and, on a much lighter note…
favorite kool aid flavor?
(its become my tard marked question, you see.)
What can I do for early morning heel pain? I get it off and on and now I have it again. I have heard ice or stretching might help. It goes away after maybe 30 minutes.
Bad News Baboon,
That’s the point of “detached concern” and the “rule” that it’s the patient with the disease. In order to be compassionate you must preserve some distance, or you get too hurt and are totally unavailable in the future.
Luckily kids usually get better.
DOCTORJ
I’d ask for advice on the match, residency interviews, etc., but frankly, I’m sick of thinking about it. Instead, I’ll ask–what do you know now, at the end of your residency, that you wish you had known at the beginning?
The American match just confuses me. Don’t ask for this advice from a Canuck. I wish I had known the following things earlier.
-
No rotation is busy or important enough to neglect occasional exercise and spending focused time with friends and/or family.
-
People in medicine judge intelligence by knowing something they don’t. If you know anything about heme-onc, this is enough. Knowing about the latest cardiology studies is gold, even if it will all be useless in ten years.
-
In the hospital, being five minutes late for something is the same as being thirty minutes late for something.
-
Treat difficult patients (borderlines, somatizers) by seeing them very often, stressing you will see them just to talk, even if they don’t have a current problem. However, limit access if they misbehave. Access is all people want. In medicine, the more available you are to people, the less busy you will be in the long run.
-
Medicine is one aspect of a busy life.
-
There were times when you goofed up, did something stupid or forgot something obvious. There were times when you got no sleep and got grouchy after dealing with demand after demand. There were times when you were yelled at for doing these things, and also times when clinicians had the chance to make trouble for you after making an error and instead turned out to be compassionate and forgiving. Be like the latter clinicians. Never be condescending or yell at anyone who makes a mistake, point it out diplomatically so it is not made again, as others did for you. Learn from your mistakes. Learn whenever something does not go as you had hoped or expected.
-
Nothing is more important than honesty, humility and clear comunication. In difficult situations, this will get you by even when knowledge is lacking.
-
You are not special. You did not invent most medical operations, procedures or protocols. Someone else did, and you are doing your best not to wander off the path. Any compassionate person of reasonable smarts could do what you do. So don’t let what you do uniquely define who you are. Instead, strive to do what you do well, since this and not your job title make you harder to replace.
DSEID
Agree evidence based medicine often unquestioned. It is useful for us generalists if not accepted uncritically. But I don’t understand why so many people accept EBM and especially meta-analyses without a jaundiced eye and tailor their practice to the latest doggerel. Older medicines work best and are cheaper.
DRILLROD
Not too old if you already have the prequesites to apply, we had a 37 year old in our class and I have heard of many classes with people in their forties. But remember med school is four years and residency is another three. Possible but difficult. Good luck.
THINKSNOW
Probably about a 50% chance of sinusitis based on what you describe, so I would treat you with Amoxicillin for 14 days and possibly FloNase (fluticasone spray). Sinusitis is diagnosed when more rather than less of: pain over 10 days, coloured nasal discharge, positive transillumination test (controversial), facial pain, headaches and the sinuses are developed (don’t order CTs in one year olds!). CTs and X-rays a waste of money in acute conditions, not in chronic ones.
MUFFIN
Performance suffers with increased time. ER docs should not work more than 40 hours or so a week, and few in Canada do. However, many surgical and obstetrics residents work 90-100 hour weeks and clear thinking is important in al branches of medicine. ER is much less busy than popularly believed and the acute cases occur less often than you think. Hence, the incentive to stick around is the opportunity to practice these procedures when they do occur.
Chest pain is bread and butter stuff, you don’t see a new trauma case every fifteen minutes.
Mr.DUALITY
I agree with you. See my response to Muffin.
CRANKYASANOLDMAN
Lots of residents are tools. Maybe 10% of residents in Canada switch specialties. In their defence, though, labour is a difficult time to judge people and obstetrics residents work insane hours (see comments to Muffin). Older students have much experience to offer a class and are a plus once accepted. Medical folks like structure and hierarchy and hence are fond of older military people, which certainly does increase your odds.
BADNEWS
You learn to break bad news, this is an important skill. Dealing with unexpected death depends on the circumstances. It can be hard. Avoid blame where inappropriate, remain concerned yet detached, provide support for the family as needed and above all, keep communication clear and honest. I like the blue KoolAid. You couldn’t get it in Canada for many years which I call the “Dark Age”. Well, no, not really.
KPM
Is it serious? What does it stop you from doing?
If not much, nothing wrong with Tylenol/ice/heat/stretching/continued use especially if this is the only affected joint. Make sure your shoes fit well and that you have no tenderness in your hip, knee and feet. Could be an Achilles tendonitis, possibly an early arthritis. Be more concerned if you have the following symptoms (and see your doctor):
pain that wakes you from sleep, intense pain, limited function, cramping pain in your legs after walking, new swelling in your legs (especially later in the day), localized swelling and redness in one joint only.
Hm…seeing as I’m also prone to develop gout, this makes sense.
&*$#ing uric acid.
I just want to say: Congratulations on being Chief Resident. Way cool!
