Sunday, November 28, 2010

Neuro rundown

It's been over a month, and I am still not sure enough time has passed for me to give an objective overview of my time in neurology. Therefore, this will be a shortened recap, because there is no chance I will do neurology as a career.

The neuro rotation is one month long, and I did mine at the VA hospital (though a different VA than the one at which I did psych). The attendings switch every two weeks. My first two weeks, my attending was pleasant but demanding. I mercifully did not have to localize any lesions for him (though the other med student did, poor thing), but his MO was to pimp you until you couldn't answer any more questions. There were two junior residents and a senior on the team, in addition to the two med students. The juniors saw the admissions, and the senior saw the consults, but when there were med students, we saw the consults. Most were old strokes, Parkinson's, rule out NPH (a constant and perennial favorite), etc. There was also an MS clinic Tuesday mornings and a general neurology clinic Monday afternoons. Those first two weeks, we had around 4-8 admissions and another 5-10 consults we were following, with a few new ones every day (and about an equal number signed off/discharged every day). It was busy, but the attending was very efficient. We started about 8 (and we pre-rounded before that), and we were done by 5-6 PM most nights.

There was some teaching built in--we had a teaching session with Dr. Daroff every Wednesday morning. I don't usually mention doctor's names, but Dr. Daroff (I have been told) is probably the leading living general neurologist. He's my kind of guy--he's been around for decades and loves telling stories. We learned about the different types of reflex hammers (he knew Babinski well!), locked-in syndrome via his own experience with perhaps the most famous locked-in patient, etc. I can listen to people like that talk for hours. He was a great diagnostician too, and we had him look at some of the trickier patients on the floor.

We also had grand rounds every Friday AM, followed by case studies the rest of the morning and regular small groups back at the med school every afternoon. It was different than psych, which had didactics spaced throughout the week instead of all crammed into Friday, but it worked. Because so much of psych occurred in AM rounds, losing Friday morning would've been much more detrimental than it was on neuro, where we were busy all day. And I was thrilled to have one whole day away from the neuro team.

So, the first two weeks were very busy but manageable. I saw some interesting cases, like progressive supranuclear palsy, ALS, fluent aphasia secondary to glioblastoma multiforme resection, and others. I also saw a lot of bread and butter neuro too: Parkinson's, old stroke, dementia, multiple sclerosis, coma, seizure, and syncope. I did not see a single new onset stroke--the other med student saw one, but most of those patients went to a different hospital system (which has a specific stroke service).

Overall, I was struck by how little we could really do for these patients. Even if the second half of my neurology rotation (which I will get to) never happened, I don't think there is any way I'd want to do neuro in the future. There is some treatment for Parkinson's, seizure, and MS, with varying degrees of success, but most of the patients I saw had no available treatment options or had exhausted all available therapy. And, I hated neuro in second year med school, and my feelings on the nervous system in general haven't changed. No offense to budding neurologists, but neural tracts and localization are the stuff of my nightmares.

As I mentioned, the neuro attendings change every two weeks. My first attending was demanding but fine. The second one was hell on earth.

He had a weird affect and poor social skills--I wondered if he was Asperger's or some other autism spectrum--and his mood varied from generally annoyed to hating life. He was super anal retentive; we timed vibrations at multiple joints with specific frequency tuning forks, he made his own reflex hammer because every available hammer was sub-par, and we measured muscle bulk on patients with a tape measure to compare symmetry. And, even if the patient was a consult, you were expected to have looked through every note in the chart (some of these patients have almost one thousand notes). It took hours to do a history and physical, and several more hours to look over the chart.

Thank goodness the service slowed down--we had 0-2 admitted patients and 2-4 consults at a time. Even then, we stayed till 8 PM or later (sometimes 10 PM to midnight) just to see a low volume of patients. These were non-call nights; medical students were supposed to take home call once a week until 9 PM. Obviously, when you are staying in the hospital as late as we were, every day is basically a call night.

The resident team also switched, and while the juniors were fine, the senior was much less efficient and involved. He hated working with the attending, and rather than helping everyone else get done, he just left people alone and let the attending get into it with them.

