Goodbye to First Year. . .Again

I will take this opportunity today to stand for what I have gone through as a first-year resident. Again.

See, some specialty residencies have a unique start to them in that there is an initial transitional or intern year which may have little to no exposure to their specialty of choice. At UAMS, this is primarily the ophthalmology and dermatology residents. Many of the surgical subspecialists (though, dermatology is not a surgical specialty) have several months of general surgery scut or other "off-service" months, but they still get several months of their desired specialty. We got one month of ophthalmology, and it was one during which we just followed someone around and weren't allowed to do much. The other eleven were all internal medicine without even a once-monthly eye clinic to attend.

So then my actual first year of ophthalmology came around. I was finally really getting used to being a medicine resident when my feet were lifted off the ground and I was pushed over without a solid surface on which to stand. Even though I was a PGY-2, I knew nothing. I was like an intern all over again.

Alas, as a PGY-3, I have surpassed that point. I know a thing or two. And for once, I can spend the next year expanding on it. I can honestly say, "Okay, I've done this. I've seen this. Now what more do I need to learn about it?" Obviously, the answer will always be, "Plenty."

Sample Medications

It's hard in this age of medicine to know what to do about free samples of medications.

There was once a day when wherever you went you were able to get free samples of the newest medications on the market, and nobody had a real problem with it. Ophthalmologists were certainly no exception to this with entire cabinets full of eye drop samples.

But things have changed. The great exposure of the pharmaceutical industry led many to become more aware of the problems with free samples. Free samples were equated with getting a patient on a branded, new medication for which they would in the future require a prescription and pay a lot of money. Most university health care settings have essentially banned the presence of pharmaceutical representatives from their campuses. Most would agree that this is generally a good thing. But have they really gained anything with the banning? If you figure that most of these patients are uninsured or have at best Medicaid/Medicare, which frequently won't cover the cost of the newer, higher priced medications, then the university wasn't a huge motivation for sales people.

Still, there is another side to it. Essentially all new drugs in their infancy are only available as the expensive brand name due to patents. And sometimes, just sometimes, the new medications is in fact the next best greatest thing.  Unless an unbiased overwhelming amount of literature and data suggest otherwise, I typically don't prescribe these drugs until they've been on the market a few years when more safety data is available. But, again, sometimes the new drug is just too good to not use. And considering many of my patients would never be able to afford such a thing, is it so wrong to continuously give them free samples? You may argue that as long as the company is giving out free samples, the cost of the medication will remain high or even rise. This, I don't think, would hold water when you figure that the overwhelming majority of the company's income goes to profit and advertisement (which they often include in their supposed "R&D" costs), not manufacturing costs. There's good literature on this out there - I recommend you read it.

So I still believe that in moderation, the dispensing of free samples can be helpful to good patient care. So long as there aren't associated kickbacks, awards, and presribers' interests at hand. Now if you want to talk about equipment and instrument representatives, that's an entirely different story.

Our Company Stole My Pain Meds

Working in a university setting we get a lot of patients who are uninsured and also frequently drug seekers. I'm not stereotyping here, but the two characteristics often occur together.

At any rate, the range of excuses used to explain how a 30-day supply of narcotics disappeared in seven days is quite broad. But this one certainly stood out the other day. In the post-operative period for eye surgery, we really don't even give out much pain medications. There are only a few surgeries which warrant good pain medications, and an open globe is one of them. One of these patients walked into the clinic, appearing to be perfectly well (aside from the obvious eye injury status post repair) and not in any pain at all. In the clinic room, it was a parent (not even then twenty-year-old patient) who first brought up the recent loss of pain medications.

It wasn't the typical "Oh, I've been in so much pain I've taken it already," or the, "No, doctor, I wasn't given the prescription when I left the recovery room." It was, "We had some company the other night who stole the pain medication."
"Well," I said to the patient, "you look to be doing well anyway."
"Oh, no, she's in a lot of pain," says Mom.
"I wasn't talking to you." I turn back to the patient.
"Oh, yes, I'm in too much pain," the patient said with the flattest face ever.

