Friday, November 24, 2006


5 adults, 2 children: ages 6 and 2. 2 bedrooms, 2 bathrooms, and 1000 square feet. That, in short, is how my Thanksgiving weekend is being spent as my wife's family has descended upon our apartment for the holiday. The quarters may be cramped, but I've become an expert not only at keeping my niece and nephew occupied while the other adults cook (turns out my huge bag of Star Wars figures, a true testament to my geekiness, is worth its weight in gold) but also to hop across my apartment like a one-legged chicken navigating a minefield as I search for spots on the carpet that are not littered with sharp toys that are sure to give me tetanus.

I'm sure that a great many of you, despite loving your families as much as I love mine, are experiencing a "fight or flight" response to the description above. Just another aspect of the paradox that is the human experience--we crave social interaction and time with family, but at the same time even the most social of us needs space to ourselves and an opportunity to have some privacy. I struggle with this just as much as anyone else, perhaps more so as I often really enjoy time to myself, but I've found that some of the survival skills I've developed during my year and a half in medical school can be applied to this situation successfully.

Case in point: last night, after finishing the post-turkey dinner dishes, I managed to find a stretch of carpet near the entryway to our apartment that was completely barren. I proceeded to toss a kid's DVD into the trusty player to occupy the kiddos and then stretched myself out on that spot, closing my eyes and soaking in the calm. 15 minutes later, I felt completely recharged and ready to play "Uncle JungleGym" for another few hours.

Having been removed from my classes and studies for a whole 48 hours I was able to put aside the negative feelings I often have about school (my own little defense mechanism) and appreciate one of the small benefits that I've gained through my medical education. Namely, the ability to find a little peace in a field that is constantly bombarding you with things you should be learning, things you should be studying, things you should be doing to prepare yourself for the next stage of your career. Sometimes you just need to listen to that little voice in your head, the one that often gets drowned out by your professors, friends, and spouse, and realize that the most valuable thing you can do for anyone is to take a moment for yourself.

I hope everyone has a very Happy Thanksgiving, and is able to find at least one of these moments to let themselves just "stretch out."

Tuesday, November 21, 2006

To Whomever It May Concern

Today we finished our ethics class in which we covered controversial topics like stem cell research, abortion, and physician-assisted suicide. I found the whole experience fairly intolerable, which surprised me until I found time to reflect on the reasons for my allergic reaction to learning ethics in med school.

First, I have found this year that I am really indignant when my school makes attendance of any class mandatory. So, of course, I was quite miserable every week during our mandatory discussion groups for the ethics course. I found this time, as well as the lectures, to be time that I wished was spent with my Robbins Pathology text or my microbiology notes. The "soft" courses in our curriculum (ethics, psych, clinical exam) have been deemed to be unworthy of my time by the academic defense mechanisms I have erected to cope with the insane amount of material which we are expected to master this year. Couple this ongoing anxiety with the impending doom of our Step 1 licensing exam this summer, and I find myself intolerant of any time wasted. Except time spent writing in this blog, of course!

The tendency of these courses to portray the "ideal" physician and putting forth the idea that said "ideal" physician can only act in certain ways is also a huge turn-off for me. I am sure there are plenty of great physicians that "feel their patient's pain" and "explore feelings and ever-changing goals of treatment" with their patients, but I am just as sure that there are physicians that simply don't have time to spend on these diversions that provide excellent care for their patients by focusing on other strengths. Medicine is far too complicated an endeavor to master simply by following a few "touchy-feely" rules, and I feel insulted when it is portrayed to us as such.

That being said, I think that a poem I wrote a few years ago touches on my conflicted feelings about ethics in medicine--in particular, that hazy line between aggressive treatment with the idea of curing an illness and palliative care in which the goal is to comfort the patient while they die naturally. I would love to hear what kind of reaction any of you have to this poem, or even your ideas about the role of the physician in the dying process and Western civilization's eternal fight against mortality. And, you know, if the poem is just way too obtuse for anyone but me to understand, feel free to let me know that too. No comment is unwelcome.

To Whomever It May Concern
Deaf men bang drums, bleeding hands
protest the primal rhythm.
The blind turn leaden eyes to the sky,
stone synapses flare to life.
An alcoholic, fire in his veins, defiant
stands before his essence, a genetic jury.
You wouldn’t understand.

You couldn’t understand
a fish joyfully embracing the sandy shore,
his best breath, his last.
Or the bulimic refusing herself from within.
A hunger artist painting a visceral desert.
The beauty of a falling eagle,
blanketed by warm vertigo.
That empyrean pull, fatal.

Not you,
you wrote the rules in blood.
You’ve got your millennial plan,
an ivory covenant delivered on death.
No, you couldn’t understand.

Grand Rounds 3.09 is up!

