The world of medicine is like a bubble. A lot of people THINK they know what goes on there, but unless you're down in the trenches it's unlikely you do. So here is my semi-anonymous blog, here to tell you what really goes on in the life of a medical resident.

Sunday, April 29, 2007

The Anti-Climax

Gah. It's done. After close to two months of doing pretty much nothing besides work and study, the CCFP exams are over. To those of you not in the know, the CCFP exams are the set of exams that family medicine residents in Canada are required to pass before hanging out a shingle. So, unlike the LMCC-II exams that I sat back in the fall, these ones actually mean something.

The first step was the written exams. They started off in the morning with some questions that were much easier that the practice exams that had been circulating around for the past month. I think it was intended to lull us into a false sense of security. As the day went on the questions got harder, and more obscure. By the end of the day we were well into "guess what I'm thinking" territory. Bah. Honestly, I'm not sure what two medical conditions preclude immigration into Canada, and I'm not entirely convinced that information should be taking up valuable brain space. But whatever. I'm just looking to pass.

The SOO's (Structured Office Orals) were kind of fun. If stress can be fun. Each situation has a patient that puts a problem on the table immediately, but you often have to uncover a second 'hidden' problem. Sometimes these problems border on the ridiculous, but generally they are pretty representative of what can walk into a family practice. You have 15 minutes to cover a staggering amount of information-- some related to the problem, some not so much. The problem with the SOO's is that the formula that you have to follow in order to pass bears no resemblance whatsoever to an actual patient encounter.

For example:

- I don't ever tell patients to 'come back for a physical exam'. In a 10-15 minute appointment in real life, we do both a history and physical.
- I would be thrilled if my patients only came in with two problems. I'm still trying to figure out an assertive way of limiting the patient who comes in for their 10 minute appointment with a list of 6 things they've been 'saving' for their appointment.
- I don't routinely ask what my patients do for a living unless it is somehow related to the reason they've come in. In the SOO's, you have to explore the impact that their complaint has had on their function. Gah.
- In the SOO's, after about 10 minutes you are expected to make an 'integrative statement'. This should sound something like "So as I understand it, this hangnail that you've been experiencing for the past month has been causing you a lot of distress, and is clearly interfering with both your relationship with your gay lover and your job as a basketweaver. Does that sound right?" I am quite safe in saying that I have never, in two years of practicing medicine, made a statement like this in the middle of a patient interview. But it is integral to the SOO.
- In the SOO's patients never wait until they are one foot out the door to tell you why they REALLY came. "Oh... I almost forgot. Thanks doc, for looking at that mole on my arm but I forgot to mention this crushing chest pain that I've had on and off for the past two days..."

But enough with the bitching. They're done, and I can get my life back. And now I have a month of geriatrics to get through. It's odd to go back to work after such a feeling of finality, but I still have two months to slog through before I move out of this town to start my PGY-3 emergency medicine year. Which is already looking to be full of interesting twists. But more on that later.

Monday, April 16, 2007

The Pharmacists Aren't Perfect, Either

I've been thinking a lot about this new law allowing pharmacists limited rights to prescribe and change treatment plans in Alberta. Now generally, I think pharmacists rock. When I'm managing inpatients I often rely on the expertise of the hospital pharmacist, who thankfully is just a phone call away and is always happy to answer my questions. In the academic practice where I've been working for nearly two mind-numbing months, we have a full-time pharmacist available who also does incredibly helpful things like scan databases of patients to make suggestions on the optimization of their medical management for certain conditions. In the community, the pharmacists (for the most part) are happy to repeatedly save the ass of the new doc in town (that would be me), faxing back to politely remind me that I've neglected to include the limited use code for an elderly patient's meds, or to tell me for the third time that I can't order 5mg of Flexeril qhs because the lowest dose of Flexeril available is 10mg (regardless of what Lexi-Drugs tells me). Then again, these pharmacists who seem so patient with my rookie mistakes may be the same ones who then turn around and refer to me as an idiot who doesn't take the time to talk to my patients (as per The Angry Pharmacist).

Not long ago I had an entire family come into my community family practice-- both 30-something parents and two sons just shy of puberty. Mom was clearly unwell. She leaned on her husband for support, and complained of a sudden onset of high fever, joint and muscle aches, extreme exhaustion, headache and cough. A few more questions and a physical exam later, I diagnosed influenza. It was actually quite classic. I took a naso-pharyngeal swab to send to public health, and sat down with the family to discuss their concerns. Most of all, the parents were concerned that their two children would get this as well. None had been vaccinated, and the severity of this illness surprised both of them-- they had thought that the flu was a bad cold, and mom in particular was shocked by how debilitated she had been.

We discussed indications for treatment for mom (and decided against starting treatment based on the duration of symptoms) as well as indications for prophylaxis for the rest of the family. The parents felt strongly that they didn't want their children to suffer from the same symptoms as mom, and decided to give both children prophylaxis. We discussed the risks and benefits, weighed both boys and calculated their dosage.

I saw the father with similar flu symptoms about a week later. I asked if the children had been treated. They hadn't. Apparently, when the father had taken the script to the pharmacy, the pharmacist told him that there was no point in taking the meds before the kids got symptoms, and that he'd be better off leaving the script at the pharmacy to be filled when the kids got sick. So that's what he did.

