Doctor I Have a Disease I Just Invented

The first few weeks of fellowship I saw a fair amount of Lyme disease which, being from Texas, was like a cool, exotic infection I'd only previously read about. Neat. The last few weeks of fellowship, however, I've been seeing a lot of chronic Lyme disease which, being a made up condition, has made me accordingly increasingly sad.

There are a lot of unfortunate, difficult to treat diseases that exist in the world: dementia, sciatica, fibromyalgia, the crazies; but for the most part there's little debate whether these are true disorders or not. Whether you believe the primary problem in management is organic or more pyschosocial isn't so important as in either case you can at the very least categorize it, label it, and provide a foundation upon which you can work with your patient. Fibromyalgia, the wackiest of them all, even has research proven therapies which can help, sort of, if anyone would ever cooperate with a physician's recommendations. Chronic lyme disease, on the other hand, is a disease that in all reality doesn't even exist. There is in fact no such thing as chronic Lyme. The patient may as well just tell me a woodland fairy placed a curse on them so I could at the very least reply with, "that's impossible. Woodland fairies don't know any curses. Only marsh fairies cast spells. Jeez." Instead I am left with either "get out of my office," or "interesting, tell me what's been going on."

The clinic appointments for these unfortunate souls inevitably becomes an endless list of various, mostly subjective complaints followed by a review of systems I wish I didn't have to go through. Everyone's abdomen will be tender. Everyone's joints sore. Everyone's blood work and imaging are completely normal. Sometimes they are at the very least a little creative with their complaints -- something I do appreciate -- but even if you can get a patient to admit that a particular symptom is getting better it is often quickly pointed out that it's only because it's about to get much, much worse. "Blue tongue you say? It doesn't look blue now." "Yes well it's not blue today." "So it's getting better?" "No! Why would you say such a thing?!" The worst part inevitably comes at the end when I must decide how I want to tell them they're full of it. Despite various approaches I have yet to find the reply that yields a grateful smile and gratitude for the visit. I am finding it is often enough easiest just to defer the conversation to my staff -- who I have to discuss the case with regardless -- who with his years of experience can tell patients there's nothing we can do for them in a very polite, scholarly, and time efficient manner.

If it weren't for the fact that most these people are otherwise good folks who are eagerly trying to figure out why they feel like crap literally all the time it would just be perversely funny. Because of their various personality disorders and tendency to believe whatever lunatic site they found on the internet over a trained specialist who can explain to them why chronic Lyme is nothing more than heavy metal induced insanity, however, I can often only extend so much sympathy. In the end the best solution may just be to give them what they typically want: an endless supply of medicine.  That's why I am actively working on a cure with the Willy Wonka Pharmaceutical Company. We hope to have a twelve month supply of prescription strength Sweet Tarts Lyme Zapper! ready to go by winter. Due to the unforeseen tastiness of the cherry and green apple formulations leading to production shortfalls, however, it'll initially only be available in grape. Thankfully that's the strongest flavor. Unfortunately it's also the most expensive. And the kind that gives them cancer; I read it on the internet.

When Casual Goes Amok

Boots and brown uniform or shiny shoes and blue uniform. Simple. Back when I was an Air Force resident I never had to decide what to wear, just had to make sure it was clean to wear it. Considering dress clothes are little more than expensive, uncomfortable ways of letting other people know how much money you make, I did not mind this situation. Now, however, I am a civilian and being a civilian physician I am also a professional. Time to don a wider variety of shiny shoes and an endless combination of pressed shirts, ironed slacks, and variably colored ties in order to instill confidence in my patients and trust in my medical decision making. A few hundred dollars later, I do not care for it.

Thankfully due to the inherent infection risks involved with ties doubling as improvised germ swabs, ties are optional and I have opted out. My wardrobe is thus about as comfortable as the uniforms I used to wear. The thought of paying $2 a shirt for a wash and ironing to maintain this wardrobe remains ridiculous to me, but I have accepted this reality and in reality it is better than the equally ridiculous alternative of wasting time doing it myself. The problem lies not directly in the wearing and caring for the clothes themselves, but in deciding which clothes to wear.

Being an infectious disease fellow I am compelled to do other things than just take care of patients and trend their blood sugars. I've got to research in order to maintain my infectious disease street cred. Traditionally this involves absolutely no patient contact, and considering our fellows' office is windowless it currently doesn't even involve human contact. I just sit in my room, in front of my computer, and make research magic. Occasionally if I'm feeling adventurous, or losing my mind from sitting all day in a windowless room, I will take my computer to a study area on the eight floor, but even there I don't interact with any human beings in any official capacity. One would think, therefore, that I could perhaps dress casually for such a job. Maybe try to make myself comfortable for something that is inherently tedious and uncomfortable. And one would be wrong.

