Inspirations...

Things that never fail to amaze:

- The caress of a warm breeze
- The hypnotic sounds of the sea
- An eagle hovering motionless against a blue sky
- An elderly couple holding hands as they cross the street

There's a lot of wisdom in the world, and I hope to one day understand a little of it...

Funny 2 - Where's My Skin?

This is the hilarious story from my colleague:

We see patients with skin cancers who come to have Mohs micrographic surgery. It's done by a dermatologist who has had specialized training in surgical procedures where small pieces of skin are taken out and immediately looked at under the microscope to make sure that the margins of the resected skin are clear. The goal is to have a extremely good (ideally perfect) cure rate for local cancer, as all the tissue margins should have been visually confirmed to be free of tumor, while at the same time, sparing as much normal skin as possible. Even with this technique, the patients are usually left with a sizeable defect that needs a further surgical procedure (complex linear closure, flaps, or grafts) to close properly.

We assist the Derm surgeon as she does Mohs cases. We try to be as helpful as possible, learn different closure techniques, and get to do some of the more straightforward closures.

So a few days ago, my colleague, Dr. X, in his first day on surgery, happens to be assisting the surgeon.

All's going well, besides the fact that he can tell the surgeon is not in a good mood. She's really quiet the whole time, and doesn't really explain what she's doing or thinking. So he's just trying to be helpful, blotting to clear the field, cutting sutures, retracting, etc. Meanwhile, she's doing her thing, and as she's repairing the wound, he finds it strange that she's snipping tissue and tossing it in the garbage can. (Usually all removed tissue goes to pathology.) So he's trying to make sense of it without asking Ms. In a Bad Mood, and figures that it's probably because our surgical trays are pretty small and given all the instruments and what not, she's probably just trying to keep things on the tray clean. So a little later, she cuts a odd looking piece of tissue and throws it onto the tray, where it lands onto a 4x4 gauze. They hit a bleeder so take some time to take care of that issue. X's running out of clean gauze and tries to get some from the tray but finds the ratty looking piece of tissue lying on one of the few remaining pieces of gauze. He picks up the gauze and tries to shake the tissue off onto the tray. Tissue is sticky. So he pulls it off, and following the surgeon's example, tosses the tissue into the trash can. Procedure goes on, half the defect is closed, things are going well. Then she turns to the tray and starts moving things left and right.

Surgeon: WHERE'S MY SKIN?
X: What do you mean?
Surgeon: MY SKIN! Where did it go? It was here a moment ago!
X: (Feeling faint) Uh, it's in the trash can...
Surgeon: WHAT? THAT WAS THE SKIN GRAFT!!!

Disclaimer: No patients were harmed in the procedure. The patient ended up having an alternate closure with a very nice result.

Funny Story 1

So a colleague and I just had a great time swapping some silly experiences in clinic. Since it's late, I'll jot down one of mine, but sometime in the future I have to write down hers too, because it was hilarious!

So as you know, we see patients in clinic. Many of them. There's a general patient pool for each clinic that is shared amongst several residents. Since there are A LOT of patients scheduled, and you don't want to be the slow resident that isn't pulling his/her own weight, there isn't time to do much else - you don't have time to write the official note for the visit, you don't have time for lunch, heck, you barely have time to go use the restroom. Which means that you see a patient, present to the attending, finalize the plan for that patient, discuss it with them and send them on their way, then hurry to see the next patient.

There isn't much time to think between patients, which works for this time of year, because if you gave me ten minutes per patient to think things through at this point in my training, I likely would not be any closer to the correct diagnosis. The other fact that I've come to grips with is that I don't know dermatology medications. In internal medicine, where I knew most of the names of medications, or at least if I came across a name that was unfamiliar, I could figure out the general category it fell under and have a broad understanding of how that medication worked and what it was for. And if I didn't even know that, I'd pull out the handy PDA and find the medication in ePocrates. Since starting Dermatology (now going on three weeks - woohoo!) it's been completely different. I've never heard of 90% of medications that people rattle off, so as they do some I'm usually subtly trying to scribble down the name to try and look it up and learn about it later.

