Trust in Pain

A comment recently received caught my attention. And not so for it’s questioning of my patient attitudeness, but more for this first portion:

I think it is interesting that you have chosen anesthesia as your specialty - the management of pain issues being one of the few areas of medicine where the physician has to simply trust the patient to report their pain since there is no objective test to prove it. Have you thought about how you will manage when a patient reports pain (and i'm not speaking of one of the flat out easy to spot drug seekers) but you feel you have treated them adequately? If you, using your prior experience and all of your knowledge don't feel they need more meds despite what they are telling you - what will you do?

Fortunately I received a great lecture on this topic early in my 3rd year that has stuck with me. Yes, there are those people out there who abuse the system and want to have narcs up the wazoo just because they want to get high. However, in anesthesia we do have to be more receptive to the idea that someone’s pain is a 10/10 even though they are sleepy.

The lecture to which I referred earlier was by a doctor who worked with the old and terminally ill. She often gave dosages of pain killers that many other doctors thought would surely kill the patient. Her advice was that pain should never be uncontrolled just to remain within the “standards” of the pharmacopeia.

“The patient will let you know when they’ve received enough. You just titrate out the amount until they are pain free or close to sleep. Then you’re at your boundary.”

In most patient encounters this wouldn’t work too well – not enough staff to watch carefully over the patient as the drugs reach their peak effect. However, in the PACU, where we have nurses who carefully observe and manage patients, we can adjust more readily. They are given orders for pain management by the anesthesiologist, who, by way of observing the patient’s narcotic need intraoperatively, will have a better understanding of how tolerant or labile the patient is towards pain control measures. These can then be adjusted based on pain scales and overall patient physical characteristics.

Addressing the notion that we lack objective tests, certainly during the operation there are physiological parameters that anesthesiologists look for when controlling pain: increases in blood pressure, heart rate, breathing, perspiration, etc. are all items that alert them to a need for increased pain management (this being said, it is important to realize that even though the “body” is responding by reflexive physiological measures, the patient very rarely has any recall). This is a form of acute pain control, often a direct result of a noxious stimulus. Many patients present with similar findings, even when conscious, and allow for more visual confirmation of pain. While easier to understand and treat, we still have people with chronic pain, vague and mysterious, that's often at the heart of these controversies between physician and patient.

Rather than label a patient as a "malingerer" or "druggie" who presents multiple times for low back pain, neuropathic pain, or "flares" we must trust them. And that’s were the catch comes. That’s were so many healthcare providers, who entered medicine wanting to help only to be burned time and again, are now skeptical of most pain complaints. The abuse they've seen and endured, at the hands of addicts and malingerers, hurts more than just the patient - we all suffer to some degree.

Considering the notion that people report pain even after receiving large amounts of highly potent narcotics, you can easily expect providers to write the patient off as an addict. Unfortunately, while true in many cases, some pain cannot be well controlled with medications or is completely untouchable. This leaves the sufferer searching for assistance, help, and relief from the constant agony. Pain specialists are often useful for these kinds of patients, using advanced pain management, through invasive procedures, to help in these cases. A rather lucrative field, I personally have no desire to entertain such thoughts, as pain patients are some of the hardest people to treat, having been "mistreated" so many times.

Many forms of pain are hard to diagnose, treat, or even moderately control regardless of level of therapy. Asking for a quantification (the best known is the 0-10 scale) is often hard to deem accurate as pain is patient specific, based on psychological, emotional, and environmental cues. Someone claiming 10/10 pain may actually have the worst pain they've ever experienced. Just because we've seen people in worse situations shouldn't cause us to feel they're lying to us - it's completely subjective.

A theory postulated by some neurologists and others has suggested that the brain “makes up” pain in order to elicit stress responses that were once normally found – we’ve just become too comfortable and it’s a fall-back mechanism gone awry, kind of like the increased incidence of allergies. I kinda like that idea and understand it – after all, many of the harder to “trust” diseases like Fibromyalgia are more receptive towards medications targeting brain chemistry and function*. Whether I believe it to be a real disease is not the question, the patient believes it and therefore they suffer from it. We need to understand that more.

I honestly feel that we must listen to a patient and assess them truthfully while at the same time the patient must also listen and adhere to physician advice. An overdose of pain medications results in decreases in many aspects important for body funtions, including breathing and cerebral consciousness. If patients are found to be sleepy, lethargic, hard to arouse, disoriented, or having some trouble breathing at a normal rate they shouldn’t receive anything more - regardless of additional complaints. That's were the education comes into play. The physician must acknowledge the limit and be in control of the situation, without allowing emotions or a concern for legal action to influence their decision.

