Medical School 2020: Year 3, Second Half

one section of a Fifth Chance Media book, ISBN 978-1-944861-02-5.

To preserve patient confidentiality, ages and other details are slightly altered. Students and teachers are also pseudonymous. Our story begins in January 2019.

Year 3, Week 25 (Family Medicine)

Orientation begins at 7:00 am. Our clerkship director, a 58-year-old family doctor, explains that we are expected to write at least two notes per day at our assigned clinic. "Get used to the SmartPhrases [canned templates within Epic, with fields such as patient age ready to be auto-filled] your team uses. Half the note is just for billing, which makes it frustrating to find information even in my own notes, let alone others'. But we have to work with it."

He describes the distinction between family medicine and general practice. "General practitioner developed bad connotations because it was basically a physician who did not complete a residency. You were considered a general practitioner (GP) in your third year of medical school. My dad delivered babies by himself as a fourth-year medical student. Family Medicine fought back against this confusion by becoming the first society to require a board examination."

The orientation was followed by a lecture on geriatric polypharmacy (drug interactions and the consequences of our pharma-happy medical system). A geriatrician (family doctor with geriatrics fellowship) in her 50s: "More than 12 percent of the US population is over 65. An estimated 50 percent of these folks take more than five medications. Polypharmacy has serious consequences; 30 percent of hospital admissions are estimated to be from adverse drug effects." Why aren't the hazards of over-pharma better known? "There are a lot of studies looking for a primary discharge diagnosis of 'adverse drug reaction' as an ICD-10 code. They will miss a situation in which the adverse drug reaction caused the primary problem, e.g., a patient falls from too many anti-hypertensives and breaks her hip."

She describes Beers Criteria, a list of potentially inappropriate medications in the elderly that can lead to falls, fractures, gastrointestinal bleeds, delirium, and overall increased risk of death. "We're trying to get away from the lady that takes a few Xanax every night for 40 years," she exclaimed. She described analgesia in the elderly. "Too often we avoid giving opioids because of the stigma, but they are frankly one of the best options to manage pain in the elderly. The alternative of NSAIDs [e.g., Advil] causes serious GI bleeds and destroys the kidneys."

She added, "When you get a few years under your belts, you'll start to notice pharmaceutical tricks. When a commonly used drug is about to go generic, the company will conduct a clinical trial with a dose that cannot be obtained from a combination of pills already on the market. For example, Aricept [donepezil], medication used in Alzheimer's dementia despite minimal clinical benefit]  comes in 10 mg and 20 mg. Before the patent expired, Pfizer conducted a trial at 22 mg. It didn’t work, but if it had, they would've sought FDA approval for the 22 mg level, and then insurance would have paid only for the FDA-approved dose, otherwise it would be an off-label [uninsured] use.  Same thing happened with Claritin." She concluded: "Learn the rules, so that you may break them properly." She requires us to conduct a polypharmacy review of an elderly patient during our rotation.

[Editor: See a March 11, 2001 New York Times story on Schering-Plough keeping Claritin from becoming an inexpensive generic via dosage tweaking leading to patent extensions: "The Claritin Effect; Prescription for Profit".]

Farmer Fiona, a 26-year-old from rural America who is interested in rural family medicine, and I are paired for our weekly nursing home days. Fiona texts the attending who tells us to meet him at the assigned nursing home at 1:00 pm. I rush through lunch at the gas station burrito shop, but need not have hurried since the doctor does not arrive until 1:30 pm. He assigns us two patients each, one admission and one follow-up. After 45 minutes, we reunite with the attending and present our patients in a conference room. My 65-year-old patient has been in and out of the rehab facility twice after pancreatitis hospitalization complicated by an abscess formation requiring laparotomy (cut open abdomen). He is experiencing worsening nausea two days after discharge from the hospital. He has no peritoneal signs (inflammation of abdominal wall), or systemic signs of infection (fever, tachycardia). We prescribe Zofran and plan to re-evaluate him the next day for possible transfer to the hospital for imaging. We then round on 5 patients in skilled nursing, and 5 patients in the long-term care section of the assisted living complex.

Tuesday morning I drive 45 minutes into the countryside to a family medicine clinic that will be my primary home for six weeks. Work starts at 8:30 am, so I get more sleep than during the surgery and internal medicine rotations. The office has three physicians, one of whom works 2.5 days per week and spends the rest of the time with her children. It isn't difficult to craft a work-life balance when a nice house near the clinic costs $250,000 and a full-time doc is earning $220,000/year. I will be working only with the two full-time physicians. We are able to perform lab draws (in-house A1C, CMP) and electrocardiograms, but no onsite x-ray.

Doctor Dunker is a 41-year-old member of a traditional Anabaptist group. He has seven home-schooled children, a beard that flows down to mid-chest, and dresses like an Amish farmer. He comes in at 8:30 am on the dot wearing a pressed white shirt with baggy black pants and a black vest. He expects the nurse (also in traditional garb, including bonnet) to have prepped his first patient and will put his black hat on the desk, don a white coat, and go into the exam room within a minute of arrival. Jane and I won't be able to complain about working hard in medical school; Doctor Dunker had two young children to care for during his medical education.

He cares for a village, about 3400 patients spanning several generations of families, twice as many patients as the other full-time attending in the practice. About half are from his traditional community, many driving two hours from the rural area in which he formerly practiced, and some making all-day drives from other states. "They just keep having children, and I can't say no." He has learned to have low expectations for M3s: "Things are crazy around here, I actually requested to not have a medical student this block. I know this isn't your fault. Today, you'll just follow me. We'll figure a way to make it work. I still want you to get comfortable with doing great outpatient encounters.  I just can't get behind on my patients because I have to leave on time."

The typical day has acute visits and medication follow-up visits scheduled in 15-minute blocks while new patients and annual visits are scheduled for 30 minutes. We are supposed to take a lunch break from 12:00 to 1:30 pm (oftentimes interrupted by 1 or 2 fill-in appointments) and are done at 5:00 pm. On two days per week, Doctor Dunker stays late and sees patients until 7:00 pm.

The first visit is a joint annual check up for an Anabaptist couple in their 70s. We start with a routine health check and filling out a Medicare annual form ($35 in extra revenue) that asks how long it takes the patient to "get up and go" (should be under 20 seconds to rise from sitting, walk 10 feet, turn around and sit back down), domestic violence screening, and dementia screening test with Mini-Mental Status Exam (MMSE, including a three-word recall and drawing a clock). The wife asks: "By the way, one more question. Our granddaughter is pregnant and needs a note to take five-minute breaks at Walmart when she gets short of breath. Could you do that?" He was silent for a second. "I cannot confirm or deny that she is a patient of mine or her situation." The couple laughed, "Oh, Doc. We know she is pregnant, she told us, and we're ecstatic. Her boyfriend, hopefully fiance, is a great guy and all about her. And by the way, you're a terrible liar!" Doc Dunker: "If she is a patient, I will reach out to her." As the old couple leaves, they comment approvingly on the Christian artwork.

We see a 12-year-old girl for eczema. Last visit, Doctor Dunker had ordered a compounded steroid cream. However, Medicaid had rejected the order, even though it is a generic medication. "This can be so frustrating. They reject what I order, but won't offer an alternative." He adds, "Finding a medication that Medicaid will pay for is like whack-a-mole."

Doctor Dunker: "The next patient is quite interesting. Interview the patient when she arrives while I see the roomed patient." A 37-year-old female former nurse, local but not Anabaptist, presents for a one-month follow-up after discharge from a stroke rehab program. After a routine dental procedure and despite being generally healthy, she contracted subacute bacterial endocarditis (heart valve infection). The infected valve threw clots into her arteries, one to her middle cerebral artery causing a stroke, and one to her left leg causing gangrenous necrosis. Her left leg was amputated above the knee. She was in rehab for a month, with follow-up physical and occupational therapy appointments.

The patient is way out of my league. I don't know what questions to ask about the post-stroke recovery process. Fortunately, Doctor Dunker knocks on the door. The patient and her husband brighten, "Doc look at this. She attaches her prosthesis to the left lower extremity stump, and walks to the door. "Oh my God. Wait here." He calls the nurses and front desk staff. "Everyone come here and watch." People cheer as she walks down the hall.

When the commotion subsides, she explains her challenges going forward. "Insurance won't pay for any more PT or OT [physical or occupational therapy]. My husband and I have worked too hard to go for the Medicaid spend-down, but we just can't afford these $150 sessions out of pocket. I wish we had known what we know now. We had only 10 sessions for PT and OT. If we scheduled them back-to-back, they count as one, but we scheduled the first few at separate times so it counted for two seperate uses." Doc Dunker: "Let me see what I can do." He calls our care coordinator, who gets her another 10 PT and OT sessions from charity care.

[Editor: when a hospital reports "charity care", it is at the fictitious list prices that are often 10X what an insurance company would pay. "How Much Uncompensated Care do Doctors Provide?" (NBER, November 2007) concluded that "uncompensated care amounts to only 0.8% of revenues" and that physicians actually were "earning more on uninsured patients than on insured patients with comparable treatments."]

The next patient is a 69-year-old male, accompanied by his daughter, for worsening hallucinations associated with Lewy body dementia (LBD). LBD is characterized by early vivid visual hallucinations followed by progressive decline in cognitive function. He called 911 at 2:00 am because he thought his wife had stopped breathing (in fact, she passed away 10 years earlier). This is the fourth time he has called 911 for a hallucination. He describes how he sometimes sees large beetles ("size of my hand") crawling on him at night. My attending describes this phenomenon where objects appear bigger or smaller than reality as Lilliputian, dubbed the "Alice in Wonderland" syndrome. The patient is quiet throughout the interview, clearly embarrassed about his behavior. Afterwards, we just sit in the room for a few seconds. "So sad, his body is fit but his mind is failing him. He knows right now he has a problem. This can be the most devastating period of the dementia." (Robin Williams who committed suicide at 63 suffered from the "terror" of LBD.)

[Editor: Williams was also being pursued by two alimony plaintiffs. New York Daily News: "Paying out over $30 million to ex-wives who were allowed to attach themselves to Williams' bank account like comatose patients on feeding tubes would be enough to make Gandhi angry and depressed."]

During most of the visits this week, I acted as scribe while my attending spoke with patients. I would jump in every few minutes to ask for a clarification or about the side effects of medications. By Thursday, Doctor Dunker was allowing me to see patients on my own. Example: a 42-year-old mechanic struggling to control his blood pressure and cholesterol despite quitting smoking three years ago and starting a rigorous exercise program. His wife has been feeding him five different herbal supplements in hopes that he can avoid prescription statins and their side effects. Unfortunately, his cholesterol remains elevated at this visit, so we prescribe Lipitor.

Jane is not enjoying her internal medicine rotation. She has been paired with Pinterest Penelope. "She thinks whenever something good happens to me that I am gunning. For example, when the intern said that she used my note, Penelope freaked out. If she had told me that, I would have said 'nice; good job.' When I tell her something cool about my patient, like check out this CTA of the chest, she'll then tell the senior and attending about the findings during rounds. Bitch, that's my patient. I'm at my last straw with her."


Statistics for the week… Study: 6 hours. Sleep: 8 hours/night; Fun: 2 nights. Example fun: Jane and I unexpectedly meet Farmer Fiona and her geologist boyfriend at a local concert. He works as a project manager for an environmental clean-up crew dealing with oil and coal waste spills. He has "call" every other week during which he must be prepared to drive up to 10 hours to an accident, but he is earning only about 1/10th of what a medical specialist who takes call might earn.

Year 3, Week 26

Week 2 on family medicine rotation. Monday morning begins with a one-hour lecture by a 53-year-old talkative palliative care specialist ("helping patients learn how to live with serious illnesses").

Palliative care was recognized as a speciality by the American Medical Association in 2008. "The profession has exploded since insurance realized that palliative care consultations save money. The problem is we don't have enough fellowships to meet the demand."  She would like her colleagues to be involved with CHF, COPD, cancer treatment, dialysis, and dementia when a patient has a life expectancy of less than 18 months. She adds, "We are far behind Canada with integration of palliative care into medical management. For example, palliative care specialists are typically at every Canadian dialysis and heart failure clinic." Why is the U.S. lagging? "Political motivation," she responded. "Palliative care became known as the 'Death Squad' created by ObamaCare."

In the old days, every physician was considered qualified to educate patients and families about the logistics and prognostics of different care options, e.g., whether to agree to surgery or proceed with intubation in a terminal disease. Now the conversation gets punted to a credentialed separate specialty: "We also investigate the reasoning behind a family's decision, we sometimes just listen but we can also use evidence-based methods to guide a patient to a more informed decision," she explained. "For example, a 27-year-old polysubstance user got into a car crash. The ICU team doesn’t want to intubate because they fear it is unlikely the patient will ever be extubated. The mother wants the whole nine yards. We came in to talk to the family for goals of care and learned that the mother's insistence was driven by a fear that the son was going to Hell. We coordinated chaplain services and eventually the mother agreed that it was time to let the son pass away." (Hospitals have a substantial financial incentive to bring in palliative care specialists, who can bill more per hour than an internal medicine (hospitalist) physician.)

Roughly 80 percent of the time, she is discouraging patients from opting for expensive yet low-value procedures. In some cases, however, it is the palliative care doctor who pushes for a procedure: "A 38-year-old male had multiple life-threatening injuries including spinal cord compression and blunt abdominal trauma leading to a partial colectomy and colostomy after an industrial work accident. He was in constant pain. His neurosurgeon recommended against spinal cord decompression due to the high risks of surgery. We recommended he undergo it even though it would likely worsen life expectancy because the family and patient could not bear to see him in so much pain."

Farmer Fiona and I happen to be assigned to palliative care for Monday, so after the lecture we head over with the attending to the palliative care team room. Each of us sees two patients. I sit in on a family meeting concerning a heavily sedated 69-year-old male with COPD and congestive heart failure in the ICU. The family has been debating for three weeks whether to stop the pacemaker that is keeping the patient alive. The wife is tearful, but says it is what he would want. "He wouldn't want to live like this in the hospital."

[Editor: It is always the spouse who wants to pull the plug, citing a never-committed-to-writing desire to be dead rather than sick, and the kids who want to keep a parent alive. Keep that in mind when setting up a health care proxy.]

After the meeting, we call the cardiology service. Some providers and device manufacturer representatives are hesitant about stopping the life-saving device. "One of the cardiologists on the service refuses to do these types of procedures," says the attending, "but the one on tomorrow understands." The manufacturer rep pushed back, but eventually relented after discussion with the cardiologist. We scheduled the shut down for the next day. This would allow the family from out of town to be present for the patient's final hours.

I join the attending for a new patient in the neurotrauma ICU. The 67-year-old male recently had a car accident and was coded for 10 minutes until a pulse came back. We don't know anything about neurosurgery and haven't talked to the patient's neurosurgeons, but we have read some notes in Epic and supposedly have expertise in how to break bad news to patients. We had a (necessarily) vague conversation that might have helped the family formulate some questions for the neurosurgery team and most definitely helped the hospital collect revenue from Medicare.

Tuesday: family medicine clinic. The first patient is a 43-year-old father of two and aircraft mechanic for UPS presenting for an annual checkup. We discuss indications for statins given his 10-year cardiovascular risk above 7.5 percent. We prescribe Lipitor and counsel regarding smoking cessation. He mentions job-related back pain. Doctor Dunker performs a brief strain/counter-strain OMT technique. "What I really need is a massage from my wife." Doctor Dunker jokes:,"Want me to write a doctor's note?"