As some of you may know, patients don't necessarily know the meds they're taking. Usually its the "little green triangular pill" or the "half black half white one" which means nothing to those of us who don't count pills for a living. And if they do happen to know their pills, they may mispronounce or say the name incorrectly. Usually when this happens, the savvy health care provider knows what the patient is trying to say. As in, if someone is taking a "water pill" and it starts with "hydro-something" you know it's likely hydrochlorothiazide.

Anyways, so I see this patient in clinic who has had psoriasis for the last several decades. He's a pretty put together guy, seems to know his disease well and know what medications work and don't work for him. As an example, corticosteroids and often used in psoriasis, and long-term use of steroids is associated with a phenomenon known as tachyphylaxis, which means that after prolonged use, the skin doesn't respond as well to the agent anymore, so you need a stronger med to get the same effect. He was able to describe this effect and explained that he cycled his medications to get around it. So I'm thinking, that's good, he's pretty sophisticated in his med use, knows what he's doing. I proceed to get his actual medication regimen from him and I get a list of several agents (that I've never heard of) and scribble these phonetically on a piece of paper. After finishing up, I leave the room, intending to try to look up some of these weird medications before talking to the attending so I have some semblance of knowing what is going on. Surprisingly, there is no line to present to the attending (there's usually a 15 to 20 minute wait) so I hurry to present the patient.

Attending: What's his med regimen?
Me: He's taking X in the morning, Y and Z at night, and switches to something called 'A' every several months. (am very grateful that I didn't forget to ask this of the patient and happy that I could say the medications without looking at the sheet)
Attending: He does X but switches to A when X doesn't work?
Me: Yep
*slight pause*
Attending: (slowly) You do know, that, X is A?? He's mispronouncing it, but A is the brand name for X...
Me: Oh... (DOH!)

Love 'Em!

This is why I love clinic. I just met a guy today who drove in 4 hours to see us. Turns out he's almost 90, and was one of the people who worked on the first aluminum can... He now has a "tiny" (his word choice) five acre farm with all kinds of fruit trees and farm animals. I learned about a variety of things, including proper tree pruning technique and the difference between a steer and a bull... now that's cool!

Warts

I had a dream about warts last night. Not something one would choose to dream about, but I guess it was expected, as we had just had a lecture on warts and I ended up seeing a patient with multiple warts.

There are many types of warts, and while they may look different, they have a good number of similarities. They're all caused by a virus (human papilloma virus) which loves the skin, they are hard to treat, and they are infectious. Warts are skin cells infected with the virus, so if you have a cut near a wart and the cut gets some of virus particles, a new wart could be in the making. This is often a problem in children, where the little petri-dishes get the warts from each other and then do things like bite their nails and end up with warts around their nails and around their mouth. And although anyone can get warts, people who have compromised immune systems are more prone to getting them, get more of them, and those warts are even more resistant to treatment.

The concept behind treating warts is that 90% of them will resolve in 5yrs and the wart is not medically harmful. Which means that treatment should be conservative and not lead to long-term effects like scarring. Treatments for warts are not very effective and take months before the full effect is seen. Some people say the goal is to treat the patient, but what you're really doing is buying time and waiting for that 5year mark.

So the poor man I saw in clinic was a HIV-infected man who had been struggling with numerous large warts for many years. He was a really sensitive guy who had just gotten over losing his partner, was trying to pull his life together, and was very embarrassed by how people responded to the lesions. Actually, he had been so frustrated that he had been using a BLOW TORCH to try to get rid of the warts. One of the first things out of his mouth was "I'll do anything - I'll be the most compliant patient." This is one of those things that is drastically different in internal medicine. In those clinics you can have patients with bad heart failure, diabetes, cirrhosis, diseases that will kill them, who because they can't see and often can't feel the effects of their disease, refuse to make changes that will improve or stabilize their health. Whereas in derm, diseases that are relatively "superficial" and benign - warts, acne, etc - really affect the patient and motivate them to help themselves. And while no one has ever thanked me for adjusting their blood pressure medicine or their insulin regimen, I was thanked profusely over and over again by this man - just for starting a treatment for the common wart.

Random Factoids - The History of Heels

Thought ya might like to know who to thank for painful feet, future bunions, and foot surgeries :)

- In the 1500's, the riding heel was a military invention to prevent the horseman's foot from slipping out of the stirrup.

