Saturday, February 28, 2009

Back to work program

I'm in the self-imposed jet lag that is the day before a night shift after time off. I stayed awake late last night, slept late this morning to the consternation of the household, and I plan to nap this PM. I work from 10 PM to 8 AM for the next 2 nights, then 1 AM to 8 AM for the next two nights. Repeat out for 7 night shifts in a row. Then 4 day shifts and off to South Africa.

The 6 first-year on-call interns admit from 1 PM to 1 AM, then there are three 2nd or 3rd year "float" residents (2 night and 1 day floats -- called NATO and DATO by our program) who cover the admissions from 1 AM to 1 PM. This can be a very, very busy shift and people generally hate it. Where you may take 5 fresh admits in 12 hours as an intern, you may take 5 fresh admits in 6 hours as NATO. One night float gets there early (10 PM) to serve as a modicum of backup for interns who are there alone and may need help with procedures or other stuff. The night floats admit to 7 AM and then signs out their patients to the interns; day float admits from 7 AM to 1 PM.

I'm not looking forward to it. First, there is the issue with switching my schedule around, which I am kind of used to. Second, it absolutely wreaks havoc with me helping out around the house at all. The kids wake up 6-7 AM, and need to get ready for school at 9 AM. They will be leaving the house a few minutes before the earliest possible time I can get home. I'll sleep sometime in mid-day, and I never sleep effectively so I end up sleeping too much during the day. Say 11 AM to 5 to 7 PM. Kids get picked up between 3 and 5 PM so I'm useless for helping with pickup duties as well. Then they are home right as I am getting up, so I'm all groggy and useless with making dinner or cleaning or playing with them.

The third reason it stinks is it is can be extremely busy, with no good time to do good workups, you just hope to admit and to stabilize patients as fast as humanly possible. You then dump them off as fast as possible to the post-post-call interns who hate NATO admissions. It's a great way to ruin your reputation as a thoughtful and complete senior supervisor to these interns. As a senior resident, you carefully supervise and critique their admissions. You review the presentation yourself, spend lots of time carefully examining and questioning the patient yourself, reviewing the literature, and then discussing it carefully with the attending and consultants. It's easy to accept the intern's adoring gazes on you as the Role Model Doctor. That all goes to hell as NATO, when you shovel a hastily thrown together pile of crap right on their head, worse than any admission that they ever would dare to bring to your god-like visage when you were running the team last month...

Wednesday, February 25, 2009

Medical licensure

They make it surprisingly difficult to get a license to practice medicine. I wonder why.

In my residency program, I am protected by an institutional license to practice medicine. When I move to California, I think I can still use the institutional license but they encourage you to get your own. This also allows you to moonlight.

Last week, I started looking into the process. It became immediately apparent that This Was No Joke. "Allow up to 6 months to get a license." California gives a 10 year window for first applying for a license from the date of your first USMLE (licensing) exam. Mine was....August 1999. Extra documentation and possibly an extra exam may be required if it is longer.

Well, I guess I better get started.

Web application then fill-in PDF application took a few hours to do.
$1330 paid online. You know that is going towards the salaries of the best bureaucracy money can buy, finely trained in the art of rifling through a stack of documents and finding incorrectly filled out spaces and missing forms. Then, printing, collation, pasting (not taping) a photograph (not scanned or otherwise modified and Polaroids not acceptable), then notarization of said forms. Web form and $50 for USMLE transcripts. Forms submitted to the medical school for official diploma and transcript. Forms submitted to the hospital for certification of training, along with hospital seal and notarization. Forms submitted to fellowship to attest to enrollment in training program. Cover letters for all of the above. And everything got mailed off at the beginning of the week.

One last thing to take care of. California requires background checks from the FBI and the state. So I contacted the webmaster to send me fingerprint forms, which I got three days ago. Two days ago, I romped around Baltimore to figure out who could roll some prints. Eventually, I found out that not 3 miles from my house there exists a specific Baltimore City office to do just that.

