Doctor

Come Back One Day and say ‘Hello’

2007-03-05T21:30:00.000-08:00

Tonight, Bob Woodruff appeared on The Daily Show. Funny I should start my first post back with this one particular fact. But it is one that stands out tonight. I will get back to it soon.

I promised to tell you about the life of a Hospitalist in a community hospital and that I shall do.

Medicine in a community hospital is a little different than in Academia. During residency, the patient belonged to an internist if he/she was on the medicine floor. But if things turned for the worse and that same patient was transferred to the ICU he would then be under the care of a new attending, the ICU attending serving in the unit.

But things in a community hospital are a little different. Here, I am your attending in the ICU as well as when you improve. I will be your doctor on the medicine floor too. And sometimes, if you go to the rehab floor here, I’ll still see you from time to time, just to make sure the old ticker is still ticking. Of course I consult with an intensivist if my patient is in the ICU, however, the final call on what goes in and what stays out remains mine, my responsibility, my decision.

In my short nine months as a Hospitalist I’ve accompanied many patients through their journey in this community hospital. I recall many whom I can honestly say would not be alive today if it wasn’t for something I did or didn’t do for them, whether they know it or not.

Some of you may misunderstand and figure I managed to pick up a god complex during those months too but that’s not what I’m driving at.

I guess the biggest drawback to the Hospitalist life is what dawned on me tonight. Looking at Bob Woodruff, I was looking at a man dressed in a suit, handsome, intelligent, well spoken, interesting, a man with a family who loves him and who seems to care much for his family. The entire time, I really mean this, the ENTIRE time I watched him I imagined the way he must have looked in that ICU in Bethesda. I saw him intubated, on a respirator, bandages across his head, half his scull removed. I saw lines, feeding tubes and urinary catheters. I saw nurses hanging IVs and getting CVPs. I saw the tears in his family’s eyes as physician after physician told them that their father was ‘critical’. Lucky if he makes it.

The single BIGGEST drawback to the Hospitalist life is this moment. When your patient has walked through the shadows of hell and has come out alive. And not just alive, Intelligent, Handsome, well spoken and a real family man, even dresses well.

This moment would have never happened if not for those same doctors and nurses in Bethesda. But if not for television, they would never have gotten to see what it was all for. Because patients almost never return as their true, every day selves. Only in another hospital gown.

I am still waiting for just one of my patients to come back to say hello. I hope one day one will.

Hope he comes dressed in a suit.

Hospitalist

2007-03-03T16:14:00.000-08:00

I don't even know if I still have a readership...IS ANYONE OUT THERE????

It's been a long while. Oh boy, how much has happened and where should I even begin.

I am a hospitalist now. It's been close to nine months that I am doing this job and it feels like internship all over again. Learn fast, on the fly, hold on it's a bumpy ride.

Private practice is sooo different than Academic. Things run much more smoothly here and they don't. Patients get much better care here....and they don't. I'll explain, I'm sure, soon. It just feels good to actually be back. I will not post much and certainly not on weeks I am working. But I'll have some fun with it.

For those of you who actually remember future intern. She is two years old and the most adorable thing I've ever seen.

We are expecting a son, any day now. But what should I call him?

Intern's Lie

2006-06-29T07:10:00.000-07:00

I’m drawing a blank. In these instances, I have learned, the optimal solution is to post something you’ve written in the past. I wrote this in the beginning of my second year of residency. Looking back I realize it’s kind of immature, but, right on the money!

Tomorrow, 7 am sharp, I embark on a new journey. I will be head of the team. This team will encompase one Attending, one Resident (that is I), two Interns (first year residents), one Sub-Intern/ fourth year med-student (from here on the “Sub-I”), and two third year med-students (a.k.a. “Students”).

To serve the readership yet unfamiliar with the medical hierarchy that governs today’s fine medical establishments I will now take the time to explain this stepladder of ass-slurpers. The understanding of this is essential for our future relationship and so if you have any questions feel free to ask.

I will comprise the list to range from least kissed ass to practically dripping. Remember, each member of the team has a primary goal, a secondary goal (if applicable), friends and enemies. It is long; I am sorry for this, but essential for the upcoming month. Let us begin:

1- The Students/ Third Year Med-School

Primary goal: To impress Attending and Resident with knowledge we were sure they never had. Secondary goals: To cloud a simple clinical scenario by suggesting that the patient has as many extremely rare diseases as possible, to name a disease the Resident hasn’t heard of and to send out for as many of the most expensive blood tests we have as the Resident allows. The sub-I is their best friend as he is closer to the resident and is always up to date on their performance thus far. Enemy: Interestingly enough, they are each other’s enemy as they are always being judged comparatively to each other. This undercurrent of hate is masked very well and only a thorough Freudian understanding of the subconscious can uncover it.

2- The Sub-I

Primary goal: Impress attending, Sub-I’s need recommendation letters for the residency match so they too can be taken advantage of by residency programs and government. Secondary goal: Discharge patients, less patients mean less work and try not to sound like Student by naming any rare disease.

The Sub-I’s friends are the Intern and the Resident, possibly third year but only if they agree to do his blood draws. Enemy: Patients with extremely rare diseases (makes Sub-I extremely uncomfortable as he now has to sound like Student).

3- Intern

Primary goal: Discharge patients. Intern will do or say anything to achieve this goal as he/she is usually overworked and would love to have one less family and upcoming tragedy to deal with. Secondary goal: Anything that ends in less patients (I cannot stress this enough).

Their friends are the other interns, amazing bonus point if able to really swing Resident to their “point of view” (often wrong!). Enemies: Patients!!!!
4- Resident (my new position)

Primary goal: To impress Attending and Chief of Medicine while also keeping Intern happy, motivated and feeling that Resident is truly on his side. Secondary goal: Constantly remember that Interns LIE! Again, they do anything to get patients out and Resident must continually double check Intern behind Intern’s back as INTERNS LIE! Friends: The Attending and other Residents. Enemies: Everyone on a certain level: as Interns LIE, Sub-I wants information primarily for Student, Student wants to name rare disease and make Resident look bad. To counteract Student, Resident must immediately say “I don’t know that but why don’t you give us a presentation on this tomorrow morning” (Gotcha Ya Bastard!).

5- Attending Doctor

Primary goal: Come for 2 hours in morning, teach, and leave as fast as possible, keep name out of chart so no one knows who to sue later. No Secondary goal. Friend: All. Enemy: No one. Remain completely oblivious to the ass smooching going on a round you. Wipe ass off after morning round.

6- Chief of Medicine

Primary Goal: Teach and run Medicine Department. Secondary goal: Absorb all ass-kissing, taking it all in as one continuous lick that lasts for many years. Secondary goal: Try to remain seemingly very humble, once in while give a lecture which makes every resident in the room feel like he knows absolutely nothing/ give up his medical license and go back to medical school.

This is the system within which we all operate. If there are any questions please feel free to ask. Tomorrow, I will do my best to avoid all questions and appease Intern to join my view of things. This will be my greatest chess match yet.

How We Die in America

2006-06-23T09:47:00.001-07:00

In undergrad we had a course titled "life and dying". I'll never forget the first words my instructer said as he entered the room: "I don't know why they call it life and dying when the course is really all about dying".

What a great course too. It was there that I visited my first hospice, learned about the choices that people in our culture commonly make when it comes to their own (impending) death and the realities that those who never think about this have to face.

Residency was a course in itself. I don't think a day went by where I didn't have to do something to a patient that I knew I would never want done to me had I been in their situation. The truth is that unless a patient specifically states his/her wishes in advance we are left with little choice but to do everything in our power. Sometimes, that translates into procedures, painful ones, dangerous ones as well.

The Schiavo case brought the issue to the public's attention and really was a prime example of how the beliefs of family members and the lack of public knowledge of one's wishes can cause tremendous chaous.

A reader requested that I post a link to this article. The article has some interesting revelations about the contrast between how we "think" we're going to die and how we're actually likely to checkout. It's from the new book, "UNPLUGGED: Reclaiming our Right to Die in America."

Here's a little exerpt:

Our doctors are equally subject to technology's allure. They learn in medical school to assess, treat, and cure. They then move into a hospital culture where a death, even among the aged, is seen as a failing. The young Dr. Lown in 1959 plied the silver paddles on the chest of a living human for the first time, and saw a miracle; a racing, out- of-control heart instantly returned to a normal heartbeat. The young Dr. Potter in 1963 compressed a chest and saved a hardware store owner, and the whole town knew it. Their tools were unbelievably primitive compared to the arsenal available to a young doctor today, but the miracles are equally wonderful. How could we deny today's doctor such joy? Or today's patient? Why in the world would we want to?

In truth, we don't want to, and we shouldn't want to. We want the technology, and we want the cure. When surveyed, the majority of us say that when our dying comes, we hope to be at home, free from pain, surrounded by loved ones, and not hooked up to machines. In the abstract, that's likely true. We also very much want to be hooked up to those machines right up to the very moment when the doctor is sure that those miraculous tools can't fix us. Trying to find that exact line is no easy business.

Moving!

2006-06-11T04:26:00.000-07:00

This time I mean for real. I am in the middle of a move to upstate NY. If not for this GPS thingy that I bought I'd still be lost on some back country road, withering away.

Congrats to Dr. Charles on making the move to his new address. We started blogging together and, at the beginning, had very similar blogs. He would blog literary stories of his start as a family physician and I would blog about my experience as a resident. We found each other pretty quickly back then and have found a way to keep in touch, maybe one day we'll even meet face to face.

But the times they are changing. I am nearly finished with my residency and he is nearly finished being a "starting" physician. Now, it will be my turn to blog as a beginning hospitalist and he can dish me the wisdom of one who is more advanced.

I am planning on writing a post that's a summary of my residency when I can see through the pile of boxes in this office. I was even thinking about writing a book about my residency and incorporating a lot of the madhouse posts into it somehow. All ideas that will have to wait for me to pass the boards.

Hopefully, I will have the time to write soon. Judging by my first week in my new local, time will be one of the things I will have plenty of.

Birthday

2006-05-27T05:07:00.000-07:00

Just wish me a happy birthday and move on because soon I'll be so soaked up in alcohol I may just answer inappropriately!

Thirty two and counting for the soon to be full-fledged doctor

Electronic Medical Record (Oh Doctor...)

2006-05-25T09:25:00.000-07:00

This week's issue of JAMA has a commentary essay about the new Electronic Medical Record system. I'd have to say that it's right on the money for how inconvinient sifting through any chart is these days. The essay is available here for free and is written in a format that really drives the point home! (highly recommended)

EMR (Electronic Medical Records) is the new standard in medical technology. Basically, hospitals are hoping to have the entire medical record of patients available on the computer system, including all notes written for that patient. You can see the potential benefits, however, the idea has run into a few obstacles:

While EMR is highly efficient in producing notes, virtually all of its notes are longer, recombinant versions of previous notes. Even notes of different authors are morphed by EMR into clones of one another. As physicians have become more adept with the time-saving features of EMR, their notes have been rendered incapable of conveying usable information by their bloated and obfuscated nature.

For one, the notes never change. The longest note I've seen thus far here was seven pages long. SEVEN pages for a daily progress note. By a Doctor!

Moreover, EMR encourages everyone to copy-and-paste the notes of everyone else so that notes become the same from author to author as well as from day to day. Even consultants are assimilated into the oneness of the EMR Borg. A cardiology consultant recently copied-and-pasted the intern's note into his own, even including "consult cardiology in AM" in his recommendations. Perhaps he meant consult a more thoughtful cardiologist.

I'm all for making the intern's job a little easier (actually, no I'm not!) but this is really starting to get ridiculous, not to mention, downright dangerous.

For example, I am aware of a case where a patient expired due to what the team thought was a Deep Vein Thrombosis that traveled to the lungs. The team was aware of the DVT and were treating it appropriately, however, the intern's notes make no mention of the possible DVT. They were continually copied and pasted. The doctors who are now being sued have very little evidence to back them with no documentation.

It should be pointed out that EMR has some laudable aspects. Notes can be created quickly with minimal cognitive effort, and their impressive length implies diligence and attention to detail.

"Minimal cognitive Effort" is the correct term here.

Grand Rounds

2006-05-16T09:50:00.000-07:00

This week's Grand Rounds are held at Doc Around the Clock.

and someone's trying to put together a Pediatrics Grand Rounds.

David Blaine is Dying to Breath

2006-05-13T18:58:00.000-07:00

About four years ago I ran into David Blaine in a crowded New York City subway station. He was performing his usual card tricks for the local street gangs. I had admired his magic for years and really thought that, as the locals say, he “Got Skillz”. I watched for twenty minutes and then went on my way but it was the highlight of my day. There is no doubt his talent is far superior to others in his field.

