Life off of the wards.

After three months of my life on our hospital's acute inpatient med/psych unit, I have moved on to the world of outpatient Developmental and Behavioral Pediatrics (and the freedom of no call). DBP is a sister field to child psychiatry -- often our roles overlap, though we come to each diagnosis from a slightly different manner. It has been interesting and valuable to see child psychiatry through the eyes of a pediatrician. And it is comforting, returning to the career that I will one day call my own. Especially after three months of adult inpatient psychiatry, though of course adult psychiatry is rewarding in a different kind of way.

Today I'm feeling nostalgic for home. I miss my family and my friends, and I'm looking forward to returning home for the holidays.

Justin and I went to The Big E last week. It is New England's equivalent of the Arkansas State Fair. It was amusing to say the least, to see New England's version of the farm-oriented fair. It was hilarious, what New Englanders passed as fair food. Sure, there were turkey legs, funnel cakes, caramel apples. But there were also bison and elk burgers, gyros, sushi, live lobster, steamed clams, fried cheesecake, alcoholic beverages, seafood ravioli, pastas, chowders...pretty much every kind of food imaginable at the multitude of food booths. Far more space at the fair was devoted to food than to rides or carnival games. Justin and I had fun. I think he'll probably comment further on the experience (update: yup, he did).

I had the opportunity to sit in on psychiatry grand rounds last week. A former state hospital resident had returned to the university to speak about the experience of a psychiatry resident in the late 1940s. Our first antipsychotic, chlorpromazine (thorazine), didn't appear in the literature until 1952. The first atypical antipsychotic, clozapine, wasn't approved for use in the United States until 1989. (For further historical reference, fluoxetine (prozac), the first SSRI introduced in the U.S., was not approved by the FDA until December 1987.) The thought of struggling to treat 4,000 patients with psychotherapy, industrial therapy, ECT and insulin shock therapy is daunting to say the least.

This further illustrates the revolutionary nature of psychiatry at this point in time. We don't even have a good grasp of how the brain works, much less the biological explanations for psychiatric conditions. Though we are aware that genetic, chemical and environmental factors contribute to the presentation of psychiatric conditions, the mechanisms and conditions are still out of our reach. We use the DSM-IV-TR to diagnose mental illness -- which is nothing more than a list of symptoms that we apply (somewhat arbitrarily at times) in order to prescribe medications and therapies that may improve the patients' care.

If psychiatry is a young field, then child psychiatry is in its infancy. We have no long-term studies telling us how these drugs affect the developing brain, yet we use them because we believe that not giving these medications we have available could prevent our patients from being able to meet their potential in life. We try to apply psychiatric diagnoses developed on symptoms as they present in adulthood to the child population, despite our knowledge that a child is not a "little adult". Child physiology is different than adult physiology -- this we know. The developing brain with its neuroplasticity is different than the adult brain, and likely functions differently. There is so much we don't know!! Yet there are so many children in need of our assistance. It is an exciting, and daunting, time to be in child psychiatry.

But anyway, I feel like I'm rambling. Chase is coming to visit!! They should be arriving in half an hour or so. Oh, and Courtney's is presenting at a conference in the French Riviera -- how cool is that?

A Brief Note From Work.

It is one of my dearest friend's birthdays today. He is the person that makes the most effort to keep in touch with me, and he appreciates that sometimes my mind is not as clear as it should be and enjoys speaking with me nevertheless. This individual is always there for the people he loves. He is an inspiration - I aspire to become more like him in the future. The very thought of him makes me smile. He deserves a wonderful birthday, but more importantly, and wonderful and joyful life.

Happy birthday, Lance.

Today is my favorite day of the week - Friday. It typically marks the end of a (hopefully) successful workweek, and the beginning of a weekend where I can escape the inevitable monotony of routine and perhaps even sleep in. Next weekend I am on call, but for this weekend, I am blissfully free, without even feeling obligated to carry around my pager.

Yesterday was a day of great excitement at work. As I mentioned before, I can't really go into details, but I can say that police officers were on our unit. (No, my safety was not at risk.) The pumping of adrenaline at the end of the day led to the inevitable post-adrenaline crash, but despite that, I felt important in maintaining the safety of a patient who was peripherally under my care.

One of the things I have struggled with on this rotation is the inability to decide if my presence is actually useful. I write daily notes and orders, and I confer with the treatment team, but I have been unable to decide if my work was actually helpful for my patients. Yesterday, I had a patient and family tell me that they felt like I had done a lot for them in the patient's care. I looked back over my actions with that patient, and I felt that I had added something to the care that my patient would not have received had I not been present. It was a good feeling.

