Man, I love having weekdays off

I'm sitting in Cafe Spritzers in Alameda after a breakfast of samosas and pluots (cross between apricots and plums and damn good and juicy) that I got from the Webster St Farmer's market. Tomorrow is my last day of emergency med at highland hospital. I think I've done well there and the training has definitely been a trial by fire but certainly made me a stronger better trained physician. Its certainly not going to be an easy road ahead. Part of me really longs for the idyllic worlds of places like CPMC and DHMC where the patient's send you wine, thank you for your help and tell you how great a doc you are. But there is something about medicine that I've realized, maybe it shouldn't be easy. Thinking about doing emergency medicine seems like a really really long hill to climb. Its no wonder so many Highland residents finish residency and then do 6 shifts a month, they are simply burned out and need time to recoup, reflect. Sure you learn how to save lives but at what cost? My thinking now has turned from do I like/love emergency medicine enough to can I even make it through this residency? Yet the skills are quite amazing. I talked for about an hour with an old Chinese gentleman during a medical code yesterday AS HE WAS DYING in front of me. He was having a severe heart attack. We had to shock him 4 times and gave him thrombolysis (clot breaking medication) to save his life. Twice I had to start CPR because we couldn't find a pulse. Both to distract him from the pain and to assess his mental status, I talked with him about the Beijing olympics, about his family, his grandchildren and what he had for dinner that day every minute reassuring him that everything was going to be okay. Ultimately we were able to transfer him to a hospital in Oakland with a catheterization lab where the cardiologists can mechanically image and make sure the blood is flowing to this man's heart and on the way I heard he began to reperfuse his myocardium. We saved his life. A few hand slaps and sighs of relief later with the residents, my shift ended and I was satisfied that we did the right thing for this man by giving him risky but life saving medication. But as I left the hospital that day, I felt something was missing. Where was that buzz of excitement that I had from saving my kickboxer patient with the rhabdomyolysis? Or the sense of purpose that I felt after giving my Chinese patient bad news about his lung cancer? I was so tired I just wanted to go home . . . to finish this month and relax . . . I know by my the evaluations and compliments I've received from patient's and supervisors that I can play the role well . . . be polite, listen to the patient . . . but is this the kind of doctor I want for myself?

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.

I've always wondered what happens after you hear the broadcast. Today I got to find out. K was a 32yo gentleman who I met in the rear galley of a 737 headed to San Francisco from Boston. He was in great health, in fact he was a former professional basketball player. K had just come from a reception in which he ate some seafood and creamy bisque soups that he normally wouldn't have eaten but then felt fine and boarded the flight. Halfway through, he began feeling nauseous. He stood up hoping the feeling would go away but the nausea got worse and he eventually had to make several trips to the bathroom to throw up. It was at this point that the overhead broadcast went out. At the time, I was engrossed in my new iphone playing a game while listening to a korean pop song. Two physicians were already attending to K when I first saw him in the rear galley. He was a tall guy, probably about 6'5" with a muscular build looking pretty sick to his stomach and sweating from the retching. I brought the doctors my stethoscope thinking it was the least I could do while reprimanding myself for feeling so self important as thought I could add anything of value as a medical student. "Its probably a gastroenteritis . . ." I overheard one of them saying in a well-practiced outside-of-the-patient's room tone of voice. "Yea, you're probably right, I have some meclizine in my bag, do you think we should give him some?" . . ." I heard the other one say. "Naaah, he doesn't need it."
They took my stethoscope, listened for a moment then handed it back to me without looking or acknowledging my presence . . . "Just like on rounds . . ." I thought to myself. So sheepishly, I decided that there was really not much more I could add at this point, after all two full fledged physicians were already attending to K and what else could I the lowly medical student hope to offer him that they could not? So I shrugged and headed back to my seat. Luckily, I among the 30lbs of books I had with me was a quick read Emergency Medicine handbook that had a short chapter on nausea and vomiting. It explained that the usual presentation of "just a gastroenteritis" was vomiting AND diarrhea and that the two most commonly missed or dismissed surgical emergencies were bowel obstructions and appendicitis. In a young guy like K, certainly these were possibilities as well right? I convinced myself that I really ought to check on him again in a few minutes. By the time I made my way over and introduced myself, the other two docs had returned to their seats allowing me to examine him alone. I found out he had some LUQ pain which he said started before he threw up, that he did not throw up any bile or blood or stomach contents but that he was not passing gas or stool. He also said he was starting to feel light headed when he stood up. I examined him, felt his pulse which was strong, slow and regular. He belly was soft not rigid and I could only elicit tenderness near the border between his ribs and stomach. He did not have any headache or trauma, no recent alcohol or NSAIDs, had not been sick or feel warm and did not have sickle cell or any other spleen trauma. We were about an hour and a half into the flight and he had been back and forth to the bathroom, didn't have any pain or swelling in his legs so I did not suspect a clot that had formed in his legs which traveled to his lungs. He had no family history or medical illnesses besides some mild asthma. Without even thinking about it, I had ruled out a series of life threatening causes for his pain and vomiting and had even gotten to know more of K's story. He had played basketball in Europe for a few years, but decided to get his master's in education because he had some bad experiences as a student growing up and wanted to change things. He had taught for a few years and risen up to become principal of a charter school near Sacramento whose student body was comprised of mostly kids from households living under the poverty line. K had finished a second Master's in Institutional Leadership at Harvard which he did as a correspondence program while working 80hrs a week as a principal, substitute teacher, basketball coach and mentor for his students. We chatted about this and other topics as I monitored his pulse and watched him as he continued to rush to the bathroom every few minutes. In between the rushes, we had a fascinating discussing about the pros and cons of affirmative action, the problems facing public funding for schools or healthcare and how to change a culture of despair into a culture of confidence and resilience. During one of these lulls, K and I shared thoughts about passion for one's work. It was then that he told me that he could tell I was passionate about medicine to which I responded that I was really tired and stressed by training and sometimes wondered if I could really handle the tough lifestyle sacrifices in medicine. K then told me something that I never thought of before. He said that passion is really about following through, persisting and taking the time and care to make sure something gets done. "You know you are really passionate about steak because when you crave it, you go out and buy some meat, grill it up and get that steak on your plate".
"If you weren't passionate, you wouldn't be back here, you would be at your seat, playing video games or reading a book, you wouldn't be spending all this time talking with me"