Of course, if you were one of the lucky few million that caught his special the other night on ABC then you probably already know what I mean. As of late though, he’s taken to doing all sorts of ‘pseudo’ tricks, like living in a bubble full of water for one week in the middle of Lincoln Center.

“Why the hell would anyone want to live under water for one full week?” I’ll venture to say it’s good for publicity. But why am I even discussing the subject on a medical blog?

Here we are and it’s Sunday night and there is a man on television about to suffer through a live apnea test in front of the whole world! And in my twisted doctor mind part of me wished I could test his blood gases, I could peak at his pH. Maybe even figure out how he would do it. So I kinda did and I thought I would share some of what I’ve learned with you. But before I launch into that, you must be wondering what the apnea test is.

Taken literally the word “apnea” means “cessation of breathing” and the main purpose of this test is to determine if a patient is clinically brain dead. It’s used mainly when it is believed that the patient underwent such a catastrophic event that he/she no longer has any brain function, including the drive to breath. We believe that brain death is the equivalent of death and we use the apnea test, as one test among others, to confirm clinical brain death.

How is the test performed? The patient is disconnected from the ventilator for ten minutes and monitored for spontaneous breathing. At the same time, we continually monitor their blood gases (the concentration of oxygen and carbon dioxide in their blood) throughout the test. When a human being ceases to breathe the concentration of carbon dioxide in the blood rises and the concentration of oxygen falls. Patients fail the test if the concentration of carbon dioxide in the blood rise to twenty above baseline levels and no spontaneous breath is recorded. But how does all this relate to breath-holding in a live human being. Well, it technically doesn’t, but the same process will go on there as well. Slowly, the amount of oxygen in Blaine’s body will dwindle as the carbon dioxide level will rise. Slowly but surely, the feeling will become unbearable and his brain will begin to signal frantically for oxygen. But at what point will all this become so unbearable that it will override his will not to inhale?

There aren’t many studies that have investigated the human ability to breath-hold. But those that have been conducted have shown that breath-hold duration depends on numerous variables. One fact of solace was that, regardless of the circumstances, human beings seem incapable of holding their breath to unconsciousness.

For one, breath hold duration is increased by increasing lung inflation. One would expect that lung volume would stay constant during breath holding but this doesn't appear to be the case, mainly due to complicated pressure gradients that are beyond the scope of this discussion. However, one theory was that the breakpoint (point at which breath holding is no longer possible) may be dependent on some minimum chest size when this deflation would cause sufficient feedback to the brain respiratory center to initiate a breath. This however does not appear to be the case.

Interestingly, breath holding duration is almost doubled by either starting with a lower than normal blood carbon dioxide level, which can be achieved by hyperventilation or holding with gas mixtures that have an excessive concentration of oxygen. For those who witnessed the event, Blaine was coached to hyperventilate (purge) prior to going under, presumably to decrease the carbon dioxide levels in his blood. Obviously, he did his homework.

Increased metabolic rates decrease breath hold duration. Likewise, decreased metabolic rates increase it. I would suppose that it wouldn't be unreasonable to think that the tank that Blaine used was probably cooled to temperatures that would decrease metabolic demand during the final event. Surely, Blaine would have taken advantage of this phenomenon.

Do arterial chemo receptors dictate the breath breakpoint, maybe yes and maybe no. the fact that there is no consistent carbon dioxide blood level at breakpoint in study subjects suggest that this is not the case, however, one experiment in patients whose arterial chemo receptors were not functional showed that these subjects could breath-hold almost double the time of healthy subjects. I can't put it past Blaine to somehow alter the response of his chemo receptors prior to the event but I believe it is unlikely.

The bottom line:

Was I the only one who thought Evil Knievil was going to bitch slap Blaine during the interview? I bet not.

During the interview Blaine demonstrated that he could hold his breath for approximately five minutes (an amazing amount of time), or 305 seconds. if Blaine was to cool the water tank to decrease his metabolic rate and even increase his breath holding duration by 25% (no exact prolongation constant is available) than he would be able to hold his breath under these conditions for approximately 6 and one half minutes. By hyperventilating prior to starting the hold he would increase his time easily by an additional 25% which would conclude a total time of eight minutes (assuming he did not do this prior to his breath hold with kenivel).

Blaine was able to hold seven minutes and ten seconds. Pretty damn good but not much improved from his prior attempt with kenivel once all other factors are taken into account.

Overall, I think it’s safe to assume the event was more of a publicity stunt for Blaine’s magic than for actually breaking the world record. The special was good. Some of the tricks were unbelievable. Now all that’s left is to see what he’s going to do next.

Heck, he’s had a week under water to think about it!

A great article on the factors involved in breath holding can be found here.

High-Fiving Where the Sun Don' t Shine

2006-05-07T07:02:00.000-07:00

All three colonoscopies didn't hurt. In fact, the only thing I remember of them was the sweet dream a little versed and dilaudid can induce. The first could actually be my first anatomy class. Some previous girlfriends would beg to differ!

I was 17 years old and after years of digestive problems I finally earned a trip to where ‘the sun don’t shine’. They tried to knock me out but didn't quite get it right. Seeing the inside of my own body was, I thought, 'so cool'!

Recently, I saw a commercial on television featuring patients exiting the colonoscopy suite high fiving everyone outside. I'm not sure it quite captures the mood of relief after the experience but kudos for the public awareness campaign. I'd rather spread the word about a possible life saving colonoscopy than about the HPV test no one really needs, or the Viagra. Personally I think they should follow every Cialis commercial with one for genital herpes. But I digress.

Colon cancer is the second most common cancer in both men and women and is responsibly for nearly fifty thousand deaths per year. This year alone, 150,000 people will be diagnosed with this disease.

Although there is no study proving that colonoscopies prevent colon cancer there is a lot of indirect evidence to support this hypothesis. Early carcinomas have been found in adenomas and the distribution of the two in the colon is very similar. Guaiac stool cards have been found to decrease the rate of colon cancer, presumably because they lead to a colonoscopy.

I understand the recent popularity of virtual colonoscopy, however, from this perspective I can say it's "virtually" useless, for anything other than making the radiologists richer. The preparation for the procedure is exactly the same and at least during a colonoscopy the patient receives sedation. Furthermore, during a colonoscopy, if something is found it can be resected immediately. If a cancer or polyp is found on a virtual colonoscopy the patient will need a real colonoscopy to boot. Bottom line, from the perspective of a three time veteran of colonoscopy the prep is by far the worst part of it and it's not any more comfortable for a virtual colonoscopy.

And this is the most important reason for getting your colonoscopy. There are only a handful of cancers for which prevention is effective, the rest are either screened for (to identify those who already have the disease) or not even screened for (no effective test). A colonoscopy can not only screen but at times can actually be curative.

It seems a complete waste when a father or a grandmother dies from a CANCER that could have been cured in a matter of minutes years earlier.

So get past your homophobia and get a colonoscopy if you need one. It rarely hurts, I promise.

And take my word for it; a little Versed is a lot of fun!

Malpractice Reform

2006-04-13T05:36:00.001-07:00

Dr. Charles recently published a post concerning malpractice reform. The long of the short is WE NEED YOUR HELP! so use the link and take the extra few seconds to send the e-mail.

As for me, sorry for the extremely long blog break that will have to go on slightly longer. I just feel like I need a break. This "hobby" of mine became too demanding in my own mind.

I Love This Guy

2006-03-24T02:41:00.000-08:00

I love it when I see posts that remind me of the Madhouse Madman. I love them more when I see them as comments on my blog. Charity Doc left this comment on my primary Care post below. And...please take it with a sense of humor. I'll have no bickering on my blog:

Don't do it!! Spend the extra 2 years and do a fellowship.

Here are some ideas:

Cardiology - you will work like a dog and be consulted every time a patient c/o chest pain (which is roughly 30%+ of all ER visits). You'll cath every middle aged and old people that have a femoral pulse. If they don't, you put a pacemaker in. If they're also dizzy, make it a pacemaker/ICD combo. But on the other hand, you'll be stinkin' rich and paid very handsomely. As far as hospital politics go, you'll be coveted and treated like a god, while us lowly, replaceable ER docs wish we have your clout with the hospital administrators and other medical staffs. I've been at this hospital for over 5 years now and the CEO, COO and CFO of the hospital still don't know who the heck I am every time I see them at the staff meetings.

Nephrology - you'll work like an ox and get consulted for every Creatinine level above 1.5 But you'll make money out the wazoo because every dialysis patient is fully funded so your reimbursement rate is...CHACHING. You'll even volunteer to dialyze road kill if it has an AV shunt in. But somehow, and for some stinkin' reason, you'll moan and groan every time you look at your census list which takes up a whole page, front and back, single spaced. Those damn dialysis patients sure have a lot of medical problems. DM, CHF, PVD, HTN, CAD...the list is endless. You'll find yourself arguing with the cardiologist whether CHF is a disease of the heart or a disease of the kidneys.

Hem/Onc - You may find it too depressing. Consult the Happy Oncologist blog for this one.

Rheumatology - No pt. seems to get any better do they? Another depressing discipline.

Endocrine - how many endocrine consult have you done? As an ER doc, I've never had to called one. Maybe you should forget this one. The chaching bell ain't ringing here.

Pulmonary/Critical Care - I'm just not feeling the big chaching factor here either. They seem to bronch everybody and scan everyone's chest. Vent management ain't that much of a mystery. It just seems that way. They're the only ones that get all excited about sputum. Sloogy docs. Everyone gets PFT's. What would you do without the cigarette industry?

GI - Oh my God! While the rest of the world upchucks and toss their cookies whenever a GI bleeder shows up, the GI guys sniffs it all in and says..."Can you smell the money??!!!" Poopy docs and Golytely pushers. They do make a very decent salary though, scoping from above and below all day long.

Neurology - Every since the NIH touts tPA for ischemic strokes, these guys are consulted all the time now from the ER. They're all over the TV and radios being spokepersons as every hospital compete to get that Stroke Center designation. What a load of crap, heh? Stroke Center. The standard of care, the 3 hours window for thrombolytic from onset of symptoms is the flipping same at every hospital. Every hospital has a OT/PT department, too. So why should any "stroke center" be any different from any other hospital? Yet, they're all over the newspaper and radio touting so.

Don't get me wrong, we need primary care providers. But why be one, work just as hard as the other guys and get pay less? Do the extra 2-3 years fellowship. It's all worth it. If I had to do it all over again, and if someone were to point a gun at me and force me to, I'd choose cardiology and nephrology as a second choice. Just my thoughts. Good luck on your decisions.

www.fingersandtubesineveryorifice.blogspot.com

ER docs are crazy and because of that they have the best sense of humor in the entire hospital.

The Case of Slobodan Milosevic

2006-03-18T07:23:00.000-08:00

Talk about jumping on a case too late. Due to an extremely busy week of interviewing and clinic rotations I was unable to write about the case although I’ve been following closely.

Slobodan Milosevic, former Yugoslav president, who was on trial for war crimes, was found dead in his jail cell at the UN detention center in Hague. Mystery surrounding the cause of his death immediately emerged. Specifically concerning traces of a drug called Rifampin which was found in his blood on an earlier exam.

Rifampin is mainly used as one of the multitude of medications used to treat tuberculosis. It is unclear how traces of the chemical were ingested by Mr. Milosevic since he was not being treated for this condition at the time and the pharmacy at the detention center does not even carry the drug.

In addition, Milosevic, who later found out about the traces of the drug found in his system, wrote to the Russian embassy concerned the possibility that he was being poisoned. In November, Mr. Milosevic was complaining of headaches, fatigue and hearing problems, possibly as side effects of Rifampin use. Speculation about how traces of the drug were found in Milosevic still ruminate and includes poisoning and self ingestion. How Milosevic could have obtained the drug is unclear although reports say that he was in a “privileged setting” where many normal prison procedures were not always followed.

As for using Rifampin for the purpose of poisoning there are certainly better options. The side effects of Rifampin toxicity are numerous, however, they are generally not lethal. In addition, Rifampin can decrease the effects of other medications and there are speculations (I know you don’t like ‘speculations’) that Milosevic was ingesting the drug in order to prevent adequate treatment of his high blood pressure, possibly as a means of earning medical leave.

An Autopsy revealed the cause of Mr. Milosevic’s death to be, as one newspaper put it, a “mild” heart attack. As a matter of policy, I limit my use of the word “mild” to non-lethal myocardial infarctions.

In addition, as an anticlimax to this issue, traces of Rifampin were not found in his blood.

Reality Check (Ruthlessly Candid)

2006-03-14T13:33:00.000-08:00

I am looking for a job.