There are tons of examples about how tough it was to work with the attending--he was a grouchy man usually, and he loved to pimp (and was happy to call people stupid on a regular basis--he was equal opportunity with that). He was rude to everyone--he actually got into a screaming match with another attending during clinic, right in front of a patient's room. He was unprofessional and nasty. And then, he'd suddenly change and try to be social. He'd talk about his kids, movies, music, etc.

I've got to share this one story--we were in the work room, and somehow the topic of kids came up. I was the only one with them, and he asked me how many I had and how old they were. When I told him, he asked me if I had ever seen the movie "Idiocracy." I said I hadn't. He said that I had to have at least one more kid, because right now I was only replacing Tim and I in the tax base--I wasn't adding to it. He said that people who did not contribute to the tax base (but drained it instead) were having many more children than were taxpayers, and it was my job to produce offspring that could continue to support generational welfare. Otherwise, the political system would collapse, and there would no longer be a tax base to support the government. Basically, the idiots would take over.

Umm, ok...

Even after brief moments of what appeared to be interest in people's personal lives, he could then switch gears entirely. The day that broke me was Sophie's birthday. It was a Monday, and I had told him on Sunday (you had to round at least one day on the weekend) that my daughter's birthday was Monday. I reminded him again on Monday morning. The service was slow--we had one admission and a few consults that we had been following at a distance for a while. Of course, rounds still took forever. By the end, we had two new consults, one in the ER and one admitted to another service. I took the admitted patient and a resident took the ER patient. Neither was life threatening--mine was a rule out NPH (turned out to be a 93 year old with moderate dementia), and the other was a Parkinson's patient who was out of medication.  We each had our H&P's done by 2 PM, but the attending couldn't come back to round right away. He didn't say when he'd be back--he just told the team to wait until he got there.

We waited for four hours--he finally showed up at 6 PM. I was already upset that I was late for Sophie's birthday. The senior tried to tell the attending that my patient could wait until the next day's rounds, but he wasn't having it. He wanted to see the ER patient first, and he was shocked when we got to the ER and the patient was gone. The ER doc said the patient got tired of waiting and went home. Instead of letting that go, we had to go through all the records, talk to every nurse/doc in the ER to see what they knew, try to contact the patient at home to have him come back in, etc. At this point, it is after 8. The senior again says that my patient is admitted on another service and can wait until the morning.

Instead, the attending sends everyone else home except for me and the on-call resident. He sent the senior (who saw the patient with me after I did the H&P), the other junior resident, and the other med student home. Worse, he singled me out, saying that I hadn't been on call that week (it was Monday) and I was supposed to be on call every week (it was actually supposed to be every other week). I can't express to you the nasty tone he took with me. He was one of those people that you couldn't reason with. The senior again said that this patient could wait, that the senior had already signed my note, and that it was my daughter's birthday. The attending said he didn't care. So, he and I went to see this very basic patient, spent forever doing another H&P, ended up just signing the note I had already written, and then said to me, "You make me tired. I need to go home." It was after 10 PM.

The on-call resident had to go to her car to get something, and she and I walked out together. I didn't even get to the parking garage before I burst into tears. I composed myself pretty quickly, but she again said that everyone knows this attending is terrible, people dread working with him, he's nasty to everyone, and I shouldn't take it personally.  I heard this from so many people--including the clerkship director, who apologized profusely for making me work with him. It didn't stop me from crying the entire drive home that night. Sophie was in bed when I got home, and she had been asleep when I left in the morning. I didn't see her awake at all on her birthday. We did celebrate it as a family the night before, so I didn't miss the party, but I didn't get to spend time with her as a family at all that night.

That was a Monday. I had to go back Tuesday, but then we had didactic sessions all day Wednesday (which unfortunately, this attending had a one hour block of teaching scheduled), the psych shelf exam Thursday, and the neuro shelf exam Friday. I steeled myself and spent Tuesday doing what needed to be done, but had I needed to spend one more day with that man, I don't think I could've taken it.

There are so many other things that made me hate my neurology rotation, but dealing with that skunk of a man for two weeks sealed it for me. I know not everyone is like that, there are bad attendings in the world, etc, but the fact that his behavior was well-known and yet still tolerated by the neurology department confirmed that this was not a group of people with which I wanted to work any further.

