Monday, November 02, 2009

Feb gets political!

So, how long did I get to do my job practicing hospital medicine before I had to argue with someone about finances?

Nine days. And what's weird was, I wasn't fighting with the party I assumed I would be.

We discharged a guy from the hospital last week, and because he'd had an unexpected event happen (I'm being intentionally vague about the specifics, but it's in that category of "maybe you can predict who's at higher risk, but you never know for sure if or when it'll get you"), he had to be discharged on a medication that was new for him. It greatly lowers the chances of future badness, but the med itself isn't exactly a glass of warm milk. You need to watch people carefully at first, test some blood, make sure the level is right. If it's wrong, things can go very bad indeed. This requires careful follow-up with the primary provider.

So I'm calling Scheduling to make sure this guy can a) get the appropriate blood test in a few days, and b) get in to see his regular doctor pretty soon. The scheduler says, "huh, that's odd" and "I'm sorry, but I'll have to have you speak with so-and-so." Then I find myself on the phone with someone who says the patient can't be allowed to schedule these future appointments, because he owes our practice group over $2000. I'm speaking not to some insurance company, but to our collections person.

Turns out, the guy had tried to schedule an appointment a few weeks back, and was told he couldn't, unless he paid some portion of his outstanding bill. Again trying to be as polite as I could, I wondered out loud if maybe this unexpected nasty thing that caused him to be hospitalized for three days maybe could have been avoided if he'd, oh, maybe seen his doctor a few weeks ago. The collections person was not impressed. Fair enough.

But this person's heart was not made of stone, and when I mentioned that the patient, sent out into the world blindly with no assistance beyond me wishing real hard for their med level to be correct, could potentially die, they did relent, and allow for one visit, for both the blood test and the primary care check-in. But no more!

From now on, when I discuss how messed up health care is in our country, I will tell this story. It's personal, it makes me crazy, and I can see several sides of it, all of which are totally and utterly, for lack of a better word, fucked. In my mind, it all boils down to a few key things:

1) Sure, this dude smoked, drank, and ate cheeseburgers; in short, acted like most Americans do. Sure, if he'd been jogging, avoiding high fructose corn syrup, cigarettes, and other vices; if he'd been eating bran muffins and celery sticks instead, he'd be better off now. But we play the hands we're dealt, and the guy in front of me is this guy, with this history. I have to treat him, not the version of him I would prefer to see.

2) According to what I could tell, he has insurance. I know a former Blue Cross claims agent who pointed out that lots of people have "80/20" plans, where the insurance only covers 80% of anything. That fits with the amount between $2000 and $3000. And of course, that bill is about to go up, from this recent hospitalization.

3) We're a private clinic group, so my own salary quite literally depends on the collections person doing their job, and doing it well. This person is, and I have no ilusions about this, on my side. God knows how many situations like this I'll encounter in my first year. If, hypothetically, my bleeding heart insisted on enough people in this situation being given care anyway, and if enough of them were unable to pay, then eventually we'd collapse and be able to help nobody at all.

4) And yet, when it all comes right down to it, I am not willing or prepared to say "screw this guy." I won't let him go out and die, or (worse for the system) get sicker and rack up more costs, just because he can't get in to see somebody. There are free clinics, but not enough, and anyway he earns too much at his job to qualify. There are a handful of sliding-scale clinics, but they have a waiting list that's months long, and he needs to be seen in a week. The walk-in urgent care centers don't do the ongoing primary care stuff, and the ER can do any test you want but it's ten times the cost so that's no solution.

And while it makes good sense in several different ways for my respected colleague the collections manager to aggressively defend the solvency of our business, how much would we have to pay his family in the event something bad happened and someone made a convincing argument that we could have done something to prevent it? (Ahh, but you can't reliably measure potential costs, and health care is all about potential expenses vs potential savings. Ask anyone who works in primary care why they don't make more money, and that's essentially the answer.)

So, for me, that's what the debate about a public option boils down to: somebody has to be willing to look that guy in the eyes and say "no." No, you can't get treated. No, you don't deserve a slice of these limited, expensive resources. No, the situation you are in, when stacked up against the situation others are in, and compared to what we have to work with, does not warrant you having this test, this visit, this intervention. And by the way, no, there is no reliable, consistent safety net we can allow you to fall into, so that at least there is a minimum standard you can count on. Have a nice day.

Because here's the thing: we say no to people all the time. We ration health care in the United States. We just like to pretend that we don't. And it doesn't go to the sickest first. In my opinion, getting anywhere near that truth freaks people out.

Well, the next person I encounter who doesn't believe in reform, or thinks a public option is Communist, is going to hear this story. And then I'm going to tell them I'm not willing to be that person who says "no, there's nothing, now get out." And then I'm going to ask point-blank if they would be willing.

Tuesday, October 06, 2009

My entire life, in 2970 characters (with spaces)

When I was writing my CASPA essay, the challenge was to shorten it enough to meet the requirements, but include enough detail that the elephant in the room -- how come you're applying to grad school at the age of 35? -- was sufficiently addressed. In a way, that made me one of the lucky ones, because the biggest problem PA school applicants have is identifying the specific goal of their own essay.

I know this because I've had the opportunity to assist a few newbies with their essays. There seem to be two major traps people can fall into: either they overestimate the uniqueness of their situation, or they completely fail to recognize it. For example, "I experienced how the serious illness of a loved one affected me and my family" is certainly a story worth telling, but in that stack of PA school applications, perhaps as many as 1/4 or 1/3 of them will tell a story along those lines. Likewise, a kid who barely graduated high school but buckled down and aced an accelerated EMT course because he was so intent on being part of the ski patrol will, not realizing that's a powerful story in its own right, focus instead on his time volunteering at the front desk of a clinic.

While it was stressful and challenging, I also had a pretty good time getting my essay together. I had just finished the post-bacc in Vermont, after leaving the stability of my previous career, and the essay was a good opportunity to tie it all together. I got (and actually used) some feedback from my good friend Jeff, whom I've known since we were both 13. He's the professional writer; I'm just a dude who knows a couple of things, including who to ask for help.

Here is what I put together. It was part of a package that got me interviews at every school I applied to.

I am not by nature a spiritual person, yet I understand what people mean when they say they have been 'called.' My parents gave me a sharp curiosity and respect for intellect, but at the same time my family prizes 'street smarts' over intelligence. I went to work after high school, finishing my BA degree ten years later. It would be another five years before I would discover my calling and return to school to pursue medicine. Like many future PA's, I have been a 'non-traditional' student my entire academic life.

In the years I worked in offices, I helped people buy houses, and gain access to higher education. I worked to become a trustworthy, effective advocate and a solid part of every team I was on, including those I led. Ultimately, although I was on a comfortable path, I came to the decision that the rest of my working days should be spent doing something I not only appreciated in an abstract way, but truly respected, and furthermore which uses my talents. Exploring those ideas led me to the county hospital.

Volunteering at the (Name of Hospital) Emergency Department revealed that medicine was that kind of work. Soon, I was certified as an EMT, and hired part-time as a clinical assistant in that same ED. That's when I learned medicine is something I could do well, and love doing for the next 25 years. My calling wasn't a dramatic or a transcendent moment; it was simply recognition of something that made sense.

There were days when I'd finish a workday at the office, walk to the hospital, and work another eight hours. Usually, I felt less tired after taking care of patients than I had been earlier, after eight hours at a desk. Once, during the day, I referred to customers as 'patients.' Clearly, my mindset was changing. Meanwhile, the staff of the ED, particularly the PA's, not only answered questions but encouraged me to take steps toward joining them.

I know now that medicine is an excellent arena for the skills I developed in college, and at work in my previous fields. I am a natural problem-solver and detective, recognizing and connecting the most important pieces of an emerging puzzle. I'm a communicator with a knack for explaining complex issues in simple ways, as well as asking the right questions. I thrive in conditions that are fluid, even chaotic. I have the passion of an idealist, and the work ethic of a realist. And of course, having spent more than two years working in a busy ED, I am aware of the day-to-day realities of patient care.

It's this last point that drew me to the PA route specifically. I have varied interests, including research, teaching, and medical writing. The focus of my practice will always be my patients, but I am drawn to the PA paradigm, where the expression of that focus is allowed, even encouraged, to evolve over time. When I consider what I would like to do, and the way I would like to do it, PA is closer to a perfect fit than most people ever find. I'm grateful to have made these discoveries, and excited about what's next.

I'm not saying this is a perfect essay, but it accomplishes several goals, and it hangs together in a way that is crucial to making this part of the application more than background noise. I may have mentioned it the other day, but it's my opinion that a bad essay can work against you even more than a good essay can work for you. Once interview day rolls around, of course, the essay matters much less (although interestingly enough a good essay can stack the deck in your favor during that moment when you're about to walk into the room and the interviewer is reminding him- or herself about who you are).

Today is PA Day, and the beginning of PA Week. Best of luck to everyone working on a CASPA application, and to all those out there in the trenches. I'll be joining you very soon.

