It may look like a walnut...

There is a notorious phenomenon that occurs in people who are in medical training; as you learn more and more about the various things that can go haywire with the human body, you gradually come to believe that an implausible number of them are happening to you. I believe that some of the reason my school's student-health clinic is staffed with semi-retired old docs is that they've seen and done everything, and most of the reason is that none of us are ever actually sick.

I, being older and presumably wiser than many of my classmates, have avoided too much trouble with this. I had a hacking, body-shaking cough for about 8 or 9 weeks, but I knew that was just a virus, combined with the dry air, combined with my train commute and incarceration in the same windowless classroom every day. Even when Teslagrl told me to go get a damn chest x-ray, I knew it wouldn't show anything. And anyway, we covered chests & lungs in the Physical Exam class, and nobody could hear anything wrong.

But then, a couple weeks ago, we got around to the male genito-urinary exam. Yeah... so I'm 37. You see where this is headed?

Before learning the correct way to inspect, cradle, squoosh, and prod another man's junk, and then go around back and knock on the back door, we learned the right way to talk about the exam. What it is, what it isn't, and why it's important. At my school we use 'professional patients,' people who are trained in much the same way we are, with all the attendant anatomy, physiology, and pathology... but from the other side. They learn how the exam is supposed to feel, when done correctly, so they can tell us stuff like "okay, you can press a lot harder than that," or "yep, you're right over it now; you should be able to feel it."

Yes, it's weird, and even though we'd already done the breast exams, the five dozen or so in my program were all quietly freaking out on "Nuts & Butts" day. We went into rooms in groups of four, which somehow made it worse. But once the guy did his intro speech, dropped the Caesar Ocatvius sheet he had added to his patient gown, and the first volunteer got to business, it was all very technical and interesting, and somehow we were all professional and more or less relaxed.

So, speaking now as a future professional, it's not a big deal. And the thing is, it's really super-imporant. A decent exam takes three minutes out of your life, it doesn't hurt, and it involves no needles and no radiation, unlike so many other tests. And the risks of being a big wuss about it and doing nothing are fairly dire. Ask Lance Armstrong about that.

Which brings me back to my own experience. Having honed my little speech, I had to consider my own very mild symptoms, from the past year or so. Nothing major, really, but some research pointed me toward an issue with the tissue, in the palace of the pants. Gradually I had to admit that if I were hearing from a friend what I was thinking, I'd tell that friend to go in and get checked. So I had to go see the stately, joke-cracking, HMO-hating doc over at the clinic.

This is a guy who graduated the very same medical school, more than 40 years ago. He's kind of a role model for me. He works pretty much because he loves medicine, and he'd be bored out of his mind puttering around at home with, I don't know, bonsai trees or model trains or some shit. He'd much rather be gloving up and getting to know me better than either of us anticipated.

He needed to leave for a minute to go find the tube of lube. I told him to TAKE ALL THE TIME YOU NEED, man. Search high and low.

And it turned out fine. My prostate is, apparently, awesome. I have no blood anywhere it's not supposed to be. Best of all, that info is documented, bitches! I'm not saying the exam doesn't suck just a little, but it's no worse a sensation than, say, the feeling of having crud stuck under your contact lens. It's less painful than irritating. You go ow ow ow ow shit ow, and you take out the lens to wash it. Then you're fine. And I'd rather have a rectal than some of that bullshit that dentists do to your gums with metal hooks.

The preliminary diagnosis? It would be nice if I didn't have to sit motionless for ten hours a day. So basically, my man-bits are suffering from IRONY. But yes, I absolutely did the right thing by going in.

The moral of the story for all my friends who are, or who love, guys: a dude should check his sack, once a month. And don't fear the finger.

Dang, I forgot Albania

This was harder than I thought. Admittedly, it's also something of a spelling (and typing) test.

62

But hey, naming a new country once every five seconds for five minutes solid isn't so bad, right? Give it a shot; how many did you come up with?