Anyway, it's done, I survived, and I don't have to do any more neurology until maybe residency. And now, I will probably try to erase it from my mind. Interestingly, I got my written evaluation for my neuro rotation, and it is actually positive and complementary. I don't know my final grade yet, but I was shocked by the clinical eval--I was sure this guy would just rip me a new one. Maybe he was having a good day...

A pediatric rotation recap to follow soon--at least that was much more pleasant. I start OB/gyn tomorrow, so wish me luck!

Tuesday, November 09, 2010

Done!

I defended my PhD today, and I passed. So, I guess that makes me a doctor! Well, kind of :) Half of the MD/PhD down, half to go! Now off to celebrate :)

Thursday, November 04, 2010

Peds, week one

Neuro redux coming soon...lots to say on that one, but let's just say it is off the list of possible career choices!

I started pediatrics on Monday...really Tuesday, since Monday was just orientation. My medical school class gets divided into three health systems for each clerkship, and then each of the health systems subdivides into main campus, community hospitals, etc. I am the only student in my health system that is at a community hospital--it is a new program, and there is only room for one student at a time. It's been a much different experience from what I have heard about people doing pediatrics at one of the main hospitals.

First, it is a hospitalist service. There is a practice of pediatric hospitalists who only see inpatient kids. They also cover newborn babies. Basically, community pediatricians have the option of managing their patients when they get admitted (or are born), or they can choose to have the hospitalist service manage their patients. That means that, currently, there are three patients being covered by my service on the peds floor, and there are 15-20 babies/day that need to be seen either for admission (after birth) or before discharge.

The pediatricians can also be called to deliveries if the OB has a concern that there might be trouble with the baby. I got to see my first delivery today (that wasn't for my own child)--the concern was for an IUGR baby, but she turned out just fine. I did get teary watching the baby being born--it's such an unreal event! I still have no interest in OB/Gyn though :) That's next month...stay tuned...

On this service, we get signout from the overnight physician on call from 8-8:30. The resident and I then head to the peds floor and see whoever is on our service. The attending is usually in the nursery seeing the newborns at that time. Then the attending comes to the peds floor, we go over the patients, and we are usually done around noon. Then it's lunch, and so far this week, then it is dead time (though this would be the time for admissions if they come in). It's good in some ways: after crazy neuro, it rocks being able to eat and pee during the day, it gives me time to look up med information, and we've also gotten to do some teaching/learning about important peds topics (jaundice and asthma so far).  The down side is that it is SLOW, and I am worried I may not get to see everything I need to see.

For instance, we had the ER call the other day with a kid who was vomiting. However, the kid was a newly diagnosed diabetic. This peds unit doesn't take diabetic kids (unless the community physician is willing to come in and manage them, which they generally are not) because they can be so sick so quickly. So this kid got sent to main campus. We had another call yesterday for a dental abscess, but there is no dental/oral surgery here, so he got sent to another hospital. Basically, we get jaundice, asthma, acute infection (pneumonia, GI, etc), MRSA abscesses, etc. That's not quite what I was hoping to see. It does make it feel manageable--anything touchy never really gets to us--but it's not what my peers are seeing in some of the tertiary care units in the big-name hospitals.

I did see one case yesterday that I wish I hadn't. Again, no details due to HIPAA, but we had a child come in that had evidence of (and self reported) child abuse. This child had "only" belt welt marks on the leg, but there was a history of abuse by the older sibling that required stitches and a general history of hitting/verbal/emotional abuse by both parents. The child was very pleasant and social--a bit energetic, but nothing off the charts for the age. Talking to this patient was tough--the patient talked about how the parents didn't want them anymore, that the parents gave them medication (focalin and risperidone) "because I am crazy," how the older sibling threatened to kill them at night, etc. The parents were arrested and put in jail briefly after bringing the patient to the ER (initially for "behavior problems"), and reading the note was so sad. Apparently, no one was willing to take the patient--the grandparents agreed to take the older sibling, but no one wanted the patient.

We of course got social work and the county involved, but the county wouldn't take the patient. So, despite a restraining order, the parents got to choose who took the patient. There was much drama last night while I was on call about who was actually coming to pick the patient up (and whether one of the people was actually the mother posing as someone else). We did all we could to try and get county/temporary foster care to take the patient, but they wouldn't. When the person picking up the patient arrived (with security, of course), it was obvious that this person was annoyed and wanted nothing to do with the patient. We all stood helplessly at the nurse's station as the patient left, knowing that more than likely, the mom/dad was waiting in a parking lot nearby, and the person who picked up the patient was going to ignore the restraining order and give the patient to the parents.