During annual visits, we evaluate USPSTF (United States Preventive Services Task Force, a panel of experts appointed by the Department of Health and Human Services) Grade A/B screenings and CDC vaccine recommendations. We often have a discussion about the new shingles vaccine, Shingrix. Our office does not carry the vaccine, which costs $100 at a local pharmacy and Medicare Part A or Part B do not cover this. Patients on whom taxpayers are spending $10,000 or more annually balk at the idea of paying $100 dollars to cut their risk of getting shingles from 33 percent to about 1 percent.

Doctor Dunker recounts several patients that have permanent life-altering complications from shingles, namely postherpetic neuralgia. "I had a retired nurse commit suicide because of the intense pain. It is just like trigeminal neuralgia." (Also known as the "suicide disease", trigeminal neuralgia is a chronic pain disorder with recurrent episodes of intense, unexpected jolts of pain on one side of the face that last for a few seconds.)

I sit in on a visit for a 68-year-old female active smoker with congestive heart failure (CHF) who does not understand her disease. She arrives with a "care coordinator," a nurse with extra training whose job is to prevent hospital readmissions and reduce the chance that the hospital will get dinged by Medicare under the Readmissions Reduction Program (RRP). She has had two CHF exacerbations requiring readmission due to a lack of understanding of her medications and when she should take her "fluid" pill to avoid becoming volume-overloaded. I use her chest x-ray from the most recent admission to explain why she's becoming short of breath and  say that we will likely need to increase her metoprolol dose to control atrial fibrillation and keep her heart rate below 110 beats per minute. Her INR (international normalized rate, a measure of blood clotting when on Coumadin) from today's in-house blood draw was increased. I told her that the hospital's latest amiodarone prescription may be responsible. I feel like I am getting the hang of outpatient medicine!

Thursday afternoon: playing around with Epic and notice an InBasket message, which I hadn't realized we have access to. Who would send me something in this? It is a request from Doctor Dunker that I look up ectopic kidney (kidney located in the pelvis). I do research on and present findings to Doctor Dunker to help him prepare for a meeting with a family and their newborn. I explain the main considerations in management of ectopic kidney are: (1) risk of hydroureter/hydronephrosis,  (2) association with other congenital anomalies, and (3) increased risk of urinary tract infections

Doctor Dunker takes responsibility for his patients, a contrast to the hospital's poor continuity of care. For example, on Friday morning, we see a 72-year-old female who was admitted to the hospital the previous week for a GI bleed. The patient was stabilized on IV fluids and 2 prbc. The EGD showed no abnormalities, but because the patient stabilized a colonoscopy was not performed. She now has to wait several weeks for an elective colonoscopy. After several thousand dollars in hospital bills, still no answer. No ownership.

[Editor: It's not all bad. Via the above incident, the hospital obtained "ownership" of several thousand tax dollars via Medicare!]


Statistics for the week… Study: 8 hours. Sleep: 9 hours/night; Fun: 1 night. Twelve classmates drive 30-minutes outside town to a new, dog-friendly brewery.

Year 3, Week 27 (Family Medicine, Week 3)

Monday morning: 84-year-old "T-Bone" car accident victim for a hospital follow up. He was admitted to the hospital for seven days with multiple rib fractures and a wrist fracture. A CT of the abdomen showed, in addition to the acute injuries, a dilated common bile duct with the radiologist report stating, "cannot rule out malignancy versus cholelithiasis [gallstones]". We explain to him the possibilities, and that to determine this we would need to order an endoscopic retrograde cholangiopancreaticography, a procedure in which a scope is placed down the esophagus into the small intestine and injects contrast into the biliary system. "Doc, I was just in the hospital for a week, it took everything out of me. I dont have the strength to get another anesthesia procedure. I've had a good life." We agree with him, and decide to monitor with blood work.

I am beginning to work on the worksheet that we must complete before the end of our six-week rotation. Having asked the three nurses to grab me if anyone needs shots, I get several intramuscular injections checked off by giving flu shots and quadracel vaccinations to children. I also need to perform five EKGs (electrocardiograms). I see a fit 38-year-old nurse who works in the Cardiac Care Unit (CCU) and has experienced feeling faint three times within the last month. Her nursing colleagues hooked her up to telemetry, which showed "an arrhythmia". I hook up our clinic's EKG machine's leads to her, but nothing happens. The three nurses all come in to help troubleshoot. We cannot fix it so we decide to have her return in a few days.

Wednesday morning, Farmer Fiona and I head into the depths of the hospital for an afternoon with occupational medicine ("OccuMed"), a clinic that treats hospital employees for work-related issues. The 32-year-old physician trained with the military before leaving to work in civilian practice. The five patients on his schedule were all no-shows, so we got a 2.5-hour sales pitch regarding the great lifestyle of an OccuMed doctor: "We have no call, our day is like a dermatologist's."

His team is responsible for safety protocols at the hospital. He explains the airborne precaution protocol. "OSHA  mandates a standardized nine-question questionnaire with any 'Yes' responses requiring a formal physical by occupational medicine. A few years ago we used a slightly different form, and we developed an in-house scoring system to determine need for a physical. Our system was actually more restrictive, requiring almost every employee to get a physical, plus we also do annual physicals on clinical workers. The higher-ups couldn't understand why we needed to use the OSHA-approved form. What we were doing was actually illegal due to the paperwork discrepancy." A big smile took over his face: "That's the beauty of OccuMed. We understand the intersection between medicine, administration, and law. And it's only getting more complex. We're the only ones who can do this."

Lanky Luke, Mischievous Mary, Geezer George, and I head to an impromptu Wednesday beers and burgers night. Geezer George describes the tension between the employee trying to get a work-related pay out and the OccuMed doctor working on behalf of the hospital trying to minimize the problem: "The doctor asked, 'Could you please bend over and touch your toes.' The patient responds, "I can't, it hurts to move my back.' 'I know, but just try and touch your toes.' 'Okay,' it's going to hurt' As he bends over and attempts to touch his toes, the physician comments, 'So you can bend over.' 'Yes, but it hurts.' He ended up getting disability."

Luke recounts his week on inpatient pediatrics. He explains: "We admitted a six-month old with RSV ["respiratory syncytial virus," a common illness at this age]. The baby presented to an outside emergency room where she was given an intraosseous catheter access ["IO", a radical drill-through-the-bone procedure with significant risks that was unnecessary for this patient] and medevaced to our tertiary center. The baby was totally fine on arrival. Our attending admitted the patient overnight because the baby was helicoptered in and said 'The patient has an IO so I guess we should use it.'" Samantha, the PA wife, recounted a similar experience: "We had a patient with chest pain -- no troponin or EKG changes -- medevaced to our hospital. My attending commented that he would never have been admitted if he'd come into the ED, but he was helicoptered in from six hours away. We let him stay the night under observation."

Thursday: I spend 30 minutes talking with a fit 64-year-old who had bilateral total hip arthroplasties (replacements) over a decade earlier. After a tooth extraction, he was admitted for a 5-day ICU admission for sepsis in both of these artificial joints. He underwent two surgeries and a 50-day rehab stay. He is now doing a 3-week antibiotic holiday to confirm no infection before a revision. He is back home, but is not allowed any weight bearing on either leg.

The next clinic patient is a 35-year-old female, BMI 32, with a history of depression and polysubstance use disorder (alcohol, benzodiazepines, and cocaine) presenting as a new patient due to worsening shortness of breath. She explains she drinks a few beers on the weekend, but has been sober from other drugs for the past three years. She is also very upfront about being incarcerated for the past three years: "I was selling cocaine and meth." My attending: "I always find it ironic when a drug user includes incarceration years as part of their sobriety time." We order an echo, but strongly suspect she is drinking causing an alcohol-induced cardiomyopathy. We discontinue her seroquel, which might help her lose some weight, order an echo, and instruct her to stop drinking alcohol.

We are required to attend an Alcoholic Anonymous ("AA") meeting as part of this rotation.  Wildflower Willow and I select a Thursday evening meeting through the AA online portal (there are more than 10 within a 20-mile radius every night). The leader asks the 35 attendees if anyone new would like to introduce themselves. Older people tend to be sober and say "I am an alcoholic" while the members who are our age are more likely to be active users and say "I am alcoholic and an addict". Willow: "I didn’t like it, it felt like we were sent to the zoo to learn from the freaks firsthand."

Friday morning: "Medicine" grand rounds on gastrointestinal bleeding at the hospital, then head to the clinic around 9:00 am. I burn several actinic keratosis  ("AK", a common precancerous skin lesion) off with cryotherapy. Doctor Dunker lets me do two punch biopsies on a patient with numerous nevi (moles) on his back. I grab supplies, including local anesthesia, suture, drapes, needle driver, and forceps. The next step is to draw lidocaine and epinephrine into a syringe and inject to anesthetize the nevi sites until a "wheal" forms.

Doctor Dunker sees that I am comfortable getting the supplies, so he lets me do an excisional biopsy on a later patient whose previous punch biopsy pathology results showed a squamous cell carcinoma in situ, but with "positive margins" (i.e., the cylindrical punch biopsy did not remove the entire lesion). Steps: acquire supplies, prep the site with iodine, use a sterile marker to outline a 1cm margin around the lesion, incise with scalpel until reached subcutaneous fat, cut tissue with scissors, place into tissue container, suture wound close. Doctor Dunker: "Great job. Haven't seen anyone hand-tie in quite awhile." (As opposed to "instrument tying" using a forceps and needle driver.) This was my first time doing surgery on a conscious patient.

The last patient of the day: 47-year-old overweight female on birth control presenting for an annual wellness visit and mentions foot pain when walking. The ankle appears swollen and slightly inflamed. Although the patient does not report any worsening shortness of breath, our concern is she may have a deep venous thrombosis of the lower extremity ("DVT", a clot in the leg, which can throw small chunks into circulation until they reach the lung). Alternatively, it could just be a sore muscle. Following the standard protocols, which are heavily biased toward defensive medicine, Doctor Dunker decides to send the patient to the ED. "Every doc will get burned by a PE [pulmonary embolism]. I wonder how many CTs it takes to diagnose one PE? How many CTs to save one life for a PE?"  (After a no-doubt multi-thousand dollar bill to the insurance company, and a whopping deductible cost for this rare privately insured patient, the hospital determines that there is no DVT.)

Statistics for the week… Study: 8 hours. Sleep: 9 hours/night; Fun: 1 night.

Year 3, Week 28 (family medicine, week 4)

We begin with a lecture: "How do people die?" A 55-year-old physician who runs a weekly geriatrics clinic explains why he became a geriatrician. "My father died terribly. He was in months of pain and misery during cancer treatment. At the end of his life he told me he regretted getting treatment. It is my opinion that his doctors did not present him with realistic expectations."

He draws a graph of function versus time on the whiteboard, each line representing a single human life. "Seven percent of people die a sudden death, meaning they are highly functioning and die out of the blue." He draws a horizontal line high on the y-axis until it plummets when the patient dies. "These are the massive heart attacks causing cardiac arrest, the motorcycle accidents with immediate death." He then draws a downward sloping line. "22 percent of people die of terminal illness -- a long steady decline. 16 percent die of organ failure where you have ups and downs, trending down for a long time." He continues, "So what's left? 47 percent die of frailty. These are people who are low functioning for a long time." In summary: "We need to think if we want to flog granny with chemotherapy and LVAD [left ventricular assist device for heart failure] just to set her up for frailty."

His clinic reviews medications to prevent falls and unnecessary hospitalizations, evaluates prognoses for dementia and advanced chronic diseases, and discusses goals of care, including independence. "One of the most challenging discussions with the elderly is when to stop driving. Remember that the patient never voluntarily gives up driving. It signifies so much for them. A lot of time driving is essential to care for their spouse." He emphasizes, "It is the doctor's job to discuss when a patient should stop driving. I remember one time a patient was referred to me and he lived a few blocks down the road from me. He could barely dress himself, but was driving every day to the store. 'Would you be okay with your son or daughter driving on the same road?' I don't understand how physicians are supposed to have these complex discussions with patients with all the EMR [electronic medical record] demands and time constraints, but we have to find a way." He adds, "A good rule of thumb: if a patient cannot perform the trail-finding test on the MOCA, the patient does not have enough executive functioning and information processing capability to drive."

"Our clinic has a three-month back up right now. We're still working off the backlog that develops during Thanksgiving and Christmas. The family flies in for the holidays only to find that mom has not bathed in months. They say, 'But she sounded okay on the phone.'"

Farmer Fiona: "I agree with what he is saying about asking patients how they want to die, and that patients are vulnerable to believing best-picture prognosis. But he doesn't say what we should do to manage unfortunate events. Should patients not undergo catheterization after a heart attack? Not get amputated after a gangrenous diabetic infection? Maybe he wants us to tell patients to keep smoking so they die of a massive heart attack, instead of the long fragility of dementia or pancreatic cancer?" Southern Steve: "Is it worth risking getting dementia to live to 100?"

After lecture, Fiona and I drive 10 minutes to the hospice clinic where we get a tour from a 56-year-old volunteer office manager. He explains: "Hospice sprang up as community volunteer organizations. We used to be able to take patients on fishing trips, meals, shopping. We can't do that anymore because of the liability of driving patients and all the paperwork involved with insurance. The volunteer tradition is going away, but five percent of a hospice workforce must still be volunteer to qualify for Medicare reimbursement."

I follow a 48-year-old hospice nurse around the city for three home visits. My first patient (a 35-minute drive away): is an 89-year-old end-stage dementia patient. Before we go in, the nurse explains that family members are "really struggling giving medications (oxycodone and benzodiazepines) because they are afraid of killing her." She explains to the son, daughter-in-law, two granddaughters, and great-grandson that the doses of pain medications are so low she will be fine: "She needs these medications. We don't want her to suffer."

[Editor: The U.S. has 5 percent of the world's population and consumes 80 percent of the prescription opioids.]

After spending 10 minutes at bedside, including a short prayer led by the hospice chaplain, our patient is agitated. We go to an empty bedroom for a family meeting. Everyone starts crying. The son: "I am not ready to let her go. I freak out about giving her medications if they are going to hasten her death." Hospice nurse: "She is ready to go. You have to accept that and prepare yourself."

Our next patient with advanced COPD and dementia lives in an upscale continuing care retirement community home. She has a 24-hour home aide who has dressed her in stylish clothing, arranged her hair, and applied makeup. She takes shallow breaths as she stares blankly into space, not acknowledging the two strangers in her apartment. We talk with the 38-year-old home health aide, a relative of family friends who has been taking care of her for two months. The hospice nurse: "You can tell she is going to die soon. She's ready. It'll be tonight I think." She calls the family's relatives to come to the apartment. (Our patient died three hours later, with her family at bedside.)

Our last stop: an 86-year-old bedbound patient with congestive heart failure living in a beautiful six-bedroom house. A professional 28-year-old home health aide takes care of him (and the bulldog who greets us at the door) five days per week and a neighbor's failure-to-launch 34-year-old son handles the weekends. We turn him over to look for bedsores; the home aide has done a very good job. When was the last time you pooped? The aide responds that it has been at least six days. The nurse looks at me. Enema time. We roll him over to one side, and perform an enema. He has so much impacted stool we do two. The enema took about twenty minutes. The nurse was surprised that I helped throughout the enema. "Most doctors walk out the door as soon as the thought of an enema pops up."