After three years of residency in Internal Medicine I have decided to forgo fellowship and go into Primary Care/Internist or Hospitalist work. I thought it would be interesting to share with you some of the offers as well as my thought process.

I think this can be interesting because due to my anonymity I can afford to be ruthlessly candid. The other reason is that as some have stated you would like to read about the true experience of being a resident, look no further.

In the past, I have done my share of complaining: about the job, the hours, the pay, the future etc. etc. I’ve stopped all that. Not because I don’t still have those same concerns but because I realize that some of my audience likely make a fraction of what an internist makes these days and so my complaining seems kind of “funny”. So please don't view anything I write here as complaining, just my honest thoughts.

And, since I always believe that two, or two hundred, heads are better than one I would certainly welcome any tips that my readership can provide, maybe something I haven’t thought about.

Before I do, I think I have to be candidly honest about my goals and current situation, so that all of you can give me the best advice:

Overall, this is the plan: My wife and I would like to be able to return to Israel to live there within 5-10 years. Since doctors make roughly $30-40,000 in Israel I do not think that I will be able to pay my medical school loans there, this is the reason why I returned to the U.S. after attending medical school in Haifa. I would also like to be able to purchase the apartment/house I will live in there, since that can be very expensive. The plan is to pay off the private loans before I go back and make enough investments in the U.S. so that I can have income that can pay off the rest of the loans by itself. Currently, we are hoping to finally purchase a home and stop renting. Preferably in a good community with good schools so that Jordan can be safe.

Current financial situation:
1. Private Student Loans: $80,000 at 6.25% variable interest. Current monthly payment can vary but minimum is rough $600.
2. Stafford Student Loans: $96,000 at 3.25% locked, monthly payments $400 over 30 years.
3. Savings: $40,000
4. Currently renting but hell-bent on buying something soon. I currently live in a major urban city and the housing prices here are on the level of prohibitive.

Thus Far: I have been to 5 primary care interviews and 3 Hospitalist interviews here is what I have come up with: I have multiple offers, here they are:

Primary Care Positions:
1. $120,000 a year. No bonus. Partnership, maybe, after two years. Housing reasonably priced.
2. $115,000 a year. Bonus once surpassing three times your income. Partnership after 3 years. Opening Concierge service possible. Housing extremely expensive.
3. $80,000 a year. No bonus. 10% of whatever you bring in. Housing extremely expensive.

Funniest trend: The more expensive housing is in the area the smaller the salary.

Hospitalist Positions:
1. $110,000 no bonus, known to be a hard hospital to work in with lots of hours of work. Housing in area extremely expensive.
2. $125,000 no bonus. Work hard. Housing expensive.
3. $140,000 with bonus. Two hours away from family and outside current city. Housing cheap. Good community. Work hard.

My current inclination is to take the third Hospitalist position since I will likely be able to save the most there. The wife and I think it is our best chance at achieving our goals even though we will have to leave the family behind.

I had intended to go into clinic based medicine but will likely hold off until I move to Israel. It is an unfortunate truth which I simply have to confront and that is that currently I cannot allow myself to enter primary care and achieve my short term goals. When I listen to my friends who entered other specialties and the offers they are getting I am extremely jealous and if I had to make the same decision again I would have chosen differently.

I Applaud Her Effor Although I Do Fear For Her Life

2006-03-13T07:45:00.000-08:00

Check out this NY Times artcle on Dr. Wafa Sultan. And here's the video they're talking about.

Hat tip to Enrico for the info.

My Conclusion

2006-03-13T07:06:00.000-08:00

Friday, I asked the readership of this blog to express their opinion on my posts which dealt with Ian Thorpe, an olympic australian swimmer, who is currently suffering of an unknown respiratory condition. My question specifically was to inquire if I was being "Unethical" in publicly stating my opinion of what I felt was the likely diagnsis. Your views were mixed. for example, Moof said:

1) Ian Thorpe is a public figure.
2) You didn't make an accusation, you made a speculation.
3) Physicians have as much right as anyone else to speculate about whomever they will - even (and especially) when the subject matter is in their field of knowledge.
4) The only problem that I can see isn't one of ethics, but perhaps one of indiscretion (gossip?) ... depending on how you see 1) public figures and 2) the nature of the speculation.

And Graham reiterated similar concerns with:

It's definitely rubbed me the wrong way since you first started posting about it. If you were speculating about something a little more benign, I don't think I'd mind. But you're speculating about something serious and terminal; I'd feel the same way if you were speculating about something like cancer or ALS, I think I'd feel the same way. (Not to mention all the stigma that comes with HIV.) I think as a physician you're automatically able to know more about some people from your training--perhaps something that a non-physician would call strange or different or normal variation, you would know it to be disease.

And then there was an anonymous blogger (a physician) who stated:

I think ethically you have to ask yourelf several questions:
1)In publically speculating, did you bring harm to the patient's character? ( gossip)2) If so, do the needs for society to know outweigh the respect for an individual's privacy?
3) By virtue of your M.D., do your speculations have greater weight, and therefore carry more potential for grater harm?

I thought all the comments were great and quite thoughtful and I appreciate you all taking the time to write them. I did have difficulty though seperating if the problem was the fact that I was speculating about HIV? Or was the problem that I was speculating at all?

Speculation by its very nature is gossip. I get paid to speculate. People pay me for my services to speculate on their medical condition based on what information I have. Most of the diagnosis that physicians make are based on "the most likely" etiology. Isn't that speculation?

So I think what bothered everyone was the fact that I speculated that Ian Thorpe may have HIV. Probably due to the fact that HIV is a disease which still carries great stigma.

It was likely my fault. I had intended to begin trying my hand at speculating on general medical issues in the media, a la CodeBlueBlog (although, I profess, could probably never be as good as he was adn I so enjoyed reading his entries). For example, was Sharon's stroke due to medical error, or more recently, what is the true reason for Milosevic's death. I just so happened to pick up on Ian Thorpe's condition as the first and in this particular case HIV was my leading diagnosis, stigma or not.

Perhaps the best advice came later in the commentary from Echo Mouse and I urge you to read it carefully. I believe some of you may be taking what you read here a little too seriously:

My view is that blogging is personal unless it's part of a business or organization. You don't affiliate your blog with your hospital, private practice or any other agency. So I view your blog as a personal blog, despite the fact that you are a doctor.

Now, when it comes to expertise, everyone has enlightenment on certain things by virtue of their occupation. A blog is a place to express personal viewpoints. Your personal views include your training as a doctor. So while speculation about someone's health might be considered wrong in your capacity as a doctor, you are not at work here, you are blogging here. Based on all of this, I don't see that you have broken the H.Oath or spread gossip. You mused on something of interest to you. On your personal blog. Granted, HIV status can kill a career but you have never claimed to be an expert on HIV nor are you being consulted about this person's health. You're just stating your thoughts. That's okay as far as I'm concerned.

One of the reasons I took a break from blogging was because it was seemingly too political for a while there. People need to stop and think. Your blog is not the NY Times nor do you work for Reuters or the AP. If they stop in to read, they need to remember it's the same as stopping in to have coffee or tea with you. You're entitled to your opinions. Trying to limit that by throwing your profession at you is the sort of thing society does to shut people up, which definitely goes against free speech.

So you see, when you stop in to read here it's just like stopping in to have a cup of coffee. So what will it be regular or decaf?

I won't have the coffee, it gives me a case of the runs.

Friday Intern Topic of the Day VII: Is the Doctor Displaying Ethical Behavior?

2006-03-10T00:46:00.000-08:00

I love comments. Yes, I agree, I do tend to be less “responsive” to commentators than other bloggers but I certainly read each and every comment that’s left here. So if you ever have something to say please take the time to leave a comment, I do love to read them.

There are, however, comments that go in one ear and out the other and others that make me think. Earlier in the week I posted an entry about Ian Thorpe. I speculated that based on the information available to me, that Ian Thorpe may have HIV. I gathered the information from press releases released by Ian and from whatever I could gather that was released by the general media. I even submitted the post to Grand Rounds. Where, somehow amid the thousand and one entries this week, it managed to get a certain amount of attention.

There was one comment left by a certain Dr. Steve that I’ve been thinking about for quite some time now and I would like to comment on it. And, I would like to hear your comments on it too:

As a fellow physician, I think it is marginally unethical of you to openly speculate, based on extremely thin second-hand guesswork that a prominent figure like the "Thorpedo" has HIV. I don't think you would like that if the tables were turned (especially if it turns out that the guess is wrong).

I actually thought it was a great comment. It didn’t contain any foul language or derogatory remarks and yet drives the same point home. Everyone, I would like you to take this as the perfect example of how to display dissatisfaction with a certain post without displaying lack of taste. Wonderful stuff and it made me think. Am I being somewhat unethical in speculating about Ian Thorpe’s condition openly on the internet?

Lately I’ve been contemplating the purpose of blogging. Other than the occasional sharing of something creative that I wrote is there really any other benefit to what I’m doing, and by extension, to blogging at all? (I contemplate too much, I know)

Here’s what I concluded:

If there is anything that we as bloggers can contribute in the big spectrum is that we are all experts at something. Likely, our level of expertise far outweighs that of the reporter who writes the column for the big media conglomerates whom we are all reading. These reporters don’t know what questions need to be asked because they are not lawyers, doctors, cops or accountants. They are reporters and that is the only thing they know.

Ian is not my patient. I took an oath to protect the privacy of my patients. It would be unlikely that, Ian Thorpe being who he is, other doctors have not already discussed the possibility on big media in Australia. In addition, Ian’s condition is being discussed everywhere, last I checked, 300 articles around the globe this week alone.

But boy does he have a point and I mean that honestly. I can totally see what he means and a certain part of me is still contemplating if I should continue this. But I really do enjoy trying to piece the information together. Is it unethical?

What do you think?

Ian Thorpe Drops Out AND Expands the Differential

2006-03-09T03:18:00.000-08:00

In a sudden and unexpected move Ian Thorpe, by far Australia’s best swimmer, has dropped out of the Commonwealth games. During training Ian, who was said to be quickly improving, was unable to complete his usual regiment, becoming winded after twelve laps. Afterwards, on national television, he announced his withdrawal from the Commonwealth games.

Previously I stated that after reading the reports issued by the press I believed that Ian Thorpe may have HIV. This was due to the following factors:

1. Ian has now been ill for more than three weeks with a “viral” syndrome and I do not believe that this is likely.

2. His coach, Alan Thompson, stated that: “The antibodies in his blood were beginning to rise”. I believe that he was referring to Ian having a certain type of immunodeficiency and by far the most likely diagnosis in his age group is HIV.

3. The Doctors and Ian himself are being extremely vague concerning what is going on and the result of his testing.

4. Ian has been placed on antibiotics for a viral condition and this is not commonly done unless the doctors are suspecting something deeper.

During his press conference Thorpe revealed that during his childhood he had to take a three month vacation from school for another bout of “viral bronchitis”. This is interesting because it hints to another diagnosis that is less likely, although possible.

Immune deficiencies are a group of disorders characterized by the dysfunction of the immune system. There are a number of disorders but each expresses itself differently depending on the specific disorder present. Although a lengthy discussion of the topic would surely not be appropriate here, you can find more specific information elsewhere.

Generally, immune deficiency would manifest as recurrent infections. However, due to Ian current age and his known health status I think that we can rule out the more malignant ones. In addition if you remember Alan Thompson, the coach for the Australian Olympic team, stated:

“He got some blood tests back today and they were positive and showed an improvement in the blood parameters and the anti-bodies are doing well"

In my earlier post I speculated that Mr. Thompson may have been misinformed and that more likely he was referring to the White blood Cell (WBC) count that is often checked on a cell count. But what if he wasn’t misinformed? What if Mr. Thompson knew exactly what he was saying?

Are there any immune deficiencies that would express themselves as a decrease in the amount of antibodies in the blood and would not present with consistent recurrent infections. I placed consistent in bold type because if Ian Thorpe was consistently ill he would not have been able to achieve all he has until now and so I believe we can assume he is healthy most of the time.

One diagnosis jumps to mind more than any other: Selective IgA Deficiency

This deficiency may be congenital or acquired (meaning people get it later in life). More importantly, it’s not altogether uncommon and many of those who have the disorder lead normal healthy lives. In addition, it is not uncommon for it to manifest as recurrent upper respiratory infections. the same condition Ian has ahd for three week now.

Ok, I admit, my bet is still on HIV. But a good differential always includes a number 2. All that’s left now is to wait for someone to leak some more information.

Go Read Grand Rounds! It's an Emergency

2006-03-08T03:10:00.000-08:00

Kim at emergiblog has this week's Grand Rounds and she's decided on an Emergency Department theme.

