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.

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.

Sometimes You Just Gotta Move

I have officially been a doctor about... oh... one and twelve thirteenths years now. Around the one and seven thirteenth mark I came to a realization about my job that although not particularly revolutionary is still remarkable. That is: there is no escaping the crazy and the boring. No matter what path I decide to take in medicine I will always have patients that are loony toony or just dull, tedious, and boring. For a while I had had reservations about pursuing a career in infectious disease due to the tendency for infectious disease docs to be the antibiotic monkeys of the orthopedic surgeons -- resulting often in clinic visits with nothing more than a demented patient, a handful of illegible nursing notes, and a PICC line -- but now I know we all got our burdens to bear.

This realization came during my neurology rotation. Although I already knew neurology to be full of the dull, tedious, and boring I was caught off guard by the amount of crazy. Where as rheumatologists have fibromyalgia, endocrinologists have "hypoglycemia", cardiologists have "chest pain", and allergists have their entire careers, neurologists have pseudoseizures. Pseudoseizures, for those not in the know, are seizures that aren't really there. Hence the prefix pseudo-. The more politically correct term currently is "psychogenic non-epileptic seizure" but I imagine this will be the case only as long as it takes people to realize "psychogenic" means "full of crap." In every case people twist and turn, writhe and shake, hop and bounce all convinced they're having a seizure when, in reality, they've just got a case of ants in the pants.

The reason pseudoseizures are such a pain is both because of the high incidence of personality disorders associated with them and the requirement of a 72 hour sleep deprivation study to diagnose them. Regular seizures are hard to provoke but it turns out not letting someone sleep for a long time is a pretty good way to do it. It is also unfortunately a pretty good way to make a healthy but ornery person into a healthy but fairly irrational and agitated person as well. The purpose of the study is to capture on video and electroencephalogram (EEG) a purported seizure. Comparing their movements and brain waves gives a nearly infallible assessment of whether the seizure is genuine or not. Although some people can fake seizures with the best of 'em, it turns out it is hard to fake an EEG.

Thankfully, amongst all the painful explaining that all the Depakote in the world won't stop you from having the seizures you aren't having, there are the lighter moments. Specifically, when the patients are *not* good at faking seizures. During my month on the neurology service there was all kinds of wackiness but the best "seizures" of the month were memorable. Runner up went to lady who back flipped off the hospital bed while first prize went to young dude who did some sort of fully upright hokey pokey. In the words of a colleague, "that's not a seizure. That's a dance move." I am sure people with pseudoseizures have great struggles both with their condition and in life, but, man, if you're was going to fake a disease at least take some disease faking classes first. Or go with psychotic parasitosis. Prove to me I don't have parasites!

The OSBID Service

I always expected sadness in medicine to come in the form of unexpected morbidity and mortality. Someone under my direct, active care expiring despite the best efforts of the team I am a part of. I have thankfully not experienced it so far this year, but have certainly in the past and so I can say, too, from experience that it is heartbreaking.

But only momentarily. It is the shock more than the event which brings about the feelings. Sad things happen all the time in medicine, it is often only when they catch you off guard that you feel them, however. Like a bullet to a flack jacketed frame, I am stunned briefly, but otherwise unhurt. For a short while I am without breath, but I recover and aside from some mild bruising am no worse for the wear.

I also always appreciated, I feel, the subtle, grinding effects of disease on clinicians. Sick, sad, hurting, angry, and confused patients and families get underneath the armor to slowly wear you down. It is not the only side of medicine -- there is an equal share of pleasant patient interactions to reward and rejuvenate -- but it is a significant side nonetheless.

What I did not expect, and what I did not prepare for in all this, was gratitude. Not thankfulness for refilling someone's prescriptions or a vigorous hand shake for treating grandpa's chancroid or a even kind word from someone who's pain was heavily medicated, but gratitude undeserved and a smile in spite of pain.

Working on the Infectious Disease (ID) service at Brooks Army Medical Center (BAMC), now more commonly unofficially known as the Orthopedic Surgery and Burn Infectious Disease service because of all the war wounded, I experienced such kindness in spite of loss on a somewhat regular basis. Most of our patients were amputees with infected stumps or burn victims with infected everything. Victims of IED blasts, RPGs, and mortar attacks. Many times, unfortunately, despite our best efforts and the collective intelligence of what I believe to be some of the smartest infectious disease doctors in the nation, things didn't get better. Antibiotics these days can only do so much. But even the completely recovered were still, well, amputees and burn victims. Young men and women whose lives would be forever different for the worse. It is possible to still live a happy and fulfilling life injured as they were, but chances are certainly not in their favor. Everyone knows this, I know this, they know it, and when they then thank me for doing a little to make life suck a little less, well, I don't know what to do.

This was worst when I could see through their ruse. Frequently I would see my patients in the cafeteria -- no frowns were on their faces but their shoulders were often enough sagging from emotional fatigue -- and we would bump into each other. Recognizing that, hey, it's me, your physician!, they would briefly, magically transform themselves and on their face would be a generous smile and a pleasant hello. Perhaps we'd exchange a few pleasantries even. If we didn't run into each other, however, if they remained anonymous, their grief and distant eyes remained. I'd see them tired enter and tired leave. It is not that I think they were being insincere or just polite -- truly their motivations are unimportant here -- but rather, simply, I was able to see them with their shields down as well. I saw the disease taking its toll. Being strong means you take the pain not that it isn't there, but it is often easy to interpret things the other way for those not enduring it.

