Allergies, Alerts, and Assessments: The Information Age of Medicine

If you have a pulse and have visited an American physician, you have surely experienced this bizarre situation. They have you show up early for your office visit to fill out a packet of paperwork on every medicine you have every taken and every orifice you have ever had examined, yet when the doctor shows up in the room he asks for all of the same information over again. MAYBE he glances at the packet, otherwise it gets scanned and filed and stored securely and uploaded “to the system”. Sometimes a nurse will even come in and confirm the info on the sheet, followed by the doctor who has no knowledge of any of this information gathering.

Or picture this. You visit a local hospital ER for some urgent thing that came up. You fill out another huge packet of info. They transfer you over to the local county hospital, where the process will surely be repeated. There’s also a good chance they forgot to send the disc with your CT scan on it, instead sending a sheet of paper with a report of what their radiologist thought it showed. I deal with these sorts of situations every single day, and the cost usually comes at the expense of the patient, with increased wait times, repeat scans, and extended hospital stays due to administrative headaches. “Transfer paperwork” is usually dozens of pages of worthless charting by nurses (patient does not have an ostomy, patient is not an Alaska native, patient does not drive a vehicle manufactured before 2004), with one short paragraph actually written by an ED doc on the patients problems, followed by another dozen pages of medical necessity for transfer and financial information.


This is the current culture of healthcare. There are two issues I want to discuss, but first some juicy secrets about how doctors interview and evaluate patients.

When I am talking to a patient, every question has a hidden purpose.  There are directions that I am leaning for a diagnosis and treatment, and I am looking for specific answers that guide me in the right direction. When I ask, “When was the last time you had anything to eat?”, I don’t actually care a lot about your food choices over the last 24 hours. I don’t care if you crushed a Chipotle burrito, I usually just want to know if you can or can not be operated on today. Please don’t walk me through each and every thing you’ve eaten. When I ask about your medications I am usually asking about your health problems in a roundabout way, asking you describe the problems you have that are severe enough to require medicines instead of saying “I’m actually a healthy guy doc. Little bit of the sugars is all!”. This also gets me around the incredibly confusing segment of the population that seems to think, “I don’t have high blood pressure because I take 3 medicines for it and it is treated.” So my questions are very directed to get me what I think is the sufficient amount of knowledge need to treat you effectively. I try to start with open ended stuff just to see what you say when I ask “What brings you in today?”, but when we get on a tangent I need to bring it back to the important stuff.

This is particularly true on morning rounds, I have to see 22 patients by 530am and I am ruthlessly efficient. Are you alive? Have you pooped? Is your pain being treated? Are you actively bleeding anywhere? I can sort out any number of issues during the day, but first I need to get a handle on the things that I need to know.


I always round with a horrible cup of coffee. It inspires me to get done in time to get an actual breakfast.

So that’s the first issue we have, and it plagues healthcare. We have all of this information about you, your meds, your vitals, you name it. We know so much about you, but not very many people know what to do with any of this information. As a surgeon, I am particularly concerned about certain vitals, labs, and physical exam findings to determine if you are going home, going back to the OR, cleared to eat, whatever. Medical doctors care about all sorts of other stuff that they order that doesn’t actually matter (looking at you, pro-calcitonin and activated protein C). Anesthesiologists care about the structure of your mouth and the ease with which you can be intubated. Since we have done a relatively poor job of identifying what we absolutely need to know about each patient, we have gone ahead and decided to record every single thing about each patient at all times, just in case it turns out to matter.

This is probably the hardest on nursing staff and CNAs. At our hospital, nursing tasks are measured per hour, and an average of 42 minutes per hour is spent documenting on the computer, leaving a lousy 18 minutes for patient care (divided amongst their 3-6 patients each day). They document the patients bed position, what food is delivered to the room, visitors to the room, the temperature of the room, and the programming on television. This became an issue a few years ago at a hospital I worked at in undergrad, with nursing leadership complaining that documentation was hindering them from providing patient care. Instead of addressing concerns with workload and documentation needs, the hospital purchased 600 computers on wheels so that the nurses could wheel around the halls and do their charting. These computers initially were called COWS, but that term was deemed insensitive by the nurses who used them and they are now WOWs (workstations on wheels). I did not make any of this up.


The result of this is a massive pile of poorly utilized, very sensitive information that we must not only keep protected at the risk of heavy fines and legal repercussions, but also pick out the important parts that could lead to poor patient outcomes.

The best example I see every day regards the allergy section of a patients chart. Actual allergic reactions are life threatening emergencies. The throat swells, you can’t breathe, and you die if you don’t get treated. Bad things that happen when you take medicines are not allergies, they are actually side effects (or sometimes intended effects). Morphine making you sleepy is NOT an allergy. Lisinopril making you cough is not an allergy. Taking a medicine while you also happened to have a viral respiratory infection is not an allergic reaction. Regardless, each thing gets dutifully logged by nursing as an allergy into the EHR. EVERY SINGLE TIME I try to place an order for medications for a patient I get that stupid chart blasted at my face to review allergic reactions. I am so used to clicking through and overriding (trust me, you really do want something for the pain after your open abdominal surgery), but I worry every day that I do miss a true allergy to sulfa or something.

