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Archive for the ‘Residency’ Category

A New Year’s Update

I struggled with the title of this post for a while. It’s a long time since I’ve written anything (for the blog), and I wanted the title to be catchy, edgy, maybe even with a touch of double entendre. Alas, my creative mind has failed me. Perhaps this is a consequence of writing nothing but clinical notes for the past 6+ months- a result of being in the intern year of my medical residency. There is no need for provocative language, crafted sentences, or grammatical subtleties in medical notes. On a good day, clinical notes are composed of brief and simple sentences. On a busy day, notes are often composed largely of sentence fragments and phrases. On a bad day, notes may largely consist of abbreviations and acronyms.

Residency: Where to begin? I suppose at the beginning.

I haven’t tried this on older, more seasoned, docs, but it can be a bit of fun to ask a young doctor about the first order they ever gave as an MD. I come from a generation of medical students that did not give orders as students (I may have written out a paper order on occasion, but these were never acted upon until cosigned by a supervisor), so on July 1st, my first day of my residency, I showed up at 5 am eager (and somewhat petrified) to start my first rotation on Labor and Delivery- never having given a “medical order” to anyone. That morning, a nurse snagged me outside a patient’s room and said “Oh, she’s having some heartburn, can you write an order for Tums?”

“Sure”, I said calmly- while on the inside I felt like a deer in the headlights, trying to think of anyway possible that giving a lady Tums might lead to her demise. I stressed, I fussed, and then- as many interns do- I consulted a fellow resident. “Can I just write this lady for Tums?”

“Sure- but she should already have them ordered in the admission order set.”

How anticlimactic…

For a lot of young doctors that I’ve talked to, that first order request is for Tylenol.

The story usually goes something like this: patient’s nurse sees new resident. “Hey- Mr. Smith in room 14 has a headache. Can I get some Tylenol?”

New resident “Sure… Give me a minute?”

New resident then scurries off to the work room to check the patient’s allergies, liver function tests, alcohol history, etc, etc, etc. Resident then checks dosing, route of administration, frequency, and scans a med list wracking his brain for anything that might cause an interaction… I have heard this story many times- plus or minus a consult with a fellow resident.

That is on July 1 (or perhaps the end of June, as many programs now jump the gun on the July 1 residency start date). Hop forward a few weeks and the same resident will likely respond to the nurse “Sure- need a written order or can you take this as a verbal?”

Back to July 1: As I mentioned- I started my residency on labor and delivery. As a family medicine resident my intern year is a mix of some obstetrics, a pinch of surgery, a dose of pediatics, a healthy whack of in-patient medicine, and a sampling of various other areas of medicine (as well as a consistent stream of out-patient clinic). I started on Ob- one of the most challenging and grueling rotations in our residency. I’ll admit that I was initially scared but ultimately pleased that my medical career started on labor and delivery. My days of shadowing and standing in the background were gone. As a medical student I was allowed to stand in the room during a delivery and catch the occasional placenta, but as an intern I was expected to manage a patient from admission to discharge, with a labor and delivery in between. As my skill set and confidence grew, so did my autonomy- I was really someone’s doctor!

Of course, claiming that title was something I was hesitant to do…

As medical students, some people introduce themselves as “Student Doctor So-and-so”. I found this verbiage absolutely ridiculous, and instead went with the line “Hi- I’m Victoria, a medical student on the team looking after you.” I often followed this with the pseudo-apology “I can’t write you a prescription for any of the good drugs, but if there’s something going on and you feel like no one’s listening to you, I promise I’ll listen.”

Back to July 1- Do I actually introduce myself as “Doctor”? Who do I think I’m kidding?!

Folks, I’m here to tell you that the “Imposter Syndrome” is real. On July 1, there was no way I was introducing myself as “Doctor”. Instead, I modified by student script and said “Hi- I’m Victoria- one of the residents on the team looking after you.” I’m pretty sure I never introduced myself as “Doctor” that whole first month.

For my second month of residency I moved to a community hospital where I was doing in-patient medicine. There, my attending physician (my supervising physician) heard my introduction and said “Your life would be much easier if you introduced yourself as ‘doctor’”. Innately, I hate this reality. Despite working hard for many years to earn a slew of letters after my name, I’m not comfortable with the reality that saying that gets me more respect.

