I’ve been busy, as you might imagine, with work, study, and applying for medical residency. However, I thought it was about time to get people up to date with some of the clerkships I’ve finished in the meantime before letting you guys in on some of the decision-making processes involved in choosing a residency.

So, time to talk about pediatrics. Pediatrics, despite a reputation for warmth and fuzziness, is a challenging field. Kids aren’t just little adults, and the treatment and diseases of infants are different than those of toddlers, which are different from pre-adolescents, which are different from the problems of teenagers and young adults. It’s an intense mixture of preventative medicine, diagnostics, and a lot of the intangible skills involved in getting the necessary information out of uncooperative patients and distressed parents. One also has to remember that a pediatrician has to spot the rare very sick kid in a field of sniffles, coughs, and possibly malingering youngsters who just want out of school. It’s a helluva a field of medicine, and if anything it has made me more passionate about educating against anti-vaxxers and quacks. For one pediatrics is critically dependent on prevention – which the anti-vax movement seeks to undermine with potentially dangerous consequences. For another, many of the diseases of childhood when they do occur are serious – but imminently treatable if recognized. The idea of a quack tinkering in this field without proper respect for the enormous amount of medicine involved, and potential for harm, is terrifying.

So let’s talk about a set of pediatric cases and just to piss off the gun nuts, why it’s a good thing that pediatricians screen for guns in homes.

Let’s emphasize the differences between medicine in different age groups. Because it’s pediatrics the past medical history is easy – they have none. Here are two cases, details altered, but both real patients I saw almost at the exact same time.

Patient #1: A 2.5-year-old male presents to the ED because her mom is concerned he is “puffy”. She sought care in a PCP’s office 6 days ago who initially treated him for a potential allergic reaction with Benadryl and advised her to return if he did not get better. The child has had no illnesses except for a cold 2 weeks ago, has met developmental milestones and is fully immunized. Mom has lost confidence in her PCP and now presents to UVA, very worried. On physical exam the child appears to be alert, awake, in no acute distress, with completely normal physical exam except for puffiness – non-pitting edema in the extremities and face.

Should we be concerned? What tests would you order in this patient?

Patient #2: A 14.5 year old male presents to the ED with a camp counselor with complaint of fainting during band practice (it’s summer and it’s hot). For the last week he has felt unwell, but has been continuing to go to practice and participating in activities. He has had no other illnesses, is fully vaccinated and has a normal physical exam. He has no other complaints except his eyes are “puffy”.

Should we be concerned? What tests would you order in this patient?
Continue reading “Pediatrics”

Medical professionalism, or WE ARE YOUR GODS, BOW BEFORE US

One of our sciblings, Dr. Signout, is learning the ropes as she struggles (and presumably excels) through her medical residency. As her writing has picked back up, she has brought up some important questions about medical education and medical professionalism. I’m a little further along in my career than she, and I have some thoughts that may flesh out her experiences, and shed some light on the medical profession as a whole.

Her latest posts brought up two particularly important issues, one about how doctors are treated “without the white coat” and the other on what it means to put others’ needs before one’s own. These, it turns out, are connected.

Even when we shed the white coat, we’re still doctors. If we are out to dinner, and we see someone in distress, we respond. If a family member or friend has a problem, they call us up, day or night. Being a doctor is uniquely tied into personal identity. This makes certain situations particularly awkward—being a patient in your own hospital is discomfiting to say the least, and visiting a loved one is often no better.
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Some days it’s harder

I’m a little down today. I’ve told you before that I take care of my own patients in hospice. I’ve also told you about watching patients and friends lose their battles with disease.

This week I had serious talks with several people about end-of-life issues (the details of which I can’t really share at the moment). I’ve also had to tell someone about an abnormal lab result (a very bad one). In fact, the best news I’ve delivered all week was telling someone they had mononucleosis (rather than something worse).

I’ve found, in my limited experience, that terrible illnesses don’t change people that much. If they were cheerful healthy folks, they tend to be cheerful (albeit appropriately sad and angry) sick folks. If they were curmudgeonly when well, they will usually be cranky when ill. Occasionally, some transformation will come over someone when they are confronted with a mortal illness, but I don’t think this is the norm. When thinking about these things, it is very tempting to wonder how I would deal with such a thing myself, but if I’ve learned one thing in the last decade as a physician it is this:

Don’t go there!

Empathy is a good thing, a necessary thing, but you cannot be an effective physician if your empathy turns into true identification. It is paralyzing. Everyone worries from time to time about what could happen to them if this or that illness struck, but doctors are in a bad position. We know too much. It’s far to easy to come up with realistic scenarios of our own demise. This is especially true when dealing with ill patients who are like is, in age, education, ethnicity, etc.