The second issue revolves around documentation. Taking the critical amount of information for a patient and distilling it into a usable progress note or discharge summary is an incredibly difficult task. In the days of paper charts, notes from docs tended be brutally short. “Doing well, advance diet, monitor fevers”. Nowadays since so much is automatically generated our notes contain all vitals, labs, and a plan that (more often than not) is automatically carried over from the prior day. Again, we seem to be forgetting what the critical information really is, and instead just copying everything down.

Part of this is related to money. We get payed for what we do or do not document, and if the choice comes between losing money or writing more things into charts, you know which direction medicine will head. We have a weekly conference where one of our CDI (Clinical Documentation Integrity) docs goes over how we lose money by not writing the correct coding diagnosis in our notes. It is so ridiculous that it makes me angry to write about it on a rainy Saturday morning from my couch. We don’t get full reimbursement on a trauma patient if we don’t do a complete assessment of history on their intake. This means that if we don’t specifically ask our 90 year old patient with an intracranial bleed about diseases that run in their family, the goverment pays us less money. It doesn’t matter that it’s actually poor patient care, it is a box on the form that must be filled out so it must be done. In the trauma bay, with often critically ill patients, we end up asking about family history, mental health screens, and vaccination status (tetanus is important but others not so much in trauma) to get the boxes checked. It’s absurd.

The other part of this data is related to patient care. We need better tools to analyze big data to see what really matters for outcomes. We track re-admissions and complications because they are easy to measure, and it has made us defensive physicians. We need to measure outcomes in an efficient manner so that we become better physicians. This will be it’s own post down the road, for now I will just drop a quick link to a recent Wall Street Journal article that discusses an aspect of this idea.

If you have skills in data analytics, interface development, or programming of any kind, you could make an actual mountain of money in healthcare. Build us a system that lets us document efficiently and share our documentation with our colleagues across the street and across the country. Build us a system that allows us to study all of our data, our financial measures, our outcomes, and our complications. We need to see it often, not locked away in the medical records department. The last decade of medicine has been dominated by the Epics and Powercharts of the world, who have made it this long for being not as bad as their competitors, but my generation of physicians sees these systems as the dinosaurs that they already are, and we are ready for something better.

This is frustrating to me because I am still boots on the ground slogging through surgery residency. I lack the computing skills to even know where to start, but I know we absolutely need something better. This is the information age of medicine, but right now we aren’t using any of our info, it’s just weighing us down. Healthcare is still using a flip phone, it’s time we catch up and break new ground.

Thanks for reading!

Surgery, Metaphors, and the Story of Your Life

Most of us have a very limited understanding of the world in general. It’s not really our fault. Our perspective is pretty well limited to our immediate circle of family and friends, and of course you have only your direct sensory perception of the world to actually create the framework of your consciousness. There’s a big world out there, surrounded by an incomprehensibly huge universe, and we’re pretty much blips. Because our own experience through our lives is very limited, humans have traditionally told stories about their lives and the experiences of others. So many ancient texts and myths have been passed down to us today as oral tradition, or essentially campfire stories that were told for generations before we finally started writing stuff down, which turned out to be a pretty big deal. Nowadays we have the entirety of the internet to connect and share (and in some cases overshare) our life stories. We have even managed to make obscure stories from long ago available widely online, expanding our collective knowledge an incredible amount in a relatively short amount of time. My story on this blog is technically contributing to that collection of knowledge, though it is admittedly drastically limited by my unwillingness to proofread and the limited sphere of influence of both of my readers (hi Mom!).

I think stories are important. I should mention here that I have read an incredible number of books over the years, mostly because I am a huge nerd. I continue to read (at a much slower pace) even during surgical residency. I love the structure of a story, the ebbs and flows, climaxes, and suspense. I like to view my life as a story, as it gives me a framework to look at my family, friends, and goals in a larger setting that may be difficult for me to grasp otherwise.

Stories work especially well when discussing shared experiences. Laughter, fear, embarrassment, stress, relief, and grief are all common across mankind, and sharing stories about how those feelings have affected our lives draw us closer to each other. People generally like to tell stories because they usually like to talk about themselves, but listening to stories is almost as good. I like telling stories so much that I take time to write them down to people on the internet.

Some stories are difficult to share effectively if the experience is relatively unique to you personally. You can communicate the facts and the sequence of events, but you won’t be able to really convey the meaning of the story unless the person listening has had a similar enough experience. I have found this particularly true when it comes to incredibly stressful events such as natural disasters, traumatic events, and surgical residency.

