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Axis Deviation

A internal medicine resident cardiology fellow shares his thoughts and feelings.

Updated: 2018-01-03T05:28:01.282-08:00








Start of Fellowship


Today marked the first day of fellowship, peoples. No more internal medicine ... from now on, your Axis will be in cardiology fellowship training. What will this mean for us?

For me, it will mean finally being in the specialty I enjoy. It means no longer dealing with patients with issues that are beyond the sphere of my interest. No more dealing with social issues and where to place patients upon discharge. And most importantly no longer am I the Plan B (or C, D, or worse), in terms of the service to whom patients should be admitted when no other service wants them.

For you all -- for those very reasons -- it might mean this Axis might just be happy for once, which, in turn might mean blog posts that aren't quite as bitter and venomous.

Who knows? We have several years to find out. Stay tuned.

Residency, By the Numbers


Years of residency3
Months of residency36
Days of residency 1094
Number of them I spent overnight in the hospital 223
Most hours worked at a time 36
Most hours worked in 48-hour period 40
Number of pts I admitted (approx) ~1500
Number that died under my watch Small handful
Number of pages received TNTC
Number of times I threw my pager into the wall 0 (!)
Number of lumbar punctures 12
Number where I shook the needle because of a page 2
Number of patients in my clinic panel 110
Number who I truly liked 2
Number of pelvic exams I did 36
Number I enjoyed 0
Number of times I pinched a cervix 1 (so sorry)
Number of times I performed the "whiff test" 1
Number of times I converted my PPD 0
Number of needle sticks 1 (pt HIV negative, whew)
Number of lawsuits 0
Number of days left of residency 0



I stepped into an elevator at work today just as another patient joined me. It was only the two of us. He was in the hospital for, among other things, ulcerative colitis, and thus was having large amounts of bloody diarrhea.

A few seconds into the ride a loud rumbling noise emerged from the depths of his GI tract, prompting a look from me in his direction. He proudly clutched his belly and announced, "Sorry, I've got gas!" When the elevator stopped on his floor, he walked out wearing nothing but his hospital gown ... which, at this time now, was dripping multiple globs of light brown watery stool with each forward step.

As if that weren't bad enough, while walking out myself, I accidentally stepped in one of his disgusting puddles.

I spent the next hour at a nursing station with every anti-infective spray, cream, and wipe that they had. You can find my shoes in the garbage.


She Had a Cold


I was in clinic today talking with a new patient, a fairly healthy 40-year-old woman, and as part of my routine sexual history I asked if she had ever had a STD (sexually transmitted disease). She responded with "I had something a few years ago, but it turns out she had a cold." I did not understand at all what she meant, so I asked her to repeat herself, to which she again said "She had a cold."

I had no clue what she was talking about. I had no idea who "she" was. I assumed I was simply zoning out while the patient was talking earlier and thus must have missed who "she" was. Thinking the patient may have been referring to a female sexual partner, but not wanting to appear as if I hadn't been listening, I casually asked her "Oh, your female partner?" and she again responded with "No, she had a cold."

Still without a clue as to who had this cold, I then asked "You mean your doctor? So your doctor had a cold?" and she again said "No, she had a cold."

I was about to lose it. Who is she? Who had this cold?

I finally blurted aloud, "OK who are you referring to?"

She then pointed with both hands to her crotch and said, "SHE had a cold!"

Oh. Ohhh. Her. Well excuse me. Couldn't you simply have given her a name and made this easier from the start?

I did laugh, though ... and yes, in front of her.

(And no, I still have no idea what she meant by "a cold".)

Scrubs, the Huffington Post, and Me


Recently I came across this Huffington Post article. Yes I know I am reading it one year and four months after it was published, but that aside, it reports how the television show Scrubs will be returning for what ended up being its ninth and final season.

Obviously I was excited -- both at the time and also currently -- to read about Scrubs, for as many of you know I am what may be considered a fan. But what was even more thrilled was that they mentioned one of my posts in their article! I had reached the end of the first full paragraph, which finished with:
Scrubs remains the most realistic medical show on television according to most actual doctors and nurses.
With intense curiosity I clicked on that link, which very unexpectedly brought me to my own article. Apparently I'm "most doctors or nurses" ... me, yours truly, your favorite Axis.

I wish I had come across this in a more timely manner, but this delayed surprise isn't so bad. Unfortunately, Scrubs has since come to an end (even after a brief and weak effort at resurrecting itself with a newer version involving medical students) so all I have of that unique show are memories ... and great articles like this.