Friday, October 02, 2009

Getting Personal

Next week is PA Week. I won't actually be at work October 6th through 12th, but I'm showing my spirit. As a touch of advocacy, a little public awareness, and also to give back to the pre-PA n00bs (whose ranks I only just left), I'm doing a little somethin-somethin I said I'd do, oh, over three years ago.

Some background: there's a discussion out on Teh Boardz about personal statements. This is the time of year when the not-really-very-early birds are submitting to CASPA. Long-time readers will remember when I was stressing about distilling my whole life down to 2970 characters, with spaces. A cursory search seems to show that it's now 500 words, so ha! to the new ones; mine was 518. I guess I just like small words.

Anyway, I contributed to a recent PA Forum discussion with some advice, and thought it fits the overall theme here. Especially if I finally post my own long-ago essay, like I once said I would. That seems like the kind of thing I can easily tease out into a few posts.

First, here's the wisdom I dropped on today's youth:

I believe that good personal statements won't tip the balance and turn a mediocre application into an interview, but bad ones can help admissions people weed out apps that are on the fence. Mine was awesome, but only because it told the story of who I was and how I came to be an applicant. That's really the goal, no more, no less. And it's amazing how many people mess it up.

On the other hand, get 1400 on the GRE and all the essay has to do is be written in English, and make some manner of sense.

(I then gave some specific advice about the essay which started off the thread, and brought it back around to the generalities.)

...I know what you're saying, but (and this advice is for everyone) you need to write for someone who has been looking at essays non-stop for two hours. Give that person a break, and stop trying to impress them. For this essay, you show facility by creating clarity. To quote Metallica, Nothing Else Matters.

Yeah, I brought Metallica into it. I'm insouciant online. That's a GRE word.

THIS WEEK: My essay, and the various forms of butt kicked by it

Thursday, October 01, 2009


Hey, what's up?

Me? Not much. I'm most of the way through Batman: Arkham Asylum. I'm in 1968 in Beatles: Rock Band, and kind of conflicted about playing more because I know what happens at the end. We've been to some weddings. The wife is six months pregnant. And I get to start my job in a little more than a week.

Yes, the long and grueling credentialing process has moved enough that it's safe to send me to orientation soon. And since I'll be spending a week at the Mayo for a conference, there's even some cushion. The upshot is, the slothful unpaid vacation will be coming to a close.

Tuesday, September 15, 2009

Medical training vs common sense

I'm a patient again. Much like what happened sometime in 2007, a random tiny scratch to the surface of my skin blew up into a cellulitis over my right jaw and temple that has me looking half as round-headed as Charlie Brown. I had a perfectly normal yearly checkup on Friday, and by Sunday night was febrile and wracked with chills.

Being relatively smart, I went to Urgent Care Sunday afternoon, so I was already downing antibiotics, and I was sure that this infection was unrelated to a minor surgical thing I had done to my right cheek earlier in the day on Friday. Nonetheless, I thought it courteous to let the Derm Surgery people know I was blowing up, and taking antibiotics. Naturally enough, they wanted to see me again today.

It was a silly visit, all in all, but I kept reflecting that if I were the provider rather than the patient, I'd want that patient to come in. The surgeon nodded, listened, looked, and agreed that I was doing all I could, or should. Then I mentioned that maybe I'd start warm compresses a few times a day, just to help the lymphatics drain. And he said something I think is incidentally hilarious:

"Well, that's just symptomatic relief."

I mean, we just got done talking about my regimen of two antibiotics. It's not like I gave any indication that a hot washrag is my idea of a cure. Also, he knows I'm a PA.

So I said "well, yeah," when inwardly what I meant was "no shit, it's just that my awareness that there are bacteria isn't what's making my face hurt, and while I wait for them to die I'd like to control the symptoms." Symptoms are by definition those things that are bugging the patient. Relieving them seems like it might be worthwhile.

I know what he meant -- controlling symptoms is not the same thing as treating a condition, and things that make you feel better don't necessarily make you better. But it's clearly such a reflexive thing for this guy to say, and he must have said it so many times, it just struck me as funny.

Tuesday, September 08, 2009

We're funnier when we're not trying

Actual exchange between my wife and me, early in the AM when we both had been asleep...

Teslagrl: Hey. Hey, wake up.

Feb: Huh?

T: You were making weird noises.

F: Oh. Sorry...

T: Goodnight.

F: ...I was dreaming about watching The Disney Channel.

T: Well, you were making noises.

F: Were they noises that sounded like Nick Jonas?

T: If Nick Jonas had a seizure, maybe.

Friday, September 04, 2009

The Coolest %@$#ing Thing I Have Ever Seen (on YouTube)

Imagine you're a 15-year-old kid from Santa Cruz. Now imagine you're a Green Day fan (not so tough for me, as I love me some Green Day). Imagine also that like a lot of 15-year-olds, you spend some time in the basement or garage with your guitar.

Okay, now imagine that you're pretty good. So good, in fact, that when you go to the concert at the hockey arena, you don't feel you're bragging when you hold up a sign saying "I CAN PLAY JESUS OF SUBURBIA" (which, for the uninitiated, is a lengthy song-suite from a kickass album, kind of like the kind the Who used to make).

Now's the fun part: because this is Green Day, and because they're awesome, there's this thing that sometimes happens at their shows...

Tuesday, August 25, 2009

RP episode 7: "Crazy Love" (Crazy, weird, radioactive, vaguely insulting love)

I'm trying something a little different for this episode. I'm still behind by four, and in the interests of speeding things up, plus making watching the show less of a task, I've adopted a format designed to keep it snappy while still touching on the most important points. It's less of a book this way, although even worse for people who might not have given the show their full attention. This week, "Boris has a shark in his basement." He also (SPOILER!) totally has cancer, or something.

The "A" Plot in one paragraph:

Jill's friend Katie (who got a call from Boris as soon as the shark arrived, remember?) is in town, for discussions about a research project which would be funded by Boris. She reveals that Jill, being a Hamptons native, has a string of summer-only flings. She also counsels Jill to be cut-throat and kind of evil about Hank... or does she?

The "B" Plot in one paragraph:

Divya's fiancee Raj is introduced; he's a floppy-haired hotelier, a nice enough guy, and I'm getting a serious "just friends" vibe off Divya. Faced with the hot-blooded, overwhelming "Lambada: the Forbidden Dance"-ness of this week's PDBs, Divya wonders what kind of relationship she's about to become locked into. This thread ends on a nicely unresolved note; is she craving a more passionate, less Old Country relationship with Raj, and frustrated because of how close it is? Or by how far away? In other words, when she kissed him with such passion, was it a test... and did they pass? He must be a good bloke, right? Who takes a freakin' bus to and from the Hamptons?

The "C" Plot in one paragraph:

Crazy, rich, Latin lover stereotypes have weird problems. Say what you want about American health care, but when we agree to secretly insert a GPS tracking device into somebody's breast implants without their knowledge or consent, we don't use plutonium-powered ones. Divya is really snotty about these particular PDBs, and ambivalent about her fiancee as a result of hanging around them. Evan hounds them for payment, and uncovers the truth; he's just as stupid about investing as she is stupid about him, so these DBs are less P than most.

PDBs of the Week:

Italian/ Argentinian/ Generic Exotic People Sofia and Javier; I had been hoping they would not in fact be redeemed by the end, and remain DBs. I was, for the most part, not disappointed. Credit is due to the writers for letting their characters remain horrible people throughout the entire episode, without much comment.

Obnoxius product placement moment:

"Wow, that's a good martini! When you showed me the bottle and declaimed the name of the brand, it made it more special."

Medical Moments:

* Opening on a stress test for Boris. Dude's treadmill is out on the patio. Nice. So, when's his colonoscopy? Sweeps?

- Roadside, after a Vespa goes off the road, Hank stil irrigates with nowhere near enough fluid.

- "I was going to cal 911, but then Divya told me about you..." say what, now? Didn't you get here thanks to a giant lawsuit arising from somebody thinking you were a dumbass who was doing too much?

* At Boris', Hank could be using enough irrigation for once, since the scene fades in on him using a 40ml syringe... but that pool table is wrecked if he's using the proper amount, with no towels down.

* When did they do a CT scan? I mean, cool. They did a CT scan. Okey-doke.

- The jewelry shouldn't even be in the same room as the MRI; never mind if it's powered on or not. It's still an enormous magnet. Physics fail. Oh, and same deal with the, uh, foreign object.


This episode sees Divya using the performance of medical duties as an excuse to postpone dealing with Raj, and the thorny nature of her personal life. This is something that plenty of real-life medical people might do, but so far it's not something we've seen on this show. So there's nothing to gague it against. I think here, it makes her look emotionally immature, rather than conflicted; and unprofessional, rather than distracted.

What's My Problem This Week:

Even before watching, I was thinking about the issues I've raised so far, and it sounds like actor Mark Feuerstein has been wondering something along the same lines. (It's a good interview at that link; read the whole thing. I'm referring to the very last question and answer.) In a nutshell, my issue is that Hank is such a nice guy, and everybody loves Hank. Always. Anybody who doesn't love Hank is either shown to be wrong and given the chance to change their opinion, or is a bad guy. But Hank, meanwhile, hasn't come to be in this situation because he's awesome; he's in this situation because things in Manhattan got utterly bollixed up. But since coming to the Hamptons, he's been nothing but wonderful.

