2 Years Later...

Residency was a bit rough on the free time. I'm baaaack!

Re-reading what I wrote about 8 years ago- namely running and my love of medicine, still ring true on a daily basis.

I am honored to say I'm now a practicing, Board Certified Pediatrician. I am living the dream. I take urgent calls in the middle of the night to take care of newborn infants in trouble, I hi-five kids who made it through their annual check up, I sit with teens and listen to their struggle with depression, and countless other scenarios. And I love it.

To practice medicine is to be curious all the time, constantly learning and relearning. I love having a new case and diving into the evidence base and primary literature to make sure I'm doing everything I should be for a kid. I love the mysterious unraveling of an accurate diagnosis: what are the symptoms, the physical exam findings, the time line, the age, the labs and imaging showing us? It's so satisfying to yield a diagnosis.

I also really appreciate having more senior, smart, caring colleagues with whom to discuss cases and learn from their decades of experience. Even after 5 years of medical school, 3 years of residency, I am still learning new things every day. It's shocking actually how rapidly medicine evolves and what you still don't know after 8 years of training!

Lastly, I love working with kids and their families. Kids always surprise me with how hilarious, sweet, scared, bored and openly hostile they can be within the same 15 minute appointment. The ultimate compliment is when the parent asks if they can schedule the next visit to see you. It's a heartwarming #Isaidyes moment in medicine.

Every day is surprising, I get a little smarter and wiser, and I bring all that I can to my patients and their families. What a remarkable career I have commenced! My heart is full to the brim with the joy I have being a Pediatrician. #worthit

-Doctor Peds

Hello Kidney

Just finished my month as senior resident on the Inpatient Kidney Service. Incredibly busy with very sick children all month. Learned a lot, worried a ton. Now have several more grey hairs and probably need a new eyeglass prescription. It's worth it though, I'd do anything for these kids, they are AMAZING. And ridiculously cute.

In case you don't know, the kidneys are really important to every day life.  A litany of potential problems, and possibly all at the same time! Hyperkalemia, Hyponatremia, Hypocalcemia, Anemia, Hypertension, Uremia, Hypertriglyceridemia, Hyperphosphatemia, Proteinuria, Hypoalbuminemia, Thrombosis, Infection, the list goes on...

Any little thing can go wrong when you have kidneys that don't work very well, especially when you are small. Many of our children with severe kidney disease live for years on dialysis until they are big enough for a kidney or until they find a matched kidney donor.

Try to imagine..

• Having a little baby and needing to connect them to peritoneal dialysis every night for 12 hours a night. 
• Trying to give a toddler 10 medicines every single day, and they taste bad.
• Your tween-age sister needing urgent dialysis for kidney failure because of a diarrheal illness a week ago
• Every time your school-aged kiddo has a fever they needed to be hospitalized to rule out a serious bacterial infection

A few acronyms from the month:
STEC, HUS, ESRD, ARPKD, CKD, HD, PD, AKI, ATN, SBP, BUN/CR, UP/C..

Electron Microscopy of Kidney's Glomerulus. Thx WikiCommons!

Kids with chronic kidney problems are at higher risk of infections than us regular folk -whether it be from immunosuppressive medicines to preserve their kidney transplant, extra fluid that can get infected or having a central line/catheter that puts them at risk for infection. Just in case you weren't a germ-a-phobe already, here's a list of the infections I've dealt with recently:

• Adenoviremia
• CMV colitis
• Cryptosporidiosis
• Clostridium difficile colitis
• Enterococcus faecalis bacteremia
• Infectious Mononucleosis
• Streptococcus pneumoniae meningitis
• Ecoli O157H7 

Bottomline: The next time you pee, thank your kidneys. They don't get enough credit for all their hard work!

"There is no greater calling than to serve your fellow man. There is no greater contribution than to help the weak. There is no greater satisfaction than to have done it well". -Walter Reuther

There was a moment today when I realized I'm doing exactly what I'm meant to do. I love taking care of sick kids and making sure I do everything in my power to get them better. Not only do I love it, I'm good at it. It's the best feeling in the world.

Thank You Cards You Have Yet to Send

Thank You Cards You Have Yet to Send is a project I helped create at Stanford Med with a few other members of the Gold Humanism Society. It's meant to serve as recognition of all the patients and families we have worked with and learned from during medical school.

Check out the article on the Stanford Med website here: Student project thanks the often-unsung teachers of medical school: the patients. Fellow student Jia Luo put it all together beautifully. Happy to see it's getting some publicity.

Decision Fatigue

Doctors taking care of patients who are hospitalized make a lot of decisions every day.

