Six Zeroes

TH took HB camping for the night. HB prepared for this by donning a shirt and tie and packing his knitting. Originally I had planned for some wilding on my part, but ...

A few months ago I put in this last-minute grant proposal? That I was not at all hopeful about? That I pretty much only did because my boss told me to?

I’m now the Program Director/Principal Investigator of an educational project that got funded to the tune of 2 million dollars.

$2 MILLION, YO.*

Which is nice.

And in the next TWO WEEKS, I have to:

1. have my usual patient hours
2. write 19 reference letters
3. write evaluations and submit grades for my most recent group of students
4. put on a workshop for a national meeting in a state far, far away
5. sit for my examination for Boards recertification (an every 10 year thing), and, oh yeah,
6. implement this TWO MILLION DOLLAR program (it has to start immediately).

I am not whining, I’m just saying no wilding for me tonight, and I’m guessing no posting for at least the next couple of weeks. (And I’m really, really sorry if my hare-brained scheme means your taxes go up.)

Wish me luck.

I am not afraid I am not afraid I am not afraid I am not afraid ...

*I do not actually get to put my hands on any of the money—not even a tiny little slush fund—so do not expect to see me partying with Paris. I do get a new title and, eventually, 50 percent “protected” time, i.e., time I do not have to spend seeing patients. (Which may be tricky, since I already have 60 percent protected time. Perhaps the patients will have to try to fix MY problems 10 percent of the time?)

More Helpful Hints

How to Sleep Better Without Pills

This is by request. A disclaimer: I don’t think there’s anything wrong with taking over-the-counter sleep aids. Heck, I used to take Benadryl every day as a child during allergy season; it’s not like taking Seconal or something. And drinking alcohol before bed is much worse on your sleep patterns than these kinds of medications. However, there are some relatively easy tricks for sleeping better—with or without medications. Most people know that you should have a quiet, cool, dark, comfortable place to sleep. Here are a few things that you may not know: Don’t watch TV in bed, even if you think it lulls you to sleep. Don’t read in bed if you can’t sleep; get up and sit in a chair. Don’t toss and turn if you can’t sleep; get out of bed and do something boring for a while. If you have a snoring bed partner, get a white noise machine. If your problem is waking up in the middle of the night, trying going to bed a half hour later than usual. And here’s one that many people resist: cover up your clock or turn it to the wall so that you can’t tell what time it when you wake up in the middle of the night. If you check the time, you get anxious, and then you really can’t get back to sleep. Finally, if you are taking something to get to sleep every night and want to stop, you should go cold turkey and expect to have 3-4 rough nights before you’re back to normal.

How To Childproof on the Fly

Releasable zip ties. (I have no idea if that’s a good website, I was just too lazy to get a good picture of them myself.) Discovering these was like finding the internet, only less exciting. With a little imagination, you can use these to fashion a way to keep a toddler out of all kinds of things when you’re in a hotel room, visiting childfree friends, etc. I used to keep a pack of them in my suitcase. I still have one around the knobs of the liquor cabinet. (I figure anyone who’s too drunk to operate the release has probably had enough. There’s plenty of beer in the fridge if you’re that desperate.) They’re also good for managing computer cables, keys … make your own magic!

How To Connect Almost Anything to Almost Anything

Non-releasable zip ties. These made it possible for me to put baby gates on our impossibly narrow stairs (gates that lasted years and endured much abuse without failing, despite my husband’s initial skepticism), and they are astoundingly strong. They also facilitated one of my most ingenious solutions:

How To Keep From Losing Tiny Remote Controls


Is this not cool? You can use anything large and squishy. (Note: I do not advise using a cat. A particularly well-trained dog might suffice.) I started out with rubber bands, but for some reason children must put asunder what a rubber band hath joined together.

How To Put Eye Drops Into Uncooperative Eyes

Some of us could pour a shot of Jim Beam into our eyes, but some—e.g., many children, my husband—blink and squirm and freak out over one or two drops of anything. The trick is simple: lie on one’s back with eyes closed, put the drops in the corner of the eye (making a little pool), and then open the eyes. (Gratuitous doctor’s soapbox proclamation: Antibiotic drops for “pink eye”? 99 percent of the time useless—and occasionally allergic reaction-producing. I know we all grew up doing it, but almost all pink eye—especially if it’s bilateral—is viral, usually a cold virus. And it’s no more or less contagious than a cold.)

How To Stop a Nosebleed

You can find that here—an oldy but bloody goody.

How To Keep Cats from Jumping on Your Head To Wake Up and Feed Them

Cats can understand cause and effect, but only up to a point; too many steps in a process and their fuzzy little heads start to hurt. If upon arising you immediately feed them, they will learn to wake you up, and often in creative ways. If you separate getting up and filling the bowls by more than, say, two steps, they will eventually forget that the two occurrences might be connected.

And finally: a picture in which you can see my own personal stomach-sleeping-preventing bumper:

(Levitating child not included.)

DoctorMama’s Helpful Hints

I’ve been neglecting you. To make up for it, I’ve prepared a real treat for you: a whole bunch of helpful hints and ingenious solutions to problems you didn’t even know you had. If I could patent these, I would, but since I can’t, you’re getting them for free. You’re welcome.

How to Stop Sleeping on Your Stomach
Those of us who stomach sleep tend to get cricks in our necks and sore lower backs. If I spend more than a few minutes doing it, I get a back spasm so bad that I am unable to turn back over, and I’m left to struggle like an upside-down turtle. One solution I’d read about was to sleep with a long pillow next to you on the side you usually turn to. Good in theory, but unless your bed is next to the wall, you’ll just end up with a pillow on the floor. My brilliant solution? Tuck the pillow under the fitted sheet, creating a bumper. It won’t fall out, and when you turn over, you naturally sling your knee over it and stop halfway.

How to Keep a Toddler (or Drunk) from Falling Out of Bed
See How to Stop Sleeping on Your Stomach above! It’s genius, I tell you.

How to Use Decongestant Nasal Spray Without Becoming Addicted
When you have a cold and can’t sleep because you can’t breathe through your nose, use decongestant spray in one nostril only. The next night, you can use it on the other side. Don’t use any during the day. You can keep this up indefinitely.

How to Quit Decongestant Nasal Spray
If you’re already addicted, quit using it on one side. Once that side is more or less back to normal, quit the other side.

How to Avoid Losing Your Child in a Crowd
Or rather, how to find your child after you’ve already lost them in a crowd. All you need is some masking tape and a marker. Put a strip of tape across the child’s upper back and write on it: IF FOUND CALL [cell number]. My son adds: tell your child to approach either a Person In Charge or someone who also has kids.

How to Clean Out a Stainless Steel Carafe or Thermos When You Can’t Reach Your Hand In
Put a Brillo™-type pad and some water in there, put the lid on, and shake it like a hurricane.

How to Fix Yellow Toenails
If you wear pink or red toenail polish, you may have noticed that they leave your toenails stained yellow. I searched for years for a cure, and finally discovered that the clear polishes that have names like Yellow Out actually work. Duh.

How to Keep Noisy Toys from Driving You Nuts
Put clear packing tape over the speaker holes. Several layers if necessary. Kids’ hearing is way better than ours; they don’t mind at all, and it makes life so much more bearable. (This trick is not my own invention; I learned from another cranky old parent.)

How to Keep Your Ice Cubes from Getting Smelly
Because I’m sorry, baking soda just doesn’t work. Charcoal odor absorbers, however, do. Drop one directly into your ice bin and voilà.

How to Cure Diaper Rash Quickly and Cheaply
Most diaper rash is at least partly due to candida (yeast). Buy a (store-brand) tube of vaginal yeast cream (throw away the applicators that come with it). It’s good as prescription cream; clears it up in, like, 12 hours. Works on athlete’s foot, too. We call it Toe-Butt-Vagina Cream.