I battled on for a day or two, with my attending introducing me to patients as a doctor and hissing over my shoulder “doctor”, when she heard me call the lab, introduce myself as Victoria, and then sit on hold for 5 minutes waiting for a result. It didn’t happen quickly, but bit by bit, either by repetition or by the slow growth of the belief that maybe- just maybe- I was actually “doctoring”, I started to become comfortable with the term. I frequently couch the introduction with “one of the residents”, but I’m now comfortable introducing myself as Doctor, and have even found myself briefly annoyed when someone introduces me to a new patient by my first name. Outside of a patient’s earshot I have no need for a title (unless it bumps me to the front of the line when calling in to make an appointment for a patient or if I call in for a lab result), but I’ve come to learn that while the title doctor may give you respect, it also gives your patient confidence in you- and that is something incredibly valuable.

And what of Evolutionary Medicine and Ancestral Health?

If you’ve read many of my old posts (save those on travel), you’ll know that I have a passion for evolutionary medicine and ancestral health. One of the reasons I chose the residency program I did was because I knew it was a place I could explore those interests. That being said- my ability to explore and practice that kind of medicine has been quite limited. In my 8 weeks of Ob I had 49 vaginal deliveries: not one of which was done in a non-conventional position. I’ve probably prescribed more probiotics than most, though how much good a bolus of pure Lactobacillus does in a gut that has been firebombed with antibiotics I’m not really sure. (Strangely people rarely seem interested in eating Kimchi to replenish their gut flora… )I’ve also probably prescribed as much Tylenol as everyone else, despite believing that fever is a symptom (and a useful infection-fighting one at that) of illness and not something that needs to be treated in-and-of-itself. I’ve had small victories, discussing the potential benefit of fevers with some patients and families, and having them agree that they don’t need or want their fevers treated unless the discomfort is such that they can’t sleep or rest. I’ve also had these plans thwarted by covering residents and nurses who can’t stop their desire to “fix a number” and “fix a fever”.

Clinic is a bit of a different picture. There I’ve recommended, sleep remediation (sans medication), exercise, and books such as “It Starts With Food” to a number of patients, and been pleased to have the occasional one come back reporting success with lifestyle intervention. I’ve also had occasional welcome surprises, as I meet new patients who (sensibly) CrossFit or embrace a high-saturated fat/whole food diet who usually look shamefacedly at their doctor saying “My family wants me to come see a doctor because they know you’ll tell me this is a bad idea…”. Connecting with those patients- ensuring proper rest in one, recommending Kerry Gold Butter to the other- is an unexpected but welcome pleasure.

6+ months in…

I’m 6 and a half months into my intern year of residency. I have worked harder, put in more hours, and been more stressed than I ever have been before (the stress of writing a PhD thesis was quite different). Having written (and then retracted, since it was a duplicate order) my first order for Tums, I have gone on to write hundreds more orders. I still get nervous with firsts, but my comfort level is rising. Yesterday I did a thoracentesis for the first time. One day I will inevitably run my first code- this thought terrifies me.

I have also made some wonderful connections- with fellow residents, nurses, and patients. I continue to believe that doctoring is about people, not just illness, and while some patients come through as just another case that is quickly gone from my mind once the discharge is dictated, others have forever shaped who I am as a person and a doctor.

And Utah- oh Utah. There is not a day I have regretted moving to this state or choosing this residency program. I work with great people who love what they do but also value having a life outside of work. I work hard, but have the opportunity and ability to play hard as well. In the longer days of summer I was taking evening hikes some nights after work. With a tank of gas and some motivation I’ve been able to put 1-day weekends to good use, and have explored many of the national and state parks. Now that winter has come, I’ve used my rare day off to take to my cross-country skis, and am in the process of rediscovering my downhill ski legs, having hit the slopes for the first time in 13 years.

So here I am- half way through my first year of residency. I’m a doctor, and I no longer feel like a fraud when I say that. Many of my academic interests have been put on hold, but I have faith that I’ll be back to them as time allows. I’ve learned a lot since I moved to Utah in June: about medicine, myself, and others. There is so much to learn, so much to think about, and so much to explore, in medicine, wilderness, and life!

Little Cottonwood

View from Little Cottonwood Canyon, near the summit of Pfeiferhorn.

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