Here is a very conservative estimate for a common hospitalized patient on their first day of admission:

Each medication: Is it necessary? how much? how often? what route? hold parameters?
x10 meds = 50 decisions
Each lab result: Is this normal? If not, do we need to do anything? What should we do?
x15 lab results =45 decisions
General work up of hospital illness -should we treat? do we need more diagnostic tests? do we need a consult?
x3 med issues =9

1 patient = >100 decisions per day

x5 patients = >150 decisions per day

or if you're the senior resident or attending x20 patients = 1000 distinct decisions in a day!

Thus, after a call day, when a friend asks you where do you want to go for dinner -your response: anywhere, as long as you decide!

I think this decision fatigue is an under recognized but significant cause of fatigue, stress, and burn out in the hospital for residents. I know many of these decisions become much easier over the years, but they are still distinct decisions, for which you are accountable for in a court of law. Not so easy in my opinion.

Did you know?

A piece of women's history and medical history...

The first woman accepted into medical school, Elizabeth Blackwell, was only accepted because her admission was put to a vote by the class at Geneva College of Medicine. As a joke, the class unanimously voted for her acceptance.

Turns out the joke was on them, as she went on to graduate 1st in her class in 1849.

The most difficult specialty in medicine

Family Medicine.

Are you surprised at my answer? Here are my 5 top reasons, see if you disagree by the end.

1. Breadth of knowledge. 
General practitioners like to say they care for patients from "womb to tomb". It's impressive. Knowing pediatrics, preventive medicine, all specialties, geriatrics, end of life care. On any given day in the clinic I would see cases that spanned the entire first two years of medical school.

2. Early infancy of disease processes.
It's easy for the specialist to look back and say, how did the PCP miss this? The tough part of primary care is that you see disease in it's early phases, often before the easy hallmarks become apparent. It's really difficult to diagnose some diseases in their early phases.

3. Behavior change.
We all know how to stay healthy: diet, exercise, sleep, joy in our life, avoid stress, good relationships, no evils like smoking, alcohol or drugs. Easy eh? These are the things that GPs deal with every day, they are in the trenches trying to improve health care in the U.S.

4. Keeping pace with changes across medicine.
How many studies and policy changes occur every year? How do you decide which ones to follow, to change your management of patient care? Keeping up with the NY Times controversies, from cancer screening to statin side effects to HPV vaccines and contraception -a frontline doc needs to stay on top of the headlines and have a critical take to inform their patients.

5. Current structure of healthcare delivery.
GPs bare the brunt of the disaster that is currently known as American health care delivery. They're also going to be the area of medicine most transformed in my life time, no doubt about it. Change is hard.

PS. Family medicine, general practitioner, primary care provider, pediatrician, general internist are all generalists, first line doctors who help keep America healthy.

Children have strokes?

Apparently.

I met several children who have suffered from strokes recently, which was shocking to me. Here is a good NY Times article that goes over one such a case: Children Don't Have Strokes? Just Ask Jared

Fortunately, with arduous rehabilitation, many of the kids can make strong recoveries. 

So much to do, so little time

I absolutely love doctoring. I've said it before, and I will probably say it again and again. Helping someone deal with sickness is really rewarding. The challenge is, that we can always do more. We can always improve the science, we can always improve our communication, we can always improve the delivery of care, the cost of care, the equality of care. Frankly, these last 8 weeks I've been really overwhelmed by how much more can be done. How much we have left to do. Medicine has gone a long ways by many measures, but all I can see is how far the road ahead is for us in terms of delivering really high quality care. I feel like I'm this little newborn baby in the middle of a rainforest trying to find my home that is 10,000 miles away. It is that intimidating of a challenge! I've found this state of frustration to be not very conducive to anything, and so I've been trying to develop the personal mantra of "Do what you can, when you can, with what you have." Still-very difficult!

 I see how it is so easy for a doctor to make their work all-consuming. But for me, the value of relaxation, the outdoors, reading, family, and friends is priceless. For me personally, and also for me as a doctor. It reminds me of why I think medicine is such an amazing profession. I get to help out family and friends. They may not be my family and friends, but they are to someone, and I always try to approach a situation by thinking "what would I want if this was my child, or my mom".  I find it much easier and much more fun to deliver medicine in this way.

I'm working on some solutions, in my spare time. Maybe one of these days I will share them with you on the blog! In the meantime, here is a quote that continues to energize me:

“Some people see things that are and ask, Why? Some people dream of things that never were and ask, Why not?

NICU: Babies babies everywhere!

Babies on the mind, caught another 2 today, 8 for 8!

Most interesting about babies is how they all start out the same. You can't predict which baby you hold will become the next President of the United States, the next doctor, or school teacher. You can't predict who will have mental health problems, obesity, or breast cancer. Just by looking at them, you wouldn't know who will live in poverty or who will be the next billionaire. We all start out the same: sleepy, hungry, and naked. We know the world by what others teach us about the world. If you teach me that I can do anything, I'll believe it, because why shouldn't I? It's all I know. Each baby I caught, I said a silent prayer for and greeted them with a big smile. It may not be much, but they came into the world into loving arms, and I hope we continue to show them how great life can be.