I drive back to the hospice clinic for afternoon handoff with Farmer Fiona. Nurses and the palliative care physician are talking about overnight drama between the hospitalist service and palliative care team regarding a terminal cancer patient experiencing poorly controlled pain. "The family did everything right and called the hospice instead of going to the ED. But this hospice does not have flex weekend home visits." The family brought the patient to the ED, and the medicine service requested the palliative team admit the patient. The palliative care physician: "I told them that we are not admitting the patient. This is a disposition issue that their social workers can manage. We are not in-charge of every hospice patient," she noted. "We'd be happy to consult on the patient in the morning to provide pain control recommendations, but we are not admitting to our unit. We have limited resources." (Last week on their service, we sat idle for half the time, sipping specialized coffee drinks made by a volunteer and discussing must-read medical books..)

Thursday morning is a normal day with Doctor Dunker at my family medicine clinic. We had a monthly potluck office lunch featuring homemade apple turnovers. Staffers are comparing their role-specific Bingo cards. For example, Doctor Dunker has a square: "Patient asks for antibiotics before patient is seen by doctor." The office secretary: "Patient no shows appointment within 24 hours of scheduling."

I depart after lunch for an afternoon at the travel clinic. The travel clinic, staffed by an infectious disease doctor, is meant as a community resource for individuals traveling for extended periods of time to remote destinations, e.g., six-month mission in Africa or the Amazon. Instead, all four of our patients are going on cruises with limited exposure to dangerous disease beyond an afternoon in Cartagena, Colombia. There is no attempt to hide from the patients that we are primarily looking up information on the CDC web site.

[Editor: Cartagena was where agents accompanying President Obama to the Summit of the Americas used government credit cards for an epic party. See "US Secret Service Cartagena scandal 'involved 20 women'" (BBC).]

Friday afternoon, we have a class meeting about prevention in primary care. The lecturer, a retired hippie family doctor, discusses the "Pay-for-Performance" era. He reviews a "landmark study" finding that the highest performing practices according to metrics in the UK had no change in patient outcomes compared to poor performing practices. "Despite this evidence, we will see more and more oversight by administration evaluating performance metrics. We'll soon be telling patients, 'I need you to get a mammogram, flu shot, etc. because it will improve my clinic performance.'"

[Editor: We learned the same thing in our data-driven medicine class at Harvard Medical School. Except for generating headlines, preventive medicine is of limited value. Popular screening tests, such as mammograms and pap smears, generate so many false positives that patients on balance may be worse off. Flu shots for adults are only weakly correlated with being diagnosed with flu.]

He continued: "One challenge for performance metrics is they address challenges of the past or are out of touch with reality. For example, hospitals get graded on how quickly we start antibiotics for sepsis and pneumonia -- the proportion started within 8 hours. This metric is based on studies in the 1990s which showed early administration improved outcomes in sepsis. However, this was on a totally different patient population and different bugs because this was in a day before the pneumonia vaccine existed. There is no evidence administration within 8 hours is beneficial, and instead might cause unnecessary antibiotic administration. You all see that so much, antibiotics are started in the ED for a few hours and then discontinued by medicine service the next day."

Statistics for the week… Study: 7 hours. Sleep: 7 hours/night; Fun: 1 night. Lanky Luke, Sarcastic Samantha, Mischievous Mary, Geezer George, Buff Bri, Jane, and I attend a free concert downtown.

Year 3, Week 29 (family medicine, week 5)

We start at 7:45 am to read up on the ten patients we'll see this morning at the clinic.

The 37-year-old nurse (from week 25) with a large MCA stroke and amputation after subacute bacterial endocarditis (presumably from a dental procedure) is the first to arrive. Two days ago, she presented to the ED as a stroke alert. "We were driving back from physical therapy," said her husband, "and she just seemed confused. She would ask me something that I had just answered a few minutes ago. I was frustrated and annoyed until I realized that something was amiss. I turned the car around and we headed for the emergency room." The community hospital ED physician called a stroke alert, which initiated her ambulance transfer to the stroke center and the ensuing work-up: CT head non-contrast, CT head angiogram, CT perfusion study, MRI brain, and transesophageal echo. The headline bill could easily exceed $50,000. After six hours, she'd gotten through the first CT scans and her symptoms had resolved. I look at the imaging studies from the Epic web-link to the picture archiving and communication system (PACS, made by Sectra, a Swedish company ). The patient has no memory of the incident prior to reaching the second hospital. Great anatomy for me to go over, especially with her prior MCA infarct, but nothing acute.

The husband repeats the story when Doctor Dunker arrives. "Did she ever slur her words?" asks Dunker. "No, she just kept asking the same questions." Doctor Dunker: "And she never had any weakness or sensory deficit on her notes. I don't think she had a transient ischemic attack [TIA, a "mini" stroke that resolves within 24 hours]. This sounds like transient global amnesia where you are unable to remember new events [anterograde amnesia]."

If she was an "observation patient," their private insurance might have paid only 80 percent of the hospital bills. Between the previous physical therapy bills and the new flood of charges they're nervous. I ask if they might qualify for Medicaid. The nurse: "We would have to spin down all our assets, we've worked too hard. My husband worked two jobs to pay off the mortgage." The husband: "It's demoralizing though, we don't know what to do." Dunker: "I am so sorry to hear this. First, if she has another episode like this you don't have to go to the emergency room. Call here. Of course, if she has slurred speech or weakness in the face or arm, head straight to the ED, but what she had is not a stroke." He also informs the family about our health system's charity programs.

After the visit, he explains to me: "I don't understand some of these ED providers. Why did they order a full stroke work up? She didn't have any focal neurologic deficits. I can understand getting an MRI to rule out a small infarct, but why does she need a $10,000 CT perfusion study? She is not a candidate for endovascular treatment, and is way outside the window for tPA [tissue plasminogen]. These patients break your heart."

My next patient: A 61-year-old presents for a two-day history of pain and swelling in his left big toe that started two days ago after his daughter's wedding. I ask how much he drank? "You know, a couple beers. I was celebrating!" What was served? "A bit of everything, fish, steak, chicken." My diagnosis: "It looks like a gout flare to me" and explain that we will get some lab work and probably start him on high dose NSAIDs for the pain." Doctor Dunker agrees that this is his first gout flare and we ordered a uric acid level and started him on ibuprofen.

Our clinic holds a party to celebrate one of the doctors becoming a citizen. He went to medical school in his native Philippines and then did a U.S. residency. He explains, "There are two options for a foreign medical resident. You can go back to your home country for two years and reapply to work in the US, or you can work two years in an underserved area."

The area continues to be "underserved" for the afternoon because I have to leave to attend a required "Bystander Awareness and Responsibility" seminar. This is organized by our university's dean and head of the Office of Inclusion and Diversity and subtitled "A sexual and relationship violence prevention workshop for establishing a community of responsibility."


The first activity involves the lecturer and her two full-time coordinators asking students to shout out examples of inappropriate conduct. Each is placed on an axis of socially recognized "inappropriateness". Rape and murder are on the far right; "a bystander would recognize someone being raped is bad and act on seeing this." We learn that a man yelling at a significant other rates lower on the agreed-inappropriate scale than rape and murder. (Every example of inappropriate conduct featured a male perpetrator.)


Next is a PowerPoint on the Pyramid of Oppression. The small sliver at the top is labeled "core offender" and is supposed by "facilitators" and "apathetic bystanders". The foundation of the pyramid is labeled "sexism, transgenderism, strict gender roles". "By changing these stereotypes we can stop the cycle of violence," explains the dean. "The power dynamics in society camouflage and empower perpetrators."


She then asks the audience to read out loud in unison statistics from the powerpoint slide:

1 in 4 women will be a victim of assault

30 percent of college couples report at least one incidence of physical aggression.

90 percent of college couples report at least one incidence of psychosocial aggression.


(No sources for these statistics were provided on the slide or elsewhere in the presentation.)

The Dean of Inclusion and Diversity adds "The vast majority of women tell the truth about rape. Only two percent are considered false stories, but this is probably an overestimate because many of those 'false' statistics are because of recantation. We can speculate that many of those recanted accounts were withdrawn because of fear and embarrassment."

We then discussed several cases in groups of 8. "How does the power hierarchy impact the way you as a bystander would behave?"


Case 1: As a bystander, you walk by the surgeon lounge and notice a resident is making two medical students watch pornographic content on his phone.



Case 2: Several students are having a discussion in a hallway. A male patient comes out looking for ice chips. He asks for assistance from one of the students, referring to her as "honey" and slaps her backside before walking away.

Suggestions from the handout: "I never thought something like this would happen - it's 2019!... No one is reacting… maybe it's not that big a deal?... That student looks mortified… I'm uncomfortable with what just happened… does this have to do with gender?... This is a patient, though. Can we say anything?... What if we say something and the patient gets mad?... Should we just let this go?... If we do, will this patient continue to treat all of us and the other staff this way?... What should I do?"


Case 3: A student is asleep in a call room. Someone else (another student) goes into the room even though they know it is occupied. They don’t come out right away, and you aren't sure that anyone else has noticed.

On Facebook, Type-A Anita comments on Joe Biden's remarks about asking permission before hugging onstage at a campaign event: "If you think it’s appropriate to joke about making a woman uncomfortable by touching her without her permission, you’re not only out of touch, you’re also an asshole. Boy, bye." [reference to Beyonce's song "Sorry"]

Statistics for the week… Study: 6 hours. Sleep: 6 hours/night; Fun: 1 night. Example fun: Grilling with Lanky Luke and Sarcastic Samantha.

Year 3, Week 30 (family medicine, exam week)

The clinic staff throws a party for my last day. One of the secretaries brought in homemade rhubarb turnovers. I express my gratitude and they respond with "We take any excuse to throw a party!" I am sorry to bid farewell to Doctor Dunker.

Family Medicine students then go to a culinary medicine workshop at the YMCA. Our school gives us each of the five groups a Visa gift card to buy food for a hypothetical family of four, one of whom has a medical issue, e.g., a diabetic child or an adult with a heart condition. A recently graduated dietician leads the class. She teaches different ways to cut an onion, but is unable to answer our questions about the current popular diets (e.g., ketogenic versus intermittent fasting versus carnivore). After an hour cooking our respective meals (paella, lentil soup, and Korean chicken with rice, etc.), it was time to eat and rate. Our paella won!

Gentle Greg organized a musical variety night at a local bar for Tuesday. Several weeks ago, 15 classmates had agreed to perform, but only 5 showed up due to exam pressure. Greg had to sing every song (examples: Silver Lining by Mt. Joy, Going to California by Led Zeppelin, and Mama, You Been on My Mind by Bob Dylan).

Exams begin with two standardized patients. The first is a 65-year-old female active smoker presenting for cardiovascular risk assessment and blood pressure management. We had to indicate all the USPSTF grade A/B recommended screenings and appropriate medications to deal with elevated blood pressure.

The second standardized patient was a 78-year-old cheerful female presenting at the behest of her daughter who wrote a note expressing concern about her ability to drive: "She is forgetting where she parked." I perform most of a mini mental status exam (MMSE) by asking her to recall three words, name a few objects (a pencil, watch), and serial sevens. I mistakenly forgot to ask the standard "orientation" questions (person, place, and time). Afterwards in the debrief, I learn that the patient believed that it is 1961 and the president is Richard Nixon.

[Editor: Maybe she was cheerful because Nixon was an awesome president compared to Donald Trump!]

The main exam is a 100-question multiple-choice exam on Blackboard. There were several questions on differentiating gastroesophageal reflux disease (GERD) from peptic ulcer disease (PUD), and on the workup of PUD (proton-pump inhibitor trial versus Helicobacter pylori stool antigen test). Every time a question had statin as an answer, it was always correct. A challenging question: A patient on warfarin for atrial fibrillation recently started treatment for symptoms suggestive of GERD. What medication caused an elevated INR (delayed clotting) test? (answer: Prilosec). I missed a question on what antihypertensive medication is contraindicated in gout (answer: thiazides because it decreases urate excretion).

After the exam, we have a debrief with the clerkship director. Pinterest Penelope complained about the limited time on family medicine: "We learn about all the different stress-relieving practices like mindfulness in this rotation, but we don't have enough time to practice what you preach." Clerkship Director: "Yeah, you're going to be busy as a doctor, get used to it." Gigolo Giorgio complained about the different format of the exam: "I couldn't mark questions for review." Father Fred: "I thought we could've done without a day at the nursing home, and instead spend a day with Sports Medicine. I don't feel comfortable with a lot of fractures."

Statistics for the week… Study: 5 hours. Sleep: 8 hours/night; Fun: 1 night. For Gigolo Giorgio's birthday, he requests to go to the gay nightclub for a night of dancing after several margaritas at his downtown apartment.

Year 3, Week 31 (psych week 1)

Psychiatry clerkship begins with orientation in the clerkship director's large office. The pediatric psychiatrist makes us all sign that we have reviewed the safety HR training modules and then summarizes them: "When entering the unit, make sure no one is behind or near the door. And don't wear earrings or necklaces." [One of Jane's patients pulled a hoop earring off a nurse, tearing through her ear lobe.] He goes through the required clerkship competencies, including several lectures. He confides, "I feel bad about all the hurdles you have to go through. The more I complain, the more metrics they create. It's a losing battle, I just gave up."

After orientation, our team meets on the inpatient psychiatry unit: attending, two social workers, care team leader (CTL, head nurse), and one medical student (me!). We will take care of roughly 10 patients at a time. The attending, a 64-year-old former astrophysicist, who looks and sounds like Dr. Sean Maguire (Robin Williams) in Good Will Hunting, introduces himself then instructs the resident to lead rounds. My resident, a star second-year resident (PGY-2) wearing a stylish polo and sleek slacks, takes me aside: "Today, just watch how we round on patients. Tomorrow ,you'll lead the interviews for each patient." He continues: "The inpatient unit is the ICU of psychiatry. Our goal is not to cure them; it is crisis stabilization. If they tried to commit suicide, stabilize their mood and coordinate outpatient resources after hospitalization."

Rounds begin and are a whirlwind of new patient cases. He presents the first patient outside her dorm room: "32-year-old female with several psychosocial stressors overdosed on Xanax. She is engaging in group classes and denies SI [suicidal ideation]." The resident: "Sometimes the patient just needs to get out of the stressful environment. The average length of stay for a patient is six days. The rack rate is $18,000 per day, but most insurance reimburses about $2,000 per day. Insurance will ask what we did, and the answer is 'not much except continue her medications and encourage her to use the milieu [group classes, normalization from speaking to other patients]'."

The next patient is a 43-year-old schizophrenic with ID [intellectual disability] who came in an acute psychotic episode. Our resident: "Schizophrenia is a brain attack, just like an MI [myocardial infarction]. If we don’t prevent it, it will happen again, and the patient loses brain cells each time." He has been admitted three times within the past two months to our unit, and had several inpatient stays at state hospitals within the past few years. He lives in a "group home." Attending: "These are basically nursing homes for mentally unstable individuals. Most are run by national companies. They make a fortune." The patient presented with auditory hallucinations telling him the devil is inside him.

Our goal is for him to be given a long term injection of antipsychotics to prevent medication noncompliance. He is on a TDO (temporary detention order) and, because we have the alternative of giving him daily pills, he has the option of declining the injection. If he declines the injectable, we could try to get a judicial override, a tough argument when there is a conceivable way for him to take his PO meds. The resident says that he has seldom seen a judicial override applied for and never seen one granted, even for patients who are admitted every 2-3 weeks (paid for by Medicare/Medicaid).