Another excellent edition of Grand Rounds (a weekly collection of the best writing in medical blogs) brought to us by Doctor Anonymous is up here. I was lucky enough to have my entry "An Unwilling Consultant" mentioned this week, and I urge everyone to check out some great writing by other medical bloggers.

To those visiting the Bad Doctor for the first time from Grand Rounds: welcome! I hope you check back often and feel free to leave feedback or topics you would like to see me write about.

Thanks again to Dr. A for his hard work on Grand Rounds. It's a job well done!

Saturday, November 18, 2006

This is what happens when you are studying for two weeks straight while self-medicating with Dayquil

My fellow medical students, throw off the chains that bind you! It is time to focus not on the differences amongst us--not our chosen specialties of interest, nor our percentile ranking in the class and chances at AOA nomination. We must look beyond our membership in various interest groups and our attendance record in lectures. Indeed, even our stance on nationalized health care must be put aside in this Time of Greatness. For we stand on the threshold of change.

Those that oppress us would that we spend every weekend of the impending year locked in the library, awash in the ignorant minutiae of propaganda-laden binders distributed to us by the bourgeoisie. No more I say! No more shall we sit idly by while they test us like mindless animals regurgitating triviality after triviality! Throw off the chains and follow your great leader to the promised land! A land of clinical relevance, a land of absolutely no required attendance functions, a land of shared responsibility for education during the day, and shared adult beverages at night! Most importantly, a land with only 5 human development lectures per year and absolutely no touchy-feely humanities classes!

As your fearless leader, long ago I promised these things and more, and your ruler and his Knights of Vanquishing fought long and hard to secure these basic rights of man. Alas, the enemy hides behind the infrastructure of a society intent on marginalizing those who seek to serve humanity's ill. They bludgeon us with board exams, subjective grading, unfathomable student loans, and endless hours of residency in which we earn less than the hourly minimum wage. Only together can we hope to transform the ripples that your valiant leader has made in the Sea of Time into great Tides of Change!

I ask you all to dust off your Netters and grab your Pocket Robbins. Holster your stethoscope (you can leave your diagnostic kits behind-those will be available in exam rooms when we need them) and clean and press your short white coats, for they will be the uniform of the People's Army. Muster your courage, my dear friends, and follow me to freedom!!! For I am no longer your ruler. I stand before you now, a Man of the People!

Tuesday, November 14, 2006

Making my first Grand Rounds

Just wanted to give my readers a heads-up to my inclusion this week in Grand Rounds over at topher's site, the rumors were true. For those not in the know, Grand Rounds is a weekly selection of the web's best medical blogging, so I definitely feel honored by being included. I urge you all to check this week's edition out and read great medical stories from some excellent bloggers.

Monday, November 13, 2006

An Unwilling Consultant

Two weeks ago we learned that my wife's 96 year-old Grandmother was in the final stages of kidney failure--a terminal condition. I only knew her for a short time, but it is really difficult to overstate the life that this woman led. She was mother to 13 children who all turned out to be wonderful people, and grandmother to 36 grandkids, 36 great-grandkids, and 1 great-great-grandchild. She was very independent, and lived alone until the age of 94, attending mass at the Catholic church down the road every morning. Perhaps most telling was the love and respect that her family had for her. I often joked with my wife when we saw her at the immense family weddings that she loved to frequent that she looked like a Polish "Godfather" with all of the people that visited her while she sat comfortably in her chair, receiving each family member in turn and treating every one of them like the only person on earth she would like to speak to at that moment. I don't throw compliments around lightly, but she was truly a stunning woman.

You can imagine the turmoil that her imminent passing threw my wife's family into. Of course they all knew that sooner or later her body would fail at her age (or, as she liked to say, her body would go "kaput") but I'm not sure they could imagine a life without her, or their immense family without her as the matriarch. The family that I had joined only a year previous was on the cusp of great change, and I soon found myself thrust into the situation, honored and more than a little terrified, as I found those I love looking to me for medical knowledge for the first time.

We received word of Grandmother's condition on the eve of my nephew's 6th birthday party. The whole family had made the 400 mile weekend journey to a small town in Michigan to attend, but the celebration was completely overshadowed by the phone call late Friday night about their grandmother's kidney failure. The next morning my father-in-law decided that he should make the trip back to Wisconsin early to be at his mother's side. While he was packing up his van and waiting for my mother-in-law to say her goodbyes, I found myself alone in the doorway with him, completely at a loss for what to say in such a time. Unsurprisingly the "touchy-feely" empathy classes at my school had failed me. With concern on his face, he said to me, "I guess they found a blood clot in her kidney. They said there was nothing they could do to help it heal."

I immediately found myself searching through my long forgotten knowledge of renal physiology and cursing the fact that I had not yet had renal pathology this year. I was not surprised that she had thrown a clot to the renal artery, as she was suffering from a heart condition that left her at great risk for an embolus. Fighting a feeling of disgust for my dispassionate medical evaluation of the situation, I simply replied "I understand."