Except that's totally not the case. The doses for prophylaxis of influenza (to avoid a full-blown case of flu in someone who has been recently exposed to a confirmed case) is not the same as the dose for treatment of a full-blown case of flu. If the father had followed the pharmacist's instructions, the flu wouldn't have been prevented and the dose prescribed wouldn't have been enough to adequately treat it if taken after the kids became symptomatic.

Now this error wasn't life threatening. And because there is a certain degree of the broken telephone game, I can't be certain what exactly was said in the exchange between the father and the pharmacist (another fact I believe The Angry Pharmacist forgets all too often). But it worries me that a pharmacist would seemingly take it into his own hands to change a treatment plan that was decided between myself and my patient with only a partial understanding of the situation.

If pharmacists were allowed to prescribe, wouldn't this scenario happen more often? And potentially with more severe consequences?

N.B. Please accept my usual disclaimer that I have absolutely nothing against pharmacists as a whole, and actually find the great majority to be an invaluable source of both clinical and practical information. And can drink me under the table.

Sunday, April 15, 2007

In spite of my lackluster posts of late (I'm chalking it up to a combination of stress and a genuine lack of seeing anything really interesting to blog about after 6 straight months of family medicine) someone found me worthy of nomination for a Blogger's Choice award. I don't know if these awards are usually slow to catch on, but the leader in my category only has 50 votes. So head over there and vote! Even if it's not for me.

I have taken this week off of work to give myself some uninterrupted study time-- the CCFP exam is in less than two weeks and there is tremendous pressure to pass. Not just because I can't afford another $1500 to take this exam again, but because I can't afford to have anything delay my ability to make some extra cash by moonlighting.

Expect to see some procrastination-fueled posts popping up soon.


Sunday, April 08, 2007

Huh. Interesting.

In the past week, I've had three random e-mails sent to the account linked to this blog. Each of them contains a link to a website, and asks me to 'evaluate their site' and consider adding them to my blogroll. I find this odd. As flattering as I find it to be included on sites that I admire (Flea and Charity Doc come to mind) and as much as I strive to someday be included on the sidebar at Mr. Hassle's Long Underpants, it would never occur to me to contact a blogger to ask to be included. Is this how people boost their hit count? Does this mean I have 'arrived' as a blogger? It would be nice to think so, but since I've never had such a request before and now have received three in short order, I have to suspect that it might simply be spam.

On the other hand, I'd like to officially introduce a couple of friends of mine to the world of blogging. Dr. H is an anaesthesia resident, her husband, Dr. J is a family physician currently doing locums in the far north. I've been enjoying their stories for awhile now, and I think that others would as well. Check them out at Adventures in Medicine.

Also, look out for yours truly in an upcoming issue of The Medical Post. I don't know exactly when it will be coming out, but I was interviewed last month for an article on physician bloggers. Hopefully, they'll make me sound somewhat intelligent.


Tuesday, April 03, 2007

The Touch

There's a joke going around the clinic where I'm working right now. If you're looking to get knocked up, make an appointment with Dr. Couz.

I've somehow managed to run the most bizarre streak of test results. In the month I have been working at the family practice clinic in town, I have done 6 urine pregnancy tests on various women for various reasons. Some to rule it out, some to rule it in. In every single case, two lines have shown up on the dipstick. Whether it was an expected result or not. It's gotten to the point that I'm even wondering if I'd recognize a negative result if I saw one.

Complicating matters is the fact that all but one of these pregnancies was unwanted. The most recent positive test belonged to a patient that was 'undecided' about whether or not the pregnancy was wanted, in that it was a result of an extramarital affair that had ended a month ago. Her husband was already aware of the affair, and had told her to come into the doctor to get tested for STD's. That morning he told he that if she was pregnant, he'd kill the baby. Lovely. She isn't sure if she wants to terminate or not. She's coming back in a week once she's had a chance to think about things. She wasn't expecting a positive pregnancy test.

Sometimes I find it really hard not to judge my patients. Last week one of the positive pregnancy tests belonged to a 39-year-old woman. She suspected she was pregnant-- although her cycles had always been irregular, she had been feeling a lot of nausea over the past couple of weeks and hadn't had a period in nearly two months. When I informed her of the result, she said without hesitation "I want an abortion".

Now I'm pro-choice. Always have been. I think that a woman needs to have the ultimate say in what happens in her own body. But this woman knew what she was doing. She had two kids. She had terminated a pregnancy in the past. She had a regular partner with whom she was living, and they weren't using birth control. No IUD, no condoms, no pull-n-pray, nothing. What the hell was she thinking? She's an intelligent woman, with a college diploma and a respectable job. Does she not know how this works? I asked her why they weren't using protection (thinking there might have been a good reason), and got a carefree shrug. Nice.


I don't know why these situations anger me. I'm pro-choice. She's pregnant. She doesn't want to be pregnant. It should be as simple as that. But when people start coming in and acting as though abortion were just another method of birth control, it bothers me. And it's something that's always bothered me, not just from the perspective of a woman actively trying to get pregnant. But I have to admit that also adds insult to injury. It's hard not to have a fleeting thought about all the women out there struggling with infertility when other women treat pregnancy as a disposable inconvenience.

So, of course, I bite my tongue. And I counsel accordingly, provide options, and offer the phone number to the women's clinic in town. And I try not to judge.

Sigh. Just call me the fertility goddess.