Medicine and the 'difficult' patient

Medicine changes people. For better or for worse, it has the potential to transform the most idealistic, I-want-to-help, good natured, hard working MS1 into a bitter, angry, and uncompassionate resident. For example, during conversations with my team in the hospital:

"[deadrocketcow], I swear I never used to be this mean. I never used to complain this much."
"I remember when I couldn't wait to be a resident. I thought it was all glamorous and helping people. But really, all you do all day is make calls and work with difficult patients. You're basically a glorified secretary."
"This sucks."
"Oh....no! Another admission? The Emergency Department admits everyone! Somebody shoot me."
"This guy [patient] is unbelievable! What does he want from me now?! Tell him to stop paging me already."

Looking at that, you might think I am surrounded by some of the most mean spirited people - doctors who don't care a fig about their patients. But after you have been working a 30 hour shift every 4 days for the past 3 months, on top of a 14 hour 'normal' work day, with no consideration for weekends, this does not sound all that unreasonable. Especially, when you have to work with the not so occasional 'difficult patient'...

Patient X, an active cocaine user, was admitted to the hospital with extremely high potassium levels (this is a dangerous thing as it can cause heart arrhythmias). He had been told for several years now that he would need dialysis, as his kidneys were no longer functioning correctly, but had decided he was not ready. Well, this time, his kidneys decided for him that he was ready since they could no longer rid his body of excess potassium. During his admission, he was beliggerent and rude to the nurses and our team, constantly demanding more pain medication, refusing to take his medication for his extensive co-morbidities, devising his own dosing schedule and demanding that we change his meds to that effect. He would also leave the hospital for hours at a time without telling his nurses, to smoke and engage in other medically frowned upon activities.

What is interesting were the contrasting attitudes my team had towards this 'difficult patient'. It was apparent that the further away you were from the start of your medical education, the more likely you were to be cynical and dismissive of this 'difficult' patient's needs, thinking "If he doesn't want to be treated, then why is he here? Let him leave."
Being fresh and naive on the medicine team, my thought was "this man is depressed about his life, his illnesses and the fact that he now needs to depend on a dialysis machine for at least 4 hours every other day in order to remain alive. He feels helpless, has no more control over his life and is expressing it by being difficult and rude to the team."
The intern, who is a 1st year resident, and still pretty close to medical school, thought "this man is understandably upset. He is very sick, probably depressed and hates being in the hospital. If he took his medications like he was supposed to, the diaylsis would probably help him feel a lot better. But what can you tell a crack head?"
The second year resident thought "this man is insane! Did he spend 10+ years learning to be a doctor that he can tell me what the correct dosage is for his [illness]? I know this must be hard for him, but come on! Maybe if he spent less time smoking crack, he would care more about his health."
And the 3rd year resident thought "He doesn't want to take his medication? Fine, that's his choice. Just don't call me at 3am because his [indicator of disease progression] is through the roof. If he wants to leave too, that's fine with me, just make him sign the Against Medical Advice form."

Let me just add: the members of my team are extremely hard working and go out of their way to be as helpful as they can for their patients, often at the expense of sleep, food and their own sanity. But working 90+ hours a week does have it's toll. Nevertheless, the medicine doctors and residents I have interacted with are very positive, taking time out of their hectic scedules to teach me, an ignorant medical student what is what. They find the time to sit with their patients and talk to them about their children, despite having 20 other patients they need to see within the hour. In the end, it works out. Somehow.

Happiness is making it to the library after a long day at the hospital

I finally made myself go to the library after I was done in the hospital today - despite wanting to collapse onto my bed forever. I can now pass a test on sudden death (for cardiac reasons), coronary artery disease and cardiac catheterization. Just imagine: soon, I may be YOUR doctor.

Some good things that happened today:
1. I went with a very nice lady to get paracentesis done and held her hand during the entire procedure (say thank ya to comfortable shoes).
2. Saw histoplasmosis under the microscope from a patient who has been mysteriously (no longer!) sick for a while.
3. Was given permission during intern conference by the director of the medicine residency program to *gasp* have a sandwich before all the interns had gotten theirs.
4. I studied. Life is good, no?

All in all, a good day. Tomorrow I am on call....so no studying for sure. Ps - I am still working out for 45 minutes at 5am during the week, strength training/lifting weights twice on the weekend (on an upper body, lower body repeater, if you're interested), sleeping an average of 7 hrs a night (got down to 4 hours once last week) and eating healthy.