It’s hard to tell stories about residency to people that aren’t residents. Most people don’t have any similar experiences to relate with, and so it’s tough to get that understanding across. This is why many residents only hang out with other residents (also no money, shockingly little spare time, and poor social skills). I recently had the opportunity to catch up with some old friends and this was made very clear as we shared about our lives. I worked more than double the amount that my friends (who have full time jobs) work each week, with far less compensation, WAY fewer benefits, and a much more hostile work environment. It was actually a little depressing as I realized how sad my life was. I found myself saying things like “I can usually do my laundry” and “I’ve been sleeping in until 5am or so lately”. I can still tell funny stories about crazy people, or gross stories about traumas, but it’s tough to actually relate with how I get through my life. I don’t get off at 5, take a lunch break, or even have my own chair. I do have a small locker all to myself, which I think is pretty great.

I really like metaphors. I think they are useful both for teaching and for communicating with others who may have some things in common with you, but not necessarily the experience you are discussing. I have an attending surgeon who overuses metaphors. He will start teaching with a sports metaphor, switch to fishing, then make a pop culture reference from 30 years ago to end it, and I can’t keep up with all that. Medical students definitely don’t, but they will laugh at his jokes, which are terrible. His metaphors are even worse, there needs to be some similarities in your metaphors for them to work.

I like to compare anatomy to cities. Surgeons love anatomy. Every little thing in the body has a name, a function, and variants to know. Then add in the insertions, origins, innervation, vascular supply….it really adds up. Anatomy is often the first traumatic experience medical students have in their schooling. Though it may cause PTSD in medicine residents, it’s a working language and constant learning challenge in surgery residents.

Learning surgical anatomy is like learning to drive around a new city. You can look at maps and get a good idea of the layout of the city, but once you get there you need to start driving and see signs to confirm that Main Street is actually Main Street. Experienced surgeons are essentially the cabbies of the city, having spent years making their living driving on every single block, watching accidents happen (and causing a few), taking alternate routes for traffic, and knowing how time of day affects traffic flow. Medical students don’t know simple things because they are still getting their bearings, they still need to drive down Main Street and see the big attractions.



This is Hong Kong, by the way.

Surgery residency is a strange beast, but I think it has a lot of similarities with baseball. Both are long seasons or careers that require endurance and daily performance. In baseball you can strike out with the bases loaded in one inning, then hit a game winning home run the next at bat. You can play extremely well and the team will lose, then vice versa the next day. No matter how well or poorly you are playing, there is always your next at bat, the next inning, the next game, and you have to continually prepare yourself to perform at your best when that time comes.

Baseball Infield Chalk Line

In the same way, surgery is tough business. Patients live and patients die. The hours are long, and the stress is real. The stress comes in different intensities, like a fire. Each morning there is the distant, soft, constant burn on the way to work. “I don’t want to hurt anyone today. I hope I can help at least one of my patients. How can I be my best?” Then there’s the anxiety when you aren’t at the hospital, but you know have a huge case the next day, or a sick patient back in the ICU. There’s the intense heat and focus in critical situations, when everything is beeping and you are the first to respond to a code, or have the MAC blade in hand to intubate a patient. Everything is on the line, and you’re up to bat. No games to win or lose, but the lives of others are at stake. Finally, there’s the huge weight of fatigue when you walk into the hospital for your 18th shift in a row, or walking out late at night knowing you’ll be back early the next morning.  Batter up.

The story of general surgery is not good. 20% attrition in residency. Huge egos competing for operating room time and influence, each person convinced in their own skill and decision making. A long, antiquated tradition of training surgeons by breaking down medical school graduates and molding the pieces into surgeons. That story is changing very, very slowly, but is still the reality for surgery residents all over the country today, tomorrow, and the next day for the remainder of our training.

If our lives are stories, each of our stories is made up of layers. Starting broadly, there are the events of our lives, or the circumstances that we either create of find ourselves in without our doing. Next, there is our conscious interpretation of those events and their effect on our lives. Separate from that are the actions we take and the decisions we make.

Finally, and most importantly, there is the internal story that you tell yourself about what is happening in your life and how you are going to respond to it. We all have inner voices, or an inner dialogue, and I think that voice is the single most important factor that drives who you are as a person. That inner voice is you, or at least as close as anything can be to you as a person. Whatever you are doing, or whoever you want to be, that voice is going to get you there. It’s remarkable how much I can affect my own day and my own well being despite the circumstances of the day, and that is the single most important thing I have learned in residency.

Intern year has been ROUGH, and there have been life circumstances that have made it more difficult as well, but it hasn’t changed who I am.  The challenge will be to maintain this for the next few years of training without burning out. I’ll probably write about that if it happens, but I hope to just keep telling you all funny stories and letting you know what’s on my mind instead.

Thanks for reading!






My Life is Very Glamorous Now

For anyone keeping score, I have not written a single blog post in almost two years. In that amount of time I have passed a whole bunch of tests, finished medical school, moved partway around the country, and become a for real, honest-to-God surgical resident. Impressive, I know. I return now to divulge all the juicy secrets about doctors and describe all the ways that my life is exactly like Grey’s Anatomy.