Such Conflict!

Here's pretty much the central dilemma for any health-sciences student who has a blog, and tries to tell interesting stories: how much can you say, without messing up the educational experience for yourself, your classmates, or your patients?

Anyway, wait for a respectable period of time to pass -- I'll think of ways to change around the identifying details, and then I'll be able to talk about my first breast exam.

(Note: not my breasts. I'm not a skinny guy, like I was in high school, but aside from that thirty-something softness in the belly, I'm not hefty either.)

Vacation is Almost Over

So soon, I'll be back to the grind. I passed a course that I might not have, and made some rather huge changes to my habits... my outlook... my inner world, really. More on that later, when I'm not so Oscar-drunk.

I'm reading some excellent books; I'm studying some interesting stuff; I have weird hours this term. I hope to be here more often.

Thanks, Michael Stipe!

This is amusing... to me, anyway. I have this lame little blog, about my career change and now my medical education, right? About how I'm trying to retain a shred of the geeky, funny personality that got me this far in life, while also becoming a responsible, reasonably knowledgeable person.

Okay, so that's the back-story. Now, anyone with a blog that lasts a while will eventually amass enough content that some of it will come up in Web searches. The Web being the Web, there's always that slim chance that one's own little blog will be lumped among the best, or at least the very few, places to go for the answer to a question. And that's happened to me.

Is it a question about being an older student, and going back to school? Not really, no. About the PA profession, maybe? Well, that has happened, true, but this is more of a multiple-people thing, over several weeks.

Is it about comparing and contrasting the arts world to medicine? Um... no.

Well, okay then, you would think; I can't seem to shut up about my friend from Minneapolis, the Academy-Award-nominated Diablo Cody*. Surely that was it.

And once again... no.

I wrote a post a while back, capturing one of my random 'WTF?' moments over a small thing that captured my attention. It neatly summed up the way the outside world has become confusing and dreamlike, since I started my stupidly intense grad school thing last summer.

I was convinced I was hearing REM's Michael Stipe doing voice-over in the new Chevron ad. (Not in a 'this famous person is sending me messages through my TV' way, just in a 'holy crap! Is that Michael Stipe?' way.) And I've had a few comments to this old post pop up, with e-mails resulting.

Don't get me wrong. I'm sincerely glad to have been helpful in some way. It's just so fittingly weird and random that THIS would be the thing that gathers... oh, at least 5 to 10 people... from the world out there to my own tiny, dusty square of the Internet.

So for the record, the voice is Campbell Scott's. He does sound a lot like Stipe. And here's some good news: Stipe sounds more like Stipe lately too. For the lowdown on what could be the best REM album in quite a while, click here.

Come back whenever you like, though. Cheers.

* Who won the WGA Award for Best Original Screenplay 2008 about two hours ago, by the way.

Found Object

I'm sleepy. I need to knock this off and get to bed. But I just wrote something I really like, in the comments section for a very sweet, sad, lovely post over at Jon's blog. Which you should read, because it's excellent, as indeed is Jon.

Because I lack for time (and therefore worthwhile content), and have almost no shame, I'm putting it here as well. Our theme is nostalgia, especially for childhood and simpler times.

* * *

We lived on a cul-de-sac, and rather than being a bulging bulb made all of road, there was a circular patch of lawn, surrounded by curb, in the middle of the turnaround. We neighborhood kids called it "the circle." There were marigolds planted around its perimeter. It can't have been more than 12 or 15 feet across, but it was an island. It was a world to itself, where you could stand and take in the whole neighborhood.

There was a buzzing flying-saucer-shaped streetlight in the center of the circle. If you looked closely, you'd see it had a solar cell down on its base, to sense when it was getting dark. That was when the parents said it was time to come home, in the summer; when the light came on.

If you put your small hand over the block of sensor dots even in the bright afternoon, and you waited, it would make the light turn on. Then you'd move your hand, and it wasn't time to go in after all.

