Internship

I'm now a nearly two months into internship and what a ride it's been so far. My program is better than most when it comes to hours, but my longest shift thus far was 33 hours. We have a night float system, but we still do 24 hour calls occasionally. The ACGME rules allow for the extra 6 hours for transfer of patient care, bringing the total to 24 + 6 (or 30) but my program supposedly abides by a 24 + 3 rule. In other words- 27. It's like they think we won't realize we're working more than 24 hours if instead of saying that the shifts are 27 or 30 hours, they say "24+3" or "24 + 6." Managing my medication on long calls is tough, and I have to make sure I don't flip into hypomania so I HAVE to take my evening dose of Seroquel, even if I'm going to be staying up all night. I take less of a dose, and make sure I get sleep when I return home. So far, so good. No hypomania. Just exhaustion- like all the other interns.

I keep my illness a secret from other people- sneaking pills from inside my Coach wristlet- and I don't think anyone I work with now would ever guess in a million years that I'm hiding something. If you met me now, you'd have no idea. It's nice to be out of medical school because my hospitalization is now a nearly three years in the past. I just tell my peers that I did a research year if it comes up that I was in medical school for 5 years. Of course when I was interviewing, I didn't lie- when asked I said I was on medical leave and then did research. But now, there's no reason to discuss this with my new friends. I just say research year, leave it at that, and I don't have to answer uncomfortable questions anymore.

It's great- sure I do struggle- but I'm so happy to have made it. Sure, there are sucky parts of internship. I had a 24 hour call last night and a nurse called me at 2:30 am to say the BP was 180/80 when it had been that way all day. But, despite these annoyances, I don't regret going to medical school.

DONE!

Yup, I am officially DONE with medical school. My graduation is in mid-May but in my mind I've already finished- yesterday was my last "working" day of med school.

I'm headed off to internship in a little over a month which is a scary thought. I matched into my top choice advanced program and one of my top choice prelim programs. To those of you reading the blog who aren't familiar with this terminology- "Internship" is the first year of residency which lasts from 3 (ie Internal medicine/ Family Practice) to 7 (ie neurosurgery) years. In "categorical" programs, internship is included, whereas in "advanced programs" it isn't, meaning, as in my case, you have to apply separately for a Preliminary year. Radiology, Ophthalmology, Anesthesiology, Neurology, Dermatology, etc, are examples of programs that sometimes require a separate intern year.

It sucks because I have to move twice- but I'm happy with where I matched so it's worth it.

I had to take my illness into account when formulating my match list. Mania, or in my case, hypomania, can actually be triggered by lack of sleep. And, being that it is perfectly legal to work 30 hours in a row, take 10 hours off, and do the same thing again, I had to pick programs with more humane work schedules. Now what I described is rather extreme- the maximum allowed shift is actually 24 hours, but then you're allowed 6 hours (in some places it's 3) for tying up loose ends, etc. People refer to this as "24 + 6" but I'm like, "whatever, it's 30." One program I looked at basically informed applicants that interns who go over hours do so because they are inefficient. That, to me, implied that interns' time sheets likely have them working < 80 hours with no more than 24+6 in a row, while the actual interns are in the hospital longer than that. I didn't rank the program.

There are programs that have a "night float" system which means that there is, as it sounds, a night shift. This means fewer 24 hour shifts for residents. Even thought night float can turn your schedule upside down and mess up your circadian rhythms, I found this to be preferable to a program where I'd be required to work "24 +6" on a regular basis. Both my intern and residency programs have night float.

I also had to think of the prescription drug plans available. I don't see a psychiatrist a lot anymore- it is basically just for crises and medication management- BUT I do take very expensive medications. Seroquel is the worst offender. I REALLY LIKED one prelim program, but had to rank it very low on my list because the prescription coverage was 400 dollars a year. (!!) And, residents had the same health coverage as one of the hospital unions. So much for collective bargaining!

I'm excited about moving on, but also a little sad because I'm leaving the house I've lived in for 4 years. I'll miss my roommates.

Bullying

I've been reading about this case in South Hadley, MA where a girl was basically "bullied to death." Apparently, she came over from Ireland and aroused the ire of her classmates when she dated a football star. From then on, it was all downhill. Her classmates reportedly called her an "Irish slut" and a "whore." Finally, on her last day, she was harassed during school, and on her way home, had a container of Red Bull hurled at her.

This poor girl walked into her house and committed suicide.

And, as if things weren't bad enough, her tormentors attacked her on a Facebook page created as a memorial. This is a little more than just juvenile bullying, this brings a sociopathic element to the situation. There is something seriously wrong with these kids, something that I really don't think can be fixed. Not only did they not feel the slightest bit badly for their actions, they had the nerve to insult the deceased. They have demonstrated a complete lack of empathy, something which reflects both character traits and upbringing.

