I had my first run-in with a former patient today. Before I begin, I should mention that I work at an alcohol/drug detox and treatment facility.

A few weeks ago we were treating an adolescent girl for heroin overdose. She was an emancipated minor, working as a cook at a local fast-food joint, trying to get her GED. I remember hearing my preceptor telling her that she had to be careful of the “kitchen culture”, in which drugs flow freely at dead-end jobs, and recovering addicts routinely find themselves back in the cycle.

Today after clinic we went to lunch, to chat about my (excruciatingly slow) progress with case presentations. We sat down, and as our sandwiches got brought out, I recognized the server as the girl we had helped get clean weeks ago. She immediately did a double-take when she saw us- her face blanched, then quickly flushed, and she walked off unsteadily back to the kitchen. I’d like to think that she’s still clean, but that look on her face makes me suspect otherwise.

It surprised me, to say the least. I guess medicine isn’t practiced in a void.

Any Firefox junkies like myself should know that Kaplan’s QBank doesn’t play well with our beloved browser. Here’s the solution: IE Tab, which opens any website you specify in Internet Explorer… tabbed within Firefox.

Go to Tools>>IE Tab Options once installed to set up “blacklists” of websites that don’t make nice with Firefox. For shame, Kaplan.

The USMLE is a funny thing. In order to test the “fuzzy” side of being a doctor, there are a number of social/behavioral sciences questions (affectionately referred to as “SBS” or, simply as “Such Bull Shit”). Of course, being medical students, we attempt to remove any hint of “fuzzy” by turning it into “science” – developing a set of golden rules that may be applied to any SBS-style question on the USMLE.

Usually the question goes something like this:

The nurse asks your patient, a quiet 33 year old woman, to put on a patient gown and hop up on the examining table while you are seeing your other patients. As you enter her room, you find that she is still in her chair, clothed, avoiding eye contact. Your most appropriate next response would be:

(a) I can’t believe you didn’t listen to my nurse. I shouldn’t treat you.
(b) Hi, I’m Dr. Zac. How are you feeling today?
(c) What brings you in today?
(d) You seem quiet. I can wait allllll day, for my time is not precious.
(e) You seem depressed, would you like to talk about it?
(f) I’d like to have a shrink look at you, crazy lady.

Thusly, without further ado…

Zac’s 10 Golden Rules of Doctordom (or, How To Rock The Boards).

1) NEVER REFER. My own personal favorite. Even if your patient has a brain tumor and you are a pediatrician with no neurosurgical background, on an SBS-type question, you should never call for a consult (see Turfing).
2) Don’t be an asshole. Answer choices with “don’t be so sensitive”, “you’d have to be inbred to be concerned about that”, and “You have cancer… now suck it up and deal” are always – here’s a shocker – wrong.
3) Never treat disease; that’s what real doctors do. These are SBS questions, not medical ones. The answer with a legitimate treatment (prescribing anything or draining abscesses) is guaranteed to somehow ignore the patient’s feelings, insult them, or be the wrong drug. Trust me. A patient is rushed into an ER with a gaping, spurting chest wound, but always ask them if they’re upset about it first.
4) Don’t break HIPAA. Kick families out of rooms while the patient is minutes away from death so you can ask if they’ve pooped in the last 12 hours… it’s privileged medical information and the most important thing is not to break confidentiality.
5) Never assume. It makes an ass out of u and me, but it also means that “you seem upset” is literally the worst thing you can say to your patient. Assuming depression because of the 15 vicodin overdose, the cuts on the wrist, and the mascara streaks means trusting your instincts – which incidentally is also the quickest way to get an SBS question wrong on the USMLE.
6) Do it yourself. If you need to perform a procedure, never ask the family to hold the patient’s hand. Get a nurse or a janitor to do it – they get paid. In fact, never ask a patient to do anything. Ever. It’s always your responsibility.
7) Don’t be racist… openly. There’s this wierd love-hate relationship between SBS, race, and sex. Black males are in the highest-risk category for high blood pressure, so you need to screen for it- but you should never admit to racial profiling.
8) Guarantees are only good in big business. Saying “I promise the treatment will work”, “There’s no way you’ve got herpes”, and “You’ll never win the lottery” is the quickest way to be dead wrong. Probably a legitimate rule.
9) You always fucked it up. Nice going, champ. Always admit your mistakes, because if something went wrong in the question stem, the correct response will always start with “my bad”, “I’m sorry”, or “Ssss….. didn’t mean to cut off your leg”.
10) Never express an opinion. After all the training you’ve been though, the sleepless nights, and the constant threat of malpractice- isn’t it nice to know that what you think is unimportant? When the patient asks if you think they should take the antibiotic you just prescribed for their strep throat, your answer should always be “I have no idea”.

