The worst form of government, except for all the others

September 30, 2008 at 5:55 am | Posted in Uncategorized | Leave a comment

If you aren’t living under a rock, you’re probably aware of the multifaceted political and financial fiasco that’s currently sucking up all the news-related airtime and bandwidth across the U.S. If I owned a house, or any stock I was counting on for retirement, the last two weeks would not be funny. At all.

But since neither of those things are true, I’m finding each news cycle to be even more nutty and entertaining than the last. These people need either a psychiatrist, or a nanny. I can’t figure out which. Seriously, this whole bailout episode is comedy worthy of Shakespeare. It’s too bad he isn’t still alive to write a play about it.

And what a PR nightmare for McCain. And I really don’t see how the Republican party can come back from this in just 4 weeks. And Palin, well, we’ll see in two days if she can rise to the occasion. She’s flubbed multiple opportunities so far, so the odds aren’t in her favor. All that Biden has to do is treat her like a colleague, no matter what she says or does, and he wins. Bonus points if she starts throwing her trademark cheap shots and folksy soundbites at him.

From what I’ve seen of Sarah Palin so far, if I were interviewing her for a job, I wouldn’t hire her. She has a very dumb kind of charisma that is mostly disruptive, and unproductive to have in an organization. She brings nothing of substance to the table. I might hire McCain, strictly to have an independent voice in the mix, but I wouldn’t let him make any critical decisions. I would want Biden as an advisor and attack dog, and I’m still not sure what Obama would be good at, other than delivering bad news in an upbeat way.

I wish there were more options.

Neither fish nor fowl

September 28, 2008 at 4:42 am | Posted in pharmacy | 3 Comments

Yesterday I picked up an extra shift at one of my favorite retail shops, where I like both the staff and the customers. The only thing I don’t like about the place is that on weekends, it’s dead as a doornail. And as you already know, when I’m working, I like to actually work.

So I was intermittently banging my head on the counter out of boredom, and chatting with the techs about their kids and the current weight loss strategy they’re using, when the cashier walks over to me and says, “there’s a guy sitting in the chairs over there, and he doesn’t look so good. He’s not waiting on a prescription, and he’s having some chest pain.”

I walk over there and sit down next to him. He looks a bit pale, although not ashen. Not really diaphoretic, but definitely not well. I start in on an H&P, and I’m really not getting much other than non-radiating chest discomfort and fatigue in a 65 or so year old man with hypertension and hyperlipidemia. And a slightly amused/condescending look from the patient. He only takes medications for the hyperlipidemia, and his last meal was 4 hours ago.

His blood pressure’s high, but neither emergently nor even urgently so. He describes the chest pressure as mild. And of course I don’t have my stethoscope with me–not that that would add much, other than to rule out a few causes of chest pain I’m not suspecting anyway. I’d really like an EKG, but that’s something pharmacies don’t generally have on hand. So I tell him he needs to go to the Emergency Room, and sooner rather than later. He said his wife was about 15 minutes away, but he wasn’t familiar with the town and didn’t know where the closest hospital was.

Unfortunately I didn’t either, so one of the techs looked it up on Mapquest and printed him a map with driving directions (yeah, it was that slow). Meanwhile, the cashier keeps asking me if we should call 911. I tell her that the man’s wife is within a reasonable driving distance, and if she gets there quickly we’ll just let her drive him to the ER. I said we would keep and eye on him, and if he started looking any worse, or if his wife took too long, we would call. She ended up getting there right as I was about to pick up the phone and call 911 to come get him. We got him a wheelchair, and she wheeled him out, and that was the end of it.

An obvious question comes to mind about all this. I’m a physician, and I’m standing there in the middle of a pharmacy full of drugs, and I know the protocol for treating an MI like the back of my hand. So why didn’t I at least give him some sublingual nitro? Or some metoprolol, since his blood pressure was high, even if he wasn’t having an MI?

