“M, what do you think about a scribe? You said you’d be open to that in the past, and I have just the guy for you. He’s the son of a friend, and he wants to get more clinical experience before he applies to med school next year.”
My partner looked expectantly at me, waiting for my response.
“What’s his background? Pre-med?”
“No.. an engineering background. So you’ll have to train him, but he’s a smart kid and I’m sure he’ll pick up quickly!”
3 weeks later and I was shaking said kid’s hand in my office manager’s office.
So earnest, so excited. So… pure.
This was a mistake, M.
When I said Yes 3 weeks ago, I hadn’t sent out my resume yet. I hadn’t already mentally and emotionally committed to leaving. I hadn’t been cheating on my clinic behind its back, responding to emails in my office with the door closed.
But, A was here, whether I regretted it or not.
“I’m really excited to work with you, Dr. M. I’ve heard nothing but good things.”
“I told him he’s going to have to be on his A game to keep up with you! You’re really efficient,” my office manager said.
Oh boy.. gotta lower these expectations ASAP.
“I don’t know about efficient, but I do type quickly. I haven’t worked with a scribe before, so we’re pretty much going to wing it. Hope that’s ok with you! Just let me know when your start date is and I’ll come up with a game plan.”
I escaped back to my office and reviewed A’s resume for the 3rd time – engineering degree, out working in the real world for 4 years, but decided he now wanted to apply to med school. He had all the requisite volunteering and mentoring items listed.
Because of course he did… we only want “model citizens” as doctors.
I really wanted to walk back into my manager’s office and ask what was actually on the forefront of my mind,
“What hole in your heart are you trying to fill by going into medicine?”
No, M. That’s coming in a little too strong. You can’t just do that.
Why not??
I found myself in the same predicament again, asking myself if it was my moral and ethical responsibility to save this person from himself.
Except it wasn’t a friend this time. This was some Joe Schmoe they could’ve randomly pulled off the streets for all I knew. I didn’t have to carry the burden of the premature death of his idealism like I did my friend’s.
Would you just think of yourself for just a second? Imagine not having to do anymore charting. Imagine being able to go home before 6 p.m.! His choices are his own.
Let It Begin…
“So, I was thinking you could just shadow me for a day or two so you can see my process and how I do things, specifically how I interact with the electronic medical record. I try to be pretty systematic in my approach, so hopefully the flow is easy for you to follow.”
A nodded his head vigorously.
God, could you be more enthusiastic? I don’t have enough caffeine for this.
“Ok.. so I usually do my history of present illness like I’m setting the scene for a story – why did the patient come in? How long have they been dealing with the issue? What is the thing that bothers them the most? Then I break it down by PPQRST:
- Provocative factors – what makes it worse?
- Palliative factors – what makes it better?
- Quality – i.e. what is the quality of the pain? Sharp, dull, achy, throbby, etc?
- Radiation – does it move anywhere?
- Severity – how would they rate the pain or how bothersome is the issue to them? How much does it affect their day to day activities?
- Timing – have they been able to figure out a specific time or correlation to an event?
Then I ask about Review of Systems, trying to rule out different things, so click this button here and just type everything I ask/the patient says.”
More head nodding. Like a bobble head. Like someone who just realized he is way in over his head.
“Don’t worry about it. It takes years to get this down. Just follow me for a couple of days.”
Fastest way to discourage people to go into primary care: Physicals
“This is the healthy food plate. We’re no longer doing the food pyramid anymore. I really want you focus on a whole food, plant based diet, so I want half your plate to be fruits and veggies. Limit your carbs to just a quarter of your plate, and try to transition more to a complex carbohydrate if you can – whole grain vs white bread, yams vs potatoes, brown rice vs white rice, etc. For protein… I really don’t care how much you get.
How close do you think you’re getting to that?
Oh, you don’t eat any vegetables? How about just one? One veggie a day. How about one broccoli? Don’t like broccoli? How about carrots? You’ll only eat ONE baby carrot. Perfect.
OK. Let’s talk about exercise.”
Just savin’ lives, left and right. This is what we do. Repeat the same thing over and over and over again. Sorry, not sorry.
11 down, 6 more to go…
Looking at the rest of my patient schedule, I spotted my next appointment: Follow up hospitalization. This could inject some excitement into an otherwise lackluster day!
Upon seeing the name, however, my heart sank. This was the case of non-accidental trauma/child abuse that ruined my last vacation.
For a moment, I contemplated not having A come in to see the patient with me.
Nope. You don’t need to protect him, M. If he wanted the experience, he needs to see ALL of it.
“So this baby we’re about to see was hospitalized for 16 days. He had bleeding in his brain causing seizures, so he had to have 2 procedures called Burr holes to help drain the blood. He also had hemorrhages in his eyes, and that’s consistent with child abuse, or what we call non-accidental trauma in the medical record.”
A stiffened. He was definitely not prepared to see this today.
