The cure for canker sores in two paragraphs, but first, a little education: I’m talking about canker sores , also known as apthous ulcers, found inside your mouth. I’m not talking about herpes sores, which are usually found around the lips or on the genitals, or syphillis chancres, or chancroid, yet another similar-sounding STD. Canker sores probably have an unknown viral or bacterial cause from what I’ve read, and are not STDs , for the damn record.

If you get canker sores recurrently like I do (mine are generally from stress), you’ve probably tried every possible cure. I’ve tried vitamins, amino acids, yogurt bacterial cultures that you have to keep in the refridgerator, mouthwashes, toothpastes, numbing agents, and anti-viral drugs, with absolutely zero success. When I was in high school, I had 17 in my mouth at one time. I’m not kidding. (Thankfully I’ve learned to de-stress since then.)

But I’ve finally found a cure (for me at least), thanks to the doctor at the student health service: triamcinolone paste (it’s a corticosteroid). The stuff works wonders. Spread the gospel, please. Dry off the canker sore, put the paste on the canker sore just before bed, fall asleep, repeat for a couple days, and it’ll hurt less and heal much faster. Your doctor can easily prescribe it, and it’s a generic, so it’s cheap.

Please appreciate this advice, I’m probably sacrificing my kissing-attractiveness by posting this one.

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One of our national pimples is coming to a head, and it’s pitting those that understand medicine against those that don’t. The former group understands that there’s never a free lunch; that you don’t get something for nothing; that everything in medicine is a trade-off between risks and benefits. The latter group expects a perfect pill for every disease (or even just a pill for every disease).

An attending that I’ve really come to respect over the past weeks made a similar comment out of the frustration with Mexican immigrant family. The boy in the family wasn’t taking his anti-seizure medication regularly (which is important, both because it prevents seizures, which can be dangerous to the patient, and because it’s dangerous to quit an anti-seizure medication cold turkey). My attending, himself an immigrant, said “there was a cultural problem,” but I now think I see what he means.

Until we develop the perfect pills and vaccines and surgeries without any risks, side effects, or complications, everyone must understand this simple fact: everything in medicine is a trade-off between risks and benefits . We do our best to minimize these risks and maximize these benefits as physicians–by doing research to discover which drugs work better and which operations are safer, but even we cannot prognosticate. Leave that to the groundhogs . We can tell you with X percent certainty that a drug will work, or that Y percent of patients will have an infection after surgery, but right now, we don’t know which people are which, in most cases.

That’s the tough part about medicine: we do all this research and publish all this crap to do our best to predict the future; we’re the ultimate in control freaks. We want a good outcome for our patients, so we study and crunch numbers to try to have more control over the outcome, but nothing’s for certain. Life’s precious and fragile. We’re doctors, not miracle workers.

Now, this is no blame-free mantra. As physicians, we must make sure patients understand the above simple fact. But we must also provide them with as much information as possible, in as easy to understand format as possible. And, as we have learned from the Vioxx disaster, we must not allow any possible risks that are known to be hidden. I’ve spoken with several patients in chronic pain with stomach problems (the only group Vioxx should have been targeting) who say that they’re very upset Vioxx was taken off the market: it was the only drug that helped them. They said they were willing to take the risks of Vioxx; it should be each person’s choice.

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I totally ruined the last post with my humor-cum-neurotic antics. So back to the difficulties in examining pediatric patients.

The whole “take a good history and physical” mantra kind of goes out the window when the human you’re trying to help doesn’t do that whole “talking” thing or that whole “sitting up” thing, or especially the “can you do what I’m asking you to do” thing. It really makes you hone your ability to draw conclusions from limited information and to use tricks to get the information you need. A couple things I’ve picked up (post yours in the comments!):

Checking reflexes requires the patient to relax their joint, but it’s a tough sell on a squirming infant. Even distracting them doesn’t always work.
“Follow my finger” to check eye movements can be tough. Following a toy or a face seems to be much easier.
Use the parent. They can soothe the savage beast, and keep the child’s attention while you’re busy poking and prodding them. Plus, they’re usually all you’ve got for the history, if the kid’s too young to talk.
Let kids see your instruments before you use them. Makes them less scary. Warning: the hyperactive children will throw your reflex hammer, and may almost hit a nurse in the eye. Keep instruments away from them.
Get on the child’s level. You’re much less intimidating there.

Other tricks, my medblogging colleagues?

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This just in: it is certifiably impossible to walk into a room with a smiling baby without your maternal or paternal instinct immediately raising the pitch of your voice at least two octaves. It is simply uncontrollable.

The first week of my neurology rotation was incredibly dry. It consisted mostly of library time, awaiting the consults that never really came. The week was slow, and seeing as though it was the first week, I naturally felt stupid, frustrated, and lame for asking seemingly obvious questions. After a nice mature little internalized tantrum last Sunday (“I hate neurology! This is so stupid! Waaah!”), things are starting to make sense and get busier. Not a whole lot of sense, but plenty busier.

The problem with all of this, however, is the selection bias. Because only the really sick people end up in the hospital, you get a very skewed view of the population. While most of us will remain fairly healthy throughout our lives (minus some high blood pressure, high cholesterol or weight problems), the medical student and the resident see the worst of the worst. Since every patient we’ve seen so far in the hospital has been for a seizure workup, I’m thoroughly convinced that every child has had a seizure in their lives. (Time out for reality: a febrile seizure occurs in 2-5% of the population, but 2/3 of those kids never have a second seizure, so neurologists don’t generally get their panties in a bundle about a first-time seizure assocation with fever. Then again, 80% of neurologists prefer boxers to panties, so pantie-bundling isn’t all that common among neurologists, anyway. Surgeons, however…)

So I’m somewhat convinced that I had a seizure, and my parents are keeping it from me. That, or the old evil babysitter they hired named Alva Camp that made my brother and I eat only rice cakes and choose between taking a nap or cleaning our rooms while they chilled in Barbados just never told them about it. (And they say psychiatrists’ children are neurotic. Clearly I’m an exception to the rule.)

