The Noble Profession

In general, I find primary care to be a rather noble specialty to go into. While the hours are fairly lax, the pay isn’t particularly good and the procedures aren’t particularly sexy (probably because they consist of the physical exam and blood draws). The physicians who enter primary care aren’t always the noblest of people either: some people are forced into it because of less competitive scores or because of financial incentives (debt forgiveness for setting up practice in a rural area). But my heart is warmed whenever I see a physician practicing primary care because he believes in long-lasting relationships with patients, preventive medicine, and public health measures. Sometimes it is their faith and dedication to what they believe is the heart of medicine that makes their behavior so inspiring.

Dr. Vaccaro and I recently saw a patient named Jessica Rose. She was a young woman who presented with paresthesias along her hands and feet. She had been worked up by her prior primary care doctor and had been brushed off as crazy, meaning there was no physiologic reason he could find to explain her symptoms. She decided to find a new primary care doctor; she searched on Yelp and found Dr. Vaccaro. Before her appointment, she went to see a neurologist at Northwestern and had a few more blood tests that showed low vitamin B12. While B12 deficiency can cause a neuropathy, the neurologist wasn’t sure that it explained her symptoms. Regardless, he started her on B12 supplementation.

When Dr. Vaccaro and I saw her, she came off as genuinely concerned with her symptoms. But at the same time she did seem to exhibit some hypochondriasis (she was extremely precise in describing what was going on and had searched on WebMD for possible diagnoses). It was unclear how to interpret the patient’s actions and behavior. After performing some physical exam techniques, Dr. Vaccaro was also not convinced that the low B12 was causing her symptoms. He ran some blood to check on her B12 and her copper and iron as well. Since it would take a day or two to get the results back, he had to go back in and talk to Jessica about what he thought she should do in the meantime.

He decided to tell her that there was a high probability that the symptoms she was experiencing were not physiological. He believed there was a 50% chance she would blow up and scream about not being taken seriously, threaten to find another doctor, and storm off to write a negative review on Yelp. He was willing to take that chance because he believed she really needed to know what his medical opinion was on the situation. So he went in and said exactly that. Jessica was actually relieved. She told us that she just wanted to make sure there was nothing that could hurt or kill her that she was missing. She said she was okay with her symptoms being a result of anxiety, because that would be easier to manage than some unknown and undiagnosed disease. (As it turns out, her blood work came back with some concerning copper and iron levels, but that’s a story for another time.)

While it turned out to be a (relatively) happy ending, Dr. Vaccaro took a risk that could have damaged his reputation and relationship with patients. He did it for the same noble reason he entered primary care: he believed it was the right thing to do for the patient.

Amethyst Sunday Morning

Amethyst Sunday Morning sounded like an odd name for an Alcoholics Anonymous meeting when I first headed over there as part of my psych rotation, but it turned out to be nearly the exact opposite from what I expected. I remember a character in this one movie I saw who compared AA to being forced to go to church when you don’t believe in God. I presumed it to be slow and painfully tedious, filled with sad, depressing people talking about their sad, depressing lives. But instead it’s an open, warm, and welcoming place of friends. It’s full of fun people who tell their stories and share in the triumphs and failures. As I sat there listening, I realized how universal the themes were. Nobody is perfect, and we all make mistakes and fall short of our ideals. Some people turn to alcohol, some people turn to work, and some people turn to religion, but it seems like we all have to find strength somewhere to help us with the challenges we face in life.

AA starts with one person telling their story for 30 minutes. This is called a “lead,” a way to get the conversation going, but it sounds much more like a testimonial at a baptism. A coffee break ensues, followed by 45 minutes of comments. The comments are supposed to relate to the lead (what they found interesting, congratulating them on their sobriety, or giving them advice for some difficult times ahead), but most of the time they were only tangentially related, if at all. I think most people just want to tell their own mini-stories, and AA provides a safe forum in which to do that. (And yes, people do introduce themselves as “I’m John and I’m an alcoholic,” to which everyone replies, “Hi, John!”) The meeting closes with everybody holding hands and reciting The Lord’s Prayer.