25 Things I Didn't Do Before I Entered Medicine


Wake up before 8am.
Go to sleep after 2am.
Look forward to sleeping nearly every night.

Wear a shirt and tie to work.
Shave more than three times a week.

Stick my finger up peoples' butts.
Ask people how many people they’ve slept with.
Ask men to tell me about their erectile dysfunction.
Ask for men to show me their penis.
Dread seeing vaginas.

Be able to tell police officers what to do (in the hospital, at least).
Talk with police officers.
Talk with prisoners.

Slam the phone on people.
Hate pagers.
Hate anything that beeps.

Drink at home, alone.
Want to drink this much.

Be thankful I am alive.
Hope that certain people would die.

Struggle for money.
Dream of money.
Despise people with money.
Despise people.

Wish I didn't enter medicine.

Holidays Are Over


Now that Christmas and New Years have come and gone, there is only one thing I can say ... thank goodness the holidays are over. I cannot be thankful enough. I was unlucky enough to have to work on Christmas Eve, Christmas Day, New Years Eve, and New Years Day. And for most of them, notably New Years Eve, I had to work night shifts.

I used to love the holidays. I loved the Christmas decorations on the streets, Christmas music everywhere, and the feel of the weather (yes it's California, but still). This job, however, has gradually eroded my passion for the holidays (among most other things in life), and this year sealed the deal.

Working through the holidays, and those four days in particular, was dreadful. Putting in my thankless slave labor hours while watching my friends and family get time off -- some of whom got two weeks off! -- was extremely discouraging and depressing. I absolutely dreaded going to work each evening, I was grumpy with co-workers in the hospital (many who reciprocated for similar reasons), and I found patients extra hateful. What kind of person prefers to be in the hospital on Christmas Day as opposed to home. Who thinks "instead of opening presents or spending time with family let me go to the hospital, complain, and get attention"? Those people are not sick in body, they are sick in mind.

Holiday season 2009 was the worst I have experienced ... and I sincerely hope no future holiday season tops it.

The Best Things in Life


I saw one of my favorite patients today. He is a 30-something-year-old guy with a history of diabetes for the last seven years who has been doing a great job over these last few years of keeping his diabetes very well-controlled. He takes his meds on time, calls in for refills when they start to run out (a rarity not to be underestimated among patients!), and has been very compliant with his routine visits. Like any diabetic, despite maintaining a good diet most of the time, he occasionally gets tempted by very sugary and starchy foods, but for the vast majority of the duration of his chronic illness he has done a great job of showing restraint.

This visit, however, he had news for me. Apparently a new bakery moved in next door to where he worked, and he fell under the spell of some tantalizing cakes they made. Initially he did not even notice the cakes. Then one day he had to go in for a non-food related reason and his interest was slightly piqued. Soon things escalated to the point where almost every day he would walk in and ask for a tiny sample of a cake. That was a few months ago. These days he was at the point where he'd ask for a slice on a daily basis. He still took his meds; he still measured his sugars; but now he was also having a generous slice of cake ... and frequently too.

So he finally succumbed. Despite his initial strength, his many years of good diabetic control, and full awareness of the consequences, he bought an entire cake and went home to eat it. Not just eat it ... scarf it down. From what I hear, he really enjoyed it. It seems that before this bakery, he had not touched cake in many years. And now, he tells me, he splurged three nights in a row, one cake each night.

After this encounter, I couldn't help but think why is it that the best things in life have the potential to be the most dangerous? Not only are they not free as the adage suggests, but they really are the most harmful, whether physically or emotionally or financially. I am not only referring to sugar, salt, fat, and other tasty foods, but other entities in life as well (e.g. excessive money, extreme sports, a neighbor's wife.) Our brains seem naturally wired to crave that which is bad for us. Or maybe it's just we covet that which we can't have. I don't see how this helps with natural selection. In fact, I bet some grand designer up above designed this system intentionally and must love observing us.

Back to my patient, he has now radically thrown off his blood sugar readings and who knows what sort of complications he may face down the line. He is regretful, although he really did enjoy it in the moment. He claims he will be back to good behavior, but we shall see.

Anyway, I don't know why I even wrote this entry.

New Interns


That time of year is here: the brand new interns ("baby interns", if you will) started a few weeks ago in the hospital. I have been looking forward to this day for nearly one year now, as last year I was on an outpatient rotation during the start of the academic year and thus did not get to interact closely with the new interns. It didn't take long, however, to realize why most senior residents dread this day.

I met my two new interns on a Sunday, a day on which our team was on call. So not only did these poor interns -- essentially just fourth-year medical students -- have to start their internship on a weekend, but they had to start on call and stay overnight in the hospital. It was a whole new world ... a whole new, brutal world that didn't care about weekends, holidays, or "after hours".

