If Shelf Exams Actually Were Representative of What You Saw in the Wards

Pediatrics

1. A 7 year old female presents to the clinic with a three week history of looking "not quite right." This is her third visit in the past four days. The patient's mother is on disability due to cologne exposure at work, and the patient is uninsured. Her mother states that she has been having fevers as high as 37.2 (99) degrees and has been having early morning awakenings, e.g. 8am. Physical exam, family history, and past medical history are benign, but limited due to the patients use of her Nintendo DS during the exam. Her mother states that she had a cousin who was sick with HIV that felt better after receiving antibiotics. What tactic might keep the patient from returning to the office in the next 24 hours.

a. Give gentamicin, hope for an adverse effect that requires a ENT consult

b. Tell the patient the office will be closed for the next week

c. Give the mother a prescription for Valium

d. Put them in the waiting room for 4 hours before telling them their rapid strep was negative

Surgery, Medicine, Neurology, Family Medicine:

2. A 46 year old male presents to the clinic with unbearable pain. He leapt unto the exam table like a Russian gymnast when no one was looking but now winces and moans in pain when the stethescope is placed on his chest, despite the fact that he complains of knee pain. All radiographic studies have been negative. He begins the interview by offering that he "isn't looking for pain meds or anything." In fact, he's never been better--in order to keep feeling better he just needs a few more vicodin to get him over the hump. When you ask how much he would need for a month he says "I don't know man!" When you write a prescription for sixty 5/500s he goes ballistic and accuses you of not "understanding" how much pain he is in. His unkempt wife sits in the corner shaking her head scoldingly. What is the next step.

a. Keep the patient from getting between you and the door

b. Refer to chiropractic care

c. Give daily cortisone shots for a week

d. Recommend physical therapy

to be continued...

Amazon Seller's Account (or The World's Worst Customer Service)

Being a medical student, you go through a lot of books. From the first day of school when you are told to purchase a dissection guide, Grey's Anatomy, Netter's, and a book of pictures of dissections, we collect lots of books that are nice to have for the 4 months of the course but have little value otherwise.

I thought I would be forever condemned to keep bookshelves full of useless materials--then I found the Amazon Seller's Account, but first a little background.

I've been buying books off Amazon for years. I'd estimate that I've spent a couple thousand dollars, both on books for myself and medical books that I've needed for courses. So you can imagine how excited I was to find a seemingly easy way to resell the books.

So within a few minutes I had opened an account and listed all of the old books that I wanted to get rid of. Keep in mind I had never opened an account before. Imagine my surprise when I received this email from Amazon within 6 hours of opening an account.

Hello from Amazon.com.

We are writing to let you know that we have blocked your selling account. Your open listings have been canceled and you may no longer sell on our site. Any subsequent selling accounts that are opened will be closed as well.

We took this action because it has come to our attention this account is related to an account which has been previously blocked for performance issues or violations of our policies. While we do not provide detailed information on how we link related accounts, we have significant evidence that this account is related to a previously blocked account.

While we appreciate your interest, please understand that the closure of an account is a permanent action. Thank you for your understanding with our decision.


Regards,

Seller Performance Team
Amazon.com

First off, who's idea was it to send out form emails like this to valuable customers, especially if there was a chance they could do it in error. For someone who puts value in their word in commitments they enter into, it was very offensive to hear these baseless acusations.

Clearly Amazon had made a mistake as I had never opened an account in the past. I expected that a quick email would be all it would take for them to correct what must have been a clerical error--how wrong I was. Here's the next email that I received in response.

Greetings from Amazon.com

I have verified that your account has been blocked by our Seller Performance team on January 30, 2010. Please e-mail them at seller-performance@amazon.com regarding the status of your account. You may also reply to the block notice in the Notification page of the Customer Metrics section in your selling account

For more information, see our Help page on Appeals for Suspended or Blocked Accounts:
http://www.amazon.com/gp/help/customer/display.html?nodeId=200370580

Questions about your funds should be directed to our Payments team at payments-funds@amazon.com.

These departments do not offer telephone support. However, they will respond to your e-mail as soon as possible.