We stepped in to the room and I rehashed everything with the family. Upon examining this little 4 month old, I could see he was delayed. He wasn’t quite rolling yet, pushing up with his arms to prop up his chest to 45 degrees during tummy time, or cooing. He had roving eye movements with no fixation that no one seemed to pick up in the room except me.
“Do we really need to see physical therapy? He’s doing fine!” mom asked.
“Yes, he’s doing OK now, but I’m concerned he may start to fall behind in his developmental milestones,” I replied.
Way to sugar coat things, M.
From seeing children affected by child abuse, I knew he may look like a normal baby now, but he could be a forever baby. Time would only tell. Not wanting to put limits on him before he had a chance to fully recover, I placed referrals to PT, ophthalmology and neurology and carried on with the rest of the afternoon, back to routine physicals and my healthy food plate spiel.
At the end of the day, I beckoned to A,
“Come. I like to look at the interesting images for my patients, and I can only do that from my PC workstation. Let’s go back to my office and look at that baby’s images.”
As I pulled up the different radiology studies, I tried to go through them with A.
You’re no radiologist.. what do you have to teach him? How do you teach someone who has no medical knowledge about stuff you’ve purged from memory?
“Let’s look at his CT Head when he showed up at the ER – do you see these squigglies here? That’s the brain, specifically, the cerebrum. This gray stuff here is the blood.”
Again, A nodded like a bobblehead. He wasn’t getting it.
Pull up the MRI, M. The T2 weighted images. That’s the only thing you remember from your radiology rotation in med school.
“Ok.. here’s the MRI. It’s much better at seeing the brain, the squigglies. You see how down here it looks more like separate fat udon noodles? Now, look at this area where it looks like the noodles have all squooshed together, like a gelatinous mess. This is where the brain has gotten swollen from all the trauma.
And all this white stuff here – this is all blood.
This is all blood because someone shook this baby so hard it sheared the blood vessels and he started bleeding into his brain.”
All the blood drained from A’s face as understanding took hold.
The white stuff was everywhere. Pushing up to the skin by his anterior fontanelle/soft spot, trying to get out. Collecting in the sulci and fissures, forcing the brain to smash together because there wasn’t enough room to accommodate everything.
TOO SOON, M! TOO SOON! You should have given him more time. You should have eased him into this. This was totally unfair of you to do.
Regret. Such regret. But I couldn’t take it back.
I just had to sit and watch the transformation on A’s face.
This is what it is to be in medicine. Yes, some days we save lives. But the rest of the time we’re just dealing with the aftermath of our actions, and it’s not as glorious as you want it to be. Is this what you really want?
Why are you being such an asshole?
Because he should know! Someone should show him! He needs to walk into this with his eyes wide open!
This was a mistake.
Yes, yes it was.
I’m the last person who should be guiding someone through their journey in medicine.
The worst person to reveal the ugliness of medicine to someone before they’ve fully committed to the career.
But if not me, then who?
Doesn’t he have a right to know?
***
Photo taken at Ramona Falls, OR.
At the depths of my burnout, while I was virtually spewing cynicism and regret, people were coming out of the woodwork asking me if their sons/daughters/friends’ kids, etc. could shadow me for a day or two. I since learned that this is one of the things you put on your application to show that you are interested.
A very good friend called and asked me if her son, applying to med school in a year, could spend some time with me at work. I said, L, you know I would do anything for your family, but if you really want G to like medicine, let’s have him shadow P (a common mutual friend, a very successful neurosurgeon and nice, upbeat guy). She knew I was not in a good place with respect to my work and career. So G shadowed P, and everyone lived happily ever after.
People should get early exposure to the darker side of medicine. Keeping it real did A a favor, not a disservice. If he can handle all of the BS and misery, well, we need more people like that on the front lines.
I agree – we do need more people like that on the front lines, but it still feels very much like I did A a disservice rather than a favour. I pride myself in being a realist, but at the same time I feel the need to protect everyone from all the horrible things, which is of course, impossible.
I think my online persona of “spewing cynicism and regret” as you so aptly said just needs to give my real live self a pep talk 🙂
LOL! That was old me spewing. New me is in a much better place. You will get there, too. 😇
Haha.. well, what is old becomes new again? I think I’m definitely old you 🙂
The non accidental trauma cases are some of the hardest. This baby still looks “normal” to the parents and passersby but the reality of the imaging tells another story. You know this, I know this. But how do you say it? How do you tell them their child’s brain is ruined and will soon that bloody tissue will die and water will take its place. Or do you not and let them continue thinking that everything will be OK? maybe it will, baby brains have immense plasticity?
A little tough love can go a long way. We all would be best served knowing what we are getting ourselves into. But in many ways you can’t really get it until you are doing it. Med school seems just like more college but being arms deep in anatomy is no where near the same as playing Halo after “class” in undergrad. Being a resident makes med school feel like a walk on a nice beach with a few kites and a pretty sunset. Being an attending might bring fewer hours but the responsibility compounds.
It is nigh impossible to explain these to outsiders.