Actually, I’m back because I got an email that someone might have hacked my page and been posting malicious content. The security threat was neutralized (unknown source, but it could have been either of my regular readers) and once I remembered my password I realized what a gold mine of ridiculous stories I am sitting on and how much I miss writing. Shockingly, this blog is visited routinely despite not logging in for over two years. There are comments from 2014 that will still be awaiting moderation when the world ends. If I had monetized this thing two years ago I could probably get a York peppermint patty at the gas station, but as I mentioned, I have been busy living a very glamorous life, which I will detail below.

The main perk of being a surgical intern is that you get do everything. Actually, mostly everything. All of the cool stuff gets done by people above you, BUT you get to do everything else, so pretty much lots of pushing buttons of the computer, taking papers from one place in the hospital to another, and keeping tabs on dozens of patients doing their best to leave the hospital to overdose on drugs or make poor decisions as soon as they can. Also, everything is your fault unless you have proof of being in a different location, being on a different service, or an iPhone video of the attending surgeon telling you explicitly to do that specific thing. The basic procedures that are “intern level” are bestowed on you as though they were gifted from God himself, but really it’s just a chief resident with a healthy opinion of himself “letting” you do a gallbladder. But trust me, you are very busy and definitely not with busy work.

Perfect resident

A second perk of being a surgical resident is the ease of managing your life outside of work. See, a “resident” describes someone who lives at a certain place. To “intern” someone also means to confine them to a certain location. The ACGME had to create new rules specifically so that we worked less than 80 hours a week. Simply put, your life outside of the hospital becomes pretty well simplified into brief periods of lucidity shortly before or after going to sleep. Starting residency, I was shocked at how little cleaning I needed to do, since I was never actually in my apartment long enough to make a mess. I have since managed to surreptitiously move into and live in an upstairs call room at the hospital, and I use the neighboring anesthesia call room to store all of my boxes.

A third perk of surgical residency, which I consider to be a defining perk of surgery in general, is the ability to wear scrubs every day of your life. I love my scrubs. My sweatpants at home aren’t as comfortable as my scrubs. I can change them whenever I want, add or subtract layers above or below them, and they are so comfortable I could wear them as pajamas. Acceptable all days of the week, on the floor, most of the time in clinic, they simplify your life and wardrobe into a nice dull shade of green. Gain a few pounds and no one will ever know. They are impossible to wear inside out once the logo and tag get washed off in the scalding hot bleachy hospital wash water. Depending on the situation it is possible to layer your scrubs for maximum efficiency, allowing you to remove and dispose of the top layer on the go (while seeing isolation patients, for example).

Finally, one of the key factors that made me choose to be a surgeon in the first place, I actually feel like I help people. Surgery, as an act, can directly fix problems. Gallbladders come out, mesh goes in, wounds are repaired, infections drained….whatever that individual needs, we can often help them in a tangible way. Of course some people have chronic issues no surgery can fix, but that’s a common theme in all areas of medicine now and a bigger problem than choosing your specialty.

Honestly, surgical residency is nothing like Grey’s Anatomy. The one episode my wife showed me started with the surgeons going to the hospital after the sun had risen, which immediately tipped me off that it was going to be incredibly wrong. Ironically, surgery residency is more similar to Scrubs than to any other show. The ridiculous “cast” of hospital staff you work with every day, the unbelievable patients and family members under your care, and the combined drama of having all of your patients experiencing their worst day ever weave together to form a story so impossible to communicate effectively that you end up just seeing the pieces.

I wish I could tell you about the stress, the anxiety, the soul crushing nights of trauma, delivering bad news to cancer patients, and grasping for ways to explain to families how their loved one has died. I wish I could share the combined experience of every sleepless night, running around the hospital while three pagers ring incessantly, worried that my action or inaction would cause harm to a patient. Conversely, I wish I could tell you about the bond I have with my co-residents, the thrill of mastering difficult technical skills, of doing work well, and the peaceful content after a job well done. There is a deep satisfaction to working as a surgeon so impossible to convey that it’s easier to just show the “skits”, the short stories that are relatable and funny, easy to tell at dinner on the weekend.

On this blog, however, I can do something different. My writing over the years builds on itself. My story, my perspective, and my experience can create a narrative that is greater than the sum of its parts. The lessons and experience I am currently gaining are coming at a dear personal cost and are worth sharing. It’s worth it to me personally to take the time to sort out my thoughts and articulate them here, and I hope that over the years this story has a meaningful impact on someone else in the world too, wherever or whenever that may be.

That’s why I’m back writing here.

Thanks for reading.






I’m a Little More Cynical, But at Least I Still Have a Heart

It’s a well known fact that medical students tend to excessively self diagnose. As we are a generally healthy cohort, it’s highly unlikely that we actually have any weird diseases, but every few weeks I study something and I feel the thought grow in the back of my mind….”I might have that!”. My classmate is terrible about this. He has spent the last week convinced that he was developing ALS, as he thought he was experiencing paresthesias in hands. He even went to the EEG lab to try to get them to “demonstrate” a nerve conduction study on him. I have a hard time believing anything he says, but I know what he’s thinking.

