Milestone: First Dinner Paid For by a Pharmaceutical Company

I went to a Resident's Research night the other night at a fancy business club downtown. I was attracted by the possibility of the free cocktails, the free gourmet dinner, the experience of seeing this fancy club for free, and not one bit by the free research speech in between.

We arrived, suitably conforming to the club's dress code, and were pointed to a conference hall in the public area of the club. I never did get to see the private member's area with the billiards tables and the swimming pool and the brandy and stacks of the Wall Street Journal. Strike 1.

After that, the first thing we noticed is that there was a price list beside the bar. By "Cocktails 6:30 - 7:00" on the invitation, they meant "Cash Bar 6:30 - 7:00." BIG difference. Strike 2.

At the end of the speech, though, which was mostly out of my league (but it kept my attention because the resident spoke so fast) they served a fabulous and delicious three-course dinner with all the wine we could drink. Outstanding. Reset the count; 0 balls, 0 strikes.

And the best part: right before they served it, they told us that a pharmaceutical company was paying for the dinner. I had been wondering how long it would be before I was getting food from the drug companies; my time had come. I have pretty much arrived. (And I don't feel coerced one bit: to be honest, other than mentioning the name once, they did a bad job of making an impression. I can't even remember the name of the drug company. That makes it OK, then, doesn't it?)

It was well worth going just for the (free) dinner, but the best part happened after dinner. Two young psychiatrists came and sat down at the table where I was sitting with about five other first-years from my class. They told us a lot about psychiatry, answered our naïve questions ("Do you have a couch?" - answer: only about 3 shrinks in the entire metropolitan area use couches), and joked around with us, and gave us some great advice.

Before I get to the advice, let me make this clear: I know absolutely nothing about psychiatry, and in fact, in all seriousness, I am a little bit frightened by the thought of being around psychotic patients. Okay, I know that statement is laden with ignorance and so forth. Go ahead and make your judgments... Strike 1, against me... but hear me out:

Despite my ignorance, I am really interested in actually overcoming my ignorance and getting to know what the profession is like (reset the count against me, 0 balls, 0 strikes). I got the doc's contact info and I'm looking forward to shadowing them in the near future to get a handle on what they really do.

All that being said, however, the most valuable part of the entire evening was the advice that the psychiatrists gave us. I'll leave you with that; it should be helpful to anyone trying to figure out what specialty they should enter.

"No matter what fascinates you now, it is going to become routine after you do it day in and day out. So, when you're in a rotation or shadowing, take a close look at the residents in that field, and see if their level of happiness, their lifestyle, the things outside of what they do for work, jive with what you're hoping for in your career. If they don't, then look for another specialty."

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The Impending Lawsuits, part 2

I've got a bit to add to my previous post entitled "The Impending Lawsuits."

I received a comment from one of my tutor group leaders in the journal I was writing for our class on the phycian's role in dealing with individual patients and soceity as a whole (yes, a journal... yes, a touchy-feely class... no, I haven't gotten anything out of it).

I wrote in that journal about getting sued, since apparently that has been on my mind lately, and he responded:

"Most doctors go through their entire career without getting sued once."

As well, in Canada, doctors are legally represented by the Canadian Medical Protective Association (CMPA) which provides legal services for physicians who are being sued.

A doctor whom I spoke with told me:

"the lawyers provided by the CMPA are outstanding. However, while this is good for physicians, sometimes it gets to a point where it puts patients at a disadvantage; I've seen patients who have had legitimate cases, but couldn't afford lawyers at the same calibre of the CMPA's, and therefore weren't able to successfully defend their case."

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Medicine has its perks... even for med students!

I went to a Rural Medicine club meeting tonight because they were giving away food (and I am indeed curious as to whether I'd be interested in rural medicine).

Not only were the speakers hilarious and the meeting very interesting, I also walked away as one of 9 winners of a free trip to a Rural Medicine conference, including flight, accomodation, food, and conference entrance fee.

Awesome.

My friend made fun of me when I was folding my ballot entry. My mom showed me some special technique and told me that it would help me win contests (she didn't tell me that it would get me made fun of). I never really believed her, but today my ballot was the first entry drawn. Thanks, Mom!

I love medicine!