I didn’t, because I’m not licensed to act as a physician without supervision, and am not eligible for such a license with only one year of training. Even though I really didn’t need any supervision in this case. But that’s the law in Washington state.

Also, without an EKG, I was only about 50% certain of what I was seeing. And I definitely didn’t have the resources necessary to deal with any adverse effects of treatment. And his condition wasn’t worsening without treatment, so my duty seemed mostly to make sure he got to the ER within a reasonable amount of time.

If I had an independent medical license, I’d have given him the nitro, and an aspirin. With just my pharmacist license, though, I have no business doing either.

I’m curious what others would do in that situation. Not that very many people would ever actually be in my particular situation here. But comments and constructive criticism are welcome.

=====================================

Thinking about it now, after the fact, it occurs to me that I could have called the local ER, and asked the physician on duty for instructions. Then I could have given the nitro and metoprolol without issue, or at least been told not to by someone whose hands weren’t tied by their licensure status. And that’s probably what I’d do, if I had it to do over again. But that’s definitely not the way I was taught, as a pharmacist, to handle an acutely or even emergently ill customer.

Feedback

September 24, 2008 at 7:39 pm | Posted in neurosurgery | 1 Comment

Ah, feedback. Not fun, but better than letting an error become a habit.

I do have a tendency to get defensive about things that really don’t deserve that much attention. However, as someone who’s always found it easy to figure other people out, and know where I stand with them and why, it’s very distressing for people to hold opinions of me that I don’t know the reason for, and therefore can’t address.

And apparently my personal statement is very dry. To which I say, better dry than crazy. Plus, that’s what happens to writing when it gets edited by large numbers of people. And mine has been edited by a small army.

Nonetheless, like George Michael, I apologize for boring you.

But seriously, consider the audience. For every resident and junior faculty who’d appreciate a shiny and entertaining personal statement, there’s a Chairman out there who’d consider it the sign of a ditzy dilettante, unsuitable for the serious reputation of their program. And if I can only show a single dimension of myself, then guess what? I’m going to play it safe.

If people want to see a more multi-faceted picture, they can always come here.

And speaking of feedback, I just got two interview invitations, both from programs that might actually be a good fit. Yay! Although you can never really tell until you visit. But it made my day. Particularly since it’s CNS week, and I really wasn’t expecting any.

Doesn’t add up

September 18, 2008 at 5:10 pm | Posted in neurosurgery | 4 Comments

Wow, I seriously underestimated how uncomfortable I would feel at neurosurgery grand rounds. Which is surprising because I did expect to feel somewhat out of place. But I actually felt frankly unwelcome.

It’s hard to tell what that means, without context. But the context in my life at the moment is a deafening silence in response to all my requests for help and advice, from nearly all quarters. And no one seems able, or at least willing, to give me any real answer why.

Think about it from my perspective. I’m a pretty normal person–easy to get along with most of the time. I get irritated when people waste my time, but usually let it go unless it involves something important. I get angry when I feel I’ve been mistreated, but almost never act on it without thinking through the consequences first. So with that as background, I work toward my career goal, and along the way people are generally supportive and encouraging of my efforts.

Imagine waking up one day, having done nothing differently than the day before, and all of a sudden people are treating you like a leper. No one will come within 10 feet of you. But no one will acknowledge that, and everyone insists that this is normal behavior, and nothing has changed from the day before. But you can see with your own eyes that it has.

There are a few people who aren’t acting like that, so you ask one of them to find out what’s going on and tell you. But then that person, instead of telling you, starts treating you the same way. Everywhere you go, and with every person you meet, it’s always the same pattern. And no one will tell you why. Or they come up with reasons that are profoundly insufficient as an explanation.

How do you get to the bottom of something like this? Because I certainly can’t fix what I don’t know is wrong.

I mean really, did I kill someone in my sleep? Are Katrina and Rita and Ike just massive Poltergeists of my creation? Am I shedding Ebola virus? Seriously, what’s the deal?