We walk in and introduce ourselves. He is restless, withdrawn, and delivers literal responses with a flat affect. Can you tell us how you slept? "Yes." As the resident struggles to get substantive answers, Robin Williams interjects: "Okay, Johnny, we'll we will be outside if you want to talk to us." He then explains: "Don't let the patient take control of the interview. Watch, in a few hours he'll be wandering the halls searching for you." I ask about his restlessness. "That's a sign of someone who has been schizophrenic since a young age. It soothes him. Schizophrenia is a devastating disease. People with bipolar and depression can be highly accomplished individuals, but you never hear of accomplished schizophrenics. They don't exist, because the disease will devastate their intellect and motivation."

On Thursday we discharge the patient after he agreed to get the long term injectable shot. We learn the next day that the Medicaid cab driver kicked him out at a gas station two miles away from his group home. "Fortunately, he walked the remaining distance back to his group home, but we definitely have a protocol issue," said the resident. "The cab drivers need to know they have to drop these patients off at the specified destination, and if there is some sort of trouble, they should call the police." Attending: "There is also a presumption that if we are discharging the patient, he/she should be sufficiently medically stable to not get kicked out of a cab."


The next patient is a 45-year-old bipolar type 1 who stopped taking her meds because she felt good. Five days later she presented in a manic episode with SI. She has several psychosocial stressors: (1) custody litigation regarding an 8-year-old son, (2) the boy's father taking him across state lines without her permission, (3) a 25-year-old daughter living with a "strange man" in her garage, and (4) the daughter's theft of $100,000 from a neighbor's house. She is afraid that her daughter might go to prison and that she herself is being investigated "because I did not call the police for a few days after learning about the theft."

[Editor: If the patient's memory can be relied on, the fact that the 25-year-old stole $100,000 and remains free is a great argument for identifying as a white woman!]


Our next patient is a 24-year-old male presenting for SI with plan. He is either delusional or merely extremely high on marijuana. [Editor: We were informed by our political leaders in Massachusetts that marijuana is the best medicine for most conditions and, indeed, marijuana retail was considered "essential" and remained open while schools were shut for coronapanic.] He is obsessed with finding his real parents: Michael Jackson and Halle Berry. The rumor on the floor from the nurses is that his listed "father" in Epic is actually his older brother, and his Epic "mother" is the brother's male-to-female transgender girlfriend. Attending: "Do you think these wacko family arrangements are dependent on SES [socioeconomic status]? Or do you think lower SES just can't hide it as well? I tell you, humans are a sick, sick species." For the benefit of the nurses and patients, our patient performs a pre-discharge moonwalk and a cappella R&B song (self-written and composed). Resident, impressed by the show: "Hey, maybe he is the son of Michael Jackson."

Our next patient is a 19-year-old African American found lying in the middle of a congested road blocking traffic. "I thought if a car hits me, fine," she says. "If not, they'll bring me in so I can speak to a psychiatrist. I want to know if I can stop taking my medications so I can get pregnant." She has a history of bipolar disorder, but has not been able to afford her medications for several months. A case manager signs her up for Medicaid based on her lack of employment. During a phone call with her boyfriend, he informs her that she might have gonorrhea. We consult a hospitalist to deal with this.


Our next patient is a 38-year-old Caucasian polysubstance abuser. He could go home, but he has "several crack ladies" living in his house. He says that they refuse to leave and injected him against his will. I ask whether he could go to a church-run rescue mission. Our resident: "Yes, but people hate those places because you have to hand over all your money so you can't buy drugs. When they leave, they then  have to beg for money to get drugs. He needs to kick out the women from his crack den house."

We finish rounds in time for a new admission, a 34-year-old morbidly obese African American G3P2 bipolar at 35 weeks with uncontrolled type 2 diabetes. There are multiple fetal anomalies and a planned C-section at 36 weeks. Her prior two children were "adopted out" [Resident: "that's usually lingo for removal by CPS"]. She receives disability payments based on diagnoses of bipolar disorder and anxiety. Roughly three weeks ago, she was feeling so good that she decided to stop taking her anti-psychosis medications. This resulted in a two-week manic episode with no sleep. The crash came yesterday and she tried to kill herself with an overdose of Geodon. Every few hours, all night and day, she says that she is having labor contractions, which forces the nurse to cart her off to L&D. The folks there refuse to do the C-section any earlier than 36 weeks, so the result is a standoff between psych and L&D.

Friday is a rainy day. Our resident: "When it rains it pours. We expect a significant surge in admissions whenever there is bad weather." We skip rounds to admit the first patient, a 45-year-old African American cocaine addict presenting for suicidal ideation and hallucinations. He's on disability due to back pain. The resident and I go back after our initial H&P to chat with him in the afternoon. We talk about basketball for 45 minutes. Our patient won state championships in high school, but never played in college. "NBA players are sissies compared to back in the day. The rules don't allow you to touch the other guy. You cannot compare the old players to the current players scoring." As the completely coherent and wide-ranging conversation winds down, the resident says, "Come on man, you made this up didn't you? It's nothing personal, we know you know what to say to get admitted." Our patient: "Yeah."

(We learn that the patient is a regular at the community basketball gym where our resident also occasionally plays. The resident takes the patient's phone number. "I plan to play with him; neat guy.")

The last patient I see is a 38-year-old nurse with a history of alcoholism. She has had multiple intervals of sobriety, most recently for ten years. She relapsed last week due to stress from the car accident death of her 45-year-old husband. She tells us that she passed out in her car in the outside clinic parking lot and the next thing she remembers is being in the emergency room. The social worker later finds out that she actually clocked into work, but passed out in front of the physician before the first patient arrived. Her blood alcohol level was .35 (the legal limit for driving is 0.08; 0.40 will kill half of adults who don't have significant tolerance).

She recounts being beaten as a child by her alcoholic parents and being forced by them to consume alcohol at age 9. Robin Williams asks the social worker to see if we can help her to keep her job. He takes over the interview and asks whether she has completed the 4th (confession of sins to another) and 5th (making amends) steps in Alcoholics Anonymous (yes and yes).

Outside the room, Robin Williams explains, "Try to determine if a patient with alcoholism is motivated to change. If you believe that the patient was sober for ten years, you can work with them. They can benefit from the scarce resources we provide versus the typical patient who comes in for safe detox. Alcoholism is a chronic disease. Relapse is a part of the disease. We don’t call the type 2 diabetic a moral failure when his A1C jumps after a UTI or binging on pizza and ice cream. We now rely on AA tremendously for treatment of alcoholism. It's ironic because AA started as an alternative to a medical community that considered alcoholism a moral failing."

Statistics for the week… Study: 6 hours. Sleep: 9 hours/night; Fun: 2 nights. Example fun: Grilling at Lanky Luke and Sarcastic Samantha's house followed by a night of playing pool. Samantha quizzes us on an interesting case of possible ehrlichiosis (tick-borne illness) that she saw in the ED.

Year 3, Week 32

Week 2 of inpatient psych. The resident is late for the 8:30 am handoff, so I talk to the night resident. There were two "soft" admissions (people who could have gone home) overnight, which I relay to the team for 9:00 am rounds. Robin Williams is frustrated that the night team put several patients on one-to-one precautions (patient cannot have a roommate), and did not re-evaluate them throughout the shift.  "Guess they didn’t want to do any work."  

The 46-year-old white female with a history of MDD (major depressive disorder) and childhood abuse presents for suicidal ideation without plan. She described her abuse as a child: "Let's just say my mother would put me on the hood in the driveway, accelerate briefly and slam the brakes. And she was the nice one." She currently takes care of her husband, who is on dialysis for end-stage renal disease due to uncontrolled diabetes and hypertension. "My mother-in-law has been yelling at me all the time. She doesn't think any decision I make is right for her son. She's not the one taking care of him everyday. She comes into our house once a week, and smothers him with love, bakes cookies, and changes his sheets. So now my husband thinks I am inadequate." She concludes: "I would have been fine if I just talked to my therapist, but it was a Sunday."

After lifting a one-to-one precaution, we are able to admit a 40-year-old white female with MDD who arrived late last week in the ICU for an overdose of Xanax (one bottle). "It's hard to kill yourself by overdosing on benzos," says the attending, reviewing her chart and seeing a prescription for oxycodone for back pain. "But add a pinch of opioid, and boom, there goes your respiratory drive. She's lucky that she didn't take any of her oxy. We'll keep that little secret to ourselves. Not all patient education is good." He continues, "It's my understanding this was a completely spontaneous overdose attempt without any contemplation. These are the people who will end up killing themselves. Really hard for the family to intervene."

New this month is a hospitalist stationed on the inpatient psych unit tasked with medically optimizing patients. The psychiatrists see this as a revenue-maximizing gimmick. "We don't need a damn echo on this patient. Who cares about a new murmur when she just overdosed on Xanax? What's going to kill her?"

(Two days later, she had yet to get out of bed or interact with anyone. While the resident and I are interviewing her, the attending jumps in and shocks us by scolding her to get out of bed and attend group sessions if she wants to be released.)

Afterwards he explained to me: "The goal of our interaction is not for me to make the patient feel bad, make me virtuous and show the patient how much smarter I am compared to her. If I need to be the bad cop and let nurse Tammy be the good cop, then so be it... Even if satisfaction is how I'm now being graded on. I'll take a hit if it gets the patient out of bed and moving forward."

He continues: "Unfortunately, health systems are realizing that it is cheaper and more profitable to hire 12 ACPs [advanced care practitioner, e.g., physician assistant or nurse practitioner] who write expensive medications over shorter visits with only one supervising doctor instead of focusing on counseling."

Our psych practice has been profitable enough that we'll get a brand-new building 18 months from now, but in the intervening time all of the hallway door handles are going to be replaced to comply with a new regulation to prevent patients from choking themselves with sheets tied to handles. Robin Williams: "A $2 million renovation for a building that will be knocked down soon. But what am I supposed to do?"

After rounds, Robin Williams invites me to walk with him to the main hospital and join for a consult with the endocarditis service. "Endocarditis [infected heart valve] used to be a disease of the immunocompromised, but now is almost entirely IV heroin and meth users. Cardiothoracic surgery will replace an infected valve and just for a few months later the patient, who will have resumed recreational IV drug use with non-sterile equipment, will present with an infected replacement valve. In addition to the replacement valve, endocarditis treatment requires six weeks of IV antibiotics so we start them on Suboxone in the hospital and get them set up with MAT [medication assisted therapy] to see if this will decrease the rate of using again."

[Editor: this reflects the American best practice of treating people who are addicted to opioids by giving them an addictive opioid (Suboxone). Note that if this works out as planned, the health system gets to bill Medicaid for surgery, a six-week hospital stay, and a lifetime of Suboxone therapy.]

The first patient, a 31-year-old white male, is angry at the nursing staff because he signed the Suboxone documents without realizing that he was agreeing to his visitors being searched, a policy enacted after quite a few visitors brought drugs to patients during their six-week IV antibiotic stays. His girlfriend was caught last week injecting an unknown substance via his IV catheter.  Robin Williams talks to the patient about working together to get sober. The patient explains that he tried methadone and Suboxone and claims to be allergic to Suboxone. Robin Williams: "You tried methadone? How long?" He responds that he visited the clinic for a month. "Wow, that takes a lot of dedication. You should be proud of sticking with it for a month." He concludes: "Now I am willing to work with you. You say you are allergic to Suboxone, I will give you buprenorphine. You have to start a MAT program at [our institution]. People who are on buprenorphine get monitored a little closer, so one wrong step and you will be out of the program." The next endocarditis patient is a "VIP" (politician) so I am sent back to the inpatient psychiatry unit.

At noon, I attend the twice daily music and art therapy group sessions. The art therapist passes out paper and coloring instruments to all the participants. The schizophrenia patient walks into the room, and sits behind on the cafeteria tables. He somehow obtains a sharpened color pencil, which makes everyone nervous. The therapist then asks each participant to pull a slip of paper out of a hat. We then draw a picture based on the word written on the slip. My word was "crossroads."

After 30 minutes of art, we begin one hour of music. We go around the room each selecting a song to be played on a bluetooth speaker. The only rules: (1) no curse words, and (2) the therapist has the right to stop the song. A heroin addict starts with "It's Been Awhile" by Staind. The therapist has to stop the song after a minute when the polysubstance users start nodding their heads and one says, "Oh yeah, gotten high to this lots of times." A benzo and opioid addict plays a song by 5 Punch Death Metal. A 56-year-old alcoholic plays "Seen it in Color" by Jamey Johnson, which triggers a 34-year-old opioid addict who excuses himself with tears in his eyes. We then transition to group drumming. The music therapist passes around drums to each participant. Each member is allotted a 10-second solo to "bang out" his or her feelings.

At 3:00 pm, I attend the psychiatry lecture series. Out of the 52 weekly lectures, psych gets to pick one as an annual required talk for the internal medicine residents. Today's lecture on "Gender-Affirming Treatment Overview" has been picked as information that internal medicine doctors need to hear. The PGY-3 begins: "The first important takeaway from this talk is that gender dysphoria is not a disease. We are still fighting this misconception because DSM-3 [Diagnostic and Statistical Manual of Mental Disorders, 1980s edition] had this under 'delusional disorder'."

"Current literature supports the 'Minority Stress Theory' in which external prejudice leads to internal stress and depression," she continues. "This results in the high risk of depression and suicide seen in GD [gender dysphoria]." We then go through the UK's Coming Out guide online. There are minimal specifics about how to initiate hormonal replacement therapy, the contraindications, etc. Much of the time was focused on discussing how to label patients in Epic. The Chief Information Officer of our hospital is in the audience and jumps in: "This has been an ongoing struggle because there is no good solution. We don't want to change the sex designation because then it would change many screening algorithms [e.g., if female over 40, ask about mammograms] and create insurance issues. We have worked extensively to roll out a new Trans disclaimer." (It might have been better if his office had worked harder on security; our institution was recently the victim of a ransomware attack.)

We have a 3:30 pm admission for a 21-year-old transgender male (female to male) with a history of bipolar disorder and polysubstance use presenting for suicidal ideation. The patient has a deep bass voice and cystic facial acne. Psychosocial stressors include: (1) missed appointment to get testosterone shot last month; (2) broke up with girlfriend during preparations for a marriage proposal; and (3) inability to reconnect on Facebook with an ex-girlfriend with whom the patient feels an "incredibly deep connection". The patient shuts down after this description: "I do not want any help, I just want my testosterone shot." During rounds the next morning, the social worker notes that she did intake on him in the ED six months ago. "He was saying he was a transgender female. Look, it's in my note… and other notes from before. He's got to get his story straight!"

Robin Williams: "Everyone talks about evidence-based medicine, but there is no evidence gender-affirming treatments improve patient outcomes like suicide rate. All the studies use subjective outcomes. What I find is that they become fixated on HRT [hormonal replacement therapy] as the solution to all their problems."

Our last patient for the week is a 34-year-old contractor with opioid use disorder. He was kicked out of a Suboxone clinic for a dirty urine drug screen (positive for cocaine). He's been buying Suboxone on the street to prevent opioid withdrawal, but hasn't been able to find much. The social worker is trying to get him back into the Suboxone program, but it will take between 1-2 months for the next intake. The attending agrees to write a prescription bridge of Suboxone.

"Some of the highest level of opioid use is in the contractor community," explains the attending. "I was getting a remodel done on my house and it was impossible to have anyone reliable. They work for their pay check to buy pills. Then I found a Mexican family who would arrive an hour early and pile out of their van. They finished the job two weeks early."

