22 June 2011

Getting it right

*(I’m studying for boards (at writing) /just took boards (at posting) = Step2 CK)*

I hate the questions I get right – cancer, terrible diseases, medications, hard side effects to deal with, long-term complications – that I know, for sure, because of anecdotes


I know how you died.
I know how you might die, I know why your life is and will be difficult.

There are the simple ones – the amoxicillin prescriptions we wrote for kids with ear infections, the reassurance, reassurance, reassurance of parents.

The patients who came in with the side effects to medications that I’d read about – EUREKA! moments – your cough, the nagging cough, and you started lisinopril at the same time.
I know the answer to the puzzle.
I win.
Un des lions indomptables, Ebolowa

There are the diagnoses I’ve made because they were so “classic.”
(The people on the subway I’ve wanted to/have diagnosed at glances because I can’t help it. That part of the brain doesn’t always turn off.)
When a friend’s telling you a story and the diagnosis isn’t the point of the story but all I can think is – the diagnosis – the one he was given, the one that makes everything so hard – isn’t right. (in the end, it turns out, I am right. Turning point. I solved it)

I hate when it’s the ones who are dying. I get it right.

But then – that’s the point, isn’t it.

We're supposed to know the common things, classic presentations - the "bread-and-butter" cases. We're supposed to know the rare things - the "zebras.*"
We all know the same diseases. But these are how I remember mine, the pictures conjured. Everyone has their own.

*when you hear hoofbeats, think...

Some patients have been so happy to be part of my education

There was the mother of one of my patients –
Maria, my patient, was pregnant with twins. I was there for the delivery – and I delivered the placentas, but I didn’t get to do the birth because it was complicated, one was breech and one was vertex (normal). Anyway. Maria’s mother was so excited that this was my first delivery, that I would always remember them for that, and that they got to be such a special part of my life.
First? No. Delivery? Well, placenta, and I did lots of those. Not very exciting.

Remember them? Yes. I remember Maria, her friend, her mother, her grandmother, the twins…her in labor, her coming in twice prior to being in labor, the preeclampsia, her friend’s cell phone ring.
I remember. And that was a year ago.

I don’t remember because of this, though maybe partially – Maria had preeclampsia. She was the first patient I took care of, personally, who had preeclampsia. So when I think about that process, I think of her, and then I think of Shonda, my family medicine patient who had had preeclampsia and was still dealing with it, weeks after giving birth. I remember her daughter’s name, and how her uncle died and she still came in for the appointment with me but she was late…And because of her, I remember the medications you give for preeclampsia.

Belize City, Belize
And then I think of Melinda, who had debilitating OCD and was losing her house and I called to remind her about the appointment and she was crying to me on the phone… and that’s how I remember that condition. Then I remember the night I met Melinda, in the ER, when she was in for evaluation of DVT versus cellulitis. I remember the work-up we did, and the differential then and later, when she was in my primary care clinic. I remember – family history – her son had a blood clot (genetic bleeding disorder?) – but mostly I remember that he died when he was 15 and she was saddest to have her house foreclosed on because it was where he had lived, with her.
And that’s how I remember the tests we run for problems with clotting, too.

What drugs people like for what.

I remember how serious pseudotumor cerebri is from Cristina, how her symptoms were, how they affected her life, what the treatments were – and in order. What she looked like – some classic features, too, in how they describe the cases, and that she preferred dialudid for pain so they called her drug-seeking.

Make me a better doctor? Could argue indirectly that I’ll get into a “better” residency with “better” scores – though, other than the quality of teaching (important), access to multiple hospitals, including tertiary care (important for breadth of learning) -  prestige won’t make me learn. My teachers will – the other residents, the fellows, the attending, with me teaching med students and later interns/residents as I move up.

But this is about pattern-recognition (so is medicine) – the African-American male (or boy) or African-American woman in her 30s or white woman in her 20s or Asian man in his 50s or obese young woman – for the test, anyway, they’re consistent, insistent, and repetitive with epithets. Those will, in general, mean very particular things.
This is about getting things right (isn’t medicine?) Medicine, though, isn’t multiple choice.

