Blog

As an internal medicine resident, a large chunk of my time is spent consulting other services to obtain their expert opinions. Sometimes, these consult requests are honored. Sometimes not. Equal parts frustrating and awe-inspiring, denying a consult is something of an art.

Here is a beginners guide to dodging consults: how to avoid doing your actual job, and letting someone else handle it. A guide to shirking your responsibilities, responsibly:

1. Master the technicalities of the order placement.

Internal Medicine: Hey, consulting you guys for suspicion of schizoaffective disorder. History of bipolar, but they’ve been off their meds for a while and they’ve had episodes of psychosis.

Psychiatrist: Wait, so is this a consult for schizoaffective or for bipolar?

Internal Medicine: Well, that’s why we’re consulting you. We’re not exactly sure.

Psychiatrist: You said schizoaffective, but the consult order said bipolar!!!

[whooping and high fives heard over the phone]

Internal Medicine: ….yeah, but…

Psychiatrist: If you want to consult us about shizoaffective, you’ll have to cancel that order and put in a new one, but we don’t take consults after 2 PM!

[The distinctive pop of a champagne cork is heard over the phone]

 

2.  Question. Everything.

Internal Medicine: Hey, we’ve got a woman in her late 40s with 1 day of RUQ pain, febrile, white count, D bili of 5, and alk phos 900. History of gallstones. You guys mind taking a look at her? Ultrasound shows pericholecystic fluid.  I’m pretty confident this is cholecystitis.

Surgery: Is that so?

Internal Medicine: …I think so.

Surgery: What’s her baseline alk phos? What type of pain is is it? When was her last CT? Who diagnosed these gallstones? Is she really a woman? How febrile is she? How long has she had this pain for? Who did the ultrasound? Who won the democratic presidential nomination in 1924? When –

Internal Medicine: Wait, so are you going to see her?

Surgery: Call us back when you have more of the history.

 

3. The Tautological Defense.

Internal Medicine: Good afternoon, esteemed colleague!

Dermatology: What’s up?

Internal Medicine: It’s a guy with really bad stevens johnsons. I’m not too comfortable managing it, wondering if you could help with some recs.

Dermatology: So if it’s an emergency, the on-call resident usually just sees them in the ER.

Internal Medicine: OK, but the ER admitted them.

Dermatology:  Right, but we actually don’t see floor patients, just ER emergencies. If it’s a floor patient, we just schedule them in clinic as outpatient.

Internal Medicine: It’s really bad, dude.

Dermatology: But the ER didn’t call.

Internal Medicine: I know!

Dermatology: Exactly.

Internal Medicine: What?

Dermatology: We’ll see them in clinic on Tuesday.

 

4. Subtly undermine their credentials.

Internal Medicine: Hey, sorry to bother you guys, but we’ve got a COPDer who’s not responding to his nebs and is on a venturi now. We’d like you guys to take a look.

Pulmonology: Who is this?

Internal Medicine: Gen Med. I’m the intern.

Pulmonology: Where’s your upper level?

Internal Medicine: She’s in clinic all day today.

Pulmonology: Yeah, usually the upper level will just consult us directly.

Internal Medicine: But I went over the case with her, she asked me to consult you guys.

Pulmonology: Nice try, bud. I’ll be looking out for her call. Tomorrow.

 

5. The “I’m on your side.”

Internal Medicine: Hey, can y’all see this one today? It’s Jones, the 70 year old with prostate cancer and urethral strictures. Rising Creatinine. You saw him in clinic.

Urology: Hey, thanks for checking in.

Internal Medicine: Yeah. You guys gonna take him back to the OR?

Urology: Good question. I don’t know, man. My attending can be really weird with some of these soft consults.

Internal Medicine: What do you mean?

Urology: Trust me, I want to see them. Like I’ll even see them just by myself. But my attending has been super busy this week, and it seems like we just saw them in clinic, so you may have to hold off on the official consult until Monday. I know, man, it sucks, I know.