As last episode showed, it's not like Hank is always even right; it's just that the show, centering as it does on him, is charitable to a fault about Hank's missteps. And a show about a perfect character is boring.

So it's nice to see a little erosion of his calm; what if Jill is only into him as an MSG? Then again, by the patented end-of-show tender moment, he's such a stand-up guy about not knowing his plans for Labor Day and beyond... he basically does the heavy lifting for Jill, allowing her to dump him with a minimum of fuss. "Gee, I'm sorry breaking up with me is so trying for you. Perhaps if I made some cocoa?"

Best line: "right now, I feel like I'm living on a Bond villain's property..."

Sunday, August 09, 2009

RP Episode 6: "If I Were A Rich Man" (...I'd fly to Hollywood, buy the writers lunch, and calmly explain where they go terribly wrong)

This is the episode full of dogs. And it's got some dog-like characteristics, in its own right.

I've found that while the treatment of Divya's career is overall excellent, in fact better than I could have hoped for when this show started, the show itself doesn't always deliver on what I optimistically like to think of as its promise. Maybe I seem grumpy about it, but from my point of view it's better to believe in the show's potential and then bitch about it than to shrug and nod at the decent parts. Besides, the most fun part of writing these is finding new ways to express my dismay when it's lame. (This was a good week for the writing project.)

Last week, Hank and Jill were flirting over drinks in a bar, and almost did it; this week, as the episode begins, they've just done it. Wow, for a show about the hedonistic Hamptons, six episodes is a long time. Especially considering that any possible reason for these two NOT to do it is... well, for one thing, not adequately shown on screen. Hank's broken engagement hasn't been anything but the Best Thing Ever for him. Jill is one of those TV women who is in control at work, and a total flake in her personal life, so by TV rules we know everything will be great for her, in the end, despite setbacks and wacky misunderstandings, once she and Hank get together. There has been no "will they/won't they?" -- it's all been "when will they?" and "why don't they?" and "why did I care about this in the first place, anyway?"

At any rate, for our opening-shot product placement this evening, we see a dashing shot of their two cars parked at jaunty angles in the huge driveway; this would be a witty visual joke about Hamptons materialism if it referred to any other two characters on the show. Then we see the whitest couple on TV, perfectly composed, not a hair or a pillowcase askew. They look for all the world like they just solved a crossword puzzle together. Now, not to belabor this but either she slept over naked and they just got around to the sex at 7am, or they haven't spoken all night, and look amazing because they haven't moved at all since drifting into their lightweight, bland dreams. My personal vanillameter is already ticking spasmodically, and then Hank offers cereal for breakfast. Awesome.

I've been noticing that when Jill and Hank talk, they frequently talk in themes, like college students at a Denny's late at night. This week, they frame a discussion about rebeliousness and wild times. As they do every week, they'll come back to this anvilicious line of conversation in the final scene, and we as the audience will go, "oh, so that's what you were trying to do." The intervening action will touch on this subject only peripherally, or clumsily. If it sounds like I'm beating on the writers, it's because I like this show, and want it to be good. And it frequently isn't. I figure the least I can do is be specific.

But we must fast-forward some, for the sake of sanity. There's a party, in fact a Bar Mitzvah, for dogs, therefore called a Bark Mitzvah (get it? get it? huh? right?) and the writers get points for acknowledging how totally stupid this is. I was not surprised to learn last weekend that these are a real thing, because you just can't make up stuff this stupid. (Also, if these writers had invented the idea, they would have had characters react to it as though it were clever and cute, rather than totally stupid.)

Christine Ebersole is appropriately loopy and infuriating, in the way a beloved but crazy aunt would be; we're always happy to see her, and she makes us smile, but soon we wish we were somewhere else. It's a fine performance, and credit is due this week to the writers who seem to have made the commitment to this character being harmless but utterly batty. Good on you, people. The rest of the show needs a similar level of clarity.

There's some medical stuff; Esperanza the beloved maid (whom the benevolent crazy lady treats like family, of course) is sick, the dog was sick a week ago, and there's a Tunisian guy in the guest room who was jetting around the world recently who's been sick for days. He's the decorator, or the decorator's Indiana Jones-style procurement guy, or something. The benevolent crazy lady treats him like family, of course.

The message of the show is frequently something like "rich people are so cute." They manage to look down on wealthy eccentrics - for their eccentricity - while simultaneously reassuring the rest of us that with that boatload of money, they do stupid shit but also some nice things for the people around them. If we find out that Ms. Newberg earned her fortune selling arms to Somali warlords, that would be quite a twist. (It's my secret hope that the rumored Burn Notice/ Royal Pains crossover hinges on exactly that revelation. A guy can dream.)

Hank has this thing about listening to people's breathing and heartbeat with his stethoscope, through layers of their clothing. In real life, it doesn't matter how good a clinician you are, you need to lay that thing on their skin or you can't hear very much, or very well. It would be more interesting if the high-strung, appearance-obsessed Hamptonites had to deal with Hank's no-nonsense approach in the little, everyday things like this, rather than just when someone is about to die.

Hank and Divya take a fairly lousy history (but at least they take one) and Hank decides, somehow, that the pneumonia is bacterial rather than viral. Despite Divya having a portable x-ray machine right outside, Hank never thinks to order a chest x-ray, which is how pneumonia is normally diagnosed (pneumonia and bronchitis sound somewhat different, but there can be a lot of overlap). So they throw antibiotics at everyone, and promise to come to the stupid dog party as a way to check on the patients.

But first, Hank sets Esperanza up with a banana bag, a classic treatment for dehydration and folate depletion - in other words, a hangover. She exhibits none of the clinical signs of dehydration -- and assuming this is because she's "TV dehydrated," so it counts anyway, there's no reason to give her anything other than normal saline. I guess in the Hamptons, we can just assume that anybody who's feeling a little under the weather is actually hung over. Not a bad thought, actually. Also: a butterfly needle is not an IV catheter. It's gonna take more than an hour for that bag to drip in through that tiny needle, which isn't meant to stay in a vein that long.

I particularly liked a bit that happened later in the episode. When Hank is leaving Esperanza, he says "I'll check on you tomorrow" and (I think) adds something like, "don't worry, you'll be fine." The next day, Esperanza is telling somebody that Hank said she was "supposed to be okay" by then. This is a classic example of the doctor choosing words carefully, but the patient still hearing what he or she wants to hear.

The B plot, with Jill and Hank's budding relationship threatening to interfere with Jill's career, was a snoozer for me. Out at brunch, Dr. Adams, who is positioned by the writing and performance as basically Walter Peck from Ghostbusters, which is to say too-concerned with the rules and dedicated to ruining the heroes' fun, warns Jill that getting involved with Hank could cause trouble, at least in terms of people's perception. He ominously asks her to think about "last time," and all but twirls his mustache as he goes. But the thing is, he's right. Come on, show, what the hell? Conflicts of interest are just The Man worrying about nothing?

Meanwhile, it turns out Divya is engaged. There's a funny exchange where she feigns outrage at Evan for suggesting this could be one of those weird, foreign-type arranged marriages, playing the "just because I'm Indian, you think my parents arranged this marriage" thing... but loses steam and has to admit that, yeah, that's pretty much it. Points to Reshma Shetty for working this well-worn comedy maneuver with a nice combination of embarrassment and pique. We get only a few drops of story on this front, this week, but yes, there will be more. So for those of us playing along at home, Divya's parents have her set to marry some guy, and they also don't realize that she has a Master's Degree in PA practice, or PA studies, or a Master of Medical Science, if she went to Yale. Best. Family. Ever.

Evan, for me, was something of a problem this week. What I was saying above, about how I think this show needs to decide what kind of a show to be, is a problem that's nicely encapsulated in the character of Evan. At times, when it's right for the story, he's a self-involved douche who cares too much about material success; at other times, he's a sweet kid who survived some crappy years with an absent and/or abusive dad, and came out of it full of swagger and talk that don't conceal his vulnerability as well as he thinks.

The problem is, while there's a way to merge all that together into a multi-layered character with several interesting facets, and while Paulo Costanzo is actor enough to pull it off, the writing, directing, and editing often give him only one side or another to work with, and so he comes off fairly bipolar. Is he a lovable but overcompensating con man with a heart of gold, or is he actually, down where it counts, a shallow jerk?

In this episode, he's more of a sociopath actually, giving a younger, even less-experienced guy some truly lousy advice, in the process proving that Tucker is more emotionally mature than Evan, and Libby is more emotionally mature than any character who has appeared on screen to date. It's to the show's credit that we have an interesting, watchable teen couple on the show; it's kind of a bummer that they're far more interesting than the central character and his supposedly adult love interest.

There is an "Evan redemption scene" later wherein he makes a lame excuse about how love makes morons out of even the best of us. While that's true, Evan isn't in love with Libby, Tucker is. So where does Evan's idiocy come from? What motivates it? The plot, and only the plot that's what. Mehhh.