I suppose it’s always possible that there’s a disconnect between reality and what my records say. But why wouldn’t someone be willing to point out whatever it is they find concerning, in that case, so that I can address it?

Or maybe no one can tell me because it’s not me that’s done something wrong, and it’s easier to exclude me than to address the real problem. I don’t know the answer, but I certainly can’t take any of these possibilities off the table with the information I currently have.

Brought to you by the letter R and the number 2

September 16, 2008 at 4:52 am | Posted in Uncategorized | Leave a comment

First swim since the end of internship. It felt great to blow off some steam. Though it was a bit weird to drive home from the gym, instead of to the hospital to start pre-rounding.

In other news, I’m finally getting my mail again. Long story short, the post office has been returning all my mail, for months. After trying to get the problem fixed multiple times through my post office, only to have it recur within days, I lost my patience. I called USPS Consumer Affairs, and they sent it up the chain to be investigated. That very day I started getting my mail again, and so far, I’m still getting it.

And good timing, too, because today I got my admission permit for the pharmacotherapy recertification exam. Originally, I’d had an interview scheduled the week of the exam, which wasn’t ideal. But you know how it is in medicine: you study when you can and take the test when it’s offered, and hope the two occur in reasonable proximity. But then the program in question asked me to reschedule the interview, almost as if they knew I had other obligations.

Of course, it’s still during my 7-on stretch, but the hospital’s much closer to the test site than my house. Plus the test is pretty short. And, hello!, my shifts are only 10 hours long. Even tacking on the 4 hours for the test (recert is only a half-day), I’d still be work-hour-compliant if I were a resident.

As I’ve said before, it’s considered a hard test. The first time around, rather than trying to memorize a bunch of algorithms and treatment protocols, I made it into a game. Instead of figuring out what I would recommend, I pretended to be the physician in each clinical scenario, and asked myself, “given what I know about each of these medications, the disease, and the patient involved, what would I do?”

That’s not all there is to the test, though. There are three domains of knowledge, and you have to achieve a passing score in each domain to pass the test. The domains are: patient-specific pharmacotherapy (i.e. patient care); retrieval, generation, interpretation and dissemination of knowledge in pharmacotherapy (i.e. ability to contribute at an academic level); and health-systems-related pharmacotherapy (i.e. pharmacy management, patient safety and regulatory issues).

It’s that pesky middle part that gets most people. You actually have to know most of the common statistical tests and the kind of data on which they are appropriately used. And I’ll probably have to review those. Fortunately, I have an excellent book for that. It’s called Intuitive Biostatistics, which among its many useful features has a nifty table in the back summarizing them all.

You also have to know a lot about study design, the advantages and pitfalls of different kinds of studies, bias, confounding, levels of evidence, all that kind of stuff. However, any PharmD worth their title should know how to dissect a journal article. It’s knowing the nitty gritty details of statistical analysis that separates you from the pack.

It’s also hard to pass the third part if you only work in a retail environment, because there’s an alphabet soup of agencies that regulate hospitals, and you have to be pretty conversant with all of them. In fact, most hospital pharmacists aren’t that conversant, either. But I have management experience, which is a whole education in regulatory issues, if nothing else. So my career path pretty much gave me all the tools to pass, and I didn’t do a whole lot of dedicated studying.

I wonder how hard it will seem the second time around?

Time is of the essence

September 15, 2008 at 6:56 pm | Posted in Uncategorized | Leave a comment

Good Lord, I am about to blow a gasket over the delay in uploading my LORs. Clearly, however good the reason, the person assigned to upload ERAS documents is not getting the job done in a timely manner. So considering the time-sensitive nature of the task, why can’t my school assign her some help?

Seriously, I’m off for a couple of days, and I’m happy to volunteer. Or pay somebody who doesn’t have my conflict of interest. Either way, as long as it gets done.