And so, I could kind of control the whole world, a little. I think that's what I miss.

Um...

...right. Sorry.

Maybe I'll talk more later about my interesting new study plan thing. Suffice to say, when you actually plot out the hours on a chart, there are not that many of them available for anything, fun or otherwise. So there you go.

But writing = good, and writing = fun, so I'll try to make sure I shovel the walk to this blog before it gets too deep.

How was your holidays?

What's in a name? A really long post, that's what

Today's post comes to us courtesy of the Reader Mailbag, where a sharp and doubtless lovely person named Barb writes:

OK, so I've got a question for you.

Is there a "proper" form of address for a PA? or is it an individual preference?

I ask because at my husband's neurologist's office the ratio of time spent with the PA to time spent with the doctor is running roughly 25 to 1 in the PA's favor. Calling her by her first name seems somehow not quite right, (too casual and familiar, I think); but calling her Ms {lastname} feels off-kilter, too.

Ahh, yes, Barb, one of the eternal questions of PA-dom. This is just one more way in which the pioneers of the field... how do I say this kindly... kinda screwed us (without meaning to, of course).

The best answer is that it's an individual preference, and if it were me, I'd just go ahead and ask your PA how she feels about it. It could be a non-issue, or you could prompt the kind of long-winded discussion I'm about to launch into. I agree, that using "Ms. ______" in the context feels weird, as though you're talking to a grade-school teacher or you're entertaining a guest in the parlor for tea.

Within the PA profession, there are some even sillier ways to try and be formal, there are ways to just ignore the difference between an MD and a PA, and then there's the first name thing. There's no perfect answer. In my experience, most of the time fellow practitioners of all levels use first names with one another, and patients call everybody "doctor" whether they are one or not.

In the small town where I shadowed a PA for 8 or 10 weeks, everybody in town was on a first-name basis anyway, so those PAs used the trusty first name basis. One guy explained that the weirdest part about practicing medicine in the same small town where you grew up was the collision of the social roles -- guys he had played football with now needed yearly prostate checks; their wives, some of whom he had dated in those high-school days and some of whom had turned him down flat, needed Pap smears. And come to mention it, so did some of their moms. So the small-town factor was bigger than the problem of what to call people.

Even so, I couldn't help noticing that with the MDs, many of the townsfolk seemed reassured by the ability to use the title "Doctor" in speaking with them, probably for the sense of decorum and legitimacy it imparts. After all, when you're in the exam room getting that super-personal exam, I imagine it's easier if you can think of those gloved hands as belonging to "doctor" somebody, rather than "good ol' Bill, the kid who really loved tater tots, and peed his pants in third grade*."

The really nervous patients called the PAs "doctor" too, out of a sense that they basically do the same job. And for all that's about 99% true, it's still incumbent on the PA to gently say, "actually, no, I'm not a doctor. I have a [Master's / Bachelor's / Whatever] degree in Medicine, not a doctorate. So just call me _______, okay?" And I've heard a few versions of that speech, in many settings. After a few years out of school, PAs seem to settle into a mode where they will give it their best shot, and if a patient insists on saying "doctor" anyway, correcting every usage doesn't seem to help.

From its conception, the PA role was always meant to dispense with that kind of formality and social hierarchy. It was the Sixties, after all, and there was a legitimate need to question all the stuff that had built up over the years, around the idea of doctor-hood. No doubt there are situations and people even today, around which rather a lot of that not so desirable, paternalistic, know-it-all identity has built up. On the other side of the coin, fewer of today's patients listen to what somebody says just because they have extra letters after their name... for better and for worse.