For more information on your Seller Performance ratings, please visit:
http://www.amazon.com/gp/help/customer/display.html?nodeId=12880481

Thanks for being part of the Amazon.com online community. I do hope this message finds you well and I wish you all the best in all of your future online sales.

Best regards,

Carlos V.
Amazon.com Seller Support

Clearly this was another form email--Amazon may not have any problem accusing people of wrongs they haven't done, but I guess they have difficulty actually responding to emails sent in response.

In my final email I stated that because my issues were in no way addressed I would be canceling my Amazon credit card and never purchasing from them again. Here was their response (note: in my email I never mentioned being "singled out" this must've been their email they send out to people who don't just give up and allow their name to be dragged through the mud..

Hello from Amazon.com.

We apologize that you feel singled out by our actions, but want to assure you that is not our intention. Be assured that our policies apply to all sellers.

We regret we are unable to provide further information on this situation. Further correspondence regarding the closure of your selling account will not be answered.

The closure of this account is a permanent action. Any subsequent accounts that are opened will be closed as well.

Best regards,

Seller Performance Team

Needless to say, if others are dealing with this problem, Amazon is going to have some PR difficulties in the future.

Update: This is the 5th ranked site in Google when one types "Amazon Seller's Account"! Which is great! I feel like in some small way I am "sticking it" to "the man," for how despicably they treat their customers. If reading this and having a similar problem, please share your story in the comments section so as to help get the word out.

Young Hearts and Lauren Hill

Yesterday we had a review of EKGs. When discussing EKGs the cardiologist mentioned that "Young hearts may demonstrate U waves." All I could think about was asking him if young hearts beat free tonight.

A week ago a woman named Lauren Hill came to the hospital to teach as about diversity. I wanted to ask her if she was familiar with the fact that: girl you know you better watch out, some guys, some guys are only about. That thing, that thing, that thiiiing.

I'm easily distracted.

The Ambiguous Psychiatrist Sound

What do you do when your goal is to elicit as much information as possible from a patient while neither supporting nor condemning their thoughts/actions? The answer is the ambiguous psychiatrist sound.

It's somewhat hard to describe if you have never heard it firsthand, but I'll do my best.

It somewhere between "Mmmm" and "Hmmm" but it isn't just the combining of the two sounds "Mmmmhmmm" because if you aren't careful "Mmmhmm" can come off as sounding condescending or disbelieving.

Instead it is almost an impossible fusion between the two sounds. As if you could be saying both Mmm and Hmm in the very same instant. It's best used with a gutteral, breathy not to disguise any possible inferences that a patient could possibly derive from the sound. Additionally, the best psychiatrists can include an almost imperceptible rise in pitch at the end of the sound to further confuse the patient as to whether it was questioning or affirming.

It's like saying "I respectfully want to inform you that I'm listening but I want you to clarify, if you are able" but with the simplicity of one syllable. In short, it is the perfect sound in the hands of a skilled practitioner and it can work wonders on the psych ward.

Health Care Reform: Medicine vs Surgery

Lost within the political debate over healthcare reform, is a battle currently going on within medicine itself. Although most if not all doctors agree that there needs to be significant changes to the health care system, there is significant debate as to what exacty this should entail. Before I get too far ahead of myself, let's go back to the opening salvos...



In response to this statement the American College of Surgeons released the following letter, which goes on to decry the gross exaggeration of what a surgeon makes on a given operation. In addition it states that misinformation regarding healthcare does nothing to further the debate, adn that the surgeon patient relationship could be damaged as a result. Also, interesting is the many surgical subspecialties that signed on to the letter. This was not just the American College of Surgeons (ACS), but it also included everything from the American College of Obstetricians and Gynecologists to most if not all of the surgical specialties (Urology, Orthopedics, ENT etc.).

More recently the American Medical Association (AMA) has come out in support of the current legislation that passed in the house relating to health care reform. In a letter to Speaker Pelosi, the AMA applauded many of the proposed changes that the bill would enact--specifically they stated that the bill would expand coverage, reform the insurance industry, and protect patient-physician decision making.

Not long afterwards the ACS shot back with this letter to the senate, cosigned by 21 other specialty organizations. It rebutted several of the points made by the AMA and focused on several key issues that it had with the bill.