The rest of the day was spent orienting them to the hospital, describing the way things work in the hospital, and providing them with an overview of day-to-day operations. In addition I had to teach them how to use the VA computer system, which is intuitive and joyful to use once you know the basics, but those basics take some time to learn. Juggling all this while receiving annoying calls from the ER for patient admissions made for a very busy and oftentimes trying day. The day was an exercise in patience, disguised as a fresh start for a group of frightened newbies.

Most surprising, although it shouldn't have been, was watching the interns' clinical skills in action. Understandably, they had not interacted with patients in many months, nor had they made any sort of oral or written presentations in that same time. The minutes of the day where I wasn't teaching them how to order medications or learn the phone system, I had to work on how to present a basic H&P. And by "basics" I mean just that. I spent more than one sitting explaining how one first presents the history, then the exam, then labs, etc. Those basics.

On a final note, just when I was thinking the next day how it couldn't get any worse, of course it did. I soon met two very young guys who introduced themselves as my new third-year medical students. In case you are not familiar, that means they were fresh-as-can-be, had-never-set-foot-in-the-hospital-before, hearts-still-racing-from-waking-up-at-7am medical students. Interestingly, though, while at times the new interns seemed like seasoned pros compared to the new medical students, much of the time they were very similar: new, scared, learning, and above all overwhelmed.

Looking back, despite some of this grumbling, the mere novelty of the week and its participants made it an exciting one me. I am glad I was present to welcome the new interns and students, but it is not something I want to repeat as a resident. Hopefully, as a fellow, I will be slightly shielded from them ... by the poor residents.

Fellowship Match


Match Day for fellowship was a few weeks ago, and dear readers, your Axis got his #1 choice!

The fellowship matching process is identical to the residency matching process, which is nice for the sake of familiarity but painful because it involves repeating a long, expensive, and tiring process.

Matching for fellowship was exciting mostly because it indicates that residency will soon end and I will begin training in a field I am actually interested in, cardiology. A third year of medicine residency lies ahead of me, but the end is now in sight.

Exciting and motivating as it is to see that end now, it reminds me yet again that I have will have had to wait several years before I can be immersed in the field of my true interest. Unlike my counterparts in, say, neurosurgery, urology, obstetrics/gynecology, psychiatry, or radiology, all of whom started training in their fields immediately after medical school (save one year of internship, of course), I have to suffer through three long years of general internal medicine before reaching cardiology. Three years of low back pain, diarrhea, runny nose, GI bleeding, and countless other symptoms/illnesses that I simply do not care about. It's hard to be good at what you do when you don't like what you do.

Regardless, the end of general training is near and soon the game of sub-specializing and sub-sub-specializing will start. I will now be Axis, second-semester senior.

Latest Grand Rounds


Check out this week's Grand Rounds, hosted by Diabetes Mine, who did a great job of organizing it. Look out for a post from your very own Axis!

New Design


Axis Deviation is growing up. Throughout its lifetime of nearly three and a half years, this blog has kept the same design. While I have enjoyed the red and grey of old, it is time to retire it and inject a new energy into this blog's appearance. So in the spirit of change, especially since there is no such thing as timelessness on the web, I have changed this site's layout.

Allow me to explain the reasons for choosing this particular template. The theme's block design offers a subtlety lacking in the old theme, which some might deem overly aggressive. I appreciate how the magenta titles contrast the melancholy blue-grey overtones, making the site approachable, pleasing, and even bosomy. Finally, the header's rounded grey squares -- majestically translucent and overlapping -- are delicately spread out, such as might give the effect of confetti blowing into the sky on a warm summer night. Plus it looks cool.


Clubbing and Coding


Excitement, dear readers, excitement! And outside the hospital, no less ... read on.

In a rare weekend where I had both days off, I went with some friends out of town and then to a club (you know, to read the articles). At one point while I was busy talking, I noticed a large group of people huddled around something across the room.

Automatically I assumed that the "something" was a person so I darted over, pushed my way through the crowd, and then saw a young man collapsed on the floor. Instinctively I jumped in. I didn't even know I had such instincts.

A few muscle-headed security guards were also kneeling down, but I squeezed myself between them. I went straight for the collapsed guy's neck to feel for a pulse, when one muscle head barked that I could not help if I was drunk (which I was not). Normally when a bouncer-type person yells at me I shy away, but this time I barked back that I was a doctor and could help. Immediately -- satisfyingly -- he retreated.