Despite the fact that there is some evidence that pain exists regardless of conscious level (i.e a sleepy patient can still have 7/10 pain) we need to accept that the limits have been met or breached and inform the patient as best as possible. I might still trust that the patient has pain, but my ability to help with more narcotics has been limited. My hands are tied.

*Is it just me, or do those commercials have the crazy patient look down? I look at those ladies, talking about their pain, and just shudder.

New Sidebar Items

Just wanted to put some emphasis on the new sidebar items I've added: MDCalc, MedCalc, Intern Survival Guide, Learning Radiology, and the EKG Library. These are extremely useful items for all med students, interns, and residents. Perhaps even a higher level might even find these useful.

The Intern Survival Guide is from the U. of Michigan and therefore has items on it that are hospital specific. With that being said, I think it's a wonderful site with a plenty of useful information - especially for me as I begin to sweat thinking about July 1st.

Kids Are to Placebos as Patients Are to...

Little children are placebo happy. If they have a small scratch, bump, or bruise that they can see they want a band-aid and a kiss. As soon as the band-aid is applied, the kiss given, they suddenly feel an instantaneous relief. If they’ve received medicine in the past for an illness they want something for their cough – or just to be like mommy and daddy. As soon as they get it, they’re happy. They're cured.

Patients are a lot like little children - at least the ones who use primary care services or the ER for minor complaints and an overt sense of entitlement. If you tell them that they’re going to be OK and try to send them along their way they get all upset.

“What, you’re not giving me an antibiotic? But I WASTED $25 for my stupid copayment! I didn’t come here to waste my money!” (as if taking up a professionals time and utilizing many years of education and training could be considered a "waste")

So, some doctors give in and prescribe the antibiotic, only reinforcing the patient’s misplaced sense of entitlement. Unlike a band-aid or kiss, this practice is dangerous as every drug has side effects and also increases resistance of normal residential bacteria.

Essentially the patient has thrown an adult temper tantrum, demanding to receive their placebo. Hell, we could give them sugar water with red food coloring and call it an antibiotic and they’d swear that they only get better with drugs.

In fact, my grandmother once told me about one of her friends who will purchase a large bottle of penicillin whenever they travel to Mexico. He then uses them with every subsequent cold he gets. I can't even begin to describe how irresponsible that practice is - I'm surprised he hasn't gotten a severe infection yet. But I'm sure he believes he improves only as a direct result of the antibiotics he takes and thinks his doctor's an idiot.

2008 Meme

Thanks, DG!

All right, in 2008:

1. Will you be looking for a new job? Yes, of course. Haven't you been paying attention to all of the residency talk around this place? Basically it will be the first job in almost 4 years - at least that I receive a paycheck for.

2. Will you be looking for a new relationship? Um, no. At least I sure as hell shouldn't be - what with being married with kids and all.

3. New house? Hopefully. Even if we stay in the same place we'll be looking at purchasing a home for the 1st time since we've been together. It's exciting to know that at most of the places were looking at we can actually afford to purchase on a resident's salary!

4. What will you do differently in 08? Try to exercise more, eat a little better, study the treatments for more diseases, and be more willing to help out medical students. I will also try to be more loving and listen better to my family.

5. New Years resolution? Stop drinking sodas (have only had one thus far), tell my wife I love her daily, and live by the motto: "Live and let live".

6. What will you NOT be doing in 08? Watching a lot of movies, sleeping more than 7 hours a night, and generally being able to live outside of the hospital (at least when July starts).

7. Any trips planned? No - other than residency interviews and a house hunting venture if it's needed. We need the money.

8. Wedding? Already been there, done that...happy with it.

9. Major things on your calendar? Hells yeah! March 18th I find out if I matched and the 20th we find out where we're matched. Residency will start in July or late June, and a potential major change in our lives will transpire.

10. What can't you wait for? Finding out where in the hell we'll be at. I'm really over all of this already...let's get on with the process.

11. What would you like to see happen differently? I'd like to be more fiscally responsible and be able to manage my budget with more efficacy. I had far too many overdrafts this last year and I hate paying out $30 a pop per transaction.

12. What about yourself will you be changing? Hopefully my body fat percentage will be around 10% or less. I also hope to try and relax more often and not get stressed over everything. I imagine that the entire process of internship will leave me with a great deal of medical knowledge that I thought I'd had, but didn't understand.

13. What happened in 07 that you didn't think would ever happen? That we'd sell Wife's car and purchase another, relatively new, one. I had planned on having both cars go through residency - but sometimes it's better having cars that work well than hoping you don't have to pay for more repairs. Another was the death of my cousin and sister (12/24/06). Both died suddenly and unexpectedly. My father was also diagnosed with renal cell carcinoma and had two operations where he lost one kidney and 25% of the other. I finally realized that I had to get glasses and now wear them readily - even if they make me look older than I really am.