And one of the parents actually is blaming the victim. This was even more shocking; I cannot imagine feeling anything but shame and embarrassment in her situation.

May Phoebe Prince rest in peace.

My Sister's Keeper

I just watched My Sister's Keeper and I did like the movie- I enjoyed watching it and felt it was a thought provoking story- but the glaring in-accuracies threaten to send the wrong message regarding the use of Pre-Implantation Genetic Diagnosis and the ethics surrounding solid organ transplant.

Now, Pre-Implantation Genetic Diagnosis (PGD) is a technology that can be used to select certain embryos for implantation in the mother. Just as described in the movie, a sibling may be "created" in this manner and specifically selected to be an HLA match to an ailing child.

But, normally, the cord blood is harvested, and that's typically where the use of the new sibling for "spare parts" ends. Once the cord blood has been used in a transplant, the sibling would not typically serve as a bone marrow reservoir. If the bone marrow transplant failed the sibling would NOT be a repeat donor.

Also, from my limited experience with transplant medicine, I've seen that PGD is NEVER used for the purpose of solid organ transplants. The doctor in the movie seemed that he would be on-board with the transplant, and the use of the younger sibling for this purpose. In real life, a doctor would NOT agree to this. Kidney donors are carefully selected, not just for their biological compatibility, but also for the emotional ability to cope with being involved in the transplant process. Organs are NEVER taken from an unwilling individual.

So, it was a sad and moving story, and I enjoyed the move for that, but it sends the message that PGD is used to create "spare parts" and gives the illusion that this technology presents ethical quandaries that in fact do not exist. Anyone reading this blog can be assured that American children are not currently being forced to give up their spare kidneys. Even if a (minor) child begged to give his or her kidney to an ailing sibling, the kidney would not change hands (abdomens?).

Health Care Issues

I watched a Dateline episode yesterday; the subject was Healthcare and the detrimental effect it's having on patient care. It really brought to light some of the actual problems with an insurance industry hell-bent on profits, but it also brought to light some of the problems that surround end-of-life care and the expectations of families.

There was a heartbreaking case- a man with cancer wanted to enroll in a study that promised cutting-edge treatment unavailable through other channels. Of course, the study covered costs directly related to the study, but outside of that, the man's insurance was supposed to kick in. And, his insurance company refused to pay for expenses related to the desired experimental treatment. There were some appeals, and the insurance company ultimately decided to cover him. But, by that time, the man no longer qualified for the study as he had gotten sicker.

The patient got sicker and sicker, and his wife spoke of a traumatic day when he took a turn for the worst, and she was supposed to make decisions regarding his code status.

The insurance company managed to avoid paying some potentially large bills by delaying the man's care. But, the wife seemed under the assumption that this care would be life saving, and that the insurance company had in essence killed her husband. And then, for reasons unknown to me (based on the fact that I was only watching this on television and have only one side of the story), the wife seemed unfamiliar with DNR/DNI and code status. She described the day her husband took a turn for the worse; a "crash cart" had appeared and she was reportedly asked to make some fast decisions.

From being in the hospital, I remember talking to the family of an end-stage cancer patient. They did not want to make the patient DNR DNI because the patient's daughter had seen a code when she was with her mother in the emergency room, and as she said, "It really works!" Her mother was virtually comatose, and a code was likely to bring nothing more than broken ribs and more heartbreak. The family saw DNR DNI as equivalent to doctor assisted murder.

The insurance companies are so hell bent on profit that care is often refused or delayed; but millions are spent every year on end of life care for patients for whom a medical code is more cruel and pointless than anything else.

But, as someone who believes that discussion of a patient's code status is important, and furthermore that DNR/DNI is sometimes a good thing as opposed to a failure of medical care, I am a card carrying Death Squad member.

I feel terrible for the woman on Dateline; while I think that the case illustrated important issues surrounding code status, it also shows that families of the critically ill are forced to argue and fight with insurance companies. A lot of wasted time and heartbreak, and the big picture is lost.

Step 2 CS

There are 3 board exams required for licensing. USMLE Step 1 is the first. This is taken after the second year of medical school and covers all the knowledge acquired during the first two years. Neuroscience, genetics, pathology, pharmacology, physiology, epidemiology, and microbiology are some of the subjects included. It's the hardest of the 3 exams, and the score counts the most. The average score is roughly 220. That's the three digit scores. Then there's the two digit score, a mysterious number that isn't a percentage or a percentile. 75 is passing. I have a 230, which correlates to a 98. I'm not sure how one relates to the other.