Unsurprisingly, there are a lot of people in Baltimore who require background checks and fingerprinting. The first time I went to the office, there was a line of an interesting pie-slice of humanity out of the door of the office. That line was just a line to the clerk. After waiting in that line, one had to wait to get fingerprinted. I'd estimate about 100 people waiting, so seeing I had to get the kids in an hour, I left. I went back this morning. I got there nice and early to beat the crowds, only had to wait 1.5 hours (I was 9th in line), paid my $20, and got my fingerprints rolled. Mailed them off this afternoon.

It is a good thing because pretty much starting Saturday, I have solid work until June save the 2 weeks of vacation for the Big Trip. Let's see what parts have to be repeated after the world-class bureaucracy gets their mitts on my application.

Sunday, February 22, 2009

The Great GRO Game

The Big Move is turning out to have many analogies to The Global War on Terror. Both are frightening, present seemingly insurmountable challenges, and are without a clear exit strategy or end-game, i.e. there's no way to get from here to there without unacceptable amounts of blood and treasure, but now we are locked into it.

If our house is like the worldwide multifactorial complex societal ills that lead to terrorism, our basement is like Afghanistan. It is cold, largely inaccessible, and filled up entirely with obstacles to our success. That is, it is a huge mess. There are three storage closets not only filled up completely with stuff, but the big storage closet is not even accessible due to all the stuff piled up in front of it. Much of it is in boxes not unpacked from our move from Houston 3 years ago. It is where empires (of cleanliness) go to die.

We have a lot of stuff. I don't know how we acquired so much stuff; of course much of it is the kids, but I think the consumerism boom of the 1990s and 2000s happened to occur at a time when we had a lot of space. Now we have no money or space, and both are gonna get less as we go out West. This necessitates the Get Rid Of, by garbage truck, craigslist, and eBay.

I filled two black garbage bags of stuff to Get Rid Of today, and packed a large box. I then looked around and realized that I've maybe now dealt with about 1% of the stuff down there, not to mentioned in the house in general.

It's gonna be a bloody spring.

Life insurance

Because I have 3 children (that I know about) and some time off, I figured there was no time like the present to take care of grown-up stuff that I've been avoiding to this time. So I called our car/rental insurance dude and asked him about life insurance.

After usual formalities, he had only one question for me -- "Do you have an exercise program?" Nothing about smoking, or family history, or smoke detectors in the house, or seat belts while driving, or my hobby of fighting bulls with chainsaws glued to their horns.

Of course with my (normally) 60-80 hr a week job, 3 kids, and aforementioned toreador duties, I don't have an exercise program. I barely have a seeing-the-kids program many months. I walk the stairs at work (I work on the 4th floor and we often have patients on the 8th), I am on my feet most of the day, and of course I try to at least roll around with the kids a little.

The question struck me as a little weird. Not because I completely doubt exercise -- it has proven benefit in preventing prediabetes turning into diabetes, also bunches of stuff on it improving COPD, heart disease, obesity, osteoporosis, yada yada yada. But it got me thinking about the science of exercise in someone like me -- mid 30s, no comorbidities, not overweight, last I checked not hyperlipidemic or hypertensive.

It proves there is not much out there. I spent a few hours flipping through the PubMed results for different searches in which I was specifically looking for outcomes. As you can imagine, most searches bring back several thousand articles, so I narrowed in to review articles. This absence of evidence is unsurprising, as a study to look for adverse outcomes on healthy adults would have to be enormous in order to show any sort of effect (because events are rare). As always, absence of evidence is not evidence of absence. The interesting thing, though, was a number of papers (for example here that I found that support really moderate physical activity (30 minutes of walking a day and it doesn't matter if it's at work, plus a bit of resistance training) in healthy people. More activity, in some studies, is associated with negative outcomes.