The best line she never said

September 14, 2008 at 7:18 pm | Posted in Uncategorized | Leave a comment

“I invite the media to grow a pair. And if you can’t, I will lend you mine.”

Video here.

I just love SNL sometimes.

Wow, who could have predicted?

September 13, 2008 at 5:51 pm | Posted in Uncategorized | Leave a comment

I’ve been glued to the weather channel for the last 36 hours (or at least, the TV’s been on the Weather Channel that long, while I catnap between NOAA updates), watching Hurricane Ike steamroll across my hometown. The last time we had a direct hit like that was Hurricane Alicia in 1983. Alicia’s eye went right over my house.

We had no electricity for a week or two afterward. Which, in Houston, in August, is pretty hellish. September’s not any better, though. Temperatures don’t get reasonable in Houston until late October at the earliest. So it was a rough two weeks for all concerned.

It was also the first flooding of the hospitals in the Texas Medical Center. The one they didn’t learn from. My mom was working there at the time, and recalls about a foot of water on the first floor of the hospital. It was considered an anomaly, and not statistically probable enough to plan on it happening again.

According to the Houston Chronicle, the power company has managed to get the electricity back on in a few selected wealthy neighborhoods (my editorializing, not theirs–they just listed the neighborhoods.) Which is kind of strange, because the neighborhoods in question are not really contiguous. So it does kind of look like cherry picking.

One of my friends is marveling, on his facebook page, at the fact that his power is still on. Of course, he does live in one of those neighborhoods. And I know he’s not that naive.

Well, at least my brother’s house is fine. Although I haven’t heard from my dad yet, his part of town wasn’t in any significant danger either.

Learn, do, teach

September 10, 2008 at 2:18 pm | Posted in neurosurgery | Leave a comment

Ugh.  There was a craniotomy today at Outside Hospital, and I missed it.  Mostly because of the nutcase factor–it would be a little odd to just show up for the case without ever having introduced myself to the surgeon or the patient.  It’s usually OK to meet the surgeon in the OR, if you’ve been taking care of the patient, or to meet the patient in pre-op, if you’re already working with the attending, but in this situation I knew neither of them.  So, just showing up would not be kosher. 

This hospital, though, is actually quite a nice place to work.  The pharmacists there have almost as much decision making authority as the interns on certain rotations at the U.  Except pharmacists don’t have to deal with dispo. W.I.N.
Although I generally do prefer to be in charge of the whole picture, and not just renal dosing, with the occasional electrolyte, blood sugar, and anticoagulation management.  Fortunately, all the protocols have a judgment clause whereby I can alter the management based on the overall clinical picture.  Because once you get a feel for a particular patient’s physiology, it becomes obvious when the protocol dosing is not appropriate, and it’s important to be able to make the decision you know is right instead of having to blindly follow a population-based parameter.
The other interesting thing about this pharmacy is that it seems to be a haven for pharmacists with medical degrees, and pharmacy students who plan to go to medical school.  I just had a long discussion last weekend with one of the students in question, and he does indeed strike me as more a physician-type than a pharmacist.  Plus he is a good standardized test taker, although I told him that won’t help nearly as much with the MCAT as it does with other kinds of admissions tests.  But for whatever reason, people in pharmacy don’t tend to be good test-takers, and so it’s usually their MCAT scores that keep them out of medical school.  I did also warn him that the MCAT includes some areas of biology that pharmacy school doesn’t require coursework in, and it might be a good idea to take an extra class or two in preparation. 
It’s nice to be able to provide some insight into the process, and help people use their time effectively so they can maximize their chance of success. 

Arte Y Pico

September 7, 2008 at 10:58 am | Posted in Uncategorized | Leave a comment


What a lovely surprise! Someonetc. at Orthopaedic Residency: the Attending Perspective has given me the Arte Y Pico award for this blog. Here’s what he said:

Hurricane Jill: This former general surgery resident, future neurosurgeon, and now pharmacist consistently writes her humorously honest prose about her day to day life and struggles.

