(It would help to hit post after writing these things. . . ) 

The last few nights have really been very quiet. So quiet that I’ve been overcome by a compulsion to study around midnight, instead of taking a nap or reading blogs. There have been enough patients with syndromes I’d never actually seen before that I can learn a fair deal of relevant stuff by just searching their keywords. My students are also getting plenty of sleep, after we see one or two interesting patients, scroll through some CT scans, and run through my stock of three solid pimp questions (primarily, the main causes of postoperative fever; I was rather surprised that no one had asked them these before, since I’ve gotten asked plenty, both in med school and in the last few months; but I guess I didn’t know the answer either, till someone asked me).

(In case you’re wondering, the catechism is as follows: The five most common causes of post-operative fever are Wind, Wound, Water, Walking, and Wonder Drug. Ie, atelectasis (and pneumonia later); wound infection, but only ~7 days out, hopefully after discharge; UTI; DVT, or PE, from not walking; and a drug reaction, most commonly to one of the fancy penicillin derivatives. Now you know more than the last five medical students I met. Be ready to recite tomorrow.)

I did have occasion to do my first complicated dressing change on my own. It worked out well, rather to my surprise. Which brings up one of the big differences between being a student and a doctor. I used to say that there was nothing magic in having an MD, but there is something. Expectations change; and that changes what you can accomplish. When I was a student, I put in about three NG tubes in conscious patients, and every time it was a big tug-of-war with the nurses, who were very skeptical about letting me try. In the last week, I’ve put in half a dozen, and every time the nurse just shrugs: “NG? You going to put it in? Thanks.” And there it goes, no problem – because it’s absolutely not an option for me to have trouble, and need the nurse to fish me out. On a larger scale: lines. The reason the more senior residents are 100% successful at these, and I’m only about 75% successful, is that there’s no one to rescue them. The patient needs a line, and they’re the one to put it in. You can’t page the chief and ask for help with a line, not if you don’t want to be the standing joke for the next ten years. There’s nowhere to go but up, nothing to do but succeed. You have to get it right, therefore you can, therefore you will.

For the rest, I spend almost more time thinking about the cast of characters I’m working with than about medical problems. I don’t understand these people very well at all. I can’t tell when patients are pulling my leg; that’s not new. I get along with the nurses that no one else likes, and then trip over a comment with the easygoing ones. I like, or tolerate, residents whom not many other people like, and can always make an excuse for them (when they’re just doing things to me, not if they’re rude to patients). I’m now inside the circle enough to be hearing a lot of gossip, and I’m confused by it. I don’t know how to put together three different perspectives on one guy, all different from my own opinion of him. My main strategy is to think as well of everybody as I can until the burden of evidence makes that impossible; that comes across as incredibly naive, but it takes up too much energy to dislike people unnecessarily.

Not knowing whether to dislike someone is not a big deal. But I’m also confused by the plurality of treatment plans. The resident will declare flatly that the patient has X wrong with him, and needs Y treatment. It sounds reasonable, the way he explains it. The fellow walks by, and explains lucidly that the patient has A disease, and needs B treatment; which also makes sense. And finally the attending announces that the patient unquestionably has K wrong with him, and needs to have L done; and his reasons seem irrefutable. The fact that these three theories are mutually exclusive bothers mainly me, because I’m the one listening to all three. Of course, the attending is always right, and we do what he says; but then what do I make of the fellow and resident? I know far too little to evaluate their plans. The solution, clearly, is for me to read some more, so that I can have my own opinion on the subject. (Everyone repeat after me: Medicine is an art, not a science. And if you could design a computer that would actually diagnose the dilemmas, and not just the easy ones, you would deserve a Nobel prize. Which now that Al Gore seems to have gotten one, is even less meaningful than it was after Carter got one.)

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