Speaking of work, I should perhaps return to it. Though I need to remember to speak of my work proposal soon.

P.S. Justin took my picture in Rockport, but my hair was blowing in the wind, and you can't really appreciate the haircut. I'll try to remember to take a picture soon. Though I suppose it has been a few weeks and perhaps it's grown out a bit. Oops. But it's still cute.

It's Been a While...

"...since I could...hold my head up high..."

Sorry. You know I had to.

But, to continue with the original train of thought, it *has* been a while since I have posted. I'm an acting resident physician now. In our orientation, we were warned against blogging about our days secondary to possible privacy violations for our patients. In psychiatry, our patients trust us with information about their thoughts and lives to an extreme that they often don't trust anyone else, including their primary care physicians or even their closest friends and family members. So since that time, I have been doing some thinking. What should this weblog be? Should I move away from my work? It is without a doubt the most interesting part of my life at the moment, as most of my days are focused around the working day or the anticipation of an upcoming weekend call. I thought about discussing my life outside of work -- about the movies Justin and I are watching together, or about memories of people and places I have been missing. And I thought about writing about the job itself, without a focus on patient's stories, or about generalizations in the people and situations we see in psychiatry.

I guess my question is, what are you guys interested in reading?

Psychiatry is wearying. It gets difficult to hear such depressing stories day in and day out. Sometimes we end up discharging people that I go home worrying about. The hours are better than most fields, but nevertheless, it is exhausting. And it gets tiring, listening to the lack of respect you get for your field. I have never had so many of my patients tell me how they dislike and distrust psychiatrists to my face before. It is as if we are not real doctors. We don't wear our white coats because it can create a false barrier between you and the patient, creating a heirarchy where the patient does not feel comfortable expressing the feelings and experiences taht are bothering them. But the downside to wearing normal clothes day in and day out is that our egos are battered daily. And believe it or not, after that small eternity of medical school, I was looking forward to that long coat.

Adults are fine, but I am looking forward to returning to children again. I have 1.5 months to go, and then I will be on developmental and behavioral pediatrics. My favorite adults are college-aged. I have considered working part-time in a university mental health clinic when I practice. It is rewarding. Adults can be rewarding, too, but some adults are more trying than others. For example, I could never do addiction psychiatry full-term. There is a running joke that most physicians could never do psychiatry, and of those that can, most of them cannot tolerate addictions. A lot of psychiatry involves substance abuse in addition to the mental health condition, but when the focus is primarily the addiction and how it destroys lives, the task is daunting, and for some, unachievable before they end up dying in overdose or coming down with an illness like hepatitis C which will probably kill them in time.

Justin and I are going to Rockport today. I have been looking forward to this trip for over a week now. It will be nice to walk along the beach and visit the fun shops. And of course, we will have to eat some stuffed clams and New England Clam Chowder.

I was mistaken for a high school student two weeks ago. A woman in the cafeteria asked if I was an intern, and I said yes, I was...but it was some time through the conversation when she gasped, "Oh, you're a doctor?! I thought you were a high school intern!!" (Another reason I like white coats...and perhaps another reason I like kids, this is never an issue with them. It is hard to be taken seriously by your patients when they you are their daughter's and granddaughter's age, even if their guess is off by a decade.) It was time for me to get my hair cut anyway -- the last time I had it cut was before graduation -- so I decided I would get it could shorter. Surely that would make me look older.

After the hairstylist went on for about 15 minutes, saying she couldn't believe I was old enough to be a doctor, she got to work on my hair style. I brought a picture of a bob:

See the picture of the girl on the left? I thought her hair style was cute. The hairstylist from Albania thought a similar hairstyle would look good with my face structure, so she started cutting with a variety of styling tools (most of which I had never seen). Meanwhile, Justin sat at the side, giving occasional commentary when it was requested. I watched as the hair began cascading down. And finally, the final hairstyle was completed. Very cute, shaped in the back with layers, and the cute front with two longer layers shaping the curve of my jaw. And when she was finally done, and the apron was taken away, she said, "Oh no. I think you look even younger than before."

That said, it's still cute, and I like it, so I guess it's okay. I've gotten a lot of compliments. And one comment that I do, in fact, look younger than before.

All right, it is time to jump into the shower. I have a Borders coupon for 40% off (Borders is quite evil -- they keep sending time-limited coupons, so I feel obligated to use them...I have purchased more books in the last few months than I have for quite some time prior). And then we will be off to Rockport! I will try to remember to bring my camera. And then I will finally have a picture of my haircut to share with the world. Have a good weekend, everyone -- I will be sure to enjoy it to the fullest, as this weekend, for once, I am NOT ON CALL!! Yay.