Future Intern: One Year Old Today

2006-03-07T03:35:00.000-08:00

Most of the readers who’ve been with me for a while know what my favorite and shortest post of all time is. It was exactly one year ago today.

I am profoundly amazed at how one year has passed so quickly and how far my little intern has come. I’m so proud of her. After all, she’s already mastered how to perform lumbar punctures and central catheters and she’s not even in medical school (Not for another three years).

Today the Future Intern, and my little girl, is one years old.

Kirby Puckett in Critical Condition

2006-03-06T07:47:00.000-08:00

Former Minnesota Twins center-fielder Kirby Puckett had a stroke at his Arizona home yesterday and was taken to a hospital for surgery, the team announced from its spring training camp. The 44-year-old Puckett, who led Minnesota to World Series titles in 1987 and 1991 and is a member of the Hall of Fame, was taken to a Scottsdale hospital where neurosurgery was performed to evacuate the bleeding in his head. Mr. Puckett is in critical condition.

This is the second famous case of hemorrhagic stroke in as many months. The most common risk factor is hypertension, which causes nearly 60% of all strokes of this type. Other causes include amyloid angiopathy, trauma, cocaine and ruptured arteriovenous malformation.

Mr. Puckett is pretty young for this type of condition. Which can make causes other than hypertension more likely. However, it is unclear is Mr. Puckett did suffer from Hypertension although his recent weight (>300 lb.) makes it likely that he did. Some of his history may suggest risky behavior and makes cocaine use likely (Although I am by no way claiming that he had).

In terms of need for surgery to evacuate hematomas. evacuation of the hematoma is generally not helpful except in cerebellar hemmorhages. Most hematomas more than 3 cm in diameter also require surgical drainage. There are other indications for surgery that include clipping of an AV malformation or placement of shunt. Regardless of the cause, the need for surgery often indicates a poorer prognosis.

More to come as information is released.

Is Ian Faking?

2006-03-06T06:46:00.000-08:00

A second differential diagnosis for Ian Thorpe:

The coach of South African swimming star Ryk Neethling has sensationally claimed Ian Thorpe's illness could be a ploy.Neethling's coach Dean Price said he had heard reports from the Australian camp before that swimmers were sick on the eve of major competition only to watch them dominate.

Thorpe is due to clash with three-time Olympian Neethling and fellow South African sprinter Roland Schoeman in the 100m freestyle.

It seems I didn't incorporate the "clashing" factor present in swimming competitions into my differential.

Now That's a Medical Miracle

2006-02-28T05:05:00.000-08:00

I am referring to having just spent two weeks in the same house as my in-laws and NOT having sent someone to the hospital in need of "trauma-surgery" STAT!

Speaking of trauma surgery (now that's a nice transition), this weeks Grand Rounds are at Cut-to-Cure, a blog who's author is a real live trauma surgeon. I didn't manage to submit, or write anything, this week. That was due to the ninety degree weather I was experiencing. Amazing how it inhibits creativity and idol time in front of a computer screen INDOORS.

While I get this thing up and running again, I demand you go and have a read.

And I wanted to thank everyone for the input on the previous post. I will try to take some of your advice and incorporated it. I am back home, grateful to the airline industry for managing to keep me out of any burning infernos.

Friday Intern Topic of the Day VI: How Can We Make This Blog Better

2006-02-23T23:16:00.000-08:00

So I would like a little constructive criticism of how I can make this thing a little more interesting.

anyone...anyone?

What?

2006-02-23T23:01:00.000-08:00

Saturday was my day off. I decided to spend part of it catching up with my brother who recently ventured off on his own and began a startup internet price engine. We spoke about the business and the general state of the market.

During the two hour conversation he told me about how "spiders” were “continually crawling his site” and “indexing pages” into the search. How he had to track “IP address” and other “browsers” to determine charges that would be incurred. This incomprehensible soup was spewing out of him like honey. Had I the guts to explain I understood but a simple portion of our initial conversation and nothing else (Specifically, when we exchanged goodbyes) I would have endured an hour long lecture. But the experience truly shocked me, the exploration of my internet age ignorance that is.

When did it get to this? We speak English mostly everywhere but even our English is divided into Spanglish, Slang and Rap. Then there's Ebonics and Spanish and in certain areas you can't get along if you don't speak the local vernacular.

I am so glad that as a part of the medical community we are not privy to these types of miscommunications, everything is plain and simple. Our vocabulary, an example of brevity and clarity.

So, the other day when a Surgery consult came to ask me to clarify what was written in the chart of a patient I had recently admitted I stared at him in sudden disbelief. Why it’s clear as night and day. The chart read, "64 y/o m was in USOH 2 d/ PTA, BIBEMS w/ c/o pain in LE and SOB, please r/o DVT/ PE. Obtain duplex, get a V/Q, D-dimer and spiral CT/ PE Protocol".

Where did this guy come from, Mars?

An oldie but goodie from the archive. Check the comment section for an explanation of the chart.

Grand Rounds

2006-02-21T21:57:00.000-08:00

This week's Grand Rounds are at Dr. Andy's blog. I love Andy's blog and recently added him to the blogroll. About my entry he writes:

Doctor, nee Medical Madhouse Madman, complains about his difficulty in getting listed on Medlogs, which is a medical blog aggregator.

I always appreciate the effort set forth by Grand Rounds hosts. But sometimes am slightly disappointed by the introduction to my posts. I mean, I didn't just complain, I turned my complaint into an international incident. It was simply brilliant. The kind of creative feces people long to read. But with the introduction above, even I, wouldn't bother to click on the link.

Still, he's got a great blog, he's very intelligent and a great writer. so check him out!

Oh, and the COTV is at A DC Briding Blog this week.

How Do You Use Your Blogroll?

2006-02-20T23:36:00.000-08:00

This vacation, although it is making my excellent coverage of medical issues slightly more difficult, is giving me a good chance to post about non-medicine related topics. Today, I would like to discuss the blogroll/link list, usually available on every blog. I guess it goes under blog etiquette but the behavior for one's blogroll is so variable and often not discussed.

It stems from the basics of internet that the best way to get people to your site is through links on other blogs. After all, the chance that a certain reader may click the link is higher than if he should search Google for that same topic directly discussed on your site. Google, as well, assigns a certain page rank to your blog/web site based on how many links it can find to your blog. The higher your "page rank" the more important your site is deemed to be and the more often your posts are archived and available for Google search results, meaning, that Google will scan your site more often if you have a higher page rank. Well, all that means in essence is that the higher your page rank, the more readers you are likely to receive.

This algorithm gets even more complicated as it's not just "how many" links are found to your site but also who those links are from. So a site with higher page rank "passes on" more importance to your page. Very interesting, but what the hell does any of this have to do with my post now?

It's so variable how bloggers use their blogroll, most of the times it's obvious as soon as one sees their page. If the link list is very long, chances are that this blogger exchanges links to boost readership and to increase Google standing. I believe it's a great strategy. Links don't cost anything, and although as your outgoing links increase your "page rank" decreases, this is a small decrease when calculated into overall page ranking. What seems to be most important is incoming links. I use this strategy here most of the time, unless the author requesting a link or their blog really doesn't interest me or has nothing to do with my topics. So yes, I do exchange links at times.

There are others who are very protective of their blogroll. I find this strategy very interesting as it is kind of counterproductive, but, I would guess that it stems from a feeling that your blog is an extension of yourself and so if you don't find another blog interesting you shouldn't add it to your list. I can accept that, although, I warn those same bloggers that they are likely not helping themselves as well.

And then there are those who use other approaches. They title the choice links "special" and others under "exchange/reciprocal links". This is instructive, as it really doesn't matter in terms of rank but achieves both motives at the same time. I think that it's probably a great approach although I don't use it here.

And then there are those who just get too big for their link list. For example, The Fug Girls, who used to have a link list until their readership became so huge that it disappeared off the page. So much for remembering the small people.

I'm not ashamed to request "exchange" links. An author is likely to blog off his list regardless of how the other blog got there. If you don't think so just check out Instapundit over the last two years and notice how the same authors are continually discussed. You'll find them in his blogroll as well, in case you were wondering. And he receives hundreds of submissions a day, so what does that tell you?

So the more links the better, links don't cost anything, they reduce your page rank marginally but can increase it substantially. Make your own calculation. My conclusion is kind of obvious, isn't it?

What's your link strategy?

For a better discussion of Google page rank check out Brad Fallon's blog. Drop me an e-mail about exchange links.

Update: I would just like to thank those who have been using the Amazon bar on the side to purchase their items. Needless to say, I haven't made a living out of it but the few dollars that have come my way as a result have been enough for a good movie and provided some motivation. Not to mention, gave me a good tickle. And to the one reader who actually used the "donate" button for a certain sum: I love you!

A Very Light Sunday Post

2006-02-19T08:00:00.000-08:00

Today, Israel anounced the first steps in the disengagement from a Hamas led Palestenian governement. It is freezing the payment of millions of dollars to our murderers next door. Which is nice, to know that at least you are not paying for your own bullet.

Kind of heavy I guess.

So here's something a little lighter. Its just occured to me how sometimes you write what you believe is a fucking awesome post and yet it gets absolutely no response. Not one! and then you write another post, which you believe is the most boring compilation of text anyone ever combined into a paragraph, much less posted on the internet, and it gets tons of response.

Why?

Friday Intern Topic of the Day V: The Danish Cartoons

2006-02-17T03:32:00.000-08:00

The following is an excerpt from an article published in this Friday's Newspaper by Uri Elitzur:

The violence over the Danish cartoons did not begin due to the cartoons just as the recent Intifadah was not caused by Ariel Sharons' visit to the dome. In 1939, many believed Hitler when he blamed the outbreak of war to "an incident" between German and Polish soldiers.

Normal people do not start wars over cartoons and Muslims are neither idiots nor retarded children. Most are not very religious either. The cartoons are not a reason but merely an excuse and when it will be exhausted they will move on to other excuses.

Do you really believe that Muslims are stupid? That they burn down embassies over cartoons? That they have been dying in the streets for five years because Ariel Sharon spent five minutes on the dome once? Do you think for one minute they don't realize that the cartoons are not really against Mohamed as much as they are a criticism of the violent nature of a so-called "peaceful" religion? "A spontaneous eruption of rage of an oppressed nation" the enlightened European says. Well, it's not.

It's not the cartoons, not the settlements and probably not the occupation either. There is a war brewing beneath the surface, burning like hot lava. It is looking for cracks in the ground where it can erupt.

Medlogs: A Terrorist Blog

2006-02-16T00:37:00.000-08:00

Armed with the knowledge that only regular readers are familiar with my twisted sense of humor, I urge you to read the following piece with a tendency towards the comical

This weekend the Palestinian Authority (PA) is scheduled to elect their new Congressional Leader. Hamas, having won the majority of seats in congress, is preparing to take over the government. The current prime minister of Israel, Ehud Olmert, has stated that all ties with the Palestinians will cease.

In addition to stopping all payments to the Palestinian Authority Israel plans to freeze the payment of 50 million dollars of tax collections to the PA, take steps to prevent international foreign aid, and as a third step, possibly disconnect the supply of electricity to the Palestinian authority. This, according to published report in this mornings' newspaper.

Which made me think, since I am currently residing in the middle East (on vacation) and have promised my readers a certain "angle" over the next two weeks, I fully intend to carry out my obligations in all aspects related to this blog. And, as previously stated, I am currently facing difficulty getting this new blog listed on Medlogs. This after first having my feed denied multiple times and after sending numerous e-mails to the proprietor of the aforementioned blog.

In addition, this blog has made multiple attempts of diplomacy in the current situation, for example, posting a public plea for help with the matter. Even after an ally of this blog corrected the feed request with the correct feed request, which was accepted multiple times on Medlogs, the feed is yet to appear.

Unfortunately, at this juncture, more definitive steps must be taken to to achieve the desired result. Therefore, the author/s of Doctor is/are declaring that if the matter is not soon corrected the link to Medlogs (currently in the blogroll) may suddenly disappear. If the matter is still not corrected and the feed does not appear I/we may ask our current readers to boycott the current blog known as "Medlogs". This embargo will continue unilaterally for an unknown period of time at which point we may have to declare "Medlogs" and blogs related to the proprietor of Medlogs a "Terrorist blog" and enemy to the Doctor.

We may or may not take steps in the current "United Federation of Medical Blogs" (Which ironically, currently resides on Medlogs) to achieve our goals prior to beginning this process. Although, factoring in the inherent bias of this body, it is unlikely we will do so.

At this particular juncture we may take steps with our allies (all those mentioned in my/our blogroll) to levy sanctions against Medlogs and to remove all aid (including links to the above mentioned) from their blogs.