I continued assessing the guy and performed some simple BLS (Basic Life Support). For some reason -- perhaps in the excitement of the moment -- I cannot remember exactly what I did the next few minutes, but I do recall one of the security guards pulling out some gloves from his pocket for his own use, and me snatching it from his hand. I put it on my own, and then he surprised me by offering the other.

Initially I thought the victim had no pulse, so the guards turned to me to see if chest compressions should be started. Just as I was about to nod we tried a sternal rub. The guy immediately started groaning and then he came to. I stepped back and left him to the guards and the newly-arrived medics.

The guy was then wheeled off and hauled away to an ambulance, slurring, belligerent, and all. Good ol' alcohol intoxication.

Any sudden and unexpected situation is an exciting one, but this scenario held special significance. Since medical school or early internship, I have had recurrent daydreams (fantasies?) where I imagine being in a public place when someone collapses, and I rush to the rescue. Whether I do this because of boredom, an overactive imagination, or a latent desire to be a hero -- in one of my dreams I order the pilot of our plane to make an emergency landing! -- this scenario has crossed my mind many times.

Sadly, when the real thing occurred, I wasn't nearly as graceful as in my dreams. In the heat of the moment I had to spend a few seconds reviewing BLS algorithms, and then later I was slightly hesitant to tell people to start chest compressions (which, as mentioned, ended up being unnecessary.) In addition, finding the victim's pulse was close to impossible with loud music pounding in the background and having multiple crowd members yell out idiotic comments does not help one's focus.

Regardless, my work and play don't often mix, so having these two worlds run into one another was definitely exhilarating.












It's really annoying, isn't it?

Thank Goodness for Scrubs


Nearly everyone I tell I am a doctor asks almost immediately, “Is your life like Grey's Anatomy?”

It is annoying because 1) it isn’t, 2) I wish it was for the sake of (unrealistic) excitement, and 3) I hate Grey’s Anatomy.

Anyway, the conversation that follows usually goes like this:

Me: “No.”

Person: “Ha ha! So what is it like then?”

And this is where it gets a little annoying. It is difficult to explain to non-medical people what an internal medicine resident or internist does all day long. What I do is not that interesting, and I am sure the average layperson would be downright bored hearing a description of my day-to-day activities. (“I start the morning by reviewing labs on a computer. Then I walk from patient to patient asking them how they were last night. Then I spend the rest of the day struggling with the computer system trying to order a lab, paging consults who never call back, and occasionally doing some procedure that inevitably takes ages to set up for.”)

Non-medical people likely don’t understand the concept of rounding, the importance of ordering and following up labs, reviewing films with radiologists, and most importantly, how the time it takes to perform countless small tasks like these quickly adds up.

Surgeons have it easy here. They could simply say “I do surgery”, and everyone in the world would know what that means. Lucky bastards.

Enter Scrubs. This TV show has done a great job of capturing the realities of internal medicine residency and making it interesting. And because it is a popular show, many people are familiar with it.

I have therefore found the best response to “Is your life like Grey’s Anatomy?” is, “No, it’s actually like Scrubs.” People immediately understand.

Scrubs ... relieving doctors like me from painful conversations everyday.

Fellowship Applications


It's that time of career again. I am now applying for fellowship, which means yet another round of filling out applications, begging for letters of recommendation, and sending lots of money to programs. I felt like I just went through this ... and what do you know, I did.

I am beginning to feel that the rest of my life will consist of this dreadful cycle.

A Catastrophe Waiting To Happen


There is a lady on my service that I admitted to expedite her pre-transplant workup. Her family comes to visit nearly every day, and here is who her family members are:
  1. Husband -- the "high maintenance" type (wants to be updated every day about the latest plan regarding his wife's care).
  2. Daughter -- the head pharmacist at a nearby hospital (of note, she is not a physician, yet parades around as if she is one, by constantly demanding detailed information regarding her dad's lab values and other numbers).
  3. Son -- a lawyer ('nuff said).
Can you imagine a worse patient family?

I Hate Internal Medicine


Last night I was on call for the first time as a resident on the wards (i.e. general medicine inpatient wards, the basic/core inpatient rotation in internal medicine), and more than ever do I hate being a resident in internal medicine.

First of all, it was a busy and brutal night. From the time we opened for admissions at 2pm and until midnight, my pager was going off nonstop. The ER certainly had a non-stop supply of patients that needed to be admitted.

