A Hodgepodge of Thoughts

As I pass through my neighborhood, I see my neighbors taking down their Christmas decorations that have mostly been up since Thanksgiving weekend. This makes me somewhat sad. Today is the 6th day of Christmas, which means that there are 6 whole more days of christmas to be celebrated (I know, you are all in awe of my superior arithmetic skills). So I hope you enjoy your 6 geese-a-laying today! Actually, does anyone else find the gifts given in that song to become progressively strange? How does one find 10 lords to be given as a gift and not only that, compelled to be leaping? And is it that they occasionally might break out into leaping or do they do a leaping routine or are they in a constant state of leaping?

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DC is a quiet place this time of year. Everyone has gone home.


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I've never really been one for New Year's Resolutions, per se, but it usually around this time of year I think about making some lifestyle changes. I think that has more to do the Bacchanalia that is Thanksgiving/Christmas/NYE.

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I'm more curious who the VP candidates are going to be. O wouldn't dare choose Biden again, would he?

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So I took my car to the shop to get my oil changed-- I know, you're shivering with excitement-- and as I waited there was a television playing the 'Maury Povich Show'. Before you ask why I bothered watching, need I remind you of the 'train wreck paradox' and the 'man and flickering image axiom' (that's the one where if you put a man within eyesight of a flickering image and he MUST look at it)? With these two excellent reasons I continued watching this pinnacle of daytime talk TV. Now, I'm pretty sure every single episode of Maury has had the same theme: 'Are you the father of my child?' After watching these totally screwed up family situations unfold, I thought to myself, "Watching men battle lions and each other in the Coliseum would have been a more civilized form of entertainment."

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Did you guys know that the NBA is back? Who knew? Rather, who cares?

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Merry Christmas and Happy New Year!

A Rash of Rashes

So, I don't think I even made it through a whole year of medical school before the questions started coming. I don't know why, but everyone I know is really eager to have their own personal physician, pro-bono of course (because you know those $20 co-pays are real wallet busters). Everyone, also, wants to know if I can prescribe narcotics and if I can take a look at some rash on their body.

With respect to the narcotics: I usually just laugh those questions off nervously as I hope that the questioner isn't serious but I'm not so sure as I see the glint in the eyes. Then I conjure up images in my mind of the DEA busting down my door and the Board of Medicine revoking my license in perpetuity, heh...

But the rashes, oh the rashes, how I hate rashes.

First off, let's just talk about me and rashes for a second. Dermatology is a field of medicine that I am not particularly fond of. Its subject may be the largest organ but it is also the most boring organ. Diagnosis is usually done by sight and nothing else, sometimes biopsies are taken. It is freaking disgusting at times (play around here at your own risk). My greatest fear in medicine is to be asked to describe a rash using proper medical terminology: macule, papule, plaque, patch, scale, ulcer, bulla, vesicle, and so forth.

Next, we have my ambushed encounters with rashes. "Hey, William, you're a doctor type person! what do you think THIS is?" They say this as they strip off clothing to give me a good view of the lesion in question. As I carefully inspect the rash, feeling for texture and raised edges, I put my best pensive face on and I think to myself, "Yup! He's got a rash all right." In my most confident voice I tell my patient, "Well, it's really hard to tell in this setting what exactly we're looking at... I would probably due a skin scraping and KOH test but it could be an atopic dermatitis [a big word for eczema], contact dermatitis [allergy], or some form of tinea [fungus/ringworm]. Try an over the counter antifungal/cortisone cream for a couple weeks and see if that works... if not, maybe you should go see a doctor."

Don't get me wrong, I think it is pretty awesome that I have the respect of my friends such that they want to come to me for medical advice. But the fact of the matter is, I don't know everything there is to know about all fields of medicine and especially not dermatology. So, bring me your sick, bring me your ill but DON'T, just DON'T bring me your rashes.

Imitating Nature

There are certain questions that are universal to the human mind or at least that's the way it seems when I talk to people outside of the world of medicine about my being in medicine. It's actually kind of funny how everyone asks me the same 10-15 questions, I really should start making notecards or a pamphlet to hand out to answer these questions. My favorite question, though, is, "Is it like House [or some other TV show]?" The simple answer is no, but where is the fun in that. As the ancient dictum goes, art imitates nature, so lets take a look at how well these arts truly imitate what they represent.