Not entirely sure what the reaction would be I tried to slowly ease into a more casual form of dress. First I ditched the pressed shirts for generic collared shirts. Then the slacks for run-of-the-mill khakis. And, finally, khakis for jeans and tennis shoes. That's apparently when I got greedy. Based on the numbered of bewildered responses and frequency of exasperated double takes I had gone too far. Research casual, it turns out, ends somewhere between a casual pair of Dockers and a dress shirt with its sleeves torn off. Maybe corduroy pants and a bolo tie would be ok, I don't know. In either case after about the seventh startled, "oh, jeans!" I decided to return to the khakis and collared shirt look just to stay in good standing. Perhaps when I get enough publications under my name I can dust off the ball cap and sport coat look. Just in case I'm feeling a little douchey.

Snowy or Extra Snowy?

Portland gave me the finger.

Actually they were much more polite than that. No one gave anyone the bird. I just got an apologetic phone call and a formal letter a few days later. And that was that. I was not going to Oregon Health Science University (OHSU).

By then I had also visited the Medical College of Wisconsin (MCoW) in Milwaukee which, I learned, is not spelled with an "a" after the "l", and received word from Dartmouth-Hitchcock Medical Center (DHMC) that they too would like to invite me out for a quick chance to turn me down. The Milwaukee interview was standard as far as interviews go, and the program was myeh. In short: it was snowy, the people were nice, I flew home. I was going to say I finally saw the Great Lakes, but then I remembered that I had seen them the year before in Toronto. Truly a remarkable experience.

Milwaukee from a snowy pasture somewhere.

Dartmouth, on the other hand, was something a little different. The obvious name recognition aside, the program had an explicit global health focus in addition to a sound foundation in the infectious disease basics: HIV, wound infections, and beaver bites. They additionally made no apologies for the snow instead boasting of the numerous winter activities you could partake in virtually year round. The staff were similarly friendly, the hospital remarkably modern, and the city was charming in the sense that it was roughly the size of a small truck stop assuming it was a small truck stop run by affluent, well dressed white people. And, to top things off, their anticipated call rotation the next year was once six weekly. Truly a magical place. Both institutions offered me a job.

Hanover from... well... anywhere.

The next week I signed the dotted line over the phone and began the process of separation from the Air Force culminating in much paper work and even more merrymaking. Of all my three options, OHSU included, I believe I lucked out with Dartmouth as I was only informed of their availability literally a day or two before I was to sign a million dollar, multiseason contract with MCoW. It is the best combination and balance of education, interest, and free time. A place I look forward to going to. Shortly thereafter I got an email from the University of Utah in Salt Lake City -- an institution that had arguably been my number one choice earlier in my search -- stating that they too had spot and were wondering if I wanted to visit for an interview....

God sure gets His jollies in weird ways sometimes.

I just hope that when they dig my body out of the New Hampshire snow hundreds of years from now they find some interesting things in my pockets.

Down From the Land Where the Sun Don't Shine

I am told Portland is a town of tree huggers. From my recent visit I can truthfully say this appears to be correct. The town has many trees and some of them appeared to have actively been in the process of being hugged. Parks and rivers run through it, bicycle lanes riddle the streets, and it is reportedly a crime to run over pedestrians. Because of all this mother nature loving, squirrel kissing, crystal rubbing hippiness there is also an active land management program by the city which aggressively manages how land is used and which limits suburban sprawl. As a result of this, then, and combined with a well-developed street car and light rail system, Portland has what seems to be one of the most livable downtowns in the nation. Unfortunately this means I need to drive a ways to find a good strip mall, but I think I may finally be strong enough to get by without massively discounted bath soap and bath soap accessories.

Portland’s urban thriftiness is never more visible than in its main medical center, the Oregon Health Science University. Perched atop a rocky and tree strewn hilltop near the city center the medical complex has been forced to work with limited land and limited not-cliff space by building less in the horizontal and more in the vertical, diagonal, and all over the place. Stand near a window in the main adult hospital and you can see a sky bridge leading to the pediatric hospital adjacent, a parking garage stationed immediately off the precipace below, and the veteran’s hospital sitting oddly at an angle sitting somewhere in the clouds. It is an unusual and striking site to see as building is built almost upon building to make it all work. So unusual in fact, that I did not take a single picture of it.

I did, however, take a picture of this:

I think it’s a sign warning bicyclists of booby traps. There was another one a few blocks down which I believe depicted bamboo spikes and an improvised of foot snare.

All in all Portland seems like a pretty great city. Mostly because I enjoy squirrel kissing, but also because the Infectious Disease program at OHSU seems quite amazing. The staff were cordial, the program rigorous, and the facilities impeccable. I am admittedly likely under qualified. Thankfully, however, just like me the suckers got limited options. Here’s to making the best of what you got. Hopefully that means I’ll soon be Oregon bound.