I couldn't help but give her two more days of pain medications and then refuse to see her on the return visit - she (her mom) would be someone else's problem.

Don't Play With Your Food

Pear

Whenever someone gets hit hard enough in the eye, though not hard enough to rupture it, it is very common to suffer what is called a hyphema. This is when there is bleeding in the eye, though in front of the iris. This turns out to be something that is heavily dreaded during the fourth of July season.

Hyphema

But recently, I encountered a type of injury a little unusual to me. A couple of kids were playing around some pear trees. Turns out a couple of them were decent baseball players. They got to throwing the fruits around and, as anticipated by the direction we're going, one of them took one to the eye and got a hyphema from it. I hope it was at least a pitcher-type that threw the darn thing.

When this happened, I immediately thought of, "Honestly, who throws a shoe?

Austin Powers

Could I Have Done ENT?

Sometimes I look back on my path and wonder what would have happened if I had decided to become something else. Something else physician wise, that is. I'm not known for my patience as a general practitioner. So internal medicine, family practice, general surgery, pediatrics, and even OB/Gyn were without a chance for my interest. Psychiatry just didn't excite me in the least.

But any of the surgical subspecialties have interested me at one time or another (orthopedics, urology, ophthalmology, ENT). I always say that if perhaps the ophthalmology thing hadn't interested me enough, I would likely have seriously considered the field of otolaryngology, or ear, nose, and throat. But could I really have done that?

Their program is clearly more difficult to get through than ours. First and foremost, it's a year longer. Then, there's the fact that their first year is riddled with lots of general surgery intern scut. Internal medicine scut is one thing, but general surgery scut is an entirely different beast since you spend about zero time in the operating room (at least at our medical center - perhaps elsewhere the training is better). Then, their call is overall worse than ours in terms of busyness. Anybody taking home call can have bad days. Although, let's face it, dermatology home call does not tend to equate to much work over the weekend. Any who think it does needs to take one of our weekend calls for perspective. The benefit for ENT folks is that there are more of them splitting the task of first call. We have six, they have a few more. Two or three more may not sound like much, but believe me, it is. We have been blessed in that the transition from the staggered start program to the traditional start program has given us a periodic surplus of residents.

Could I have done it? Sure, but I probably wouldn't have the time to do this.

I Was Admitted, But I Won't Admit You

I have learned through time and personal experience how things change.

When I had my eye injury several years ago, I was under the umbrella of my dad's insurance. It was good coverage, and was even better if used at the hospital where he worked - which it was. With good coverage comes good payment to the hospital and the physicians. So, naturally, I was admitted to the hospital for about two and a half days after a fairly simple corneal laceration. And it's not like transportation would have been an issue for daily follow up - we lived maybe five miles away.

Since becoming an ophthalmology resident, things seem to have changed immensely. Whenever we see globe trauma, no matter what hour of the night, the patient is taken to the OR, repaired, and then sent right home. The patient sometimes earns an observation admission if the repair is going to be delayed several hours for some reason. The only other time a hospital admission occurs is if there are other injuries and the patient isn't even on our service. A rare exception might be if the patient lives far away and/or is not likely to follow up as asked.

First of all, most of our patients don't have insurance. They would never pay a hospital bill, and aren't likely to pay the emergency room and operating fees. So that would just be pure lost money. Secondly, perhaps in the growing realization of poor cost effectiveness practice in most of medicine today, we have realized that such hospital admissions are not necessary.  If not downright fraudulent in the case of a well-insured patient.

Never Say Never

I apologize for not having written anything in nearly a week. It was a busy weekend, and the motivation left me for a  few days since since then.

At any rate, as doctors, we sometimes tote a certain complication or disease as being rare. And for those of us who are young doctors, the rare things may never have been seen. Yet.

In this amazing field of medicine, there are ever changing treatments available for different things. Age related macular degeneration (ARMD) is a common eye disease of elderly people. Treatment for it has been mostly lacking and disappointing. But when the disease becomes "leaky" or bleeds, we can at least give an injection into the eye. It's with a medication which binds and clears blood vessel growth factors, the root of the problem. We always tell the patients that in the process of doing this, there is a rare complication of getting an infection in the eye: endophthalmitis.