This makes physiologic sense. Among the only things that have prolonged lifespan in animal models are reduced caloric intake. The metabolic process itself generates bad things, like the over-hyped "free radicals", which contribute to disease and aging. It doesn't make sense to overeat and then to try to burn it off in the gym because you are just causing metabolism to go into overdrive.

In short, I think I'll have to incorporate some resistive exercise and increase my walking, probably to stave off hypertension, hyperlipidemia, and frailty. Also to keep myself from becoming overweight, which is expected as metabolism normally slows down with age. But it's far from clear that a regular exercise program beyond the very mild recommendations does anything to promote health or survival in a healthy age group, and I don't see why it's the first question from a life insurer.

Thursday, February 19, 2009

New Music! New Music! New Music!

Got Andrew Bird's "Noble Beast." I don't like it quite as much as "Armchair Apocrypha" yet, but "Oh No" is a terrific song. This YouTube demonstrates what a weird musical genius he is (and how cool the Line6 delay looper pedal is in the right hands, I bought one after seeing him the first time and I'm not even in the same galaxy...)

But how can it get any better than this?

Speaking of cool festival performances, here's Shearwater doing Rooks at SXSW. Cool, cause they're an Austin band (even cooler, the lead dude was/is an ornithology grad student at UT).

Anyway. Also got the new Beirut today. Very excited about it, but I haven't listened to it yet.

Tuesday, February 17, 2009

Deodorant and call

I had another all-day clinic today. Same old, same old. Systolics above 200, fingersticks in the 400s. Blah, blah, blah. I am a terrific clinic doctor...

I ran out of deodorant two days ago. I have a backup stick, which I never use, except in situations like this. This is because it was part of my "call kit", which I bought in the Monument Street Pharmacy on my third call as an intern because I realized I had left my overnight bag at home. It consisted of a stick of antiperspirant (not my regular flavor), a very cheap toothbrush, tooth floss, and a small travel-sized tube of toothpaste that was quickly used up and replaced by the Crest out of the patient supply cabinets on the wards. The Monument Street Pharmacy was never known for its amazing floor stock.

The neuroscientists teach that the reason that smell is so closely linked to memory is because the olfactory bulb projects to the piriform cortex which is on the inferior surface of the brain, in the median temporal lobes and by all the mysterious knobby bits, one of which is the hippocampus. The hippocampus (or seahorse) is a bit of gray matter that is key in formation of short term memory. Damage both hippocampi and you end up like HM (who just died) or Mr Short Term Memory or Leonard Shelby.

I suspect this is all bullshit, just like most overly simplistic mechanistic explanations of how the brain works. Needless to say, this antiperspirant brings back the post-call in a bad way.

I'd wake up around 9 AM on a call day. Into work at noon; lunch seminar if my patient load wasn't out of control. At 1 PM, the hits would start and just keep comin' just like Casey Kasem would like it, as the on-call intern is open for business for new patients from the Emergency Department. "Chart biopsy", run down to the ED, make sure the patient was as advertised, start the history and physical, and admit the patient.

As the afternoon moved to night, your fellow interns sign out their patients to you. Before you know it, you have 20 odd cross cover patients. Now your pager is going off with small fires ("Mr H hasn't got a diet order") to big fires ("Mr H isn't waking up") not only on your patients, but on the 20 odd cross cover patients that you only know in passing. And, by three months into it, it's just you. No other doctors around except your fellow first-year 'terns (unless you call in the cavalry).

By late night, hopefully you have had time to eat, change into scrubs, and maybe take a dump. Better hope for 2 of the 3. You've done the ED shuffle 4 or 5 times, maybe taken a downgrade from the intensive care unit or a day float patient. Now you try to think clearly as you formulate the all-important Plan. Go back to those 4-7 H&Ps in the corner, and actually try to 1) stamp out disease and 2) logically express those thoughts on paper in a coherent way after 14 hours on duty while 3) putting our fires and 4) recognizing that you are nearly halfway through your shift.