Internal Medicine: I see.

Urology: In my soul – deep down – I know that seeing them is the right thing to do. The moral clarity of your request shines brightly, as if a great, blazing  torch lit atop an echoing mountain of freedom. I stand with you. But I stand in silence.

Internist: …

Urology: Just consult on Monday.

 

6. And, if all else fails, use one of these lines:

• “He doesn’t sound that sick.”
• “We don’t generally get consulted for that.”
• “Did you consult IR?”
• “Something something evidence based.”
• “Let me call you back after this case – it may take a few hours.”
• “I’m just stepping out for a conference.”
• “I’m rotating off service tomorrow – it may make sense to just hold off on that consult for a few days. Thanks!”

 

The dim monitor atop the COW (Computer on Wheels) outside room 916 flickered to life after a few insistent mouse clicks. COWs are now a ubiquitous part of hospitals, since medical records have essentially all been digitized. I briefly reacquaint myself with the patient’s chart before I enter the room. I head over to “Notes.” Pain management checked in with adjusted morphine dose. Cards noted that the patient’s EF was diminished, and that they would be starting a diuretic drip. In neat 2 hour increments, nurses left notes about bowel habits, pain, and vitals. People are constantly logging in and out of the COWs, and I don’t begrudge it the few seconds it takes for the screen to turn on. Though essentially all hospital personal document their patient interactions electronically, sometimes I get the feeling the COW would rather just be left alone.

Of all the notes the COW displays, the most incongruous has to be the ones from the “clinical chaplains.” Hospitals employ religious leaders of most mainstream faiths to help those inclined navigate the uncertain terrain of severe illness. While I’m not particularly religious, I think it a kind and decent thing for hospitals to do. Discussions that help patients clarify their end-of-life goals, or even their life goals, are helpful. But it has always struck me as somewhat bizarre that notes from these chaplains are mixed in among those from doctors and nurses.

Cows and God have a bit of a history. Moses got very angry at the Hebrews for deciding to worship a golden cow while he was away getting the 10 commandments on Mount Sinai. Thought it was disrespectful. I have to think that Moses would be, at the very least, confused by our modern COW/God symbiosis. We don’t exactly worship COWs, but we come pretty close. Medicine depends on COWs these days. As any medical professional will tell you, if the hospital-wide EMR ever shuts down (which has happened to me several times), the result is Tower of Babel chaotic.

I find the notes left by clinical chaplains, rabbis, imams, and pastors incredibly strange. For one, I don’t think most patients even know about the existence of such notes. I suspect it might change the way patients interact with hospital clerics. I’m guessing Catholic confessionals would be very different if the priest were jotting down what he heard and storing it in a permanent online file.

The bigger, issue, though, is that these notes just don’t get read. It may be due to the template-based format that so many EMR notes take nowadays. I will often peruse these notes out of curiosity and see the same auto-filled sentences trotted out. “Counseling offered.” “Spiritual empathy employed.” “Affect brightened by encounter.” Chaucer this is not. What it also is not, though, is useful, especially when you are trying to find an actual medical note. This may seem trivial, but I have seen patients with no fewer than 10,000 total notes written about them over the course of their hospitalizations. It is hard enough to piece together what different medical teams plan to do to patients, even when talking face to face, without having to wade through rivers of unnecessary text.

Moreover, everything you’d want covered by a note in the medical chart from a pastor is already covered, elsewhere. Patients have facesheets that document their religious affiliations. Hospitals urge patients to consider end of life decisions and advance directives early in their stay. Trained, professional social workers and counselors are also always available. And if patients reach a decision about their treatment plan from a talk with a chaplain, it can always be communicated to doctors in person.

It’s been a strange few millennia for God. After guiding desert tribes as an alternating pillar of smoke and fire, smiting those who dared to touch his ark, and creating the entire universe, he now finds himself rather unceremoniously inserted between the “total urine output” and “pre-anesthesia checklist” notes on EMRs across the country. I think guidance from religious leaders is perfectly appropriate for the faithful, and I am happy to call clinical chaplains for my patients. But please, let’s keep those conversations between the patient and the pastor, and out of the medical record.

