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Back in Medicine

Wow, been a while. Just finished up a medicine subinternship where they told me that I was “rusty” . . . hahaha, so much for trying to do both business and medicine eh?

Still, it was pretty  to take care of patients again. The high points of seeing patients get better and go home to the lows of telling a patient he has cancer and has weeks to months to live.

Ah medicine, its wonderful taking care of patients, but you’re usually too tired to give  a crap.

The bad news is that I don’t think I did very well on my subinternship. The good news is I think I can safely rule out internal medicine as a specialty, hard to be passionate about a specialty where you are paid by your notes so you end up spending most of your time typing and making other people see your patients so they can type notes too.:)

In all seriousness, the system is pretty broken, tests are too easy to order, thinking and teamwork are discouraged and the patients too often get care that they did not want or need and may be bad for them.

On that lovely note, I’m back to business next week working for a consulting firm in Boston . . . more later

Emergency Med reflections

Been a busy couple of weeks. Professionally, its the middle of the hump right now and emergency medicine has definitely been a roller coaster, if nothing else. Part of me likes the excitement, there are definitely lots more procedures and you really do feel like your doing real medicine. Real world patients, you really do get to learn how to save lives, a little bit of ICU, a little bit of OBGyn, a little bit of peds, a little bit of anesthesia and a little surgery as well as a whole boatload of medicine problems. I do think I miss the safety and security of a structured and slower paced environment like an internal medicine at CPMC. During my shift I always feel like I’m frenetically running around and treading water just to stay afloat. But as Jane said, I will definitely give it till the end of my rotation and having a little patience before really weighing in on it. On the other hand, I do really like it when I am complimented and my confidence level goes up a bit.But man am I tired after doing these shifts.

Right now I think Emergency Medicine would be ideal from a career point of view, higher pay, less hours in the hospital, very interesting and exciting which would allow me to do VC or be an entrepreneur while still supporting myself.

On the other hand, I just like hospital medicine more: a little slower paced but not outpatient, more time and opportunity to think through differentials and read up on diseases. And I kind of like the academic environment and the people are more to my liking, more thinkers than doers. And you have time to think in a less hectic setting where there are still acute things. And you still have the opportunity to do outpatient later on in life. I will definitely say that being in the clinic is definitely a lot more chill than having to go to the hospital every day. It just makes me feel a little inadequate though to think that you really won’t be very proficient with procedures compared to ED with internal medicine. And the pay is almost half that of EM which is unfortunate and I really don’t think the culture is quite there of moonlighting etc.

Maybe all this rumination eventually comes down to that last line.

A good day in outpatient medicine

Its been a while and I need to catch up on blog entries (Not that my life is so exciting between studying for boards and being cooped up in the hospital).

Anyway, ongoing thoughts about outpatient medicine. I’m on my last day with Dr. H here in Claremont and its really been surprisingly good. There is a side of outpatient medicine that is attractive: getting to really know your patients and also being the first line to pick up really bad things when they could otherwise go unnoticed. One of the highlights during this rotation was finding a woman with a large retroperitoneal abscess likely either from a ruptured appendicitis or a appendiceal tumor who came in because she was just feeling lousy and looked kinda crappy and had some diffuse aches and pains and a tender belly and some pale eyelids. We got a stat white blood cell count which showed that she had 20,000 white cells (normal is less than 10k) and was anemic with a hemoglobin of 12, scanned her belly and found the abscess. She got the abscess drained and put on IV antibiotics. We probably prevented a life threatening blood infection in her and probably saved her life. In some ways it was kind of like the emergency which WE found and upgraded rather than the patient defined emergencies for which they go to the ER on their own initiative. Either way, you’re really saving a life which is very meaningful. A very different twist on Emergency medicine!

Of course my preceptor (this funny German guy who is VERY German, always on time, uber efficient, the ultimate task master who expects things to be done 10 minutes ago whose idea of fun is to rent a smart car instead of a taxi from the airport) think I ought to go into primary care because “its more important”.

Great day in Medicine!

