I helped to take care of a highly intelligent, talented, and funny teenage girl while I was on my psychiatry rotation. She happened to struggle with severe major depression, for which she was under our care. I found out within the first couple of days that she loved poetry and used poems to cope with her illness, and since I was able to recall a couple of lines from the poem Invictus after seeing the most excellent movie of the same title, she thought I was a fellow poet. (Had she seen my “poetry” she would not have been so fooled!) On the day she left the hospital, she left me a folded piece of paper with the following written on it:

Happiness

Happiness is like a crystal
Fair and exquisite and clear,
Broken in a million pieces,
Shattered, scattered far and near.
Now and then along life’s pathway,
Lo! some shining fragments fall;
But there are so many pieces
No one ever finds them all.

You may find a bit of beauty
Or an honest share of wealth
While another just beside you
Gathers honor, love or health.
Vain to choose or grasp unduly,
Broken is the perfect ball;
And there are so many pieces
No one ever finds them all.

Yet the wise as on they journey
Treasure every fragment clear,
Fit them as they may together,
Imaging the shattered sphere,
Learning ever to be thankful,
Though their share of it is small;
For it has so many pieces
No one ever finds them all.
- Priscilla Leonard

May each one of you treasure every piece of happiness you find in the New Year. – Paul

Ah summer, when a young man’s fancy turns lightly to thoughts of national, standardized exams. And that young man begins to realize that…

Everything I Need to Know About Medicine, I’ve Learned From USMLE World Questions

For example, did you know that…

…a rare disease of iron metabolism called hereditary hemochromatosis predisposes one to infection by several seemingly unrelated bacteria? (Listeria, Vibrio, and Yersenia)

No, no, no! Enterocolitica, silly!

- …consulting the hospital ethics committee is always the wrong answer? Poor hospital ethics committees…they are never going to be consulted by the upcoming generation of doctors. They will just sit around, waiting for an ethical question to debate, but no questions will be forthcoming because we will be busy demonstrating our ability to apply the principle of patient autonomy to every situation possible.

Hospital Ethics Committees, take a good look in the mirror.

- …iron toxicity progresses through 5 somewhat distinct but largely overlapping phases? It does. “Who,” you ask, “would overdose on iron pills?” The obvious answer, of course, is toddlers who take lots of delicious iron-containing Fred Flintstone multivitamins when mommy’s in the bath shaving her legs with that new BIC razor. (I just got 20 cents when you read that). However, this makes too much sense to our beloved question writers, so instead this question comes in the flavor (if you’ll pardon the pun) of a 16 year old girl who has been feeling moody for the last couple of weeks (which clearly makes her suicidal) and, despite being on iron, Tylenol, and nightshade, decides to reach for the iron when it’s time to say goodbye. I’m just kidding, she wasn’t on digoxin, but still. Thankfully, when presented with 5 options for management, you astutely chose to measure a serum iron level, thus comfortably outfitting the pathologist with the tools to wrap up a nice autopsy report. Strong work!

I just made another 50 cents when you looked at this picture, yo.

- …you can lose up to 50% of your blood volume in one half of your chest? I’m not much for math, but by my calculations, this means that if you were to bleed into both sides of your chest, you could lose…100% of your blood volume. Into your chest. Wow, that would be bad! I bet you’re CA1 hippocampal neurons would be pretty darn hypoxic and red. But the heart is in the chest, so maybe that stops it from filling up all the way to 100%.

This chest could fill up with blood, given the right unfortunate circumstances. Are those raccoon eyes? Maybe we should admit him.

- …diagnosing acute rheumatic fever is easy as spelling J-O-N-E-S? That’s right, up until now I’d been resistant to learn the Jones criteria for acute rheumatic fever, dismissing it as a needlessly complex system for diagnosing a disease that I’ll never see unless I become a specialist of things that no longer exist in the 21st century. (I hear that pays exceedingly well). But now I see the Light. (yeah?…pleural effusion-? oh, never mind. you’re hopeless.)

All you have to remember is that in a patient with a history consistent with group A strep exposure or laboratory values indicative of infection including positive anti-streptolysin-O or anti-DNAse B, if you have two of the following “major criteria”: syndenham’s chorea, migratory polyarthritis, carditis, erythema marginatum, rheumatoid nodules – or if you have only one of those major criteria but you have two of these “minor criteria”: elevated acute phase reactants like C reactive protein or sed rate, arthralgia, fever, or heart block on ECG – then you have yourself a case of acute rheumatic fever. Oh but don’t forget that if you count arthritis as a major criterion then you can’t count arthralgia as a minor criterion, because no duh your joints hurt if you have inflammation of your joints so that wouldn’t be fair to double count them now would it, oh yeah and if you count carditis as a major criterion then you can’t count heart block as a minor criterion, because of course the heart block is presumably the result of the cardidits, I mean it’s not like the heart just all up and blocks on it’s own, right? – and if you have syndenham’s chorea then actually you can just go ahead and call it rheumatic fever without all the other stuff sowhydidweevenincludeitinthemajorcriteriainthefirstplace, shouldn’t it just be in it’s own category called the “Super Criteria” or something, the only problem with that being that you wouldn’t know what syndenham’s chorea was unless it was tattooed on the patient’s forehead in 81 point Times New Roman monospaced font.