This week I felt part of the team. I wrote notes on half the patients, including assessment and plan (e.g., medication changes, social worker communication, etc.) with minimal edits by the resident and signed by the attending, and I helped with determining if medical evaluation is necessary. I see several patients that need medical care. We prescribe penicillin for strep pharyngitis. I evaluate someone for LE pain with a raised leg test [rule out cauda-equina syndrome]. I recommend someone follow up with neuro for a parkinsonism tremor and bradykinesia.

Statistics for the week… Study: 5 hours. Sleep: 8 hours/night; Fun: 1 night. Buff Bri, Ambitious Al, Jane, Straight-Shooter Sally, and I go to a local Blues/Jazz club. We dance the night away.

Year 3, Week 33 (Psychiatry, Week 3)

After a 45-minute drive, I arrive at 8:30 am for paperwork at the local Veterans Administration (VA) hospital. Unfortunately, due to my short time here, I won't get access to their electronic medical record system. I am joined by a podiatry resident, an internal medicine resident, and a medical student from a different school. After 2.5 hours of picture-taking and forms, we have our ID cards and are ready to experience the largest healthcare system in the United States.

Tuesday was a typical day: Arrive at 8:20 am for the first patient at 8:30. He is a no-show and the psychiatrist says that the no-show rate is roughly 50 percent. We chat about various psych topics while he does calf and neck stretches. One topic is the difference between ego-syntonic and ego-dystonic. "Both terms have fallen out of favor," he said. "In DSM-3, homosexuality was considered ego-syntonic because it was a behavior that did not go against a person's ego. This is compared to the dystonic behavior of obsessive-compulsive disorder in which the patient knows these compulsions are interfering with his/her life." He explain the components of a mental status exam, including identifying common cognitive distortions, such as all-or-nothing thinking, emotional reasoning (equating transient feelings to reality), and overgeneralization (assuming one negative outcome results in inevitable failure of that goal)

I saw 2-4 patients per day, each for a 30-minute visit (workload would have been 4X at our home institution). When a patient arrives, I begin the interview and the psychiatrist interjects with clarifying questions and counseling regarding medication changes. I leave at 4:00 pm.

[Editor: As of 2019, a VA psychiatrist could get paid up to $320,000 per year. If we assume 3 patients per day for outpatient work, plus a full 40-hour week once/month on inpatient duty, that's 1000 hours per year (if we assume 30 minutes of paperwork after every 30-minute visit) and $320/hour plus pension and other benefits bringing total compensation to $500/hour?]

As in civilian psychiatry, the typical diagnoses are anxiety and depression. Most patients were in the military for only two or three years and were never deployed abroad nor served in combat.

I see a 45-year-old who worked at a Pentagon desk for 10 years as an intelligence officer. She presents for follow-up on generalized anxiety disorder. Although the majority of wealthy white women voted for Trump, she is not among them. When asked how she has been doing since her last visit, she responds with a discourse on Donald Trump's racism and sexism. How much of her day was spent thinking about politics? "A few months ago, it was 75 percent of my day. I'd say it is now only 25 percent." What coping mechanisms had she implemented? "I watch MSNBC only once per day." She then explains that another 20 percent of her worry is about the recent remodel of her house.  "We just got these custom-ordered massive glass pane windows. One of them is trapezoidal, and it has several streaks on them." She gets up on a ladder every day to scrub these and then calls the glass vendor.

[Editor: This proves my general rule that people who rent are a lot happier and have more mental space to think about interesting things than homeowners, constantly burdened with their amateur property management tasks.]

A 38-year-old medically discharged Air Force pilot presents for follow-up on generalized anxiety disorder with panic attacks well-controlled on Prozac and Ativan. He had flown the C-130 in Afghanistan and Iraq. There was an explosion due to mechanical malfunction that left him with damage to his arena postrema (vomit zone in the brain) and asthma from chemical inhalation. He described the weekly intense bouts of nausea that come out of the blue. "All my buddies are now pilots for the airlines, but I'm not allowed to because of my asthma." His biggest current stressor is finding a job that is meaningful and pays well. "Even with my disability payments and my wife's earnings as a secretary, money is tight with two small children."

A 27-year-old overweight white male describes his experience as a flight engineer in the Navy. He was bullied and did not fit in. His team was being investigated for a spy in their midst who was allegedly sabotaging equipment on behalf of China. "At first they thought it was me," he said. "You don't know what it's like to have everyone looking over your back. When I left, they still hadn't caught the spy. There was never any evidence that it was our team. I never had anxiety before this ordeal." He had been dishonorably discharged, but was now trying to get that changed to a medical discharge for major depressive disorder and generalized anxiety disorder. He described symptoms that could have come straight from the DSM-5. If we supply the requisite documents to change his status, he will get 100 percent tuition, housing, and books for his computer science studies. Ultimately, we tailor the note to say that his symptoms began during and as a result of his service, so he should be on track for a taxpayer-funded college degree.

[Editor: It seems that a dishonorable discharge is a bar to receiving most VA benefits, but a veteran can still be seen at a VA facility for "disabilities determined to be service connected."]

There are workshops for the five VA psychiatry residents at lunch, led by an attending. I told them I was still waiting to see psychosis or mania. The chief resident responds: "Oh you'll see that at the state mental hospital." A graduate of an Iranian medical school now doing her residency here interjects: "No, no, if you really want to see mania or psychosis, go to Iran. Only about 10 percent of patients in state hospitals are legitimately psychotic. In Iran, it is 100 percent. You only get into a hospital psych bed if you are truly psychotic." What about those who suffer from depression or anxiety? She laughed: "That's life. Deal with it." What was her psych rotation in Iran like?: "Everyone was telling me they are Jesus, Moses, or Muhammad. One asked me, 'Have you ever spoken with God?' When I said no, the patient responded, 'Well you are now.'"

The chief resident describes the challenge in choosing between a position at a state mental hospital versus at the VA. "The state mental hospital job is a two-year contract with the government contractor that staffs the state hospital. There are no guarantees at the end of the contract and the work is intense. The VA offers more money and stability for much less work, but I think that I have too much energy for the VA, I want to change things." He explained his plans to take the state hospital job and supplement that income with part-time work for a telemedicine psych company.

[Editor: An FAA employee told me, "I was unhappy in this job until I accepted that I was never going to accomplish or change anything."]

The VA has implemented a new program in which a psychiatrist goes to the VA's primary care clinic for consults with veterans who were flagged for mental illness by the primary care docs. This eliminates the waiting period from primary care to psych appointments. I see a 50-year-old former intelligence officer who is presenting for depression and anxiety. Her immediate concern is that the state is trying to euthanize her pit bull after the animal attacked a neighbor's child. The psychiatrist decides to set an appointment up for her to come see him before and after the upcoming court hearing.

[Editor: Our Florida neighborhood, for a radius of about 1 mile, is entirely pit bull-free due to homeowner association rules.]

We then walk to the inpatient psychiatry unit to cover for an attending who has to leave for a family emergency. We admit a 65-year-old who served in the infantry during Vietnam. His diagnosis is polysubstance abuse, primarily crack cocaine. He was recently paroled after 15 years in prison for drug-related offenses and has been working as a mechanic, but was tripped up with a positive test for cocaine on a routine drug screen. The parole officer gave him the option of voluntarily admitting himself to inpatient psychiatry instead of going back to jail. We screen him for depression. He describes feeling that he has nothing to live for. His wife divorced him, took all of the joint assets, and now receives the lion's share of his veteran's pension. He lost touch with his daughters while he was in prison and they don't want to reconnect. "I know I am going to kill myself if I keep using. Can you help me?"

On Friday afternoon, I say farewell to the VA and attend a required lecture on motivational interviewing ("MI") led by a child psychiatrist. Primary care physicians can now deal with addiction easily if they can remember "SBIRT": Screen, Brief Intervention, Referral to Treatment. We watch William Miller, a founder of MI, in video interviews with addicts. He gives us another acronym, OARS: open-ended questions, affirmation, reflexive statements, summary/synopsis. "There should be a 2:1 ratio of statements to questions. Once the patient begins talking, don’t interrupt him/her with a targeted question, but instead make an affirming or reflective statement."

After the prepared PowerPoint ends, we do live practice. He goes into role as Johnny, a 10th-grade pothead taking several AP classes and maintaining a 4.3 GPA. He adds, "Weed is the number one cause of outpatient referrals. From now on, I am not myself, so I don’t want anyone writing me up on evaluations for what could be said."

As a group we practice MI. What brought you in today, Johnny?" Johnny: "My father and I used to build cars and hang out. Now he is on my back about school and smoking pot. I used to not have any friends, but now I actually hang out with people. Smoking pot hasn’t impacted my grades, it's just my dad is butthurt. I'm a parent's wet dream!" We continue to practice responding with statements, and not questions. Bad: "Do you miss spending time with your dad?"; Good: "It must be challenging to balance spending time with your dad and with your new pot-head friends." The goal of motivational interviewing is to make the patient reflect on the benefits and costs of a bad behavior, e.g., smoking. Do they actually like smoking, or do they smoke because of some other stressor?

After the conclusion of the exercise, he becomes animated on the subject of marijuana. "I will come out and say that I support legalization," says the child and adolescent psychiatrist who just told us that marijuana leads to demand for adolescent mental health services. "I think the war on drugs has proven time and time again that locking up nonviolent pot smokers is not the answer, and overall is not effective in addiction treatment. The answer is education and awareness about the real harms of marijuana, especially THC and cannabinoids. There is quite convincing evidence that adolescent pot smoking can lead to harmful impact on depression, anxiety and development of psychosis."

[Editor: … but a beneficial impact on the incomes of psychiatrists….]

Statistics for the week… Study: 5 hours. Sleep: 8 hours/night; Fun: 1 night. Stopped by Gentle Greg's house for his birthday party. Several physical therapist (PT) students attend.

Year 3, Week 34 (State Mental Asylum)

After a beautiful one-hour drive into the countryside, an imposing six-story concrete building rises from the hillside. Locals comment about the Soviet-era architecture. The campus also includes several smaller dormitories near the main building. It started out as a sanitorium for tuberculosis patients in the early 20th century.

The enthusiastic coordinator sets me up with a badge, parking permit, and color-coded set of keys in the first 10 minutes, a huge contrast with the VA where time stands still in the face of bureaucratic requirements. She explains how to open doors in the hospital. "Before you can go through the second door, you have to ensure the first door is fully closed behind you. Some of the doors you have to jiggle to open. We recently had an elopement so everyone is on alert about the doors." (In the mental health world, to elope is simply to run away and does not imply a marriage.)

She shows me the cafeteria, open for staff meals at unusual times, e.g., 9:15-10:15 for lunch and 4-5 pm for dinner. She gives me a tour of the facilities, including the small dormitories for staff and visiting students and drops me off at a lecture on personality disorders by the medical director. I meet the three other medical students. All of them are staying in the dorms and admit to being creeped out by trying to sleep through the on-campus screams. They have no cell service and only intermittent WiFi.

The hospital has six floors: Two for adult males, two for adult females, and two for geriatric patients. I meet Pranav, a short attending from India loved by all the staff for his patience, on the long-term geriatric resident floor. Opening the door from the stairwell reveals several patients waiting by the exit. I squeeze through and quickly shut the door as patients lunge for the open exit. After it's closed the patients go back to their normal routine of walking the halls and pulling on any locked doors. The nursing station is a locked room with a customer service window through which patients can receive medications.

Pranav shows me the paper charting system, a sharp contrast with the VA, which was an early adopter of computerized medical records. Binders of color-coded papers are placed on a turntable in the middle of the nursing station. Each patient corresponds to at least one binder, which may have up to 600 pages. When a new order, e.g., medication change, occurs, you pull a 3-inch by 6-inch tab out from the binder so the nurses see that there is a "To-Do" item for that binder. Orders end up being performed faster than at my home institution, despite its $100+ million Epic system, due to face-to-face communication between doctors and nurses. The attending sits at the nursing station instead of retreating to a computer room or office.

Pranav instructs me to review the charts of the two new admissions.  "We'll see them for the first time together in the afternoon. "Go get lunch and let's meet back up for the 1:00 pm staff meeting." I struggle to navigate the various parts of the paper chart, so I ask a nurse. "Purple is prior admission records, Blue is transfer documents, Red is admission H&P and progress notes. You'll get used to it, honey!" She adds: "The red binders are [Pranav's], the Blue binders are the other attendings'." I scan the binders for patients on our service. During a manic episode, one patient murdered her husband, and then set herself on fire to burn out the Devil that she believes is inside her. Three patients are here after being found not guilty by reason of insanity ("NGRI"). Most of the geriatric floor patients are here because of dementia that progressed to include delusions, hallucinations, and acts of verbal or physical abuse to caretakers.

I join Calvin, a third-year medical student studying at a Caribbean medical school planning to do psychiatry (one of the easier-to-get-into residencies), for lunch. Spaghetti and meatballs with a bowl of apple crumble is $2.15 (cash only). Calvin's family is two hours away, so he typically returns home for the weekend. He describes his first night sleeping in the dormitory. "The WiFi doesn't work in my room, so I went to the common area and heard two people having sex in the security office. I learned the next day that it was the security guard and a new nursing assistant who was finishing orientation week. Someone apparently reported them... it wasn't me. This was the guard's last week so she did not face any consequences, but he apparently was fired."

A PGY-4 (senior) resident doing an elective here joins us. He describes the hot job market for psychiatrist graduates. "I just signed a $300,000 salary with a $100,000 signing bonus for an outpatient practice in the Bay Area."

[Editor (2019):: With $300,000/year, he'll have a one-bedroom apartment, a Nissan Leaf, and enough left over to splurge on Blue Bottle coffee once a week. Editor (2022): Good news is $300,000 per year; bad news is that's also the price of a Diet Coke.]]

Over the loudspeaker, we hear that a Code White has been called. Several staff get up and hurry to the exit. Calvin: "Come on, let's go." On the female adult floor, two overweight African American patients admitted for bipolar disorder got into a fight. They're both roughly 30 years old and Patient A has accused Patient B of using her perfume. Patient B allegedly threw the perfume bottle on the floor and says that she has a piece of glass and threatens to stab the other patient. It turned out that the perfume was in a plastic bottle, and the "glass" was merely a plastic cap. Everyone disperses as the attending, a funny overweight 45-year-old white psychiatrist, diffuses the situation. Afterwards she explains to me, "Neither patient should be here. [Patient A] claims that she is bipolar and that she stopped taking her medications to the EM physician, who then calls the state psych admission service. Lamictal [mood stabilizer] does not stop in five days. She gets violent when she does cocaine."

Caribbean Calvin and I head upstairs to the geriatrics staff meeting with three social workers, the head nurses, and both geriatric attendings. We discuss each of the new admissions, and concerns regarding prior admissions. The meeting focuses on a 56-year-old with rapidly progressive dementia over the course of six months. The chart states that his wife started to notice he would become confused about daily activities, then started to have behavioral outbursts. Last month, he became disinhibited, yelling at people for nothing and groping strangers in public. He was admitted to a rural hospital and then transferred to here for further evaluation. He is not oriented to where he is and he has lost the ability to communicate to others except for random unintelligible outbursts. The nurses are having a crisis because he goes into other resident's rooms, grabs their clothes, and puts them on himself. "He goes into Ms. [Georgia]'s room, a frail 90-year-old, rips her sheets off her bed while she is lying on them, twists them around himself, then grabs her panties and shirts, and puts them on. He's almost choking how tight they are on him. And then walks down the hallway. Clothes fall off him. It's a danger to other residents because they can trip on them. Last week, Ms. [Hansen], tripped on some of this clothing and broke her hip. And he's strong. What are we going to do about him?" Pranav: "I've never seen anything like this. We're taking a broad differential with him. He has some language skills and memory. He is reciting several verses from the Bible out of memory at the nursing station every morning. We're waiting on tests, but this could be frontotemporal dementia or prion disease. Let's see how he does on lithium, which should kick in during this week."