We don’t really talk about this much. I mean, we talk about “not going there”, but we don’t often acknowledge to each other what it means to “go there”. As someone who teaches young physicians, I deal with their irrational fears all the time. Every lump, bump, cough, in the mind of a young doctor, is the seed of their own death. It takes a while to build up a bit of a skepticism about your own ability to evaluate your health. It also takes a while to find the right balance between empathy and identification—how to feel for the patient, without feeling like the patient.

Still some days it’s harder. I was talking to a friend today (a fairly new friend, as it turns out) who is going through a particularly rough round of chemo. I grew up with her husband, she has a kid my kid’s age; it’s very easy to identify with her. If she were a patient, I would try to throw up that flexible fence with empathy on one side and pathological identification on the other. But she’s not my patient. Where do I build my fence?

I don’t. Sometimes it’s possible to over-think things. She’s one of the “cheerful” ones. She’s not crazy, not stupid, not in denial, just a good person with a good attitude and a lousy disease. When it comes to friends and family, sometimes you’ve got to set aside the white coat and allow yourself to laugh and cry with someone, allow yourself to get close to someone even if you don’t know where life is heading.

It’s not always an easy ride, but it sure is better than the alternative.

Putting the Rose to Bed

Okay, as Denialism’s lawyer, let me get to the issue of the rose tattoo.

A medical procedure is a battery. Patients consent to it, thus allowing the doctor to engage in even invasive touching without liability for the battery. The scope of consent is key, however. Many individuals have a rough sense of consent; they think that if consent is given to one thing, anything goes. But, the law takes a much more nuanced approach to consent. Thus, a patient does not consent to all forms of touching, just ones that are consistent with the procedure authorized.

Was applying a rose tattoo within the scope of consent? Many people get off track by focusing on the temporary nature of the tattoo, but why should that fact matter? The key here is whether the touching itself is authorized. Whether the touching caused a permanent mark goes to damages, not to the consent issue.

It is clear that applying the tattoo, temporary or permanent, is a battery. And a doctor engaged in such pranks can end up paying through the nose for it. Take the facts discussed in Woo v. Fireman’s, where Dr. Woo (real name) applied temporary teeth to his patient (who was also an employee) while under sedation. The teeth were boar tusks, and thus made the patient/employee look very funny. Dr. Woo took pictures, removed the teeth, finished the procedure, and then showed the pictures to the patient/employee. The touching did not physically harm her, and the teeth were temporary. When presented with the pictures, she never came back to work again.

Dr. Woo settled the case for $250,000. That might seem unreasonable, but from the patient’s perspective, there is an incredible amount of anxiety surrounding general anesthesia. Apart from the medical risks, there is the fear that while unconscious, anyone could do anything to you, and you may never learn what happened. Therefore, any deviance in that type of situation can cause years of suffering and anxiety.

The tattoo was a bad idea. They should have known better. And if a patient can recover $250,000 for temporary false teeth, don’t you think a similar or larger award could be appropriate for a below-the-underwear-line application of a temporary tattoo?

Scene II, in which I clarify my previous statement

My Scibling DrugMonkey brought up a half-valid point. The half that was valid was that none of the medical bloggers spoke out about the surgeon who assaulted a patient. The half that was insane was where this is used as further evidence that doctors are arrogant pricks. Based on this comment and those of the commenters on my blog, some further clarification is needed.

I can’t speak for other doctor-bloggers, but the story of the surgeon who tattooed a patient wasn’t that interesting to me because of its isolated nature. When looking at antivaccine claims, altmed claims, and all manner of woo, we look for patterns of thought and behavior not in individuals but in society and in movements. If it were found that there were a true sub-culture of surgeons doing this to patients, I would probably rant for days about it.

That being said, there are certain aspects of the incident which seem to confuse our readers.
Continue reading “Scene II, in which I clarify my previous statement”

Why am I hearing this nonsense from a scienceblogger?

Who wrote this?

As someone who spends a substantial portion of his professional time teaching medical students, I can tell you that this kind of attitude-that physicians are gods, not mere mortals, and wield power over other human beings that no one dare question-is inculcated in them from the very beginning of medical training. It is an ugly secret of our medical training system. And the more prestigious the institutions where physicians receive their training, the more overweening is this attitude.

Anything that a physician calls a “joke” or “for the patient’s benefit” simply is that, and how dare anyone question that judgment!

Surgeons are the worst, they cut people’s fucking asses open with sharp knives, and they are basically used to functioning as dictators in the operating room. These leads to the development of attitudes which makes perfect sense in light of the practical demands of surgery. But they do not work well in other areas of life. Put a surgeon in charge of any enterprise that requires leadership through persuasion or consensus, and you are totally fucking fucked.