How to Stop Picking at Your Face (Or at Least Cut Down)
Put 25-watt light bulbs in your bathroom.

How to Soothe a Sore Throat
Suck on a baby aspirin. (Do NOT let children do this.)

How to Keep A Cat From Shredding Your Furniture (Besides Declawing)
Keep its front nails clipped. A regular nail clipper works fine. You’ll probably need a second person to do the cat holding, but it’s not as hard as you’d think—nothing like trying to pill a cat.

How to Get Children to Behave
I have no frickin idea.

Bitch, Doctor, or Normal?

There’s something I want to get off my chest, at the risk of offending some. It’s this: I really don’t like reading blog entries (or Facebook updates) about people being sick. Wait wait wait—I don’t mean terrible illnesses, or hilarious entries about horrendous plagues that necessitate HazMat cleanups, or updates on, say, surgical procedures that others are concerned about. I mean the “I have a cold / stomach bug,” “I still have a cold / stomach bug,” “I’m over my cold / stomach bug” entries.

Wait wait wait—I love you! I care that you’re not feeling well! I’m sure I’ve done it myself! I welcome your medical questions to me, truly! I thought your last entry about that awful situation was funny!—I just don’t like it when I’m expecting to read, well, something else and instead have to read about run-of-the-nose snot.

Is this because I’m

a) an unsympathetic bitch
b) a doctor or
c) normal?

Opinions?

The Problem with Lists (Updated)

A while back, I made mention of doctors’ dread of lists. Now, I love a good list. I make them all the time. For example, here is a list I made for one weekend day last month. (And I wonder why I feel pressed for time. The ones on the side, by the way, were the “possible if I magically morph into a superhero,” so I don’t feel too bad about all the blank boxes. I’m not sure why “side tables” merited an exclamation point, unless it was because I was unlikely to attend to them, as evidenced by the glaringly unchecked box next to that item. And yes, Aaron did come.)

I don’t mind most patient lists either. A list like this one is quite helpful.

But. A list like this one will give any clinician an overwhelming sense of being sucked into a vortex of negative energy. I have removed anything that might identify this patient in any way, but I will tell you that this patient is in their 20’s and is remarkably healthy, despite having had these symptoms for years.

Healthy, but not well. When you see a list like this, you know that you are about to embark upon one of the least satisfying clinical relationships in the world. Because this is a person who, for some reason, must be a Patient. This is a person who has no interest in being well, because they feel so rewarded by being sick. Why? I have no idea. Personally, I find being a Patient absolutely horrifying; I will deny that I need help until I am lying on the floor, and even then I’ll refuse to go to the ER.

Wanting to be a Patient has no relationship to how sick you are. I have one patient with a terrible neuromuscular condition who comes to my office on a ventilator, in a motorized wheelchair that he steers with the one finger he can still move a tiny bit. When I ask him how he’s doing, he has to wait for a puff from the vent to answer, “Great!” (I doubt my aversion to being a Patient would take me quite that far, but I like to think it would.)

It’s very hard not to take these list-writers by the shoulders, shake them, and shout “Get a life!” Maybe I should, because what I do—nod sympathetically, gently suggest exercise and possibly antidepressants, and try my best to avoid the unnecessary testing that will involve random false positive results that will then engender more testing—doesn’t seem to help much.

It seems a miserable kind of life, but then again, how would I know? Perhaps this feels like fun for them. Perhaps what they need is a Patient Theme Park: giant stuffed medical personnel walking around and giving injections, an MRI Tunnel (with Realistic Banging Noises!), a 24-Hour Urine Collection Log Slide, lots and lots of blood draw concession stands, a place to pose for overpriced photos of yourself that make it look like you’re intubated, and people hawking baseball caps emblazoned with Another Sufferer of A Really Rare Disease Whose Doctor Totally Dropped the Ball* and t-shirts that read I MAY LOOK FINE, BUT I KNOW MY BODY.

*Not that this does not ever happen, OF COURSE. I have dropped a few balls myself. However, most bad things will “declare themselves,” as we say; they get worse and become diagnosable. Not-bad things usually go away, and the less you test for, the better off you will be. As I teach my residents, “follow” is not a dirty word.

UPDATE: To all who are saddened/angered by this, let me say a few more things:

• There are many, many crappy doctors, I know. Believe me, I know. I do not excuse any of them. They’ve messed me up too.
• Most of us have had frightening, unexplainable symptoms at some time or another. That doesn’t make us Patients.
• Yes, most people just want someone to listen carefully and, if appropriate, reassure. I love listening to people, watching them, finding out what it is that frightens them about their symptoms. I’m not talking about those people here. I’m not talking about you here.
• There are a few diseases that have multiple seemingly unrelated symptoms that can be overlooked. I test for these where appropriate. That patient who wrote the list? Had had multiple tests already.
• These folks can get sick too, and that’s frightening, because they do fall victim to the crying-wolf problem. It’s part of what makes them so tough as patients.
• There are also, I am quite sure, many diseases that we cannot yet diagnose no matter how many tests we do. We doctors must remain humble about this.
• And know this: if you’re suffering, I wish I could help you.

What I Really Think

A couple of weeks ago during office hours, I saw a particular name on a chart, and my heart sank. This is a patient who sucks up an inordinate amount of my time every time she comes in, and to no discernible benefit to anyone. She has severe hypertension, for which she is on medication, and she obsesses about it. She takes her pressure three times a day, documents it each time, and brings the list in to convince me that she doesn’t really need blood pressure medication. Thing is, her numbers don’t even look very good. She doesn’t want to stop her medicine – I’ve told her that she is of course the boss of herself and doesn’t have to take my advice – no, she wants me to tell her to stop.

I sighed heavily to myself, then went into the room. And as I was sitting down to talk to her, she handed this article to me. Uh-oh, I thought, here we go.

My patient had circled one of the statements from the article:

I know that Reader’s Digest recommends bringing in a complete list of all your symptoms, but every time you do, it only reinforces my desire to quit this profession.

And I’m thinking, How am I going to get out of this one? Because I absolutely do feel that way. Then my patient says, “I read that, and I thought, That’s me! I bet that’s what DoctorMama thinks! So you know what? I didn’t bring any notes with me! And I stopped taking my blood pressure all the time – and you know what? I feel so much less stressed!”

And we had a really pleasant visit; she even hugged me on the way out.

Naturally I was curious to read the rest of the article, but I found that while I did agree with some of it, most of it didn’t resonate with me at all.

Here’s some of the things I have to admit I do agree with:

The most unsettling thing for a physician is when the patient doesn’t trust you or believe you.

“Unsettling” is the right word for this (though not necessarily “the most”). It doesn’t make me mad, it doesn’t make me insecure – I just don’t know where to go once I realize that a patient thinks that I’m full of it. Usually I just back off and say, “I can only tell you what I recommend; what you decide is up to you.”

It saddens me that my lifelong enjoyment and enthusiasm for medicine has all but died. I have watched reimbursement shrink, while overhead has more than doubled. I’ve been forced to take on more patients. I work 12- to 14-hour days and come in on weekends. It’s still the most amazing job in the world, but I am exhausted all the time.

Yup.

At least a third of what doctors decide is fairly arbitrary.

Absolutely. But I usually let patients know this right up front.

Most of us haven’t been to see our own physicians in five years.

Quite true, but not just because we don’t practice what we preach. People mostly shouldn’t go to doctors as often as they do. I never lecture a patient who is essentially healthy about not coming in more often. Every visit is an opportunity for iatrogenesis, really. And most screening is overrated. Doctors screen folks a lot more often than the data say they should, partly to avoid having to argue about it and partly to avoid being sued for it.