Additionally they reaffirmed the need for Tort reform in this statement:

CHICAGO: The American College of Surgeons applauds Democrats – led by House Majority Leader Steny Hoyer (D-MD) – for recognizing the need for Congress to address medical liability reform as part of the overall health care reform bill currently under consideration. Over the past few weeks, we have been encouraged to have heard Democrats and Republicans across the country talking with constituents at town hall meetings about the need to address this important bipartisan issue.

The current climate in this country is one in which surgeons and other physicians are forced to practice in an environment of defensive medicine, sometimes ordering additional and possibly unnecessary tests in order to avoid lawsuits. Addressing medical liability reform as part of the overall health care reform bill will help to stem the tide of rising health care costs.

The American College of Surgeons urges President Obama to make medical liability reform a more central component of his call for overall health care reform. Further, we urge the leadership of both the House of Representatives and the Senate to include this important issue in the bills that they will take up in the coming weeks.

Here is President Obama speaking to the AMA regarding Tort reform.


Recently, the ACS has released a side by side chart of the House and Senate bills, along with what they view as some of the drawbacks.

The battle lines seem to have been drawn, with the AMA standing with the president and the majority of the Democrats (except Tort reform), while the ACS and most Republicans stand in opposition (although both groups support repealing the Sustainable Growth Rate provision--something opposed be most Republicans and some Democrats). It's interesting to me how this has happened, I wonder if the average surgeon would describe themselves as being right-leaning politically and the average medicine doctor would say they are left-leaning, or whether this is just how the chips fell in this one instance.

Surgery - The Start of Third Year (Part 1)

After two days of ortientation both to the hospital and the surgury rotation in general we were finally able to start getting our hands dirty learning the basics of general surgery. I was both extremely nervous and very excited, nervous that I would make some glaring mistake, nervous that I would ask stupid questions and be thought of as a student not deserving of the trust that was placed in me, nervous that I would not be able handle the long hours associated with the surgical rotation, but most of all just nervous that maybe I was not going to be able to cut it as a clinical medical student. At the same time I was also very...

Excited. Excited that I never again would spend days on end studying for a (mostly worthless) biochemistry test. Elated that I was now going to be working with real patients. Overjoyed that I was going to play some small role on a team that was working to help heal patients. Needless to say it was a time marked by dramatic mood swings.

Before I get too far, I should give a little more background.

The surgical rotation that I am on does mostly common general surgical procedures, for instance gall bladder removals, appendectomies, thyroid and parathyroid surgeries, some melanoma removal and emergent surgical cases.

The service that I am on is specifically a trauma service, so over the course of the next 6 weeks I'll be helping to take care of a lot of patients who have been in a car accident, or fallen and broken bones, or patients that require an emergency appendectomy or other urgent procedure.

I found all this out during the first two days of orientation, but nothing that they tell you during orientation could prepare you for the experiences and emotions that you will feel as you walk into the hospital on your first day of work.

Immediately I met the chief of the service--for the unindoctrinated, the chief of the service is a doctor who is in the final year of their residency, in general surgery this means that they have been out of medical school for 5 years. In my situation the chief resident had been a doctor for 6 years as she had taken a year to do a fellowship in critical care.

Also on the trauma team was a first year resident, aka an intern. At many hospitals, about half of the interns are on a track to become general surgeons while the other half are either in a year-long "preliminary surgery" program or are in a "transition year". For the most part, those in those in the "preliminary surgery" program are either US or international students that didn't match into the surgical specialty they wanted to (ortho, ENT, general surgery, etc). Students in a transition year have already been accepted into other programs, but as part of their training they rotate through different specialties for their first year. For the first month we had a transition year student who was accepted into the Radiation Oncology program, and the second month we had a Preliminary Surgery resident.

I was very fortunate in that I was on a relatively small team for my surgery rotation. In other hospitals, 4 medical students would be assigned to teams of 10 residents. The major difference between our 3 person team and the larger teams seen at other hospitals was the lack of mid-level residents on our team. In other words the 10 person team would have a number of 2nd, 3rd, and 4th year residents sharing the workload. The downside to a small team is that when there are 40 patients on the rounding list for a Saturday you only have the three of you to see them all. The upside is that many times in the OR it was just me, the attending and the chief resident doing a case. Which for me was the most interesting.

