September 18, 2007

The Waiting Room

It's one of the things people hate most about going to the doctor's office: waiting. You show up 15 minutes early for your appointment, spend 15 minutes filling out paperwork, another 30 minutes waiting reading your National Geographic from 2001, then you get called back. Progress! This will all be over soon!

You get to the back room, talk with the PA/RN for a few, then bam, another 30 minutes of waiting in a cold room, except this time they don't even give you the common decency of a 6 year old magazine. Bastards. Finally, an hour and a half after first arriving, a knock! The doctor enters, time for them to listen intently to your story, give guidance, immediately offer a remedy that will cure all ails, and you leave engaged in laughter and smiles. Except instead, the doctor talks to you for 5 minutes, doesn't seem to really listen, then slaps a piece of paper in your hand and send you on your way.

Today, I'd like to tackle two issues: why all that damn waiting? and also, why all that damn waiting for such little face time?

First... all that damn waiting.

Most people are under the impression (as I was for a long time) that when a doctor is in clinic, he is making his way around in a big circle through the clinic, seeing a patient, finishing, moving to next patient, finishing, etc. The reason the doctor is late either because of a difficult patient or because he's just slow. I will now in the longest run on sentence ever attempt to capsulize what a doctor is ACTUALLY doing while you're waiting.

While you are waiting, the doctor is following up on tests run on patients earlier in the day, receiving requests for referrals on more patients, requesting referrals to other physicians, receiving phone calls from patients with questions, receiving phone calls from fellow physicians with questions, receiving phone calls from hospital/clinic staff with questions, receiving phone calls from the press asking questions (yes, this happens), attempting to finish up out-patient notes on all the patients they have seen before you, reading up on the few assorted difficult cases of the day, getting paged incessantly for any variety of reasons, seeing the patient(s) before you on the day's appointment list, and attempting to preview your chart as you are in the waiting room.

Ok, I may have squeezed an ounce of sympathy out of that hardened heart of yours, but it truly is impressive to see the multitasking the physicians I've been around pull off on a daily basis.

Now... why so little face time?

At the beginning of the day, the doctor previews his or her appointments scheduled for the day. They know you're coming up. While you are waiting in the room, they are looking through your chart. If you're a follow up for surgery or something of the sort, they are looking at any x-rays/MRIs/CT scans that you may have on file. They are reading notes from previous physicians if you are a referral. Generally, they have a pretty good idea of what is going on before they even step foot in your room.

In medicine, we have what we call a differential diagnosis, which is basically to say, a list of things we may think be going on with you in order of decreasing likelihood. As we gather more information, certain things move up and down the list.

Even if the doctor is not quite sure of what is going on as they knock on your door, they already have a few ideas. That is when they begin to ask you questions about the symptoms to add to their differential diagnosis. Most doctors have it nailed what's wrong with you within a period of 5 questions. Yes, they are that good, or rather have so much experience that when a certain set of responses come from the patient, well, one doctor described the diagnosis as "a trigger finger reflex - you just KNOW." So while you're still hashing out the how the only reason you were even AT the picnic where you broke your ankle was because your ex wife's brother who you thought was a nice guy was sneaking around with your mother and you were there to break his jaw but had a change of heart because the children were around but that's when you tripped over the dog, which your ex-wife got in the divorce, that bitch, your doctor has already clearly figured out what's wrong, already has a plan of treatment, and is smiling and nodding because he likes dogs and has an ex-wife as well so he can relate.

This is the conundrum of the doctor visit. Your doctor wants to stay and hear about your embarrassingly promiscuous mother, but the phone calls for referrals, about referrals, from patients, from doctors, from press, from staff, the pages, the emails, the charts, the difficult patients are all backing up outside that little room you two are in. And while your doctor loves talking about picnics with you (they really do), they don't NEED to hear about it because they already know exactly what is wrong with you and how they want to treat it.

So you end up waiting 90 minutes for 5 minutes of face time. Is there a better way to do this? I have no idea. But there's two things that your doctor truly appreciates. (1) That you are a good patient, because these are a lot more rare than you'd expect and (2) That you might be willing to let him move on to the next person because you two have gotten you to where you need to be, because that extra time you free up will be sorely needed for dealing with those patients in which things are difficult.

They call it the rule of 20/80. 80% of your patients will be a joy to work with, with a clear and present problem and realistic expectations of how that problem will fix itself with treatment. But the other 20% of the patients will be a pain in the arse, and those 20% will suck 80% of your time. So while you are waiting in your room, your doctor may be next door trying (hoping) to make a patient understand that no, he may never be ABLE to be a wildfire firefighter again because he was in a motorcycle accident where he broke 28 bones in his body, split his pelvis in two, and has enough screws and plates in him to put together a piece of ikea furniture (true story). But hoping the patient could at least lower his expectations a little bit, simply because when they peeled him off the asphalt they had to shock his heart 3 times and put him into a coma for 3 weeks, so its honestly a miracle that person is even sitting there to begin with.

I don't know where I am going with this. All that is apparent to me is that inside every doctor is this war. They want to spend as much time with a patient as the patient truly wants, but simply, physically, cannot. How much personal connection do you balance with necessary brevity? Because when the doctor has to sink that 80% of their time into those 20% category of patients, ultimately, it's not just you who ends up waiting, it's the doctor - waiting to finish for the day with all those phone calls, pages, emails, and cases. And waiting to go home for the day.

September 10, 2007

Welcome to the jungle.

My name is no longer MedZag. My name is #5814.