Most recently, I’ve been thinking I might be coming down with early onset dementia. Technically, I suppose it is now called neurocognitive decline, as dementia has that whole connotation of being possessed by demons, and people tend to not like that as much. I have been noticing some early symptoms of early neurocognitive decline, and my wife could certainly vouch for several of them, so I’m still a little worried.

Essentially, I have the same problem as my aging laptop computer. I don’t multitask well, randomly lose important items in my memory, and overheat when I am even mildly exerted. My procedural memory is still intact, and I am pretty sure I am lucid, but here I am writing to strangers (and my mom) on the internet about my perceived medical conditions, so that even my sanity could be questioned at this time. Plus, I keep showing up for medical school every day when all I really want to do is sleep and pursue my budding career as a musician. Just kidding. I can’t sing worth anything.

I only joke about my own neurologic decline because I have to take a test soon, and those are regular reminders of my below average-ness. I have been fortunate enough to see some real, true neurologic dysfunction over the last few days, and it’s affecting me quite a bit.

First of all, my standards have dropped significantly. Coming from a family of high functioning people, I have spent most of my life expecting quite a bit from other people at their “baseline”. There are many reasons for this, but I used to expect people to be able to hold down a job, pursue hobbies, actively work to accomplish their dreams, and take care of the people in their lives who depend on them. Now I’m just excited when a patient shows up sorta on time for their appointment while wearing pants. “Normal” people that come in are unusual and really enjoyable to treat as patients.

A few days ago I traveled to the county jail and did a forensic psych eval on a patient to determine their competency to stand trial. This guy was nuts. He would sing random words, complained of multiple hallucinations, and would repeatedly interrupt you by screaming, then humming loudly with his eyes close. Here’s the thing: he was faking every bit of it. He was not schizophrenic. It was all a show. He was playing us in an attempt to get a court ruling of insanity. I’ve also seen kids faking seizures (while hooked up to EEG monitoring) for attention, I’ve seen inmates faking seizures and psychosis, I’ve seen addicts faking pain and withdrawal. I’ve seen patients get arms hacked off by machetes and drunks get in motorcycle accidents at 10am on a Tuesday. Overall, I’m just a little bit harder to impress than I was last year (but I’m still gullible and really dumb, so don’t get too carried away).

The best part about this whole crazy experience is that I really do like it. Of course there are rotations that I would describe as “less than interesting” but even then I can usually find something in their to improve on, whether it be physical exam skills, bedside manner, or just a lot of time to read and study (looking at you, family medicine), I feel like each day can be thought provoking if I want it to be.

And for the rotations that I like, days go by in mere seconds and weeks pass like nothing has happened. I enjoy those rotations and love the feeling of working hard. In that sense, medical school is pretty cool. I’ll graduate in less than a year now. If I still think medical school is pretty cool after this long, I can’t be that cynical, right? Right?

Thanks for reading!


A Day in the Life of a Teaching Hospital

So you or a loved one has been admitted to a teaching hospital. While this is not an ideal situation, there are some things you need to know before being hospitalized or spending time with someone who is hospitalized. Consider this your peek “behind the curtain” to what really goes on during the 23 hours and 45 minutes that you are not seeing your doctor. Also consider this a therapeutic post for me to process some of the crazy stuff I see every day. Here we go. First things first….

A Hospital is a Huge Living Organism

I have no idea what hospital this is.

Hospitals famously never close and never sleep.Large hospitals provide a huge amount of jobs to the local community and healthcare makes up around one sixth of the total GDP of the United States. At my hospital, it is estimated that 10,000 people per day show up for work. Another larger hospital in town is estimated to average 30,000 people per day for weekday operations. Between the care that needs to be provided, support staff, and ancillary services, a hospital becomes a mini city of its own. Add in all of the associated Subways, flower shops, Walgreens, and pizza places and you have a mini economy.

If you are a patient in such a hospital, fear not. Though 10,000 people may go to work in the hospital every day, in reality there are only a few hundred that really matter to you. These men and women are the movers and shakers of hospital healthcare: surgeons, attending physicians, chief residents, etc. These people have schedules catered around their wishes and influence not only on your care, but also hospital policy as a whole. In general, the various pieces of the elaborate healthcare machine don’t move until directed to do so. More on this later.

Concepts like “day” and “night” don’t matter in my hospital because it is a windowless, rundown pile of sadness. The best way to tell time is by the regular nursing shift change. Promptly at 7am the entire hospital comes to a screeching halt while all of the various units and floors go through their signout procedure from the night before. Promptly at 7:30am pagers and phones around the hospital begin to ring with questions from nursing staff regarding meds, orders, and whether the patient has pooped. This will be repeated again at 7pm (or 3pm and 11pm, if the hospital runs three shifts).