Back to Jill and Hank, we find that now it's Jill who has a good point - perception matters, at least to some degree, and especially in small towns - and it's Hank who pouts like an adolescent upon learning that the world won't bend to his every whim and desire. Also, he skirts an ethically weird area where he clamps down the party into a quarantine zone, without wanting to, y'know, actually call for backup and activate a real quarantine. Although everything that happens shows him to have been wrong about that decision - the party guests would have run amok in the community if not for Jill making the call - Hank learns nothing, and in fact they never mention that he was wrong.

There's a nice moment where Hank shuts down a complainer who says she "only saw the assistant" instead of the doctor; he says that Divya "is a medical professional, not a secretary." Yay. The portrayal of the PA profession turns out to be the thing about this show I have the least to complain about.

Then, for some reason, Hank is 'doing surgery' on Koufax, the dog who today has become, I guess, a man. Actually what he's doing is draining an abscess, but it's hard to convince a dog to hold still while you just numb up an area of the skin, so let's go with it. Lots of things were messed up about this:

- Intubation is always done with the laryngoscope in the left hand. Doesn't matter if the clinician is left- or right-handed.
- When you're passing a tube down a person's (or a dog's) throat, it's important that you never take your eyes off the vocal cords. You've gone to all that trouble to find them; raising your head to say, "okay, give me the tube" is defeating the purpose. And Hank's supposed to have been an Emergency doc, so he's done this a bazillion times. You put out your hand, and somebody who knows what they're doing slaps the tube into it, right way up and curvy side forward.
- Hank gets points for clipping Koufax's fur closely with scissors, rather than shaving. The latest word is that infections happen easier when the skin is irritated and the hair shafts are cut way down. But the tiny little daubs of Betadyne he put on the dog's belly were stupid. He should have just about poured that stuff on there.
-Having expressed a nice big blob of pus, Hank goes all Van Leewenhoek and re-invents the microscope. That was fun, and gave us the important info that we were dealing with MRSA.

...but hang on. Sure, MRSA can colonize the respiratory tract, but just because the dog has a MRSA-infested abscess doesn't mean that same bug is in his lungs. These are two different infections, and there's no particular reason to think they're caused by the same pathogen. Even given that the previous antibiotics didn't work - which by the way has not been proven after just a day or two - we'd need to get a sputum sample to really see what's in these people's lungs, throats, and noses. But having Esperanza hawk up a big loogie isn't as MacGuyver-ey as cutting into a dog.

So, to recap: Evan was wrong, and made Tucker even more wrong. In fact, Tucker's not just asking Libby about the websites brings him closer to Evan's level of plot-imposed stupidity. Jill was wrong to be offended when Dr. Adams suggested this thing with Hank might give people pause, and should in fact be thinking about that, even if it does hurt Hank's feelings to consider the rest of the world for a minute. Hank was wrong to get annoyed with Jill for wanting to involve the public health system in a public health problem, and she actually saved his ass by making the call. The medical parts of the show gave us some cool bits, but totally failed to reflect reality. And the Divya stuff was almost interesting, but got too little attention.

Except for a couple of specifics, I just described every episode so far. Hmmm. I'm going to have to find some different approaches.

I'm traveling this week, so in another 10 days or so, I'll see what's up with the next episode.

Still alive, still awake

What's up?

You'll have to pardon my spotty posting, yet again. I was out of town, relaxing lakeside with friends. All my paperwork is definitely in, I made sure, so I'm waiting it out to see which comes through first, my temporary permit or my permanent registration (which I am given to understand they will soon be calling a "License" in my state, since it's the same board that approves MDs, with essentially the same process). And I've watched "the dog episode;" even took notes. I just have yet to write about it.

I've had little glimpses of future episodes, and there is indeed more Divya ahead. Okay, then, I'm doing it for Divya.

Which is not to say it's painful, exactly, to watch this show. Overall, Royal Pains is not bad, it's just not grabbing me the way its lead-in, Burn Notice, consistently does. And House, which is medically pretty silly sometimes, nonetheless gives what I think is a nicer, clearer idea of how medical thinking works, and how that changes the course of the story.

So I'm struggling a little to adjust my ideas about the show that RP could be, as opposed to the one we get each week. And that process is hampered a little by some quirks of the writing and plotting that I'll say more about as I go -- basically, I'd like it more if they took a firmer line and showed us what kind of show they want to be. For now, they're still kind of all over the place, and there's a lot of mush in between the fun, smart, or cool moments.

Naturally, this has become the highest-rated show on cable right now, and has been picked up for a second season.


Saturday, July 25, 2009

It's Not Them, It's Me

I am now two episodes of "Royal Pains" behind. I have yet to watch, much less write about, the sixth and seventh episodes aired. Whether this is significant, or how much so, I can't say yet. I am given to understand that Divya's storyline is featured a little more in the next few episodes, so when I get around to it I may be happy about the project.

Hey, professional TV critic Alan Sepinwall stopped watching or blogging about this show three weeks ago. You're totally getting what you pay for here.

I've been simultaneously busy and lazy, which isn't easy to do. I was out last night with some of the crew from my old ER job, and tonight I was seeing live thee-a-tah, with a friend tearing it up in several cool roles in Wilder's The Skin of Our Teeth. Which is anatomically just wrong, by the way.

After some more resting and recreating, I'll get back to this little project of mine. Soon enough that paperwork will go through and I'll have actual work to do.

Wednesday, July 22, 2009

Royal Pains Ep. 5: "No Man Is an Island": My reception is flagging a little, too

I've taken my sweet time writing up this episode, and indeed haven't watched episode 6 yet, for a few reasons. Most importantly, as mentioned in the previous post, I am temporarily living a life of indolence and sloth. A close second was that this episode didn't realy grab me. After the heady thrills of seeing the PA profession portrayed in a pretty damn positive and generally realistic light, here we have an episode with nearly no Divya. As much as Hank and Evan's core story was advanced a little, and despite a couple of nice moments from the actors, this episode felt, to me, solidly okay but by no means great. I'll run down what I can from my notes of a week ago...

Hey, that's some kind of record: this week's shameless product placement came approximately 0.8 seconds into the episode. Mmmm, doesn't that Gray Goose vodka look classy as it drifts across the screen on a silver tray? Smooth. And bills paid, we move on to some Hank/Jill flirting, which is about as white as humanly possible, seeing as it includes a job offer and talk of playing glockenspiel in marching band. I know this show is set in the Hamptons, but it really is embarrassingly Caucasian.

Anyway, Hank now gets to consider whether he'd rather stay the course in his new life of glamor and heroism, tending to the needs of PDBs who are, deep down, not all that bad, versus returning to the ED. To his credit, he politely tells Jill he'll think about it. Laughing in her face would probably kill the mood, anyhow. There follows an almost-sexy scene, cut short by Evan being almost funny. Already this episode is failing to grab me. Our wacky caper this week involves people who are stupidly rich, even by Hamptons standards. Okay, that's new. Sort of. The sooner this show resolves its schism about whether being wealthy is a) fascinating and exotic or b) just a characteristic that some families or people happen to possess, the sooner we'll be over the need to blather about nanotechnology being "so last year" and get on with the interesting bits.

A small dose of Divya helps, somewhat. On the tarmac of the local airport, she is competent, in control, and will be doing all the medical stuff on the mainland while Hank and Evan screw around with the PDBs of the week. It's the 21st century and I have digital cable; can't I just stick with her story for the entire time period of the episode? Evan by the way has had his obsequiousness ramped up to eleventy-five by the writers this week. It's possible they are trying to humanize the PDBs by placing them next to a super-douchey version of Evan in their first few onscreen minutes. Divya drives off, taking my enthusiasm with her.

Sigh. So the PDBs are a family made wealthy by technology, who get away once a year to their island. The two sisters have fond memories of roughing it in a little 2000-square foot cabin, with electricity, running water, a gourmet kitchen... you know, the bare essentials. The high-strung mom's kids carry more gadgets than most IT managers (shout-out to Nintendo DSi, surely another sponsor), and even the granola mom's tech-scion husband is lost without his Blackberry. Oh, and she's approximately 1000 weeks pregnant*. Subtle, right?

For some reason, they take a helicopter, rather than a boat, because while they need to carry a lot of stuff and will be utterly cut off if -- for SOME REASON -- something should happen to their one satellite phone, it's important to the experience that they also be totally reliant on the outside world. This is certainly less of a plot hole than the tick-in-the-ear thing from a few episodes back, but one line of dialogue would have made this a lot less dumb.

Fast-forwarding, there's some decent-enough medicine in Hank's well-mom check. Fundal height, blah blah, rare blood group, etc etc. Wait -- RARE BLOOD GROUP? Ruh-roh! I wonder if that will be important later?

Evan's presence is partly redeemed by a plot wherein he bonds with the young son, who appears to be useless and irritating in much the same way as Evan. Although in the end he will be the hero, he first has to indirectly cause a totally gnarly leg injury in the kindly caretaker of the island. Hank whips out his acid-washed jean jacket and goes into MacGuyver mode, practicing Wilderness Medicine. I'm not sure what's up with the antacid, other than it should in theory be sterile water. Sugar isn't a bad topical antibiotic for the situation, though I wonder about vodka.