In many ways, doctors are held to an unrealistic standard. We are never, ever allowed to make a mistake. I don’t know anybody who can live that way.

Yup.

Sometimes it’s easier for a doctor to write a prescription for a medicine than to explain why the patient doesn’t need it.

Kind of true, but not stated correctly. What it should say is, Sometimes it’s easier for a doctor to write a prescription for a medicine that won’t work than to explain why it won’t.

Some of the statements seemed neither here nor there to me – such as:

Those so-called free medication samples of the newest and most expensive drugs may not be the best or safest.

Well, duh – I hope that most doctors are telling their patients this!

In many hospitals, the length of the white coat is related to the length of training. Medical students wear the shortest coats.

This is not a secret, is it? Medical students identify themselves as such, in my experience.

But most of the stuff in the article I could not relate to at all. For instance:

Not a day goes by when I don’t think about the potential for being sued. It makes me give patients a lot of unnecessary tests that are potentially harmful, just so I don’t miss an injury or problem that comes back to haunt me in the form of a lawsuit.

I would say the potential for being sued crosses my mind maybe twice a month, max. I long ago realized that the thing you get sued for is never the thing that you would have avoided had you been thinking about being sued.

It’s pretty common for doctors to talk about their patients and make judgments, particularly about their appearance.

No, not particularly about their appearance – about their personalities, yes.

In most branches of medicine, we deal more commonly with old people. So we become much more enthusiastic when a young person comes along. We have more in common with and are more attracted to him or her. Doctors have a limited amount of time, so the younger and more attractive you are, the more likely you are to get more of our time.

I feel almost the exact opposite. I am much more impatient with and bored by people who seem a lot like me. I love the crazy old coots – I could talk to them all day. (And “attracted to”? Um, eww.)

Doctors are only interested in whether they are inconvenienced—most don’t care if you have to wait for them.

What an awful view of the rest of the world this person must have. This is far, far from the truth in my experience.

When a doctor tells you to lose 15 to 20 pounds, what he really means is you need to lose 50.

Huh? Why would you do this? I don’t tend to talk in absolute numbers anyway, because a healthy weight for one person is different from that for another of the same height, but if a patient asks me how much they should lose to improve their health, I’ll give them an honest estimation.

Ninety-four percent of doctors take gifts from drug companies, even though research has shown that these gifts bias our clinical decision making.

and

Doctors often make patients wait while they listen to sales pitches from drug reps.

Long ago I took the No Free Lunch Pledge, and I’ve stuck to it. I don’t take stuff, and I don’t talk to drug reps. I made this decision when I realized that everyone thinks they’re the one who isn’t influenced by such things, and yet studies show everyone is. Why should I think I’m special?

Overall I think the article probably caused more harm than good. But maybe it will inspire a few more doctors to take the pledge. And I’m sure glad my patient read it.

P.S. Now that you know what I really think, you can go here for a (flattering) idea of what I’m really like.

Bikini 'n' Snake

Now that I’ve drawn you in with that title, I will take advantage of your attention to complain:

I once read somewhere that a lot of working women say that a good thing about working is that even if things aren’t going great at work, there’s always home to escape to, and vice versa. But what about when nothing seems to being going right anywhere?

I used to love my job. Adore it. But for the past year or so, I often hate it. I really don’t know what to do about this. Today I had my first (near) panic attack in years. I just got back from vacation to get some very bad news at work. Then today I was busy busy busy and got to the cafeteria just before it closed, only to discover that they were out of grilled cheese sandwiches, OH MY GOD, NO GRILLED CHEESE, and there was nothing else I wanted to eat … and suddenly I felt like I just couldn’t take it. And I don’t even particularly like grilled cheese sandwiches.

Then there’s home. Something I haven’t blogged about at all because I really hate to whine about him is TrophyHusband’s relatively recent obsession with cycling. LATELY ALL HE THINKS ABOUT IS HIS FUCKING BIKE(S), there, I’ve said it.

Then there’s HellBoy being hellish. While he was out sick, his usual bud Justin started playing with Jack instead, and now they won’t play with HB, which makes HB come home in a fouler mood than usual, which, trust me, is saying a lot. He is so ill-tempered, this kid.

Then there’s BadCat, who has escalated from peeing on things that are not his litterbox whenever he’s mad to defecating on things that are also not in the litterbox category. He is also half blind now and looks like he’s giving you the evil eye all the time:



So it feels like everything kind of sucks. Many nights I fantasize about checking into a hotel all alone.

Do you still want to see me in a bikini holding a snake? Here you go:


Proof of the mysterious unpredictability of phobias. I know, I’m wearing the same dumb shirt and hat as in last year’s picture. Same bikini too. At least HB got upgraded to a Superman suit. And even if everything is falling down around my ears, baby’s got back.

Me and My Big Head

Being a physician is for the most part a humbling experience. You think you’ve figured out the key to helping a patient control her hypertension, and the next week she gets admitted to the hospital with a pressure of 230/110. You don’t even think of asking the sweet grandmother about substance use, and she has a stroke from smoking crack. You reassure a chronically complaining patient that her shortness of breath is nothing to worry about, then find out that her oxygen level is low enough to qualify her for home oxygen. I shouldn’t be using the second person; I did all of these things.

But every now and then, you—I—hit one out of the park and feel like a freakin’ genius.

The other day, another attending was supervising the medical residents in the outpatient office when she pulled me away from my own charts.

“You like Derm stuff,” she said. “Maybe you can figure this out.” It was a very young woman who had what the attending and the residents thought looked like bad psoriasis—but it had happened very quickly and in some unusual areas, including in the places where she’d irritated her legs by shaving them dry.

I swept into the room, which was now filled with several residents, a student, and the poor girl, who was sitting on the table clad only in a gown. A red, angry-looking, scaly rash was spread over her elbows, her wrists, her abdomen, her knees, and down her shins. In many places, the rash was in the form of small round patches.

“Mm-hmm.” I said. “Tell me: did you recently have strep throat?”

“Last month!” she said, her eyes widening. The residents literally gasped. “It was culture-proven,” one of the residents said.

“Yep, that’s it,” I said.

“What?” they all asked.

“Guttate psoriasis,” I tossed off casually. “Happens after a strep infection. What’s on the legs is the Koebner phenomenon.”

Now they think I’m The One.

I won’t tell them just yet about the guy I said could go home who went to the ER instead and ended up in the ICU, intubated, in a hypothyroid coma.

Under the Wire

A few weeks ago, I was chatting with one of my very first Maggots, someone I ranked up near the top of my Successes list, when she said something that made my blood run cold:

“So I’ve been running regularly for a year and a half now, and I never want to stop … even though I’m no good at it.”

“Say what?”

“I just kind of suck at running. I still can’t run for the whole half hour.”

I was stunned. Here I thought I’d taught her so well, and she’d been ignoring my second edict:

Everyone makes the same mistake when starting out: going too fast. When you start, you need to go SLOWLY. So slowly that you could probably walk faster. So slowly that you will feel humiliated if you see anyone you know.

“You idiot! You’re going too fast!” I said. She looked skeptical. So I slapped her upside the head and told her to start doing it right. And now she can run the whole half hour.

She’s a stubborn sort, but it made me realize that I must not have emphasized this point enough.

SLOW DOWN.

IF YOU CAN WALK YOU CAN RUN, AS LONG AS YOU’RE GOING SLOWLY ENOUGH.

Am I making myself clear?

Someone asked if I ever get in a slump, and the answer is, of course – especially during the winter, and especially if I’ve been sick and off my schedule. The one and only solution is to put on my shoes and get my ass out the door. Once I’ve got that first run in, the next one is exponentially less painful. So far this winter it’s happened twice in a row, and it was really annoying to have essentially wasted my first couple of getting back to it runs.