It is important to look at clocks frequently while in the hospital, because there is a distortion of the time space continuum once you step inside. It is also important to think happy thoughts and remember that you are a nice person. Each hospital has a culture that is somewhat pervasive….it works its way into the walls and infects newcomers. These are not often productive thoughts. For example, many times every single person in a hospital will claim to be excessively busy. While many people work many long hours, I can promise you that the administrative secretaries eating their regularly scheduled noon lunch in the cafeteria are not busy, but they have to act like it to fit in. While they certainly do work hard, they also arrive 4 full hours after the surgery team, and leave earlier too. Another silly idea is that you are somehow the only intelligent person in a hospital full of idiots. Each nursing floor tends to think of themselves as the best floor in the hospital, each medical team thinks of themselves as the best doctors, and everyone thinks the Emergency Department is dumb. While some people have a reputation for being somewhat dim, generally everyone is about on the same level. With that in mind, we need to talk about the characters in the hospital

These People Are Super Important to You as a Patient

Way before the crack of dawn, the first workers will begin to arrive. These are primarily surgeons, surgical residents, and the hardworking people who need to cook breakfast for 5,000 people before 7:30am. The surgeons and their residents will wait until the reasonable hour of 5am before waking their patients and asking the same questions to everyone (in pain? Eating? Pooping? Chest pain?). At around 7am the day nurses arrive and perform their intricate signout procedure. As a patient, this morning time is super important. You need to talk to your nurses and doctors before rounds. It might be chaotic, and you might be seen by any combination of the following people, but this is the ideal time to have your wishes be heard. These people include

1- Your Nurse. This person will be most closely involved in your care, and she has the number for the doctor. She can get you food, pillows, blankets, take your blood pressure, give you meds, walk you to the bathroom, and give you a bath. Please treat this person well. They have a grueling, tiring job and receive no appreciation.

2-The Medical Student. This person is in the unique position of desperately wanting to help but having absolutely no idea how to do it. You can ask them for anything, but they will need to ask permission before they give it to you. Even if it’s a cup of ice, they will probably page their resident and make sure. They have lots of time to listen to your concerns and help, so take advantage of this. Medical students can be identified by their short white coats, youthful appearance, and the look on someone’s face when they are perpetually lost.

3- The Resident. This person is an actual doctor, but still getting some supervision. They will do 90% of the work in your care. They also have 25 other patients and absolutely no time to spare. If you are mean to them they will hate you. If you look funny they will hate you. Actually, residents mostly hate everybody and everything. If you are surprisingly pleasant to them they may take a liking to you and move you to the top of the list. I mostly see residents as blurs, since they are always doing 5 things at once and answering pages.

4- The Attending Physician. This is the older doctor you see maybe once per day. He is ultimately in charge of everything that happens to you, but depending on the situation may be more or less involved in your care. When he comes by and sees you with the team, that means we are rounding on all of our patients, and now is your single best moment to make magic happen. Finally share your secrets (“I’ve smoked crack cocaine for 20 years”) or the thing that is really bothering you today (“I haven’t pooped this month”). If you don’t do it now, you will have to wait for tomorrow. This is one of those “movers and shakers” in the hospital, because anything you ask that the resident doesn’t know or is unsure about will have to go through the attending. Also, sometimes the resident will have his plans disrupted by an attending with different plans.

Medical students are usually found bobbing around in the wake of attending physicians, furiously jotting notes.

The Interface

Let’s say you are in the hospital. In my hospital there’s a better than even chance that you are faking your illness, but let’s say you legitimately have pancreatitis. You will not be able to eat anything for several days, and your belly hurts badly. You push your “I Need Something” button and a young nurse comes in. You ask her to please give more pain medicine, but there is nothing she can give. She tells you she will ask the doctor.

You would think this is a simple process that involves a quick phone call, or perhaps a message on the computer, but it actually is an intricate system. My best analogy is that it would be playing with one of those trampoline tarps from grade school. You know…one of these.

In the middle of the tarp is a pile of numbers and letters. To communicate effectively, you need to maneuver the tarp in such a way that the pile of letters in the middle communicates to the doctor on the other side of the tarp.

So the nurse will page the resident, who will call back sometime this week. The resident may send his med student to evaluate the patient. The med student will not know what to do. The resident will come and evaluate the patient. The patient will finally talk with the resident and maybe get some additional medicine. The resident then needs to put the order in the computer and sign it, at which point the nurse needs to check the computer, see the order, obtain the medicine from the magic minifridge, and bring it to the patient. You can see how many places provide opportunities for this communication to break down. This, in a nutshell, is why nothing ever gets done in the hospital.

To make this even more complicated, every single thing needs to be documented in an archaic computer system so that if something does go wrong and the hospital is sued, they can theoretically document every second of your hospital stay.

“Why should I even go to the hospital? This is terrible!”

Well here lies the great paradox of the teaching hospital. Our inefficiency and the ignorance of the trainee (med student and resident) make sure that mistakes will happen, but introduce so much redundancy that the quality and outcome of your care ends up being really good. This is why six people walk into your room one by one each morning to ask if you pooped yet. This is why we agonize over medication doses, past medical records, and treatment options. From medical students who offer fresh, ignorant perspective to experienced supervising docs able to spot subtleties and guide treatment in difficult cases, the entire medical team provides really great care. And right now, it’s the only way we can train new docs to take care of us when we get old.