Tuesday morning begins with a physician-turned-ethics-consultant teaching grand rounds on transgender cases. He went through several landmark court cases, and asks for audience participation on what should be done to resolve the issues.

The Case of Ms. V:. A transgender female wants to go to a residential group home for survivors of rape. The home has been reserved for women who were raped by men. Ms. V was accepted to the home under the condition that she inform the other residents that she was endowed with a penis. Litigation ensued. Should the group home have accepted her unconditionally?

He asks the audience (of about 60, including social workers, nurses, and psychologists) for a show of hands: "Who thinks we should accept Ms. V to the home with no conditions?" Hands go up from most of the audience. Who thinks she should not be accepted? No one has the temerity to raise a hand. Pranav asks some of us sitting nearby, 'Shouldn't we consider the rights of the other residents? Will they be traumatized when they see a penis in the shower or hallway?" The larger audience hears this question and competes for who can offer the most vehement "No." Example: "We would not deny placement for Muslim women if all the residents had PTSD from 9/11."

Case 2:  A Transgender male with bipolar disorder and borderline personality disorder requests gender-affirming surgery.  On review of charts, he has a history of factitious disorder (the desire to play the role of a patient, not necessarily with any intention of financial gain). Although there is nothing wrong with his hearing or vision, he has previously presented to the emergency room with deafness and blindness. Should he be allowed to undergo this surgery? "I used to treat these individuals. You never start gender-affirming therapy until the patient is stable." Pranav interjets: "That used to be standard of care. We all know that this is not true in some cities now. You can go in and be scheduled for surgery in two days."

[Editor: Pranav sounds like a potential hater. He might want to read "Factitious sexual harassment," by Sara Feldman-Schorrig, MD, 1996 ("prompted by the lure of victim status"), and "The Psychodynamics of Factitious Sexual Harassment Claims," (Bales and Spar, 2016, Journal of Psychiatry, Psychology and Law), "Factitious sexual harassment claims are those in which the plaintiff's wish for victim designation is a major driving force behind the claim."]

Case 3: GG vs. Gloucester County School Board. "G.G. is a transgender male student that requested use of the boys' bathroom. The Gloucester, Virginia high school originally agreed, but student and parent complaints led to a reversal of this decision and creation of a gender neutral bathroom. The court ruled that the school had violated Title IX," said the ethics consultant. "Keep in mind that Title IX was written in the 1970s before any notion of gender identity existed." The student graduated in 2017, but the litigation lives on (at least through 2019) and now the girl-turned-boy is hoping for monetary damages. If our group of 60 were the jury, Gavin Grimm would prevail. Everyone agreed that being restricted to a special bathroom was discrimination.

[Editor: Gavin won at the appeals court level in 2020 and the Supreme Court refused to hear the school board's petition in June 2021. The school board paid $1.3 million and Gavin got $1. The rest was pocketed by his/her/zir/their lawyers, mostly the ACLU.]

After grand rounds, the ethics consultant shifts gears to consider the rapidly progressing dementia patient. Several ideas have been floated, including moving clothes from resident rooms to a communal closet. The ethics consultant predicted that this would be a difficult case to make to a court. "It is well established that having access to your own clothes is a basic human right. I just don't see how we can violate everyone's basic human right because of one offender." The lead nurse: "They would still have access to their clothes, just they would ask a nurse to go to the closet." The two-hour meeting results in no solution to the clothes-covered floors and the nurses having to spend much of their time picking up so as to avoid more broken hips. "I have nurses saying they are going to quit because of this patient," says the head nurse. "We are already short staffed." They decide to try to rotate nurses to different floors one day per week and revisit the case next week.

We admit a frail 85-year-old with dementia for psychosis. She refuses to speak or look at me or Pranav for several hours as she stares at staff through the customer window. Pranav asks, "I know you can talk. Tell us what you feel?" No response. "Are you scared?" After a 5-minute staring contest, she finally responds, "Oh, I know what you are doing. You don't fool me, silly man."

Two patients stand outside the nursing station most of the day reading the Bible. One patient believes she is here because the FBI stole her money (she actually was robbed of nearly $1 million, but by identity thieves whose connection to the FBI was never established). A patient with antisocial personality disorder (a sociopath) stabbed two people to death including his cousin and believes that the FBI owes him two million dollars for him "sending in secret codes every week that they used to do their job."

A 58-year-old male is transferred from the county jail because he refused to take his medications. The female head nurse says,"There is no reason this patient needs to be here. Tell the police officer to watch how the 'real men' [her all-female nursing staff] do it." After the "real men" (nurses) solve the medication problem, I interview the patient alone. He is difficult to keep on topic as he tries to relate every detail in his life. He was living behind an abandoned church. New owners of the property called the police who informed him he had to vacate. When he refused, he was arrested for trespassing. At the jail, he refused to take the medications on his chart, which he had not taken for years. "Since I was a young boy, I never liked sleeping under a roof. I always liked sleeping on the porch. My parents would be so confused, but I knew what I liked. Four walls makes me restless." He continued to describe how he is applying for a patent for the Uber of grocery cart transportation. "People say Uber started the gig economy, but trust me, I thought of it first." He knows all the medications he is supposed to take, including blood pressure medications, cholesterol and anticoagulation for atrial fibrillation. "I don't like the entire concept of pills. No, I'm not taking them. I know why they tell me I need them, but no." I report back to Pranav, "I think he has schizotypal personality disorder. He is not psychotic, and doesn't even really have delusions. He just has magical thinking!"

On Friday morning, I attend a temporary detention order (TDO) hearing in a conference room. The patient sits at the table with a public defender, an administrative coordinator, a representative from the community service board, and finally the judge. Witnesses and observers such as myself are in chairs along the walls. The first case deals with continuing medications for a patient who does not have capacity. Judge: "Ms. [J], do you have anything to say about your care?" The patient responds that she trusts completely in Pranav, there are no objections from the public defender, and the order is continued. The next patient, a 24-year-old African American with bipolar disorder, is accused of raping two preteen girls. He plans to plead not guilty by reason of insanity. I overhear the public defender discussing the case with the patient before the hearing. "You have two options: you can either be willingly admitted to the hospital, or undergo a TDO. I strongly recommend you willingly accept admission." During the hearing he stares at the ground.

Statistics for the week… Study: 6 hours. Sleep: 6 hours/night; Fun: 1 night. Burgers and beers with Sarcastic Samantha, Lanky Luke, and Mischievous Mary. Mary was excited that she was just accepted for two away rotations, one month each, in cardiothoracic surgery at prestigious institutions. She is hoping to do a 5-year direct cardiothoracic (CT) surgery residency instead of going through 5 years of general surgery followed by a 2-year CT fellowship.

Year 3, Week 35 (Consult Service)

Consultation and Liaison (C&L) service. I meet the team at 7:45 am in the C&L workroom, a windowless room that crams 3 computers and a loveseat. The 35-year-old attending who completed an Internal Medicine and Psychiatry dual residency runs the list with the 40-year-old PGY3 resident who was a psychiatrist in India and myself. We then go down to the ED to begin seeing the new consultations for the day where we are joined by the ED psych social worker.

I interview the first patient, a 40-year-old obese Black female with major depressive disorder presenting for suicidal thoughts. She has been working with the homeless assistance team (HAT) to get set up in housing. She has rejected two different apartments. When the social worker informs her that she needs to work with HAT, she responds: "I want an apartment that I want. It cannot be across town." She adds, "Also when I get admitted, I want a good doctor, not just any doctor."

The next patient is a 28-year-old obese female with bipolar disorder presenting for suicidal ideation. She is also a regular. When our team goes into her alcove, she is busy eating french toast. We barely understand her one word responses. She proceeds to get up from her bed, and beds over to reach her purse on the floor. "What other specialty would you get to see that?" asks the attending. "She doesn’t stop stuffing her mouth with french toast, and then moons us slowly."

We then proceed to see consults in the hospital who have been admitted to other services. I am assigned two to see alone while the attending is busy performing transcranial magnetic stimulation therapy.

The first patient is a 65-year-old grandmother with rheumatoid arthritis who overdosed on her opioids and benzodiazepines. "I regret that it did not work," she says. "I wouldn't have done it if I knew it would not work. I'd have tried something different." What are your stressors? "Well son, take a seat. My daughter is a heroin addict who brings strangers to our house to shoot up. I have custody of her and our grandson. I live in chronic pain.  CPS have already been contacted by the primary team. We recommend inpatient psychiatry after medical clearance. The primary team is surprised that she is still alive. She had a five-day ICU stay.

My next patient is a 65-year-old with Lewy body dementia admitted for a GI bleed. We were consulted due to concern for MDD. His wife has cancer and cannot have sex. "I want to express my love for her while I am still here. I know I don't have much time left." We explain to him that an SSRI might help improve his depression, but may cause sexual dysfunction and decreased libido. "That's good, give me that!"

I attend psychiatry grand rounds regarding a controversial topic: Combat Addiction, a recently proposed new syndrome within the umbrella of PTSD. The former Stanford clinical psychologist presenting describes Combat Addition as an addicted phenotype in which afflicted individuals seek to recreate the adrenaline rush. "This is not a new phenomenon, but just one that is increasingly common. The soldiers in Vietnam and World War II had limited combat exposure, and the ones that did had few recurrences. The Middle East wars are different. They are the perfect storm for addiction: high intensity, repeated exposures."

[Editor: From the above we can learn that people at Stanford were well-insulated from anything that went on in Vietnam and World War II. There were, for example, 11,846 helicopters shot down or crashed during the Vietnam War compared to roughly 400 in Iraq and Afghanistan together. Approximately 340,000 American troops died in World War II and Vietnam, compared to fewer than 5,500 in Iraq and Afghanistan.]

Our speaker goes around the country recording combat veterans' stories. He retells one soldier's comment: "The first fire fight is an unreal experience, better than sex. You want it again." These experiences are defined by a loss of context, revenge, betrayal (by country and politics). They undergo an intense bonding with their brothers, then return home to what they see as a meaningless life." In an effort to recreate the environment, he reports, "One soldier told me that he got a concealed carry permit and was 'waiting for someone to shoot at me to make me live it again.'"  He cites dangerous speeding on motorcycles to recreate the adrenaline rush of combat.

Our hospital had set up an audio-video link to the VA and several of their psychiatrists call in with questions. "Thank you for highlighting this. Your definition so accurately portrays many of the combat veterans that I see. Are there any diagnostic criteria or evidence-based interventions?" He responds, "The VA forbids any research into this syndrome. We haven't even characterized the progression of the disease so we have no trials investigating treatments. Some of the patients I have followed for several years seem to age out of the longing to simulate combat, but they seem to still struggle with disillusionment." He continues, "The one item I see that helps is community with comparable peers. It is challenging for providers to engage them because they look down on those claiming PTSD symptoms, believing that patients are motivated by the prospect of disability benefits." He ended by citing several ongoing clinical trials with psilocybin and other psychedelics that may be beneficial, although "I cannot imagine some of my older veterans doing this."

Statistics for the week… Study: 4 hours. Sleep: 7 hours/night; Fun: 2 nights. Example fun: Four of our classmates brought their respective dogs for a playdate at the local park. Only one ran away.

Year 3, Week 36 (Group Therapy)

Last week on psychiatry. I am paired with an outpatient psychiatrist who specializes in addiction medicine. He splits his time with group therapy sessions and individual appointments for general psychiatry patients.

Monday morning begins at 8:00 am. The psychiatrist explains the suboxone program enrollment agreement. A psychiatrist accepts the patient into the program at an initial consultation, also called "intake." The patient then attends weekly group sessions for 6 months in addition to two individual appointments per month. Once stabilized, the patient attends a monthly one-hour group session and quarterly individual appointments. At each appointment, the patient takes a drug screen. "Most of my patients do multiple types of drugs, so although we call this opioid addiction therapy, each patient is unique in their social situation and drug addictions," the attending notes.

Our first group session begins at 9:00 am. Of ten patients, two patients are brand new to the meeting, having just enrolled for addiction treatment. Most have been with us for 6 months to 2 years. Two are "oldtimers", having been in this group for over 5 years. One female oldtimer is actually off suboxone completely.

The meeting starts off with short introductions. Our oldtimer: "You all know me. I'm a recovering addict of alcohol, heroin, pills, and cocaine. I've been sober now for 10 years." The psychiatrist asks how her daughter is doing. "Well most of you know I got custody back of my daughter from my ex husband. She's starting middle school!"

[Editor: Why should a plaintiff's consumption of alcohol, heroin, pills, and cocaine interfere with an ultimate family court victory?"]

One of the two new members, a 22-year-old unemployed male addicted to pills, introduces himself. "Hello, I'm [Brad]." The psychiatrist asks him to share some hobbies or interests. "Well, I recently lost my job as a construction project manager. I play video games." The oldtimer mother asks. "Great to meet you, Brad. Do you have a girlfriend? " He responds, "No, my girlfriend overdosed last year."

The psychiatrist goes around the room. He calls out one who tested positive for cocaine. "[Johnny], if this happens again I will have to kick you out of the program. This group is based on trust." (He later tells me some psychiatrists have a zero tolerance policy, but he prefers to tailor it to each circumstance. Johnny had recently been sued for divorce by his wife.)

After the group session, he writes notes until the afternoon appointments, which start at noon. We see depressed and anxious patients and have new consults for addiction and bipolar disorder. I begin the interview of a new consult. The 30-year-old male electrician presents for methamphetamine addiction. He was arrested for possession, but our city has a program that enables those accused of drug crimes to avoid jail if they seek addiction help.

I ask about his employment. The patient makes $4,000 per week constructing power lines, "when I work." The psychiatrist chimes in. "How many weeks a month do you work?" He responds, "Maybe one. Whenever I need money I find a job." The attending acknowledges this, "You can be quite functional after a weekend cocaine binge, but coming down from meth, you'll be out for a week." He responds, "Yeah, cocaine didn't do it for me after I found meth."

"How badly do you want to be clean?" asks my attending. "How much are you willing to give up?" He responds, "I'll do anything, Doc." The psychiatrist states "Okay, I will set you up at the rescue mission. Take only a backpack. You will be gone for 6 months." The patient looks distressed. "I need to think about it." The psychiatrist acknowledges. "Okay, you let me know when you have decided."

Once the patient leaves, the psychiatrist turns to me. "The patient is here only because he has to be. He has no interest in quitting." He continues, "Meth is a destroyer. To get over meth, you have to hit rock bottom. The only times I see a patient conquer a meth addiction are via incarceration or if they drop everything in their life, leave all their friends and family, and move away for several months." He asks me, "How do meth addicts die?" I cite heart attacks and strokes, recalling my internal medicine rotation where massive heart attacks and intracranial hemorrhages were common among the meth-addicted.