Convocation and Hippocrates.

University of Arkansas for Medical Sciences
College of Medicine
Honors Convocation, Class of 2009

Administration of the Oath of Hippocrates

I do solemnly swear by all those things I hold most sacred that I will lead my life and practice this art in uprightness an honor;

That I will be loyal to the practice of medicine and just and generous to its members;

That into whatsoever house I shall enter, it shall be for the good of the sick to the utmost of my power, holding myself far aloof from wrong, from corruption, from the tempting of others to vice;

That I will exercise my art solely for the betterment and cure of my patients and will give no drug, perform no operation, for a criminal purpose even if solicited, far less suggest it;

That whatsoever I shall see or hear of the lives of men and women which is not fitting to be spoken, I will keep inviolably secret.

If I be true to this oath, may a full life and good repute be ever my fortune; with the respect of all good persons, in all times. But should I trespass and violate this oath, may the reverse be my lot!

Quite a difference from the original translation, as published in the National Library of Medicine:

I swear by Apollo the physician, and Asclepius, and Hygieia and Panacea and all the gods and goddesses as my witnesses, that, according to my ability and judgement, I will keep this Oath and this contract:

To hold him who taught me this art equally dear to me as my parents, to be a partner in life with him, and to fulfill his needs when required; to look upon his offspring as equals to my own siblings, and to teach them this art, if they shall wish to learn it, without fee or contract; and that by the set rules, lectures, and every other mode of instruction, I will impart a knowledge of the art to my own sons, and those of my teachers, and to students bound by this contract and having sworn this Oath to the law of medicine, but to no others.

I will use those dietary regimens which will benefit my patients according to my greatest ability and judgement, and I will do no harm or injustice to them.

I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan; and similarly I will not give a woman a pessary to cause an abortion.

In purity and according to divine law will I carry out my life and my art.

I will not use the knife, even upon those suffering from stones, but I will leave this to those who are trained in this craft.

Into whatever homes I go, I will enter them for the benefit of the sick, avoiding any voluntary act of impropriety or corruption, including the seduction of women or men, whether they are free men or slaves.

Whatever I see or hear in the lives of my patients, whether in connection with my professional practice or not, which ought not to be spoken of outside, I will keep secret, as considering all such things to be private.

So long as I maintain this Oath faithfully and without corruption, may it be granted to me to partake of life fully and the practice of my art, gaining the respect of all men for all time. However, should I transgress this Oath and violate it, may the opposite be my fate.

My long-time followers may recall that I commented on the Hippocratic Oath in my second post, after I posted my Medical Student Oath. At that time, I mentioned that primum no nocere was not a part of the Hippocratic Oath. (See a 1595 copy with the Greek and Latin translation here.) However, the original oath does translate, "I will do no harm or injustice to [my patients]." Notice that this phrase is not in the modern version of the Hippocratic Oath that I was asked to take. Nor does it include an obligation to teach medicine to those who desire to learn it without a fee, or a promise to stay away from surgery, or a pledge against performing abortions, or an oath of not engaging in romantic relations with any of my patients or their family members. It is interesting to note the wording that the medical schools choose to adopt to keep with the tradition of a "physician's oath".

The American Medical Association does not endorse any form of the Hippocratic Oath, though it has its own Code of Medical Ethics. Many "modern" versions of the Hippocratic Oath exist, but it appears that medical schools can pick and choose a version as they see fit. According to one study, in 1993, 98% of schools stated some form of the oath, but in 1928, only 26% included this component. According to a summary of the research in an article in JAMA, while all of the oaths pledged commitment to their patients, only 43% of the 1993 versions vowed for physicians to be accountable for their actions, 14% prohibited euthanasia, 11% invoked a deity, 8% prohibited abortion, and only a shocking 3% prohibited sexual contact with their patients.

In the times of Hippocrates, a verbal oath was a sacred affair; it was more than a promise, it was the fiber upon which society was maintained. But in this day and age in the United States, a vague oath to society is more like a promise -- well-intended, but not shocking if it is broken. We are not required to sign a contractual oath as a requirement for our medical licensure; as long as we do not break the law, we are within our rights to adopt -- or to not adopt -- any code of ethics that we see fit. If someone managed to get into medical school who is unethical, yet they are able to complete the schoolwork -- well, it's too late at that point. If the Boston University medical student had not been arrested for his probable secret life as the "Craigslist Killer", then he would still be standing by his colleagues as a rising third-year medical student. As a former member of the Honors Council during half of my graduate education, I can attest that the ethical board designed for student accountability is laughable.