PAs were meant to be different in several ways, and that lack of entitlement was one of them. The profession grew in part out of wartime experiences that proved to the grander institution of capital-M Medicine that a competent, hardworking man or woman could be trusted with serious medical stuff even though they'd had less of the advanced hard-sciences-style training -- as long there was a solid foundation in how to think about and how to perform the component tasks of medicine, and as long as the conditions were right. Meaning, if help is available from some Captain not so far away, you can trust a Lieutenant to patch somebody up M*A*S*H style, or treat all the runny noses on base. As a matter of fact, the PA can be trusted to treat 3,000 runny noses and STILL catch that one brain tumor, with the right training. And so that's the training we get.

But for all that, in the planning stages it was decided that we should never really try to cross over into that special, ill-defined, highfalutin' area that marks where official doctor-hood starts. Some of it is politics, of course. Some is a return to the good ol' accessible "country doc" spirit of the earlier 20th century (and Star Trek), and some is a look forward to a more competency-based way of thinking, where a person's title means less than their skills. Over the years this has played out in good ways and bad.

We saw a video in one of our classes last term, demonstrating some ethical dilemmas and providing a point of departure for some really good discussions. One thing everybody commented on was the way the people in white coats were calling one another "PA Smith" and "PA Jones," as in, "I see here in your chart that you spoke to PA Jones about this." Our instructors assured us that we would not have to act like gigantic dorks and call one another "PA" anything. It turns out that's how it's done in the military, bless their hearts, but after all that's an environment where titles give important information and everybody has one. Calling somebody by a first name there might be an embarrassing breach of protocol.

And lastly, I was really fascinated by something I noticed back in my job at the County ER: as the Emergency Med residents got farther and farther in their training, they seemed to appreciate the PAs more and more. The way this manifested sometimes was that the senior residents, the ones about to graduate and go out into the world to become attendings, would be talking with patients and refer to the PAs as "doctor [lastname]." I found this to be pretty weird, but eventually caught on that it was the same kind of shorthand that patients use, where the word "doctor" doesn't mean "person who has completed a terminal degree that's beyond what other fields might consider a grad program," it means "person who completed a program sufficient to allow that person to provide medical care," and even more than that it means "person who provides medical care."

Which is all pretty cool, I suppose, because it means that in some places, the idea of competency over credentials is becoming the reality. And that's nice. But I specifically didn't want to be, and don't want to be, a doctor. So I will be correcting people, both patients and colleagues, at least once.

Hope that answers the question, Barb. Thanks for reading!


* There is no story about any of the nice practitioners in that town peeing themselves. At least, not as far as I know.

I also knew this season of "Heroes" would be lame

Here's me, in October of last year:

"...my pal, future Golden Globe-winning screenwriter (and eventual Hollywood Squares center square) Diablo Cody..."

Here's today's news:

"Besides Cody's screenplay nomination, "Juno" was nominated for best comedy or musical. Star Ellen Page, who portrays a precocious 16-year-old who decides to give up her baby to a yuppie couple, was nominated for best actress in a comedy or musical."

Yes, yes. Those chickens don't hatch until January 13. Duly noted. I'm just saying, is all.

Hollywood Squares 2025 will be rated TV-14, for adult situations, suggestive dialogue, and fantasy violence.

Fairly Legal

I'm not sure if you're aware of the state of the medical Blogosphere, but in the past year or so, there has been a spate of closures of medical-type blogs. To be sure, there are some shining examples of ways in which working health-care types can enlighten, opine, and entertain. Many are a great read, some are intellectually and/or politically challenging -- but I guess it's an endeavor that is not without risk. In these waters, there be sharks. Arrrr.

When I started this little experiment, I was sure to make mention of HIPAA, the medical privacy law, as it applies to blog postings. I'm aware of where the rough outlines of appropriateness start to blur even more than usual... and in fact, I'm one of the few people I know who has actually read the text of the thing. Even so, when it comes to guidance, there's really nothing concrete, and nothing a poor student could call reliable. Because nobody really knows. Like so much of law, once you get into it a little, it's more a conversation than an edict from on high.