No patients...

It is 7:08pm and I do not have a patient. Since both patients I was following last week have been discharged, I have to wait until a patient comes in so I can have work to do tomorrow (and not look like a total slacker). However, as I am a newly minted MS III with 1 week experience, it takes me at least 3 hours to examine a patient and write up an admission note. This does not include reading up on the patient and practicing my presentation so as to be the budding superstar that I am on attending rounds. Looks like I'll be here until 10pm or 11pm....and yet another day with no studying done.

Medicine Week 1: Awkwardness to the nth power (where n = infinity)

On Mon, July 6th at approximately 9:30am (after a brief introduction by the course director), 11 or so hapless, naive and incredibly awkward 3rd year medical students (yours truly included) were thrust onto the floors of the general medicine department at New York Presbyterian hospital to help take care of patients. With no inkling as to what to expect and what to do about not knowing what to expect, important questions began to arise:

1. When the team is going around (rounding, if it pleases ya) seeing patients first thing in the morning, where is the medical student to position his or her person so as to provide the least amount of interference with on going proceedings? In other words, how can I stay out of their way, yet remain visible?
2. How many times is it appropriate for the medical student to ask "Do you need any help?" before the energy and time required by the attending/resident/intern/physician assistant to respond, "Thanks for asking, but not right now." greatly exceeds the benefit of said proffered assistance?
3. What is the role of the medical student, exactly? Is it appropriate to be seen sitting at a computer and checking one's email?

It all seemed so hopeless. However, much can be accomplished in the space of 5 busy days. I am on a team made up of an attending (the lead doctor ultimately in charge of patient care), a 3rd year resident in internal medicine, a 2nd year resident in internal medicine, a physician assistant and two interns (first year residents who have to fulfill basic requirements before they can focus on what it is they are doing residency for). And me. Of course.
Since the same basic pattern repeats itself every day, it became easier after Wed or so, to get a sense of what was going on and then, at least, in my opinion, to make myself useful.
I get to the hospital at around 6:30am, check up on any events that transpired with the patients over night, taking special care to ensure any patients I am in charge of (2 - 4) aren't in critical condition and that I know exactly what state they are in. This is important, both for my own education, and in the event that I get pimped by the attending and lose points by Not Knowing My Patients (my evaluations are a big deal, thank you!).
At 7am, the team, sans attending, goes around and checks on the patients (about 20 or so) to find out if anything is pressing and how the patients feel. We then sit down at 8:30am with the attending so that the person who was on call (stayed through the night to provide continuity for patient care) describes in detail what happened to each patient during the night and if there are any new patients admitted.
From 9am - 10am, we round with the attending, checking on any new patients as well as those who are in critical condition. This is the point when the team comes up with a plan for patient care, with the attending deciding if this plan is appropriate. Since the attending is under pressure to get the on-call person home, so as to avoid exceeding the 'work hour limit', that person goes home at 10am.
After all the rounds are complete, it is time to get down to the nitty-gritty of patient care - paper work, writing notes in the patient charts, calling other doctors to call other doctors so that specialists can come in to see patients and other such scut work. In my case, I help my team as much as I can, and focus on the 2 - 4 patients I am in charge of: from examining the patient and writing a note about their progress, making sure medication is being given, that tests are being sent and carried out to mopping up patient vomit.
Usually, I have a class at 12pm - 1pm. When I come back from that, everything repeats itself. At 6pm (medical student official going home time) my feet are screaming for mercy and my stomach is yelling blue murder. However, this is a critical moment. It is tempting to rush out the door without a backward glance in order to eat and begin studying, but it is important to ask everyone on the team if there is anything that I can help with. The fact is, there is always something, so I am guaranteed another hour or two of work. As such, I usually get back from the hospital between 7pm and 8pm too exhausted to think about anything beyond food and sleep. If I got a new patient that day, I practice my presentation on them for the next day's rounds and read about their disease. If not, I read up as much as I can about all my patient's diseases and their treatment. Not a great substitute for hard core studying, but I have weekends for that.

So far, I am still eating healthy, getting some exercise (5am - 5:45am, if you can dig that) and sleeping no less than 6 hours a night. Let's see how long that will last.