14. Will you be nicer to the people you care about? That's part of my resolution for this year.

15. Will you dress differently this year than you did in 07? I'll still be dressing in work related attire: scrubs, slacks and shirt and tie. So, no.

16. Will you start or quit drinking? What are you, nuts? I love beer. I'm not stopping any time now. A good beer with a football game or after a hard days work is wonderful.

17. Will you better your relationship with your family? Hope to. Losing some family abruptly and having cancer spring up made me realize that I need to keep in contact more often.

18. Will you be nice to people you don't know? I will try. The fact that some of these people will be the nursing staff who can make my year a living hell or nice might play into my affability. Plus it's always nice to have a cool intern when you're starting out the clinics as a med student.

19. Do you expect '08 to be a good year for you? Sure, why not.

20. How much did you change from this time last year till now? I finally know what I want to do in medicine, I'm focused, and I'm less likely to lose my sanity. Other than that, not a whole lot.

21. Do you plan on having a child? I'm not sure...we're kinda in a weird place in the marriage where anything could happen. So another child might not be the best thing right now.

22. What are your plans for new year's eve? Stay at home, celebrate with my family, and drink some wine as the ball drops.

23. Will you have someone to kiss at midnight? Yes, Wife.

24. One wish for 08? That I don't kill anyone when I start my intern year.

No one will be tagged - I don't do that.

Sexual Harassment

An interesting topic was generated by Hoover over at MedSchoolHell. It discusses some of the sexual harassment that many medical students have to endure during their clinical years. While I've seen some forms myself (and been a victim once) I don't recall anyone reporting the events. All too often I've found that surgeons tend to be the greatest offenders (lots of inuendos during surgical cases - what with the "suck this" and all), but many other professions are also culpable. What I find interesting is the SDN feed that he links - the mindset of many students is to just let it go and be "professional".

You know what? I'm really sick of that catch-phrase being tossed around to shame medical students into submission.

I agree with the suggestions of going to the legal department and risk management. Your dean's office or coordinators are not going to be able to help you. They'll sweep the incident under the rug.

Obligatory Comment Induced Post

In reflection on my post dealing with Psychiatry I found the responses completely perceptable. Of course, having dealt with similar forms of misunderstanding or degrees of complete arrogant ignorance directed towards my chosen specialty I can understand the knee-jerk reaction towards my apparently incendiary comments.

They were expected. I anticipate more, perhaps as others are directed towards the jerk med student who knows nothing about psychiatry. Imagine if I’d bashed acupuncturists or homotherapeutics – we’d be swimming in the assaultive commentations.

Yet the fact remains – my experiences, my teachings in a school of medicine by residents, attendings, and social workers demonstrated a very sad state of affairs. The social workers were more involved in talking with patients than the doctors who, instead, spent a great deal of their time reading or leaving early. Patients improved here and there, but there were very rare circumstances where a physician actually worked hard at understanding the patient’s needs or point of view. Unfortunately, this is all too common in other areas of medicine, but damnable from a psych perspective. If my exposure has been insufficient to truly warrant a degree of opinion, I am aware.

Yet, even friends entering the psychiatric field have expounded on the degree of psychiatric training they've tried to avoid. They agreed with my perceptions of the residency we rotated through and noted some others where they'd interviewed whose residents actually would state: "we need to get a real doctor's opinion". That's where my concern for Psychiatry lies - in the apparent loss in some training programs in keeping their residents grounded in their medical school knowledge.

****

There have been discussions regarding the desire of psychologists to receive training to begin prescribing medications. If what I’ve heard, that being drug management is more lucrative than couch talk, I can understand their wishes. However, and let me be clear on this, I do not think that psychologists should be giving out drugs, regardless of my perception of the state of Psychiatry. If for what little medical treatment and disease pathophysiology psychiatrists actually recall, they received 4 years of post-graduate training revolving around the medical needs of patients in all arenas. Their understanding of pharmacology, side effect profiles, and dosing have been inculcated during this process and they are, therefore, more likely to be able to understand the toxic-therapeutic ratios, effective dose over lethal dose, and other nuances that a physician must evaluate when prescribing medication.

As little of the understanding of psychologist training I do know I don’t feel that they are as well prepared to be able to understand, nor be able to review, drug interactions and potential dangers as a psychiatrist. And perhaps it is the 4 years of residency training that I bemoaned earlier, focusing on the drug management more than psychoanalytical jargon, which further qualifies the psychiatrist from those who want to be included.

But what of the additional year or two that psychologists have suggested that will enable them to understand these concepts? They still lack the fundamentals, ingrained throughout 4 arduous years of medical school, that all physicians rely upon. Rather than being on the same footing they've already started behind and, worse yet, have years of training that have narrowed their mental process towards what they studied.