I never thought of it that way but when I think about it medicine is really the only thing I have ever done which I can really say I put 100% of my effort into over such a sustained period of time (5 years if you could my post bacc studies). And still I think about the planning, the anxiety of doing a good job, staying late to make sure a patient's labs are reported, rounding on the patient one last time before the shift ends, coming in early to check on someone and spending an additional 5 minutes with a patient to listen to their story before rounds. These are not things that typically characterize me.

And then I realized that doing whats right and not whats convenient is what medicine is all about. But it has its perks. K told me about the story of a student who "made it" and I could feel the passion in his voice when he talked about how great it felt to know that this person would be the first in their family to go to college then pass that work ethic and resilience onto their kids and so one for the next generations. Perhaps all of my thoughts and schemes of finding the perfect dream job focusing on what this person has and that person has and wouldn't it be nice to have is misplaced. Perhaps what I should really focus on is not what others have that I want but on what I have that others do not. Perhaps being great is not just about securing a fancy sounding title or degree or maximizing your potential earnings but about using your skills and your passions to follow through, build relationships and make a difference in someone else's life.

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".

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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.

I think Barack really understands on a human level this connection that can happen in a big crowd or with one person, one at a time. Its this ability, this quality of inspiring others even when he is criticized (including by myself several times in conversation) that he is too abstract or too dreamy that will attract those around him to believe in his vision and put in the work to achieve that vision. Having seen the fruits of leadership in several institutions now, the leader not only sets the vision, but creates a culture within their organization within which the work of achieving that vision happens. Whether its in a residency program who attracts the right kinds of residents and lets them be their friendly, caring selves or a business that attracts the brightest but also most competitive individuals that do not like to work together, it is ultimately the leadership who sets the cultural tone for the organization and inspires others to either work for the common good or work for themselves. I believe that I've underestimated this quality, this ability to inspire the best in others that Barack possesses which is so vital to leadership. I've become so mired in memorizing molecular minutia in medical school that perhaps I've lost the perspective that its seeing the big picture that may matter most in the end. Vote for Barack Obama in November!

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That pretty much sums up my decision.

Me, Mark, Dr. Guzman and Dr. Kandell

Me and Ernest - family med nurse extraordinaire

Me and Dr. G

Entrance to the hospital

Our good ole family med trailer

Family med clinic waiting room (at lunchtime)

Our last Friday Flea market (this is where we got the good roast mutton)

Gimme some mutton!

Last day at Dinebito (rural clinic 45 min outside of Tuba)

Couldn't leave without a nice sandstorm to send us on our way

Me and Mabel

Me and Dr. Tang (lookit my hair!)

Allosaurus tracks in Tuba!

Raptor Ribs mmmmm

I guess I wasn't the only one who thought that looked good . . . petrified dino dung

Goodbye Monument valley!

A stop in Arches National park (here's Mark at window arch)

Delicate arch

Turret Rock - looks like a gun turret I guess

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