"I guess her doctor said she probably had about 7 days..." he continued, clearly hoping for me to fill in the missing pieces of the story. I felt relief that this was a topic that I had at least a basic understanding of, having given a presentation this year about dialysis discontinuation and the stages of the subsequent death by renal failure.

I replied, "I've read that in a situation like this it can go anywhere from 5-10 days usually. I would say that's a pretty fair estimate. The good news is that for most of that time she'll be conscious and able to visit with you guys. Probably during the last two days or so she'll start slipping away peacefully. She really shouldn't feel any pain." I timidly placed my hand on his broad shoulder, trying to provide some degree of comfort.

I knew this was a bold prediction to make for a mere second year student. Part of me trusted the references I had researched on renal failure. I also knew the palliative care nurses that were tending to his mother would be experienced in renal failure, and would be capable of easing any discomfort she might feel during the week. Most importantly, the human side of me, maybe the part that has yet to be claimed by the ofttimes dispassionate profession of medicine, knew that this was what he needed to hear right now. To him, at that one moment, I was an insider source on the secrets of human life and death, and my juvenile opinion held the weight of the world. I can say with all honesty that I did not relish that position, and do not look forward to facing it again in the future.

Grandmother died 9 days later, surrounded by her family, who had kept a vigil at her bedside throughout the week. Her final wish to pass on a Sunday was granted. In fact, she died the day before her 73rd wedding anniversary to her husband who had passed 9 years prior, and the family took comfort in the thought that they would once again be able to share a "first dance" together.

By all accounts, she felt no pain.

Wednesday, November 01, 2006

Interviews with Wolves

It's that magical time of year again, interview season at medical schools across the country! For those unfamiliar with the archaic system that is the medical school application process, I'll try to provide a quick summary. Essentially all med schools require applicants to take certain classes to be eligible, then all applicants take a standardized exam called the *name deleted to protect would-be applicants from themselves*. Then, typically following their junior year of undergrad, applicants submit a standardized "primary" application to any school of their choosing through a national computer program. This includes a personal statement that is invariably embarrassing and chock-full of half-truths, a list of impressive-sounding extracurriculars and awards, and your transcript and standardized test score. Did I mention that submitting the primary application and taking that test costs buckets of money? Ok, good.

At this point, the schools check out your goods along with thousands of other applicants. Then they choose a subset of applicants to further query in a "secondary" application with school-specific questions and requested information, including a small photo of yourself (which I'm sure are treated by the admissions personnel with nothing but respect and never, ever become running jokes in the office). This is largely a huge pain in the applicant's ass, which is undoubtedly the only reason to make these mandatory. I feel I should mention in passing that the schools all charge an additional fee (which averages to about $75 or so) to consider these secondary applications when you turn them in. Oh, and most successful applicants apply to anywhere between 12-15 schools, with some crazies applying to over 40 of the 120 or so schools across the country.

The schools' admissions committees then review each applicant individually, and if their review is favorable they will invite them for an interview at the school. This requires the applicant to travel to the school while taking time away from work or their senior year of undergrad to spend a full day learning about the school via tours, Q&A sessions, and countless powerpoint presentations. The applicant is responsible for the airfare, the business attire required at the interview, and usually lodging costs, all for a chance at the coveted role of MEDICAL STUDENT. Did I mention that medical school tuition usually leaves graduating physicians with over $200,000 in debt? But let me be fairhanded in this tale: the medical school is kind enough to provide lunch during the interview day. Although chances are your nerves will be far too rattled to actually allow you to enjoy a meal. Life can be such a cruel, cruel mistress.

Now that my 2,000 word introduction is finished, I would like to share with you the story of my medical school interview. This was actually my third interview as I had previously applied unsuccessfully two years prior. Turns out that schools are not as amused as one might think when applicants show up in a high school counselor-style sweater and khakis rather than the traditional business garb, even if said applicant is tall, dark, and disarmingly handsome. Who knew?

So I sat, facing a random door in a large office space full of bustling admissions personnel and fellow applicants running like the proverbial headless chicken to find their next interview. I had already completed one interview with a 3rd year medical student at this particular school. He had been a little cool in his demeanor, but I soon broke through his shell, as I am a master of communication. It turns out (and at the time I had no idea that this is a scientific law even more bulletproof than evolutionary or germ theory) that medical students like feeling superior. So all I had to do was ask a question about his opinions on different curriculum choices or the grading system at the school, and wait for his answer. At this point I eagerly lapped it up like manna in the desert, making sure he felt like a medical student demigod. After 10 minutes or so of this game, we spent the rest of the interview discussing the bars that he and his fellow students frequented when they were not studying their brains out. It went well.