Overall, medical training allows the students and residents more capacity to understand where, when, and how to obtain vital information – regardless of specialty. What's more is the fact that these same students and physicians have a less focused perspective as they've been trained in broad strokes from the getgo.

Yes, we all forget how to manage certain diseases (I can’t for the life of me recall how to classify Salter fractures from surgery nor what the management would be), but we have studied them before and understand enough to be able to review with better efficacy. It's like riding a bike - you never really forget, but it's harder to teach an old dog new tricks.

What’s more is that through this process we’ve been able to interpret more readily what we don’t know. I’ve felt that a PhD enables someone a great deal of knowledge about a very precise and minute area of science. Truly they are experts in a small area. The problem that occurs is all too often someone with a specific focus begins to believe that they can do more without realizing their limits. I do not agree that a PhD enables anyone the option of performing as a physician – the training is to myopic. In fact, I find it disturbing to know that some professions are actively trying to erase or blur the fine line between the physician title of “doctor” and their own within medical settings. Because, unlike a rose, a doctor by any other name is not the same.

Single Payer Naysayer

Want a single-payer system? Sure, we all do – right? Free healthcare for everyone and we all live happily ever after.

Wrong.

One of the most basic reasons that single-payer will not work is that it’s controlled by government. I don’t need to point out the troubles that are staring the NHS and Canadian systems in the face to make this point (and therefore did not provide links – you can get them yourself if so inclined).

Instead, imagine why patients are scared of the VA. Put yourself in their place – having to be seen by government paid healthcare providers who do “only what’s in their job description” and nothing more. A friend of mine has yet to receive adequate care for his illnesses and has begun to utilize homeotherapy - he's sick and tired of being "treated like shit by dumbass docs". I’ve seen some awful events, terrible care, and a complete lack of responsibility for patients at the VA during my few rotations. All perpetrated because the government employee mentality sinks in and once caring people become clock-punchers.

Beyond that, think of the military heroes whose medical care is being taken care of by places such as Walter Reed and other embarrassments of governmental medical care. Having spent 2 months in an army base I can tell you that more often than not the patients, doctors, nurses, and techs were more than frustrated by the ridiculous administration set in place to hinder movement through the system. What’s even more outlandish are the wait times in order to even see a doctor – months. Would you want to wait months for care? Months to receive surgery?

You can already see the impact imparted upon the medical field by beaurocracy crazy pencil pushers (regardless of association). If you haven't read or seen the images of nurses waiting to clock in and out in order to avoid infringements I can tell you it's completely absurd - patient care suffers. JCAHO is another entity who seems hell bent on making ridiculous mandates in the name of "patient safety". Do you really think that a single-payer system wouldn't be frought with these forms of "suit abuse"?

Then consider that your choice of doctor will be limited. Your care, paid for by your hard work and budgeting, will be reduced to “equalize” the care between poor and “rich” alike. Now consider whether you still really want a single-payer system. What's more, have you ever had or knew someone who had an HMO medical plan? Right.

That's government healthcare, clearly not "the answer" as preached by idealists all over the US.

Personally I feel that I and my family should be able to get the care that we work for, pay for, and earn through responsible actions. I do not want to receive mediocrity in order to help those who are less fortunate, immature, drug-addicted, slothful, and polybabydadics be spoon-fed more than they already receive.

Wouldn't Know the First Thing

Rather than post about the continuing discussion regarding my rank list with Wife I will instead post about some other topics until I feel I can discuss the situation with more perspective.

With that being said...

A post from T at Anesthesiobiost (a rather interesting blog about an Anesthesiologist living in, I think, Philly, who is trying to learn the Oboe) illustrated a point that I’ve made to some of my colleagues regarding Psychiatry.*

Unlike Kris Kringle in Miracle on 34th Street who holds a great deal of respect for Psychiatry, I do not. Perhaps my experiences have been dominated with poor understanding or observation of the absolute worst form of practice, but I truly don’t feel Psychiatrists should be held in the same realm as physicians.

For that matter I don’t understand why they need to attend medical school in order to become head shrinkers.

Consider the experiences I’ve seen:

- Patients in an acute Psych ward were treated only by the nurse practitioner for diseases like high blood pressure, diabetes, and headaches. The psych residents and attending were unable to treat these diseases and frequently asked for “med consults” when these “problems” arose. They would then ask the students about the medications and what they did as they didn't know.

- During an ECT day while on an Anesthesia rotation, we were forced to wait for the Psychiatrist to arrive 30 minutes late for the last ECT (consider that we were scheduled in another room after we finished). Once he arrived we were once again appalled to see him spend another 30 minutes talking to the patient about why they were happy having not eaten that morning (as per OR guidelines – NPO after midnight). Then, without alerting the OR team or anesthesia team, this guy allowed the patient’s family to enter the room and observe the procedure. Afterwards he described what they had done and feebly tried to recall the reason for the anesthesia team’s involvement. He fucked up the basic physiology and pharmacology so badly I lost absolute respect for him.

