In medicine, patients who have been admitted to the hospital have an option to leave despite being deemed too ill to be discharged. We refer to these patients as leaving “against medical advice”, or AMA.  Many times patients sign out AMA whenever they feel a desire to leave the hospital when work-up is still pending. I once had a patient who presented with symptoms suspicious for myocardial infarction, but had a flight to India several days later. He felt symptomatically better a day after presentation, and decided to leave to pack his bags even though we had not completed all of this cardiac tests.  I had another patient who was admitted for a gastrointestinal bleed from ruptured esophageal varices. No sooner had I finished transfusing him 6 units of red cells did he demand to leave. This guy was a cocaine addict who needed another fix. These are the cases which disobeying medical advice could result in death.

Other cases are not as obvious. I had a young diabetic teenage patient who was admitted for drainage and antibiotic treatment of an infection neck abscess. He left AMA before bacterial cultures could be speciated. While he was unlikely to die from premature cessation of his antibiotics, he did not complete his treatment and risked developing a superinfection or worse, a superbug.

Interestingly enough, the one universal bond that I have noticed about AMA patients is that they were all cared for by a medical team. Not a surgical team. Not a gynecological team. You can argue that fewer surgical patients leave AMA simply because there are fewer surgical patients in the hospital, but I believe the explanation is simpler: surgery has more tangible results.

The argument that surgeons “do more” for their patients is not only stated by surgeons, but also perceived by patients. When I was a medical student, the surgical attendings considered themselves the “Physician +” because they are expected to manage their patients medically and surgically. Those students choosing to specialize in surgery crave the satisfaction of intervening in order to make the patient better. Patients admitted to the surgical service expect a tangible intervention, like removal of an organ or excision of a tumor. They are not likely to leave against the advice of the doctor. Even those surgical patients who are managed medically, such as the small bowel obstructions, almost never leave the hospital without a doctor’s blessing. They are in pain, they cannot eat, and they also know that there is still a possibility that they may be cut open.

Sadly, the same cannot be said about patients managed by internists. The diabetic in ketoacidosis will start feeling better when their anion gap is near closure, but we cannot send them home if their white count is sky high from an unidentified infection. The patient doesn’t see this. He feels better, and wants to go home. The HIV patient with cryptococcal meningitis feels great after I hit him with some narcotics and a dose of amphotericin. He thinks that all he needs are some painkillers. Think again. If he goes home after this, he will be as good as dead–the amphotericin will have just enough time to frag up some fungi in his system to trigger whatever is left of his immune system to go berserk and maybe put him into sepsis.

It is unfortunate that medicine is perceived in this manner, by doctors, patients, and even insurance companies. It is at times frustrating to practice medicine in the context of this disconnect; it feels as if doctors are broadcasting on a different frequency as everyone else. Policy needs to be revised. Policy is being revised. But in the meantime, we will have to wait it out.

medicine medicine, work

Several days ago, I attended a medical meeting in which Sandeep Jauhar was a guest speaker. I had recently finished reading his book, and was excited to have the opportunity to meet an author. A real book author! As fate had allowed, I ended up getting an autographed copy of Intern, and got to be in a picture with him! I felt like the kid in Slumdog Millionaire who dived through the bottom of a latrine in order to get a celebrity’s autograph.

The irony is that if I were a medical resident at LIJ, I’d see him every day in rounds at the cardiac unit. He would have been no different from any other teaching attending, prodding residents rationalize their medical decisions. Would this guy still hold celebrity status in my book? How is this guy any different from Gerald Appel, Richard Axel, or Eric Kandel?

He isn’t. Each one of these people has his own celebrity factor.  All of them are book authors. Axel and Kandel are Nobel Prize winners, and Appel cares for high profile people. Jauhar writes guest columns for NYT and NEJM. The bottom line is that I have his autograph and photo. Coolness.

medicine life, medicine

A friend of mine introduced me to Intern, a recount of a cardiologist’s experience during medical internship. The author, Sandeep Jauhar, trained at New York Hospital–it is now known as NYP-Cornell. While internship is difficult regardless of where you train, his book details many of the experiences that still have gone unfettered by social reform, at least in NYC hospitals. Certainly, the unionized nursing staff in the city makes even basic morning labs and vitals a chore for the house staff, even to this day.

From what I saw as a student in the ivory towers, overnight cross coverage still remains harrowing, with an incessant onslaught of pages, difficult patients, and codes. What this experience amounts to is not only a learned resident, but a tome of unfathomable tales that you’d otherwise imagine only to be fabricated.

On one occasion in his book, Dr. Jauhar describes performing a paracentesis on an ascitic patient. He instructs the patient, with tubing in his peritoneum draining the fluid, to remain still while he checks on another patient outside. When Dr. Jauhar returns, bodily fluid covers the floor. When asked to explain why he moved, the patient stated that someone walked into his room and seized, knocking all of the ascitic fluid bottles over.  Frighteningly enough, that actually happened.

I had cared for an elderly gentleman (86-yr old) when I was a 3rd year medical student. He was bawdy and demented; on several occasions he would ambulate around pantless, and void in the hallways as if he were hoping that someone would slip on his urine.  His behavior was probably not entirely due to age; his brain was ravaged by neurosyphilis. One evening I saw him with a bruised forehead and ecchymotic eye. Had he fallen despite having a sitter? No, it turned out the sitter had punched my patient. I had a helluva time explaining that to my attending in the morning.

I’m relieved that I escaped from the city for internship. At times, however, I wonder whether this rite of passage would have made me a better doctor. It sure would have added to my list of stories I could reminisce over with friends at the bar.  Regardless, I’ll be back soon enough.

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This video says it all:

Ironically, “Outside Hospitals” usually have higher resident salaries, more benefits, a working nursing and phlebotomy staff, and nicer facilities. Must be those caths…

medicine humor, medicine

While it is bad enough that medical residents are mistaken for students, I’ve come to realize that there are many other misinformed people in the community that do not realize what medical training entails. Yesterday I spent the afternoon at a private ophthalmologist’s office, and I chatted with his senior technician for a while (she has been working as an ophthalmic technician for 14yrs):

Technician: So, do you want to be a doctor?

Me: (wearing long white coat with my name embroidered on it): Yes, but I’ve finished medical school already. I am training to become an ophthalmologist.

Technician: So will you be doing surgeries as well?

Me: (getting agitated) Yeah, I chose to become an ophthalmologist because I wanted to perform surgeries.

Technician: How do you even learn to do a cataract surgery? Do you have to go through special training?

[Thought: she needs to be educated.]

At that point, a new patient arrived, and I walked off to examine him.

Later in the afternoon, I had another conversation with her that started with her asking me whether I had applied for ophthalmology training. While I assume that there are people who are bold enough to advertise themselves as future doctors when they were 10, 15, 20, or even 25 years old, it would have been pretentious of me to state that, “I am training to become an ophthalmologist” without having matched for a spot in residency.  This is frustrating indeed. Read more…

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