If all the steps previously mentioned still do not lead to a favorable outcome we will have no choice but to take forceful action and release our spam comment battalion into action. We anticipate that this will lead to a cessation of all quality postings of the so called author "Jacob Reider".

We/I feel that it is most unfortunate that it has come to this but we see no other means of negotiation at this point. Mr. Reider is solely responsible for the actions committed by the blog known as Medlogs as he is clearly listed at the top of the page as the owner and current leader of this questionable organization.

Updates to follow…

How Long Do You Have To Live?

2006-02-16T00:34:00.000-08:00

It's slightly hard coming by good medical news here but this little nugget just happened to fall into my lap since the press here is having a field day with this one. It seems to me that anytime one can simplify the human condition into twelve easy to answer questions we, as the human race, are always for it.

And so, a new study from the VA in San Francisco (I am trying to translate from Hebrew so forgive me for any disparities), which included more than 11,000 individuals above the age of 50, attempts to predict survival over the next four years based on risk factors. According to the investigators the test is correct 81% of the time. It is designed for people over the age of fifty.

Follow the list, one at a time, and add the appropriate amount of points for each medical/human condition listed:

1. Age:
Below 50: No Points
60-64: 1 point
65-69: 2 points
70-74: 3 points
75-79: 4 points
80-84: 5 points
85 and above: 7 points

2. Sex:
Female: No point
Male: two points

3. BMI (weight in kg/height in meters squared):
below 25: no points
above 25: 1 point

4. If you have cancer: 2 points

5. Diabetes: 2 points

6. Chronic Lung Disease (asthma, COPD): 2 points

7. Congestive Heart Failure: 2 points

8. Smoker: 2 points

9. Unable to Shower alone resulting from difficulties in health or memory: 2 points

10. Unable to manage a checkbook or pay bills appropriately due to health or memory problems: 2 points

11. Unable to walk short distances due to medical condition: 2 points

12. Unable to carry heavy objects due to medical condition: 1 point

Result: add all points that you accumulate

0 to 5 points: less than 4% chance of death within the next 4 years
6-9 points: 15% risk of death within the next 4 years
10-13 points: 42% chance of death within the next 4 years
14 points or more: 64% chance of death within the next 4 years

Some Thoughts: Of the entire list only two risk factors (smoking and BMI) are amenable to lifestyle changes. The list includes a multitude of chronic diseases but does not address a change in prognosis on the basis of adherence to treatment. Of course, this is probably discussed in the original paper and not in the public media (my current only source of news), which tells a lot about how medical news is distributed.

Smoking carries the same weight as Congestive Heart Failure, chronic lung disease and dementia and is worse than currently having cancer. Do we need to continue driving home this particular point?

Middle East Angle: The study fails to address a change in prognosis based on current residence in the Middle East (in particular Israel). According to the news, Hamas is scheduled to take over the PA this week and Iran continues to enrich Uranium. My estimation states that this particular risk factor is worth something along the lines of 50 points, leading to a four year prognosis of "God can only save you now". The Rabbis around here tell me he's been doing it for quite a while now.

The Middle East Angle

2006-02-16T00:33:00.000-08:00

It would be fun, I thought, that while I reside here on vacation that I should include a "Middle East Angle" in my current posts. So look for this at the end of all the posts over the next two weeks. It should make the whole thing more interesting, or depressing, or downright dangerous!

Maria, Will You Be My Valentine?

2006-02-13T22:59:00.000-08:00

The "Internal Medicine" wife, the future intern and I arrived in Israel two days ago so that the in-laws can get a little glimpse of the skills that the intern has so far developed. I believe she may do a back-to-back Lumbar Puncture on both of them for her demonstration tonight.

It probably would have gone over so much better if she didn't catch a virus. This jetlag and a runny nose is a real deadly combination. Hamas would surely love to learn to cultivate this duo for the production of some sort of weapon of mass destruction.

While I dodge bullets on my way to a beach I suggest reading this week's Grand Rounds at Intueri. Maria wrote a very creative Valentine's Day edition. Makes you just want to cozy up next to a fireplace in the twenty feet of snow my parents are complaining about.

Friday Intern Topic of the Day IV: Say you Hate your patient?

2006-02-10T00:33:00.000-08:00

As a follow up to the previous post I would like to throw out this as a topic of conversation.

My wife, who is an attorney, recently had to excuse herself from a case after finding out that one of the clients involved is a relative of ours. The law, fearing this could lead to bias, demands that lawyers disclose such information to their clients and, when possible, excuse themselves from the case when such a situation develops.

I often wondered what goes through the mind of Israeli doctors when they are forced to attempt to save the life of a suicide bomber after he has just murdered so many other innocent lives. It happened to this doctor in Iraq and he describes the anger that was slowly building within him:

“The more of the story I heard, the more angry I got,” he said. “But I was still able to do my job and realized I am a professional and I’m going to take care of this guy.

It always ends that way doesn't it? "I'm a professional. I did my job". Well, but all professionals are also human beings who have feelings and exhibit anger and resentment. Can one really, honestly, say that those feelings will have no consequence on the type of care your patient recieves?

In other words, should physicians be forced to dislose when they feel anger towards their patients. And...should they then be forced to sign off the case? After all, we don't even trust lawyers when it comes to simple money matters. Should we trust physicians when it comes to human life?

Seeing Red

2006-02-09T13:28:00.000-08:00

The first time we were robbed I was only eleven years old and new to this country. My parents worked harder than they ever have in my short lifetime and they were gone most of the day. We understood that they were trying to build a better future for their kids. Personally, I had special admiration for them.

It’s why my heart wept for them when we walked in on our belongings strewn about on the floor. They had spent a good fraction of their weeks’ earnings that day to take us out to an amusement park in the area. We had a great time. And then we came home.

Money was missing. Our house was a mess. They broke precious items from our past, invaluable diaries of our childhood. I could not imagine anyone doing this to my parents intentionally. They are such well intentioned people.

The second time was even more dramatic. It was another apartment we had moved to and we just came home from vacation. We feared going into the house once we opened the door in case the burglar was still inside but my fathers’ temper got the better of him and he raged inward hoping to take his anger out on a possibly extremely dangerous thief. Looking back on it now, I’m not sure I would ever do that but, at the time, I definitely admired him for it.

The last time was by far the scariest. After a long day visiting family we had arrived absolutely exhausted. My brothers and I headed straight to our bedroom while my parents kept busy arranging the house. As my mother proceeded to the restroom she heard a strange voice from within. She called our names one at a time, hoping for a reasonable answer, but only heard grunts from the inside of the room.

As she attempted to open the door a strong opposing force slammed it shut in her face. Instinctively, I believe she knew what was going on but waited until she called panic. Years later, she told me in confidence, that she did not want my father to attempt to catch him and felt we were all better off if he was simply allowed to escape through the same route through which he entered. And he did, jumping out our bathroom window to the ground outside.

My father chased out with a knife. I, now older, right behind him with knife numero dos. Luckily, the thief escaped and my father kept himself out of jail. We needed him a lot more anyways.

Our emergency room is situated relatively close to a large police precinct. The surrounding area is one regarded as having one of the highest percentages of drug usage and trafficking in the country. All in all, we get more than our fair share of intoxicated patients.

Often, patients addicted to opiates (heroin mainly) or those taking methadone who somehow managed to find themselves arrested end up in our emergency room. They are brought there by the local police who fear they may withdraw from their addiction while in custody. They are there to receive a, just small enough, quantity of methadone to prevent that very complication from happening.

This morning, as my shift was slowly coming to an end, one such character was carried in with a tag along cop for company. “I did tons of heroin in the last couple of weeks”. How much I may ask? “Six to eight bags a day”.

Looking at this poor soul, one hand cuffed to a stretcher railing, I asked the next most obvious question. “That must be really expensive, how do you afford it?”

He chuckled and grinned. Told me how he robs houses for money and valuables which he sells to supplement his healthy diet, which is how he now ended up with a badge for an escort.

But I only saw red.

Memories of fear, resentment, helplessness and hate flashed before my eyes and I felt my upper extremity exert an immense will upon the rest of my body to swing at this pathetic, chinless, wimp of a man. I wanted blood. His head now resembled a large target sign in my hallucination.

I found this part of the past buried within that was simply begging me to let the anxiety, nausea and vomiting that was about to commence erupt unobstructed. I wished for the pleasure of watching his heart race like a thoroughbred on the monitor, to see sweat and saliva engulf and swallow whatever little pride this man had left. Just for a little torture in the form of payback. Do you remember those people in the picture you broke, they were my parents and they didn’t deserve it!

But I didn’t.

Eventually, I gave him his measly dose of methadone, which secretly I hoped was not nearly enough. I sent him and the rest of the cops on their marry way to a cellar. And then I called my mom and she told me of all the cool ways my father made fun of her yesterday.

My parents rock!

Click here for signs of opiate withdrawal. The next post probes the question: Should physicians excuse themselves when caring for a patient whom they dislike?

A Great Doctor

2006-02-07T07:05:00.000-08:00

The Cheerful Oncologist gives a speech to the appreciative audience above about the attributes of being a great doctor:

Thank you for that warm welcome. It’s a pleasure to be standing here today in front of such an attentive crowd. As you heard in the introduction our topic today concerns the traits that comprise a great doctor, or as Sammy Davis would say, what kind of fool am I to want to go into medicine?

I counted, I'm 0 for 6.

Grand Rounds

2006-02-07T02:52:00.000-08:00

Fresh off the presses, this week's Grand Rounds are brought to you by a biologist.

No Wonder they Call it the Holy Land

2006-02-06T05:30:00.000-08:00

Don't worry, the clip is in english.

Friday: Intern Topic of the Day III “Where does Grand Rounds Go from Here?”

2006-02-03T02:37:00.000-08:00

An interesting post from this week’s Grand Rounds. It seems the Grand Rounds are getting a little, how shall we say,…Grand!

From California Medicine Man:

Is it possible that Grand Rounds are getting too big? Perhaps those that host it might consider paring down the number of entries that are actually published more? It's getting difficult to separate the wheat from the chaff!

Perhaps we need to decide what the purpose of Grand Rounds should be? To increase the traffic of all who submit entries or to elevate and educate those that come to Grand Rounds to read and learn and gather insight from the many different perspectives represented (Physicians, nurses, researchers, administrators, payers and of course patients).

Personally, I'd opt for the latter. The great thing about the blogosphere is its democratic nature. Traffic comes to those who write clearly and have something to say. Grand Rounds should be one more way of bringing readers to the "best" of the medical blogs. Far be it for me to define what the "best" is. I'm perfectly content to have the criteria for that decision vary from week to week depending on who the host is.

I'd simply recommend that those hosts limit the number of entries on each given week. It's unrealistic to expect that every entry (or given the explosion of medical blogs, even most entries) are of equivalent interest to readers. I'd like to see the hosts worry less about potentially offending bloggers whose entries on a given edition were rejected.

I'm not in any way advocating a form of elitism here. Each blog entry should be taken at its face value for consideration. Each participant in the world of medical blogging should be judged on an equal footing by the hosts.

I think this will move us away from the more superficial objective of simply increasing traffic to our own blogs.

I thought about it for a while and found that the proposal would pose a set of problems:

1. Those who write well, write well: Isn’t it possible, or even probable, that the same bloggers would get picked to be included every week. That instead of Grand Rounds reflecting the medical blogosphere that it would end up being a compilation of the ten, consistently, best bloggers. Wouldn’t that be a contradiction to why carnivals were created in the first place?

I always thought it was to give the small guys a little exposure and maybe, eventually, a bigger following.

2. The blogosphere depends on links: And although I have nothing but the highest respect for everyone involved in putting the rounds together each week. Could the prospect of a lucrative link (big blogger, lots of traffic) loom in the back of the hosts’ mind and, let’s just say, slightly bias the selection process? It’s not double blind you know.

This week’s host addressed the issue on his own blog after the carnival:

When determining what to include in Grand Rounds this week I decided to be ruthless in my exclusion decisions. I excluded posts from many bloggers including those who make up some of my most prominent sidebar links and are on my blogroll (my favorite bloggers). I hope that those whose posts were excluded don't take offense or think that I don't like your blogs. This certainly isn't the case.

No offense taken, my submission was omitted, so what? But I have a level head and knew that I’d been included in the Rounds before, many times. I have a readership, a pretty good one. So I wasn’t offended.

But what about the little guy? If this was the first or second time he/she submits and he gets rejected once or twice, he may just never submit again. Well, he wouldn’t link to Grand Rounds, he wouldn’t support it. Wouldn’t we then be losing readership?

So Nick, whataya gonna do now?

And, what do you think?

Consumer Watch Dog Video

2006-02-03T01:04:00.000-08:00

Go check out this animation. It's great and funny, in a really disturbing sort of way. I recommended sending it to Micheal Moore for his upcoming documentary.