What does this say about the role of physicians and their requirements and educational process? When did obscure medical factoids become more important than the respect, professionalism and art of medicine? Did it begin with the Flexner report, which standardized medical education across the nation? Is it a reflection of contemporary society, that information becomes more valuable than human relations? Is it the training process, or is it the people that undergo the training? Numerous articles have been written documenting the loss of empathy through the medical education process. Perhaps it is time to reevaluate our priorites in medical education. Perhaps it is time to reinstate accountability as a priority in our contemporary society.

I feel like I am leaving medical school more jaded than I entered. I know more than I ever would have imagined, and less than I feel I should. For those of us without immediate family members in the field, we jumped into each step of our medical education without the guidance we expected. We were told we needed to learn it all, and we were told we were failures when we faltered. We were told to take nine-hour exams we were expected to prepare for on our own in our "free time", we were told to apply for residencies and interviews without guidance, and we were expected to fly around the country for interviews out of our loan checks. Yet, our knowledge of professionalism -- we were to learn by example. We never saw a copy of our version of the Hippocratic Oath until our convocation ceremony, where we were supposed to recite it.

Medical education has become fundamentally flawed. Standardization is necessary, as is the training program of 150-170 students per class -- the need for physicians is ever growing, and supply is not meeting demand. But we have lost something in the standardization and the tightly scheduled requirements -- we have lost the values that once defined our profession. And though Hippocrates' Oath is outdated, it represented inherent values and qualities of the profession. This is what our current system is lacking -- love of our patients and the art of medicine, over the love of our selves and our selfish desires and limitations.

But yay woot -- I've graduated!

Dead Man Walking.

Justin has requested my commentary on the following topic:

If a zombie was brought to my hospital with wounds that would result in the zombie's death without my treatment, would I be obligated to treat him?

I have given this topic a bit of thought. I suppose the first question is your definition of a zombie. Is a zombie a human? Would his treatment (or lack thereof) be better suited for a veterinarian, as he is no longer a human being, but a creature that follows animalistic urges?

But I will submit that the appropriate medical professional would be a physician. His prior status was as a human being, and if "zombism" is assumed to be the result of a transmittable disease in the form of a mass plague, then he would be best treated by a medical doctor. Furthermore, zombies do not exist in the natural order of the animal kingdom, either...so a veterinarian would not be suited to their care, either.

Physicians treat patients in order to ease suffering and/or to continue life. A zombie is a corpse that has been reanimated, and thus is not alive, per se. In addition, because a zombie is a corpse with no forms of communication, personality rationality, or emotion (an entity without a "soul", if you will), then it cannot suffer. Thus, the treatment of a zombie would not ease suffering, nor would it continue life -- though potentially, it could continue reanimation.

This then raises the following question -- what is the ultimate goal of medical care? Is it to continue existence, or is it to ease suffering? The American healthcare system tends to reflect the former view, though the small subset of palliative care physicians follow the latter care model. In other countries' models of care, this question of obligation of care would likely not even be discussed. Zombies are evil, and they lack that spark of humanity that some classify as a soul, and therefore it is a disgrace to the individual that used to reside in that body to allow the zombie to continue to walk among humans.

But do we have the right to define "evil"? And if zombism is the result of a plague, doesn't it follow that the new life created through corpse reanimation is indeed part of the "natural order"? Since physicians are charged to not make paternalistic decisions with regards to the lives and autonomy of our patients, are we therefore ethically obligated to treat? As we are not reanimated corpses, do we truly have the right to suggest that their existence is flawed and unappreciated by the being whose existence we would be allowing to end?

I guess a physician wouldn't know how they would act unless they were in the situation.

But anyway, I have now officially graduated. I am now, finally, a doctor. But I will wait and discuss this in another post.

Banana Pancakes.

To keep to my Jack Johnson theme -- it just continues to be applicable!

As of yesterday, I am twenty-six years old. I believe it was Garth Brooks who sang, "I'm much too young to feel this damn old." There are days when I am frustrated by the details of living I don't know, and there are others when I feel like I know too much for my own good. The night before last, I was at an Ingram Hill concert. Women older than me were partying it up in their cute attire and their flat-ironed hair. I was surreptitiously glancing at my watch at ten-thirty and hiding my yawns -- and Ingram Hill didn't even make it on stage until eleven. Now don't get me wrong -- I very much enjoyed Ingram Hill, Sterling Y, and especially The Red Suite (they were cute). But 10:30 -- unless I'm on call, that's my bedtime! Especially on a weeknight! (At least Lizzie agreed, lol.)