And by "needed to be admitted" I mean patients for whom the easiest thing for the ER to do would be to admit them because they were feeling a little too ill to be at home (or a lot too lazy to want to return home). The ER definitely could have discharged them, but because ER doctors are too spineless and unconfident, the patients were admitted to the hospital. Honestly, a quarter of patients admitted to internal medicine teams are admitted for so-called “social” reasons, referring to reasons like those I’ve just mentioned.

Therein lays my biggest gripe -- to put it politely -- with the night and with the field of internal medicine in general. We get dumped on. We have to admit every patient. We accept every patient the ER decides to admit to the hospital; or every patient from a surgical service that no longer has a surgical issue; or -- and this is the one I absolutely hate the most -- every patient presenting with a surgical problem that the surgery team who’ll tend to it is just too lazy to admit.

(As an example, I just admitted a young man with several neck masses that he had noticed over the last several weeks. He had no other medical problems and was completely stable; and somehow the ENT teams decided he would be better served on a medicine team. All I do every day is look for the latest recommendations by ENT. Seriously, talk about lazy and work-avoidant doctors.)

Ridiculous admissions like these make me hate what I do. Yes I hate what I do, I really do. I feel that if one wants to be an inpatient internal medicine doctor, one must have a pushover personality. There is no other way to survive each day without feeling discouraged and powerless. Fortunately I will be sub-specializing with a fellowship and thus hopefully avoiding such lame admissions in my future career, but I am not sure I can survive another year and a half of this. Each new admission boils my blood and makes me resent even more the patient population at large.

Anyway, let's go back to my night of call. Lucky me, that was only my first night of call this month ... and I have four months of wards left this year. At least I'm paid well.

Ads Are Gone


Just an note on a minor update to this site's design: I decided to take down the Google Adsense ads that used to be on the sidebar. I felt they were not very relevant or useful, especially since they displayed ads mostly about hospitalist positions.

More importantly they cluttered up the page, which I like to keep very clean and uncluttered.

Let me know if anyone is horribly distraught by their absence.

It's All In the Hands


Much of the training to become a doctor involves the physical exam. This is the time-honored skill of performing tasks like listening to the heart and lungs, palpating the abdomen, feeling for pulses, etc.

(Many people currently will also argue that the physical exam is obsolete, being rapidly replaced by lab tests, imaging, and other fancier technology. Personally, I don't entirely disagree.)

One of the most important parts of the exam, however, is the mere task of inspection, which involves just looking at the patient. This simple act can provide volumes of information. I feel a patient's hands, and in particular their fingernails, are very telling and provide useful information that the patient herself will not reveal. Here are a few findings I have observed over the last few years.

Dirty nails -- It doesn't take much time or effort at all to maintain fingernail hygiene, so if a patient has clean and trimmed nails it is inconclusive. However, nails that are ungroomed and dirty usually suggest clues about the patient's underlying social history, such as a broken or non-existent housing situation (e.g. as an extreme, being homeless).

Clubbing -- A classic, and the most medical of all these. Clubbing is the buildup of material at the proximal part of the nail bed, giving them a very exaggerated curvature. Often a sign of occult lung disease or cancer, if you notice clubbing consider evaluating the lungs in some detail. I once had an old man present with a set of very vague symptoms. When I noticed his hands and toes had severe clubbing, I started a workup that revealed metastatic prostate cancer.

Long fingernails -- Subtle, but in my view, very telling. I have noticed that long, unclipped fingernails often indicates someone with psychiatric issues. A mind fraught with psychosis or depression has more pressing issues than clean fingernails. Again, it doesn't take much to maintain one's fingernails, so when I see this I wonder if the patient is mentally sound.

One long, groomed pinky fingernail -- Historically this was a trait of gangster bosses, drug dealers, or the like, who proudly displayed a long and groomed nail to signal that they were white collar, and not a manual laborers who used their hands to make a living. Today, it means you're a douchebag. While this finding doesn't provide true medical information, it is always good to know when you're dealing with a douchebag.

Resuming Post-Election Life


The election is over, and thank goodness. I can now get some sleep without stressing over whether America will have sense enough to vote the right person into office. For the first time in a long time (8 years, in case you were wondering), I can say I am proud of my country.

Anyway, with that said, regularly scheduled programming will now resume. Stay tuned!

Election Day!


Go vote peoples (if you already haven't)!

Seriously. No seriously.

If you need help finding your polling location, go to

The Dumbest People Ever



I know that I -- in my vast bitterness -- have insulted patients many a time, insulted nurses many a time, and insulted fellow doctors many a time as well. However, no one tops the following people in terms of sheer, absolute dumbness (for lack of a better word).

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(In case you require a medical-related reason to watch this video, just imagine the blood pressure effects of listening to the people featured in this video.)