In respect of privacy (and to keep the gunners of the class from gloating so much their heads explode), my medical school assigns each individual a designated exam number. As soon as test day comes, you cease to exist as a person, and you rematerialize as this number.

#5814 will be the barometer of my medical school success for the next two years. That being said... med school exams are not nearly as bad as advertised (yet). I show up to school at noon today to take the bitch down, run into the token hyperventilating classmates (God rest your souls) and head on down to the lab. Contrary to popular belief, identifying 50 different structures on 25 different cadavers ain't so bad. Granted it sucks, and your brain works hard, but in the grand scheme of intellectual effort I think there's 6 levels of effort: (1) Can do it while watching Rock of Love. (2) Can do it while watching MythBusters. (3) Can do it sans television with music. (4) Can do it. (5) Kinda difficult. (6) F*cking impossible.

For the exam, I grade (out of 150 questions) 20 as a (1) 10 as a (2) 45 as a (3) 70 as a (4) 5 as a (5) and 0 as a (6).

End score: Reasonable. Big bad medical school exams are big, not really bad. But totally doable. End verdict comes Wednesday (and Monday).

Maybe my good feelings of the day come down to my playlist from the morning. I woke up, listened to some Eye of the Tiger, and went of my way. I should really attest my entire medical school career so far to 80's rock bands.

On a totally unrelated note, Portland has begun to be invaded by Vespas. The annoying whine of what used to be a uniquely European phenomenon now has penetrated (ha, penetrate) the culture of the dear state of Oregon. And it really doesn't work for our poor town, the damn things just seem so out of place. It's like Seattle, WA and Florence, Italy got together for a hot and steamy night after a crazzzzzy time at some bar (what bar Seattle and Florence would both hang out at, I have no idea) and Portland, OR was the "accident" that popped up 6 weeks later. I just hope Florence took the news well. Yes, I am making Seattle the woman in this analogy. Or perhaps a better analogy would be when two attractive celebrities get together and make a baby and you go "damn, that's gonna be one good looking baby" and the end product ends up looking something like this. Thank you, Portland.

Another random musing... one of the doctors who leads our PCM (Principles of Clinical Medicine) looks and acts exactly like JD from Scrubs, give or take 20 years. I find it truly hilarious, though I think my group thinks I'm a little weird for laughing a lot more than I'm supposed to. But what else am I supposed to do when all I can think about is a correlary Dr. Cox rant going through my head all throughout small group.

September 6, 2007

Private Snowflake.

I've never really had a problem with tests in my life. Not because they haven't been difficult, I've had my fair share of those. But I've never been the type to stress out before tests (or study for them). Get in, get out, quick f*ckin' about.

Enter medical school. Our first exam of the year looms at the end of the weekend, a 4 hour behemoth called "GIE Exam 1." I just battled my way through the first level of medical school, now I gotta beat the boss. And you know the funny thing? I'm not stressing too much. Oh, I have enough of apprehension in me to keep me in the library all weekend, but (and I can't believe I'm saying this), the material doesn't seem "that bad." Just 3 weeks ago, I got my 2 inch syllabus, and my jaw dropped 20 inches. Now, it all seems damn reasonable. A continual evolution of me, I guess. That being said...

Preparing for an exam in medical school is like preparing for war.

Studying for it is an intensive endeavor. Packing my bag in the morning is like preparing to go on a week long recon mission. I need my manuals (books), water to stay hydrated, source of energy, source of caffeine, radio (ipod). Throw it all on your back and trudge off for 12 hours.

The exam is close to 4 hours long. For comparison, the LSAT is close to four hours long. I am taking an LSAT I only had 2 1/2 weeks to prepare for.

The exam is split into two parts. The first half is multiple choice based on lecture material and the questions are framed to be like what we'll see when we take the United States Medical Licensing Exam (USMLE) Step 1 following our second year. I haven't taken a multiple choice test since my lower division sociology class at Gonzaga (upper division profs considered them "too easy"), but wouldn't you know, I'm taking them in medical school. The second half of the exam is the lab practical. The day before the exam, the lab professors and 4th year students go through each of our dissections. They grade the dissections, and choose structures from each group's cadaver that are good representations of what things SHOULD look like (or, as our course director says, "we're really superficial, we choose things that look pretty"). For the lab practical, you enter the lab and start at a station. In front of you is a cadaver, and in this cadaver are tiny metal pins. At the tip of these pins could be a variety of structures. The filum terminale of the spinal cord, the recurrent branch of the median nerve, the extensor carpi radialis brevis muscle, the thoracolumbar fascia. If its a muscle, you might not be asked the name, but will be asked where it originates, or where it inserts, or what it does, or what nerve innervates it. Obviously, this is a very daunting task with no Word Bank to help you out. You have 60 seconds to identify the pins, pick their names out of thin air, and move on to the next station, where a whole new set of pins await you. At least we get to stand.

Obviously, this sounds like a really fun way to spend a Monday (sarcasm). I've been trying to put my finger on why I'm not FLIPPING SH*T about this exam, and I've yet to find a good reason why not. Maybe its because I'm a person the world needs most (thank you Gonzaga). Maybe it's my ego. Or maybe my brain is really just running that well after years of lack of use (and abuse, likely). I think above all the main emotion I'm feeling going into the exam is simply... curiosity. These will be the things that judge my progress for the next two years, and I just want to get the first one out of the way to see whether my study strategies have been working so far.

So, we'll see how it goes. The class is going out to happy hour after the exam, and I'll either be celebrating or drowning my sorrows. The nice thing is all you need to do is pass. As they say, "P's get MDs."