- Whenever a Psych consult was requested at my main teaching hospital additional measures had to be taken in order to get a resident or attending to see the patient within the week. On OB/GYN we had to personally track them down and walk them to the patient floor in order to see mothers before they were discharged. They always acted put out and asked ridiculous questions about the patient’s disease or status (like did they look tired when they delivered – of course they did!).

- An attending stated that psychologists are better talkers than psychiatrists. The job of the psychiatrist had moved from “the couch” to the pharmacy. “Let the psychologists handle the psychoanalytical discussions with the patients, they’re better trained at doing that now than we are anyway. We deliver the drugs that help people”. No, really, he actually said that.

- I spent 2 days being lectured on Freud despite many of his ideas being disproved. They guy was a fucking coke addict with a major sexual compulsion – why are we still being taught about him?

I completely agree with T’s anger over the issue she describes. I don’t understand psychiatrist’s need to attend medical college – because they sure as hell forget about disease processes when they enter residency and apparently are just glorified drug pushers.

* I am not sure what T's opinion of Psychiatry is and am not trying to make any references to the like. Her post only allowed me a moment to reflect on the level of absurdity I feel with Psychiatry.

Of Course, Something Else

After all was said and done about knowing what my rank list will be, I was hit with a major obstacle. I showed the presumptive list to Wife, after we had talked about the locations of my top 3-4 programs a week earlier, and she calmly stated that, wait for it…she wouldn’t move to my 3rd choice.

Of course I was rational about the whole event – not. You see, I’ve tried to keep her involved in this decision, let her know where I was thinking about applying, and asked her opinions of the cities and overall locations where we’d potentially be moving. A few cities where I had wanted to apply were lost in this process and I proceeded to interview with the assumption that, despite not wanting to move, she’d be OK with where we ended up.

The other notion that ran through my head was an absolutely selfish one: I’ve sacrificed 7 years for her to be near Stepson, lost a year of undergrad, gained $15,000 in out-of-state debt, and was forced to only interview at 2 medical schools (of which only one actually interviewed and accepted me). I’ve done a lot for her and this was my training: 4 years to become an Anesthesiologist, board certified and all. I felt that, given the fact that I’ve put up with 4 years of bad experiences at my medical school with feelings that I might have been happier at another location, I should be able to rank programs based on where I feel I’d receive the best training.

Selfish.

This argument eventually ended up in discussions by her about going separate ways. Wife feels we’re not on the same path anymore – and all because I got upset about one program. Now, don’t worry too much at this point – she brings this idea up every now and then when we have a heated argument. However, I feel somewhat betrayed at the suggestion that I just went about “interviewing all over without talking to me”.

I felt I had taken a great deal of steps to try and avoid this problem – only to have her start 2nd guessing the whole notion of moving. So now I feel that, unless we end up in the program we both want as our primary choice, she’ll decided that it’s not worth it and stay here.

There is a burden I’ve carried for a while now – the idea that she has sacrificed her aspirations for this process. I also worry about where we’ll end up because Stepson will not be coming with us if we move. I’ve spent more time at home, trying to be helpful in order to assuage these concerns, but I’m getting sick and tired of feeling like I’m the bad guy in this situation. It sucks, yes, but I honestly feel that I attempted to keep her involved throughout.

So I’ll move the program low on the list (despite being an outstanding place) and try to patch things up later today. But you know, residency is not going to be easy – anywhere.

Rank Advice

Tomorrow I can enter in my rank list for residency programs. Hurrah, it’s almost there! Even though I have 2 more interviews to undergo, I already know my rank list and plan on entering it just as soon as I can. These interviews are more formalities – I already have seen what they have to offer outside of the dangerous interview day and an extra day isn't going to change anything.

For what it’s worth I found interviewing a struggle. How can you honestly determine a program’s worth for you based around self-aggrandizing statements, sweetened webpages, and residents who tell you that: “It’s awesome here! I would do it again!” Perhaps, but still…something’s not right.

So, with that in mind, here is a list of some items that I’ve come across that tipped me to some redflags which pushed a program low on my list:

1) Residents not being able to get out to their assigned dinner meeting with applicants because there’s no one to cover for them. Hey, if they can't even go meet their potential applicants because they're stuck, how do you think you're going to get treated?

2) Mention of the word “probably” when asking a resident if they’d rank their program #1 or come back as a resident. Yeah, I'd probably want to get reamed again too...if I forgot how bad it was.

3) Program directors or chairs who aren’t at your interview day and never talk to you. Seriously here, if one of them can't be at the interview (expecially the PD) then how likely are they going to be there for you when you're having some issues or need to talk about the program? Major red flag.