I really hate winter.

Christmas was okay. We had it here for the first time ever, and it was less onerous than I expected to put up a tree. HellBoy was pretty angelic, for him. Chanukah probably helped soften him up. (Yes, we do both. And by “we” I mean me and the rat in my pocket.) My stepdad did crack everyone up when he declared that he’d found HB’s theme song: Tom Petty’s “I Won’t Back Down.” HB himself agrees that it’s appropriate, and learned the words after hearing it twice – not that the lyrics are particularly complicated. (Petty doesn’t seem nearly as convincing singing it as HB does.) (Get this: lately HB’s been staying up later than we do. We tell him to stop jumping on our heads and go play in his room, and he goes … somewhere. Not for very long, and he can’t unlatch the gate to the downstairs, so I don’t think he can do much harm.)

My folks came here, which was pretty nice. My parents don’t usually push my buttons, partly because I’m a tad insensitive and my mother is a tad ... vague. However, my mother does have this way of looking at me that I know means “I’m worried you’re too busy.” I know the look means this because from time to time she actually says “I’m worried you’re too busy” when she looks at me that way. And I am, but – where to trim things down?

Here’s a start: we hired a new physician who starts this month, and I gave myself a 20% lighter clinic schedule. I didn’t exactly get permission to cut back my schedule, so we’ll see how long it takes before my bosses notice. Then we’ll see what I’ll do if anyone does notice …

Here’s to less guilt in 2008.

Picky, Picky

It’s been a while since I’ve done an advice post. So, inspired by a few inquiries from friends, I bring you the following public service post.

Are you a face picker? Are you obsessed with removing every little imperfection in your complexion? Do you spend a half hour at a time sequestered in the bathroom, up against the mirror, scanning every inch of your skin, imagining defects if you can’t actually see them? Do you inevitably make things worse, leaving yourself with an angry bleeding crater where there was nothing before but a slightly tender little bump? Do you promise yourself you’ll never do this again, only to be back at it the very next day?

I’m here to help.

I’ve known a lot of you. Under times of stress, I’ve joined your ranks. I’ve see many patients, almost always young women, with the telltale red marks fanning out across their cheeks. It’s never their reason for the doctor visit, and I know how painful it is for them when I bring it up, uncovering their shame. But there are things that can help you, if not stop, at least minimize the carnage.

Rules to Pick By

• Don’t think you’ll be able to stop through willpower alone. Habits like this—nail biting, hair twirling, face picking—are notoriously hard to break that way, at least in the long term. You need a strategy.
• The simplest trick of all, yet the one that is most resisted: Wherever it is that you’re doing it, switch the light bulb for one of exceedingly low wattage. When you can’t see the “problems,” one of the triggers is gone. Stop arguing about this one. Just try it. You can always switch the stupid bulbs back again.
• Get a face care regimen, and stick with it. It doesn’t really matter much which one. Most of them are based on one of four ingredients: benzoyl peroxide, retinoids, antibiotics, or salicylic acid. Some are over the counter, some are prescription. They all work ok, but none of them work overnight. You need to give a product at least a month to see if it agrees with you. (This is probably why the Pr0@ctiv system is successful. Although it’s just benzoyl peroxide, it gets you to buy into the regular use for a month thing. You can get similar “systems” for much less at the drugstore.)
• Consider investing in one of those electric pimple-zappers. These are pricey, but can be worth it. They ostensibly work by heating the blemish, and are meant to be used on the deep painful kind of blemish. This may or may not be effective at curing the pimple, but is definitely effective at hurting like hell. This is psychologically quite useful, because it gives you something serious to do. Take that! You can think as you hear the zap and feel the pain. If you can transfer your compulsion from picking—which is especially counterproductive with this kind of pimple—to zapping, you may be able to short-circuit the impulse to try and “fix” it by squeezing.
• When a pimple is healing—whether you picked at it or not—it usually flakes. Do NOT pick at these flakes with your filthy fingernails. Get a flat-tipped tweezer, and remove the dead skin with those. And don’t peel the skin back—pull forward, to pull off just the dead part. Scraping at the skin with your fingernails will grind bacteria in, and then you’ll get all sorts of nastiness.
• In fact, never scrape at your skin with your fingernails ever. If you end up with a blemish that MUST be manually removed—you know the ones I’m talking about, the kind that you avert your eyes from if you spot one on a stranger and wonder how on earth their loved one let them leave the house like that—do NOT pick at it with your fingernails. Use a washcloth, a cotton pad, almost anything but your fingernails.
• If you should end up with something on your face that is bleeding—which should only happen if you’ve ignored one or more of the instructions above, but whatever—I have a neat trick for stopping the bleeding in time for you to get to work. Remember how I said you should never use decongestant nasal spray for decongesting, but you can use it for a nosebleed? Well, you can also use it for other kinds of bleeding. A few drops on a bleeding wound constricts the blood vessels and stops the hemorrhage.
• Never use antibiotic ointments on any wound, but especially not on the face. About a third of folks who use these for any length of time develop a contact allergy to them, and the result looks just like an infection. So you keep putting the ointment on, and make the allergy worse, and put even more on, etc. … plain Vaseline is good for wounds, but use sparingly on your face, since if you spread it around, it’ll make you break out more. A tiny dab will help keep a lesion from looking quite so crusty.
• When you need camouflage, Dermablend is amazing stuff. Unfortunately it’s almost impossible to figure out which shade is best for you on line, which really sucks. If you can find a store that sells it, that’s probably the best way to find out, but I’ve never had the guts to approach one of those white-coated cosmetics ladies at the department stores myself. I’m not sure what I’m afraid of, but it has something to do with the thought of someone peering at my skin under bright lights and then gasping in horror. My skin is ok, but they’re paid to make you think your skin is only fit for a freak show.
• Try to remember that the vast majority of blemishes do not contain anything that has to come out. Yes, there is the odd whitehead or blackhead that can be easily removed, and very rarely an exceedingly ripe pustule that can be released, but most of the time, thinking that there’s something there that you can get out and thereby fix the problem is the path to madness, and to the wreck of a perfectly nice complexion.

On Is Better

I recently had a nice demonstration of the difference between being On an SSRI and being Off.

Some six years ago, while I was Off, TrophyHusband and I moved into our first house. It was 200 years old, but had just been completely renovated. Which is how I knew that the wee baby cockroach creeping across the floor toward me when I got up to pee in the middle of the night had been imported from our prior residence, a slum of an apartment building—actually, from the basement, where we had been storing our boxed wedding gifts next to the leaky pipes and bare wires.

Bugs—especially spiders and cockroaches—being one of my phobias, I felt a bit woozy, but I talked myself through the squishing and flushing of the little fellow. I felt a little worse when I spotted #2, but I handled it. As I did with #3, #4, #5, and #6. At this point I was sweating, nauseated, and lightheaded, but I was keeping it together. A few tiny cockroaches weren’t going to hurt me!

Then I turned around and saw—the mother. This one was the size of a small mouse. I could hear the noise her legs made as she moved. She was moving pretty slowly, too—almost as if she knew I was too phobic to be a threat. There was no way I could squish this one. This one would crunch, and she might put up a fight.

I tried. I got around her and made it to the vacuum cleaner. Genius! I wouldn’t have to touch or hear a thing! But as I neared, hose in hand, she perked up and … scooted under the door into our bedroom, where TH lay sleeping on the mattress, which was lying on the floor. Surrounded by heaps of half-emptied boxes.