I have always told people that it is very rare, and I had never seen a case related to injections. That all changed recently. Sure enough, a patient came into the VA ED with a painful eye one week after an injection, and was found to have an infection.

Start counting. I can now say, "Well I've only seen it happen once."

Another Year Older

Yep - 28 years old today. Don't really have much more to say about it. Get to celebrate by making final preparations for my presentation tomorrow.

Now That Really Could Have Waited Until Morning

It is very common for people to present to the ED at odd hours of the night for problems that have been going on since they woke up, or for several days even. You know this. I've bitched about it before.

But this was even more ridiculous. I recently got a consult from the ED about a patient who had gotten mace sprayed in his eye. He complained of a lot of burning. Probably not a huge deal, I thought, but might warrant a visit by me nonetheless. I mean, isn't that the whole idea of mace? If it caused any damage to the eye, it would have long been pulled from the market. Still, if someone has a lot of continued burning of the eyes after getting something in them, it might be worth looking at.

"Have you checked the pH?" I asked.
"Well, uh. . ." the doc stammered.
"Could you?" I asked.
"Well, the patient's already gone," he said. "I just thought I could get him some follow up."
"And you felt you needed to call me at two in the morning for me to make a clinic appointment? What, you think I am going to call him now and set that right up?"
"Well, uh. . ."
"Fine. What's his name?"

Don't call me before the hour of seven about a patient and ask for advice and follow up if the patient is already gone. I really need my beauty sleep to balance out my ugliness. Thanks.

What is a Workin?

There is this phenomenon commonly encountered in the resident clinic. It's called the workin. A workin is a patient who wasn't on the schedule at the start of the day and was later added for whatever reason. Much like everything else, workins typically get inappropriately dumped on the resident clinic.

You see, there is one huge advantage to academic medicine - office time. In all honesty, I can't wait for it. But at any rate, it is time dedicated for an attending to be able to work on administrative or research duties. And the reality is, it not uncommonly amounts to time spent away from work - a time when you are essentially unavailable. Again, I can't wait for this -  I would likely do the same. The exception comes when you're talking about program directors and department heads.

But as residents we feel the brunt of it at times. Suppose a patient of Dr. Azulweebum comes with a complaint of some sort. In the private world, that patient would be put in Dr. Azulweebum's clinic. And if Dr. Azulweebum was absent, and as long as the patient's issue wasn't dire emergency, the patient would just be told to come back to her next scheduled clinic. Not at JEI. Patients get worked in left and right because that's the JEI policy - see all who come in. And there's a lot of office time to be had. But a line has to be drawn.

The other day, one of Dr. Azulweebum's patients needed an exam to renew her contacts. See, without a complete annual eye exam, most contact suppliers won't renew your contact prescription - as it well should be. So Dr. Azulweebum's primary tech, in her infinite wisdom, decided to work her in to my clinic which was already full, and I the only resident. Did anyone ask me if this was okay? No. Did anyone ask the attending if this was okay? No. And I can guarantee that if she had asked, the answer from either of us would have been the same: No.

This does not qualify as a work in. If you need your annual eye exam to renew your precious contact prescription, you can schedule an appointment with your regular Dr. Azulweebum just like everyone else. A workin should be limited to urgent issues, not to include patients who are four hours late or need their glasses fixed (which happens at JEI).

But no one ever asked me. Or Dr. Azulweebum.

I Actually Kind of Like Presenting

I have had to do a lot of presentations in the last few weeks - with the biggest one yet to come. And you know what? Overall, I rather like giving presentations.

Now Dwight over there didn't think he would like presenting, but after some secretly helpful tips from a trusted coworker, he pulled through just fine, taking the stage away from his boss.

My methods were different. Sure I needed coworker tips at the beginning to understand what certain people expected out of a grand rounds presentation. But this knowledge mostly just came from having sat through them, week after week. There are fine details preferred by different attendings directing the show on a given day, but these can be discussed ahead of time. The biggest trick is mastering the presenting materials, and the presentation itself. You can't put a presentation together the night before and go through it in its entirety the first time in front of an audience and not stumble a time or two.

