pleasedotheneedful

[pleasedotheneedful]

#screaming internally #i recently entered the transfer portal

[pleasedotheneedful]

I got an email in the middle of this night shift giving me a "reminder" that I need to distribute patients equitably between myself and the teaching service.

I was livid. Not because I'm never wrong, but because I specifically go out of my way to give the night residents options. I'm only 1.5 years out, I still intend to practice like a residents' attending. When I get a bulk of admits I let them pick patients, I'm transparent about when I need their help, and I offer to help them with any issues they have. I ask them at the start of the week how they like to have their shift loaded--some prefer to have the admissions front-loaded, others prefer a steady trickle.

There have been several nights where they get a few more admissions, usually because I'm tied up with a sick patient (like last night) and because the census is skewed such that the nonteaching service has too many patients. At the end of the shift, the night residents and the teaching service are all still under cap.

It's a no-win position. If I go easier on the teaching service, the nonteaching side will blow up and then they'll get all pissed off that I'm not balancing the census.

So all that being said, I told them exactly what I've been doing at work this week. Because did anyone ask? No. They just told me to let them know if I wanted "specific guidance."

Here's some specific guidance, how about you get your asses over here and pick up nonteaching/night shifts with the rest of us? Then I'll care what you think.

I think I might ask for my hours to be cut so I can explore other jobs. This double standard is straight trash. Are all academic places like this?

#screaming internally

[pleasedotheneedful]

this is hospital medicine, I'm here to remind everyone to be judicious about how you use your patient's allergy list.

if I go to review the chart and there's an anaphylactic reaction listed to sulfa antibiotics, but a month after that was entered I see the patient received bactrim without issue I will have questions

or if I see a dozen allergies listed with "unknown" reactions and "unknown" severity, with some of those medications having been given without issue *during this very admission* I will be reaching out to you

please document purposefully ty

#screaming internally

[pleasedotheneedful]

ED intern: hi, I'm admitting this patient with a GI bleed. they just had colon surgery last week at main campus. there's two units of blood hanging and I think they're stable enough to be out of the ICU me: have you talked to surgery? ED intern: oh. uh. I did not me: would you mind doing that? there's a high chance this is a surgical complication, I would at least talk to our surgeon on call or just bypass him entirely and call downtown.

I checked back in the chart a few hours later, this mf is accepted by his surgical team at main campus. the fuck was I going to offer this patient by accepting him? a continuous chocolate fountain of blood?

this is an intern so there was no reason to take it out on him, but this is emblematic of how little oversight they get. it seems to be specific to our ED. the admission requests frequently come through with no work-up, improper dispo, neglectful management, and a story that leaves me wondering if they even saw the patient. and often when we push back, we're told "well it's not gonna change management"

except it often does if you put any thought into what's happening to the patient. neglecting to evaluate for a head bleed and sticking them on med-surg is begging for an ass whooping after the patient decompensates. the hospital is not just some nebulous get-well zone, it matters not only that they leave your department but that they have access to the correct amount of nursing care.

#screaming internally

[pleasedotheneedful]

This still reflects my take away from my PGY4 year

PGY2 sucks and I hate everything and I hate this program and I wanna go home

[pleasedotheneedful]

me, watching the teaching service struggle to obtain coverage as I quietly reclaim career fulfillment outside of my employer

there's a double standard I'm noticing here that made me realize chasing this carrot at this hospital is sucking way too much joy from the other aspects of my life and negatively affecting my performance.

look, all I'm saying is I think you'll regret not investing in a deep QB room.

see: NFL teams in Ohio

#screaming internally

[pleasedotheneedful]

also very belated shout out to the hospitalist that told my friend they follow my tumblr

[pleasedotheneedful]

hospital medicine rambles

I'm picking up substitute teaching shifts on the opposite side of town (well, more like in the neighboring county). The coordinator moved me from two weekends ago to this one without telling me, and it appears she scheduled me for an extra day tomorrow.

If I were a resident I would be livid and probably refuse to come in, because fuck you I don't get paid enough for someone else's mistakes. But since I'm an attending and get paid appropriately for picking up these shifts it's gravy. Plus these residents seem to like me so far. I keep encouraging them to give me their feedback directly (before it hits the paper evals) so I can get better at it, and also to tell my boss they want me to keep coming back (if that's the case).

