I always “knew” that I was going to be the nice fellow. Partly because I’ve had some terrible experiences with fellows during residency (which I’m still salty about, by the way. I mean, listen, there is never a scenario where I, as an intern, am ‘deciding’ to consult you. The intern is just doing what they were damn well told) – but mostly because I figured I didn’t know anywhere near enough about pediatric neurology to be mean or even a wee bit testy.
… I was perhaps wrong.
This gradual realization reminds me of being an intern and “knowing” that I was going to be the cool intern, the intern that never questioned medical students. (see: 10 Things Med Students Should Never Do) and then discovering that indeed, many – if not all – med students were once pre-meds, and as everyone knows, pre-meds are terrible.
I think the crowning moment was last month, when I was paged – not once, but twice – by 2 different members of the same ICU team, to have the following conversation:
“Hey, we have this patient with epilepsy – he’s been on carbamazepine and just got a g-tube inserted this morning, so we need to curbside you for AED management.”
“Oh. OK. …. wait, because the g-tube isn’t safe to use yet?”
“No, because he just had a g-tube placed.”
“Okay. … I mean, that’s fine… but carbamazepine is an oral drug. Does he.. can we not use the g-tube? Is he having seizures?”
“Uh, no, no, neither of those.”
“…. Oh, so he’s been on an IV AED while waiting for the g-tube to be placed? Yeah, if it’s been over 1 week we do need to restart the carbamazepine at a lower dose, and I just need a second to look up the titration schedule -”
“No, no, he’s only ever been on carbamazepine.”
“Huh. So… he’s been on oral carbamazepine, and you’re transitioning him to.. oral carbamazepine?”
“We just need you to weigh in on the pill to liquid conversion.”
I dare you to find a way to suggest that the “pill to liquid conversion” is always 1:1 without sounding judgmental. (Bonus points for receiving a 3rd page 2 hours later, during which the resident “just wanted to clarify” that it definitely didn’t matter that the medication was being given by g-tube rather than by mouth.
… I mean… the mouth connects to the- there is no significant sublingual absorption in a medication that is not sublingua- I mean it’s exactly like zofran and tylenol and any other medication ev- aw, lord, nevermind. )
But by and large, I have been able to live up to my ideals. I have driven from home to the ward at 1am to do the emergency LP that the primary team could not get. And I showed up again at 7am the next day for consult pre-rounds.
I have spent hours getting pseudoseizure patients admitted to the epilepsy monitoring unit rather than the general floor. I have, in great detail, explained to many residents how a headache cocktail works and how they can in fact learn how to order one themselves – because no one ever explained this to me before my adult neurology year, and it seemed like a useful gen peds thing to know.
I have also gotten a disturbing number of calls from outside hospitals and EDs where they have asked for my advice, received it, and then… followed it. And my attendings weren’t aware, because it was 2am and they neither needed nor wanted to be aware of anything that went well.
Man. Remember when I was posting about anatomy test anxiety? I wish I could go back in time and tell myself “Look, in the future, when you’re on-call at 2am… google will exist. You’re just gonna have to be really quick about it. It’ll be fine.”
Even though I’m still disturbed that I’m somehow now in a position where attendings actually listen to me at night (and even weirder, sometimes in a position where I get angry on the rare occasion that they don’t) – I’m mostly just glad I seem to have made it through the anxiety.
Looking back, I really can’t believe how anxious I was about antibiotic coverage.
… I actually no longer know antibiotic coverage. And at the time, I thought that would make me a terrible doctor.
Instead, I know that when a patient on phenobarb, keppra, and a versed drip starts having breakthrough seizures at 2am, I can pretty much use whatever rationale makes sense to me to decide which one of those medications to load and then increase – and the day team will just appreciate that I did something, and especially that the something I did involved some sort of logic. Regardless of whether it worked or not.
And if the ED calls me about a patient who had a weird movement that was maaaybe a seizure, maybe not, but they’re back to normal now – I can either admit the patient or recommend we see them as an outpatient (spoiler alert: either way, we should probably just see them as an outpatient), and again, the world will not end if I am wrong.
I have found this out first-hand.
Basically, if I could go back in time and shake myself out of the weird anxiety-laden hole I had dug for myself, I’d do it in a second.
And I’m only writing this in case you’re identifying with me from the past, in which case… you’ll be fine.
You’ll be fine.
needed this today! Glad to hear it’s gotten/ gets better! thanks for sharing 🙂
Missed seeing your posts! have been a silent reader for a few years and really enjoy your humour. Glad your fellowship is going well.
Yay! Welcome back AP! We’ve missed you. Been following your blog as we’ve trodden similar journeys from medstudent and boards hell to resident and fellow. Spot on observations, and keep up the good work (on patients and more importantly, on the blog ;))
Hey AP! Through random internet tangents ended up re-visiting your blog after several years’ gap. Loved your posts while in med school, and still find them super relatable now (just finishing fellowship as well, then on to… more fellowship). Thank you for your posts!
Saw this today and thought you’d appreciate this similar take:
OK, oops, I thought I was commenting on your billing post. So, can’t follow directions. . . .