David and Kevin present some old favorites

Almost 2 years ago, David and I started IDDx with the humble hope of turning this site into a blogging powerhouse that could be our one-way ticket out of the obvious career dead-end that is medicine. Clearly that has not happened. But we have still managed to build (and re-build) a loyal following of readers that have somehow found our inane drivel to be entertaining (or at least interesting in a car crash-y kind of way). We thought this would be an appropriate time to revisit some of our old posts as a kind of year-end-review and maybe serve as a best-of (or worst-of, as the case may be with Jess) list for the newer readers. (Re)Enjoy.

-Kevin and David

Medical student life: A few insights into the fast-paced world of call-taking, baby-saving, and retractor-holding.

David, Robby, Dan, Beth, and the Johns save lives while on vacation.

Kevin wishes these classes were real.

Kevin falls, David watches.

Pre-medical advice: Words from the arguably wise about facing the application gauntlet.  

David tells you what to do (in an admissions interview).

Kevin debunks 2 myths about med school.

David presents the 15-15-1 theory.

Comics: Only stick figures can provide a true window into the inner med student soul.

MCAT - Then and Now

OB exams are tricky

Ideal vs. Reality - Emergency Medicine

Guest authors: Who's better - Julia, Jess, Julia, or Julia? You decide.

Julia knows exactly the kind of doctor she will become.

Jess tries to reach the keeds.

Julia presents a landmark case of PMS.

Random thoughts, pet peeves, and theories about life: A potpourri of IDDx musings.

David Presents His #2 Pet Peeve: Considers It Tomorrow At Midnight Guy

David has difficulty with doors.

Kevin contemplates the diet of the Little Mermaid

Julia ponders a career in Neurology

As one of our school's rare 3rd years over-eager enough to attempt Neuro before 4th year, the mantle falls to me to talk about the good and negative aspects of this specialty. That… and Jesse is trying to steal away my tiara for himself. For shame.

Jesse's MRI confirmed some long-held suspicions...

3 Reasons for going into Neurology:

1. You might actually get to see your kids grow up.
It’s no psych, but damn it’s good to be a neurologist. During my time on this rotation, on most days it seemed possible for the non-call residents to get their patients tucked in and notes written by mid-afternoon. Plenty of time for David to get home and watch the nanny take care of the kids. Definite life-style points.

2. Fascinating pathology
While the neuro hospital floor is primarily dominated by strokes and seizures, consults come from all over the hospital. Although much of this will inevitably end up being delirium (or even nothing), every now and then the illusive and coveted zebra appears. The brain truly is a wonderful and enigmatic organ, and just because everyone keeps cheering that we’ve made so much progress in the past 10-20 years it doesn’t mean you still wont be surprised.
For example, I will truly never forget the consult on a patient with anoxic brain injury where, about 15 minutes into the interview, I realized the patient was confabulating everything! Because of his brain damage, he had gaps in his memory where he would fill in with false information. If the lie is subtle enough, it can be difficult to discern the confabulations from the truths. But then again, sometimes the lies are so outrageous they become readily apparent. No sir, I dont believe I've asked you these same questions 30 years ago...

Anyways, just remember the next time you see a patient who just had a right-sided intraparenchymal hemorrhage (i.e. brain bleed), it probably is worth it to ask them to draw a clock face.

3. Informative physical exams
Depending on which specialty you go into, the physical exam could either be a crucial component of the clinical picture or only a necessary hassle for billing purposes. For example in surgery the physical exam boils down to two things: bowel sounds = good, no bowel sounds = bad. Neurology lets you do a bit more. If you like solving puzzles, this is where it’s at. If you’re savvy enough with your physical exam skills and knowledge, not only can you identify at which level of the nervous system the lesion is located, you could probably tell something about exactly where in the brain or spinal cord you expect it to be. Some party trick, huh? Then you order the appropriate scan plus labs to get a more definitive answer. Neurologists out in the community or away from a major academic center may be the true LOTPEs.