And there you have it! We can now quickly apply Rule #2 to answer choices (a),(c), and (d) ( (c) is “too abrupt”), Rule #5 to answer (e), and Rule #1 to answer choice (f). This leaves us with “Hi, I’m Dr. Zac, how are you feeling today”, which probably seemed like the right thing to do in the first place.

My preceptor and I, dressed in scrubs and looking thoroughly medical, were coming back from a lunch break. He is, among other things, a trained surgeon and pediatrician. As we got into his car, a disheveled woman came up to us.

“Please, do you know how to get to the medical center? I just got acid all over my hands, and the doctor said I have 3rd degree burns, but you see, I don’t have any money for gas… I need about $2.50 so I can afford the gas to get to the hospital, my fingers hurt so bad, I gotta get ‘em treated.”

View 1: She’s talking about 3rd degree burns and holding out her fingers as if to prove it. Unfortunately, she is talking to one highly trained medical professional and one trainee who can both clearly see that she has no burns at all (let alone 3rd degree, which by definition involve all layers of the skin and are therefore incredibly obvious). She is also standing directly outside of a 7-11, and the “burn scars” look suspiciously like “nicotine stains”. Plus, there are no doctor’s offices remotely near this particular 7-11. Busteeeeed.

View 2: This woman needs money, and who am I to call her out for lying to me? I’ll give her a $5, and then ask her if she needs a ride to the hospital* so she can get some antibiotic ointment put on her “burns”.

By the way, the naive, altruistic medical student in this case took view #1, while the hardened, bitter doctor took view #2. I’m thoroughly ashamed of myself.

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*which she refused, so she could go inside to buy cigarettes.

What do I do when I’m bored, you ask? Well, aside from my amazing Guitar Hero skills (of which I have plenty, might I add), I check up on the medical blogosphere. It’s lively, it’s interesting, and sometimes it’s pretty funny. There’s a whole group of medblogs that everyone seems to read- Kevin MD, Scalpel or Sword, Over!My!Med!Body!, Grunt Doc, Trench Doc, and others.

This recent exchange made me laugh pretty hard. Scalpel made a John Edwards joke, which prompted Graham to call him a bigot, which caused Scalpel to give Graham the e-finger.

I find the whole thing pretty funny. My well-known liberal bias aside, I don’t think Scalpel meant any harm. I’ll still read ‘em both. Actually, I’m even putting Scalpel on my blogroll.

Last night I had a nightmare that I was given a pager by some shadowy hospital administrator. It was about the size of a car battery and sounded like an air-raid siren when it went off. With a sickly smile he told me to make sure I was wearing it at all times, and then melted back into the darkness.

I should say at this point that like the good Dr. Blackman, I hate my cellphone almost more than I can bear. Don’t get me wrong, being able to call anyone from anywhere is pretty nifty, but I hate people trying to get in touch with me. In fact, I’ve gotten so adept at thumbing the mute button through my pants that I rarely pick up my phone any more at all. The less people expect to get in touch with me, the less they will. Win-win!

Unfortunately the reality is that I’ll have a pager within 6 months, so any hope of not being at someone else’s beck and call is a moot point. My pager will wake me from my sleep, interrupt at dinner, and shriek during movies. All in all, kind of like a baby, except that babies are cute and cuddly.

The good news is, I guarantee I’m going to get really good at conveniently having my pager go off when I want an excuse to leave the room.

My grandpa mentioned yesterday that his foot had been hurting. I proceeded to ask if it was his big toe, and if his doctor had put him on allopurinol “for the pain”. He looked at me like I was some crazy psychic and said yes to both. He muttered some suitably grandfatherish thing about me being “…a whiz” and looked rather impressed.