Thanks to Consumer Watch Dog for creating it.

Jumble of Falling Musicians

2006-02-02T05:56:00.000-08:00

“Nearer, my God, to Thee” was not the hymn played by the ship as the Titanic went down…The band, a brave group if there ever was one, played the “Autumn”.

The hymn ended in a jumble of falling musicians and instruments.

I read this scenario a hundred times over. But that was a scenario and this is you. You are a mother, a wife, a daughter, a provider and many people love you and they don’t want you to die. And I don’t want you to die. And you are dying. Stop dying! Please?

When I entered the room you expected me to save the day. I looked paler than my white coat. Did that make you nervous? Guess what, I was nervous. Underneath this white coat I am only human and as many times as I poke myself it still hurts, I still bleed and continue to be every bit as human as you.

Have you made mistakes before? I’ve made mistakes and continue to make them. Did your mistakes cost another life? Did your mistakes cost someone an arm or an eye? Do you want that responsibility?

Neither do I! Every day I wake with heaviness in my chest. A pressure so immense I have problems differentiating if something is truly wrong. This is taking its toll. I seem slow, groggy? I’m not really. But once you’ve made costly mistakes you really understand the importance of oversight, negligence, error. There really sometimes is only one chance to get it right.

Every day this coat feels heavier and heavier. On occasions, I want to rip it off my shoulders and leave, never turn back. But too much is invested now.

Like watching captains go down with the ship. Cue the orchestra. In many ways this coat feels like a cage.

I feel trapped in my white coat.

I wrote this piece back in November of 2004 for the Chronicles. I am republishing it here as it reflects upon this weeks' previous post.

Woodruff and Vogt: an Update

2006-02-01T09:34:00.000-08:00

Feb. 1, 2006 — Nearly three days after surviving a roadside bomb, "World News Tonight" co-anchor Bob Woodruff is slowly being brought out of sedation and will be weaned off a breathing tube in the coming days. The condition of cameraman Doug Vogt, who was also injured in the attack, continues to improve.

Vogt was said to be awake, alert and talking.

Woodruff has increasingly shown signs of consciousness. "He started to wake up more — move his arms and legs and just this morning started opening his eyes"

As per the same NEJM article discussed in the previous post:

At Walter Reed, the severity of a Traumatic Brain Injury (TBI) is assessed according to the duration of loss of consciousness and post-traumatic amnesia, according to Louis M. French, a neuropsychologist who is the DVBIC's clinical director. A mild TBI (which is usually not associated with visible abnormalities on brain imaging) is one that causes loss of consciousness lasting less than 1 hour or amnesia lasting less than 24 hours. A moderate TBI produces loss of consciousness lasting between 1 and 24 hours or post-traumatic amnesia for one to seven days. Injuries causing loss of consciousness for more than 24 hours or post-traumatic amnesia for more than a week are considered severe.

If Woodward is only beginning to regain conciousness now (and not as a consequence of being sedated) it point to a severe form of traumatic brain injury. Vogt sounds like he's in better shape, with reports stating that he is awake, alert and talking.

Bob Woodruff: A Look at the Injuries

2006-01-31T05:32:00.000-08:00

Bob Woodruff, co-anchor of ABC World New Tonight broadcast was seriously injured Sunday with his cameraman Doug Vogt from a roadside Improvised Explosive Device (IED). According to reports, Woodruff suffered wounds to his extremities as well as his head. He is currently recovering in Germany and is scheduled to be transferred tonight to a medical center in Bethesda, MD.

The most common cause of personnel wounded in action recently are due to roadside bombs. These are land mines or booby traps made out of locally available materials or another piece of ordnance, such as a cannon shell. These were used as far back as the Vietnam War. The IED today are larger as they are intended to damage the armored vehicle as well as the personnel inside of it.

I thought it would be interesting to review some of the injuries caused by these types of devices and some of the challenges facing Bob Woodruff in the coming months.

Most of the injuries caused by IED are traumatic in nature and are caused by foreign bodies. While woodruff suffered trauma to his extremities he was said to also have suffered head injuries. In the Iraq and Afghanistan conflicts, traumatic brain injury (TBI) accounts for 22 percent or higher of the injuries - a larger proportion of casualties than it has in other recent U.S. wars. This is because the personnel in Iraq and Afghanistan are wearing body armor which does a great job of protecting the core, however, their head and extremities are still exposed.

From an article published in the NEJM in May (Available here for free):

According to the Joint Theater Trauma Registry, compiled by the U.S. Army Institute of Surgical Research, 22 percent of the wounded soldiers from these conflicts who have passed through the military's Landstuhl Regional Medical Center in Germany had injuries to the head, face, or neck. This percentage can serve as a rough estimate of the fraction who have TBI, according to Deborah L. Warden, a neurologist and psychiatrist at Walter Reed Army Medical Center who is the national director of the Defense and Veterans Brain Injury Center (DVBIC). Warden said the true proportion is probably higher, since some cases of closed brain injury are not diagnosed promptly.

But those serving and touring do wear protective helmets and eye shields so how do they still have such a large proportion of Traumatic Brain Injury? There are also closed brain injuries:

Kevlar body armor and helmets are one reason for the high proportion of TBIs among soldiers wounded in the current conflicts. By effectively shielding the wearer from bullets and shrapnel, the protective gear has improved overall survival rates, and Kevlar helmets have reduced the frequency of penetrating head injuries. However, the helmets cannot completely protect the face, head, and neck, nor do they prevent the kind of closed brain injuries often produced by blasts. As insurgents continue to attack U.S. troops in Iraq, most brain injuries are being caused by IEDs, and closed brain injuries outnumber penetrating ones among patients seen at Walter Reed, where more than 450 patients with TBI were treated between January 2003 and February 2005.

A blast creates a sudden increase in air pressure by heating and accelerating air molecules and, immediately thereafter, a sudden decrease in pressure that produces intense wind. These rapid pressure shifts can injure the brain directly, producing concussion or contusion. Air emboli can also form in blood vessels and travel to the brain, causing cerebral infarcts. In addition, blast waves and wind can propel fragments, bodies, or even vehicles with considerable force, causing head injuries by any of these mechanisms. Approximately 8 to 25 percent of persons with blast-related injuries die.

Twenty five percent of those with blast related injuries die. Not such great odds for Woodward but so far all the indication are that he is improving.

Thus far, not much has been said to specifically address the injuries suffered by Woodruff. It is not known if they were serious enough to cause other complications.

The brain's size frequently increases after a severe head injury. This is called brain swelling and occurs when there is an increase in the amount of blood to the brain. Later in the illness water may collect in the brain which is called Brain Edema. Both Brain swelling and Brain Edema result in excessive pressure in the brain called Intracranial Pressure ("ICP"). Around-the-clock monitoring during this time is essential in order that Intracranial Pressure can be immediately treated. Treatment of brain swelling can be difficult. Very strong medications are administered and in some cases, removal of small amounts of fluids from the brain may be beneficial. If all these measures fail, a craniotomy may be performed.

But let’s say all ends well. What will Woodward have to face after his stay in the Intensive Care Unit?

Soldiers with TBI often have symptoms and findings affecting several areas of brain function. Headaches, sleep disturbances, and sensitivity to light and noise are common symptoms. Cognitive changes, diagnosed on mental-status examination or through neuropsychological testing, may include disturbances in attention, memory, or language, as well as delayed reaction time during problem solving. Often, the most troubling symptoms are behavioral ones: mood changes, depression, anxiety, impulsiveness, emotional outbursts, or inappropriate laughter.

Long term the prognosis is good. Most adults with a mild TBI recover completely within a year, but moderate and severe traumatic brain injuries are more likely to cause long term effects.

I am constantly amazed at the courage and perseverance of our young men and women who are in Iraq. Their life is threatened every single day. They are targets, just as those traveling with them are targets. Reporters who enter battlefields and war zones do it for the sake of their career and because it’s their job.

The endless numbers of those reporters who have been injured or captured as hostages continues to increase.

Is it really worth it?

So why do correspondents do it? Go here for the answer.

Grand Rounds

2006-01-31T04:55:00.000-08:00

This week's Grand Rounds are up at barbados Butterfly. I guess my submission got lost in the mail.

Perhaps We can All Work Towards This

2006-01-30T06:13:00.000-08:00

How do you deal with all that happens and not get depressed?

This comes up a lot, usually from the friends not in the medical field. It goes hand in hand with questions like “Have you ever killed somebody?”

So I took some time off from actively killing someone and it occurred to me that, considering the circumstances, it is unlikely that many physicians don’t get depressed and that more don’t eventually commit suicide. So why don’t many more doctors get depressed?

Depression is a common syndrome affecting a large proportion of the constituency. One would think that all that pain and suffering witnessed on the job would induce depression even in Richard Simmons, Not to mention the experience of being an intern. Not to mention being MY intern.

Here’s the answer: They do get depressed, often, in deadly ways, and more commonly than the general population.

Most of the research of depression rates in physicians points to higher rates than the general population but predisposing risk factors which are the same as those in the general population. Surprising, as one would think that physicians are more prone to depression due to the nature of their profession. But this is not, and is, the case.

My only thought is that the rewards of medicine compensate somehow or that it becomes a “job”, and as a defense mechanism loses its magnitude in the eye of the practitioner.

There are some aspects of “the job” which do predispose physicians to depression, but they're not the ones you may have guessed. From an article published in the NEJM on physician depression and suicide:

Another way to view the problem is that the professional burden carried by doctors leads to social isolation and an increased probability of undergoing phases of disturbances in their social networks. It has also been noted that physicians tend to neglect their own need for psychiatric, emotional, or medical help and are more critical than most people of both others and themselves. They are more likely to blame themselves for their own illnesses. And they are apparently more susceptible to depression caused by adverse life events, such as the death of a relative, divorce, or the loss of a job.

There are few interventions in place to help prevent suicide among physicians. Such safeguards might include the provision of discreet and confidential access to psychotherapy and open discussion of the stress encountered in a medical career. The barriers that may prevent physicians from seeking help for mental disorders (such as the threat of losing their medical licenses) must also be addressed. In time, perhaps these and other measures will help doctors to do what they do best: save lives, beginning with their own.

From JAMA: Cross-sectional rates of depression (15%-30%) are higher in medical students and residents than in the general population.

It gets worse, medical personnel are more successful at suicide, which led to a consensus statement released in JAMA in 2003. Among the issues addressed was the difficulty that physicians face when trying to obtain help for mental health disorders:

Thirty-five percent of physicians do not have a regular source of health care, which is associated with less use of preventive medical services supporting the observation that the medical profession does not encourage physicians to admit health vulnerabilities or seek help.

It is reasonable to infer that physicians' concern about disclosure of mental health records is widespread, although studies are lacking. Breaches of confidentiality also are believed to harm openness between the physician (as patient) and the treating clinician and may result in needless disclosures to coworkers. Those concerns, coupled with professional attitudes that broadly discourage admission of health vulnerabilities, are likely the driving forces behind physicians' disinclination to seek mental health care.

Wonder what they were discussing? (From the same consensus statement)

The culture of medicine accords low priority to physician mental health despite evidence of untreated mood disorders and an increased burden of suicide. Barriers to physicians in seeking help are often punitive, including discrimination in medical licensing, hospital privileges, and professional advancement.

I know two physicians who committed suicide. And have heard of many more medical students who’ve succeeded as well.

If you are a medical professional and would like help you can find more information here: http://www.afsp.org/physician

Friday Intern Topic of the Day III: Hamas Wins Palestinian Elections

2006-01-27T03:39:00.000-08:00

I had to do a doubletake but it is really true. After years of oppression the Palestinians finally get a taste of freedom and democracy. And as their first chosen leadership they choose a terrorist organization hell bent on the total destruction of Israel through whatever means necessary. Including, but not limited to, convincing young men and women to commit suicide for the sole purpose of murdering other innocent lives.

This was clearly a choice. Through a democratic process. Which means that it is the MAJORITY of Palestenians who prefer this as their way of life.

Pajama Media has a blog roundup:

Laurence Simon: "This is what happens when a Bush goes back on his word."

Powerpundit: "Complicate is an understatement, as this now presents a major roadblock to peace in the Middle East. Hamas is responsible for many, many Israeli civilian deaths, and if it has a major role in Palestinian government then it is highly unlikely that Israel will be able to bring itself to trust such a government enough to make any meaningful moves that will lead to the hope of a lasting peace."

Jay Lapidus notes what he sees the one good thing about the Hamas victory.

Israellycool: "[D]espite what many would have you believe, a majority of neo palestinians do not favor a two-state solution. Nor do a majority of neo palestinian people oppose terrorism."