Also, we tend to call them "open fractures," not "compound." Hank was doing that talking-aloud thing again, and apparently he was talking to a group of Boy Scouts.

Meanwhile, on the mainland, there are wacky misunderstandings. Divya is holding down the fort, and just when we're wondering why she needs Hank at all, she and Jill have a heart-to-heart. Divya is kind enough to delete Jill's horny, confused, generally 15-year-old-sounding voice mail, and Jill learns that Divya has tried and failed to start up a concierge practice twice before. Hank's arrival just happens to have served a pre-existing plan of some long standing. Hunh. Eeeenteresting.

Later, we learn that Jill's ex was an ER doc (an EM doc, if we want to be stick-up-the-bum about it). Hmm. Maybe she's into guys who work weird hours. Meantime, Hank is demonstrating a basically accurate Direct Coombs Test, if the test didn't require a reagent and you didn't need to wash the cells. For TV medicine, it's complex enough to demonstrate the basic idea: the family trait means matches are rare. Having a ten-year-old test himself is a little funky, but there's no time to think about that. The loser kid is the hero of the day.

And if Hank has IV tubing for some reason, how come he doesn't have antibiotics or wound care supplies?

There are some good Evan scenes near the end, together with little glimpses into the Lawson boys' formative years, so the actor wins me back despite a growing sense that the character could go utterly clown-shaped any moment. There's another nice scene where Hank calls the kindly caretaker out on sharing this weird blood trait with the family -- eighth-grade life sciences teachers across the cable-viewing nation may want to take notice. In the end, naturally Hank wants to stay Dr. Robin Hood.

So. A perfectly nice episode, and true to the central theme of the series, but now that some of the novelty is wearing off, I have some misgivings about how well or how long things can maintain. Not to mention, the paucity of Divya took some of the shine off this sunny summer series for me. Call it a B- this week.

* By which, I mean of course that 36 is closer to 1000 than it is to 100,000.

Tuesday, July 21, 2009

Awwww. Thanks!

Had a very interesting comment the other day. Apparently at least one person in the world thinks I need to talk about myself more.

Not to worry. I'm concentrating on this TV show at the moment because it's kind of a cool opportunity to talk about my career - the one that's just getting going for real, now, after a long and intense period of preparation - in a pop-culture-related way. And I have always been about the pop culture, even in the midst of my transformative journey.

So I will say more about, for instance, moving back to the Twin Cities, and what I'm up to as I get to actually spend time with friends and family. I'll get into what it's like to actually be doing what I've been working toward all this time. But for the moment, I'm kind of in Limbo. I can't start my new job until the state registration paperwork goes through, which gives me time to sit around the house and do nothing. After revving the engine pretty hard for the past four years or so (if you count Post-Bacc time, which I do), it was jarring at first to not have a deadline or an itinerary. I have since gotten over that, and am enjoying being really lazy. I can't even keep up with a weekly show that took a week off for a holiday, but I'm steadfastly refusing to worry too much about it.

This is a change, true, but I don't think it's a permanent one. Much, much earlier posts were about coming to terms with a huge undertaking. Then there were the ones describing what went through my head as I realized I was actually on the road. Now, I've arrived at the other end of that process, and like someone who has just driven cross-country without significant stops, I kind of want to sleep for three days. Maybe open the mail, make some toast. You know, nothing too challenging.

But the message is very appreciated. And I'll get back to my usual navel-gazing in due course. I promise.

Wednesday, July 15, 2009

Royal Pains Ep 5 niblet

This week, things keep chugging along for HankMed. We got some very MacGuyver medicine, a new batch of PDBs who are deep down very cool people, and one sexually-frustrated hospital administrator.

Not a lot that adds to the cause of PA awareness, but some nice Divya moments regardless.

A much longer review to follow.

Wednesday, July 08, 2009

Royal Pains, ep. 4: "TB or not TB" (but definitely PA-C)

It's been a big week in the Febrifuge household. Of several new developments, perhaps the biggest was that the household moved 400-odd miles. So, in terms of my own convenience, USA picked a great week to hold off on airing new episodes of Royal Pains. It took me a while to get to it, but I was rewarded with an overall good episode, featuring several refreshing bursts of Divya being awesome. It actually appears to be an intentional story arc that the PA is established as more than "doctor's little helper." Also, I got a job, and as recently noted, I passed my board exam and earned certification not long before that... so it's a good week to be me.

But enough yappin'. On to the show. As always, I'll try to concentrate on the medical stuff, with what I'm sure will be mixed results. Bullet points are for organization, but + means [yay!] and - means [meh.]

* Is it just because I'm watching on Hulu this week, or is the funky underwater title sequence really gone? That was cool, dang it. Okay, we're in a kitchen, people are busy, this one lady is really intense... oh, I see, somebody here is going to be the patient of the week. The head chef is too obvious, so I bet it's the tall skinny guy.

Oh, wait. This only looks, sounds, and feels like House. My mistake. It's Alison, the restaurant owner, who has weird neuro symptoms. She hallucinates that the high-end Italian food in her restaurant is something that Chef Boyardee made yesterday... or no, that's just what it looked like. Looks like there's a prop master out there whose employers need to pay for a few good restaurant meals. For research, y'know? Honestly, the blurry effect really was low-rent House stylings. Better-done, I would have called it an homage.

Medically, they had her experiencing blurred vision, and using the word "pizza" when she meant to say "pasta," then not realizing she'd done it. Actual word salad tends to be much weirder. My good friend M. Giant has had attacks where the language center of his brain crapped out on him as it's suggested Alison's has here. Since he's a writer, you can check out his description, for a more appropriate level of oddity and fear. In an otherwise healthy, young person, these symptoms are very scary indeed.

Since this isn't actually House, Alison's spell resolves, and rather than the sound of Massive Attack, there's another scene or two. The HankMed crew come in to administer PPDs to the restaurant staff.

+ Here, we have some impressively accurate medical procedure. Hank and Divya are both using the correct, 0.5ml syringes, placing little blebs of the solution right into the skin on the forearm, and telling people what the test is, and how it works.

- This week, the one conveniently overlooked part of the process that would obviate an entire plotline is not asking the patients about previous exposure to TB, previous positive tests, or previous immunizations. Especially given that more than a couple of the people working in this particular restaurant are from the old country, where the BCG vaccine is used, you'd think that would have come up. Huh.

+ Later, Hank is speaking privately to Alison about her freaky symptoms, and does some excellent doctoring in the way he counsels her. Sometimes advocating for the patient's best interests means getting in their face a little. And anyway, Hank's such a nice guy (I am 1/16th culturally empowered to call him what he is, a mensch) that he barely seems to be harping on Alison. Honestly, I'm ready to see the character turn the frustration up a notch, and be a little less perfect.

+ No wait, the title sequence is here after all. The show is just messing around with the best place to put it, and seems to be studiously avoiding the most House-ian possible placement, immediately after the 'tease' in which someone gets ill. (And thanks to the CG guy who was nice enough to post a comment saying he'd created it. Yes indeedy, the use of clozapine, an anti-psychotic, on the label was cute. There is no version that comes with APAP - which is acetaminphen, or Tylenol - but I agree that the guy who added that was on to something. I'm all for creative license.)

+ Just after we're back from commercial, Divya delivers a lecture to Evan that is music to my ears. After Evan makes the fatal mistake of calling her "doctor's little helper," she unloads on him with a combination of the "What is a PA?" text off the AAPA website, and a beguiling mix of excellent diction and attitude. "I am a certified Physician Assistant," she says, much the same way one might say "I am going to stomp your smirky face into chunky salsa." I stop to wonder if because she's in New York, she might not want to say "Registered Physician Assistant," instead of the "certified" that is standard everywhere else in the US, but give up the thought as she rolls on.

"That means I practice medicine. I prescribe medications. I order and interpret tests. I assist in surgery..." And then Hank strolls up, having figured out he can't be there in three days to collect results on all those tests, so asks her to do it solo. He delegates that part of the practice to her, having her do it independently, conferring his legal and clinical authority to her.

+ And I pretty much faint, because that's exactly right. That's what it is, that's how it's done. I've been worrying about how the PA will be portrayed in this show, and whining about the "Screw the Midlevel" moments I saw in the first episode or two, and here the show is saying almost exactly what I would tell them they should. And since this is only episode 4, surely this scene must have been written - and filmed - before the pilot aired. So, nice work, show. I feel much better about this whole Divya the PA thing.

- Later, there's a level of product placement that is impressively tricky: advertising two different car brands at once. I applaud at the TV, sarcastic clap style.

+ Paulo Costanzo continues to walk away with all the Evan/Hank scenes, despite an alarming trend toward overly broad, buffoonish moments. Driving a golf cart across town? Ehhh. Maybe not. But Costanzo's tirade against brunch, and especially his delivery of the phrase "french toast salad," are comedy gold.