That is all. Thanks for reading!



I Still Don’t Know Anything About Brains

I wrote a post about two years ago discussing some of my struggles from my neuroscience course. That post was subtly titled “I Don’t Know Anything About Brains”. Fast forward two years. I am now struggling through my neurology clerkship, and I have come to the realization that I know even less about brains now than when I took the course as a first year.

About that course…..I’m still not sure I passed it. I took the first test (the “midterm”) and did poorly. By “poorly” I am really saying that it was the single worst test grade I have ever received in my academic career. I buckled down and studied really hard for the remaining month, then proceeded to get a worse score on the final. In my gradebook it says “Pass”, but the math says I probably didn’t pass, and at this point I’m just scared to ask questions and suffer recurrent nightmares about having to retake that class. We did a portion of the exam where we sat in a giant lecture hall while they displayed images of brains on the screen, with little arrows pointing at stuff that we needed to identify. It was basically two hours of people cursing under their breath and staring hopelessly at the front.

Now that you have some context, let me tell you a little bit about the Neurology clerkship so far. First of all, it’s just not that interesting. We see mostly strokes, seizures, altered mental status, and a handful of other conditions that require hospitalization periodically (Myasthenia, MS, etc). I know that there are doctors and medical students who love this stuff, but it just doesn’t do anything for me. I struggle to pay attention in lectures, can’t find motivation to study after work, and surf Reddit a lot on my phone. This has been easy for the last few weeks, as the residents and attendings I have been working with have set ridiculously low expectations for us and they have been easy to meet and exceed.

The funny thing about this is that I can really appreciate the way neurologists practice medicine. I have spent the last six months on teams that look at patients who develop an altered mental status (AMS) for about thirty seconds before saying, “Well he’s altered. Better call neuro.” Neurology and psych notice subtle details in history and exam, pay close attention to their findings, and usually do a thorough exam on patients that the surgical team won’t even see during rounds. Further, neuro has an intimate understanding of neurologic anatomy and pathways. Our residents have been able to localize lesions in the brain in less than a minute. At that point, I’m still reasonably confident that they have an injury affecting their brain area. You know, the one in the head. So while I appreciate the practice of neurology, I can’t see myself doing it at all.

My favorite phrase in neurology is “back to baseline”. We use this phrase for patients who undergo strokes or seizures, then have a period of altered mental status or decreased awareness. We talk to the patients, their families, and caregivers to determine whether or not this patient is “at their baseline”. Sometimes, our exam shows that this person is full alert and awake, they are just really dumb. If they are stupid at baseline, well……we can’t fix stupid. For example, a hillbilly from way out in the country didn’t know who the President was. Not because he was confused, just because he didn’t know. He even votes, he just forgot who it was. I gave hints and it didn’t help this guy. To evaluate peoples reasoning we will often ask them to do basic tasks, like “serial 7’s”. We will have patients start at 100 and count backward by 7, so “100,93,86,79,72,…” etc. This guy had no hope. He started out wrong and it got worse. He actually ended up adding 10’s, so he ended up at 134. We spent over an hour in another room trying to explain medication dosing and intervals to a family whose brother had just had a seizure. It was not hard. One new med, and two changes in doses to existing meds. We went over it about 15 times before we realized that their combined IQ was about 60 and that they literally could not remember what we were telling them. I think we could have admitted all of them for altered mental status, but instead we let them drive home!

Some patients have neurologic injury and exhibit neurocognitive defects as a part of their injury. For example, I saw a patient who had a stroke, and the only words he said to me all week were “Jose” and “ouch”. He also had perseverance of speech, which means that once he said a word, he kept repeating it over and over. Another patient was a very nice old man who was 75. He had severe memory loss, and legitimately thought that he was 50, it was 1990, and that his dad was alive and 78 years old. He was so nice and polite, and no matter how many times you informed him that it was actually 2016, he would forget within a few minutes of you telling him.

I’ve learned a lot so far on neuro. I feel like I am much better equipped to handle patients that are not responsive or have altered mental status. I have learned some great tips for examining and interviewing difficult patients that I will use for the rest of my life and practice. But I still don’t know anything about the brains!


7 Rules to Surviving as a Clinical Medical Student

If you are reading this and are currently a medical student, you will understand these rules perfectly. If you are going to be a medical student, print these rules out and memorize them before clinic time starts. If you are never going to be a medical student….then…well, I guess you’re welcome here also.