No, I'm not closing down the blog. I'm just long-windedly saying that people act like HIPAA provides a clear, bright line, when it really doesn't. The best a guy can do is to keep the conversation going. So, when I started school last summer, I had a conversation.

The handbook for my school seems pretty up-to-date, when it comes to real-world questions. There's a policy about the finer points of how and when alcohol may be served at school events, for example. I am expressly forbidden to use not just school computers but also school bandwidth to download pornography (or, presumably, to upload it). Care is taken to let me know that the use of the school's name and logo is controlled, and there's a procedure to follow, when it comes to getting a possible class t-shirt design approved.

Yet it says nothing about blogs.

My opinion, based on my interpretation of the law, is that writing here is a part of my learning process. It's a tool I use to reflect on the ideas and experiences that will make up the foundation of my training and eventually, my practice. So if I'm doing well, writing here is part of a system that is getting good results. If I'm struggling, the blog might represent a means by which I can identify and address problems I'm having with my own learning process.

As I've said before here, losing out on academic or professional standing because I keep a blog would be mortifying, not least because I like to think of such conflicts as avoidable. I am still (relatively) young and naive as I write this.

So, in the first week or two of classes, I sat down and spoke with the director of my program. I told him that this blog exists. I explained that thematically, it's about the story of how I got from where I was to where I am now. I mentioned that a handful of interested parties, most of them family and friends I talk to in the real world, keep tabs on it, in a loose way. I said that I can't expect it to be totally anonymous, but I make an effort to at least obscure details, and explained to him a few of the minimum things involved in my process for doing that.

He said it's cool. As long as I don't mention individuals by name, and I don't specify the name of the school or be too very detailed about its location, he sees no problem.

So... have no fear that I'm jeopardizing my present or my future. If you've got questions about what "studying medicine on fast-forward" is like, or about the deal with the PA world, give me a shout. It's nice that a core group tries to keep tabs on me this way, and it's always fun when unexpected people pop up, having followed me from more interesting places.

I'll try not to be so terribly cheese-sandwich-ey, but then again the definition of a blog is personal writing that is interesting... to the person writing.

I have a break coming up soon. This could be a good time for me to perk this place the heck up.

In The House

So, we have a new class this term. It's called "Clinical Decision-making." And it is AWESOME.

I am practicing (and hopefully, perfecting) the art of differential diagnosis. You know how on House, about 30 to 60% of any episode is sitting around and thinking about "what it might be?" That's what this class is. Naturally, I frickin' LOVE IT. (And yes, I have already whispered "it's lupus!" to the person sitting next to me.)

It's like being a Cheers fan, and having a class where you're asked to drink beer and insult each other. Or being into Miami Vice, and taking a course where you use the door of your Ferrari as cover in a gun battle where for some reason nobody's wearing socks.

The class happens each week, over a couple of days. On the day of the class, we have to write up our first impressions, and what our next steps would be. That night, the Web portal for the class shows us what the lab results and images and whatnot tell us. If we asked the right things, we can assume we now have those answers, and those go into a write-up that's due the next day. It's really fun, and exactly the kind of thing that I learn from. Back in EMT training, I killed one such hypothetical patient, and still remember those lessons. So far this term, no imaginary sick people have cacked it on my watch. Knock on wood.

So far, I have correctly recognized a Congestive Heart Failure case and a heart attack. Nice to know I can make 2 and 2 equal 4, I'd say. I was too conservative with the CHF'er, and wanted to wait for some labs to come back before getting some meds going. I was sure to say "STOP FUCKING SMOKING," though maybe not in those exact words. For the heart attack, it was presented a little cleverly, such that not everyone in the class saw it as what it was. My treatment plan was maybe a little too cute: it went, "1: CALL 911. 2. Do everything else in the ambulance and/or in the ER." I did go on and explain what 3-7 would be, but only grudgingly.