I lost my mind. I flung open the door, turned on the lights, jumped onto the bed and started sobbing and yelling. Poor TH leapt up, naked and disoriented. Finally he understood what was going on.

“Don’t worry, I’ll kill it!” he said.

“You’ll never find it!” I wailed.

He banged around, shoving boxes this way and that, and finally uncovered it and beat it to death with a shoe.

I started crying harder.

“What’s wrong? I got it!” he said.

“But I know there are moooore,” I sobbed.

That night TH had to feed me sedatives to get me to go back to sleep. The next day I began feverish research into how to eliminate cockroaches. The two most important things: 1. You cannot starve cockroaches. Even if you could remove every speck of food in every crevice of your house, they can survive on soap and candles. But you can drive them away by cutting off any access to water. Fix any dripping faucets (we had one), then plug all the drains every night. Leave no open water around, such as glasses of water by the bed. (Aaagh!) 2. They adore corrugated cardboard. They slip into those little tunnels and stay there all cozy until the lights go off.

I have never unpacked so fast in my life. I also trained myself to sleep through the night for the first time ever. I fixed the problem, but I had the heebie-jeebies for months.

Last week, it became clear to me that one of our rowhouse neighbors had brought in an exterminator and driven their roaches west. I knew this because one morning I saw one cockroach on our kitchen floor, then another on the bathroom floor, and finally one clinging to the back of my son’s t-shirt. But now, I am On an SSRI. Now, I was able to dispatch them all while hardly breaking a sweat, and when I didn’t have time to get all the plugs I needed to seal off all of our drains that day, I was able to wait another couple of days without any particular mental distress. I didn’t like it when I went downstairs in the middle of the night and disturbed two black shiny Hummers of the roach world—seriously, they were so big, you could see under them when they walked; if they were SUVs, they’d have really bad rollover statistics—but I didn’t freak out. (Where do those really big ones hide out during the day, anyway? They can’t fit into any of the crevices I’m aware of.)

Don’t worry, we’re on top of it now. You can come over and nothing nasty will leap out at you, aside from BadCat, who has conjunctivitis in his right eye and looks like an extra from a horror movie. But that’s a story for another day. Anyway, On is definitely better.

I'm Here, Sort Of

The last time I was this frantic was when I was a resident in the ICU. I considered abandoning blogging, but I really don’t want to. I know I keep saying this, but please hang in there while I try to regain my balance. In the meantime, here’s an update:

Good news: I fired the temp assistant
Bad news: my old assistant still hasn’t come back, and it’s looking increasingly unlikely that she ever will
Good news: two of my associates in the outpatient offices had babies
Bad news: there is no one but me to fill in at the outpatient offices
Good news: I got a raise and a bonus
Bad news: I was given an offer I couldn’t refuse to take over as Medical Director of my outpatient office
Good news: I was relieved of several detested duties
Bad news: I have four months’ worth of unfinished work to get through
Good news: my parents are coming for the weekend
Bad news: TH is going away for the weekend
Good news: HB had a tiny growth spurt and grew out of his 2T overalls in time for his upcoming third birthday
Bad news: Nana is still convinced we’re starving him
Uncategorized: HB weaned himself (without ever learning any words for breasts)

I feel like I’m at a dead run from the time I wake up until I slide into bed, and sometimes all night long. But overall it’s a reasonably good busy.

And now I’m late for a meeting.

Two Medical Truths

Hearing stories like Snickollet’s makes everyone—including me—nervous. What if what happened to her husband happens to me? we ask. And then: How can I make sure that doesn’t happen to me?

The short answer is, you can’t. When someone comes come to me and says “I want to be tested for everything,” I try to explain that most dread diseases can’t be “caught early” and that it’s actually dangerous to be tested for things you’re not at high risk for, but I know that this isn’t reassuring.

The truth is scary. The truth is that any of us, no matter how healthy our lifestyle, can be struck down by something awful at any time. Most of us won’t, but there are no guarantees.

There are really only two things you can do to vastly increase your chances of living a long and healthy life, and neither of them is something that I can order a test or write a prescription for. Nor will they make the cover of any magazine. They are:

1. Don’t smoke

and

2. ALWAYS buckle your seatbelt.

I’m not saying that you shouldn’t exercise, eat healthfully, wear sunscreen, get a Pap smear, or be checked for high blood pressure. But honestly, worrying about any of those things when you haven’t taken care of the first two is like worrying about whether your underwear is clean while you’re stepping in front of a bus. (As for worrying about any of the latest health fads—don’t get me started.)

My advice? Do what you can to keep yourself safe and whole; do your best not to fret about what can’t be foreseen or prevented; and savor your time on this earth.

Why Ask Why?

Humans are wired to constantly search for causes for (and solutions to) every problem. This is probably our most useful adaptation, but it can lead to certain difficulties, especially for doctors.

Take flu shots, for example. It has been shown conclusively that flu shots do not give you the flu. (They couldn’t give you the flu due to the way they’re designed, but people went and did studies on it anyway.) Yet there are many people out there who swear that flu shots give you the flu. Why?

Flu shots are given during cold and flu season. A certain number of people will come down with an upper respiratory infection in any given week. If one of those people happened to get their flu shot that week, it’s easy to see why they would assume that the shot was to blame. Forever after, they will attest that flu shots give you the flu—and will probably convince a few other people of the same. Trying to argue against this is nearly futile. I attempt a preemptive strike with every flu shot I give, telling them that the shot won’t fully protect them for about two weeks, so they could still catch the flu in that time, but I’m not sure how well this works.

Trying to bring on labor is another example. Studies have shown that NOTHING works to bring on labor, with the exception of the drugs used for formal induction in the medical setting. Castor oil? Doesn’t work. Having lots of sex? Doesn’t work. Scrubbing the floor on hands and knees? Doesn’t work. Nipple stimulation? Doesn’t work. Acupuncture? Doesn’t work. Ankle massage? Doesn’t work. Walking/jumping? Doesn’t work. Stripping the membranes? Doesn’t work. Primrose oil? Doesn’t work. Raspberry tea? Doesn’t work. And so on and so forth.

But wait! I can hear a lot of you (probably most of you) thinking. My doctor recommended having sex, and it worked for me! My best friend used castor oil, and it worked for her! My midwife swears that several of her patients have gone into labor after drinking raspberry tea! I know these things work!

But think about it. No matter what, every pregnant woman eventually goes into labor. And whatever thing she did just beforehand will always be credited with doing the trick. Therefore of course all of these things have “worked” for some people. But when they’ve been formally studied—having fifty pregnant women do nothing while another fifty twiddle their nipples, for instance—the rate at which they go into labor is exactly the same.*

Birth defects are yet another example. I was talking with a pregnant friend recently about how nutty everybody gets about pregnant women doing anything—taking medications, drinking coffee, having a little alcohol, lying on their backs. This hysteria seems to be getting worse and worse. Partly this is just part of the whole trend toward fetishizing pregnancy, I believe, but partly it’s because of the way birth defects occur. There are only a few things that are known to cause terrible birth defects—thalidomide, oral isotretinoin, and a couple other uncommon things—but even if you don’t have exposure to one of those, there is a 2-3% risk of major birth defects. And when one of these spontaneous defects happens, of course everyone starts wondering what caused it, and remembering every cold tablet and cup of coffee and hot bath they took during pregnancy. If you do a retrospective study looking at birth defects, the mothers of babies with defects always remember more exposures to everything than the mothers of healthy infants. But if you do a prospective study, following people through their pregnancies and documenting exposures, there’s no difference between those in which defects occur and those in which they don’t.

