Thoughts from the third week of my second year

I'm relieved to say that being a second year is fun! It's frustrating, different, astonishing, but not near as scary as I thought it would be. I've lived through my first code, multiple RRT's (pre-codes), and my first overnight call. My hours are better. And, trying to manage an intern and a medical student has taught me:
A. I really have learned a lot, even though I feel like I can't learn enough!
B. Trying to teach someone requires a lot of patience
C. I'm REALLY Anal.
D. Trying to prioritize codes, patients, clinic calls, pages, and all the other craziness that goes along with being a second year is hard!

Still, getting to be more in charge has been fun. Letting my intern write notes and answer pages is even more fun. But I truly enjoy seeing how I can help someone grow. I like interacting with the families more closely, and talking to the consultants and attendings. Medicine is even more fascinating this way.

I thought I'd try something different and attempt to write about a particularly memorial patient once a week or so, as most of what are the highlights or struggles of my week revolve around a particular patient. I've learned so much about people and society too, through my patients. Of course, there are privacy rules so I'll have to be appropriately vague. This week, I thought I'd tell you about a lady we had, 88 years old, who came to us in terrible shape. She was painfully thin, blind, slightly demented, and hornery as they came. She couldn't even sit up without help. She had been found unconscious by a friend, no one knew how long she'd been like this. Long story short, she has been living alone, unsafely, for two years now. She had never married, no kids, no living relatives but a nephew, who was worried sick about her. She had had adult protective services called on her many times but she refused to let them in. She was determined to live her life as independently as she could and to die "on her own two feet, kicking and screaming", just as she'd lived her life. She had had her electricity cut off because she'd forgotten to pay the bills. She was paranoid, so she refused to let anyone help her with her bills. She thought we were trying to poison her and steal all her money. She thought she was getting along quite fine, thank you, and was eating like a horse and getting to the store herself and we were all crazy to think she needed more help. This, of course, put us in a bad spot, as it was clear this was not true and she was not safe to go home herself and that she was delusional. We were able to find a way to start the guardianship process for her nephew and to get her to agree to go to a nursing home, but I had such mixed feelings about all of it. It was sad to me, that she had had no one to look after her for so long. It seemed sad to me that we live in a society where we are too busy to take care of our elderly people and instead send them to places where all they see are other old, sick people. What a way to cheer them up! We felt bad that she so obviously didn't want to go to a nursing home, and we basically were trying to convince her to do something she didn't want to do, but we couldn't send her home. We just couldn't, it would be like sending her to her death. Maybe she'll find she likes the nursing home, where they can wait on her and she can eat all she wants. I was impressed with her indomitable spirit. Maybe she will get better and go home in spite of our dire predictions. I rather hope so.

Thoughts from 6/29/07, the end of my internship

It’s been a little more than a year now that I started my internship, and in two days, I will be a 2^nd year resident. I can’t believe how fast it’s gone, and how far I’ve come in one year. Most of the time, I despaired at ever learning more. I always felt no matter how much I read, or how hard I worked, I never knew enough. I felt the information I was trying to take in went in one ear and out the other and why did it take reading something 5 times for anything to stick? (my dog is sliming my shorts as I type this with his wet nose) But then, I met the new interns. They are nice, intelligent, wonderful people. But it helped me to realize that I indeed have come a long way. So many little things that I never knew were important until tried to explain it to someone else. Such as, the social worker is your best friend. When trying to discharge a patient to a nursing home, make sure you fill out the right kind of paperwork. If someone doesn’t have insurance, you can’t get them much aid. If a patient’s belly is rigid, no matter what they say, it’s BAD. You can call the pulmonologists day or night, and they’ll be nice, but be careful of some other subspecialists. And on, and on, and on….

It’s made me feel a little more confident that I’ll be ok as a second year. My program director made the good point that we’re very good at being interns. We like being interns. So now that we’re second years and have an intern to supervise, we’re going to let the intern do what had been our job, and learn a whole new role, and it’s going to be hard at first to let go. And it’s true. I’m very comfortable being an intern. I know what it’s all about. Also, interns don’t have final responsibility. We’re pretty low on the chain, as far as responsibility goes, so now that I’ll be more responsible, I’m nervous. I’m nervous running codes, and being alone overnight in the ICU and being in charge of making sure wards teams run efficiently. I’m nervous to teach my medical student and be the one to call family members everyday. So many decisions to make everyday, I wish I felt 100 percent confident. But no one does, so I just try to remember that and be excited that I’m moving on.

I’m also very happy that I’ve learned that I love taking care of patients. Being a doctor of the underserved in the US is hard. Our health care system doesn’t work. It just doesn’t, in any way at all, and it’s hardest on those who need it most. It truly breaks my heart to think of all my patients who I want to do so much for but can’t. I can’t even list them all. I have my undocumented Mexican worker, a young man with 4 children and a wife, who has a particularly aggressive cancer and will die without treatment but is terrified of being deported and I have a hard time getting him to fill out paperwork so we can at least do some charity care for him through my hospital. Another patient, only in his 50’s, who had a stroke with residual cognitive defects such that he can’t even get to my office on the bus himself or else he gets lost, loses his bus pass, has a panic attack, etc. His brother provides for them both and he can’t even apply for disability until three months after his stroke occurred. Meanwhile, he can’t afford occupational therapy so these first few months, which are often the crucial months for rehabilitation, he has slowly lost function when he should have been gaining it back. Then there’s one of my meth user, who has had a few near-death experiences because of her meth use, who has finally admitted using to me after many months of me knowing she was a user, but who was afraid to tell me because she’s had such bad experiences with people looking down on her or turning her away in the past even though she truly wants to quit. Next, there’s the homeless guy I took care of in the hospital with diabetes, who needs insulin but gets his medications stolen on the street all the time so he never has medications for longer than a week after he leaves the hospital. He’s a very nice guy but it’s clear he is a little slow and it’s also clear that the other people who live on the streets take advantage of him and dupe him at every turn. He will die from his diabetes soon, I can tell. The fact the he is still alive now is a downright miracle to me. He promised he would come to see me in clinic so I could take care of him. He never came.

Finally, there was my experience at the jail. I have this great rotation called population based health at my program, which is two weeks of learning about health care systems, health disparities, all the needs in medicine, and how people try to solve these problems. My program wants us to be a part of changing the system, and to be socially responsibility, and not just complain about it or forget about the things that need to be changed. One thing we do is spend a day in the jail. What an experience. Like Africa, I think every doctor ought to spend some time at the jail. It is a very sad place. It is a place we put psychiatric patients, who have nowhere else to go. It’s a place we put drug abusers, who really need to be at rehab but are in jail instead. It’s a place for those who aren’t safe on the streets and actually feel safer in jail. And health care in the jail, well, there IS free care but it’s only certain things. Very limited. And these guys have such basic physical needs, it’s sad that only in jail can these guys get any care at all. We turn such a blind eye to those less fortunate than us, and being in medicine makes it impossible for me to do so. Yet I feel there’s so little I can do. I hate it.