Who knew that my little exercise in self-indulgence would be of interest to anyone besides myself?

But let’s answer the prior question first: what the hell is the Arte Y Pico award? Click on the link and all will be explained. That is, if you can read Spanish. Yeah, I can’t either. But my trusty Google Translate made it pretty entertaining to read.

If you read my earlier post on awards, you know I am ambivalent about them. Nonetheless, I like this particular one. Mostly because I get to give it to, not one, but FIVE other blogs. How cool is that?
The rules of this award are as follows:

  1. You have to pick five blogs that you consider deserve this award in terms of creativity, design, interesting material, and general contributions to the blogger community, no matter what language.
  2. Each award has to have the name of the author and also a link to his or her blog to be visited by everyone.
  3. Each winner has to show the award and give the name and link to the blog that has given him or her the award itself.
  4. Each winner and each giver of the prize has to show the link of “Arte y pico” blog, so everyone will know the origin of this award.
  5. To show these rules

So without further ado, here are the blogs I’ve chosen:

  1. Cut On The Dotted Line by Dr. Alice. Her earnest and empathetic writing is a constant reminder of the idealism we all still have, somewhere underneath the tough skin we’ve developed. She is also someone you would never expect to go into surgery, and her transformation into a surgeon is a story not to be missed.
  2. Indifferential Diagnosis by Kevin and David. These guys are having way too much fun. Someone needs to crush their spirit, STAT! But really, this blog, with it’s ironic commentary on medicine and medical education, and anything else that occurs to them, is the funniest thing I’ve seen in a while. Thanks to Scalpel for the link.
  3. The Angry Pharmacist. Pharmacy’s answer to Dr. House. Frequently vulgar, crude, offensive, what have you. But thoroughly on point regarding all things retail pharmacy.
  4. DrugMonkey by DrugMonkey and PhysioProf. The view from inside the ivory tower. Well written, and by authors who are far enough along to have an opinion, and willing to share it.
  5. Running a Hospital by Paul Levy. The only hospital CEO with the confidence (and courage) to speak openly and honestly about his organization. It helps that it’s well-run and highly regarded. But the level of openness is still remarkable. And for physicians, it helps to see things from the other side, because the things that hospitals do don’t always make sense from ours.

There are lots of other blogs I read regularly, so it wasn’t easy to make this list. But I wanted to focus on blogs that were well-written, frequently updated, and which add a unique perspective on medicine as a whole. It’s just too bad there aren’t any blogs by neurosurgeons.

AKA Atlantis School of Medicine

September 5, 2008 at 2:12 pm | Posted in Uncategorized | 2 Comments

So the quandary today: reapply to the programs that interviewed but didn’t rank me?  Or blow them off for making me spend real money, that I’ll have to repay with ungodly interest, to accept an interview invitation I might as well not have attended?  It still pisses me off whenever I think about it, but I don’t like to make career decisions out of anger.  People always overestimate the impact of such decisions on who- or whatever they’re pissed at, and understimate the impact on themselves.  So thus far I’ve refrained from taking a stand one way or the other. 

Although the most egregious example is a program I’ve already chosen to get over myself and apply to, for reasons that don’t hold a lot of water when examined closely.   So I don’t know what the point would be in taking a stand on the others.  It might make me feel better, but I doubt it will accomplish more than that.
In other news, I’m still waiting on Tulane to return from the Gustav evacuation, and scan in all the documents they’re responsible for.   There’s only so much I can do on my end.
And now it looks like Ike may be headed in their direction as well.  So there may be another evacuation in the near future.  Maybe I should petition to have the ECFMG as my official Dean’s Office.  
Because this is getting ridiculous.