If something happens often enough—a colicky baby being fussy, for instance—it’s easier to figure out (by trying a lot of things that don’t consistently work) that nothing you do causes it or cures it, and it just needs to be waited out. Relatively rare things that can occur randomly (getting pregnant, birth defects, most cancers) or that inevitably end with time (pregnancy, a chest cold) are the things that really lend themselves to myth-making about causes and solutions.

The belief that every phenomenon can be explained and every problem solved is a wonderful thing much of the time. It’s great when someone with diabetes understands that eating carbohydrates causes their blood sugar to rise or that taking their medicine brings it under control. But it’s frustrating when someone can’t accept that doctors don’t have the solutions to everything. (The doctors who can’t accept that—and there are many—are even more frustrating.)

I wish I had a better way of explaining this to patients. Sometimes when people ask me “Why did I get this disease?” I’ll answer, “Just bad luck,” and they look at me like I’m crazy. I suppose if I were religious, I could answer, “Only God knows the reason,” but 1) I’m not, 2) my patients might not be either, and 3) even if they are, it could be an annoying thing to hear (“I’m sure God has a reason for why you had this miscarriage!”).

How do you deal with things that can’t be explained?

*UPDATE: OK, I should know better than to use an inflammatory example such as this. I say the following in a comment below, but I’ll add it here too: the induction of labor example was meant mostly as an example of a perfect setup for fallacious beliefs to take hold. Yes, there are studies here and there that suggest that a couple of these things might increase the odds a little bit of delivering earlier (though several of those studies were actually done in conjunction with oxytocin, so I’m not sure that you can count them). But having looked at the evidence, I’m standing by my assertion that none of those things is worth having anyone put themselves out in any way to do, because if they work at all, the effect is teeny-tiny. Remember, negative studies mostly don’t get published, so if there are a few weakly positive studies—or positive weak studies—chances are very good that there are at least a few unpublished negative studies.

I’m not saying that everyone should be induced medically by any means; I think too many people get induced as it is, and if we just waited until babies were done gestating we’d have fewer c-sections. I also think childbirth has been overmedicalized in general—I even think that the evidence supports the superiority of (supervised) homebirth in multiparous women. But the things that I see heavily pregnant women doing to try and bring on labor just seem miserable, and the amount of advice they get about it could give anyone a headache. (Which doesn’t help bring on labor either.)

And yes, I’m having a wretched day, and week for that matter.

I’ll Show You a “Little Pinch”!

You might be surprised to learn that medical professionals are some of the most needle-phobic people around. You should hear the whining in the line for the flu shots every year: “Which nurse looks like she hurts you the least?” “Is it a big needle?” “I hope I don’t faint!” Not to mention the ones who just avoid their shots. “But don’t you have to stick needles in people all the time?” you may be wondering. Well, yes. Into other people. Most (though not all) needle phobics don’t have too much trouble with a stranger’s blood or pain; it’s our own we’re concerned with. I have an (untested) theory that needle phobics may in fact be drawn to medical careers; there’s an aspect of phobia that involves deep interest in the object of fear. It’s invested with such power in your mind that it becomes fascinating.

There are different broad types of needle phobia (that site I just linked to is pretty good, by the way); I had a combination of the two most common, vasovagal and associative. The vasovagal type involves the symptoms typically associated with phobias: nausea, rapid heart rate, sweating, and a drop in blood pressure, resulting in lightheadedness and even fainting. A tendency toward becoming vasovagal seems to be just the way some of us are made, and usually we have more than one phobia to contend with. (A couple other phobias of mine are spiders and phones. I did have a fear of public speaking, but overcame this in quite a different fashion — maybe I'll tell that story too one day. Snakes, heights, and mice bother me not at all, so you never can tell.)

“Associative” needle phobia usually develops from an unpleasant experience with needles in childhood (whether your own trauma or something you witnessed). Mine probably started when I had two separate episodes of scarlet fever that necessitated very large injections of penicillin into my butt. They held me down while I screamed and fought. (Not the best way to go about it, one would think; I hope this isn’t a typical pediatric procedure anymore.)

From then on, anytime I knew in advance that I was going to have to get a needle of any kind, I would live in anxiety for days. Those who suffer from needle phobia often avoid necessary medical testing and treatment (some avoid pregnancy solely for this reason). I usually made it through, but not always, and I definitely delayed my infertility workup due to this. I vividly remember the days before my first bloodwork, wondering how I was ever going to be able to get through ART. That blood draw went ok, but the relief I felt after it was “It’s over with! Never again!” rather than “That wasn’t so bad!”

The first time I had to have an injection at home, I premedicated with an anxiolytic (the good stuff), but I was still so tense that I put my husband through a good half hour of “OK! — No, wait! Wait! — OK! No no no!” It ended with me in tears, though the injection was eventually administered.

Then I learned the first trick that helped me. It’s a simple technique for overcoming vasovagal reactions. Most people make the mistake of trying to relax as much as possible before and during the experience, but it turns out this makes things worse, because it allows your blood pressure to plummet, and makes your symptoms more severe. Whereas if you cross your legs hard and clench your fist on the side opposite the injection or blood draw, you help maintain your blood pressure, and then you don’t feel woozy, and the cycle can be (temporarily) halted. (Take care not to make it look like you are about to punch the phlebotomist; they can be touchy about this. I actually pinch my thumb really hard between my other fingers, and scrunch up my toes.)

The next trick I learned was visualization. Most people have categories of pain: some pain is ok, some is scary, and some is actually good. Everyone’s different, of course, but some examples of good pain might be: tweezing a stray hair; lancing a boil; popping a pimple; getting a tattoo; bikini waxing; digging out a splinter; having a newborn latch on to tender nipples … you get the idea: sudden pain that serves a worthy purpose. If you can pretend that the needle stick is actually one of the “good” pains, it seems to hurt much less.

The technique I learned that was most helpful for the “associative” part of the phobia was re-associating the procedure with something good instead of bad. What helped me the most for this was focusing on the goal: a baby. At the last infertility clinic I went to, they had pictures of patients’ babies up on the wall facing you as you had your blood drawn. Some people were offended by this, but if I could find a really cute one and focus on it, it went much better: it’s for a baby! Ouch! Not so bad!

A technique that helped with both aspects of my phobia was distraction. When my husband had to give me deep intramuscular injections of progesterone in oil—with the BIG needles—he developed what I called his “patter”: he would think of an interesting story to tell me, and right when it was getting to the good part, WHAM! he’d stick me. Sometimes he’d forget to talk (an amazing lapse, if you know my husband), and I’d have to yell “Patter! Patter!” as I lay on the bed with my pants down.

And finally, a great treatment for most phobias is habituation. This can be hard to achieve with needle phobias—playing with needles is not generally practical or savory. But infertility treatment was just what the doctor ordered, ha ha. Intramuscular injections daily—hell, twice daily, why not? Blood draws, let’s see—let’s do them every other day, just in case! It’s not clear why habituation works, but after a few days of this, most phobic people just chill out. (You will rarely see a really ill needle phobic in the hospital. Rather, you will see them, but you won’t realize they were ever phobic.)

The one thing I wondered was whether I would be back at square one once infertility treatment was done with, because habituation often fades if the stimulus isn’t continued. But not too long ago I came down with strep throat, and realized that rather than take pills for a week, I could just get a shot in the butt. I looked at the syringe beforehand, and it was the biggest, longest, fattest freaking needle I had ever seen. In addition, the quantity of liquid was prodigious, and was a disturbing milky white color. I gazed at it for a moment, then said, “Eh, stick me!” and dropped trou. It was only later, as I was limping around the office, that I realized that this was the very thing that had triggered the whole problem in the first place. And I finally felt cured.

Placebo Deficiency

Is the light therapy working?

I do feel less gloomy and more energetic than I did before. And when I think about how long it will be until the sun really starts making a comeback, that seems like a simple fact; I don’t feel it in my bones.