What’s that? Oh, got it.

…oh and – tattoo parlor guy – in English, please. Thanks! – PSR

This past Friday was a day like any other day. Except, of course, that it marked the flipping of a very specific calendar – that of the KU medical school scholastic calendar. (Also, it was the first time I ate a real meal in days after being afflicted of the intestines for several days, but that’s for another post.)

Pre-meds, enter stage right. You are the new first years, and you may be green as husks of Iowa corn, but we all remember fondly being in your shiny new shoes (the ones that you bought with that new black suit for you interviews). You will wear your dippy short white coat with pride, you’ll buy a 500$ stethoscope and then put it on so that the ear bud thingys angle backwards, you will be absolutely clueless when your family and friends ask you for medical advice, and you will develop a bond with your new tablet computer so strong that it nearly achieves sentience. You’ll learn that medical school is difficult, but you have lots of support, and you can handle it. Go get em, greenhorns.

Earbuds forward, Dan.

First year boys and girls, you are now second year men and women, seasoned veterans of the process of imbibing whatever random facts are thrown your way, digesting them into a four week-sized cube, and smearing the contents of that cube all over a computerized exam every month. You have become a master of efficiently assimilating information into your tablet-human brain, such that it is now second nature. Congratulations, you machine, you. Now step back and start fitting all those facts into the big picture. And don’t forget to be a human being

Second year fact-finders, you have crossed the Rubicon of Step 1 and will shortly enter into the foreign lands of real people with real problems that unfortunately can’t be found in real books, which you wouldn’t read anyway since you are Real Tired all the time. You will be asked what specialty you want to go in to eight thousand times by two thousand people, who are generally very kind, very well-intentioned, and will very promptly forget and subsequently ask you the same question at least three more times. Carefully develop an enthusiastically honest and thoughtful answer to this question, and if you want to do radiology, keep your mouth shut about it. Also, remember those people skills that you used to have before you became a human-tablet cyborg? It is time to dust those off and start putting them to good use. (If that fails, search for an empathy algorithm that you can run when needed.) It’s a whole different ballgame now, but thankfully for us, it’s still just a game. Play your best, and always be honest and a good sport.

“Sorry, but the appropriate response to this situation wasn’t in any of the USMLE world questions I studied. However, if you’d be so kind as to provide me with five options, I’ll happily choose the single best answer from among them.”

Third year blunderers, you are now fourth year badasses. Put on your devil-may-care attitude, sign up for those golf lessons, and if you can somehow be lucky enough to choose your groundhog year in advance, pick this one, because fourth year is going to be awesome. At least, that’s what they tell me – I have searched for some devil-may-care in my closet and found only devil-wears-prada. (just kidding, never seen it). Also, you do need to now have some sort of life plan in place. Ruh-roh…med-peds, anyone?

If all else fails….now, am I sane or crazy? Grr…I can’t decide!

Fourth-year badasses, you are now steely-eyed interns. The good news is that it is now real. The bad news is that it is now real. You’re (sort of) in charge, enough that you could actually potentially harm someone, which is certainly fuel for a mental freak out. You’ve come full circle, green as Iowa corn as an MS1 to green with flippity-floppity stomach as PGY1. Thankfully, you can now write that prescription for NervesBeGone (ativan/propanolol/haldol/morphine 4 in one combo) that you’re going to need to take on the first day, or at least you could if you had your DEA number yet, and if someone had done us the service of actually inventing this wonderful-sounding combo pill.* Remember that you were once of our short-coated brethren, and use us well – you of the long coats are gods to us, and we only want to help you. We’re just, well, incompetent. But we’ll try to only triple your work. (Feet kissing not necessary).

And lastly, to everyone else – residents, fellows, attendings, nurses, dieticians, janitors, basketball coaches, radio DJs, accountants, authors, people who do something more productive with their time than sit around writing blog posts, ballet dancers, kindergarten teachers, skinny people, fat people, diva celebrities, newborn babies, monarch butterflies, protozoans, Arnold Schwarzenegger, and any other groups I may have missed who also got a day older on Friday: You somehow continue to suffer us to “practice” medicine on you in word and deed. Thank you. May we be worthy to serve the suffering. – PSR

Thank you.

*Disclaimer: PSR does not support the abuse of any animal, vegetable, mineral, real or imaginary, except for poodles, which are absolutely ridiculous looking animals.**

**Second disclaimer: PSR does not condone the misuse of poodles, either. Apologies to the eight thousand or so of you who sent me hate mail in reference to the above disclaimer and suggested that I sit myself in the bucket underlying a cholera cot. (Very clever suggestion, though, I do salute you, though I shall ultimately pass on the suggestion.)