My attending adds, "I see a lot of female meth users. Meth, intensifies sex. It makes women do things they would never imagine. The acts they tell me they did is scandalous. Their boyfriend keeps getting it for them for more intense sex. Eventually, the woman cannot have sex without meth. I see so many pregnant meth addicts." He concludes, "Once you treat meth addicts, alcohol and opioid addiction seem like nothing."

Our next patient is a 40-year-old morbidly obese female nurse with major depressive disorder and anxiety well controlled on a serotonin and norepinephrine reuptake inhibitor (SNRI). She reports proudly that she finally got around to divorcing her husband. "He is addicted to pornography. He doesn't acknowledge me. We haven't had sex in eight months." My attending congratulates her.

Another attending stops by the office to chat. He complains that the community service board (CSB, the regional safety net mental health organization) keeps prescribing the newest antipsychotics as a first-line agent. "I don't understand why they jump to these new medications, which are so expensive." My attending responds, "Medicaid pays for it. I completely agree, the older ones are cheaper and just as effective."

[Editor: See the book Bad Pharma by Ben Goldacre, a British physician, regarding the typically marginal improvements (at best) of new expensive meds compared to old generic meds.]

Wednesday's group session features a new patient, a 24-year-old male with schizophrenia and opioid use disorder. His psychiatrist managing schizophrenia started him on risperidone. "Google says I am going to grow tits. I'm not going to take it." Another member exclaims, "Oh my God, don't take that." My attending responds, "[Jimmy], this is not the time to discuss this. Remember why you take this medication. I want you to talk with me afterwards and call your psychiatrist." He agrees. After the session, a 35-year-old female asks if she can get an additional film of buprenorphine. She explained, "One of my friends overdosed on heroin. I ground up suboxone and injected it. I saved her! But now I don't have enough to get through this week."

We take the psychiatry exam. Example question: Which of the following patients should be admitted to an inpatient psychiatric bed? Answer: a patient expressing suicidal ideation with a clear plan rather than vague expressions of hopelessness and no plan. We then have a debrief session with the clerkship director who asks, "What surprised you on this rotation?" Sarcastic Sally, "The inpatient pediatric psychiatry wards were eye opening. There are so many troubled kids. Without protective factors, such as having a safe home without addicted parents, we could've been them."

Statistics for the week… Study: 2 hours. Sleep: 8 hours/night; Fun: 3 nights (gatherings at various bars with various classmates and their dogs).

Year 3, Week 37 (VA and neurology consults)

Neurology rotation. Three days at the VA and then three days at our home institution.

Groundhog Day: I meet the VA coordinator at 9:00 am to get my badge and a campus tour (it happened last month, but I have to do it again). I am joined by four trainees from other institutions: a third-year medical student starting her one-month psychiatry rotation and three podiatry residents doing three months of training on the "indigent" VA population. "There is an endless supply of feet to amputate. We meet our case log requirements from this month." A new-hire struggles with the badge machine, but two hours later we all have badges and start our tour of the VA campus. I am dropped off at the neurology clinic at 12:00 pm. My physician turns out to be a rotund neuro-ophthalmologist. In the Department of Physician Heal-Thyself, he's  recently returned to work after a quadruple bypass. The mid-day patients are no-shows so he sends me to lunch. We meet again at 2:00 pm to see four scheduled patients, two of whom show up (see Year 3, Week 33) and clock out at 3:30 pm.

A typical day starts at 9:00 am after a 45-minute commute. The attending prints out his most recent office note for each follow-up patient because students do not have access to the VA's electronic medical record (EMR). Each new patient starts with me in a vacant office, then goes back to the waiting room, and eventually we go together to the attending's office. Despite the 50-percent no-show rate, he's usually running behind due to his struggles with the EMR. Each 30-minute or 45-minute visit with a patient is followed by 30 minutes of single-finger typing. Has he tried to dictate? "It's just as bad. I spend more time correcting the damn machine than it takes me to type." He has near-perfect recall of previous visits with patients, surprises patients by remembering details they offered months earlier, and would have thrived in a pre-EMR era.

[Editor: The good news for this guy is that he will be able to learn a whole new interface for the 2020s once the VA finishes with its $10 billion transition to commercial software.]

We see patients with multiple sclerosis (MS), Parkinson's disease, pseudotumor cerebri (condition mostly occuring in obese females resulting in vision loss), and rare vision disorders, e.g., Charles Bonnet syndrome, which results in progressive blindness combined with intense visual hallucinations. If he thinks it will help a patient with a terminal neurological disorder, the attending will spend over an hour counseling on the prognosis and what everyday life will look like. The nurses grumble that he "destroys the schedule without warning". He lets them go as soon as the last patient has checked in and will see his final patients without any support.

My attending misses the 1980s: "We don’t talk to each other anymore. We search blindly in the endless expanse of notes. The primary doctor orders a consult and wipes his or her hand. Then the specialist wipes his or her hand when the note is filed. No one calls." He spends 10 minutes finding an example of a recent patient for me: a 68-year-old male had a stroke during a five-day hospitalization for pneumonia. After the stroke, he developed Parkinson-like tremors. "There are 240 pages of notes. Look at this! They have to put in where the meds were manufactured! Is that necessary?"

In the afternoon we walk 10 minutes to the inpatient wing to see consults. "All these damn hospitalists are useless," my attending grumbles. "They consult for anything. A patient feels weak because they've been in the hospital for a week for heart failure. No shit they are weak. This is not a stroke. Did they go to medical school?"

Thursday starts at 8:30 am. Each week the three medical students on neurology clerkship meet in the office of our clerkship director, a quirky tall gentleman in his early sixties. We get a group text each night with cases to review and present and offer diagnoses in the morning. Today's case is on Guillain-Barré syndrome, an ascending paralysis from an auto-immune response, typically after a viral illness. "The main concern is respiratory failure. That's what they die of. If you can get them through it, they will typically have a complete recovery. When I was a medical student, we were in charge of getting daily PFTs [pulmonary function tests], but we no longer require this because the RT [respiratory therapist] can bill for the test each day."

(A student in another class at our school developed Guillain-Barré syndrome during a medical charity trip to Central America, tipped off by a GI bug. She had to be transferred from the ventilator in the overseas hospital to spend three weeks in our own ICU. She graduated, but suffers from a permanent loss of dexterity.)

Around 9:00 am, the neurology resident texts me the three patients to follow today. I chart review the patients, then go see them in person before meeting the attending in the administrative section of the hospital to run the list. The physicians lounge is typically off-limits to students and residents, but no one is going to question Queen Maleficent, a 75-year-old attending infamous for rolling around a loud purple suitcase stuffed with diagnostic gadgets and, unlike my VA attending, has adapted to the computer era. "I've taken out a lot of the tools because of this new neuro App," Queen M points to her iPhone. "It has all the color vision tests that I used to carry."

Our primary role this week, which seems to be typical, is to relieve the hospitalists of liability for not checking every possible box. Out of 10 consults per day, an average of 2 will have neurological symptoms or deficits. We also coordinate with the psychiatry service for odd neuropsychiatric symptoms. One interesting case was a 55-year-old smoker presenting for worsening shortness of breath. A PFT done by his primary care clinic showed an unusual inspiratory effort, but nothing critical. A few weeks later, his wife called 911 saying that he couldn't breathe. He demonstrated normal inspiratory effort in the hospital, so pulmonology has booted him to the neurology service. We cannot identify any neurological disorder so we consult psychiatry. Queen M: "Psychiatry might enjoy talking with the wife. My hypothesis: he is trying to compete with her fibromyalgia and chronic opioid use."

Queen M asks me to do a brain death exam on an 80-year-old ICU brain bleed patient who has been on the ventilator for four days. "Text me when you are done, and I'll confirm what you find." I look on UpToDate for a refresher. Five family members (wife, two children, one daughter-in-law, one grandchild) are in the room and their refusal to withdraw care has prompted this exam. I ask them to excuse themselves while I cover the glass wall with curtains and perform the exam. I first test for reflexes, and response to pain (none). I then perform the primitive brain reflexes e.g., gag, corneal, oculocephalic (doll test, rotate head to see if gaze does not adjust to rotation), caloric nystagmus (squirt cold water into one ear and watch for nystagmus). The nurse and her nursing student join to watch. When Queen M arrives, she repeats the exam, then orders an apnea test (must be performed by two physicians independently). We preoxygenate the patient with 100 percent oxygen, then hold the ventilator as the respiratory therapist draws blood gases every few minutes. A positive apnea test is failure to initiate a breath once the CO2 level reaches a certain threshold (typically 60 mmHg). We put in our note for the primary team: brain dead.

We are paged for a 35-year-old male whom I previously met on surgery rotation for a problem with his gastrostomy tube. He is chronically disabled and epilectic after a car accident three years ago. His wife left him, taking the two-year-old and 6-month-old children. His mother now devotes her entire life to his care. We walk in and he is less responsive than usual. The mother explains: "Something has been off every since yesterday afternoon." Queen M orders the nurse to administer Keppra and Ativan. The nurse asks "Have you put the order in? [into Epic]" Queen M responds quietly: "If you don't do it, I will. Open the code cart if you can't get it from the Pyxis." (Pyxis is an automated pharmacy cabinet that dispenses common medications with a fingerprint and badge swipe.)

The last consult is a 28-year-old postpartum female in the labor and delivery ward. Five weeks after delivery, she was leaving backing out of the driveway with her newborn in the back seat. The husband rushed out when he heard the car hit a utility pole and saw her seizing for a few seconds, then go limp. We have to decide if this is postpartum eclampsia (90 percent of postpartum eclampsia occurs within the first week of delivery), new onset epilepsy, or an isolated seizure. She has no history of seizures and no family history of seizures. Her eclampsia labs and first 4 hours of EEG are both normal. We are skeptical this is postpartum eclampsia so the discussion turns to anti-seizure medication. "Once you are on seizure medications," says Queen M, "very few doctors have the courage to take you off." Having learned nothing definitive, we decide to do an overnight stress EEG, and re-evaluate. Considerations include balancing anti-seizure medication safety during breastfeeding against the risk of a seizure while driving or holding the baby. "I am willing to do a monitored outpatient experience where we follow you every two weeks," says Queen M. "You cannot drive during this period." We tell her that the average patient has a 24 percent risk of a seizure recurring. The mother weeps.

Statistics for the week… Study: 8 hours. Sleep: 8 hours/night; Fun: 2 nights. Gigolo Giogio's birthday celebration includes a thirty-person pregame at his house followed by fruity drinks and dancing until 2:30 am at a Drag Queen club.

Year 3, Week 38 (Neurology, stroke service)

During our morning session on multiple sclerosis, a stroke alert is called. The clerkship director and I walk over to the ED. A 66-year-old female is presenting for left-sided weakness (arm more than leg), but there is no facial droop. Her husband explains she was normal when they went to bed, but when they woke up at 7:30 am, she "just wasn't right". She has already gotten the imaging workup, but there is nothing to be done because she is well outside the 3-4.5-hour window for TPA (tissue plasminogen activator) and this is not a large infarct. (Even if we did know the time from initial event, she has been on oral anticoagulants for atrial fibrillation. These are difficult to reverse and a contraindication to TPA.) We put in admission orders to optimize her recovery, including blood pressure and sugar control. We also order an MRI to diagnose and prognosticate the extent of the infarct. The attending cancels some of the orders placed by the ED and the psychiatry PGY2 resident. "This is the tyranny of the order set [default groups within Epic, intended to save time and typing]! Why order a carotid duplex when we just got a better picture of it with the CTA already performed? We are just wasting hospital resources and Medicare dollars."

[Editor: The hospital CFO may not consider it a "waste" when Medicare dollars are transferred to the hospital…]

We arrive at the Situation Room, a narrow office crammed with two computers and an old couch. The clerkship director, resident, and I hang out here until the next stroke alert. I am pimped on the types of strokes. I fail miserably, citing only two of the common sites of brain bleeds. There are two main types of strokes: intracerebral hemorrhage (ICH, brain bleed, rarely lethal) and ischemic (occlusion of an artery, potentially fatal due to increased intracranial pressure). This neurologist gave a great lecture on strokes during second year, so I pull up the slides on Blackboard and then UpToDate each topic for more information. A common cause of ICH is hypertension due to cocaine and meth use among the young and poorly controlled chronic conditions among the elderly. ICH can also be caused by anticoagulants and Alzheimer's (amyloid angiopathy). "You can quickly figure out what is the cause by the location of the bleed. Hypertension is a deep brain bleed, in the basal ganglia, thalamus, pons, or cerebellum. Dementia patients bleed into the cortex."

He asks me, "What kind of workup would you do for the patient we just saw in the ED?" I answer, "Well, she is out of the window for TPA, and not a candidate for endovascular therapies [clot in proximal artery]." I recommend ordering an echocardiogram, carotid duplex, and EKG. "Right, we need to rule out the preventable causes of ischemic strokes" These include cardioembolism (a result of, for example, atrial fibrillation, an infected heart valve from iv drug use, or a ventricular thrombus after a heart attack), carotid stenosis, and a patent foramen ovale or hole in the heart, that can allow a clot to pass from the venous circulation into systemic circulation). We check Epic and see that the MRI images are available, though without a radiologist's read yet. He points out a small infarct in her posterior limb of the internal capsule. Nothing to do.

(I followed up with her over the next several days and her condition was unchanged. She'll have a permanent limp and some arm weakness, but can live independently.)

We get a stroke alert for a 76-year-old diabetic female who had a breast cancer lumpectomy one year ago. Her husband reports returning from grocery shopping to find that she was slurring words and unable to walk. He promptly called 911 so we're probably seeing her about two hours after the onset. Her blood pressure is 215/100, too high for TPA, so she's on a nicardipine drip in hopes of bringing it down. The neurologist calmly examines her with standard techniques ("follow my hand with your gaze") and some of his own design ("close your eyes and tell me what you feel" as he hands her objects such as a key or lighter). She has a left facial droop, dysarthria (speech disorder due to muscle weakness), right gaze preference, and a left hemianopsia (blindness). Like most of our stroke admits, she gets a CT perfusion scan (five minutes and reimbursed at $12,000 by Medicare) to see if she is a candidate for endovascular intervention, i.e., clearing out a plumbing clog with a drain snake. Her scan is among the 10 percent that suggest endovascular intervention: proximal (closer to the heart) clot surrounded by potentially viable tissue. Her clog is in the middle cerebral artery (MCA, the main artery of the brain).

She is carted off to the endovascular suite. I call Straight-Shooter Sally, who did not get to see an endovascular procedure on her week of stroke service. We meet up in the Interventional Radiology suite; endovascular procedures are split between interventional radiology and interventional neurology. We're both excited, but the neurologist doesn't say anything during the 45-minute procedure. "Well that was useless," says Sally. We follow up with the patient the next day and she has almost no symptoms, except mild weakness in her right wrist.

(It seems obvious that cleaning out the pipes would work, but there are no good clinical trials to support the anecdotal evidence. A lot of patients who get endovascular therapy would likely have recovered on their own.)