At first I was thinking it might just be a placebo effect. Then I remembered—I have a serious deficiency: I am immune to placebos. I used to be proud of this, thinking it meant I was less gullible than other people, but over time I have come to realize that it just means I don’t feel as good as other people. Because the placebo effect is a marvelous thing.

I always suspected that I was missing out. I get terrible post-viral coughs, and used to drink gallons of dextromethorphan without noticing the slightest decrease in the hacking. (I continued to take it mainly because the people I lived with got terribly annoyed if I didn’t—as if I were destroying their sleep on purpose.) I felt vindicated when I finally saw data that over-the-counter cough remedies are entirely useless aside from their placebo effect—but the knowledge didn’t help me cough any less.

My first attempt at (illegal) mind alteration was a dud. It was a pretty pathetic scene: three of us huddled around a tinfoil-and-tampon-applicator b0ng containing a tiny dried-up lump of h@shish. J, who supplied the stuff, was an anorexic who consumed only Tab and tiny, strictly measured mounds of trail mix. After a few minutes of inhaling hot cotton shreds, J said, “I feel it! I definitely feel it!” My friend S, a 2-pack-a-day smoker who was fluent in three languages, politely said, “Maybe?” And I said, “Nope. Don’t feel a thing. Let’s go get drunk.” (This non-starter led to unfortunate overindulgence much later on, on the suspicion that I just might need a higher dose; the result was not unlike that described by Feral Mom here.)

The real proof came one evening when I was staying at my sister’s house. She and her (first) husband went to a dinner event without me. I got takeout Mexican and happily sat down with a book and a beer. I didn’t much like the beer—some weird German brand I found in their fridge—but I really felt like I needed a drink that evening. Strangely, after I finished the beer, I still felt like I needed a drink. Must be really stressed, I thought, and cracked open another. But after draining that one, I still felt like I needed a drink. Am I becoming an alcoholic? I wondered. It was not until I pulled the third beer out of the fridge that I noticed the fine print on the label: non-alcoholic. I swore a bit, rummaged around and found a real beer, and was perfectly happy after drinking that one (though a bit bloated by that point).

While others are happily enjoying their buzz or being relieved of headaches and such, I’m moping in the corner wondering how I can get my hands on the good stuff.

I’m always a little amused when people get started on antidepressants and after about four or five weeks say, “You know, I’m feeling a lot better, but I don’t know if it’s really the medication—maybe I’m just snapping out of this!” Not that that could never happen, but it’s interesting that it almost always seems to happen right around the time when one would expect an antidepressant to kick in. And here I am, wondering the same thing about the light therapy.

So, I guess it works.

If You Don't Think Studying Is Hard, You're Doing It Wrong

A disclaimer: I never said I had a fun or easy way to study, or even a particularly original one. I only said that it worked (for me).

When I decided I was going to try to get into medical school, I’d had thirteen years of grade school, three years of college, and two years of grad school. But the vast majority of this time was spent in classes in the arts, and the art I perfected was that of doing just enough to get an A- in anything. (The trick to that, if you’re interested, is: read the assigned material closely enough to get the gist of the ideas, show up to most of the classes (in particular the first three and the last three), write a paper that is slightly longer than the minimum assigned length, and string together coherent sentences for the midterm and final. So few people (no matter how fancy the school) manage to do all of those things that they’ll feel guilty marking you down much for simple crappiness (and believe me, I was guilty of much crappiness). There were a few classes that I got really into, but it seemed like even when I flayed myself open for a class, the T.A. wouldn’t care for my take on the subject and would give me an A- anyway.)

So let’s say I was a tad unprepared for premed classes. I had a heavy load of them, too, since I pretty much hadn’t done anything in college that counted as a science course, with the exception of Physics for Phreaks (where all I remember doing is going on a field trip to walk through a noise-canceling room while some poor grad student babbled about waves). I crammed into a two-semester period almost every required premed course, including labs. I read the books and got the gist; I showed up for class; and when I sat down for my first test—a physics quiz—I wasn’t too worried.

My attitude was rudely adjusted when the quiz came back with a big red “59” written in the top right corner. Thanks to the curve (a lovely device not often used in liberal arts courses), it worked out to something like a C, but holy shit—a 59??? I had blown 41 percent of the questions?? This wasn’t going to get me into med school. And I’d already quit my job.

OK, so it was firmly established that I was no Feynmann. I needed to get serious. Here’s the method I followed:

• Realize that how painful something is to study is directly proportional to how much you need to study it.
• Go to every class—and stay awake.
• Read all of the material, painstakingly slowly, at least three times over.
• The “gist” is useless; memorization is what counts.
• After you think you’ve memorized something, try writing it all down on a blank sheet of paper. Hmm, maybe not as well memorized as you thought?
• When you quiz yourself, which should be often, make sure you get all of the answers right three times in a row.
• Beware the mnemonic. Mnemonics only work in very specific circumstances. For instance, “NAVY” is a handy mnemonic for remembering the order in which one encounters the important structures in the groin: Nerve, Artery, Vein, Ying-Yang. Most mnemonics, no matter how clever or bawdy, just inspire one to invention. Does that I in “PILES of POOP” stand for Ischemic? Infectious? Iatrogenic? Ipsilateral? Italian? Who the hell knows? I found that making up a memorable saying works much better. For instance, if you drink enough alcohol to affect your liver, there is a tell-tale pattern to the increase in the liver enzymes: the AST, aka the SGOT, is usually twice as high as the ALT, aka the SGPT. I remember this by saying “You AST for it, you SGOT it.” (I know it’s stupid. But it works—I remember not only the pattern, but that AST=SGOT.) Corny tricks like the ones for remembering someone’s name (you know, picturing Mr. Heinz as a giant ketchup bottle, for example) work well also.
• You will never be hip again. Obviously.
• Get enough sleep. Cramming all night the day before a test does not work for science classes.
• Study similar things in proximity to each other. Calculus and physics go well together, for instance.
• If studying something is making you fall asleep, take a power nap.
• I said power nap. Do not let yourself sleep longer than 20 minutes.
• Colorful highlighters and tabs and note cards are festive and helpful—up to a point. Past that point, they become time-sucking OCD rituals.

Hey, like I said, it’s not fun. But it worked for me. Despite my pathetic start, I went on to get the highest grade of anyone in that physics class, and I got an A+ average in my premed courses. I realize now that if I had used these kind of techniques in my liberal arts courses, I probably would have rocked them, too. Even when I worked hard, I neglected ever really to learn the material by heart.

In a few years I’m going to have to take my recertification test, so I’ll be hauling out these methods pretty soon. For now, I confess that I’m often getting by on the gist.

Scurvy of the Soul

Medical school is full of “That’s how that works?!!” moments. One I remember especially clearly was when I learned about scurvy:

Scurvy is a disease caused by a dietary deficiency of vitamin C (ascorbic acid). The disease has occurred with regular frequency throughout human history and prehistory in populations lacking fresh foods … Deficiency of the vitamin causes a breakdown in the binding function of these tissues, producing a series of characteristic signs and symptoms: weakness, lethargy, irritability, anemia, purple spongy gums which bleed freely, loosening teeth, the reopening of healed scars … and hemorrhaging in the mucous membranes and skin. In severe cases the mortality rate is high.

Up until then, I’d believed that scars were stronger than regular skin. When in fact they're weaker. Maybe this was something most everybody else knew, but it really shook me up. The mantra “What doesn’t kill you makes you stronger” is so satisfying. “What doesn’t kill you leaves a scar that may weaken and rupture again if stressed” is kind of scary.

I got to thinking about this recently when I was doing a computer search to see if a paper I’d had published recently was showing up yet. Only one other person with my last name is published in the medical literature, so it was quickest to type in just my last name to look for my papers.