- At about the same time, male French aristocrats made the heel "court" wear, which heels between three and four inches tall! This fashion eventually spread to the women of the court.

- By the late 1700's, the aristocrats stopped wearing heels - the French Revolution was around the corner, and being "well-heeled" could bring on the wrath of the populace.

- Late 1800's - the heel resurfaces almost exclusively among women.

It's All Relative

Funny how all things are relative and how easily one can lose perspective.

Some of the more seasoned derm residents have been complaining about having to drive to the hospital on their weekend call. Now, having just finished a year of internal medicine, and knowing the strenuous call schedules of my classmates who are not in Dermatology, I have NO complaints about the call schedule. Depending on different programs, Dermatology call usually consists of being on call one week or one weekend at a time, and the call is rotated among the residents so that you're really on call every few weeks. When you aren't on call, every weekend is off (SO NICE), and work is usually wrapped up by about 6pm at the latest. So this schedule is incredibly better than most residency programs, and most of us new residents can't really relate to people who complain about our schedule. However, we've been warned that as time passes, people tend to forget that we have an awesome schedule and that's when the complaining starts.

It's easy to see how this happens. If you are on neurosurgery call with 30 hour days every two nights or ICU call every 3rd day, just switching to a every 4th day call is a blessing. Or if you work six out of seven days (most residents), having two days off a week seems too good to be true, but think of all the folks that work Monday to Friday with 2 days weekends who think the weekends are too short and complain about going back to work on Monday. So this post is to serve as a reminder to myself (and a slap upside the head) of how things used to be (and could be) if and when the complaining starts.

Pointy Shoes

It's almost hilarious that I am writing about pointy shoes, and on some level it's horrifying that I am thinking about getting a pair. This is coming from someone who has always thought that said shoes, besides being painful and dreadful for foot health, often make the wearer look like they forgot their broomstick at home. And, for most of my adult life, I have cared little for the whims of fashion and cared less about people's opinions on how fashionably I dress.

So. Why the change?

I think part of the reason is that our perceptions of beauty change. Not surprisingly, advertising works. If you look at any of the online catalogues of say, Banana Republic, or Nordstrom, and search for "work clothes," you'll pull up pages and pages of professionally dressed models with POINTY SHOES! And while the first few hundred pairs of pointy shoes may look ugly, by the five hundredth pair, they start looking like they go well with the professional outfit...

Which, while compelling, is still not a complete reason to buy a pair. Common sense and a lot of research has proven that high heels, and especially pointy shoes, are BAD for feet. And as someone who wants to stay away from any type of general anesthesia, I swear by the ever comfortable Danskos. Heck, this is someone who interviewed across the country in her Danskos!

So the new change is that I've started my residency in Dermatology. As a rule, dermatologists are a well dressed bunch. And, sad to say, as one of the newbies in the department, part of me would like to blend in as much as possible. After all, you have to try to look the part. (Which brings back memories of "wearing"/hiding underneath a white coat as a medical student, deathly afraid that someone would find out that I really knew very little about the profession.) Luckily, our department is not as cutting-edge fashionable as some across the country - there are quite a few scary sorority-like derm programs out there - but a majority of the residents and the younger faculty wear these darn pointy shoes. And thanks to years of advertising's brainwashing effects, and perhaps the achilles heel in my "I don't care what you think" armor, I now think those pointy shoes look good, and dare I say, add a nice touch to a professional outfit. And while the shoes will likely not affect attending perception of a resident, hopefully looking like I blend in will help me fly under the radar, at least until I actually know what I'm doing...

What's Your Differential?

It's humbling and frustrating to see patients in clinic and have no idea what the diagnosis is. After medical school, internal medicine clinic was often a breeze - one could easily come up with a list of possible and probably diagnoses for things like chest pain, cough, headache, etc. And even if you weren't sure, you could kinda think through the problem and work your way (or BS) to a list of possibilities. Now patients show you a spot on their skin and want to know what's going on. The only catch is I've never seen such a spot before in my life! So when the attending asks "what do you think is going on," the answer, most unfortunately, is often "um, no idea..."

Must... Read...

Holy smoke there is a lot of reading to be done!