Doctors as Team Captains

I just finished my first day at the Telluride Patient Safety Roundtable. What a great day! It's been really fun getting to know the other students as well as meeting faculty who have such passions for improving the delivery of health care. 

Reflecting on today's conversation, I saw the connection between doctors and team captains. Doctors wear a lot of hats, we are scientists, surgeons, educators, shared-decision makers, advocates, managers, and team members. On the wards, doctors are in charge of large teams of care, ranging from residents, medical students, fellows, nurses, medical assistants, nutritionists...(the list goes on). It reminds me of being captain of the track team. Not only do I have my 7 events to perform and improve on, but I worry about the goals of the team, each individual teammate, ranging from freshman to seniors, injured, superstars, the 100m sprinter to the pole vaulter to the 10,000m runner. Team dynamics, coaches, trainers are all involved. As team captain you have some power, but you aren't the coach involved in everything, but you have a lot of influence. I wonder how we would approach training doctors if we approached them as team captains in training.

The ER

After getting to the hospital at 7am Friday morning, I found myself back at the hospital at midnight that night, for my first 8-hour Emergency Medicine shift. Running on adrenaline only, I was perfectly alert all night, because the ER is a fascinating place. I made my way around to almost all the patients, talking with them, asking the nurses to show me things, asking the residents to explain some things. I learned all about patient registration, the supply room, trauma protocol. I was impressed with how streamlined it seemed from the nurses and doctor's perspective. From the patient's perspective the number one complaint was how slow everything seemed to happen. They all wanted to either go home or be admitted to the hospital. I can only imagine how being in "ER limbo" must feel when you're sick and scared that it could be something really bad.

Overall I was very impressed with the professionalism of all the staff in the ER, from the person cleaning the rooms to the attending physician. I had the opportunity to participate in a trauma call, very organized, and thorough. I also cleaned and sutured up some lacerations for the first time (really cool).

Above all though, my favorite part was talking with all of the people and their families, hearing their stories reminds me of why I think that being a doctor is the best job in the world. It fires me up to realize that I have the power to make people's lives better. Even last night, I did my best to listen, educate when I could, and comfort always, and I think I made some people feel better. I was so impressed with all the staff in the ER, and it humbles me to know that I'll have the priveledge of working alongside these people when I head into my clinical rotations full-time in July.

Holidays and the BCC

The weeks between Thanksgiving and Christmas are probably my favorite weeks of the year. I had the priveledge of attending my 4th UCSF Breast Care Center Holiday party tonight. As eventful, festive and fun as always. The Intern skit was once again phenomenal, poking fun at the idiosyncrasies and hysterics that make up the BCC. I absolutely love being able to see old friends and colleagues, hear they are well, and what they are up to now. The BCC really was a work-home, very different than anything I've experience in medical school, and an environment I will really strive to find in the future. I really miss being part of a team working towards a goal, in med school you're constantly floating through teams, never a full fledged member yourself.  It was my first full-time job, where I fell in love with medicine, and realized that work doesn't have to just be work, it can be a passion, a calling, and something you do with friends and colleagues, not just coworkers, something that is fun, creative, and worth your while, What a terrific reminder about what the holidays, and life in general, are all about. Also a good kick in the butt reminder of why I'm doing all this studying now, with finals 6 days from now, its the extra uumf I needed!

Platelet Donation

The last time I donated blood, I asked the nurse to check if I was eligible to donate platelets. A very small percentage of people are eligible to donate, for a variety of reasons, including prior pregnancies. too small, not enough iron, cytomegalovirus, travel exposures, I could keep going...

A week later I received a call from a very nice woman who was just SO excited to inform me I was an eligible platelet donor. Her words were "there are so few of you out there, I'm so glad you're eligible. You can give every 2 weeks!"

This evening was my first platelet donation. First impression: they take more care of you, give you selections of dvds, a nice tv with headphones, sweet deal. It takes longer than a whole blood donation, but that means I can settle in and read for a while. The platelet process is strange. Whenever I donate blood, I always think of the scene in the StarTrek movie where they enter a hospital on Earth for a sick man who is about to undergo brain surgery, the Space doctors are outraged at the barbaric, ancient care and use a laser to heal him instantly. It makes me think about how in the future, hopefully we'll have synthetic platelets and blood, and we won't need centers all around the country leeching blood from willing donors...The process really is oldschool when you think about it. Nonetheless, the platelet machine is a fancy centrifuge with a lot of dials and ringing bells. It felt very strange feeling blood pushing through my veins back into my body. I also felt a little strange in general after giving, but I'm doing alright.