What I really need is one of these:

Oh, So That's A Chart Review

The big "Resident's Day" is nearly upon us. We are all required to do some sort of research on an annual basis. This is the day we all get to talk about what we've done. There will be plenty of other people speaking as well - a few attendings with some topics to discuss, the PhD's who have done work, and of course a guest speaker who will give multiple talks.

My research consisted of a chart review. I gathered a list of patients with a common diagnosis and surgical procedure. For each patient, I performed an investigation into the chart to gather several pieces of information from the initial presentation of the problem to its immediate surgical management to long-term follow up of outcomes. The first step was getting the list of correctly identified patients - but that in itself was a challenge.

I spent a good amount of time on my vacation in San Antonio working on this since the list of patients was generated near my departure. Fortunately, I was easily able to do most of the work on a computer by remotely accessing the electronic medical records. But, I had to search out several different documents in the chart to gather the desired information. This was even more difficult when I came back to Little Rock and worked on the charts from ACH, which seemed to have much less usable information in a paper format. But I gathered what I could.

Once the data was all in my hands, it was sent off for analysis. What I got back was a bunch of percentages which failed to reach statistical significance. Yay - no publication from this.

It's OK You Didn't See it and I Did - I'm an Eye Doctor

I like my ER buddies, but sometimes they make me giggle.

Recently I got called to the emergency room to see a patient who presented after a full day of excruciating one-sided eye pain. After a very thorough exam by not only the ER resident but an attending as well, I was called and they said, "We just don't see anything wrong. Please help us and come see this patient."

"No problem," I said. I was sure something simply got missed. I talked to the patient who told me about how he had been working in his fields the prior day - working around a lot of soy seeds. At the time, I didn't know what soy seeds looked like, but now I can say they look like this:

At any rate, the exam was superficially unrevealing except for an angry red eye.

But after flipping the lids and peeking underneath, I found what appeared to be a small shell of a seed, not but a couple millimeters in size.

The ER docs were nearly embarrassed for not having found it. I told them it was quite alright. The fact is, I flip someone's lids inside out nearly daily, and have become damn good at getting a good look at everything there is to see under there.

It's okay - I'm an eye doctor. We are better at examining eyes - I hope - than you. Just like you are better at placing chest tubes than us.

Is that enough pictures, Jess?

The Difference Between an Adult and Pediatric ER

The consults that come from the pediatric versus adult emergency rooms are amazingly different - and it's actually somewhat of an enigma to me.

When I get called from a physician in the adult emergency room, as a general rule, the problem is accurately stated. The severity of the situation is usually conveyed well. In fact, with some, I can expect  an accurate diagnosis from the initial phone call.

For some reason, things are very different from the pediatric emergency room. (The exception being when one of the adult emergency medicine residents happens to be rotating at the children's hospital). One of two situations is commonly the case. The first is when I get painted a picture of doom and gloom with a probable open globe and a bad marginal laceration; but on my arrival, there is little more than a small conjunctival laceration and a nick on the eyelid - neither of which will need anything done to them, although would require my visitation. The second is of course the exact opposite. I have been told about a "normal" eye exam (which doesn't even warrant a call to me) and come to find something much more - something very much not normal and needing ophthalmology care.

This is to be expected from residents - we are all learning and no one knows everything. I would never fault a resident early in their training for this kind of stuff. But this has not always been the case. I kind of feel an attending should be involved at least peripherally before the decision is made to consult someone. But no matter, because even the attendings at the pediatric emergency room do the same things. I don't know why this is. Is the training in eye probelms inadequate? Is there just a tendency to pawn stuff off onto consultants when the going gets rough? I know the latter is true since the consulting becomes more poorly done as the waiting room fills up.

I am always more than happy to help - when it's appropriate. But you don't call a cardiologist before you've listened to the heart, right? So why would you call me before you've actually taken a second to look at the eye and have some of your own thoughts as to what's going on? A well-informed consultant is always better than a blind one.