Sometimes in life, but more specifically during a medical residency, you have to stay up all night. As a kid, staying up all night could pretty much only be awesome. It meant:

• A sleepover* was happening
• A snow day was imminent
• The olympics were happening in some foreign country, and for that week you and your whole family became ice skating experts at 3 AM (“She’s nervous…I can just tell. Her axels seem way off base.”

*Sleepovers are basically raves for little kids. Except that the drugs are video games, the club was just the house with the best food (this was critically important – you had to know whose house had the real snacks, and whose house had the rice crackers and soy paste), the promoter was your friend’s older brother, and the owner was a shadowy authority figure upstairs, wearing a robe.

As we progress through life, the night becomes more necessary and less charmed. The night becomes less of a buffer against what you failed to do during the day, and becomes more of the prime working time. Homework happens at night. Ditto for test studying. Sometimes it is preferable to working during the day – you aren’t taunted by sunlight and the promise of a frisbee toss, or whatever it is that real humans with respectable work/life balances do in their spare time outside (Run? Catch fireflies in jars? Laugh giddily in cornfields?)

I’m now working at a hospital nocturnally for a few weeks. The dreaded “night float” rotation. I’m covering for the primary teams while they are sleeping. I’m keeping watch. I’m like Jon Snow at the Wall. I’m like Batman, if Batman were called for very mundane and routine bureaucratic hold ups (“Help! Batman! Our W2’s were filed incorrectly!”). Now, I’m being a little hyperbolic (obviously). You never know when you will be called for a code, or a rapid response, so you always have to be sharp. And awake. But you have to admit, it would be sort of funny if Batman were called to the scene, and it just turned out that someone needed Tylenol for a minor headache.

BATMAN, (in his ‘dark and scary’ voice, whispering into the ear of a frightened old man): TAKE TWO. YOU SHOULD BE ABLE TO GO TO SLEEP NOW. IF YOU NEED ME, FLASH THE BAT SIGNAL. OR JUST HAVE YOUR PHARMACY CALL MY OFFICE.

OLD MAN: Thank you, Bat-

FWOOOOSSSSSHHHHHHHHH

[The OLD MAN‘s window is open, curtains flapping. BATMAN is gone]

[Bewildered, the old man is about to take his medications, when-]

FWOOOOOOSHHHHH

BATMAN: AND DONT FORGET TO CLOSE THE WINDOW. YOU’LL CATCH A COLD.

What are the benefits of working at night? Honestly, this is tough, as it really does just make a lot of sense to not do things when it’s dark and to do things when it’s light. But here goes:

• It’s peaceful, in the sense that ghost towns are peaceful before all the weird paranormal stuff starts happening. Sort of like the movie Hancock, except that you aren’t as cool or productive as Will Smith in your spare time when everyone else has died. Seriously, he was like cracking jokes to himself, and still working out despite no one else being alive. What a go getter. Wasn’t he a god or something in that movie? I forget. If everyone else died I think I’d probably stop going to the gym.
• You are actually at home during the day, so if you need to do anything to function in modern society like buying clothes or food, coordinating repairs, or going to the dentist, you can do it**
• You get an incredible sense of victory going home at 7 AM. It just feels like you’re winning more than you should, like you’ve dominated everyone else who is waking up because you’ve just been doing more than they have. Of course, this is fleeting, as you then get mediocre sleep in a too-bright room, then have a raging headache, and then curse yourself for working a nocturnal job. But there is that initial feeling, which is cool.

**This is, however, at the expense of sleep, which makes it utterly not worth it.

OK, that’s all I’ve got. I’m really excited to get back to a normal schedule.