4) The feeling that “there’s nothing that needs to be changed” when asking someone where they feel the program will be heading in the next 5 years. Really? Nothing? Just like anything, you can always improve.

5) Students from programs that tell you they hated, or the residents hate, the program. Additionally, if they state that they’ll be placing their own school’s program low on their list – you better dig more. These are the best source of information, but can also be very devious since they're interviewing for the same specialty as you. I was asked about one of my school's residency programs and was honest. Some people will tell you accurate info while others lie. Take it with a grain of salt.

6) Program where you feel a nauseated feeling after leaving – something’s not right, but you’re not sure what…trust that instinct. Unless it's food poisoning from the fish the night before.

7) Less than forthcoming program director when questioned about ACGME troubles or a low cycle year. They should tell you what they were cited for, their improvements, and where they hope to be when they get reevaluated. If they can't, they're hiding something bad.

8) Dirty and run down hospital setting. Look, I know a lot of hospitals aren't pristine, but I’ve already dealt with this for 4 years and I want to work somewhere that I have pride in being at day to day. Worrying whether the ceiling tile will fall on my head is not beneficial.

9) Environment where you’ll work – is it run down, nasty, scary? If you don’t want to work with certain populations (perhaps having to speak ebonics more than english at any one time) come early and watch whose walking around the hospital.

10) Residents who tell you “don’t come here”. Yeah, you might want to avoid that one altogether. Didn't actually hear that, but some people have and I actually cancelled an interview after learning a co-applicant was informed that by the residents.

Just a few hints that I picked up while out on the trail. I personally am grateful to have run into students from various areas in order to get a better appreciation – because I honestly think you get the wool pulled over your eyes a great deal during this process.

Low On Gas

Recently I took some of that golden free time over the holiday to try and drum up some more “MSG Worthy” blogs. Not that I’m all powerful and everyone bows down to my suggested readings located to the left. In fact, it would seem that no one pays particularly much attention to me anyway (as my siteviewer indicates an increasing drop in visitors), so it’s merely more of a “favs” for me when I'm away from my traditional PC. Now you get it – yes?

Anyway, I found that I had a rather hard time finding Anesthesia related blogs. I was fortunate in being able to find a couple that I enjoyed perusing and, even more fortunately, they also had a couple links here and there of other blogs written by Anesthesiologists that for one reason or another were relegated to "look at later".

But I’m concerned…just 3 blogs overall that I found worthy of being placed on my “read regularly” list? Where are all of the great Anesthesia bloggers? I know they have stories – just like surgeons – and are a great deal more well rounded than their said counterpart. Humour, intelligence, and personality abound in anesthesia, so why so few?

I tend to consider the nature of the job when I ask this question. I also find that most people really have absolutely no idea what it is to deliver anesthesia which, possibly, leads to a great deal of frustration. I mean, how many times have I read in Michelle Au’s blog a comment here or there where some commenter says something like: “Yeah, but you were like, a REAL doctor today!"? Far too often, I'm afraid.

I see these, read them again, and think: "WTF? Real doctor? Idiot".

Anesthesiologists are more than just technicians, but most people honestly believe we just put you to sleep and leave the room. Even amongst those we work with regularly I see an amount of ignorance - even if they do hold a great deal of respect for their colleagues - that I just don't understand.

Fortunately I'm hearing that more surgical interns are rotating through anesthesia for a month or two in order to gain a fuller appreciation of the nature of perioperative medicine and it's strengths/ pitfalls before they're too hardened. On top of that more anesthesiologists are also branching out into critical care medicine and other medical fields where the true nature of perioperative medicine can be utilized...maybe we really can all get along.

Perhaps it is the lack of understanding, even amongst our co-workers, that's the causation behind the diminished interest in the anesthesia field to author a weblog or, for that matter, in the reader to actively search out the “Gasman”. Surgeons and ER docs seem to hold a great deal of notoriety as the coolest docs out there and therefore seem to have more opportunity to capture an audience (look at Medblog Addicts "Calendar Docs" on her sidebar and you'll see what I'm talking about). Who cares about the guy who "watches the surgeon work"?

I guess that as I progress in residency I’ll loose a lot more readership since I'm entering a less than cool field (to you, not me), but at least I’ll be another voice in a specialty that doesn’t receive nearly enough acknowledgement or praise.

Caring For Loved Ones

One of the more frustrating things that come with a medical education is having people expect you to give advice or fix them right away. I’ve had Wife’s friends and coworkers call me, unexpectedly and unacknowledged, to ask me if their doc was crazy, or if they should be doing this for that, etc. I’ve told all of them a very similar message: I don’t give advice over the phone or in person, I’m a medical student, go see your doctor. I have stated and firmly believe that you shouldn’t give advice to people without being their doctor - regardless of the relationship. It can come back and bite you in the ass.