I found a few things about the experience fascinating. First, almost everybody had a coffee drink in their hand or on the table in front of them. It might have been because it was an early Sunday morning, but I think it’s because these people feel stronger and more resilient every time they drink something that is not alcohol. Second, there was a common thread of people turning to alcohol because of feeling left out and/or not fitting in, especially in military families who move around every few years. Third, and most interesting to me, is that they describe alcohol as a friend, someone who understands them and makes them happy. They described it as a love affair with Jim Bean. One person went so far as to compare it to domestic violence, where alcohol would keep knocking you down and you would keep coming back like a battered woman to the abusive relationship. Fourth, alcoholism does not discriminate. There are people of every age, of every gender, and of every ethnicity who have all fallen victim to the siren call of alcohol but have found their bearing again. Fifth, alcoholism is a lifelong disease, similar to diabetes. These people don’t say that they used to be an alcoholic; they still are alcoholics, even though they’ve been sober for 20-30 years. They’re still dealing with their disease, in much the same way a diabetic will always be fighting off diabetes. They’ve just been lucky not to have a relapse in a long time. Sixth, these people treat the program as their religion and apply the principles of the program to every aspect of their life, not just alcohol. They speak of AA’s co-founder Bill’s story similar to gospel (and some even know exactly how many pages certain passages are). The period where Bill faced a multitude of difficulties trying to quit before finally re-emerging a new man sounded strikingly similar to the temptations that Jesus faced before being crucified and coming back to life.

I can imagine AA—like church—to be terrible if it’s forced upon you, but one of the requirements to beginning the program is that you have to be willing to stop drinking. I think that’s essential. You absolutely cannot prescribe AA to someone if they don’t want to quit, because it will be wholly and utterly ineffective.

And I did find out why it was called Amethyst Sunday Morning. Amethyst literally means “not drunken” (think of a- as not and methy- as alcohol) and comes from Greek legend where Bacchus, the god of wine and revelry, got so drunk he was about to harm someone he loved. She was protected by an amethyst gem and Bacchus saw the errors of his drunken ways. It may be an odd name for an AA meeting, but it’s certainly appropriate. I was recommended to hear the stories being shared at another meeting called The Mustard Seed. I can’t wait to find out how it got that name.

First month on rotation

Two weeks ago I switched from psychiatry consult/liaison to inpatient psychiatry.  It felt like starting all over again from scratch, but not in a good way. Instead of being excited and thrilled to try something new, I felt like I was just watching people get work done around me—that is, when I wasn’t in their way.  I feel like switching teams is a little bit like moving apartments.  The basics are all the same (your couch, your desk, your bed, your silverware), but they’re organized differently.  And it takes a certain amount of time before you stop looking like a doofus walking out of the elevator not knowing which direction to turn.

My consult/liaison team consisted of three med students, five residents, two fellows, and one attending.  As each new patient came, he was assigned one resident and one med student, whoever was next up in the queue.  The residents came in with us and watched us as we conducted the interview.  Once we said all we could think of, we glanced at the residents so they could ask all the questions we knew we needed to ask but just forgot to.  We quickly discussed the assessment and plan together, then went off to see the newest consult patient.  We discussed all of our patients as a team over lunch (sometimes after a student-led presentation) then visited them together.  At the end of the day we would write our notes, call collaterals, and set up patient appointments. It was all very safe, encouraging, and structured.

My inpatient psychiatry team consisted of two med students (myself and someone who had already been there for two weeks), one resident, one attending, three nurses, and one social worker.  On my first day, I arrived 30 minutes too early due to a paging fiasco and took the elevator to the eighth floor.  I stepped out and stopped dead in my tracks, looking left and right and left and right, seeing only unlabeled doors and empty offices.  Luckily, a few minutes later another student came and led me down the seemingly convoluted path into the workroom.  I waited about 30 minutes until the resident came in, then waited quite a bit longer because he had nothing for me to do.  He finally found a task that even an unfamiliar, foreign med student could do—get consent from a patient to discuss his care with his sister.  I started in on it, but the patient did not want to sign the release.  And I failed at the one task I had all day long to do.  I felt meager and out of place; the resident must have sensed my defeat because he let me go home at 3pm.  I felt more tired than all the times I stayed in the hospital on consult/liaison until 7pm.

But I got used to it pretty quickly.  But this past Monday I moved again.  I hope it won’t take me very long to figure out the right way to turn after exiting the elevator.