Bipolar disease is awful. Let’s just get that out of the way right out of the gate. It’s a mood disorder characterized by large swings in thoughts and behavior, from peaks of mania to valleys of depression. To have bipolar disease is to know what it must feel like to be zooming through life on a roller coaster blindfolded.

Most of us know what it is like to feel depressed, or have seen a close friend or loved one go through it. It is characterized by:

-Sleeping too much during the day / not enough at night

-Lack of interest in activities that used to be meaningful

-Feelings of guilt and worthlessness

-Fatigue, lack of energy

-Difficulty concentrating

-Loss of appetite

-Anxiety and lethargy

If anyone feels these symptoms for a significant amount of time, they should seek psychiatric help immediately – this is treatable!

Perhaps less well understood generally is mania. It is a period of incredible intensity which can sometimes lead to overt psychosis. Here are the classic mania symptoms:

-Distractibility, easily frustrated

-Irresponsibility, erratic and uninhibited behavior

-Grandiosity

-Flight of ideas / racing thoughts

-Increased goal-directed, often high-risk activity (gambling, sex, improbable business ideas)

-Decreased need for sleep

-Extreme talkativeness

These are generally thought of as the two ends of the mood spectrum: doldrums on the one hand, and rock and roll on the other. However, to what degree is mania a part of, and even integral for, modern success? Does anyone know an ICU doctor who gets enough sleep? What about a CEO who didn’t have a grandiose vision of the company? Wasn’t Steve Jobs famously easily frustrated? Aren’t most worthwhile investments high-risk?

Enter hypomania. As with most things in medicine, it started with Hippocrates. Its definition has changed a bit since the Greeks were running things, but at varying times it has meant “partial insanity,” “craziness,” and “monomania.” It now generally means “less than mania,” in that it shares similar features, but does not result in psychosis and doesn’t affect people’s functioning as much as mania or depression. Here are the descriptors of hypomania:

-Extremely energetic

-Talkative

-Confident

-Creative ideas

-Excitement

-Highly productive

Now, look at the above list. Pretty impressive. What exactly is this thing? Is it a disease? Or the profile of your dream spouse/senator/graphic designer? Should you be treated for this, or be happy that your brain’s neurochemistry allows for you to be a motivated, competitive member of society? Here are some more ridiculously advantageous benefits of hypomania, from Christopher Doran’s 2007 book called The Hypomania Handbook: The Challenge of Elevated Mood.

-“Euphoric”

-“Visionary”

-“Overflowing with new ideas”

-“Significant correlation between hypomania and creativity”

-“immune to fear and doubt”

-“negligible social and sexual inhibition”

-“life of the party”

-“offer solutions to problems”

-“finds pleasure in small activities”

Again, what is this thing? It’s made it’s way into the DSM-IV, so it’s currently listed as a disease, with treatment options. But what does it mean to have hypomania? Don’t we all get this, to some extent, at varying points in our lives? Think to a time in your life when you’ve been your most productive. That night that you stayed up until 3 AM, made a pot of coffee, and wrote the essay. That day off where you made a list of 10 things, and then gleefully ticked them off as you got groceries, went to the gym, paid your rent, hung up that picture you’ve been meaning to hang, and called grandma. That party where you had a bit too much to drink too quickly…and liked the resulting confidence, disinhibition, and euphoria of finally feeling like you just don’t care what other people think.

I think most of us experience hypomania. If I’m being totally honest, I wish I experienced it more. It’s enjoyable. It’s no wonder that people generally do not want to be treated when they are diagnosed with it. We treat and medicate and diagnose and define deviations from normal. But it’s usually the people who aren’t normal that propel our humble race forward. Building a civilization is hard, and it wasn’t that long ago that we lived in trees. If the key to creativity and success lies in psychological deviation from the norm, is it a disease? Or our salvation?