I also could have done more to treat the irritating chest pain the patient was suffering. Sorry, fake patient. Next time I'll give you some morphine for your ride in the fast boxy truck.

Why yes. Yes, I do enjoy getting the props.

Today in a lecture, we talked about nosocomial infections (infections that people get from BEING in the hospital, as opposed to ones they come in with). There was a PowerPoint slide about a specific factor that accounts for a big proportion of these infections: people with indwelling urinary catheters account for like 80% of all cases.

I raised my hand and asked the lecturer, an MD who specializes in Infectious Disease, "what about the percentage of people who have catheters? What's their likelihood of contracting an infection?" See, what I did there was to turn it around.

This was, apparently, awesome. It kicked off a tangent, a brief and productive one, with everybody in class clacking away at keyboards and scribbling notes. We got some high-yield and helpful info about how stuff works, that wasn't on the original PowerPoint. I got a compliment. "See," said the MD. "That's the kind of thinking that's worth more than just knowing the factual information."

It was a nice boost, and one I needed, because seriously, sometimes the sheer volume of the factual stuff gets ridiculous. I have always been lousy at the "binge and purge" method of studying, and as a result I've dragged myself, kicking and screaming, into these advanced studies. Half the time, forcing myself to study is like getting a toddler to eat cauliflower. I do not get A's on everything, and truth be known, I rarely get A's on anything. But it's okay. As long as I know that they know what I know, it's okay.

It would be cool if there were some type of exchange rate, where props could be converted to points.

Breaks from tradition

Happy Turkey Day, random Intarweb people!

This will be only the second Thanksgiving since I've had the opportunity that I will not be enjoying the thoroughly amazing meal at my dad and stepmom's. I'm really happy to come from a gigantic, loud, slightly nutty family, and I'll miss them. But that's what it's like at the moment -- I need to make strategic decisions about how I saw everyone a month or two ago at stepsis' wedding, and about the mountain of studying I need to do with my very few days off.

Two years ago was the first time I was out of that particular Turkey Day loop; Teslagrl and I were alone in the big farmhouse out in rural NY State, and I made a small bird plus a Tofurkey, and all the trimmings, myself. I was inspired by the great kitchen at the place we were renting, and my housemate's Bittman cookbook.

This year will be spent at the home of friends who live nearby; we get the Thanksgiving experience but without so much of the traveling. Which is nice, as just this morning it has started to snow a little.

Here's a bad sign...

When the first lecturer of the day starts by asking, "who has Tylenol?", and in response to a sea of quizzical looks, he continues, "...because I guarantee you'll have a headache at the end of this."

Um... yay?

My take on the WGA strike

There's a famous story about old Hollywood. It's probably not true, but it illustrates a point, it's too good not to quote, and it probably has a grain of truth. According to the story, Irving Thalberg, the uber-powerful producer, saw The Jazz Singer in 1933 (...so, not the Neil Diamond one...) and sniffed that sound in movies was going to be a passing fad. The point being, some things never change, and today's studio heads also don't seem to have a solid grasp on how things are going to work in the future, no matter how good they may be at operating under the status quo.

Besides, the wounded moguls are full of shit. They argue that DVD sales and Internet streaming are NOT going to be important sources of revenue, but if that's so then they shouldn't care if the residuals earned by creators (use the word "royalties" and think about book authors, if the legal-speak makes you glaze over) went up from 0.04% (where they are now) to 0.08% (where the WGA wants them). If there isn't any money in these avenues, the studios shouldn't care if they had to give up 8%. Or 18. Or 80.

85% of the households in the nation have cable now. Some TV seasons on DVD outsell some movies. There are more PCs than adult humans in the United States. Consumers spend money on TV in ways that didn't exist 20 years ago. Somehow, I'm sure there will be enough to go around, and I'm glad the WGA is taking steps to prevent getting completely screwed. As Aaron Sorkin said in "SportsNight," anybody who can't make money off these opportunities needs to get out of the money-making business.