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!

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