As you guys probably know by now, I matched into a combined double board program in Psychiatry and Child & Adolescent Psychiatry at the University of Massachusetts in Worcester, MA. I'm looking forward to the program, but the process of moving is rather intimidating. I spent the day reading horror stories about the moving process, and I'm now a nervous wreck. We're going to Worcester on Tuesday to attempt to find a place to live. I'm seriously considering selling my Saturn. I've been completing paperwork, trying on white coats, and picking out rotations for next year. My benefits paperwork is available, and I need to start working on it. I need to decide how to handle my Stafford loans in the next couple of weeks, and I need to decide what kind of relocation loan I will need to take. It's a rather stressful process -- once again, I am gambling that I will like a career and a training program, but this time, it is on the other side of the country. Wish me luck!

A wonderful thing happened on Wednesday: it was my last medical school lecture EVER. (It was titled "Not Another Damn Medical School Lecture.") It was actually a somber talk on the perspective of a resident who became a patient in the worst possible way -- as a newly diagnosed AML patient with a poor prognosis. You get a bit of reality when you remember what it is to be the person on the other side of the stethoscope. And, oddly enough, it made me miss hem/onc. It was my road not taken.

I really liked the passage of my birthday card:

Wishing you
everything beautiful in life --
time for the dreams
you hold closest to your heart,
quiet moments to enjoy,
and most of all,
the contentment that comes
from knowing you're loved.

Beautiful, eh?

I'm procrastinating, so I need to get back to preparing for the arrival of my dear friends from Fayetteville. Hope everyone is having a wonderful day-after-my-birthday. *grins*


P.S. With regards to the applicability of the title -- Justin made me banana pancakes for my birthday. He was a great birthday promoter! He knows how much I love birthdays, and he does his best to make them special. I'm very lucky to have him. ^.^

I've been sitting, waiting, wishing...

Kudos to those individuals who know the music artist to which this title references.

As most of you have already figured out, I have submitted a rank list. And in fact, I will find out where I have matched on Match Day, which is exactly one week from today. Forgive me for not posting my rank list online -- if you would like to know, please feel free to call me, where I could explain ad nauseum the reasons I made the decision I made, and, also, my regrets.

The last few weeks have inched by. The minutes have been creeping ever since the rank list was submitted. And in this time of waiting, I have thought of how my life would have been so different, depending on my specialty.

The life of a surgeon, while tempting, was ultimately not the life I would choose for myself. It is a powerful feeling, knowing that you cut people open and (hopefully) fix them. I am sure a time will come in medicine where the concept of the types of surgeries we do today will sound barbaric, but nonetheless, it is an intoxicating feeling to be a surgeon. I could have done it, and I would have been good at it. But I would be afraid that I would have become impatient, perhaps even callous, with the stereotypical annoyance at other specialties. I want to spend time with my patients. And, as my time on neurosurgery is reminding me, surgery is not that specialty. (With the possible exception of ENT. *winks*)

The life of a pediatric hematologist/oncologist, on the other hand, is quite the opposite. They devote themselves to their patients, almost to the extreme. It is the field that most drew me, outside of child psych. I wanted to be that person. I wanted to be the doctor that patients and their families trusted to help them, and I wanted to grieve with them when I couldn't. But many hematologists and oncologists exist in this world. The child psychiatrists are few, and just as needed. It is not as flashy, perhaps. But I believe it will be just as rewarding.

I see myself as a family practice physician, as med/peds, as medicine or pediatrics alone. I see my life as a neurologist, and I see my life as a physiatrist (physical medicine and rehabilitation). I see my life as a geriatrician, or as a gynecologist, or as a plastic surgeon. I see myself in all of the fields of medicine, and sometimes, the lives of those not in medicine. They are all appealing, in their own ways. I remember my first day on medicine wards, the first day of my third year of medical school. I remember the sigh of relief, when I realized I could become an internist, and I would be happy. It was a huge relief, that the previous two years had not been in vain. I was so scared that I wouldn't like medicine. But I had the opposite experience in a lot of ways. I liked it all. (Well, except obstetrics.) I had more trouble deciding what I wanted to do, because I saw myself fitting into each path. And I realized that each path would change me, affect me differently. My ultimate decision came down to, what kind of person did I want to be? How did I want to be there for my patients?

There are days that I grieve for the paths I didn't take. I hope and pray that I made the right decision. But when it came right down to it...it was the only one I could have made.