Daimnation: "Considering the years of incitement and propaganda to which the Palestinians have been subjected, not to mention to corruption, incomptence and authoritarianism of Fatah, I can't say this result was unexpected. If the Palestinians believe they're better off with genocidal Islamofascists running their government, so be it. It's their choice, and they'll find out the hard way what it's like living under a Hamas government."

Clive Davis: "Hamas's new media consultant is already hard at work on that 'image problem'"

Truthdig: "A terrorist group will now be setting the Palestinian agenda. And with right-wing pretenders lingering over Sharon’s death bed, have prospects for peace in the Mideast ever looked more distant?"

Treppenwitz: "There can no longer remain the fiction of the the Palestinian majority who silently wish for coexistence with The Jewish State... if only Israel will allow them to fulfill their dream of self-determination. What these election results declare loud and clear is that the Palestinians intend to make their national dream Israel's worst nightmare. [...]
This victory doesn't now mean that every Palestinian is a Hamas terrorist any more than a Likud victory meant that every Israeli was in favor of Ariel Sharon's vision for Israel's future. In fact, we've all seen how people can vote for one thing and get quite another. However voting for a particular leadership places an electorate in the position of accepting the future actions of those leaders. That's democracy at work. So when the majority of Palestinians tell me with their words and deeds that they have committed their future to Hamas' vision of Israel's destruction... then I have no choice but to take them at their word."

Secular Blasphemy: "Will it be a disaster, or draw Hamas in a democratic direction? If Hamas is already calling the shots in the areas, they can just as well get control of the 'democratic' institutions there."

Jihad Watch: "The Tiny Minority of Extremists has won the Palestinian elections, which in itself is not actually a demonstration that the jihad ideology enjoys broader support among Muslims than most analysts would like to admit, since Fatah itself was not exactly an epitome of opposition to that ideology."

Roger Simon notes the reports that Hamas supporters have stormed into the Palestinian parliament amid clashes with Fatah loyalists, and writes: "Actually, on ten minutes reflection (it's pretty early here in LA), I am glad Hamas won. Elections should reflect the will of the people and this one reflects the will of the Palestinians. Now we know."

Austin Bay: "Hamas Wins– The Slow Civil War Takes A Twist."

As with nearly everything the future will depend on the money. Most of the foreign aid to the Palestenian Authority (Nearly 80%) comes from the European Union. My instinct is that the initial reaction will be strong but that it will quickly taper as this news leaves the spotlight.

Once again, when we have to depend on Europe we are all in big trouble.

Widow Maker

2006-01-26T04:14:00.000-08:00

I wrote this piece for the chronicles on my first rotation of my second year of residency. This patient eventually left the hospital, although, her quality of life was never the same again.

There is a young fifty eight year old mother of two currently walking the tightrope between life and death in my Coronary Intensive Care Unit (CICU). She had a massive heart attack earlier and was rushed to the angiography lab where one of the critical arteries supplying blood to the heart failed to appear on the monitor- it was completely blocked.

The “Widow Maker” was the affectionate name we give to a stenosis of this vessel. It’s all in the name, they say. Most commonly, this fatal stenosis usually affects fifty something year old men, fatally. But diseases never read textbooks and Ms. R had no idea of this horrible monster forming in her arteries. Now it threatens to end her life.

I told her family that the situation is grim, they cried, I had nothing to say to comfort them at all. She has a very slim chance of survival and they better be prepared.

At the moment she’s nearly maxed out on all the possible medication we could give her to raise her blood pressure and the only thing standing between her and the other Unit in Sky is the love of god and a resident with 14 months of experience.

I am scared.

Back to work!

For more information on the Left Anterior Descending arterys' nickname go here. Coronary artery disease is among this nations top killers. It is silent and deadly. If you experience symptoms of angina please go to you doctor to report them and have the appropriate work up.

Code

2006-01-24T06:12:00.000-08:00

Adrenaline intensifies the experience. Rather, “Epinephrine”, is the medically correct term.

It’s during a “code”, a word substituted for “cardiac arrest”, which is a descriptive term for the final common pathway for all causes of “death”, that one feels its effects sharply. It’s a funny word if you think about it.

My thoughts race as I run the white corridors. I am responsible for all that reside within the confines of these walls. Looking at them now as they surpass me by, one can’t help but make the heavenly association. My patient slowly drifts towards a white light and I run through it as fast as I can, fighting to save him, back to my white walls, my insane world.

“Attention, attention, attention, cardiac arrest five west”

Five West is the Gynecology floor and quickly I note to myself that they probably don’t know what to do in this situation. Doctors who care mainly for young patients rarely have to perform under the pressure of an arrest. Those more accustomed to this battle should volunteer to help.

So I did. Noting all the while, as I run full speed through the corridors, there is a young woman on the other end. White corridors, she is probably dead now. And I am violating hospital policy. “Slow down doctor, running is not allowed”. Who said rules are made to be broken?

“Epi, atropine, shock” I rehearse…

“Epi, atropine, rhythm” correcting myself. Sweat slowly accumulating on my brow. I need to join a gym. I can’t believe I’m thinking about this right now, distracted.

Chest compressions, intubate, continue chest compressions. I think codes look so great and exciting on television. Do we have a central line yet? Where the hell is Anesthesia?

The crash cart is open, there is blood on the floor, there is some on the bed and also on the doctors, their scrubs and the floor, again, I note. She is intubated and we continue chest compressions. There is some blood on my scrubs as well. Iodine is everywhere. Codes look peaceful on television.

Cardiopulmonary arrest is defined as the abrupt, unexpected cessation of spontaneous and effective ventilation and systemic perfusion (circulation). Cardiopulmonary resuscitation (CPR) provides artificial ventilation and circulation until advanced life support can be provided and spontaneous circulation and ventilation can be restored.

CPR saves lives. Certain states now encourage the purchase of an automated external defibrillator by allowing a tax credit for this purchase. Please take a CPR course so that one day you may help another, and get the word out so that one day, someone may help you.

Grand Rounds

2006-01-23T17:54:00.000-08:00

Grand Rounds are up today at Kevin M.D. He blogs so much I'm convinced he's lost his actual job a long time ago. While you're there you can check out all the podcasts of your favorite med bloggers as well, just scroll down.

Need Help with Medlogs

2006-01-23T17:52:00.000-08:00

So for some particular reason I can't get my feed accepted to Medlogs. The feed validator says it is invalid and after two weeks of trying I finally give up. Can anyone help. Jacob Rider is not answering my plead.

I Hate Spleens Too

2006-01-23T04:19:00.000-08:00

Kim, at Emergiblog writes about an experience she had with a sickly spleen. I am rather vigilant with patients who may not have a spleen. They get sick so quickly. So any patients who has had abdominal surgery get extra attention coming their way.

An interesting trend I noticed. Most patients don't know if they've had their spleen removed during their old surgery. I usually make it a priority to know what vital organs I no longer have, I think you should adopt this sage advice. Oh, and good nurses aren't made that way by studying at home...and...you really do have to have at least a highschool diploma:

Be a nurse and make good money....why gosh it never occurred to me to be a nurse until I picked up these matches!

Kim has more.

Friday Intern Topic of the Day II: How to Get a Real Live Person

2006-01-20T05:11:00.000-08:00

RLC has the facts about how to get a real live person on the phone when calling your local telephone/cable/electric/gas company. And by the way "This conversation may be recorded for quality purposes". So we can record everything you say and use it against you at a later date:

And thanks to the people of this country who take the time and make the effort to find and promulgate information to help others in every conceivable area of life. The sovereign individual is the most endangered species on Earth today, and people like these are keeping it from extinction.

The Adorable Forgetful

2006-01-19T08:34:00.000-08:00

This is an entry I wrote back when I started the Chronicles. I’ve re-written it here a a follow up to my previous post.

There are two types of demented elderly (of course there are many types of dementia, but for the sake of argument, let’s keep this simple). There is the angry demented and then there’s the pleasant kind. The angry demented upset everyone. Family never visits, no one calls, the home health aids are constantly changing.

The other is always smiling, even during codes, even during their own code. I love them. It's a blessing to be happily forgetful, constantly. They don't even know how much they don't know or how slow they've become or how incontinant. We love them because they make us feel like we're helping, even when we're not.

The truth is that I've resigned myself to a future of Alzheimer's. My memory is horribly bad and if I don't get it then we can junk the whole disease-progression theory.

I just hope to be Pleasantly Demented.

The COTV

2006-01-18T10:56:00.000-08:00

This week at Free Money Finance. Go grow you net self worth.

I never got Tagged

2006-01-18T06:29:00.000-08:00

I keep getting requests for interviewes about my blog. It seems everyone wants to know who is behind the name and why he loves to blog so much?

I never thought it to be interesting at all. In fact, I don't even find myself interesting at all. the truth is I'd probably be a really boring interview with absolutely no insight into anything involving medicine. I feel sorry for the would-be callers.

but this is interesting:

An entertaining game of "tag" has been running through the online diabetes community (OC) in which bloggers hit each other up for "Five Random Facts About You." I did a little checking and discovered that the game is actually running all across the blogging world. No idea how it got started. Just for fun..

Diabetes Mine, an excellent blog, for the rest of the story.

Attending Effect

2006-01-17T09:56:00.000-08:00

Those who have suffered through internship, any internship, can attest to what I like to term the “Attending affect”. An embarrasing event which happens after taking a thorough history from a patient. Initially you may have believed that he/she may have extremely worrisome disease but based on the answers the patient provided you’ve managed to rule out most of the more dangerous pathology. The next morning you give a great presentation to the attending pointing out how you’ve asked all the appropriate questions. And then everyone as a team, including the Attending, comes to examine the patient.

The entire story suddenly changes. Every lethal complication you’ve managed to rule out on the basis of history the patient manages to rule back in and all of your hard work goes out the window.

“What? Sure I had crushing chest pain and a very difficult time breathing. Of course I did!”

“No, it only happened to me one time before, you know, before I had that emergent cardiac catheterization I forgot to tell you about”

...As you feel the blood rush to your cheeks and the neck suddenly loses all ability to continue holding up your head.

How the same story changes overnight I’ll never understand. I can sympathize with the poor intern, just another victim of an undefinable phenomenon. This adds yet another challenge to the first year of doctoring. A year filled with unexpected obstacles.

No lesson, though, is more embarrasing than that of the “pleasantly demented” elderly. And every intern, on one occasion or another, will fall pray at the hands of the pleasently demented.

This newly demented individual is so slick that they can obscure this fact quite well, especially if a deeper investigation of the fact is not taken. Usually, the morning presentation is smoothless. The patient is “Alert and Oriented times three”. The intern rejoices in his own glory.

Later, when we find that the patient believes it’s 1969 and that the Mets are actually a good team, all accounts of the story can be filed along with the recycled trash being picked up in the basement. All the hard work for not.

When you “assume” you make an….

Once again, the intern has fallen pray to the adorable forgetful, the pleasently demented. And such a fall from glory, especially when your peers are watching, is always fun to watch.

Quit Smoking

2006-01-17T07:10:00.000-08:00

I love reading Aiden:

She smirked at me, as if to say: Oh dear, how precious. You want to save me. But behind her cool blue eyes, under the silver cap of elderly hair that shaded her skull, I could almost see the nicotine devil in charge of her freewill. Its puppetry was masterful. The old woman’s yellow-stained fingers stroked her mouth as if searching for a phantom cancer stick.

If there is any one thing that you can do right now to dramatically improve your health it's to STOP SMOKING!

BTW, go buy the book. You cheapskate!

Grand Rounds

2006-01-17T06:33:00.000-08:00

Grunt Doc is a blog devoted to the art of Emergency Medicine (I use that term "art" loosely). But no matter what my views on the subject I still enjoy reading what he has to say every week.

Today he hosts Grand Rounds. so go there and check out the week's best writing.

So it's No Babies or No Sex?

2006-01-16T09:15:00.000-08:00

Now a controversial new study suggests that the pill not only suppresses desire, but can also do so for months after a woman stops taking it, by raising levels of a certain protein.

Just a little more incentive to substituting the wife's pills with some sugar caplets. Go to Rebel Doctor for the rest of the story.

Friday: Intern Topic of the Day

2006-01-13T04:35:00.000-08:00

Every Friday these interns start arguing about some irrelevant issue, or rather, one that is unconnected to medicine. At least today they argued about something I care about. And yeah...how come superheroes don't die naturally?

I’m not saying this lack of aging heroes is wrong. Being a super-hero is a dangerous occupation, after all. Heroes are going to die in the line of duty or make enemies who will hunt them down after they retire. Frankly, I doubt there’s much interest in an elderly super-hero title, so I can’t blame anyone for not publishing one

Go read the rest here at Polite Dissent.