Dr. Gregory House
As the caption of the photo reads: Seriously, how does this guy keep his license? I mean, he breaks into people's homes, he nearly kills people with unnecessary treatments, he performs procedures without indication or proper consent and the guy is total a-hole. Yeah, everyone lies and we deal with it but we don't turn it into The Spanish Inquisition or A Few Good Men. Given that bedside manner is a more important determinant in a physician getting sued for malpractice than actually being a good doctor, House would have been sued 8 ways to Sunday. By this point, House's malpractice premiums would be through the roof and he would be unemployable. Then there is the issue of his team. House, head of diagnostic medicine (WTF is that?), has working under him a neurologist, an immunologist, a surgeon, a plastic surgeon, Kumar, and a variety of other doctors. This is utter nonsense. What House does have going for it is the way they portray the brainstorming sessions: we do do that.

Grey's Anatomy
Using a play on the name of the landmark textbook that no one actually uses anymore, Gray's Anatomy, Grey's Anatomy is a show that I've seen, maybe, about 5 minutes of. From what I can surmise, the apple fell off the tree, grew legs and ran into an orange grove. Call rooms are used for sleeping. Only sleeping. Maybe some work before or after sleeping. And people don't survive Stage IV melanoma, especially with metastasis to the brain and liver. NEXT!

Scrubs
I know what you're thinking, "there is NO way that Scrubs is anything like real life!" Well, minus the jumping into your pals arms and screaming "EAGLE!" while he lifts you into the air (at least that's my story and I'm sticking to it), and the funny business in the call rooms it is pretty true to life. Dr. Cox, the jaded mentor, who, beyond the callous exterior cares for his patients and proteges. Dr. Kelso is part the old guard who gets sick pleasure out of belittling those beneath him. The Todd is a surgeon. Elliot is that super idealistic girl who somehow keeps her idealism through it all. We go on rounds and get pimped. We deal with diseases and persons. We have lives outside of medicine and sometimes the two meet. And the janitor has it out for us all.

So there you have it. Now you have a better idea of what my career is like. Except it is not as interesting...

Show Me the Money

Some of my friends have asked me recently: "Why are you starting a blog?" These queries have not been asked in the standard interrogative, rather, in a tone that suggests, "Why in the hell would you be starting a blog? Isn't it kinda passe? I mean really, what are you, a teenage girl?" And when I say that this was suggested, these are things that my friends actually said to me. In answer to the question, I have this to reply: I don't know, it seemed like a good idea at the time... It's likely a product of having way too much time on my hands and a somewhat productive use of said time. But as I mused over it more I thought it would be a nice creative/artistic contrast to the world of medicine where I spend most of my time.

Now that I've given you an answer as to why I am writing here, perhaps you want to know why you should visit my blog.

• You're my friend and you want to make me feel important - seriously, humans are totally flattery operated and I am no exception. The more I see that hit count go up the more I think, "yeah, you're a rockstar, but you're going to stay true to your roots and remember where you came from"
  
• You're my enemy and are hoping to catch some dirt to use against me - think about it, I'm practically writing about whatever pops into my head. I'm bound at some point to say something you can use against me... there go my political aspirations, oh well
  
• You like to chuckle - I'd like to think I am marginally effective at accomplishing that, I reference this post. If you don't laugh at that, then you have no soul.
  
• You like variety - I will talk to anyone about anything. Seriously, I'd talk about trash cans if we could discover differing opinions on the subject but don't worry, I won't bore you with such nonsense. You will find in my pages medicine and non-medicine, arts and sciences, humorous and serious. As we speak, I am also wrangling up a couple guest writers that should provide differing opinions on a wide range of subjects.
  
• You want to help me conquer my student loan debt - did you know that Google will just give me free money? Just by you coming to this page and viewing the ads on the page over there >>>>> I get a fraction of a cent. And THEN if you actually click on the ad, they give me MORE money. The joke is on them, suckers. So, if you're bored, just come to my blog and go crazy clicking on some ads.