+ I was impressed by the way that for once, a TV doctor's blunt declaration "she's had a stroke" made some kind of sense. Given that Hank had spoken to Alison previously, and being a kick-ass doctor, it made sense that he could be so sure in his diagnosis so quickly. This was refreshing.

Hey wow, what a concise and timely explanation of thrombolytic therapy. Dr. Exposition, please report to Act Three. Doctor Exposition, Act Three. And I suppose it's cool to show that Hank doesn't get to go wherever he wants inside the hospital, even if he is dating the administrator.

Someone who works in NY state tell me if the short white coat is really what MDs wear in the hospital. I saw the 40-something guy rocking the short lab coat and thought, "huh. Another non-traditional student." And I still say people look like steakhouse waiters in those damn things.

Um... why does Boris need a tiger shark? Who is Katie, and why does she need to be called right away now that he has one? And holy crap, tonic immobility is a real thing, although no way does it last 20 hours. Looks like I must have missed a couple of Shark Weeks.

(Total and utter tangent: this week I also saw an amusing signature line on one of the medical forums I visit: "Live every week as if it were Shark Week." Inspirational, isn't it?)

Wow, they must be rich in the Hamptons, because Dr. Short-Coat responds to Hank's request "Can you get me some thrombolytics" with "sure." Not with "don't you mean tPA, Dr. Slick?" and not with "you mean the package that has to be back in the fridge in half an hour if it's not used, and costs like three thousand dollars if you so much as peel back the foil?" nor with "you don't have privileges here, and can't walk past the yellow line, and I'm going to hand over super-expensive drugs? You want a fistful of Perocet too, you delusional weirdo?"

But then again, not having the magic meds (which looked amazingly like a 10ml saline flush, and apparently didn't require mixing or prep of any kind) would have robbed us, the viewers, of another MacGuyver medicine moment. The DIY Bair Hugger (which in the medical world is essentially what they made: a blanket made of hollow baffles, through which warmed air is pumped) was pretty cool, I'll grant them that. And presumably Divya established two really fast IV lines, with that pimped out SUV kit of hers.

Speaking of which, Mac-compatible, portable Xray? Damn. Notice too how the readout had Hank's name on it; the PA-MD team very often puts the MDs name on stuff like that. The team's medical decisions are ultimately the MDs responsibilities, but the PA has as much latitude and independence as the MD wants to grant, so presumably the practice agreement says that Hank is totally comfortable with Divya's ability to read a chest x-ray. Maybe she'll ask him to check it out later, as a quality measure, but when she says "it looks good," that's the same as Hank saying it.

The episode winds up with what I take to be a future plot point: who was Jill formerly married to? My money's on Boris, actually. If not him, then a new character, played by Ted McGinley.

Overall, I have become very impressed with some of what's coming out of the writer's room on this show. Not having viewership numbers handy, I can't say for sure but they have done more for the public's understanding of the PA profession than our actual professional association has, in my opinion. If only they would add a layer of quality control to the plotting, and stop letting conflicts arise via series of events that would be rendered moot by the same common sense the characters show except when the plot demands they be dumb. That's the kind of story-craft that makes Three's Company plots work.

A- for the episode as a whole. Some good doctoring from Hank, some silliness over poor Italian translation and a critical question never asked in any language, tempered by Divya-liciousness. The minus is for Divya knowing the BCG produces false-positives, but only knowing it in Act Five.

A+ however for what's going on with Divya's character progression. If I find out the AAPA is connected to the bracingly clear way this show presents what a PA is and does, I'll take back most of the things I've said about them.

Thursday, July 02, 2009

A week off

Looks like the nice people at USA are skipping an episode of Royal Pains for the holiday weekend. This is nice for me, as I just moved 400 miles, and I'm taking off for the holiday to a place where there are no Internets.

So watch next week for my write-up of the fourth episode broadcast.

Friday, June 26, 2009

'Royal Pains' review delayed

Episode 4 aired last night, and ordinarily I'd have watched it by now, but Monday is moving day, so we're up to our necks in boxes and things to do. Early next week should be about right. Take care!

Thursday, June 25, 2009

The Fun Begins

As I said a while back, I had to take, and pass, my national certifying exam before I could call myself a PA-C (for 'certified,' as though that were not already obvious).

The test was Monday. I answered my 360 questions in under four hours; hey, I was on a roll. And this morning I got my results. I'm official.

Friday, June 19, 2009

'Royal Pains' ep. 3: Strategic Planning (but not very much, or very well)

Okay. So, the pilot was enough to get me interested (well, that and the marketing assault on Facebook and Twitter). Last week, there were glimmers of hope in terms of how Divya, the PA character, would be presented. In this, which appears to be the second episode written/ filmed but the third one shown, there were several 'facepalm' moments. Consider it one step back after last week's two steps forward, which means in other words that I agree with the decision to show these out of order. Bottom line: if this had been on last week, according to my lovely wife, she might not have been watching last night. I would have, because I'm an old man and I enjoy yelling at the TV.

A + denotes something I liked, and a - is so much more than just a bullet point-style dash.

In the opening bit, Hank is trying to get Evan to go for a nice cardiovascular system-exercising run, while Evan is trying to a) scope chicks and b) get Hank to admit their new enterprise should probably involve caring about money, just a little. While trying to make a questionable point about how dogs and women are somehow the same, Evan causes a dog-walker, who is otherwise minding his own damn business, to be bitten in the hand by one of his charges. Rather than stomp Evan into a coarse paste of hair gel and poor judgement, the kind-hearted dog walker (whom I want to call "Benny," and will since IMDB is no help today) apologizes. Hank, being Hank, looks at Benny with soulful eyes, says "I'm a doctor," and mumbles physical exam findings. Yup, that's a dog bite, all right. Pretty crappy exam, though.

+ Hank quite rightly says Benny needs to get to the ER for 'a thorough cleaning' instead of stitches. We don't sew puncture wounds.

+ It's good that Hank pokes holes in his water bottle and squirts the jets into the wound to clean it (a little, anyway). Research shows that the two main things that prevent infection are 1) using A LOT of irrigation, and 2) having a little pressure behind it. So just unscrewing the cap and dumping it would be, according to some research, less helpful.

- On the other hand, there were like 8 or 10 holes in that thing, which means the effect is lessened... and lots of the water was nowhere near the wound. And of course, whatever's left in Hank's 20-ounce bottle is of almost no help. Would have been easier to just hold the guy's hand under a drinking fountain or a simple garden hose for a good 10 minutes.

- And the number one question Hank would ask, as a real-life Emergency doctor: "When was your last tetanus shot?" THAT'S the reason he needs to go to the hospital.

After this B plot is safely sailing, some more silliness occurs. Further evidence that this is actually the second episode comes in the form of a conversation with Boris. Later there will be scenes between Hank and Jill that completely ignore what we saw last week in the 'real' episode 3, and a conversation between Hank and Divya that bears (scrawny, shriveled) fruit last week, which would have been 'next week.' Honestly, I'd have preferred they leave this one in the drawer, show us Episode 4 now, and call it good. But I'm getting ahead of myself.

Hank and Divya arrive on the scene of this week's "Privileged D-bags Who Are Actually Not That Bad Once We Understand Them Better." I'm going to call them PDB's, for short. On the way in, Hank gets Divya to confirm the info I previously had as a rumor, which was that she somehow went to two to three years of PA school, for 8 to 12 hours a day, without her family catching on. Oooo-kay.

I can't decide if this is a Screw the Midlevel moment, because Hank recognizes Divya's smarts and talent, saying she's "qualified to work at any of the major clinics in Manhattan." Instead, I think this is meant to be her big defining conflict for the first season. I'm already looking forward to the scene where Brian George appears as Divya's strict and demanding father, whose heart melts when he realizes what a strong and capable woman his little girl has become. And sort-of-almost a doctor, too!

And then we meet the PDBs. Momma-PDB is a driven, icy matriarch who is focused with such laser-like precision on her family's success that she neglected to develop a third dimension to her character. Her offscreen husband is a former Fed director and current US Senator, but not the President, and therefore is a total failure. Good Son PDB somehow bears his mom's pathologic orchestrations with good humor, perhaps by doing drugs or appearing in drag shows in the city every few weekends (either of which would be far more interesting than what actually happens). Daughter PDB is as high-strung as Mom, as bland as Good Son, but is blonde. This must be offscreen Dad's contribution. That, and a slow-burning irritation with The Way Things Have Always Been that will result in a totally unsurprising confrontation later.

Seriously, the first time she tries to object to something, Mom lays down the law, and closes with her wacky catchprase " that okay?" we already know about 75% of the dialogue for that inevitable scene. Which will of course have to happen today, and which will of course feature Hank standing nervously nearby, because he needs to, House-like, catch the one key phrase that randomly blows the whole case wide open.

Okay, here's the deal. I have advanced training in medicine, but I also have a degree in theatre. And I'm here to tell you, this writing sucks. It smacks of unused bits from the pilot and random scraps from pitch meetings past. For the rest of this week, I'm going to try to stick to the medicine, so as not to get too depressed here. Oh, I'll be watching next week, and I'm sure it will be better. Because it can't help but be.