The more knowledge A has about the good, bad, and ugly of medicine the better he will be better able to make deice whether to pursue medicine.
I hear what you’re saying – you really don’t know how things are going to be until you’re in the thick of it. I just don’t know if dragging someone into the thick of my burnout cesspool is really a fair thing to do. At least online, people can just click on to something else, but this poor guy has to follow me for 8-9 hours a day!
Fortunately I can keep most of my cynical commentary to a minimum and I do try to make it worth his while to teach him something while we’re going along, but I’m waiting for the day he doesn’t show up and I’ll have to do all my typing again. I keep reminding myself that he is getting paid to be here, unlike when we were in med school and paying $50,000+ a year to shadow someone who may or may not have fed us little breadcrumbs of teaching for the rotation.
At the same time, it’s important for A to see this stuff. It’s not all saving lives and television drama stuff.
The most devestating things I see are almost always events I can nothing about. Most of them kids.
While maybe it’s not the best time for people to shadow you, you didn’t say or do anything wrong. It would have happened at some point later down the road.
I look forward to following the rest of your journey and how it all unfolds.
TPP
Well, I hope you’re up for a whole slew of scribe stories, because they’re a-coming 🙂
Is it wrong that I’m picturing your scribe going home at the end of the day, curled up in the fetal position, rocking back and forth, questioning his choices in life…and laughing just a little bit? I blame my inappropriate reaction on your diabolically clever and humorous juxtaposition of internal dialogue with actual dialogue. Really, it’s your fault I’m thinking this stuff, M. Shame on you. 😉
Haha.. well, he hasn’t quit yet, so that must mean he’s just a little insane to keep working with me 🙂 I try to give him little clinical pearls throughout the day – just the important stuff, like the different varieties of acne. Keeps him coming back…
Wait, do you really go over the healthy eating plate with patients? If yes, that’s pretty fantastic. I just came back from a plant based nutrition health conference and one of the knocks on modern day medicine is that medical students get only 4 hours of nutrition in the entire 4 year curriculum, so they find it easier to just prescribe pills rather than actually going through the lifestyle therapies that can prevent chronic disease.
I, myself follow a whole food plant based diet. So I thought the inclusion of the healthy eating plate in this post was interesting.
Haha.. yes, much to the chagrin of my poor scribe who has to listen to me say the same spiel 10 times a day, I do go over the healthy food plate in great detail. I even made my own handout so my patients can go home and put it up on their refrigerator. I highly doubt that happens, but it’s nice to dream 🙂 I will say prescribing pills is much easier, but it doesn’t promote real wellness.
I grew up with a vegan father who still likes to tell me I’m making my body a cemetery for dead animals whenever I do choose to eat meat, so a plant based diet has always been a thing for me 🙂
Wow! That’s so good of you to consult all of you patients on healthy diet and lifestyle choices. I’m sure not all of your patients put your handouts on the fridge, but I’m sure at least one has. And by keeping your message consistent, I’m sure it’ll plant a seed and stick in their minds somehow 🙂
LOL! Your father is funny! My wife and I talk about how we should raise our daughter. We are pretty set on raising her vegan in the household. She’s only 6 months old now. So whatever we introduce to her will be her only frame of reference until she goes grows up, goes out with friends, and makes her own decisions.
My wife is a lawyer and she said she would actively discourage a career in law with our kid(s). I’m not going to encourage her go into medicine, but if she really wants to do it, I’ll provide encouragement.
I don’t know if anyone has put it on the fridge, but I did have one patient tell me she put it at the back of her closet to remind her when she was reaching for her “fat pants”. I guess I’ll consider that a win 🙂
I’ve toyed with going full vegan, but I just can’t let go of my ice cream and cheese. Kudos to you on keeping up with that lifestyle with your little one!
It is interesting how medicine looks from both sides of the coin, one when you are trying to get in, and the other where more and more are trying to get out.
My father was a physician (internist) and I had a strong desire to be just like him. I just saw the trappings of the physician (respect, nice home, nice car, awesome kid 🙂 ). I didn’t know how much sacrifice and effort it took to get to that level and had no idea what his day to day work was like.
I just wanted to be a doc like my dad.
Now that I have been in the medical system for 15+ years I realize what the hidden dark stuff that medicine also piles on you does. My daughter has stated she wants to be a doctor “like her dad.” She’s 12 years old and sees the outer trappings of success like I did decades earlier. It is a debate I go through about trying to warn her of the perils of medicine but right now I will let her progress and see if it still retains her interest by the time she is finishing high school.
Before I went to med school, there were several doctors who tried to warn me not go to into medicine. But I, of course, thought I knew better, with the idealism of a young 20 year old. I don’t know if I really could have been dissuaded from going into medicine, if I’m being honest. Experience is unfortunately a better teacher than warnings from well-intentioned mentors.
I read somewhere 9 out of 10 doctors would not encourage their children to go into medicine. I’m not sure if your daughter is singularly minded as I was, but perhaps she will be enticed by something else before she starts on her career journey