The Rules:

  1. Figure out what you need to know. There are three kinds of learning, and its your job to figure out which category this lesson/fact falls under.
    1. Things you MUST know: for example, this could include maintenance IV fluid rates, first line treatments for common diseases, basic workups, etc. You need to know these things because you are going to be a doctor (probably). These are equivalent to the “High Yield” facts to know for boards and exams and you should learn them.
    2. Things you need to know FOR THE TEST: these pieces of information are usually a little more abstract. Your residents will either not know anything about it or say something like “I used to know that when I took my boards”. This is often a completely separate set of information. I did horrible on my OB-GYN shelf because I assumed the information that I was learning in clinic and the OR was also the information that would be stressed on the test, and oh boy was I wrong about that! This is why you need to spend your precious time off reading through Case Files, Lange, or Pre-Test.
    3. Things you need to know to get through your day. On bad days, this gets down to a really primal level. For example, on some days I just needed to find a bathroom. Any bathroom. Otherwise you are more focused on learning the workflow of the team, where to be for rounds, conferences, surgeries, consults, etc. An easy way to do this by default is to stay with your resident at all times, but that can get annoying, and I try to minimize the annoyance that my presence often causes.
  2. Never miss a chance to eat.
    1. If you see a donut, you eat the donut. If you have five extra minutes somewhere between 10:30am and 2:30pm, you just got lunch. If you then go to a lecture and some rep or something has lunch, you smile and also eat that lunch. This is especially true on surgery. This rule has some broader applications as well. For example, if you see a place available to sit down, do it. (Disclaimer: by “available” I mean you are literally the only person in the room standing, there is an empty place to sit, and you have been expressly instructed to sit. Don’t go taking chairs from residents and attendings. That’s a beating if you do.)
  3. Never miss a chance to go to the bathroom.
    1. Similar to the rule above, use the bathroom all the time. The reasons for this are many. First of all, you never want to be stuck somewhere and think “I need a toilet right now”. And honestly, you’ve made it this far managing your bowel habits, so I don’t need to help you there. I’m talking about the hidden benefits of going to the bathroom. First of all, you get time away from all of the craziness going on. No one is ever mad at you for going to the bathroom. What are they going to do….force you to not ever urinate? It’s like a nice short break: no one knows where you are, it’s perfectly legit, and you can use these breaks to help you through your day.
    2. Pro tip…scope out the really nice bathrooms in your facility. The best one at my hospital is on the 11th floor and always has a window cracked for fresh air, with a decent view of the city if the weather is clear. Don’t go using the dingy one in the basement, and don’t use the one that all the patients and families use in the main lobby or by the cafeteria.
  4. Your resident (and sometimes attending) is always right.
    1. This one has some nuances to it. Your resident is almost always right for the simple reason that they can make your life hell very easily. They are always busy, have an unlimited supply of scut work, and can often be short tempered or grouchy. These are often the people that will send you home at the end of the day (see rule #6). They may also be the ones writing your evals. Do NOT cross your resident. The only acceptable circumstance that your resident can be wrong is if they are actually wrong and the attending is calling them out on it. If this happens, the best thing you can do is discreetly insinuate that the resident was correct, it was you, the naive medical student, who actually wrong. Your resident was helping further your education, that’s all. I’ve done this before, and it works great. Your resident will like you, the attending might yell at you for a little, but hey, I cry myself to sleep at night already, so no big deal, and ultimately the whole ordeal ends up going away. Tl;dr Your resident is right most of the time.
  5. Carry all of the things with you all of the time.
    1. This is the reason you wear the short white coat. My coat actually weighs around 10lbs when it’s fully stocked. You need to have survival basics to start. This includes your stethoscope, 3+ pens, your name tag, a granola bar for a snack, an emergency granola bar if things get real, your phone charger, emergency contact information (I’m only kidding a little bit), a Maxwell’s, your patient lists, and maybe an iPad mini because they fit really well in your pocket. After your basics are loaded in, get your service specific items next. On surgery, it’s great to have trauma shears, suture removal kits, surgical site marking pens, lots of gauze, alcohol prep pads, all of the kinds of tape, maybe some Dermabond or Mastasol, and while you’re at a Foley tray (just kidding). For neuro/psych, you’re looking at reflex hammers, tuning forks, and probably the printouts for evals and consults depending on your institution. I’m 90% sure I got honors on a short surgery rotation because I had a suture removal kit in my coat for a patient on rounds (the other medical student didn’t, and she got a pass), so this matters.
  6. Be Early
    1. Being early is the start to a good day. If conference is at 6:30am, you better be in the med student section (that’s a thing, by the way. If there is a scheduled conference or grand rounds, I guarantee that the med students sit in an assigned area, so you need to find that out beforehand) with your coffee at least 10 minutes early. If handoff is at 5am, you are there at 4:45 to print off patient lists for your residents. You want to beat the residents there, otherwise you will be perceived as late, and if you are actually late that reflects really poorly on you and your grade. So be early always, because on the day that you actually do get stuck in traffic/can’t start the car/get lost in a new hospital you will have extra time that might make all of the difference.
    2. Part 2 to this rule is my most important rule: when the resident/attending tells you to go home, you go home. This isn’t some sadistic contest to see who can stay at the hospital longest without eating, this is real life. I usually ask briefly if there is anything else I can help with to show that I am an eager and enthusiastic medical student who wants to be a team player (at least I hope that’s what they put on my eval), but then I gather my stuff and leave promptly after.
  7. Never touch the pancreas. It is weird and I’m not really sure what it does, so I never touch the pancreas.