That being said, it’s harder when it’s your family. Both my kids were sick recently (10 days of hacking cough and 2 days of violent food poisoning) and I’ve been trying to take care of them as best I can. Since they’ve been sick with illnesses that would resolve on their own I’ve really just been dolling out comfort care. But it upsets you, to know that you’re looked at to fix them and that being post haste. Plus, on top of that expectation is the very real notion that you're not believed.

“What good is your medical education if you can’t take care of this?”


"I didn't really believe what you were saying, but I guess you were right."

I’ve heard those statements before and will most likely hear them again. It’s hard to tell your loved one that they just have to “suck it up” and deal with it for a while – there’s nothing that can be done beyond supportive care. Certainly you feel that you want to be proactive and heal your family, but at the same time you must realize that in order to be a good husband and father you have to distance yourself from your medical training – at least to some extent.


I've had conversations with my mom about my dad's cancer, if it's progressed, and similar topics. She recently asked me, while out for an interview, to come with them to a follow up appointment where a new growth was going to be discussed. Because this subject was well beyond my training, I went and asked only a few pertinent questions. My goal was to be a support while trying to not interfere with the relationship developed between my dad and his doctor. Mostly I was there, I think, to make my mom feel better and certainly not second guess the treatment plan. They were glad I accompanied them, but I understood the hazards that were in place at my being present and tried dutifully to avoid traversing them.

There’s a slippery slope that can develop if we get too involved in caring for our family or friends. Regardless of your experience I feel that we can get too emotionally involved and attempt too much without the guidance of other, perhaps more appropriate, physicians and nurses. I’ve had times where I felt guilty for wanting to take Daughter to her pediatrician because I felt there was something that they could do - anything - just make her happy again. I've also had times where I've felt ashamed for presenting with an illness that, in retrospect, was an easy diagnosis that did not require a sick visit.


Between all of these cases she's been OK, but it still bothers me. Stepson's dad has taken him to their doctor after I've told him there's really not much more they can do - too which I've found some degree of anger directed towards him. Regardless of whether or not I was accurate I have since realized that it's not his job to trust me (nor I him) as I'm not their physician. And because of these understandings, based on pride and shame, I realized that I was too involved in the care of a loved one and could have made mistakes shadowed by emotional attachments.


A perk of medical training is being able to take care of people around you, but it is imperative that all physicians realize there's more undertaken while caring for a family member than a regular patient. Important findings could be minimalized by a desire to avoid a tough discussion or diagnosis and bonds that were once strong can be broken forever. I personally have decided to never provide healthcare for my family that would normally be part of their doctor visits.

Primary Fever - Catch It!

"...That's what you said about yellow fever and that was no fun at all"

In touch with very little since medical school began, I find that I have been able to keep up with a great deal more during these last few weeks. Perhaps a month’s vacation has been good for more than just interviewing.

Since we’re in the primary season and Iowa showed us that the ‘Clintons’ are not about to run away with everything (though NH sure wasn't making me happy) I thought I’d discuss my personal political opinions (I wonder what this will do?).

I consider myself an Independent. Despite originating from a Republican dominated family in a red state I found that the impulse to vote for anyone running with an elephant backing was absurd. So I try to figure out who has the best ideas, who appeals to me more, and overall has the best chance to do something worthwhile – regardless of their party affiliations.

Enter the presidential candidates. There are a few here and there that I have some tendencies to admire and others that scare the bejesus out of me.

Democratically I only favor one, that being Barack Obama. He is by far the best of what they’re offering. He understands that the healthcare system needs help, but has stated that a single payer system would not be beneficial at this time. He wants tort reform, but unfortunately doesn’t support federal mandated caps. He's new enough to politics that I don't hear lies with every flick of the tongue. Plus he'll offer something that this nation has never had - a minority president. Cool.

Hillary is far too polarizing – we’d end up with every nation hating us or loving us (like we already do, but worse) and healthcare reformations a complete disaster. Part of my dislike for her, apart from the above, is the entire ‘feminist pride’ that I see and hear constantly when women talk about her. We don't need to vote in someone who, at every turn, cannot be taken seriously. She is so bereft of genuine goodwill that it's scary. She scares me - a lot. Also, why does she keep saying that she’s running on 30+ years of change? Am I mistaken in saying that her husband was elected into every office until her NY senate win? Why am I supposed to believe that he did everything with her by his side (and we clearly know he did a lot away from you)? I’d vote for a woman for president without a problem, but not one who clearly is so malevolent, so condescending, untruthful, and unappealing as her.