All the same

September 4, 2008 at 5:16 pm | Posted in Uncategorized | Leave a comment

Well, I did get paid today.  But the tightwad in me can’t bear to part with that much money all at once, so I’m pacing myself with respect to application submission.  I used up all my free and cheap spots, and there are still about 30 programs I’m interested in.

I’m also still hoping not to have to apply any further.  Although as each day passes, it seems more and more imperative to hedge my bets.  And the amount of money I’m willing to spend to do so increases, the longer my uncertainty continues.  
It’s the typical risk/reward curve, with the added dimension of time.  Most behavior conforms to it. Over the years, I’ve found that if someone’s behavior appears not to, it’s simply because I’m not accounting correctly for that particular person’s perception of risk.
In fact, that particular universality is the reason I changed majors in college.  I had started as an economics major, mostly to game the system.  In reality I was undecided.  But being an undecided major at that time, at my undergrad, meant waiting in line for hours and hours to do any kind of academic paperwork: registration, advising, adding and dropping classes…all the lines for undecided students were ridiculously long.  And the quality of advising is always inversely proportional to the number of students requiring it.
Economics, on the other hand, had no lines for any of these things.  It also had the absolute fewest required courses of any major at the school.  I had checked into the matter pretty thoroughly, so I knew that it would give me plenty of room in my schedule to explore other things.
I did take a few economics courses to mollify my advisor, though.  One of them was international economics.  And I don’t know what possessed me, but one day I took out the book and just flipped through the pages like it was one of those homemade cartoon booklets–you know, the ones where you flip through the pages really fast so it looks like the figures are moving.  Anyway, when I did so, it struck me that every single graph in that book looked essentially the same.  The only differences were in the slopes of the lines and the variables they represented.  The fundamental relationship between the variables was identical.
I was so disillusioned.  The professor was making it all sound so complicated, when in reality it was just one fundamental concept, with applications that differ only in the details.  I decided to stop wasting my time with the social and behavioral sciences, and instead learn something real and useful.
So now I kind of look at everything in the social and behavioral sciences as some variation on a theme, and it makes a surprisingly excellent framework for understanding actions at the individual level as well.  The trick, as with any kind of math, is accounting for all the variables.

Where is it?!

September 2, 2008 at 3:57 pm | Posted in neurosurgery | Leave a comment

Thursday, people. That’s when I get paid. But I certified it today.

New Orleans gets a break

September 1, 2008 at 3:05 pm | Posted in Uncategorized | Leave a comment

Fortunately, Gustav made landfall a bit too obliquely, and too far to the west to generate the same forceful funneling of storm surge through the MRGO that inundated the 9th ward after Katrina.

Then again, Katrina made landfall too far to the east to be a worst-case scenario, either. In fact, it was right at this point that we all breathed a sigh of relief, thinking that the worst was over. And as we all now know, it most definitely wasn’t.

However, this time I think it is. There’s much better surveillance now of the levees across the city, and I think if the floodwaters were creeping up anywhere in New Orleans, we would know by now. So that’s very good news. I wouldn’t wish that kind of disaster on my worst enemy.

My comment about the levees remains valid, however. It’s worth noting that Gustav, a Category 2 hurricane, that made landfall obliquely and too far to the west for New Orleans to see much more than its tropical storm-level windfield, still caused significant overtopping of the levees. Which is completely unacceptable.

Even more unacceptable is that the Bush administration will likely tout the lack of flooding in New Orleans as a credit to its hurricane preparation and levee reinforcement. When in reality it was probably not a storm that would have destroyed New Orleans even in 2005.

Remember, Katrina’s storm surge was reported to be 28 feet. Gustav’s was 18 feet at most, and actually only about twelve feet around most of the levees.

I’m very happy the city is safe. But let’s not dislocate any shoulders patting ourselves on the back over it. Because it certainly wasn’t any action by the Bush administration that spared the city.

Create a free website or blog at WordPress.com.
Entries and comments feeds.