+ I was amused at the medical equipment in the PDBs' former 'game room.' Hank and Divya might have a clue how to operate maybe half of that stuff. Mostly, the 'executive physical' line made me smile (since I've been to two of the Mayo facilities, and that's kind of how patients are encouraged to think sometimes), and idea of a yearly head-to-toe physical done as an action montage! was loopy fun (for me, because I'm weird).

- Why the eff does a healthy 18-year-old need a treadmill stress test, or even an EKG in the first place? Must be a college athlete thing, hey? And what, no hernia check? That's easy comedy gold right there! An echocardiogram is always a nice visual. And sweet zombie Jesus, where did Divya learn phlebotomy? That looked like a two-inch, 18-gauge needle attached to nothing in particular she was jabbing into the patient's AC.

+ Need to check your patient's vision, but don't have a Snellen chart? Yeah, there's an app for that.

+ Later on, after Good Son PDB gets really sick, really fast, for no good reason, they'll do a spinal tap. He'll be in fairly poor position, and they'll take out a whole lot of fluid, assuming the vials we don't see are as full as the one we do. But props must go to the writers who refer to there being four of them, and which tests to do on each.

- And, um, -SPOILER ALERT!- part of that executive physical would be looking in the ears the way they checked the eyes. AUTOMATIC FAIL for not seeing the deer tick suctioning off Good Son's football awesomeness drop by drop through his ear canal.

- Wait. It would have been a good idea to get him to a hospital earlier, but now he's too unstable to move? What did you do in there, Dr. Hank? And in the pilot, after you opened up Tucker's pericardium with common household materials, you remembered that the helicopter is a flying ICU. What, now that you're staying that's not good enough? Wow. You've changed, dude.

- Divya. Yo, Divya! Hey! Look, thanks for pre-oxygenating the patient before the intubation (holy crap, you did have the O2 hooked onto that thing, right?), but now that the tube is in, it would be helpful if you a) checked the end-tidal CO2 thing, b) listened to make sure the tube is in the trachea, or at least c) BAGGED A LITTLE MORE SLOWLY. We're not trying to get this guy overinflated or alkalemic. Air has to go in and come out. Where did you go to school, again?

But eventually, the offending parasite (literally, not any of the PDBs) will be removed, and everything will be cool. And this being the Hamptons, Hank has not actually just wasted tens of thousands of dollars on a workup that would be obviated by looking in the patient's ear, because the money was already wasted when Momma-PDB bought the equipment. So I guess that's a win, in terms of the larger health care system.

I'm not talking about the fastest-developing case of hot tub folliculitis ever, because Evan was an embarrassing 80s-movie cliche horndog this week, and I'm not sure if those girls were supposed to be over or under 21. Everything about that plot was creepy and weird. "Hey, girls! We're hanging out with a skinny loser we just met, but his house is nice! Let's do body shots... off, um, each other maybe? I guess? I really didn't think this through, but don't worry because USA Network wouldn't make us actually do it, so long as we say 'body shots' a couple times! Wooo!"

+ Grudging props are however given for the line "I tried all day to convince these girls I wasn't a douchebag, and they all went home smelling of vinegar and water." I have an uncomfortable feeling that the entire plot worked backward from this line, but what the hell. It was funny.

At the end, there's a heartwarming scene where Hank earns a gold star for the first part of this exchange:

Hank: So we should talk about your title...

Divya: What's wrong with 'Physician Assistant?'

Hank: Well, people tend to just hear the second part of that.

My heart swells, I get a little misty, and I hug a throw pillow to my chest. "Oh my god," I think, "the writers of Royal Pains really understand me. And they... they like me." Hank continues:

Hank: I was thinking more like, 'Associate.'

And, y'know, fair enough. There are plenty of people who would prefer 'Physician Associate' to 'Physician Assistant,' and indeed back in the very earliest days of the profession, the former term was actually the one that was used. And people really do trip over the 'assistant' part. It's true that no, we are not independent practitioners (and don't really want to be), but we are professionals. We practice medicine too, and our job really isn't following the doc around, fetching stuff, or answering phones. It's practicing some of the medicine, so the doc can concentrate on his or her own part of it.

But for better or worse, Divya's license says 'Physician Assistant,' and so does her Master's degree. She can be "Hank's associate in the practice" and a PA at the same time. It would be far better if she would stop saying she's "Hank's Physician Assistant" (even to the point of inserting a word into the phrase "Hank's assistant") because that's just as confusing.

But whatever. They just started working together. As time goes on, he'll understand how well-trained she is, and how good her skills are. She'll learn (mostly medical) stuff from Hank; he'll learn (mostly Hamptons survival skills) stuff from her. Eventually, Divya will show up for calls herself, and get Hank involved on those cases where she recognizes she needs the backup or additional expertise.

Maybe. If the show turns into a more interesting (and more realistic) direction. I still have hope, but wow, this was not the episode to show to people who want to check it out for the first time. This one was a C+ all the way. It might have been a B-, but having seen what they can do, I know they either weren't trying here, or else they were trying and failing to illustrate some point about Hank being out of his element, the team needing to learn to work together, or something. The acting was fine, but writers just failed to have a decent plan.

Friday, June 12, 2009

"Royal Pains" Ep. 2: There Will Be Food (and potential)

So, there's a new summer show on USA. It's on after the ridiculously enjoyable Burn Notice (which is itself kind of a mix of The Rockford Files and a Bourne movie), and worth checking out. But what's germane here is that Royal Pains features a PA character, the first on American prime-time TV since Jeannie Boulet on ER way back when.

Given the show's premise -- talented Emergency Med doctor's career goes boom when hospital beaurocrats throw him under the bus after a hospital trustee dies; he falls into being concierge doc to the spoiled rich in the Hamptons -- I was curious how a PA would fit in. The pilot showed us Divya Katdare, a sharp young woman from a wealthy family who apparently wanted her to be an MBA instead. This being New York, I'm assuming she's RPA-C (since they use both the R for 'registered' and the national standard '-C' for certified), but it's not like they're showing us close-ups of the characters' business cards.

Last night was only the second episode, so I have many questions, hopes, dreams, and fears when it comes to how this all might play out. It would be pretty sweet to have a PA as a major character on a popular hour-long drama. Likewise, considering all the annoying misperceptions there are about the career, this new show could wind up part of the problem. So I'm watching, carefully.

So much so, in fact, that I decided I'd take a page from Scott, MD over at Polite Dissent, and do a weekly write-up of the episodes, evaluating them for medical as well as narrative quality. He does it for House, and it's a great read every week, whether or not you are a medical person. Put a bookmark there, and check it out whenever you've just watched an episode and wonder "wait -- does it really work like that?" (The short answer is, probably not, but like I say, Scott's site is about enjoying the details.)

So I basically watched Episode Two in liveblog fashion: I fired up the DVR this morning, took some quick notes, and proceeded to pick things apart. There's good stuff too, so annoyances and errors are denoted with + or - for bullets.

* Hey, new pre-title voiceover to set up the plot. Wow, we really do love Burn Notice, don't we?

- Would it kill the producers to have Hank say "Emergency doctor" instead of "emergency-ROOM doctor?" Not that it's their job to correct every little misconception, but I don't see the benefit to perpetuating them. Whatever. Last week, he was not only EM trained but also did a fellowship in toxicology.

- Um, hey, you don't need an MD to examine a wound or take out sutures. Divya could totally handle that; but I see, having Hank present in that scene was important to the story, so that the crew could be invited to the party. I'm going to count these instances of "Screw the Midlevel" as we go on through the season. They could just as easily have had Hank walk up to Divya finishing the suture removal, with Tucker saying something like "naw, I just wanted to see if you felt like hanging out." This not only doesn't screw the midlevel, it fits the whole "Tucker needs a dad" thing.

- That wound looked okay, if a little too red at the medial aspect, but the sutures looked like crap. Apologies to the props person or set medic who gamely threw some stitches into a piece of moulage putty, but ya should have gotten some better reference photos. That looked like it was done by a Navy Seal under fire. On his own abdomen.

+ The actual title sequence, with trippy underwater stuff and backwards-cam, was pretty cool on first viewing. I wonder about all these cheap stethoscopes in the promo materials for the show, but maybe you'd have to pay 3M or something if everyone rocked a Littman like in real life.

+ Evan gets all the best lines. As a temporary Chicagoan, I laughed out loud at "ketchup is for dillettantes and three-year-olds." My wonderful, lovely wife puts it on everything, and I mock her for it.

+ "You need some blood work. I'd love to have my associate Divya do a full workup." Holy crap! They do understand what PAs do... unless they think she's a phlebotomist. But no, let's give the writers some credit here. Divya would, according to Hank, draw the blood, get the lab to do the appropriate tests, and then interpret the results. Which is true. But then, that makes instances of "Screw the Midlevel" that much more notable. Okay writers, you're officially having it both ways. (I'm doing that gesture where I point to my eyes with two fingers, then turn them around to point at you.)

- You do realize that 'I get blackout drunk on those rare occasions when I drink' is still kind of a red flag, right? I mean, nice plot device and all, but Hank is so concerned about everything, all the time...