I make no pretense of being a good writer; I have little practice. I've avoided it all my life. I am pretty sure many of my major life decisions have been based on the amount of writing that would be involved, i.e., the less writing involved the more likely I was to choose that path. So you should not be here if you are looking for eloquent prose. I am not a visionary, ergo my writing will not likely incredibly inspirational, unless it is by some mistake and otherworldly muse speaking through this blunt instrument. I am not here to talk about politics; people do that for a living and I'm not really that tapped in. But if you can stomach my drivel, please continue to come back and read my pages.

An Honor and a Privilege

At the risk of sounding pompous and self-important, I am a keeper of an ancient and sacred art.

I am bound by an oath that is thousands of years old.

I have heard your most intimate secrets, secrets that no one else in the world knows. I have seen you cry as you've confronted your greatest fears. I know more about your bowel movements than any normal person ought to. I have seen you naked but our relationship is professional. I have touched your body in ways that that would result in any other person landing in jail. I know things about you that you don't. And I just met you ten minutes ago.

I shroud myself with the cloak of science. My stethoscope and hammer are my trusty companions. My white coat, with grime on the collar and sleeves, is my badge of honor. But it's a keen ear that is my most powerful tool. My weapons are diuretics and antibiotics.

I am expected to cure your ailments but you will most likely get better or worse no matter what I do. Truth be told, I am not that different from a sorcerer: standing over you reciting Latin and Greek and giving the impression of power while I let nature take its course.

I am a healer. I am your servant.

There's a hole in my stomach, dear Liza

Patience is a virtue with which I have a mixed relationship. At times, I am unflappable. At others, I am most-flappable. One of my greatest causes for flappability is the ineptitude of others (my own ineptitude I generally perceive to be brilliance that is merely not understood by my peers). 'Suffering fools kindly' is not a virtue to which I am particularly inclined.

This takes me back to an incident where my patience was put to the test. It was the middle of July, I was rotating through surgery and I was towards the end of my second month. I was miserable. Surgery is a specialty that, in my opinion, is occupied by only the most masochistic of masochists. I was on call. At about 130am, I hear the shrill "BEEP! BEEP! BEEP!" of my pager for only about the eleventy-billionth time that day. By this point my reflexes have become so attuned to silencing my pager that I manage to shut it up about mid-way through the third 'beep'. It read, "Please go see patient in ER#32." This was the fifth patient I had to go see since I had a break for dinner at about 9pm.

As I got up from my computer to make the trek down to the emergency department, I felt every last muscle in my body ache. I had been in the hospital for going on 20 hours. I had walked countless miles in that time, at least half of which involved climbing stairs. I was at the end of my physical and mental rope. This was not aided by the prospect of having another 10 hours in the hospital ahead of me. As I walked the long and lonely corridors my mind was void of content. Not blank but more like a television tuned to an abandoned frequency. At last, I arrived at my destination.

I met the patient. She was a 35 year old lady who was in the hospital with a skin infection. I started off the conversation with the usual introductions (though, lacking in the usual charm) and asked, "so, tell me what brings you in." Her story would have been considered coherent for a toddler, I had no idea what she was talking about. "OK, lets start from the very beginning... you have an infection, where? How did you get it? Wait, keep going back why did you have a tube in your stomach?" Patience was holding despite this patient's best efforts thus far.

So with a little redirection, I get her to tell her story. She had had a feeding tube in her stomach because she lost too much weight after bypass surgery. Reasonable. Last month her family went on vacation to a lake. Uh-huh. And she decided to go swimming... in the lake... with a hole in her stomach... At this point, my internal monologue started going wild Are you serious? You actually thought that was a good idea? There was a hole in your stomach! A HOLE! Anyways, the hole in her stomach got infected. Surprise, surprise, I didn't see THAT one coming! So she went to the local hospital where they removed the feeding tube and treated her with antibiotics and sent her out with a prescription for a full course. Strange, why do you still have this infection... But when she went to the store to buy the prescription, she decided it was too expensive and she had already received a lot of antibiotics in the hospital. Are you freaking kidding me? You can't possibly be serious! You have acrylic nails and your hair is done, that's what was more important than buying your medications? 