If you are lucky, maybe you can nap for 15 minutes or an hour if things are the unspoken Q word (it's 5 letters and rhymes with "riot"). Maybe if you are a sick freak, you can take a shower before rounds in the morning. Hopefully, you can break out the travel sized Crest and the strange antiperspirant. Change back into a shirt and tie for rounds. Most often, you'll be greasy, tired and bleary, and stinky-covered-over-with-strange-antiperspirant. Honestly, though, the teeth brushing makes all the difference. The only way I can describe intern year to a lay person is imagine working a full day, then flying to Tokyo on a turbulent flight surrounded by screaming babies, then working a full day. Do this every third or fourth night. Lather, rinse, and repeat for 10 and a half months in a year.

By morning, though, another little miracle part of the brain kicks in: the pineal gland, where Descartes thought the soul resided and by some thought to be the residual third eye. It tells your brain that since the sun is up, it's time to wake up and go on about your business. And that cocktail of melatonin, endorphins, caffeine, adrenergics, and stupidity gets you through until your shift is up at 6 PM. Or rather, usually till around 4 PM when you are working on your signout list to get ready to hand over care to the next intern.

Needless to say, 90-odd post-call days with this antiperspirant is just a wee stimulus for bad memories. It's going in the trash right after a trip to Rite Aid tomorrow.

Monday, February 16, 2009


This weekend we started packing for The Big Move. I packed away all of my CDs. I filled 2.5 boxes with them; a total of around 800 I suppose. I do this with the full realization that once they are in a box, they are probably not going to come out for the next two decades, given that most of them have been ripped.

Many, however, have not -- I went through and ripped most of my classical CDs this weekend finally. But in identifying ones I have not processed, I am faced with a momentous decision: will I want to listen to this CD any time in the next 2 decades?

Hard drive space is cheap; it is more a question of having to look at these in my iTunes library. I have managed to acquire a CD of digeridoo music, 3 (count em) CDs of classical guitar, 6 CDs of bits of classical music from a music history class I took in college, and many, many, questionable rock albums (Ocean Colour Scene or Kula Shaker anyone?). I've gone ahead and ripped most of them, with only the truly unlistenable (Tibetian Buddhism chanting, the aforementioned digeridoo, some god-awful stuff that I detest now) left out.

I betcha I'm gonna want to listen to "The Riverboat Song" tomorrow.

Sunday, February 15, 2009

Random medical fact

Pseudohypoglycemia can be caused by severe Raynaud's phenomenon, for instance in scleroderma.

Computer day

My calendar needs are kind of messed up. I love Google Calendar, but I have years of calendars in Apple iCal (and iCal in OS X Tiger can read-only read gcals). I got an iPhone (mostly) for this simple reason, because my old Samsung couldn't quite understand iCal or for that matter gcal. Since I am poor and haven't upgraded to Leopard, iCal doesn't speak to gcal. The new iCal, of course, can speak both ways to gcal. So I use a unix hack, gcaldaemon, which apparently has stopped working. So I reinstalled it today. Rather than spend $116 to get Leopard.

In the process of getting this working (it is still kind of splotchy after most of the day of reminding myself how to use vi and editing conf files), I noted that now gcal can synchronize directly to the iPhone (beta feature!). The problem again is that gcaldaemon is kind of splotchy. So the third leg isn't working. But I figure since gcal and the iPhone are the future, I'd rather base the triangle on those two legs rather than iCal and the iPhone, as I am away from my Apple and therefore I should let iCal be the passive leg.

I did this all without managing to delete all of my calendar information, which is what usually happens. Luckily, the Big One was at a playdate and the Medium one was out shopping with mom. So just me and the baby and she can't/doesn't complain as much when I am using the computer.

Saturday, February 14, 2009

Lazy Saturday

It's nice to actually live like a human on these weekends that I now have off. We ordered a pizza, I played Wii with the kids, cooked the NY Times chocolate souffle. Now it is nap time for the Boy One. After, it will either be my wife's nap time or my wife's shop time.