It's (reflex) hammer time

3 Reasons to stay away from Neurology:

1. You can't cure a lot of the things you diagnose
Here’s a quote from a real-life attending: “Hmm… you know, I’ve never really felt the need to cure anything—sometimes it’s enough to just be able to tell them what it is.” While this is true, in some cases just being able to put a name on what ails you is therapeutic enough, it may not be very satisfying to you. Not mention, even if you do locate a resectable lesion, the patient gets bounced to neurosurgery. Sigh, those guys hog all the glory (and reimbursement). So if you’re on your neuro rotation and find yourself feeling a little too excited and relieved by meningitis because you can kills the buggers with antibiotics, then maybe this isn’t the field for you.

2. Medically sanctioned elder abuse
The patient might look like your favorite grandparent or that sweet little old lady down the street, but if they’ve got a decreased level of consciousness you can be sure you’ll be giving them a strong pinch! The idea is that you’re looking at their ability to sense, localize, and/or withdraw from painful stimuli. Keyword: Painful. Abnormal posturing (e.g. decorticate – flexor, decerebrate – extensor) can tell you something about the severity of what’s going on in the ole think-box. However, when my patient’s tearful and terrified wife is standing right there, it can be a pretty uncomfortable to do what would be considered elder abuse in any other situation.

Your heart sounds great ma'am. Just FYI, I may or may not need to jab you with a sharp stick in the near future.

3. Half your patients are delirious
For me, this is the biggest problem in neuro. Inpatient neuro is dominated by strokes, withdrawal, seizures, delirium, coma, and bad ass brain tumors. In short, most of your patients are going to have some sort of altered consciousness, so the normal exchange of the physician-patient relationship is lacking. Oncology is another specialty where there is a relatively low “cure” rate, but in the battle against cancer you the provider can learn so much from your patients. For me, this is probably the most challenging aspect to deal with day in and day out in neurology. It's hard feeling connected to my patients when they're accusing you of stealing their Jello to give to our alien overlords.

Jess tries to reach the keeds

Back and angy as ever, Jess attempts to unseat Julia as the premiere guest author with this, his latest rant. Enjoy.

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The recent revival of this blog and its stream-of-consciousness ranting affords a golden opportunity to similarly revitalize my own journalistic career – since this medicine thing may soon come to a screeching halt. I’m currently on pediatrics. I could simply refer you to Kevin’s elegant artistry to depict my feelings about the rotation, but that would ruin the cathartic nature of this medium. I’ll take a more positive approach than my colleague did with childbirthing – I’ll give one positive before launching into my top pediatric peeves.

The Good: A lot of kids are cute. When they’re in a good mood, they’re friendly and laugh and want to see how your tools work and it gives you that warm fuzzy/good feeling that you can only get from the sound of a child’s laughter – before passing them off to the demonized shot-giving nurse (which, by the way, must be the worst job in the world). I genuinely enjoy kids in general so this works out well. But there’s a lot to hate in general, so let’s not delay:

1.  The Vaccine Talk.

Every physician knows this one. For those of you unawares, let me break this down for you. We have, on one side, modern medicine and every doctor you’re likely to ever meet who contend that babies shouldn’t die. We have, on the other side, this guy. Now here’s the kicker: People believe Jim Carrey. To be fair, a “doctor” did originally perpetrate this bogus theory. One Andrew Wakefield proposed that MMR vaccine was related to a small subset of cases of autism via immunologic shenanigans. He then proceeded to present this and cause a panic which led to refusal of immunizations and then an outbreak of measles. Read that again. Of measles. Let’s get one thing clear: no one in the Western world should ever contract measles. The only time anyone should get measles is playing Oregon Trail.

If only YOUR MOM had vaccinated you.