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Addition to Top 10 list: Things that make me feel like I'm becoming a doctor (as of First Year)

I have to add one more item to this list (the original ten can be found here).

11. Getting a stack of twenty brochures about talking to your doctor along with a medical journal.
Received twenty brochures in the mail today. I guess they assume that by being a member of the association and receiving their journal, I must be a physician. Nope. So, I'm not sure what I'm supposed to do with them; if I were a GP I'd probably put them in my office waiting room, but as a medical student, well, who knows. Any suggestions?

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Brain Surgery

Today I watched brain surgery. It was incredible. I'll finish this post later, and tell you all about it.

**Update 6/1/07
The promised post can (finally) be found here.

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The Impending Lawsuits

We've just started receiving lectures on the legality and ethics of medicine, and already we're all very aware that we are all going to get sued, inevitably, and soon.

One of my tutors, a family practitioner, told me that of all his friends in plastic surgery, each and every one of them has at least one pending lawsuit at all times. If one gets settled, there's always another one that is ongoing.

So every time I've heard of a doctor getting sued, I've started taking a mental note as to what they did, so that I won't do it. Here are a few of the mental notes I've collected.

• If a patient needs blood to save their life, and they're carrying a Jehovah's Witness card saying "no blood," don't give it to them.
  
• If you're putting in a central line and you put the needle in the wrong place, pull it out before adjusting the angle; moving it around inside will cause it to damage important nerve tissue.
  
• If you have gotten a patient to sign a consent form, it doesn't mean they've given consent. They can still pull their consent after they've signed the form, and the verbal dissent is what's legally binding.
  
• If someone tells you "Come help, someone is having seizures," don't reply, "Bring them here." If they're a reasonable distance away, failure to attend is professional misconduct.
  
• Don't diagnose things outside your office for your friends. Bad, bad, bad. If you do, don't forget to say, "If it gets worse, go see a doctor."

So you can understand why a post about lawsuits on a blog that I read and enjoy is one that I will undoubtedly read and remember.

EDIT (11/23) - Follow-up to this post here

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"Don't Ask Shit Questions": To FIFE or not to FIFE

Another med school first.

I'm about to tell you about the first time that I was sworn at by a patient.

I've heard patients swearing at doctors before, but never at me. This was a wholly new and wonderful experience and I am taking it as though I have reached new depth in my irreversible spiral of being sucked into the health care profession, complete with its highs and lows, the latter of which can include being sworn at, among other things.

I'm happy to recount this saga. Unfortunately, it does not come without a lengthy, but hopefully entertaining, prologue.

Prologue

In our medical school we're taking a course on how to interview patients. Sure, most of it is common sense, but in the day and age where doctors are taking hits on having poor bedside manner, the logic behind this can be understood. I have seen, and have heard first-hand accounts, of physicians such as a surgeon who would enter a patient's room, remove the surgery bandage, look at the wound, write in the chart, and leave, without so much as a word to the patient. Yeah, these cases are in the minority, but there are enough of them for the medical schools to start teaching doctors how to be compassionate and how to talk to patients and show empathy and feeling.

So, someone somewhere in medical school curriculum development land decided that there were not enough acronyms for med students to remember and separate them from the general public untrained in medical expertise other than through what they see in ER and Grey's Anatomy, and thus invented "FIFE."

The students in my class have taken very dearly to this acronym, and instead of talking about "asking a patient the FIFE questions" or "using FIFE," my classmates have taken towards stating it in terms of "FIFEing the patient." "In this interview I'll be sure to FIFE my patient," I have heard often, or in further abuses of the loose resemblance of the term another word in the English language, some students will say "FIFE your patient! FIFE them until you can't FIFE any more," or "I definitely FIFEd the _ out of my volunteer patient." No disrespect is meant to the patients, just to the dude who thought that "FIFE" would be a safe word to give to young men and women early in their medical training.

Even our faculty tutors sometimes use this term in a way that could possibly be phrased more gently. A medical student at my school was practicing interviewing a volunteer patient in our communication skills class, and called a "time out" because she didn't know what to ask. "Did you FIFE your patient?" the tutor asked. The patient, with a look of surprise and horror on his face, exclaimed, "'FIFE?!' You're going to FIFE me? What do you mean FIFE?!!"