Man, what a great day. It started as normal, actually a little later than normal because I got out of bed late which made me preround on my patient late which subsequently made me late to morning report. As I sheepishly slinked into my seat, I beat myself up in my mind for being late, what would my program director think of this guy that’s always late? I thought to myself. Gave a nice presentation on Cdiff colitis with my team and then retired to the doc’s lounge to “read” and just sit around. Then around 1-2 got a page from the GME office that I had a package. It turns out that one of my patients, a sweet old lady who had a TIA and some hyperlipidemia owns a vineyard down in Carmel and actually SENT ME A BOTTLE OF CABERNET from the vineyard with a little card directed to “Dr. Eugene Hsu”. After celebrating a bit and telling my senior resident M about it, I happened to ask M to fill out a little evaluation card for me to give back to Dartmouth. On it, I didn’t expect to find a comment about how one of my patients actually said to M that she wanted me as her primary care doctor. It was literally one of the best compliments I have ever received in my life! It really made me feel good about myself better than any compliment, score on a test or feedback in med school. Then to top things off, at the end of the day around 6-7pm, I still hadn’t admitted any patients despite lolling around all day and I decided to “stick around for one more patient” despite my senior resident telling me I could leave and that “it wasn’t worth it” to see this last patient. It turns out this patient had some lower abdominal pain associated with filling of her bladder and needed to go constantly ever 10 minutes to relieve the pain and I was able to come up with a diagnosis (interstitial cystitis) that fit her clinical findings PERFECTLY and presented the perfect assessment and plan to my attending who agreed with me and told me the H+P was “great”. It all went so well, I felt so confident and on top of my game. Anyway, I left the hospital whistling and singing. Later, J told me that this was a lesson in faith, patience, interdependence. Whatever it was, for the first time in a while I think I know what I’m doing . . . and I’m doing it WELL!

Excited!

Wow, its amazing, I just had dinner with my buddy Dan who is an MD/MBA and inventor of medical devices. Man, that stuff is so exciting. It makes me excited just thinking about doing that stuff. Anyway, hopefully I can work on that stuff when I get to Tuck . . . can’t wait, can’t wait, can’t wait

Medicine – on the differential

Since second year when I shadowed Dr. P at DHMC, I have liked the idea of hospital medicine. You get to romp around the hospital, changing orders, negotiate with specialists, communicate plans, counsel and even break bad news to patients. Its more continuity than the ER but not the agonizing length and commitment of outpatient medicine which I think I simply do not have the patience for as important as it is. Add to that the versatility of seeing both routine “social visit” patients and very complex acute care patients and hospital medicine seems like a good choice.

The patient I am seeing now is a case in point. This guy is a noncompliant 65 yo patient with full blown AIDS and a CD4 count of 18 and a viral load of 176k who is here with 12lb weight loss, fever and chills likely due to an opportunistic infection exacerbating some possible hypogonadism (fancy word for your endocrine system not working well anymore and causing your metabolism to be out of whack). I like stabilizing the patient and then taking symptoms, tests and thinking and looking up literature about what could be causing this guy’s problems then going back, discussing it and coming up with a diagnosis or plan that is not only the state of art care for the patient but is also the result of my creative and diligent researching. I like explaining these things to my patients, educating them, treating them and then discharging them when they get better.

I guess the only drawback is the acuity of care, there is still a difference between surgical and medical patients in the sense that surgery is really still the last line of defense when medical options have failed and carries with it the gravity (and also the rewards) of being responsible for the life or death of a patient. I wrote to Dr. B at the end of my trauma experience thanking him for teaching me how to save lives. As cliche as that might sound, I really meant it because the satisfaction of seeing my kickboxer patient who was literally dead weeks before sitting up in bed and talking to him knowing that myself and my team played an important role in saving his life was probably one of the most meaningful experiences in my life.

A reminder about residency

Just got off the phone with my old boss from J&J who reminded me once again 1) of how much fun I had at J&J and 2) of how important it will be for me to become a real physician. He told me about a story of how he walked through the ER and was able to pick out a young guy who was having a heart attack just because “he didn’t look right” and I also shared with him my story about the kickboxer I took care of who had severe rhabdomyolysis and multi-organ dysfunction who we saved on surgery. He told me how important it was in organizations where people are too scared to make decisions to have the skill of making the right decisions with insufficient data, the skill that physicians put into practice on a daily, if not hourly basis. And for the rest of my day at least, I will be feeling pretty good about where I am and where I am going.

From Alice

I heard something today from one of my patients that I really have to write down . . . she told me “Please, be a good doctor . . . or else don’t do it because its going to be a lot of hard work”

That pretty much sums up my decision.