Edwards is a joke to think about. Consider the fact that he made his fortune by suing doctors over birthing injuries without real proof of when the injury took place and worked ardently to cloud the issue related to cerebral palsy (blaming the incident entirely during the time during birth) and then look at whose blog your reading. His malpractice lawyer roots are more than I can stomach – it’s no wonder he doesn’t support any real tort reform (nor does he believe that there’s a real crisis). The only thing this man wants to do is make himself wealthier while destroying the rest of the nation.

Mitt Romney is my favorite out of the Republicans. I think he has a firmer footing in the nation’s problems and is handling the ridiculous concerns regarding his religion with a great deal of tact. Republicans, being as they are, support tort reform more fully and are less likely to approve a single payer system (afterall, why should people be forced to provide to everyone?).

Guiliani has some good about him as well, but I’m really kinda over hearing about 9/11 with each speech.

Huckabee? I mean, do we really want someone whose name sounds like Huckleberry running our country? Another Arkansas governor? I didn’t think Bill Clinton was the best president either, so why would I put another Arkansas man in the office? I agree with some of what he stands for, but I tend to lean more conservative.

What of McCain? I like him well enough, but being in the political spotlight for decades always makes me less sure of what you're selling. You're more likely to get someone who lies through their teeth, is in deep with lobbyists, and just has no real idea of what being an American is about anymore.

Whatever your political ideals are, regardless, we should take some interest in these people. Our nation is at one of its lowest points and we need someone who will actually do more than play simple party politics. Bush has been bad, but what we don't need is someone coming in and fucking around with the country more.

Back at It

Well, after a lovely couple weeks break from interviewing and 5 weeks from medical school I'm back at it. Last weekend (yes, an interview on Saturday - I've got a couple places doing those) I interviewed at a nice enough program, but - and thankfully - I knew that I wouldn't rank it high. I've vacillated enough about my rank list already and I really didn't want some place that I wasn't keen on to begin with to suddenly astound me and fuck things around again.

Today I'm supposed to start my Radiology rotation. Supposed to. But, I'm several thousand miles away for an interview tomorrow. I had to fly out yesterday in order to ensure that I could make it to the dinner and the interview since the weather out in the west has been lovely.

Of course, trying to get information on the rads rotation, the change in our starting date, and attempting to alert the coordinator that I will be out for the next 2-3 days (remember, the last time I flew through this area I had to sleep in an airport for another flight) I have, naturally, not received any reciprocating e-mails from this rotation.

Sigh...

I wonder when the school will realize that I'm paying you to help me here, it's part of your job. Some assistance would be nice - but then again, I'll have a quarter of a million in debt for a study-at-home medical degree. YES!

I'll be glad when interview season is over. It was fun at first, but having time off has made me realize that it's hard to try and kiss ass all the time and appear interested in anything being said.

***Addendum: I received an e-mail from the coordinator regarding my first e-mail, 2 weeks ago. She wants me to call her and explain myself. Hey, I tried to get to you already, now you'll have to wait.

In With the New

As far as 2008 goes, I'm going to take it a little easier on myself - as far as resolutions go, that is. After all, 6 months from now I'm going to be getting dumped on in a manner I've never dealt with and I'm sure I won't have time to - you know - read more, eat better, exercise 5 days a week, etc. What I can change I hope will help with a lot of these anyway.

1) stop drinking sodas - makes my stomach miserable at times and there's a crap load of carbs, calories, and bad juju in those bottles.

2) tell my wife I love her everyday - regardless

3) don't sweat stuff that doesn't matter anyway - live and let live. Getting that fat bastard to understand that they have to take better care of themselves is important, but most likely not going to happen - so don't sweat it if they keep eating out. It's their life, after all.

That's it. Pretty simple.

Not So Happy New Year

So the new year did not start out well for me. Stepson had a touch of gastroenteritis the other day and I feel I picked this up while caring for him.

I awoke yesterday, after imbibing with a few beers, wine, and some non-heart healthy food the night before, to a very nauseated stomach and generalized body aches. Thinking that I was being punished for the overindulgence I went about my day, got the kids breakfast, and tried to clean up some of the dishes. An hour later I was in the bathroom - dying. The whole shabang of gastroenteritis hit me - diarrhea, violent vomiting, and serious hurt. I ended up putting Daughter down for a nap around eleven in the morning and proceeded to sleep.

Thankfully Stepson took care of her after she awoke because I was out till 3 pm. The remainder of the day was spent trying to keep warm (I was freezing), making it to the bathroom in time, and staying hydrated with the left over Gatorade we had from Stepson's episode. I went to sleep at 8pm and slept till 7 this morning. I feel better - hazy, but better.

So, after that experience, I had to wonder how I would be able to manage to work as a resident if that same scenario played out. Residents have been known to work through serious illnesses, some having IV's placed in order keep hydrated. All I know is I was useless yesterday - how would I care for patients?

Anyway, Happy 2008!