I'm very proud of my family in that we did absolutely nothing for Valentine's Day.

Here's a little Bruce for you:

Thursday, February 12, 2009


Today was the first day of my 2 week research rotation. Last year, I had a full 3 months of research, enough for me to do a project and get enough data to present a poster at ATS in Toronto. This year, I'm on a CCU rotation at q3 call during ATS so I'm less motivated. That, and I have 3 separate 2 week blocks of research which makes meaningful research a bit more trouble than it's worth.

So my research project, which will be completed (I swear!) by the end of my two weeks will be entitled "A prospective randomized trial of watching TV from my love seat versus my couch." I'm devoting nearly 100% of my time, apart from two all-day clinics, to data collection.

This and the two weeks of vacation in which we will be on The Big Trip to the Motherland, are my only dead time between now and my last day of work, which is looking to be June 10th. Between now and then, 13 or so clinics, 8 night shifts, and about 9 calls. And probably 3 jeopardy shifts so potentially 3 more calls.

Time off at this point is refreshing and of course well appreciated by me and my family. But the ember of the type A personality in me wants to put my head down and just get done with those last 12 weeks of work now, instead of knocking back 2 weeks of down time now, 2 weeks of night float, 2 weeks of vacation, and then 10 straight weeks of hard rotations. This is added to by the fact that I only have 1 hour of TV on the DVR up on which to catch. Hah, prepositions you won't get me today!

Tuesday, February 10, 2009

I'm ba-ack

It's been over a year, but since my wife can write a blog I figured I restart mine. A good place to document the upcoming Big Vacation to the Motherland and then of course The Big Move in June.

Hard day today. Hopped on the bronchy donkey at 7:30 AM (courtesy of the pulmonary consult team, letting a lowly resident do the BAL) and then off to all day clinic where 12 of 13 showed up. Only took me till 7 PM to get through all of them.

We have around one clinic day a week, where we see patients that we follow through our 3 years of residency. Actually how it works is that intern year you get a hodge-podge of new clinic patients and overflows from your "clinic pair" who is a 3rd year resident. Then July 1 of your second year comes around and suddenly you have this whole continuity clinic of patients who have been seen by the same progression of doctors since the mid 1980s, of which you are the latest in a line.

Well, it has taken me over a year and a half but I know this collection of 80 or so unfortunate souls pretty well. I know which ones need extra coaching, which ones need a shoulder to cry on, which ones are on the button, and which ones are dumber than a bag of hammers. I don't get intimidated by 15 bullet point Problem Lists that include things like "amiodarone induced pulmonary fibrosis" and "multisystem sarcoidosis" and "Wolff-Parkinson White" and "gastric cancer status post Bilroth II." I imagine that it is almost like a real doctor's practice except that a real doctor may actually have ambulatory skillz, something which I decidedly lack. Don't let my patients know, as the last 4 or 5 residents who ran the clinic were God-like and inspired adulation from my collection of fawning old ladies who make up the core of my practice. I guess I'm breaking the streak, but I'm really trying to eke out the last momentum of that adulation and hope it lasts me until The Big Move in June.

What's starting to get me is that they know what is coming. They are starting to get a bit of the abandoned puppy dog look in their eyes. They know the goodbye form letter is coming. Oh to be sure, I've connected with a good number of them and I'll miss them too. It is just our clinic is so under-emphasized in our program that it seems that the only way to keep things from careening out of control is moxie and gumption as opposed to competence. I lack all three, as it happens.

What also gets me is that I have to get things a little tidied up so I can successfully hand off these slow-motion train wrecks to two soon-to-be-overwhelmed junior residents (my clinic is now so large that it will be split in two). I know quite well how to do that in the hospital. But besides from making sure everyone has had a colo and a tetanus shot, I have little idea how to do it in the clinic. I'm hoping that these soon-to-be-juniors have a bit more moxie and gumption than I ever had.