We all had fears that this patient would get beaten, and the parents wouldn't come back to the ER, since they got arrested last time. This patient was returning to a terrible home life. We protested, we called social work/the county continuously all day long, and there was nothing we could do to keep the patient from it. I'm praying that I don't recognize any news stories in the next few days. The attendings were frustrated too, and they had other stories about abuse kids--how long it took to finally get kids removed from homes, how sometimes what you fear ends up happening, and just generally about how some parents can do such terrible things to their kids. The attendings tried to reassure me that cases of abuse like this are rare, but it didn't make me feel better about this patient.

I am a fixer, and if I could have, I would've personally taken this patient away from the family. I wanted to protect them from what they were facing.  It was so sad--the patient said that they feared the mom, dad, and sibling, yet they wanted to go home. While the patient was here, all they wanted was approval. They tried to please the nurses and doctors. The patient was happy and social here--I know no one can live at the hospital, but the fact that life in a little room was better than what waited at home was so sad. The entire time the patient was in, no one called about them, no one came to visit, and no one wanted to take them out of the hospital. It was absolutely heartbreaking.

It also exemplified the biggest concern I have about peds. Let's start with what I like first: the people are great, I enjoy working with kids, and so far, the hours are fantastic. The downside: depersonalization (or lack thereof). I am so protective of these kids. The first day, there was a patient the exact age of my son. The patient's parents were teenagers, and they really wanted nothing to do with the kid. The child couldn't roll over, couldn't sit up, and actually had a flat head because of always being laid down. The parents were never holding the baby when we came in--they were sleeping at all hours of the day, and the patient was in the crib, alone, all day. The patient was so excited to see other people come in! I wanted to smack the parents around. If you don't want the kid, give them to someone who does!

Other patients have been fine--there are plenty of parents who are very worried about their kids and want them to get better. But I think I would have a hard time in peds dealing with parents who obviously could care less about the kids--or worse, parents who are negligent/abusive. I am way too involved with that emotionally. I don't expect parents to be perfect--I am FAR from perfect, and I think a good chunk of parenting involves making mistakes. However, if you learn from the mistakes, and you try to be a better parent, that's the right thing to do. I just don't know if I can see parents that are uninterested or mean to their kids.

The attendings have said that you get desensitized to the parents, but I am not sure if that is good or bad. I think children need advocates. I'm naive in the sense that I think I can make a difference. I don't think I can fix every bad parent out there, but I want to help the kids that I do come into contact with. I just don't know if I can do peds.

And, if I did peds, I couldn't do general pediatrics. I know nothing as a med student, and already some of general peds is mind-numbing. It's the same issue I have with adult medicine--my personality is such that I like knowing a lot about one small specialty, and I like when things are challenging. It's a balance though--I don't want every case I see to be life or death, but I want to have to think about diagnosis/treatment challenges regularly. I like being a detective. Specialty pediatrics could be a lot like specialty adult medicine, which could be fun. But I'd still have to deal with the parents. At least adults are responsible for their own bad decisions. Kids don't have responsibility for what their parents do.

I'm curious to see how I feel at the end of this month. Maybe I will learn to depersonalize and find a way to channel my need to smack parents upside the head. I really enjoy the medical people so far, and they seem very understanding of work/life balance. Those are definite advantages. However, I don't want to come home and feel demoralized and dejected because I couldn't help kids the way they needed to be helped because their parents got in the way. 

I may have to do a rotation in one of the busier tertiary care pediatrics wards to see what that is like. Other med students have said that their pediatric rotations were intense and very busy. While I am thrilled that this is low key (I need a little of that in my life right now), it may also not be representative of real life.

Plus, there's always the issue of what to do with my PhD if I do peds. I'm still not convinced that I want to do bench research again, but I also don't want that six years of my life to be a total waste, career-wise.

I guess this pediatrics thing is still TBD. I like the medical people, I like the lifestyle, and I like kids. We'll see if that is enough to put pediatrics on the list!