Why do I give platelets you ask? In honor of my lovely grandmother, who is very fortunate to be the recipient of weekly platelet infusions. And all the other family members, mothers, fathers, daughters, cousins, grandfathers, who wouldn't be here today without platelets. I may not be a doctor yet, but I'm finding ways to contribute to treatment and care in my own way...

So, next time you give blood, check if you can give platelets. It really is a blessing.

NEJM Letter on Arizon Immigration Law

Thought it necessary to share this brief letter to the editor...While I was reading it, I was struck by the fact that the Arizona law has such similarity to the Fugitive Slave Law of 1850 that made it illegal for people in the Northern states to "conceal, harbor or shield" a slave and effectively turned police officers into "slave catchers". This is wrong. If I ever am subjected to such inhumane laws, I will choose to nonviolently protest and disobey.

Arizona Immigration Law and Medical Practice

To the Editor: The new Arizona state immigration bill (SB-1070) signed into law on April 23 will seriously obstruct, if not undermine, the practice of medicine in the state of Arizona. It specifies that those who "conceal, harbor or shield or attempt to conceal, harbor or shield" a foreign person who came to the United States illicitly "are guilty of a class 1 misdemeanor" punishable by a fine of at least $1,000 (Sec. 5, Section 13-2929).¹ It can be argued that health care providers who neglect to report illegal immigrants under their care will violate the law and be considered criminals. The bill provides physicians with no guidance as to what constitutes "reasonable grounds" to suspect that somebody is in the country illegally, leaving the particulars of such scrutiny to anyone's imagination (although the fact that Arizona shares a border with Mexico rather than a European country suggests that whites will not be "reasonable" suspects). One interpretation is that health care providers in Arizona will need to ask for a passport before seeing certain patients (and providers themselves will need to carry their own passports at all times, depending on their physical appearance or accent). Arizona practitioners, hospitals, and medical associations need to ponder the extent of their liability under the new law and draft clear institutional policies to defend their patients and employees from potential harassment. Asking patients to produce immigration documents violates the trust that physicians, nurses, and other health care workers endeavor to earn from them.
This bill threatens one of the oldest traditions of medicine: physicians shall protect patients regardless of nationality or race.² This legislation, if unchallenged, will force health care providers to choose between the dignity of their profession and the indignity of violating the law.

Lucas Restrepo, M.D.
Barrow Neurological Institute
Phoenix, AZ

Musings on medicine and money

The more problems I see with medicine, the more I blame the infusion of money and business for the erosion of the medical profession. As a profession, we need to do more to uphold the integrity and ethos of our practice. This means being open source, nonprofit, honest and transparent. It's easier now than ever to make money as a doctor, through biotech, boutique medicine, private practice, and if we want to keep medicine as a profession, we need to stop this. Patients should always feel 100% confident that the tests we order, the surgeries we do, and the visits we schedule, are in their best interests, there should be no doubt about this. If you want to join me in making sure that medicine stays an independent, noble, and honorable profession, please let me know. Support open source software, support the removal of big pharma from our education and practice, and speak up against those who say otherwise. I'm reclaiming medicine as an honorable profession, I'm proud to work hard now to help my patients in the future. The debt, time, and hard work is worth the honor and esteem that comes along with being a doctor, and mark my word I will be a physician of virtue and always act in the best interests of my patients. When the integrity of medicine is doubted, physicians lose their power. Our voices are supposed to be the ones advocating for better care for our patients, better political policies and social programs. It should NOT be the case that medical societies speak up in the name of their paycheck and not their patients. That is a disgrace to medicine and other physcians, me included, need to vocalize this dismay. If we don't, who will?

A Walk to Beautiful

"A powerful story of healing and hope for women in Ethiopia devastated by childbirth injuries." You can watch the entire documentary online here.

A Reminder of My Purpose

In the midst of studying for our first HHD exam, I am reminded of the Stanford Affirmation that we recited at our ceremony way back in August:

"On my admission to the Practice of Medicine I pledge to devote my life to the service of humanity. The care of my patients will be my first consideration.....I will hold all life dear, and let knowledge, wisdom, courage and compassion guide my therapy. I will use my medical knowledge to promote human rights, social justice, and civil liberties."

More knowledge now = better doctor later = better care for my future patients.

My head is clear, my heart is full, I feel that my actions are aligned with my values, and I'm doing the best I can.  I go to bed restful, peaceful, and recharged, truly thankful for all that I have been given and all the wonderful people in my life.

Vital Amines

Vitamins were named "vital amines" when they were first discovered in 1911 because they were found to be essential for life.

My cool fact of the day.

Also: Happy Birthday Dad! Hope you enjoyed your Green Monster, it's full of vital amines. :)

Got a New Book in the Mail!

My Amazon.com order came in, my new nighttime reading is Walking Out on the Boys, a true story written by Dr. Frances Conley about her days as a neurosurgeon at Stanford and what lead her to resign from her tenured faculty position.