Rusty

2006-01-12T06:39:00.000-08:00

his was one of the first entries I wrote for the Chronicles. I've changed much of it to reflect how I would have written it today

I’m re-reading, for the fourth time, the algorithm of a code. I remember nothing now. The churning of the metal in my brain slowly creaking as it comes to life again. My neurotransmitters begin to form as the body retrieves their original chemical formula; I realize I am facing an uphill battle.

Wish me luck my friends. Over the next 2 weeks my supra-tentorium should return to life, and who knows, maybe my blogging will be slightly more interesting

While for the last three months I’ve come to think of myself along the same lines as a Hula hoop instructor (I just finished three months of “Kick back” rotations), tomorrow, I become a real doctor again. Not just a real doctor in any old place, tomorrow, I’m the resident in the Coronary Intensive Care Unit (CICU).

Of course there is some good news involved. Although my first rotation is in the CICU, it’s one of the two rotations every year that we spend at a private hospital. And while rotating in the CICU is usually misery personified, serving in this Unit is nothing short of pure pleasure.

And I’ll tell you why.

The nurses are still motivated and practically run the place. Residents get to sleep (if we’re nice enough to them) and when we wake up they tell us everything they did, all by themselves. God bless their souls.

The nurses in the Mad House, on the other hand, are overworked and underpaid. Sometimes it feels that they’ve resigned themselves to mediocre work, just to protest the situation. Of course the residents are stuck in the middle, more specifically, the interns. Someone has to do the job correctly. And the patients don’t benefit greatly either. Sometimes we feel that the only thing watching our patient is the wall.

But all that is behind me now, at least for the next two weeks.

Schizophrenia

2006-01-11T06:03:00.000-08:00

Maria has such a great way of putting things. I never thought about my patients this way:

“And yet, even though you know you know! that you are married, someone else is telling you that you aren’t, that it never happened.”

Go read the whole thing.

Carnival of the Vanities

2006-01-11T02:20:00.000-08:00

Is up at The Hip and Zen Pen:

"And doctors go snarky on doctors over at a blog called, simply Doctor"

Interesting, does anyone feel "Snark-ied"?

New Links

2006-01-10T09:09:00.000-08:00

I am writing this as a special request to those who would link here. First, I would very much appreciate the link and would be happy to reciprocate to help you with your traffic. Please, link under the term "Doctor" as that is the name of the blog and not "Internal Medicine Doctor", as many of you have been doing (I do understand the confusion with the URL). This is important in terms of Google finding my page.

Thanks again for any links I really do appreciate them.

Joe

Exacerbation

2006-01-10T06:40:00.000-08:00

She can't breathe now, again. Every attempt at oxygen begins and quickly ends with an inefficient wheeze. Draining whatever strength is left.

She is pounding the cement sidewalk flopping about like a fish out of water, the crowd gathers around her. She is slowly choking. Her fingers turn into various shades of blue. No oxygen. The execution has begun.

We are all praying for air.

Once again, her life is threatened by this monster that lives inside. The noose around her neck tightens, the future is questioned and slowly she drifts into the darkness. This vision now fades, slowly to black. She stares in her daughters' eyes.

She is only four now, she is panicked. "Mommy is in trouble", she thinks to herself. But she cannot speak. She cannot hold her daughter and calm her now. No air.

Again she tires the pump in her hand to no avail. Nothing helps! and the cold frigid air leaves no sign of the good fight. She feels herself slipping away now. The rumbling of an ambulance shakes the ground, slowly nearing. Benevolent in its intentions.

I admitted her tonight.

She was extubated in the emergency room and is doing well. My admitting diagnosis was “asthma exacerbation”.

I'm constantly amazed at the serenenity of our "admitting diagnosis" when compared with what actually happened. Or what could have.

Grand Rounds

2006-01-10T03:27:00.000-08:00

This week's Grand Rounds are up at the Clinical Cases and Images Blog

work in a large tertiary care center which is probably one of the biggest and busiest hospitals in the world. There are doctors from all sorts of subspecialties, nurses, supportive personnel and, of course, thousands of patients who make this whole endeavor worthwhile.

Go check it out.

Introducing the new tool for the academic literature search: Google?

2006-01-09T07:33:00.000-08:00

According to an article published in this week’s New England Journal of Medicine more (most) medical literature searches are being performed with the use of engines other than Medline. The most common of which, as you can see in the figure above is Google.

Among those searches which provide link referrals to Medical Journals, Google ranked number one, with Yahoo taking the number four ranking. Among other things, convenience seems to be the major factor.

The number of searches performed with PubMed has increased steadily to about 70 million per month. Yet at the same time, an increasing number of people are finding their way to citations and abstracts in PubMed through searches that begin with Google the largest single source of referrals to PubMed or with Google Scholar or Yahoo.

My thoughts of possible causes: Whereas Pubmed requires the user to understand how to enter a search term to optimize search results, Google requires no such understanding. In addition, Google Scholar, a new search engine specifically designed to search the academic literature further simplifies these requirements and optimizes search relevant results. But the article specifically points out that most referrals do not come from the Scholar search but instead from the general google search engine.

The article does cite a different reason:

Many articles are available through Web sites maintained by journals, although there may be charges or registration requirements. Some are also available without charge through nonjournal Web sites — sometimes with the permission of the publisher, sometimes without.

Kind of like what I'm doing here.

It’s an interesting trend though, wouldn't you say?

More on Sharon's Condition

2006-01-06T11:47:00.000-08:00

From DB:

What should we learn? We must always remember that our treatments have both risks and benefits. Sharon’s physicians gave the right treatment - but sometimes the risks become complications. Unfortunately, Sharon has had a major unfortunate complication of a correct medication

As an Israeli I feel that the whole situation is unbelievably tragic. We've made such great headway and I fear that it may all be lost now. I can only hope for Israel.

The Chutzpa

2006-01-06T06:40:00.000-08:00

The Fake Doctor (What's with people using a pseudonym with the word "Doctor" included?) writes a hilarious entry on Parenting tips. It reminds me of when we were trying to find a good name for Jordan:

So three cheers for all the Darcquan's, La Fawnda's (I guess that qualifies as a not-so-obscure movie reference), and Zzyzzx's out there. This is not about them. This about all the parents out there who have the chutzpah to pick out from among the vast landscape of potential names a small subset that are almost guaranteed to send that kid straight to the NICU with some sort of awful disease. Yep, this is a warning to all the future Miracle's, Destiny's, Hope's, and Prayer's out there

"Destiny" was actually in the running. I guess I can breath a sigh of relief now.

Medical Consulting

2006-01-05T05:50:00.000-08:00

This is a light hearted post I wrote back when I was on the consult service

Dear surgery intern: “give me your tired, your sick, your poor huddled masses yearning to be free”…of your horrible care!

As an exhausted and frustrated house medical consultant for all the surgical specialties during the last three days, I’ve come to this one conclusion: Every patient in the hospital deserves to be on the internal medicine service and all the other services should be strictly consulting.

In the Mad House, medical consulting is restricted to third year medical residents. I remember how during the second year my elders would tell us of the horrors they encounter on the service as they shared with us the full list of confusing and often conflicting orders they found in the surgical charts. I never thought these to be true, probably exaggerations added for comedic value.

Oh. My. God!

For the sake of the health of future patients I offer all surgical residents, or any other specialty for that matter, these informative suggestions as general guidelines for the future care of your most favorite patient. Consider yourself forewarned lest your name be mentioned behind the closed doors of our favorite call room.

-In diabetic patients, generally, 5% Dextrose (D5) is not a good choice of fluids. There are times when D5 would be appropriate, for example, if the patient suddenly became hypoglycemic. Otherwise, your overwhelming need to put the patient in a hypeglycemic coma is not a valid indication.

-If the patient requires pressors to maintain an acceptable blood pressure. Pushing beta blockers every six hours concurrently to slow down the heart rate is contra-indicated. There are times when tachycardia is a blessed thing.

-Bolusing patients with two liters of normal saline may not always be the best pre-op strategy, especially in those patients who have congestive heart failure. You may want to consider dialysis patients along these same lines.

Of course surgery has its perks. For example, every surgeon I know gets to ask his/her patient if they’ve “passed gas” yet. I think that’s wonderful. They have a license to ask patients if they’ve farted. Even more impressive, farting is good.

A day will come when internists will no longer need to apologize for inquiring about flatulence.

A Wonderful article

2006-01-05T05:46:00.000-08:00

There is a wonderful article published in the NYT recently by Abigail Zuger, M.D. about the reality of hospital medicine versus how it looks in the medical journals:

It was 4:30 a.m., the hour at which, if you are up all night in the name of medical training, you begin to shiver uncontrollably no matter how many patient gowns you layer on. Just when it seemed there might be time for a little nap before morning, our fifth admission of the night rolled in

Hat tip to Shrinkette for the lead.

Ariel Sharon Suffers a Massive Stroke

2006-01-04T16:27:00.000-08:00

Ariel Sharon suffered what sounds like a massive stroke two hours ago. According to the news he had bleeding into his brainstem, very tragic news.

My sympathy goes out to his family. I can only hope that everything he has worked to build doesn’t come to an end tonight.

The 77-year-old's powers of office were transferred to Deputy Prime Minister Ehud Olmert shortly after Sharon arrived at Hadassah Ein Kerem Hospital.

The stroke was Sharon's second in less than three weeks.

Sharon had been taken from his home in the south of Israel to the hospital, where doctors diagnosed a cerebral hemorrhage

Here for the rest of the story

Welcome to Doctor

2006-01-04T13:08:00.000-08:00

So how do you like the new home?

Very similar to the old one wouldn’t you say? Same design with a new logo. But I like the new one better and I like the name better.

Although “Chronicles of a Medical Mad House” had a great ring to it, I’ve grown tired of its meaning. One and one half year later I have come to terms with the fact that it is the record of my residency and all of its wonderful experiences. I will never remove it from the internet. It will always be there for me to sift through when I become nostalgic.

This new blog called “Doctor” will have posts with the same sarcastic, dry, inappropriate humor you’ve come to expect of me. I hope to continue improving as a writer and a physician and I expect it will reflect in my writing and I really want you to be there to witness it all. I would also like to begin doing things I haven’t done on my site before.

The Blogroll is nearly identical to before and I would really appreciate if you update your blogroll as well with new blog name and address. It should help readers (and Google) know I’m alive.

Again, Welcome to Doctor and I hope you stick around.

Ruined by Reality

2006-01-03T13:18:00.000-08:00

Was that me, dressed up in a dark suit doing my best not to look intimidated?

Three years have changed and these fourth year students filing into our conference room remind me of a younger self. How they shine bright with curiosity for answers only their future will tell. The prospect of a career in medicine is exciting for them now. It is the beginning of a new world. Everything, it was all for this. Again, with another September starts another match.

It is that time of year again, when a competition ensues to capture the most valuable of prizes, a medicine residency in a prestigious institution. There are only a handful of these and that makes each and every position precious. Each of these students knows it will be a critical steppingstone to a future glorious career, and so did I.

I had survived a breakup with my fiancé, struggled through four years of medical school in a foreign country, even found the love of my life while there and got married. I came to the Mad House is 2002 anticipating a day of sweating and squirming as I attempt to guess the most desired answer. I had the future in my hands, they wanted me, and the prospect of a career as an internal medicine doctor was exhilarating. I remember running home to tell my wife that I was offered a position, hardly able to contain myself.

So what happened?

That young man and this seasoned resident, they are such different people. In between them three years of an internal medicine residency that drove that same young man on a path to…well, you read this blog don’t you?

Unfortunately, the real world happened.

Saving a troubled father of two from a severe bout of congestive heart failure was rousing. Saving that same father from another bout and yet another simply because he refuses to take medications can be downright depressing. They say memory is selective, I find mine tends to select for depressing moments.

This is one of the reasons I never delete negative comments. They ground me. Often, they allow me to reflect on the true magnitude of what it is that we do. Somewhere and sometimes I make a difference. And that is essentially one of the greatest things anyone can do. But I’ve lost a large part of my former compassionate self.

At times though, I do miss that young fourth year. Would he disapprove of what he has become, a new breed of healer and warrior struggling with himself to survive?

Reading this you probably think my patients don’t appreciate my efforts. But, my patients actually do like me. I know you wouldn’t think so from reading this blog but judging from the comments and gifts I get at my clinic, they must.

So to all the fourth year students who have that jazz in their step, bouncing on clouds, hoping to high-heaven they do well. I wish you all the best. Moreover, I wish you the wisdom to know that what you are doing, as depressing and downright useless as it may sometime feel, is immeasurable good, even if your patients don’t know it.

Like well trained warriors, don’t let your compassion run dry, but do learn with who it’s worth fighting your battles.