Meanwhile, of course, autism didn’t miss a beat. Andrew Wakefield has now lost his medical license and practices homeopathic medicine in Texas. There are even new allegations that he fudged his data – but by God, that doesn’t matter, because a lack of understanding of basic statistics or physiology is no reason you should listen to your “doctor” about vaccines, because he’s probably just brainwashed and doesn’t think for himself (I swear, people say this). And you’ll hear the same random half-baked logic:

“Too many shots these days,” “given too young,” “those diseases don’t exist anymore (AND WHY MIGHT THAT BE?!?!)”

It wouldn’t be so bad if these people listened to reason. Or at least attempted to listen to reason. The following is an almost word-for-word transcription of my preceptor’s attempt to convince someone to get their kid a meningitis vaccine:

“Here’s all the excellent and well-founded scientific reasons why your kid is way more likely to die from meningitis than from getting this very safe vaccine.”

“Yeah but I don’t give my kids shots until they’re 1 year old.”

“Why?”

“I just don’t. I’m convinced I know better than decades of data and scientific research and besides I can selfishly rely on herd immunity which, by the way, I undermine by not getting vaccinated.”

“…..Kay. But seriously, why?”

“I just don’t.”

You get the picture.

2.  Schools waste doctors’ time. 

Everyone has had this experience –little Johnny had a cough/cold/stubbed toe but, because he missed time from school, he requires a doctor’s note to allow him back. This means that little Johnny gets to wait in the office for 2 hours with all the bacon-lungers so that he can get a doctor to confirm that yes, in fact, he was coughing, and no this was not some elaborate falsehood perpetrated by the parent. But even if he wasn’t sick, he sure as hell is now. In which case, of course, he’ll have to come back and get a separate doctor’s note just so he can expose everyone to it. At what point did we stop believing parents when they say their child is ill? Congratulations, Principal Jones, you’ve once more saved the integrity of your pedagogical bureaucracy – but at what cost? 

At least they're NOT VACCINATED.

3.  First-time parents possess no common sense.

This may represent a failing of our public education in some ways, but so many new parents seem to have no other option when their child is ill but to come to the ER in the middle of the night and/or demand to speak to the pediatrician on call. I understand that you can’t tell for sure how sick your 10-month-old child is. He can’t talk. But with a few tidbits of arcane medical knowledge, several ER visits could be avoided: 

1) 99 degrees is never, under any circumstances, a fever. I don’t care that your baby usually runs 98.4 so it’s a little hot. Being asked to write a note justifying school or daycare absence for a temperature of 99.1F rings hollow. Pediatricians don’t get too concerned until 100.5F, so don’t bother them.

2) Babies are rashy. Please do not demand to speak to the on-call pediatrician because your child has one new red mark on their skin. It’s not cancer. It will likely be gone within a week without a single symptom. Go to bed.

3) Babies are loud. If your baby is crying, try feeding the baby. Try holding the baby. Try rocking, cuddling, or singing to the baby. (Do not ever shake or throw your baby). If these don’t work, does baby otherwise seem sick? If not, it’s probably not an emergency.

4) For God’s sake, triage nurses exist for a reason. Self-explanatory.

I enjoyed my time on peds, but as you can tell, there are more than a few things which could be more satisfying about the setup. I did almost entirely outpatient pediatrics, so I was mostly in clinic the entire time – which can be numbing on its worst days.

Julia knows exactly the kind of doctor she will become

"Sorry, can't educate you about this Fragile X Syndrome your baby boy has, but I CAN talk to you about German health care reforms from 2003-2007."

Ladies and gentlemen, since you were aghast at the long silence on this blog, let me tell you what has been keeping our two class-clowns from their ranting: our med school’s obligatory course on health care structure, policy, and reform*.

Yes, this is a good idea at its core… after all, if we didn’t know anything about the organizations that will be paying us some day that would be pretty lame. However, this class is decidedly a scheduling bully—perhaps a little insecure about itself, and therefore going to make your life miserable to puff up it’s own sense of self-importance. Weekly quizzes requiring recall of minute details from the readings and lecture slides? Awesome. In-class “debate” group presentations, where the professor may-or-may-not call you a liar? Hmm… alright, I guess... Arbitrarily restrictive, two-page, double-spaced paper proposing 1-3 major health care reforms, while giving background and then providing objections to it? Ugh, just leave me alone already!