During the 4:00 pm debrief in the "Situation Room", I ask if all stroke patients should get a $12,000 CT perfusion scan. "It depends whom you ask," responds my attending. "The people who designed our current protocols say, 'Yes.' But they mostly are not neurologists. Medicare doesn't understand the purpose of the CT perfusion scan. Two out of three scans that they pay for are unnecessary in my opinion. Only a small percentage of strokes are amenable to endovascular therapy. And we are not an institution at the cutting edge doing research on other indications. There is no excuse except laziness and dipping into a free pot of gold." I ask about the VAN score to screen for patients for a large proximal clot. If a patient does not have focal weakness and one of the following: Visual disturbance, Aphasia, or hemi-Neglect, it is extremely unlikely to be a large proximal clot amenable to endovascular therapy. My attending doesn't disagree with the VAN system, but thinks it adds little to an experienced neurologist's judgment. "Stroke centers are graded by the door-to-needle time [time to get a stroke patient administered TPA]. The ED is so focused on taking the thought out of medicine with protocols." He noted that every stroke patient now goes through the same steps: (1) non-contrast CT brain to rule out brain bleed, (2) CT angiogram to look for a clot, and (3) CT perfusion scan to evaluate salvageable brain tissue. "Though lucrative, most of this is unnecessary and doesn't change management. CMS hasn't investigated us yet, but I hope they do."

In his opinion, what would help more patients at a tiny fraction of the cost is simply speeding up radiology. "During nights and weekends we don't have in-house radiologists. We use teleradiologists who are contracted to get back to us within 30 minutes. We need a 5-minute look at brain anatomy, but they take the full 30 minutes to give us a detailed report so that they can't be sued for missing something. We get a report on spine, teeth, lungs, etc. The ED can't read images, so the stroke patient is sitting there for 30 minutes without any therapy. A good  neurologist reads his or her own films and a brave one will make the call without a radiologist."

[Editor: Smaller hospitals are unable to do either the CT perfusion scans or the endovascular intervention ("thrombectomy"), so our near-octogenarian Presidential candidates might not want to spend too much romancing voters in small towns. See "A Breakthrough Stroke Treatment Can Save Lives—If It’s Available" (WSJ, February 6, 2018).]

Statistics for the week… Study: 7 hours. Sleep: 6 hours/night; Fun: 1 night. Burger and beers with live music. Mischievous Mary has already started looking for visiting away electives in cardiothoracic surgery.

Year 3, Week 39 (Emergency Medicine)

It's May and we're back from an uneventful week of vacation.

Emergency medicine rotation, 12 shifts in 30 days. I am one of the first medical students in my class to complete EM. One quarter of the class completes EM clerkship during the third year; the remaining wait for the fourth.

I begin at 7:00 am in the simulation center with the EM clerkship director, a toxicologist. He gives us an overview of the ED. "We have a mantra in EM: "Anyone, anything, anytime. You will see a bit of everything on your shifts. EM docs are a master of none, but a jack of all trades." He continues:  "All of you have done internal medicine rotation already. I am sure you have the impression that the ED consults everyone. In fact, we discharge over 70 percent of the patients from the ED." Emergency Medicine changed overnight when EMTALA passed in the 1980s. "This requires emergency rooms to screen and stabilize all patients that come in regardless of insurance or ability to pay."

He explains that the ED risk stratifies patients and recommends we all become familiar with PERL rules, Nexus criteria versus the Canadian criteria for cervical spine clearance, and the HEART pathway and OTTAWA rules.

After this introduction, my six classmates and I head over to the first simulation room. The room is similar to the trauma bay in the hospital with a mannequin on the bed, various screens showing vital signs and fully stocked closets with e.g., endotracheal airways and chest tubes. The first simulation day is focused on ACLS, and management of various cardiac arrhythmias. The EM clerkship director, and two simulation staff (a former medic and a former ED nurse) step out into the viewing section behind an opaque glass window. We hear them over the loudspeaker giving the simulation introduction. Then the EM clerkship director gets into character: "Ugggh, I don't feel so good." We begin to ask questions and request tests. "Can we get an EKG?" The staff put up various EKGs and we are supposed to respond by treating the arrhythmia, whether that is to shock the patient (synchronized cardioversion versus defibrillation) or administer medications.

My first shift is slow and the 34-year-old PGY2 resident has plenty of time to teach. Before medical school, she worked for 5-years as an operations engineer. (EM residency is a three-year training, the majority do not go on to fellowship training). The attending's high level of trust in her is evidenced by the fact that she manages 10 beds by herself and updates the attending on any admissions. We have a COPD exacerbation from a nursing home and an uncontrolled type 1 diabetic in DKA. My resident starts the patient on her preferred protocol (K+ and insulin drip) and then updates the attending. The attending discusses his view of bolus versus drip only, as he prefers bolus. "It's your patient, your move." We have a patient transferred about 150 miles from an outside hospital due to a stable GI bleed. I do not understand what hospital would transfer this patient. He doesn't even need a blood transfusion. His only comorbidity is well-controlled type 2 diabetes and hypertension. The PGY2 summarizes the situation: "He was driven all this way for a digital rectal exam." She continues, "He has supplemental insurance, so I'll offer to keep him under observation. We might catch something to flip him into inpatient and get him an EGD and colonoscopy. But he frankly should be discharged and sent for elective outpatient colonoscopy. I feel bad for the guy and the wife who is driving here now."

Statistics for the week… Study: 10 hours. Sleep: 6 hours/night; Fun: 2 nights. Brewery outing with classmates and pups. Lanky Luke and Sarcastic Samantha are training their puppy, however she only listens to Samantha because Luke is always working on his internal medicine rotation.

Year 3, Week 40

The second week of EM. As soon as I put my bags down for the second shift (2:00 PM to 10:00 PM) at the physician/nurses station, a code is called over the loudspeaker – "Code Blue, Triage." My PYG3 resident, a 30-year-old mountain biking enthusiast yearning for his upcoming Montana life after graduation in a few short months, waves for me to join as several residents, nurses, and attendings briskly walk over to triage.

A 70-year-old obese female is lying on the floor surrounded by six people. Two are taking turns performing chest compressions. A resident is attempting to ventilate the patient with an Ambu Bag manual resuscitator. We get the patient onto a stretcher, and cart her off to one of our rooms. The ED is divided into a trauma section, triage, a sick section, an observation unit, and a healthier section. Once she is on a bed in the sick section, an attending and her resident prepare to intubate.

The attending hands a GlideScope, a video-assisted laryngoscope to the resident.  Unlike a traditional direct laryngoscope that allows only the intubator to see what is happening, with the GlideScope both the attending and resident can see what's in front of the scope, The resident then inserts the blade and visualizes the cords, but struggles to get the ETT (endotracheal tube) through the vocal cords. They are tight. He asks for a "boogie," a long thin bright blue bendable plastic tube that he is able to pass through the vocal cords. He takes the laryngoscope out, threads the ETT over the boogie, and pushes the ETT forward aggressively. The attending asks, "Are you in?" He responds, "Yes, I feel the tube gliding over the [tracheal] rings." The attending agrees, "I feel you too," as she removes her hands from the neck.

The respiratory therapist (RT) hands us the tubing connected to the ventilator. Every tube  at initial intubation is hooked in series with an end-tidal CO2 colorimeter. If the ETT is correctly in the trachea (i.e., not in the esophagus) carbon dioxide on exhalation will change the color confirming correct placement. While this is going on, another attending and resident are "dropping lines" including a central venous catheter and arterial line.

We learn that a granddaughter brought the patient after she had trouble breathing with wheezing. The daughter said, "She was just in the hospital for a COPD exacerbation two months ago." The patient was coding for 20 minutes. My attending asks if the family would like to come in during the code to watch. (Afterwards, she says there is evidence that the family seeing the end-of-life code is helpful for the grieving process.) The granddaughter, daughter, and son-in-law take one step into the room and begin sobbing. They step out after a few minutes. On the next pulse check, the patient is still in asystole. My attending asks if anyone has any other thoughts. "We've ruled out other reversible causes of arrest." After a short pause with silence, she announces, "Time of death – 15:25." There is a quick debrief afterwards, and then everyone scatters. I help the two nurses get the patient presentable for the family to come into the room for one last farewell. The charge nurse can tell this is my first code. "Oh sweetie, thanks. We cannot forget to clean their bottom." The other nurse chuckles, "Post-mortem shits. Nothing quite like it."

Immediately after this a mother brings in her 20-year-old daughter, a bone-thin IV drug user with uncontrolled type 1 diabetes who presents for weakness and confusion. She is found to be in diabetic ketoacidosis (DKA) and is septic from likely bacteremia. She is tachypnic (breathing fast) and becoming more lethargic. The attending states, "We need to intubate her now." The attending and resident let me intubate the patient. The resident instructs the charge nurse to grab an induction agent and paralytic. We first pre-oxygenate the patient by placing a non rebreather (breathing mask) over her mouth. After two minutes, the attending tells the nurse to push the sedation followed by the paralytic.

The resident hands me the GlideScope. "Watch the teeth! It's not a rotation motion, it's a lift up to the crease between the wall and ceiling." I struggle with the motion, being too timid. The attending pulls my hands to the sky, supporting the entire weight of her head and neck off the table, pulling into view the vocal cords (pretty much a perfect view… she is an easy intubation). I guide the ETT through the vocal cords. Once through, the RT blows up the balloon. Once intubated, the RT connects her to the mechanical ventilator.

After a few minutes, the nurse comes out to the station saying the patient is now hypotensive (low blood pressure). The attending asks, "How much fluid has she gotten?" The resident says, "She's gotten two liters, and she is a tiny skinny lady." My resident turns to me, "Would you like to place a central line?" I exclaim, "Yes.". "If you can grab all the right stuff, it's yours." I speed off towards "Walmart", the ED stockroom. I grab a central line kit, sterile ultrasound probe cover, enough suture to weave a sweater, and several pairs of sterile gloves. The resident jokes, "Not bad." While I was off, he had already grabbed everything we needed. "Let's get started, the hardest part is positioning everything."

After we place the patient in Trendelenburg, we open up the kit on a stand. I put a sterile gown on with my resident's help, and then my gloves. He does it all by himself. We prep the patient. The nurse hands us the ultrasound and we are ready. Okay, show me the internal jugular. I grab the ultrasound and scan up and down the neck. "It's the plump vessel, next to the pulsing carotid." I push down with the ultrasound probe, thereby compressing the internal jugular (IJ) vein. "Notice how the IJ nearly compresses on inhalation. She is quite hypovolemic." The resident hands me all the tools in the right order. I insert the access needle into the IJ under ultrasound-guidance. "Don't freak out when blood squirts back at you. Hold steady. I'll hand you everything. We both will freak out if it is pulsatile (indicating we hit the carotid and not the IJ)" Once I get blood return, he hands me the guidewire that I thread through the needle. "Look at the ectopy on tele!" (when the guidewire knocks around in the atrium it can cause aberrant heart beats.) I communicate, "It's threading easily." I take the needle out, and he hands me the dilator followed by the flushed catheter. The catheter goes in smoothly, I suture it in place. I struggle placing a sterile covering, a fancy plastic lining that goes over to try to prevent infections. "I'll do that, this is our signature for nurses."

As we walk out, the resident shares, "One of my best friends has type 1 diabetes. I've noticed that type 1 diabetics are either extremely health conscious and disciplined, or are complete wrecks and die of massive heart attacks in the 40s."

I leave exhausted, but am too excited to fall asleep. Type-A Anita has been active on Facebook. She writes about a New York City article citing the rise in divorce rates: "I'm glad the divorce rate is higher. You want to know why the divorce rate was so low back in the Day? It's because your grandmother did not feel safe to leave the relationship. It means women feel empowered now to leave their shitty husbands because they are not dependent on any man. #StandUp"

[Editor: Type-A Anita is on track to make $400,000 per year in ob-gyn and her fiancé (now husband) is in a much less lucrative career. If she is unwise enough to settle in one of the states that awards alimony, in about 15 years we might find that her opinion on this topic changes…]

Statistics for the week… Study: 10 hours. Sleep: 6 hours/night; Fun: 2 nights. Beers and burgers with Sarcastic Samantha. Mischievous Mary unexpectedly joins midway. She recounts walking away from her Tinder date without introducing herself to the young man because he showed up to the restaurant  in an undisclosed wheelchair.

[Editor: It would appear that the medical school's heavy investment in diversity and inclusion education is not reaching everyone.]

Year 3, Final Weeks (Emergency Medicine)

Night shift: midnight - 8:00 AM. My resident is a 28-year-old whiz kid with slicked-back hair. An ED nurse rooms our first patient and drops off the paperwork. She teases, "Have fun, he's here for bugs!" My resident sends me in there alone. "Good luck!"

The 55-year-old is presenting from home complaining that there are bugs crawling all over him. He wants us to write a note agreeing with him, so he can sue his landlord. "The bugs are everywhere. They are crawling inside me now." I ask him where they are. "Everywhere. See." He pulls out a zip block bag with a q-tip with ear wax on it. "See the bug." He denies any drug use except marijuana. He is so convinced that he is convincing. Searching for the bugs, I am almost as confused as he seems to be.

I present to my attending and resident. Within a few words, my attending has already figured out the problem. She states, "MJ is laced with meth around here. These delusions can be so strong that nothing will change their mind. I've had people bring in zip-lock bags with tampons claiming there are bugs. I just hope there are not any bed bugs on him." We go in to see him together, and try to explain that there are no bugs on him but he may have taken meth. We offer to do a UDS [urine drug screen]." He becomes combative. He storms out of the ED.

My attending summarizes, "EM would be amazing if not for the addicts and psychotics. They suck out your soul."

[Editor: Maybe she would be happier practicing medicine in a country where the government-run health insurance system doesn't purchase opioids in tractor trailer quantities?]

My resident asks me what I want to do. I respond that I am not sure. "Well, if you're debating between EM (emergency medicine) and IM (internal medicine), it's easy. If you like to perseverate on stuff that probably doesn’t matter and will get better with time, do IM." He continues, "EM is for people who have ADHD and want to fix things quickly and do procedures. We deal with putting out the fire. I'm not going to be great at everything, but we get the job done. We do eye procedures and central lines. We're not as good at eye stuff as the opthamologist and we're not as good at central lines as the intensivist. I had to put in a suprapubic catheter to drain 3 liters of urine [the bladder ordinarily holds no more than 0.5 liters]. I've never done that so I looked up the procedure steps and watched it on youtube. I got the job done."

After a slow few hours, a neighboring resident comes over to our pod and asks if I want to do a lumbar puncture (LP)? A 45-year-old female presented with a several-week history of worsening headaches, gait disturbances, and visual changes. Neurology evaluated and is concerned about the possibility of a rare encephalitis. Neurology is busy so they asked if the ED wanted to perform the LP. After we consent the patient, the attending and resident help me prep the patient and numb her up with lidocaine. We lay her on her left side and ask her to bend over, thereby flexing her spine to open up the lumbar vertebrae. I insert a long spinal needle into her back, slightly off midline, while aspirating on the plunger. I keep hitting bone. After 3 attempts, the resident takes over and also struggles. The attending gets it on the second attempt. "That was hard, she must have some bad arthritis."

After the last clinical day of M3 year, our entire class gathers in the medical school lecture hall for the M4 lottery. We are each assigned a number and go in order selecting M4 rotations. Straight-Shooter Sally is stressed because she would like to do "Acting Internships" at other institutions. "If I get the wrong order, I won't be prepared when I have to do my AI." (For example, someone interested in a cardiology AI would try to do the cardiology rotation at the home institution just prior.)

Statistics for the week… Study: 12 hours. Sleep: 7 hours/night; Fun: 2 nights. House party at Buff Bri's house to celebrate the conclusion of M3 year. Sarcastic Samantha talks about her job distributing new admissions among the hospitalists.. She explains, "I have to fight with the hospitalists. They act like children. When we get a new heart failure exacerbation in the ED, they whine, 'Why is it my turn?' Because you haven't taken one all week."