But it turns out that they’ve been slowly working backward in time to put medical articles into the citation system. Which is why the last time I entered my name into PubMed, two articles written by my father appeared.

My father was a statistician who collaborated with medical researchers, so it’s not surprising that he had some papers published under his name. But he died when I was five, and all I knew about his job is that it had something to do with computers. Seeing his name pop up without warning like that was painful; a reminder that he’s not here, and of how much he has missed. I had never even thought about the fact that we could have talked about my work.

People often say that you never get over a loved one’s death. When I was much younger, I hated to hear this. I spent a long time trying to convince myself that my father’s death didn’t really have an effect on me. It happened when I was so young, after all. But things did sneak up on me. When I was driving down a street one day I caught sight of a little girl learning to ride a bicycle, her father running behind her, his hand on the back of her seat. Suddenly I was so upset I had to pull over to the side of the road. Then I remembered that my father had just started teaching me how to ride a bike the summer he died. After he was gone I had to do it myself: there was a big pothole in our driveway, and if I climbed on the bike at the top of it and rolled down, there was just enough momentum to get me started. I did it over and over again until I had it.

Once glimpsed, the knowledge that a person who loves you and takes care of you can disappear in an instant never goes away. It can teach you to appreciate people, but it also makes you very wary.

The truth about what happens when something wounds you is that first there is pain and bleeding. Then you start to heal, and a scar forms. A scar is vastly better than nothing; at least the acute pain goes away, and you don’t bleed to death. But it’s never the same as it was.

I think that human interaction is like vitamin C for the soul: get too little, and your psychic wounds can reopen.

I guess that’s why I keep blogging.

I Didn't Mean Right NOW

I got a call from the Medical Examiner's office that one of my patients was found dead. It was the woman I saw the other week, the one who couldn't stop drinking, the one I called a drink-yourself-to-a-miserable-death alcoholic. The cause of death was clearly alcohol-related. She was found by her daughter, who had stopped by with her newborn baby. I didn't even know she had a daughter.

I spoke with the daughter on the phone. She talked about how the alcohol was the only thing that mattered to her mother; she only ever called her daughter to scream at her. The daughter seemed incredibly nice.

I haven't got anything profound to say about this. I'm just trying to imagine what it must be like to care more about getting drunk than about your daughter, or your brand-new grandchild, or your own life.

Ghouls and Ghost Stories

Yes, I backdated my post to October. Suzan-Lori Parks may have been able to write a play a day for a year, but I know I’m not up to writing even a decent post a day for a month, so I don’t want to imply that I’m doing so by posting on November 1st.

Yesterday I supervised the residents for outpatient office hours. I mostly enjoy this part of my job; it’s a perfect opportunity to teach the art of medicine. There are all kinds of techniques for giving patients what they need and want AND being efficient. Sitting down when talking to them, asking “What else?” and “What else?” and “What else?” until they can’t think of anything more, asking “What questions do you have?” at the end of the visit instead of “Do you have any questions?” Explaining that something “isn’t dangerous” rather than saying “it’s not serious.” Oh, I’ve got tons of cute tricks up my sleeve.

Yesterday got a little out of control, however. We saw 17 patients between 2 and 5 pm, and most of these patients were not 10 minute visit types. A couple of them were very appropriate for Halloween, and haunted my thoughts all night. (Some details altered to shield identities.)

One was a patient I’ve been following for a couple of years; she got put on the resident schedule because I was out of town last week. This patient is truly horrifying. She’s an alcoholic, but not a flunked-a-couple-CAGE-questions alcoholic; no, she’s an old-school, drink-yourself-to-a-miserable-death alcoholic. She used to have a real job and a real life, but has lost it all. She has developed almost every sequela of alcoholism there is—heart damage, liver damage, brain damage, nerve damage—but most frightening is that she keeps falling down and damaging her flesh and bones. She drags herself into my office about every two months for follow-up from a visit to the ER with another horrifying injury. She fell flat on her face and smashed her nose in. She fell and bit through her lip, almost severing the whole bottom lip off. She’s broken both arms several times. She’s so malnourished at this point that she can’t heal properly. She’s a trembling, emaciated, misshapen wraith. And she’s always furious. Furious that she’s in pain all the time (and that I won’t give her narcotics, though she usually has plenty left over from the ER and the orthopedic surgeons). Furious that everyone is “shitty” to her. Furious that she has no life. And especially furious that everyone keeps “implying” that her problems are due to drinking, because she DOESN’T HAVE A PROBLEM, GODDAMMIT. She cries and shakes and fills the room with the fumes of whatever she had to steady her nerves that morning and licks her scarred lips with her cracked, swollen, vitamin-deficient tongue. And begs for sleeping pills.

My poor resident was terrified. I ended up doing most of the talking, because at least I’m used to her. There’s really not much to say; I just agree and express sympathy about the fact that her life is hell, and then decline to write prescriptions for mind-altering substances, explaining that I’m concerned they could make her fall even more often. I’m not sure why she keeps coming back. I don’t know how to help her. So that was the only lesson I could give the resident: sometimes there’s nothing you can do.

The second frightening patient seemed only perplexing at first. He was a new patient, a mild-mannered elderly man. He spoke only Albanian, so everything had to be said through the phone interpreter, and even the interpreter seemed to have difficulty figuring out what he was saying. He came with a “case worker” who knew absolutely nothing about him (and definitely didn’t speak Albanian). He presented with papers from prison stating that he had some medical problems and some psychiatric problems. He’d been released several months ago, and had been able to fill his regular meds, but not his psych ones.

The resident came out of the room and explained all this to me. “Someone has to know the story,” I said. “Talk to the case worker and find a number we can call.” She seemed skeptical, but returned to the room.

Turns out that this patient had been in prison for 25 years after becoming psychotic and strangling his mother. He’d been treated in prison with monthly injections of antipsychotic meds, which apparently worked well enough that he was released to a halfway house. Off his meds. The pharmacy hadn’t filled the prescription for the injection because they didn’t carry it.

We slowly and carefully went back in the room and got on the phone with the Albanian translator again, determined that the patient was not interested in harming anyone at present, and explained that we would be starting him on some new pills that he must take every day. (We also got him an appointment with psychiatry, but in our institution that takes a month or so.)

The last scary patient was frightening in what she had rather than who she was. She’s a sweet little white-haired 85-year-old woman who was recently admitted for a possible stroke. As they often do, the neurologists had sent a test for syphilis as part of her workup. The initial test came back positive, but they assumed it was a false positive, and discharged her with instructions to follow up with me and get the results of the confirmatory test.

Of course, the second test was positive too.

The resident was panicked. “How am I supposed to tell her?” he asked. “Her daughter is in the room!”

So I went in with him. First I asked if the patient understood why she was there.

“For the test results,” she said.

“And do you know what the tests were for?”

No.

So I politely asked the daughter to step out for a minute, then dropped the bomb.

She sat for a moment, her eyes narrowing. Finally she said, “That brings back some bad memories. That no-good son of a bitch. My mother told me I shouldn’t marry him!”

Turns out her husband had cheated on her some forty years ago, and she found out because he’d given her syphilis. She’d been treated, but she didn’t remember how, since she was allergic to penicillin.

“That’s why I kicked him out,” she said. “He’s dead now, and it’s a good thing, because if he weren’t I’d throttle him myself. I thought this was over and done with.”



By the time I got home last night, HellBoy had already gone out trick-or-treating and come home—he’d had enough after just one house. He was having a good time sitting on the stoop with his dad greeting all the other kids.

I didn’t stay out there long. I’d had enough of ghouls and ghost stories for the day.