+ Hey cool. Andrew McCarthy is Cary Grant as C.K. Dexter Haven from The Philadelphia Story. I love that movie! ...Oh, no, wait. He's an ass. And a very well-done "that guy is an ass" scene it is, too. Yowch.

+ I'm really enjoying not only Evan as a character, but what Paulo Costanzo is doing with it. The cooking/dancing went on a little too long, but it won me over. Although, how long did that food sit out if the ballerina wasn't coming over until after sundown? I also really liked when he admitted that NYC had gotten stale for him, which sheds some additional light on his drive to get Hank to the Hamptons last week.

+ The "Robin Hood of medicine" thing, as illustrated by Hank's speech on Bill's boat, is an appealing fantasy. Gosh, if only more of us could just draw fat checks from random rich people, and give our services away to the rest of our patients!

+ The running gag where Hank never, ever, gets to eat a bite of anything (until the end, sharing Chinese food with Jill) was cute. In the ER, nothing makes more work appear like ordering or heating food.

+ Hey, House writers: see how it works? A character who understands physiology sees a patient go into shock (shock being defined correctly as "perfusion insufficient to meet the metabolic needs of the patient"), looks at the heart monitor, and then identifies it as 'cardiogenic shock.' A little clunky and over-exposition-ey, because 1) who really cares at that point, and 2) duh, but still. Divya clearly knows medicine. This is nice, because as of now I trust the writers to know she's not a medical assistant, even when they treat her as one. (Caveat: I haven't seen this reaction to gluten, and I'm a little skeptical it would clear that quickly. Also a three-lead portable monitor isn't a Holter, and come to think of it I never saw them put pads on the patient, but since so much of medicine is boring we give some slack on these matters.)

- People, we never shock a flat-line. That TV trope has to go. Draw up the epinephrine or atropine, but put down the paddles and back away.

Overall, this was a nice solid A- of an episode. I'm feeling generous since while things are still very new, I'm seeing more to like as more is revealed about how the writers and producers approach the characters and the medicine. The show is finding its equilibrium between commenting on how "the system is broken," presenting its version of what's both cool and important about the practice of medicine, and keeping the story moving for its characters. My PA-touchstone character got zero development in this episode, but on the other hand she displayed some competence and knowledge. I'm feeling a Divya-centric B plot coming soon, if not a main story. Let's hope I'm proven right, and they do a good job.

Wednesday, June 10, 2009

Oh, and about those extra initials...

You'll note that for now, "I'm Febrifuge, MS, PA." I can say that much because I got my diploma; the MDs who graduated at that same ceremony are MDs as of now, as well. None of us can actually get a license, hospital privileges, or prescription rights until we pass our respective Board exams.

Actually, there's more to it. The MDs have residency spots lined up, which gives them a sort of blanket license to practice in their home hospitals and any affiliated sites. Me, I need to sit for my national certifying exam (which I'm doing later this month), which when passed lets me apply for all that stuff you need to practice.

At that point, having passed the test, I get to be "PA-C" for certified. That's when the fun begins.

Tuesday, June 09, 2009

Febrifuge, MS, PA

Hey! I graduated!

The law of inverse blogging, or whatever it's called, was in full effect this past couple of months. (Seriously, is there a name for that? The more stuff that happens, the less you feel like/ have time for blogging about it?) Rotation #6 was back home at the very ED where I was a tech, but now I was treating patients and doing the same job as the residents. #7 was an elective in Trauma; I had such fun working my ass off in Michigan that I thought of trauma & critical care as a career option.

Turns out I was a genius for picking this elective, because nothing clears up the rosy glow of a great rotation like doing something similar in a crappier environment. Compared to the group of highly-skilled, generally pretty happy surgeons and kick-ass PAs I'd worked with in Flint, the West Side Chicago crew was overworked, overextended, territorial, and maybe shouldn't have had students around in the first place. It was not awesome, but I learned a ton about the work environment I don't want, and how to recognize it.

Oh. See how much more honest I can be now that I have my diploma?

My final eight weeks was in the suburban ER. I liked the idea of this, because whether it was back home prior to PA school, on my EM rotation, doing surgery in the 'hood, or the Trauma elective, all my ER experience has been in the grim n' gritty urban centers. And the jobs really tend to be in the suburbs.

Again, there's a lot to be gained from seeing things from the other side. I liked the work, and I was pretty good at it. The skills I've developed over this whole thing are the ones that sort of have to come to you organically; one preceptor said I have "street smarts," which I loved to hear. And in the 'burbs, those come in handy, if not very often. Maybe I'll tell you the story about the guy who, no kidding, said "my father is on the board of this hospital." I'll definitely be talking about the TV show that reminds me of.

So I don't know. I love emergency med, and I'd bet I'll wind up there for a long time... but maybe not quite yet. I want to do other things too, and maybe for that all-important First Job After School, I should start in an area where I can do more general, hospital-based work. More on that as we go, too.

Saturday, March 14, 2009

Febrifuge's Eponyms, part I

Last week down in the ED, we consulted on a 40-something gentleman who had been smacked with a baseball bat and had a goose-egg so big it looked as though he was working on a second head. His initial CT scan was negative (well, as negative as it can be with a depressed, nondisplaced skull fracture). We wanted another one in the morning, after he chilled out in the step-down unit. He was advocating for the position that he get back outside and go about his business. The one thing he'd said that made any sense was that we should call his emergency contact, his mom.

Signing out AMA is no big deal, so long as you're competent to do so -- which is a legal question, and one we don't want to get into. We're concerned more with the medical question of whether you have capacity to make the decision. (If you don't see the distinction, then you're probably a normal person, and not someone who could be called to a courtroom to talk about something somebody else said or did several years ago.) If you're drunk or high, it's an easy call to make. If you're calm, reasonable, can count backward by sevens, and remember what you had for lunch yesterday, it's likewise pretty easy.

If you're acting like a tool, you're a little drunk, and you've been hit in the head recently, the way you're acting could be due to any possible combination of columns A, B, and C. So that's a little trickier.

The ER folks, with the patient's mom in agreement, decided that holding this guy against his will, for his own good, was the way to go. He naturally disagreed. So what I learned, and what I'm taking credit for naming here, was something I'll call Febrifuge's Equation.

I'll have to work out the specifics, but on one side we have all the factors that identify a person as medically obnoxious, and increasingly potentially dangerous to self or others: their blood alcohol level expressed as a percentage by volume, their body weight in kilograms, the number of security personnel needed standing around their gurney to approach an equilibrium. On the other side of the equation, balancing everything out nicely in this guy's case: his mom.

The equation would have to work such that "mom" (M) comes out to either a positive or a negative value. So long as M is a positive number, the person is able to be persuaded to stick with the plan. The values on the other side of the equation can adjust downward so long as M is still enough -- the number of guards can be reduced; with time the ETOH level will decrease; and everything will stay cool. But if M becomes a negative number, then not even the patient's mom can help. This is when things get tricky.

Sunday, February 22, 2009

Hi, My Name Is ___ sleep deprivation ___

I know there is probably already a documented "law" that states the more one has going on in one's life, the less time and energy there is to blog about it. If anyone knows of such a thing, please let me know what it's called, so I can chuck it into the memory banks with all the other stuff named after people.

Beck's Triad; McBurney's Point; Morrison's Pouch; Murphy's Sign; Colles' Fracture; Boxer's Fracture, Pugilists Nose; Swimmer's and Wrestler's ears. Someday it's my hope to identify something or other that's unique and useful, and stamp it Febrifuge's _____.

Sorry I've been so silent. All that time I spent back home, in the very Emergency Department where I used to work. In my defense, we stayed at Jonny's otherwise-uninbabited house; we paid stupid-cheap rent and kept the place occupied, but there was no Internets. And as we all know by now, I only add to this blog at weird times of the day and in short random bursts.

Emergency is still awesome, even now that I've actually done it, with some responsibility. I can see the career going ahead as planned. Currently I'm back in Chicago, and back in Trauma. Aside from the nasty commute and the 4:40 wake-up time, it's pretty sweet.

Since a couple of weeks ago, I've had a special hatred for pulmonary emboli. More than that, I don't really feel I can say. I can't do justice to it. Suffice to say, everyone is someone's family, and the thing for people in my position is to remember that, but still be able to think, and act.

Last week I renewed my disgust for handguns, in re: what they do to people's bodies. The surgeon I was with said, "most people never get the opportunity to see this." True... but being part of my educational experience probably doesn't help make anyone feel better. Anyway, another random bullet in the big city, another stupid exchange of words, another overreaction, another kid who won't graduate high school. I guess if I can continue to love humanity in the abstract even when dealing with this kind of thing, I must be in the right place.

Thursday, January 08, 2009

Just a quick thought for the day

It's true, there is no such thing as a free lunch.

However, having already paid my $23000 for the year's tuition, I cheerfully accepted a box-lunch turkey sammich and Diet Pepsi today, as we students attended all the same lectures as the Emergency Med residents.

And although the academic part of the day means I have some down-time before I see sick people from 3 to 11pm, at least I can stop by here and say hi.

So... how are you?