I kind of like being the weekender, the hospital is less hectic and there's no didactics so I can talk about stuff to the residents without rushing.

There's a degree of flexibility in hospital medicine that doesn't exist in the outpatient setting, which is one of the reasons I've been extremely hesitant to change jobs as the majority of the openings around here are outpatient. Like last week I was sick as shit with a once-in-a-decade bacterial sinus infection. Knowing we never have enough coverage available, I didn't want to call off and my colleagues all like being the ones to arrive/depart earlier, so I just came in late which gave me time to empty my face every morning before talking to patients. I am sure it was better than the potential alternative of having to divide up my patients amongst themselves.

#screaming internally

[pleasedotheneedful]

long time no see

I diagnosed hyperthyroidism in a patient who was just admitted for a hip fracture so that was cool. HR was 130s so I figured it was just due to pain and some post-op anemia but it persisted after that was resolved so I dug deeper into her chart and she's been running that high for at least a few years. Someone even had the foresight to order a TSH/T4 in that time but it's never followed or mentioned again. It was wildly abnormal, so I checked it again and even more abnormal.

Ordered a TRAb and checked with cardiology to make sure I wasn't missing something else, they took it upon themselves to talk to endo. Next thing I know she's on propranolol/methimazole and her HR is riding in the 80s. Discharged her to endo follow-up.

Moral of the story: for better or worse, we operate in a swiss cheese model and it can work well if you accept that (by minimizing assumptions that something has been evaluated)

#screaming internally

[pleasedotheneedful]

what's new in pdtn land

became a dad last month

had to fight tooth and nail to get 8 weeks of unpaid leave for child care though, because I have < 1 year in service and HR/admin in my hospital system is a fucking disaster. my wife has similar rules about her maternity leave but her admin waived them without any pushback. she works for a different hospital system and gets 12 weeks fully paid. guess who's more likely to retain their physician?

2. had my teaching titles/roles stripped back in January, rather suddenly. I admittedly let myself get into an unhealthy cycle over the winter and wasn't doing a lot of teaching, but I'm surprised they took me off the schedule entirely for a year. I'm not sure how I'm supposed to get better without actually getting reps on service. I talked to the PD about it, who acquiesced but when the new teaching schedule came out I wasn't on it. yet we share the same vision for the program and its residents.

3. moved into a new house to accommodate #1, which unfortunately meant moving out of the city. the housing market is total insanity still, houses were impossible to find without an HOA and even then, flying off the market within 48 hours.

4. given #1 and #2, I have limited prospects on staying at my current job. the pay is good and the day-to-day work on non-teaching is pretty manageable. but it's not what I want out of my career long-term. I'm toying with the idea of going part time or PRN here, and putting that time into being a mercenary. locums pays well and requires fewer hours--there aren't any benefits but since I'm on my wife's plan that doesn't matter to me. so I can use that time to be at home more, and expand on my private practice hybrid concept. the locums gigs also offer me a chance to get a diversity of references instead of being tied to one employer. if I'm not back on teaching with some frequency by next January, I'll probably scale down to PRN by the subsequent summer or walk.

#pleasedotheneedful #pgy-11ty

[pleasedotheneedful]

As someone who is currently doing hospital medicine, one of the biggest complements I get is a patient asking for my card and if I have an office where they can continue to see me.

[pleasedotheneedful]

Got into an argument with the GI NP about a consult I placed. they said "happy to see the patient but not sure why the consult is needed"

So I explain that the patient's ileus is nonsurgical (passing gas, already seen by surgery) but after his NG tube was removed his presenting symptoms (severe bloating) started rapidly accumulating. Etiology remains unclear. I'd like to blow out his colon and see if that helps reduce the bloating.

She goes on to say that well, surgery said he's still passing gas and he's improving so I'm not sure what else we would offer. We can see him in the office.

I say yes, I know what they said but what I see/hear from the patient is different. I understand if you don't think a full consult is needed but I would like to know your thoughts on doing an aggressive bowel regimen, as it's evident he has quite a bit of stool regardless. A curbside/your off-the-record input is fine.