So it is this combination: seeing them freely hurting and seeing them graciously smiling that gets me. It is one of the few experiences during the day that get me out of the hustle of paper work and data collection and actually make me stop to feel what I am doing. It is not that I do not care for or about my patients otherwise -- I certainly do -- it is just that the intellectual practice of medicine often detaches you in the process. I am on the Cardiac Care Unit (CCU) service now and people are dying but it is not the same. I will briefly shed a few tears for some of the lost in the unit, but I have so far only been deeply moved by the the patients I've taken care of while on ID. Unexpected.

So that was sad. Anyone watch Wipeout?! What a great and entirely terrible show.

Gone a Soldiering

After a two year long hiatus I have once again incorrectly donned my BDUs and headed off for a brief active duty tour with the United States Air Force. Zoom!

Wright Patterson AFB in Dayton, Ohio, is an immense installation occupying a large portion of the surrounding area. If you look at it on a map you may think, "dang, that's a big base." Well, not quite. The area encased by acres of razor wire and blocked off gates is indeed quite large, but it turns out its mostly well watered putting greens and hazardous sand traps. Aside from the hospital it seems that much of the base is offices and golf courses. I can't complain, though, the less personnel there the less likely it is anyone will notice I've almost completely forgotten what I'm doing. And they have the most unbelievable wooden playground I have ever seen. Some day I will make a pilgrimage with my own kids here; it will be glorious.

One of the greatest truths I feel about the military is that it does the best with what it's got. Sometimes this is quite a lot, and sometimes it's not much. In this modern era of ours medical doctors are frequently somewhat hard to come by generally speaking, and this shortage is particularly acute for the armed forces. Few doctors want to undergo further teaching, testing, and training all for a bit less money and with little say on where they get to live only to be yelled at in the end that they're doing it wrong. As a result the military frequently has to go out of its way to limit the extra burden it places on its new recruits and so sends them off to things like Commissioned Officer Training (COT) hoping in one month to teach them everything they need to know about being in the military. The end result is perhaps a few more doctors, but they're all doctors that march crooked and salute funny.

And so with this in mind I returned for another month of the airman's life with a significant degree of anxiety. I was reluctant to leave my hotel room -- more formally known as the Visiting Officers Quarters -- for fear that I was doing something wrong and when I did do so I made sure I moved as efficiently and discretely as possible so as to avoid attracting any attention to myself. Thankfully the hospital, as it is itself composed of mostly high ranking COT medical graduates, was particularly laid back, but even there I was not free. On the first day I got ten demerits for having with me the wrong colored backpack and a week or so later I received a couple more for wearing my hospital ID attached to my BDUs outside the hospital's doors. Aside from these few infractions, however, I was mostly safe and within a few days was once again at ease. I did have one last incident of note, though, involving twice running into the same foreign military officer and not knowing what to do either time. Do you salute? Does he salute? What rank is he anyway? Are those stars? He can't be a general; looks too unimportant to be a general. Why do all these foreign uniforms have so much flare on them? Is he staring at me? Oh god, now what? Stare back? He's not moving. Keep staring. Stare harder. Now look away. And... pass. I still have no idea what exactly I was supposed to do, but after awhile I've learned you get comfortable with that feeling.

Anyways, the Air Force business aside, the residency program was, I felt, not so bad. The hospitals looked fairly nice, free food at the awesome Miami Valley cafeteria, much more attractive nurses than down in San Antonio. What was disturbing on the other hand was the people involved. Although I don't think any of the attendings were bad people per se, many of them seemed to feel obligated to have an uncomfortable, unpleasant working relationship with their residents and interns. The residents seem to have gotten used to this. The interns seem to have become depressed. I honestly felt an air of melancholy while I was in the hospital. The place just seemed unhappy.

My interviews were mostly a huge waste of time. I suppose many of the staff need to get at least a rough idea of my personality, but that's all they got as few questions were asked and each session was mostly a brief conversation and a good series of hand shakes. One of them didn't even ask me any questions aside from how I was liking my rotation. What bothered me, however, was not the general silliness of the interviews with the Air Force folk, but my one interview at Miami Valley. The woman knew nothing about me aside from the limited information on my personal statement which was short and vague in compliance with the military's requested word limit, and yet she chose to ask me, "are you the first doctor in your family?" "What makes for a good attending?" "What do you like about our program?" What do I like about your program?! Uhh, pass? I don't like your program. I wouldn't be applying for your program if I was not limited to it and two others one of which was recently destroyed by a hurricane. How about your cafeteria, that seems pretty nice. Do you actually want to know anything about me? And so our interview went. Thankfully the other fourth year HPSP student I interviewed with felt much the same. If I'm gonna be arrogant and presumptuous at least I can be arrogant and presumptuous with friends.

My interviews aside the rest of my stay was mostly joyous. The Uniformed Services University of the Health Sciences (USUHS - pronounced "yoo-shuss") students were all for the most part friendly and cordial. Went went about town most weekends, listened into the Sheryl Crow concert (who knew the woman had so many famous songs?), and even visited the much talked about Oregon District (in Ohio Oregon is apparently pronounced "Ore-eh-gone") which consisted mostly of scarcely occupied bars and adult erotica stores. I also made it to the USAF Museum; a surprisingly enjoyable and interesting experience. Also a ridiculously difficult place to take pictures in which, combined with my naturally poor picture taking abilities, produced some pretty crappy photos. Ohio, as a whole, I feel is not a bad place to live. I wouldn't mind coming back the residency program notwithstanding. It's definitely different than San Antonio, though the obesity's the same, but in many ways it's an enjoyable different. We'll see what the Air Force says.

As a final thought, it seemed most streets on base were not named with historical figures, important geographical landmarks, or really anything the least be significant or inspiring. Instead they were things like Evergreen Wood and Doe Brook. If ever tasked with naming the roads on the base I end up at I'm definitely going to be living on Exploding Freedom Avenue.

Pictures!

Oh, and it turns out I do like Infectious Disease after all.