Start of a New Chapter

A week ago I started a new chapter in my medical life; 3rd year rotations. It has been a huge adjustment, but a very fulfilling one at the same time. No more speding days on end with my nose buried in a book. From now on the majority of my learning will be hands on.

When I have the time I'm going to be writing about the experiences that I have while on rotations so that I can someday look back and remember what it felt like to be just starting out.

For my first two months I am rotating through surgery (which I first saw as a curse but am now really enjoying) at one of the busiest surgical centers in the country (in terms of # of surgeries at this hospitals three sites).

Drag Me to USMLE Step 1

I'm stuck in a never-ending Step 1 studying, phase of life, I'll post some more once I emerge.

Secrets of Happiness

A Harvard study of which has been running from the 1960s to the present found that there were seven characteristics common to the happiest of the men studied. The characteristics were: mature adaptations (chosing altruism, humor etc in response to difficult situations), education, stable marriage, not smoking, not abusing alcohol, some exercise, and healthy weight.

The complete article can be found here.

Here is an exerpt from the article taken from The Atlantic:

What happened to you?

You grew up in a kind of fairy tale, in a big-city brownstone with 11 rooms and three baths. Your father practiced medicine and made a mint. When you were a college sophomore, you described him as thoughtful, funny, and patient. “Once in awhile his children get his goat,” you wrote, “but he never gets sore without a cause.” Your mother painted and served on prominent boards. You called her “artistic” and civic-minded.

As a child, you played all the sports, were good to your two sisters, and loved church. You and some other boys from Sunday school—it met at your house—used to study the families in your neighborhood, choosing one every year to present with Christmas baskets. When the garbageman’s wife found out you had polio, she cried. But you recovered fully, that was your way. “I could discover no problems of importance,” the study’s social worker concluded after seeing your family. “The atmosphere of the home is one of happiness and harmony.”

At Harvard, you continued to shine. “Perhaps more than any other boy who has been in the Grant Study,” the staff noted about you, “the following participant exemplifies the qualities of a superior personality: stability, intelligence, good judgment, health, high purpose, and ideals.” Basically, they were in a swoon. They described you as especially likely to achieve “both external and internal satisfactions.” And you seemed well on your way. After a stint in the Air Force—“the whole thing was like a game,” you said—you studied for work in a helping profession. “Our lives are like the talents in the parable of the three stewards,” you wrote. “It is something that has been given to us for the time being and we have the opportunity and privilege of doing our best with this precious gift.”

And then what happened? You married, and took a posting overseas. You started smoking and drinking. In 1951—you were 31—you wrote, “I think the most important element that has emerged in my own psychic picture is a fuller realization of my own hostilities. In early years I used to pride myself on not having any. This was probably because they were too deeply buried and I unwilling and afraid to face them.” By your mid-30s, you had basically dropped out of sight. You stopped returning questionnaires. “Please, please … let us hear from you,” Dr. Vaillant wrote you in 1967. You wrote to say you’d come see him in Cambridge, and that you’d return the last survey, but the next thing the study heard of you, you had died of a sudden disease.

Dr. Vaillant tracked down your therapist. You seemed unable to grow up, the therapist said. You had an affair with a girl he considered psychotic. You looked steadily more disheveled. You had come to see your father as overpowering and distant, your mother as overbearing. She made you feel like a black sheep in your illustrious family. Your parents had split up, it turns out.

In your last days, you “could not settle down,” a friend told Dr. Vaillant. You “just sort of wandered,” sometimes offering ad hoc therapy groups, often sitting in peace protests. You broke out spontaneously into Greek and Latin poetry. You lived on a houseboat. You smoked dope. But you still had a beautiful sense of humor. “One of the most perplexing and charming people I have ever met in my life,” your friend said. Your obituary made you sound like a hell of a man—a war hero, a peace activist, a baseball fan.

Don’t!

Here's an interesting article on delayed gratification, something I'm sure most medical and pre-med students are all too aware of:

Dept. of Science: Don’t!: Reporting & Essays: The New Yorker