If you don't know what this means, you're probably wondering by now what the heck I'm talking about. You are not alone, and I have chosen to enlighten you. FIFE stands for Feelings & Fears / Ideas & Impressions / Function / Expectations, and are headings for a number of questions that doctors can ask patients about their illness to determine where the patient is coming from.

For example:
F: "Do you have any specific fears or concerns?"
I: "What do you think might be causing this illness?"
F: "How is this illness affecting your daily functioning?"
E: "What are you expecting from this visit to the doctor?"

You get the idea.

Some doctors don't use these guidelines, some doctors do. Some avoid even the idea of it. A girl in my class told me that her clinic preceptor pretty much used "the anti-FIFE" - don't ask any questions about their feelings because there just isn't enough time if we're going to fit in 6 patients per hour.

In some cases, though, the FIFE questions can be very helpful. To demonstrate this, the course directors brought a standardized patient (an actor portraying a patient with an illness) who complained of wheezing and chest tightness. Questioning the class made it clear that we were all ready to assume that proper treatment would be along the lines of doing a lung test and prescribing asthma puffers; however, FIFE produced valuable additional information that would not have been discovered otherwise. The best example came upon asking the E portion of FIFE ("What are you expecting from this visit to the doctor?"). The patient revealed that she knew of friends and family that had suffered from heart conditions, and she wanted a heart test to rule out this possibility. Us budding physicians hadn't considered that the patient might have been hoping for this, so FIFE prevailed and we were all immediately and wholly convinced as to its efficacy and even stopped making fun of it just a little bit.

Saga

With that introduction I can now move in to the saga of my being sworn at.

I was in my third week of Family Practice clinic and was sent to a room to interview a patient. I walked into the room to see a gentleman in his late thirties peering out the window through the blinds. I wasn't sure how to approach this odd situation, so after composing myself I asked, "What are you looking at?"

"My car. I don't want my car to get towed," he said hurriedly.

He turned around to reveal a gentleman in his late thirties, I'm guessing blue collar, with blond spiked hair, an earring, and a large tattoo on his back and neck. He was the type of guy you might see get out of a beat-up pick up truck at a bar to have a few beers, watch a hockey game, and yell at the TV with his buddies.

I respected his implication that time was of the essence so I decided to proceed a bit more quickly, without asking about his family and hobbies and the like. I introduced myself as a medical student and asked if it was okay for me to interview him; he almost cut me off: "Yeah, yeah, do whatever you need to do, that's fine with me."

I proceeded ask him about the chest pain that had brought him in, and the typical questions about how long, how painful, and the like. "It hurts like hell," he said. I asked, "On a scale of 1 to 10, where 10 is the worst pain you ever experienced, how bad is it?" He replied, "Well, I have gout, and that is horrible pain. Compared to that, this would be like a 1. But this hurts like hell." I tried to figure out what that meant while I scribbled notes on my clipboard.

Once I had gotten a good idea of his pain, admittedly a bit flustered that I was thrown off my normal questioning routine by trying to rush the interview, I realized that I was running out of questions.

Without skipping a beat or showing any signs of distress, I immediately resorted to FIFE. I had the good sense to not ask this man about his feelings, and instead asked what he thought was causing the pain.

"My smoking, for sure."

Score one for FIFE.

I reached into my trusty FIFE question kit and carefully selected another question to present to him.

"What do you hope to achieve by coming in today?" I asked.

He stared at me.

"Um," I rephrased, "what are your expectations for this visit to the doctor?"

He looked at me as if I had just grown a third ear.

"I want to know what it is. I want to know what the fuck it is. Make the fucking pain go away."

And then the fateful blow:

"I just want to know what the pain is. Don't ask me any of your shit questions."

"Shit" questions?! I was devastated. I thought I had been armed with the tools of interviewing by my infallible supervisors, and yet here I had gone and agitated a patient to the point of cussing. How dare he call FIFE "shit questions"!!! FIFE had failed me. And it only went downhill from there.