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Pardon the dust, won’t you? A new design is on its way.

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I’m a little worried it’s my institution (and former members of the team I’m on) that this woman rightfully complains about in the NYT yesterday. (I only say this because the woman is from a nearby city, and our service does a lot of breast surgeries.) However, in none of my experiences has anyone done anything remotely similar to what the patient describes:

Mary Duffy was lying in bed half-asleep on the morning after her breast cancer surgery in February when a group of white-coated strangers filed into her hospital room.

Without a word, one of them – a man – leaned over Ms. Duffy, pulled back her blanket, and stripped her nightgown from her shoulders.

Weak from the surgery, Ms. Duffy, 55, still managed to exclaim, “Well, good morning,” a quiver of sarcasm in her voice.

But the doctor ignored her. He talked about carcinomas and circled her bed like a presenter at a lawnmower trade show, while his audience, a half-dozen medical students in their 20’s, stared at Ms. Duffy’s naked body with detached curiosity, she said.

After what seemed an eternity, the doctor abruptly turned to face her.

“Have you passed gas yet?” he asked.

“Those are his first words to me, in front of everyone,” said Ms. Duffy, who runs a food service business near San Jose, Calif.

“I tell him, ‘No, I don’t do that until the third date,’ ” she said. “And he looks at me like he’s offended, like I’m not holding up my end of the bargain.”

I’d be just as upset as this woman if I was treated that way in the hospital. On my service, we always knock before entering a room, we greet the patient, we tell the patient what we’re about to do (“I’d like to take a look at your incision”), and we always cover a patient of any area that doesn’t need to exposed. Any time we remove a part of a patient’s gown, we make sure to close the curtain in the room.

Also, our teams are two medical students max–not half a dozen.

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Turned 25 today. Pretty damn uneventful. Me, internal monologue style:

Wake up, groggy.
Ugh, it’s 5am.
Look at phone.
No one called. Sad.
Oh, wait, you went to bed at 9:30, and the bf called at 10:10. You barely remember the conversation, but you’re sure he was sweet.
No one else called. Sad.
Oh, wait, it’s 5am. Who would be up this early, and even if they were, would they expect me to be up this early?
Get in shower.
Put shampoo in hand. Hey, it’s your birthday.
Joy. Rapture. 25. Car insurance now cheaper.
Finish shower. Get dressed.

Two days left of surgery, and on Monday I’ll start with Neurology. My, how time flies. Down to LA this weekend for a birthday celebration. A little delayed gratification is always good now and then. Especially when you have a scary surgery exam in two days and have no idea what to expect.

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Even though it’s sometimes hard to see a patient as more than just their disease, I’ve really started to think about how this is, for most people, just a tiny little part of their life. You forget that you’re seeing a patient at their worst–sick as stink, post-operation, and feeling crummy. They haven’t showered in days, they’re eating crappy hospital food, they’re too weak to do more than lay in bed most of the day, and they’re away from their families, their cultures, and their homes. Sometimes they’re unconscious, or so drugged up that they’re not even with it. And because this is almost all you see of the patient, it’s not uncommon to make what’s called the fundamental attribution error in psychology–believing that a person’s actions or behavior is due to the patient’s own personality than it is due to the situation he or she is in.

Even in clinic, seeing the patient before they’ve had any sort of procedure or treatment, the attribution error can stick. The clinic is usually running late, so the patient has been waiting for awhile; he or she is probably nervous about seeing the doctor and learning what kind of treatment will be necessary (especially when they know they’re in a surgeon’s office for a reason); he or she might not be feeling well, and any other number of reasons. So if the patient (or a family member in the room) is crabby when I enter the examination room, I automatically assume it has nothing to do with me or the other person. I’ve learned to take no offense. I automatically give the person the benefit of the doubt. It’s not uncommon for patients to get a disappointed look on their faces when I enter the room anyway–they’re expecting to see the surgeon, and then I introduce myself as “the medical student on the team.” (I do think, however, they are slightly relieved to find out that someone as young as me will not be performing the operation.)

This all came about because of a sick-as-stink patient we’ve had on our service recently. He’s been in and out of the ICU, unintelligible when he attempts to talk, and pretty much out of it–due to his own neuro issues or the psych drugs we give him to keep him calm. (He’s been pulling out his drains.) One day, however, I guess a family member must have brought by a little collage of photos of the patient and his family. I couldn’t believe it was the same man. Him as a 30 year-old with his wife. Him in his 40s riding a horse with his daughter. Him with his extending family at a 50th birthday party. Scanning from picture to picture, none of them matched the dehydrated, sickly, wasted man lying in the bed next to me. All this time I had thought of this patient’s life as culminating in his surgery, cancer, and hospital stay, and I hadn’t even realized it. The egotism of my idea of the man blew me away.

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An attending once told me a story about a colleague doing an abdominal operation on a morbidly obese patient, cutting through layers and layers of fat, only to hit the operating table on the other end. The surgeon, getting lost in the patient’s adipose tissue, went completely through a roll of fat, as opposed to cutting down to the abdominal wall.

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Although I’m spending countless hours in the hospital with little thanks or appreciation, the ice machines here rock. That is all. Back to your regularly scheduled programming.

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