Diagnoses off pathognomonic features are fun!

It’s always interesting how it feels to be on break.

Just for posterity, I should mention that for two weeks leading up to exams, I hadn’t woken up later than 7:30, nor gone to bed earlier than 11:30. Almost all the time in between was studying.

What’s wierd about it is that you take that last exam and your own, personal world stops turning. It’s like a runner dashing through the ribbon at the end of the race only to find that the run is over, but momentum is still carrying them forward. I’m continually surprised that the world isn’t taking a break just like myself. The news is still news, my sister is still in classes, and my dad still has to go to work. It’s an odd feeling.

As a side note, I also must say- medical school is an incredible breeding ground for addiction. It’s all I can do to prevent myself from taking sleeping pills every night to force myself to sleep, and to chug 2 mugs of coffee every morning to wake up again. Actually, I do drink that much coffee- I draw the line at the sleeping pills. They’re more… pill-ish.

So here we were sitting in class the other day, listening to my least favorite professor. This guy is really, really bad. He contradicts himself, he doesn’t sound like he knows what he’s talking about, and he has a particularly nasty attitude. As a consequence nobody ever shows up to his lectures. Actually, I suppose I can’t really say that, since I don’t go to his lectures and therefore have no way of knowing.

He’s got it out for our class. It’s a vicious cycle, really. He teaches badly, so nobody comes, so he puts less effort into his lectures, so even fewer people show. At some point he started making jabs about how nobody comes to class*, and ever since people have been pretty wary of him.

Anyway, during his review, he started going off on details that he had never mentioned in class or written in the notes. People started to get a little punchy (we medical students are a pretty fastidious** bunch… we don’t like change, especially 3 days before an exam). At one point, he pulled out his line “well, maybe you guys would know this stuff a little better if you bothered to show up to class”. One of my classmates called out “we watch you on the tapes, doc. Not our fault.” Several people sagely nodded their heads in agreement.

“Yeah, you go great on doublespeed!” was the someone’s followup comment. Stunned silence. Mental note- it’s ok to disrespect your prof by not showing up to class. It’s another thing entirely to tell a prof he sucks to his face in front of 105 medical students and 10 PhD’s. Yikes, dude, I’m getting you a shovel for your birthday. You’ll need it to dig yourself out of the holes made by your complete and total lack of tact.

*by the way, doc, unless you’re teaching at 8AM and/or immediately before exams, your ability to fill a lecture hall full of medical students is directly proportional to your capability and likeability as a professor. Don’t take it out on us.
**double points to the first commenter who can tell me which bacteria is fastidious and grows only on dark chocolate agar.

I was grabbing dinner, feeling sorry for myself that I have to studying for exams (I know, life is hard) when I overheard a woman named Miko talking to her friend CJ.

Miko and CJ were in their late 20’s. CJ never quite grew out of the “goth-punk-star-wars-nerd” phase when he was in high school, while Miko never quite grew out of the “angsty-asian-girl-with-red-streaks-in-her-hair-listening-to-NIN”. You all know who I’m talking about. I think CJ was just stoked to be with a girl, so he let her do most of the talking (As the angsty spiky-haired asian girls usually did).

Anyway, as I was sitting around waiting for my fries Miko started talking about the people that really made it from her high school. One went to ITT tech and is now an IT sysadmin at a local company. The other got promoted from waiter to bartender at Olive Garden. She was trying to make a pass at both of them, but apparently they turned her down because she gained weight between her high school days (90 pounds) and now (at my best estimate, 190). CJ was obviously uncomfortable hearing her talk about other men, but seemed too much of a pushover to do anything about it. The other success stories were the valedictorians, both of whom were pregnant and hitched to lawyers. Good on ‘em.

I realized all of a sudden that I live in a totally different world now. The people who make it in medicine go on the lecture circuit and have mansions. The people who don’t still make 6 figures. By Gray’s Anatomy* standards, you’d think that we have to fight people off of us at bars, not make passes at the bartenders.

Back to studying for me. Sometimes you just need a reality check.

*I’m really starting to hate that show.