I tried not to look too flustered and tried to wrap up as fast as I could. I asked if he wanted a flu shot, then I asked if he was taking any medications. He mentioned a drug for his gout, then looked at me and said,

"Dr. Milton knows about all my conditions. I've talked with him about all that already. My history is not your fucking business. Do what you need to do with this, and ask me nothing else."

Again trying not to act too flustered, and sensing something less than appreciation for my efforts, I ended the interview, and told him, "You know, I usually come back in with Dr. Milton, but if you prefer the doctor can just see you on his own."

His response was not what I expected.

"Oh, no, no, that's fine, I don't care if you're here."

A bit confused, and a lot flustered, I left and presented the case to the physician quickly, and hoped that this paradoxical patient would stop trying to test my limits. The doctor came in, diagnosed the illness, and wrote down a prescription. As the doctor was finishing up, he told me to take the patient's blood pressure.

I realized I had subconsciously edged my way as far as possible away from this patient and had my back against the wall, and so upon being asked to take his blood pressure I slowly made my way towards this man that I realized I had been distancing myself from.

He didn't make it easy for me, either. As soon as I put the blood pressure cuff on his arm and had inflated it with a single pump...he freaked out. He jumped and pulled his arm away.

"What the hell!?" he shouted.

I was pretty much at my wit's end, and shocked and confused as to why this guy was reacting this way to the very minor pressure that a blood pressure cuff exerts after only one squeeze of the bulb. I looked up at him in surprise.

"Just kidding," he said.

What the heck!? I'm not sure if there was something not right in this patient's head. My classmate suggested he might be bipolar. Either way, he was enough to make me seriously wonder about his sanity.

Postlude

(Any story with a prologue must have a postlude. It's just good Englishing, and I am a huge proponent of doing grammar correct.)

So that was my first experience being sworn at by a patient, and I can probably expect it to happen again. Fortunately, in the grand scheme of cusses that patients can direct towards their health care providers, this was very mild. At least he didn't start swinging at me or anything; heck, he didn't really even swear at me, just around me. And I couldn't wait to tell my interviewing class small-group tutor what the patient had said about FIFE.

I'll definitely be more selective about when I choose to pull out the "shit questions."

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Top 10 list: Things that make me feel like I'm becoming a doctor (as of First Year)

EDIT (11/21): I had to add a number 11. Find it here.

I kindof had to make this list to convince myself that I'm actually in med school. Like I've mentioned before, our first semester is a lot of just basic biology, things I learned in undergrad (biochem, physiology, etc.), so I can't help but feel that I'm still just taking more biology classes. Until I get to third year, where I report to the hospital every day (and on weekends...and I am given evening shifts...And I'm put on call...) it still seems kindof like school, still. Hopefully this changes a bit in January when we start going through the body organ systems, block by block. Until then, I have this list to go by:

10. Got my second issue of the CMAJ today
It always makes me feel like a member of the profession.

9. Calculating IV infusion rates
Finally, there is an applicable use for algebra and natural log calculations. Boy, was I rusty on those for a while, though!

8. Getting my ID tags
I wear these a bit too often, my excuse being because they're on the same retractable carrier as my bus pass. The third-years make fun of me.

7. Being allowed to shadow doctors in the area
It's hard to arrange this when you're a pre-med!! I've already shadowed an ER doc back home, an ER doc here, and going to shadow a surgeon next Monday.

6. Learning how to interview actor patients in my interviewing class

5. Interviewing real patients in the family practice clinic

4. Getting sworn at by a patient in the family practice clinic for asking questions I was told to ask in my interviewing class
I'll definitely tell this story soon!! EDIT (11/20): This post is now available here. (Title will be: "Don't ask shit questions" - To FIFE or not to FIFE. Another time, though; I'm keeping busy and don't have the time right now).

3. Cadaver lab
Partly because I get to wear scrubs, and partly because this was something I envisioned doing when I got to medical school, since not many people get this privilege.

2. Giving injections
This isn't #1 because some of my friends who were in nursing when I took my undergrad were giving injections way before me, so I was jealous of them and when I got to do it I only felt like I was caught up to them.

1. Getting my stethoscope
The excitement of this has started to wear off, but the day I got it I felt like I was pretty much ready to graduate and be called "Doctor". Don't laugh. Small things amuse small minds. And when you pay that much for something, you may as well appreciate it.

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