We're officially assigned a "textbook" to read for the year, which doesn't sound too bad. But in reality, the text ain't enough. For example, to be able to truly read the text, I need a dictionary. A big one. The there's the issue of the text not being comprehensive enough - we need a text for the basics, a text to supplement the basics, a text for histology, and a text for pharmacology. (That's about >$1000 worth of bound paper...)

It's a sad day when the cashier at the bookstore says 1) Whoa - you know how much this is, right? and 2) Darn, that is a BIG book.

One Week Old

I'm now officially a one week old resident :D

It's been an awesome week. We have a fun schedule, where most of our half days are spent doing vastly different things - mornings may be surgery and afternoons are more medical, or morning can be continuity clinic with afternoon pathology session... We're actually pretty busy during the day - rarely have more than 5 minutes for lunch, if that, but that makes time fly. And the variety is great!

Clinic is currently "down-booked" for us newbies - which means they schedule less patients per resident. As is, we're seeing 7-9 patients in about two and a half hours, which is record-setting by internal medicine clinic standards. We still seem to be painfully slow at getting things done - whether it be seeing patients, writing notes, or sewing up a wound, and the senior resident blows us away by her speed. One day, that too, may be us... :)

Specialty Medicine

I'm loving every minute of this beginning of our PGY-2 year, but there are a few things that are very different from prior experience in the medical field (medical school and internal medicine internship) that will take getting used to.

- We no longer work in a group (in internal medicine that used to be a whole slew of people including one resident, 1-2 interns, 1-2 medical students, possibly a fellow, and the attending); rather, we work one on one with attendings, and sometimes have a student around. It's a little strange to not have others around, partly for the social aspect, but also because you lose the sense of what you are supposed to know - whether or not you're performing at the expected level or whether or not your knowledge level is adequate...

- We get lectures on topics that we don't know, but they are spread out throughout the year, so there are diseases and medications that we are NOT familiar with. I guess that is similar to the jump from medical school to internship, but at least for that change we had 4 years of medical school "training" mainly geared towards internal medicine, so even if we weren't very familiar with the material we had at least heard of it, or knew exactly where to go to look things up. Now there are diagnoses that I'm not even sure I'm spelling correctly as I scramble to write down the term to look it up later. And there are a different set of medications that are commonly used...

- This is pretty much a completely new field for us. Most medical students are mainly taught internal medicine in school, so all of the specialty residents have to try to pick up a new field once they start specialty training. Which means you get through the day seeing patients, then have to read, read, and read some more when you get home. They say learning in medical school is like drinking from a fire hydrant - if so, this is the 2nd fire hydrant in medicine.

One encouraging thing - today a third year in our program was discussing a differential diagnosis with the attending and pulled out a whole bunch of diagnoses that sounded really foreign (and very cool), and it's good to think that in two years, maybe, just maybe, we might be in her shoes...

Welcome to the VA

Yesterday was our first official day at the VA and it was GREAT! We were extremely busy but it was a lot of fun. For the most part, the patients at the VA are very pleasant to work with. Our clinic nursing staff is really helpful, and although learning the system has been tough, it's been a blast. It's great to finally be the specialist and be able to focus the visit on one organ system, and there's no lack of variety in our field - lots of interesting problems and a good combination of medical and surgical treatments. Never a dull moment!

Orienting...

Day #2 (and final day) of Orientation

Lasted from early morning until 6pm. A lot of words passed on in one direction (orientor ?? to orientee), much of which was standard fare - "this is required by the VA," fingerprinting (the government solution to a stolen laptop?), etc. At 6pm, one of the older residents had to give us a real orientation with information that can actually help us get through tomorrow...

The VA is a "high volume" clinic, but apparently in preparation for our anticipated ineptitude, the clinic has "down-booked" patients so we will only have to see four an hour... bring on the madness!

Aloha!!

Am back to reality after a great week in Hawai'i... Really enjoyed the beautiful scenery, the people, and the culture, and you can't beat poke, plumeria, and green sea turtles!! :) Each island really deserves its own little blurb, and hopefully I'll get around to jotting the thoughts down after processing everything.

For now, it's back to work. I'm starting in a new specialty in a new system and am really looking forward to it. Today was orientation, which was a little overwhelming - I guess you just have to accept that the first few days (weeks? months?) will be information overload, both on a medical and on a systems level... Should make for good posts :)