This class single-handedly managed to eat up more time weekly than musculoskeletal, genetics, and hematology combined!

So, while that pain in your shoulder causing you to be unable to raise your arm to shoulder-level may be very concerning… Can I interest you in a discussion on the pros-and-cons of a physician’s duty to follow public health mandates during a disaster?

Julia presents a landmark case of PMS

We here at IDDx are always looking for ways to improve the quality of our content (see: Beef Stew). A few months ago we experimented with guest authors by publishing an article written by the now infamous Jess. However, the reviews were less than favorable, featuring comments such as “Oh god my eyes,” “I think I just threw up a little in my mouth” and the much feared: “You’ll be hearing from my lawyer.” One drawn out mental anguish lawsuit later, we have decided to venture into the realm of guest authorship once again, this time with a new, less Jess-y, author. Enjoy

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Okay, so PMS in the general population may not be that remarkable, but when a landmark case - such as I am about to relate to you - is encountered… well, is there not an intellectual duty to report it?

I was in the hospital cafeteria trying to grab some lunch in the small window of time between my visit to the gym and class. I grab some veggie burrito and head over to the cashier. I get into a line behind a woman who is already checking out and thank my lucky stars that I managed to avoid what is normally a long line and crush of people at lunchtime. Things are working out today. Huzzah!

Wrong.

While this woman is seemingly gathering up her plate and soda, the cashier has already rung me up. As I am handing over my cash, this woman turns and tries to walk through me, presumably to get a napkin or utensil or something. Instead of then going AROUND me the way a normal person might, suddenly I hear her bark at me “Uh, could you not put your dirty hand over my food?!” I am so shocked by this I simply say sorry, take my change and go.

Come to think of it, I don’t even think my hand WAS over her food. Perhaps it was in the airspace adjacent to the plate in question. But, to be fair, there is no way to prove that the microbes on my hand WEREN’T propelling themselves into the air and free diving into her mashed potatoes, so we can probably overlook this. Aren’t we always hearing about what a problem iatrogenic infections are around hospitals?

So I walk out of the cafeteria, prized burrito in hand, and begin to head back to class. However, I quickly realized that someone was on my heels, tailgating me. I turn my head to look over my shoulder et voila! It is the nasty lady herself. Is she done with me yet? Oh no, dear reader, she still has a little something snotty left.

“Oh great and why don’t you get your hair everywhere too?”

Excuse me? Now, what we had here was a definite pot-and-kettle situation. I have long curly hair that I was wearing down at that moment. However, she ALSO had long, dark curly hair that was down.

Think, Julia, think! “Um, could you try and not ruin my day as well?” Ok, not the wittiest thing I could probably have come back with, but honestly I was so shocked by this behavior coming from a total stranger… I mean REALLY.

Well at this point she just ignored my existence and stalked back towards her office. Touche, cranky-professional woman. Until we meet again... one month from now.

Jess Judges People Who Take The Internet Too Seriously

Note: Jess, a frequent comedic muse for all of us here at IDDx, has chosen to grace us with his vitriolic brillance in this, the blog's inaugural guest post. Enjoy.
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In an effort to break the previously nigh-impenetrable color barrier of YM/IDDX, I have decided to end my months-long silence. Perhaps you’ve seen the way I seem to dominate the subconscious of our two gracious hosts and co-authors and wondered: “who is this mysterious and much-maligned ‘Jess’ about whom David and Kevin cannot stop thinking?” I know I have.