The field of medicine evolved, principally, as a field of observation. Hippocrates (the first, and perhaps most famous physician, for whom the oath is named) would press his ear up against his patients to listen to their innards, a precursor to the common modern technique of auscultation. People used to dig up skeletons in graveyards and drew them for a better understanding of anatomy.  The french realized that you can tap on wine casks to see how full they are, and then realized you can basically do the same thing to people. Our attempts to understand (and ultimately fix) the human body have relied on thousands of years of looking and listening.

Describing a patient well has, and will always be, useful in medicine. A concise, accurate description of a patient’s history and physical examination remains one of the most elusive and difficult skills to master as a medical student and resident. This skill has proved especially useful in modern medicine, where patients are handed off between colleagues more and more as duty hour restrictions have hardened.

An interesting consequence of medicine’s collision with modernity has been the devaluation of physical exam findings. Ultrasound, CT,  and MRI imaging techniques have all brought the insides of our patient’s bodies into crystal clear focus. What used to be either inferred, missed, or seen retrospectively on dead patients, is now rapidly available, usually in under an hour. Modern imaging is something like a miracle. I dare you to even try to understand the science behind an MRI,  for which the nobel prize in medicine was awarded in 2003. A friend of mine is a medical physicist, which is an entire scientific field devoted solely to understanding the physics of medical imaging modalities like MRI and operating them. He once described the science of MRI’s to me as “basically indistinguishable from magic.”

Modern imaging has collided head on with the physical exam. Because imaging can catch so much that the physical exam misses, the physical often feels somehow fake. Forced. Like the opening ceremonies at the Olympics, it’s glitzy, it’s expected, it’s analyzed (albeit by fashion blogs), but in the end it ends up being a lot of arm waving before the actual games are played.

Recently on the wards, I saw a patient who had obvious signs of congestive heart failure. Edematous, swollen legs. Fatigue. Trouble laying flat. His blood, unable to be pumped fully throughout his body, was backing up into his lungs and his extremities, collecting in places it wasn’t meant to collect. He, indeed, had heart failure. This was proven to the team by echocardiography (sound wave imaging) only hours after he was admitted to the hospital.

He had a special kind of heart failure stemming from aortic insufficiency – blood was flowing back through his aortic valve, causing a buildup of fluid in his lungs. Aortic insufficiency has a characteristic murmur on auscultation: an out-of-place whoosh that trails off in a decrescendo where there should be only silence.

I imagine that in the days before transthoracic echocardiograms, this murmur would have been the crux of the case. The physician that found the murmur would have solved the riddle. I can picture several physicians, stooped over the man’s chest, ruminating for minutes on the exact degree and characteristic of the murmur, comparing it to others they had heard, debating the acoustics and dynamics.

Today, things are different. The murmur was heard, but it wasn’t heard. It was noticed, and promptly forgotten. The echocardiogram was ordered, and it did the heavy lifting. “Severe aortic insufficiency seen. Left Ventricular Ejection fraction 20%. Recommend CT for full characterization of aorta; concern for aortic root dilation.” Pressures, gradients, valve areas, and outflow jets velocities given in neat tables.

After receiving this information, we went back to the patient’s bedside the next day to find the murmur. There it was, waiting for us the whole time.

Hello, internet! I’m excited to enter the blog-o-sphere. It’s not actually as round in here as people make it out to be. Much flatter. Almost dismayingly flat. But I suppose that the ‘sphere’ part is pretty catchy. It’s better than ‘blog-o-normal-dimensions,’ or a BOND. Although, people, let’s be honest. We are not aiming for a BOND. We are aiming for a BAND. A blog-above-normal-dimensions. That’s right. I want this thing to be so good that it proves string theory (string theory is only correct if there are 10 or 26 dimensions). So lets kick this BAND off in style, with some good old-fashioned mind blowing neuroscience quotes. Here are two:

“There are more connections between neurons in a cubic millimeter of brain tissues than there are stars in the milky way galaxy.” -David Eagleman

“There is no such thing as color in the physical universe.” -A neuroscience textbook I read in college

With those thoughts in mind, I’m going to head to bed. Goodnight!