I know, you guys are saying, Gary Null, or Joe Mercola, or maybe the Health Ranger Mike Adams. But you would be wrong, actually this snarling little piece of anti-doctor slander came from someone within our own community. Not only that, it came from someone who teaches medical students at a major academic university. This is, of course, PhysioProf. Now, if anyone knows me, and what I write about, what I really care about is standards for arguments. As a member of the scienceblogs community, it is understandably upsetting to see a evidence-free rant, based on bigotry, from a scibling that tars a group of people that I know to be some of the most caring, the most thoughtful, intellectual, careful and conscientious people I have ever had the pleasure of working with.

What to do about this I wonder? What solution is there to this problem of such a fool in our midst, spouting such hate and nonsense at others? What can we do about someone who holds medical students and doctors in such contempt, when he himself teaches them daily?
Continue reading “Why am I hearing this nonsense from a scienceblogger?”

Medical Education—service vs. education

Teaching new doctors is an interesting process. Much has been done over the last ten years to improve the way we teach new doctors. Medical residents still work very hard, but there are strict rules on work hours and other “service” duties that can interfere with education and safety.

One of the issues that often comes up in running a residency program is the problem of “service” vs. “education”. Per the accrediting body that does these things:

The learning objectives of the program must not be compromised by excessive reliance on residents to fulfill service obligations.

Along with details such as work hours limitations, this is one of the more important guiding principles for residencies. This can be a real problem on certain very busy medical services, such as an intensive care unit.

Residency is work; there is no getting around that. But in exchange for this work, residents expect to receive teaching, feedback, and respect. There are operational measures of these parameters used in evaluating residency programs.

When residents aren’t treated with respect, aren’t given proper feedback, and aren’t taught, it frankly pisses me off. These young doctors are counting on us to mitigate their fears and build their confidence. They are counting on us to impart the practical knowledge that they will use to save lives. There is very little justification for using a resident as your personal scut-monkey, and even less for yelling, degrading, or otherwise humiliating them. That’s not how you make good doctors.

On being a doctor—humility and confidence

The practice of medicine requires a careful mix of humility and confidence. Finding this balance is very tricky, as humility can become halting indecision and confidence can become reckless arrogance. Teaching these traits is a combination of drawing out a young doctor’s natural strengths, tamping down their weaknesses, and tossing in some didactic knowledge. I supervise residents—they make the decisions, but it’s my name and my ass on the line, so I keep a close eye on things. Some teaching physicians dictate every decision on patients, some do nothing at all. I try to keep toward the end of the spectrum that allows for resident autonomy. When I’m presented with a case, and asked what I would do, I cry foul:

You are the doctor,” I say. “Tell me what you’re planning. I’ll tell you if I disagree, and I’ll let you know if I disagree enough to override your decision.”

This technique must, like all others, be tailored to the individual learner, but I want them to worry—I want them to think, “if I don’t do this right, no one else will, and a patient will be hurt,” because that is what the rest of their careers will be—being awakened in the middle of the night out of a sound sleep, having to make a quick assessment, and being reasonably sure that you’re right.

Except I’ve got their backs.

Of course, that confidence can lead to arrogance. It’s an occupational hazard. If it’s simply a personality quirk then it’s annoying. If it includes a lack of humility, a lack of knowing what you don’t know, then it is as dangerous as indecisiveness.

It takes years of training to develop the decision-making skills that go into being an effective attending physician.

This is one place where we part ways with the cranks and quacks.
Continue reading “On being a doctor—humility and confidence”

Adventures in staffing—a new physician

When a resident of student presents a patient with me and I help them formulate a plan, we call it “staffing” the case. Recently while I was staffing, I was presented with a patient who speaks little English, but speaks another language fluently. Unfortunately for us, this language wasn’t Urdu, Spanish, French, Romanian, or Hindi (languages spoken by the people immediately within my reach). The medical instructions we needed to give were fairly complex—too complex for Pidgin English, so I paged one of my interns.

“Hey, S.,” I said, “how well do you speak (insert little-known language here)?”

“Quite well, why?”

“Well, I have a nice older woman who speaks it as well, and her resident happens to be graduating. She could really use your care, both for your medical skills and your language skills.”

“You can put her in my schedule as soon as you need to. If there aren’t any openings soon, tell her to come right at 1pm and I’ll just see her before I start my clinic.”


It takes a lot to make a doctor. I’ve talked about teaching medicine: how to give bad news, how to help patients with difficult diseases, and I’ll probably write a lot more.

But some things aren’t taught—you just know them. My resident just knew the right thing to do. Despite her hellish schedule, she offered time to a patient in need. This behavior is not a given. It is the mark of a true physician.