If you’re looking for a break from the pet peeves, the snap judgments, the arrogance, and general holier-than-thou attitude demonstrated by the Ubiquitous Duo, I’m afraid I’ll have to disappoint. In the spirit of this interblog, I’ve decided to contribute my own pet peeve, inspired by a recent firestorm of controversy surrounding David’s latest post. That’s right, Takes The Internet Far Too Seriously Guy, this post is about you. Your self-righteous but, ultimately, cowardly anonymous soapbox rant has found semi-permanent purchase in the electronic archives of Indifferential Diagnosis. Congratulations – if there’s one thing I love more than a good rant, it’s irony.

TTIFTSG, or TISG, for short, is an odd and unfortunate beast. Cursed with a chronic case of Perineal Silicosis, and a close relative of Self-Righteous About Obvious Or Long-Ago Resolved Causes Guy, he spends his evenings perusing and, usually, enjoying the assortment of witty banter that can be found on the internet. Usually benign, TISG has a proclivity for sudden bouts of ineffectual whining and self-righteousness which manifest, usually, in anonymous posts on blogs which have, intentionally or otherwise, touched him in a sensitive place. An ironic animal, TISG often vents his own insecurities by assuming the moral high ground over complete strangers, often engaging in copious amounts of projection in order to make himself feel like a sensitive, intelligent, and worthwhile human being. What places TISG an evolutionary stratum below his cousin SRAOOLARCG is that TISG often, by definition, hides behind the veil of internet anonymity to foist his presumed ethical superiority on others, thereby preventing any potential retaliation.

There are a number of logical fallacies inherent in our local variant of TISG’s behavior. In no particular order, they are:

1) TISG admits to having read at least ’10 other posts’ with ‘shit like this.’ Presumably, if it offended him in this post, ‘this shit’ offended him in these other posts – and yet, he visits this site frequently. Many times a day, in fact. That’s right, TISG – we can see you. In fact, I counter your rhetorical query with one of my own: who goes out of their way to read a blog, created by individuals he does not know, if it offends him so?

2) TISG has judged David and Kevin to be insecure, judgmental people based on their harmless, stream-of-consciousness rants in a blog predominantly intended for friends and classmates. His assertion is based on the UD’s habit of ‘going out of their way’ to judge others. By going out of your way to pass judgment on D and K, TISG, are you not every bit as insecure and judgmental as you accuse them of being?

3) That you continue to read the blog is evidence that you enjoy it. Therefore, one can only presume that you are looking to assure yourself that you can read this blog and still be a good person by condemning others – the difference between you and our hosts is that you, TISG, meant it. Don’t get me wrong, D and K mean every word – especially in re: me – but their intention is not to make anyone feel bad (though they obviously have), but to amuse others who enjoy such humor. You, on the other hand, are serious – and your intention was simple: to attempt (unsuccessfully) to make them feel bad for their work. I leave it to the kangaroo court of classmates and friends to determine which one is, as they say in ‘the biz,’ douchebaggier.

4) The simple truth is that David and Kevin’s posts are predominantly inspired by, to use your eloquent colloquialism, ‘shit like this.’ Without people who acted ridiculously, how would they propagate their insensitive and judgmental wisdom throughout the internet? The self-righteous hilarity of your comment is precisely what makes them, and their fateful readership, tick. That they are meant light-heartedly and sarcastically has obviously been lost upon you. Ergo, you’ve prompted precisely the sort of behavior to which you are opposed.

Still, I must commend you – comments like yours, coming from outside of the intended audience (comedically-astute and thick-skinned individuals) make this all the more enjoyable for those of us. Simply put, TISG, your presence, while confounding and ultimately self-contradictory, is panacea for a pair of writers with nothing better to do than belittle others for their own amusement – immediate reward for minimal effort, borne entirely of your embarrassing misstep. And make no mistake – this is embarrassing for you.

For those of you who want a one-sentence summation of this rant, here it is: the blog is called Indifferential Diagnosis for a reason. Thank you for coming, but check your soapbox at the door.

Unless you’re David or Kevin, of course. That’s just one of the many unfair societal double-standards to which we’re subjected.

I feel so much better about myself, now.