What’s the criteria for implanting a defibrillator? My family history is significant for arrythmias* but not high cholesterol. At age 32, holter monitor report states that I have multifocal PVCs. Do I just wait around until my heart freaks-out sometime within the next 20 years and hope that somebody gives me adequate CPR and that paramedics get there in time to make a difference or can I ask for an implant? Does being female reduce my chances of getting a device implanted?
*Grandfather, uncle, and mother died from going into V-fib and not being able to be revived.
“Better treatment” applies sometimes in an office or hospital setting, partly because MDs can tell when the’re getting jacked around and are less likely to put up with it. When it comes to HMOs though, all bets are off. HMOs are equal opportunity screwers, MD degree or no degree.
Nice responses on the patient interaction stuff, Dr. P.
I’ll grant that’s true, but in defense of my own judgment, my husband wanted to punch him, my doula was outraged, and my labor nurse apparently had words with him out in the hall after his little visit to my room. So it wasn’t just the laboring mama who thought this guy was out of line. 
RYSDAD
It does, since gouty folks get more kidney stones. Keeping attacks under control is important.
KPM
If it does bother you a lot, it could also be a plantar fascitis which might respond to a steroid injection. Since injections in the bottom of the foot are painful, and in effective if you don’t stay off the foot for two days, and also of variable benefit… if it ain’t bad, don’t go there.
GKW
PVCs are common and not by themselves a good reason for a defibrillator-pacer. Multifocals are grade 3 out of 5 on the PVC lown classification. In the absence of heart disease, this could be ignored completely. If you have several risk factors: diabetes, high blood presure, obesity, cholesterol, family history of stroke or heart attack before the age of 60 or smoking then you should consider MEDICAL therapy with a class I-III drug (e.g. beta blockers if you are not asthmatic, or amiodarone). But you are probably making too much of it and can relax. Pacemakers are good in established heart disease (which you do NOT have due to PVCs unless an echo or stress test shows otherwise) when there are syncopal spells or a more serious arrhytmia; defibrillation might not be needed if the rhythm can be controlled but is needed in recurrent VTach Vfib.
So my heart’s OK, I’m just a little neurotic
Thanks Dr P.
Gastroenterologist said it was okay to take smaller doses of NSAIDS even though I had had 2 episodes of GI bleeding, one very serious. Scopes revealed nothing. Consequently, had another episode after only taking 3 asprin once a day, three days a week for about two months. GE said this shouldn’t have caused bleeding, so he diagnosed some kind of abnormality in the small bowel. I felt uncomfortable about this diagnosis so I went to an internist who said: (1) bleeding can occur from NSAIDS anywhere in the GI tract (2) have to stop taking all NSAIDS. I want to believe that now that I have stopped all NSAIDS it won’t happen again. Very, very scary. Is it true that only a small dose of asprin could have caused massive amounts of blood again? Have to see yet another GE next month on referral. Neither doctor has seemed to want to answer any of my questions. The GE thinks he is a comedian and treats everything as a joke. The internist is Asian and very stoic; just repeats over and over, “NO NSAIDS”. We live on an island in a rural part of Maine so not much choice for doctors.
KK
If a bilingual first-year medical student is having his first encounter with a real patient, is it appropriate for the doctor to have the student break the news to the patient in Spanish that he’s got terminal cancer?
The heel pain doesn’t limit my activities since it only happens in the morning. I do have slight arthritis which I take Vioxx for but that is getting better - it’s not RA, more like slight OA. I have had the heel pain on and off before I had the arthritis. I think it flairs up when I start exercising more. When should I stretch or use ice or heat -at night? Thanks for your advice.
SUZIEK
*Is it true that only a small dose of aspirin could have caused massive amounts of blood again? *
Yes, it certainly is possible given your history. NSAIDs can induce gastritis and cause bleeding from ulcers, in some people this occurs at small doses. You should probably avoid them if other alternatives are available. This is not always easy in patients with heart problems who do benefit from an aspirin a day (baby or normal) or patients with bad joints (who are often started on NSAIDs). You should probably have an EGD scope where they look at your esophagus, stomach and duodenum to find a cause, and might have already had this done. Not all NSAIDs have the same risk of re-bleed: Tylenol (not an NSAID), Misoprostol, Celebrex, Vioxx and Mobicox probably have a lower rate of bleeding than aspirin; sometimes adding sucralafate to increase stomach mucus also helps. However, you are at higher risk for having re-bled and need to determine the exact cause. Until this is done I would avoid NSAIDs.
BOBSCENE
*If a bilingual first-year medical student is having his first encounter with a real patient, is it appropriate for the doctor to have the student break the news to the patient in Spanish that he’s got terminal cancer?
*
Possibly not. If the student is good at breaking bad news in English, and the doctor has seen the student do this, it may be appropriate to let the student do it in Spanish providing:
a) the student knows the wishes of patient and family
b) the student has done this before, or has had training or experience in breaking bad news
c) the doctor does not have a much closer bond to the family than the student and hence the family would not have a very strong wish to hear it from him – i.e. a long term patient of the doctor.
The fact he or she is “first year” is less important than the other factors.
KPM
If you have osteoarthritis, you may get benefit from applying cold and heat, but different patients report different results. At best, the cool helps the pain and should probably thus be applied in the morning; heat helps the stiffness and should be applied when this is predominant. Of course, both these can be repeated through the day and you may have to experiment with the timing.