She then says I don't know if I would do an aggressive bowel regimen, miralax is fine. and mainly, please save inpatient consults for acute inpatient issues. Surgery says he is improving.

...

My headspace: I WILL DESTROY YOU, I WILL COME TO YOUR HOUSE, STEAL YOUR PLANTS, AND PISS ON YOUR DRYWALL.

I take a deep breath.

"I realize that's what surgery said, but he wasn't improving when I saw him yesterday. Though passing gas his symptoms were ramping back up. This was shortly after the NG came out. I was looking for additional guidance, you gave it. I am pretty judicious with my consults coming from a program where I was expected to discuss my rationale over the phone."

Don't you talk down to me, motherfucker. I don't have to chug dongs the way I did for the previous five years.

An hour or so later, I get a message saying she saw the patient and would discuss with the GI attending.

I love that I have the support of my division in pushing back on petty shit like this. I usually just give my chief a heads up in case anything gets back to him.

#screaming internally #pgy-11ty

[pleasedotheneedful]

done with IM boards

I decided to try a new test-taking method. It starts with a breakfast of coffee and a mix of macronutrients (in this case, in the form of a breakfast sandwich). This supports the efficacy of my AM meds.

Then I "use the energy while I have it" and power through the entire exam without using my breaks.

This was an attempt to move away from running out of time for every section and using my breaks maximally. It was tough, yet way easier for me this way.

The noise-cancelling ear muffs provided by the center were also pretty helpful.

[pleasedotheneedful]

Oh, also, thank fuck residency is over lol. I can't believe they let me graduate after all the shit they pulled (and I pulled in response) over the past 7-8 months.

Wish I had more to say about it, but what I mostly want to say is first, I'm grateful for my co-residents. Second, any program (and person) not constantly taking a second to evaluate their actions is doomed to slide into malignancy.

That doesn't mean ruminating over every decision or statement you've ever made, it means pausing briefly to ask yourself "am I doing the right thing here? who are the main stakeholders and how could this have impacted them? am I offering enough transparency about the program and if not, why?"

There's your fucking QI project.

[pleasedotheneedful]

"She went on a long rant about how she understands I'm new to the country but it was really important that I learn about adolescent lingo and American customs. Like one time she made me read this long article because I didn't know what 'dabbing' was."

a resident recalling her experience with our only adolescent medicine attending

This same attending literally just found out what dabbing was from a patient I saw while on rotation with her two years ago. I knew she was intense and weird but I didn't realize how strong her internalized ethnic biases were against brown women until I was talking to residents this past month.

I think there are positives to her practices but having her as the sole option for our adolescent medicine month is pretty weaksauce. Comparatively, my month was okay but I'm a brown guy with a middle-American accident working in middle America.

[pleasedotheneedful]

Sharing a story I posted to a fb group for docs with ADHD last week:

Story time. I was in our peds urgent care on Thursday and my first patient was a 7 yo with behavioral concerns who was recently expelled from school. Teachers says he won't pay attention, is aggressive, acts out. Mom says she does struggle with the attention and acting out at home. While I'm in the room the kid is pretty standoffish but I try to make sure I talk to him while also addressing mom. He's playing with some toys a little loud but otherwise he's pretty appropriate in the room. Mom brought him mostly to drop off the school evaluation that was done, which flagged for ADHD. I go to staff with my attending and we each end up discovering the other person has ADHD. It's urgent care and he has an active PCP so we're not starting meds but my attending is addressing all of an overwhelmed mom's concerns about the behaviors and the possibility that this is ADHD. While she's doing that, the kid looks at me and goes "do you have ADHD?" Of course I said "I do, actually!" And after that he opened up, he asked me to play with him which I absolutely did. Maybe it changed his perception that this was some strange condition and saw this doctor who had it, and felt okay about it. To think, there's another peds attending here who is convinced I'm "probably a better internist than a pediatrician" because I'm not good at playing "guess the esoteric thing I'm thinking of." And my program just seems to follow his lead (even though he is notoriously harder on med/peds residents). This was another reminder than I picked med/peds for a reason, despite the best efforts of some bad actors.

#peds side of the moon #pgy-4: i'm out of ideas

[pleasedotheneedful]

#deep space 9 #star trek #cleveland #ferengi