Friday, February 20, 2009

In Memory of Miller Lite and other patients....

Okay. HIPAA forbids me from using names. However, with a name as common as Miller or Smith, I think I may be safe.

During my last 2 months of back-to-back internal medicine wards, our team took care of a wonderful, witty, very sick 70-something male with the name Miller. Mr. Miller had suffered a massive heart attack several months ago that ended up with him getting bypass surgery. Although he pulled through the heart problems okay (sort of), he never really bounced back. By the time he came to us from the nursing home where he was (still) recuperating, he had developed fluids in both lungs and had lost so much weight, he appeared pale and cachectic. With the graveyard humor that hids the pain that is unavoidable as one watches life ebb and patients die, I nicknamed him Miller Lite.

Over the 8 weeks that we were on the wards, Miller Lite from "let's keep fighting" to "I want to die". Miller Lite always had something funny to say to you when you went into his room. He never sounded bitter, critical, frustrated, although sometimes he sounded sad. He had one living child, a daughter he had raised practically by himself. It was touching to go back and forth between daughter and father and hear the exact same admonition:

"Things don't look good, do they. Well, be easy on (insert 'dad' or 'daughter'). I don't want him (her) to suffer!"

I don't think I will ever forget Miller Lite. He died almost within days of being moved from the medicine ward of the hospital to the Palliative Care unit.

It reminds me of another patient that died. Ms Mindy was a 50-something female with cognitive delay with a moppy disposition who had endured multiple abdominal surgeries and wasn't recovering. I was a third year medical student and it was my first surgery rotation. I was married at the time and once wistfully remarked to my attending after countless days in the hospital:

"I think I know more about when Ms Mindy last passed gas or had a bowel movement than I know about how things are with my wife or my family." We both laughed and then there was the awkward silence that comes after a sad truism has been uttered.

Taking care of patients is emotional business (this clinical distance is a myth) and with the long hours and years of training of medicine, is it any surprise that a number of your emotive experiences and memories become those of your patients?

The psychologist who lost his mind

I am spending the month in neurology. I got to spend a day working with a specialist in dementia. We saw a 73 year old male for a follow-up appointment. This gentleman was a Ph.D. psychologist by profession. It was moving to be a part of this encounter.

"Mr. J, I am sorry to inform you that I will not be able to support your application to the Department of Transportation to let you drive."

"That's... I can... why...."

Mr. J, I understand how frustrating this must be for you. You've probably had patients with Alzheimer's and might remember what this disease does..."

"I used to be.... I know! I... Alzheimer's... not fair..." and after a painful pause, 'frustating!

There is an irony in this encounter. The psychologist who measured the slipping away of memory is now in the 'driver's seat' of the very condition that will take him...literally... out of the driver's seat.

Friday, February 06, 2009

The IMGs

IMG stands for International Medical Graduate. In the U.S. medical system, it used to identify a physician who went to medical school outside the United States. A subset of this group is sometimes identified as FMGs (Foreign Medical Graduate) -- to distinguish 'Americans' who studied outside the United States from foreign nationals who did their medical training elsewhere (often their home country) and who have come to the United States to pursue residency and perhaps fellowship training and perhaps to stay on and practice in the U.S.

I am an IMG. In the eyes of some, IMGs are viewed as somehow being inferior in their training and abilities to practice medicine in the U.S. As I finish residency training, I want to highlight a few of the IMGs I know...

Dr. RD is from Sri Lanka. He went to medical school in St. Petersburgh in the former Soviet Union. After completing his medical training, he returned to his country and pursued post-graduate training as a surgeon. He then served in their army as an Army Surgeon. He saw 'action' in the civil war. He subsequently came to the U.S., trained in Internal Medicine in New York state, and is now a board-certified Hospitalist.

Dr. MS studied medicine in her native India. She went on to do post-graduate training in Obstetrics and Gynecology and practiced as an OB/GYN for several years thereafter in India and the Caribbean. She came to the U.S. and started a residency in Pediatrics and is now a fellow in Pediatric Neurology in Boston.

Dr. NG is also from India. After completing medical school and post-graduate training in Dermatology and Venerology, he went to the United Kingdom. He practiced as a House Office there and became certified as a Member of the Royal College of Physicians. He is completing his residency training in Internal Medicine now.

Innumerable others trained in India, Palestine, Austria, Russia, the Ukraine, Sudan as physicians, surgeons, anesthesiologists, Internists, Cardiologists, Ophthalmologists and came to the States to train again, often in other specialties because their specialty would not accept but the rare IMG. Others have served in wars in Bosnia, Kosovo, Darfur and the Congo. Some have studied Russian, Serbian, German and French to be able to study medicine. A few have worked at gas stations and convenience stores while studying for U.S. board exams to get into residency training. Some have done Masters and Doctorates in Public Health, Microbiology and other subjects in order to have a visa to interview and study for entry boards before residency.