Alas, I had spent my karmic capital on that half-hour of glory, yet I sat before the door of judgment completely clueless. All I knew was that I was about to be interviewed by Dr. X who was a faculty physician subspecializing in gastroenterology. Entering the interview, I knew that my acceptance was waiting for me. I was entitled to it, like Michael Jordan was assured his sixth NBA Championship. As the clock struck 3, I knocked gently on the door and slowly turned the door handle. I entered the tiny room, scanning it with my eyes before settling on my interviewer, his desk, and the lonely chair that sat across from him. He was a stout old man, bespectacled and adorned in the traditional long white coat that marked him as that rarest of creatures, a physician. He looked up from what I assumed was my applicant file, and gave me a penetrating glare. I took my first step into the room and he opened his mouth and shot forth a verbal volley the likes of which I had not been privy to since my years of living at home with a teenaged sister.

"From your application photo, I expected you to be a lot uglier. You looked fat."

I stopped in my tracks, midstride on my way to the seat and spent a millisecond weighing my options. I could either launch myself over the desk like the physical specimen that I am and teach him just how much physical punishment my "fat ass" could inflict, or I could take my seat like a civilized young man and forget he had made such a comment, hoping that it was merely his geriatric senility peaking through. The first in a long line of regrets in my medical career, I chose the latter.

The interview proceeded in much the same manner. I was forced to defend every choice made during my undergraduate career (who would have thought that minoring in English could have offended someone) and explain the evolutionary biology research I helped with in excruciating detail before having my role dismissed with the wave of a hand. I found myself attacked for any opinion or insight I tried to offer, even in my own preferences in employment (no, I did not strip for a living). I had made the statement in my application that I really enjoyed interpersonal interactions and developing long-term relationships (one of those half-truths I was telling you about) and had intimated without sounding entirely committed that I might enjoy a career in primary care with its psychiatric component. Now, being a specialist, this evidently enraged my interviewer. He repeated over and over again that a huge part of his job was developing relationships with patients and treating them psychiatrically. Fair enough, he knows what medicine is like more than me. I told him as much, but then added in a not-so-rare moment of Bad Doctor stubbornness "I'm sure you do all that, but a primary care physician is going to have more responsibility to treat their patients psychiatrically and socially due to the nature of the office visits and the illnesses that they present with." I probably would have been better off telling him that Perry Mason was a filthy commie.

Later, I found my race up for debate. Looking thoughtfully at the pile of papers that so perfectly summarized my 23 years of life's work sitting before him, Dr. X. stated, "You know, by looking at your application, I would have thought you were Native American. Do you think that a trick like that is going to help you get accepted?"

A little background might help place this ludicrous notion into context. I had attended a high school in a town near a tribal community college. Now this community college was open to anyone of any race, and it just so happened that my high school had an agreement with this college to get students college credit for advanced classes. I had earned some credits in this manner, and as instructed in the applications had listed all of my college credits and the official name of the college at which it was earned. The only other mention of Native Americans or their culture in my application was in my transcript where I had taken a Dakota Literature class to finish off my English minor. The class had exactly three Native Americans attending it out of at least 20 students. Most importantly, in the race section of the application, I had clearly marked "caucasian." I guess he forgot to check that minor section before accusing me of race camouflage. Needless to say, I was mortified.

Finally it was time for the interview to end. I maintained the plastered-on smile that I had so heroically kept up throughout the interrogation and answered him when he asked whether I was going to make the 8 hour cross-state drive back to my hometown that night. "Yes," I meekly replied, "I am really looking forward to seeing some of the autumn leaf changes during the drive." Now, I ask that you look past the inherent lameness of my response and instead focus on his assertion that, "It's going to be much too dark out there to see anything. You'll probably have a really boring drive." At this point, I had had just about enough of his crap. I was exasperated, and without thinking blurted out, "Then I guess I'll just have to settle on playing chicken with the deer that try crossing the highway." He looked at me as if he would rather see me in his headlights than in his clinic as a student. Knowing when to cut my losses, I got up from my chair, thrust my hand toward him abruptly and lied straight to his face: "Thanks for your time. It's been really enjoyable." With that, I tucked my tail between my legs and ran and ran.

Needless to say, this is the school at which I earned my first acceptance, and also the school which I attend. Some may be shocked that I actually accepted a spot at the school after such an interview experience, but they would be missing that this is truly the final move that will checkmate my opponent in our battle of wits. I plan on taking a gastroenterology elective during my 4th year, when my MD is pretty much wrapped up. I'm going to seek out the kind, old man that interviewed me, shake his hand and thank him for all he did for me and my career. Then, I am going to watch him keel over in disbelief.

In closing, let me summarize this story for you in one sentence: Beware medical school interviews with people who have dedicated their professional lives to sticking probes up people's asses.