Some residency programs have "cut off's" and supposedly won't even consider lower scoring applicants. These tend to be the more competitive programs- the ones on the "ROAD" to happiness (Radiology, Ophthalmology, Anesthesiology, Dermatology) as well as Ear Nose and Throat, and Neurosurgery. I'm really not sure how hard and fast these cut-offs are, but I do know that when our Step 1 scores were released, one of my classmates sadly decided that Neurosurgery wasn't in the cards for him. Another was convinced he would never be an a Radiologist. The former chose another field, the latter is a second year Radiology resident.

Step 2 is taken after third year of medical school, the clinical year. It comes in two parts, CK, or Clinical Knowledge, and CS, or Clinical Skills. It's a little easier, and covers mostly clinical medicine. The score for Clinical Knowledge is also given out as a three digit, and the mysterious two digit, score. It's mostly important for those who feel they didn't do well enough on step 1. My score was again, a 230, and this time, my two digit score was a 95. Step 2 Clinical Skills tests students on their patient interactions. Each student must pay over a thousand dollars to interview, and perform physical exams on, actors.

Step 3 is the final test, usually taken during, or after, intern year. It's supposedly the easiest of the three steps, and supposedly, the score counts the least.

Anyway, I'm studying for CS right now. The patients are actors so in many cases they don't have actual physical findings. So, they act. If a patient is supposed to have a heart murmur, he or she will say "hush hush hush" when you put the stethoscope over the chest. No air going into the left lung? The patient holds his breath while moving his shoulders up and down as you hold your stethoscope over the left lung.

And, if you laugh, this means you lack empathy. Laughing puts you in danger of failing, in which case you will have to pay over a thousand dollars to take the test again.

I hope I don't laugh.

I was pretty sure my resident didn't like me. On my team at the hospital, the main players were my attending, the resident, and a medical student. The attending has the highest rank- she was the one on the team who'd graduated from medical school and who'd finished residency. Dr. Mia, the resident, was lower on the totem pole. She'd graduated from medical school two years prior to my stay, and was working her way through a Psychiatry residency. The medical student was what I was supposed to be. She was doing her third year clinical rotations.

Mental patients, particularly those with personality disorders, do something called "splitting." This basically means that they either really like someone or really dislike someone. As an example, if I really liked the nurse on the night shift, and really disliked the nurse on the day shift, for no apparent reason, this might qualify as splitting. Those lucky enough to bask in the light on the positive side of a split may be showered with compliments. But, this may be short lived, as the splitter can very easily move someone from one category to another. Someone who is wonderful one day, may be terrible the next from the point of view of the splitter. This usually causes problems, because the splitter often complains about certain people on the team, and when the behavior isn't recognized, the splitter may succeed in manipulating those trying to help her.

I was certain that Dr. Mia didn't like me. But I actually can't say that for sure- I do know that I didn't like her. She told me that I shouldn't worry about not returning to medical school, as many people are successful with college degrees. I didn't really NEED to become a doctor. Leaving medical school wouldn't be such a problem. This caused my eyes to fill with tears, and I answered her questions grudgingly, staring at her shoes during our sessions. Would Dr. Mia be happy if her dreams of becoming a doctor evaporated? I wondered bitterly. Her words swirled around my head and I became angrier and more resentful towards her as the days continued. I liked the attending and the medical student. I worried that my obvious dislike of Dr. Mia would be contrasted with my feelings towards the medical student and attending, and that my team would decide I was "splitting."

Patients who split are considered more difficult so I tried valiantly to hide my feelings.

"Splitting" is most notably associated with Borderline Personality Disorder, a label that is often a euphemism for "I don't like this patient." Personality disorders are also called "axis II" disorders. When evaluating the psychiatric patient, a doctor tries to fill each of 5 categories, called the 5 axes. Axis I disorders include Bipolar Disorder, Schizophrenia, and Major Depression, among others. These are generally considered "not the patient's fault" or sometimes "biologically based." Treatment is generally covered by insurance. Axis II disorders include anti social personality disorder, borderline personality disorder, and dependant personality disorder. Axis II disorders are usually considered to be lifelong, and related to a patient's character. Someone with an "Axis II" problem is often considered to be someone with undesirable character traits. Axis II disorders are usually not covered by insurance. Axis III includes any medical problems, such as pneumonia or diabetes. Axis IV includes any social stressors the patient may have. Being a medical student might go in this category. Axis V is denoted by a number, from 1 to 100, which reflects the patient's over all function. A patient who is a 10 is likely confined to a hospital. Someone who scores 100 is able to function in the world.

When a psychiatrist speaks of someone with "axis II issues" he or she usually means someone with "undesirable character traits." I learned in a subsequent psychiatry rotation that tattoos, sitting cross legged in a chair while speaking to a doctor, and attachment to a stuffed animal past the age of 15, are all indicative of axis II issues.