How I’ll always remember what Crohn’s does to a person. Seven years on a college police force and how many days he had to take off from work. He hoped this surgery would work for a longer period of time. As I was about to leave the room – history, history, physical, and me listening in to the gastroenterologists as they explained the condition and what would happen from the operation to him – he stopped me. “So, what does laparoscopic surgery mean?”
Somehow we’d missed that point. Words that become commonplace. So the CO2 insufflation, the little camera and TV screens and tools through small ports – something I’d seen enough to describe. And I remember what they did with the tiny instruments operated by larger hands, and why.

Serena, twenty-five, aching joints, weight loss, fluid around her lungs, fluid around her heat. Getting married because of a diagnosis of lupus – and all the symptoms of lupus – she had most of them. She had all the lab values too – those get tested a lot.

Tikal, Guatemala
Myxedema – what happens when hypothyroidism goes to your head. That was the Portuguese-speaking patient, Julia, who hallucinated numbers she drew into her hand. Everyone thought it must be difficult to communicate with her, with the language difference – that and her tongue, so big from the matrix deposits from Hashimoto’s hypothyroidism, not quite fitting in her mouth. She and I discovered we could communicate in Spanish. I wonder who had tried that.
At any rate, the changes in personality, per family, her forgetting things, and her dreams and dreams and dreams of numbers that she drew on her hand and on the back of my patient list – I wasn’t carrying any other paper.

CHF* exacerbation vs pneumonia, or COPD* exacerbation: that was one of my first ER patients, and it’s a common distinction to make. I got it wrong in him (the resident got it) . And that’s how I remember. The disease and how to distinguish. Mostly I picture him where I met him, on that gurney in the ER hallway (busy day, that was Yellow Hall bed J, or something), long hair sweaty around his face, uncomfortable, leaning forward, trying to breathe better, pausing between every few words. That and how he couldn’t afford his medications anymore because he got a job that didn’t pay enough to cover them but mean he had more than zero.

*Congestive heart failure. Chronic obstructive pulmonary disease: emphysema, chronic bronchitis

A classic hand fracture and how I effectively used a hand musculoskeletal, cardiovascular, and neurologic exam. The snuffbox fracture and how I was more worried that the patient would reinjure it because basketball playoffs were the next week (this, to me, wasmore of a reason to cast it, poor kid) . If we didn’t? He could lose blood supply to that part of his hand and end up with a permanent injury, nerve damage, etc. . .Good kid. It was right after his birthday, too. He understood. I remember the treatment – the spica thumb cast – because everytime I called radiology they were either not in the office yet (too early for them) or about to go to lunch (I win!), they’d read the X-ray over the phone with me, and then I had to call the orthopedists to make an appointment. Again. Or call the patient and tell him to go to urgent care. Again.

The angry little girl? Her condition comes with very rare infections. I remember the bugs and I remember the drugs we used, they showed up in my repetitive progress notes every day. I know the treatment regimens from talking with her and her mother. She showed up on boards.

There was the kid with the rare immunodeficiency and brain abscesses, on IV antibiotics at home (devoted, attention-to-detail mother) . He came in for appendicitis that we knew he didn’t have, but anyway, he’d had these abscesses in his brain and his lungs. And he didn’t have appendicitis. But I met him and I met the family and I read the chart. That kid showed up a lot in boards practice questions – the disease he has, at any rate.

How to remember genetic inheritance of diseases encountered. Who in the family has it? I pin diseases to people, in my tenuous neuronal connections. One disease is a friend-and-her-family-tree. I’ve read about it. It’s interesting. It can have a lot of features that she (thankfully) does not have. But I care because of her. And she’s how I remember it.

I’ve seen a lot of patients this year.

Side effect? getting questions right on a nine hour multiple-choice test.

Effect? Learning how to take care of the real ones.

No comments:

Post a Comment