When you meet these physicians, you will not hear these stories. There is no sense of entitlement or pride or sacrifice. You will not hear about the number of times they have started from scratch, been discriminated against, been judged or slighted, often by those with much less training and experience than they have. You will only see them try to fit in and do right by their patients, bringing to the doctor-patient encounter a world (pun intended) of experience.

As I have rubbed shoulders with these physicians in training and learned from their cross-training, international exposure to medicine and marveled at their multi-lingual and multi-cultural sensitivity and competency, I cannot help but feel that once again, the United States is gaining the best. The shame and modest reticience I felt in identifying myself as an IMG when I began residency is gone now.

I am an IMG.

Thursday, February 05, 2009

Announcing my babies to the world!

Those of you who know me know I rant about bacteriophages. It has been a long four years of dreaming, many weekends and nights of labwork packed into the 'free' time of my residency, and here they are! These are two different species of bacteriophages isolated from the anterior nares of humans, being shown for the FIRST time ever! I believe no-one has ever reported the existence of these cute little fellows in the anterior nares of humans before. Of course, I shall be publishing soon.

Here they are infecting Staphylococci:
I told you I would find them. These are my babies and I am very proud of them. One day, little guys like these -- in some form -- will be the new antibiotics. Many thanks to all the great phage devotees out there who have helped...

Morning Report Nostalgia

It was 8:05 am and nursing a plastic cup of chocolate chai (a specialty of the Cattails Cafe in the lobby of the Marshfield Clinic) I was one of many bodies sitting in Conference Room G next to the cafetaria in St. Joe's.

The funny thing about the last year of residency is the nostalgia of some of our rituals. While I listened as the presenting senior resident teased up with the case of the day, I looked around the room...

I could see a 3rd year medical student reading out of his red Pocket Medicine -- the eager learner, probably overwhelmed. I remember those days... trying to drink all the water coming out of a fire hose and feeling the panic as gushes of the water of knowledge slipped past me.

Further down the line sat.. or rather snoozed a second year resident in scrubs... no doubt the resident on call the night before -- the night float. The post-call haze is still a familiar sedative to my mind and promises to meet me the day after my next call night and that comes soon enough.

Further down sit some of the third years: one of them is a good friend who is nearing the end of her pregnancy. Just looking at her face reminds me of all the experiences we have shared: nights of call, codes, inservice exams, morning reports, co-presenting at meetings. I shall miss her as she heads off to Nevada for the next year. She has taken a hospitalists job. She has a three year old at home, a second one on the way and a husband working in Vegas.

Around the corner of the horseshoe arrangement of the joined tables sits one of our attendings. He adds questions and reminds us of a couple more diagnoses we should add to our differential as we think through what our mystery patient might have. I remember how intimated I was by him my first year. Now, we joke around. I still admire him but he is more human to me now.

As my eyes round the table, fixing in turn upon each person present -- medical student, intern, second year, third year resident, attending, I cannot help but feel a comfortable sense of family. These are my comrades with whom I have served: nights on call, racing down steps toward a Dr. 6 code, standing in an ER bay examing a patient and sitting tired in the cafetaria wolfing down a quick meal as our pagers go off. A pager goes off. The CCU intern gets up and walks towards the phone at the back of the room, others making room for her.

This is my family and I am misty eyed as I think my days doing this are numbered...

Time Crunch...

Sigh! It's been so long since I've written...
So much has happened...

Well, did I mention that with the beginning of my 4th year, I became the Chief Resident of my program?

During most of this year (academic year) I have agonized over:
1. Should I do a fellowship or look for a job?
2. Where is my place?

After soul-searching, I have abandoned my earlier plan to do an ID fellowship. Not to be arrogant, but with all the education I have, if nothing else, I should be able to learn outside of a structured curriculum. I love all of medicine, so I don't want to do a fellowship and narrow myself down to something. Perhaps what I will end up doing doesn't even come in a fellowship box.

Anyway, with that decision made, I began to look for jobs. I applied to mostly university programs and a couple of private clinics and hospitals with university affiliations. Although I have never dated, I get the feeling that these job hunting interviews were kind of like going out on first dates: everyone is formally dressed and showing off their best side and the whole event is somewhat orchestrated and pre-programmed.

I learned many things about the process and of course, myself in the process: promises are made that are not kept.

What I was looking for in my 'dream' job was the opportunity to:
1. Practice both medicine and pediatrics
2. Do so in an academic environment and,
3. Have the time, resources and opportunity to do research.
4. I was partial to places with existing infra-structure in international work since that is something I know that God has got for me in the future.

After travelling far and wide and having many fun experiences, I found my 'dream' job. It is right here at the Marshfield Clinic!

I am pleased to announce that come July 13 2009, I shall be the newest faculty member of the Marshfield Clinic Med-Peds department. Thank you, thank you.

I am setting up continued research collaboration with Sanjay Shukla's lab and my bacteriophage research. I shall look into getting an academic appointment from UW -- foundations for future research and teaching ventures.