After a deep breath to calm myself, and a forceful biting of the tongue, I proceeded on to my exam. There was a hole in her abdomen that was leaking clear yellow fluid consistent with gastric juices, the area was infected. I hand her gauze so she cover the leaking hole but instead she uses the gauze to try to clean up some of the leakage but each time she wiped the pressure forced more gastric juice to be expressed from her stomach... giving her cause to wipe more up (I think you can see where this is going).  As she proceeded to play this futile game of whack-a-mole, I interrupted her, "STOP! Just cover the hole!" She replied, "But it feels like acid on my skin..." I starred blankly at her and counted to three, and in a dry monotone I said, "That's because it IS acid." In complete shock and perhaps horror she looked back, "It is? What kind?" She can't be serious, is she serious? I think I'm about to lose it. Again, counting to three, "Hydrochloric... Stomach acid." Knowing what was best for me, I quickly get her cleaned up and leave the room.

Looking back on that event, a couple things struck me. A physician's role is to be an anti-Darwinian agent. No, I don't mean that in the sense of needing to disprove his theory of evolution. I mean, rather, that a physician is there to defy nature's law of the survival of the fittest. Also, if I am to be a physician and an anti-Darwinian agent, then I need to develop a higher threshold for dealing with those who are other than the fittest.

The biggest day of the year

Medical students look forward to one day during their fourth year of school with unprecedented anticipation. That day is not graduation. Graduation is a mere formality and almost a nuisance. Fourth years are pretty much checked out sometime around October and are looking to their futures. They day that they are looking forward to is called 'Match Day'.

No, Match Day is not the day where medical students receive tips on how to match their shirts to their pants or their socks with each other (perhaps there should be some time dedicated to this in medical school because fashion sense is not something that medical students excel in). Match Day is a day in mid-March where medical students find out where they will be spending the next 3 to 7 years of their lives in that breeze in the park known as 'residency' (N.B., by "breeze in the park", I mean anything but a breeze in the park. 4 days off a month, working holidays, incessant pages (yes, we still use pagers) and more!).

The build up to Match Day is more than 6 months long. In early August, ERAS opens for editing. ERAS is a convenient universal form for residency applications. Although it is convenient, it is perhaps one of the most arcane and byzantine pieces of software I have ever used. Every action requires a click, followed by a window followed by two or three more clicks... and then you aren't sure if the preceding series of clicks actually completed the desired action, so you click back through again to make sure it did what you wanted to do. After all but 1 too many hours of working on this stupid abomination of a program, you let the application age and mellow until September 1st, the date ERAS opens for submission.

What occurs next is a process that is strange and I imagine is something like what occurs when high school athletes go through when looking at playing D-1 sports. Some places express interest in you and invite you for an 'interview', other places reject you outright, some places just leave you hanging, but it's clear, people out there want you... they need you. But wait a minute, Dr. Harvey, why did you put those quote marks around "interview"? How observant of you, I'm so glad you asked! Up to this point, my experience with interviews is a 1-2 hour process where you show up and the spotlight is on you, sometimes feeling more like an interrogation directed by members of the FSB. You'd imagine that residency interviews were something like this, but they are so far removed from the idea of an interview in your head that they don't even deserve the same name. These 'interviews' are more like hard-sell recruitment sessions. They start the night before with a dinner (one of these dinners was the occasion of my having a bread pudding that I call the 'ontological proof for God's existance', i.e., that than which nothing greater can be thought). Then the next day over the course of 6-8 hours you are fed at least twice, put through hours of slide shows as to why you should go to this program and why they are awesome, led on tour after tour (if I am led around the inside of one more hospital, it will be too soon) and then you have a 1 or 2 brief, low-key interviews. These interviews were described to me by a member of faculty as "making sure you're not some social freak."

People often ask me questions that would make sense like, "when do you know if you get in?" Or, "What if you get multiple offers?" But The Match is a whole different ballgame. In February, the warlocks of the NRMP demand of you your "rank-list" and likewise they take rank-lists from each applicant and program. They take these lists into their lair deep below Stonehenge, apply potions and perform seances (This is not the official story of the NRMP. They claim to use 'computers' and 'algorithms', like THAT is believable). After about a month, they return with The Match, which you are only allowed to find out about on Match Day. You are matched to one and only one program. You are contractually obliged to accept that position.

Kind of nerve wracking, ain't it?