscopies I observed in my first year. For my father, and probably a lot of other people, this is the exact scenario you hear about on TV or from a family friend on how they first discovered their carcinoma and a precursor to a long road of chemotherapy and maybe even death. Thinking about it now, I wish the doctor on my dad’s case would have explained things to him better. I wish he would have asked him if he was worried about anything they might find and presented all the possible pathologies. I don’t think it would have taken more than 15 minutes. I suppose this is a learning experience though, for me more than anyone else. I’m sure it will make me a better physician.
I got my sylabus for my first rotation, neuro-psych, today and it made me very excited. Excited? To start school again? Heck yes I am.
Meanwhile, dad’s still in the hospital. Cardiac issues are completely ruled out at this point and an endoscopy is scheduled tomorrow which I’m hoping to observe. Oh the privileges of having a short white coat. They’ll almost let you in anywhere. If I sound nonchalant about the whole thing, I assure you, I’m concerned for my father but I’m not worried. He’s not even hooked up to anything. He’s hanging out in bed board, reading, and hoping to get back to work soon. I’m more worried about the ridiculously expensive cost of staying in the hospital for so many days. I wish the doctors worked in shifts to do things like endoscopies and not just one person from 9 to 5. He could have been out of here this morning. Anyway, we expect the problem to be either an ulcer, a hiatal hernia, or an infected Mallory Weiss tear.
I wanted to get in the hospital but not this quick.
My father took a trip to the ER this morning and wound up being admitted for severe abdominal pain. I think he’s going to be fine though. The doctors and nurses have focused on making sure it’s not a heart problem and have pretty much ruled that out at this point. We’re hoping they’ll finally focus on the real issue which is his GI track soon.
I made an interesting observation today. In general, when people hear that someone is “in the hospital” they freak out and think the worst. They assume something terrible has happened and death must be imminent. But for me, and probably most people who actually work in the hospital, the phrase is somewhat benign. I mean, there’s not really any fear attached to it anymore. There may even be some hope there. The hospital is not where people go to die, it’s where people go to find out what’s wrong with them, get it fixed, and keep on living. It’s a safe place. Of course I realize I am a naive 3rd year medical student who hasn’t started my clerkships and seen a lot of death up close yet. Still, I think I will probably keep at least a bit of this adjusted, realistic perspective after all of my training is over.