Wayfaring MD

I am a family medicine resident who likes to highlight the hilarious in medicine as I write about patients, medical school, residency, medical missions, and whatever else strikes my fancy.



Disclaimer:
HIPAA is for reals, folks. All of my "patient stories" have been changed to protect patient privacy. I will change any or all identifiers, including age, location, race/ethnicity, sex, medical history, and quotes. Also, I am an anonymous internet person. Why should you trust an anonymous internet person to give you medical advice? Don't ask me, ask your doctor!
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Specialist attending: Ugh, I’m exhausted from yesterday. I saw a total of 14 patients! That’s the busiest day I’ve had in weeks.

Wayfaring: Really?

I thought the morning was pretty slow. I saw 9 patients in just 3 hours yesterday afternoon and it wasn’t bad. 

Specialist: WHAT?! How many patients do you guys see in a half day?

Wayfaring: I think the limit for 3rd years is 12 or 15 in a half day. 

Specialist: Whoa! How do you guys do it?! I only have to deal with one problem and you guys have to deal with multiple problems in each visit! How can you see 20-30 patients a day? 

Wayfaring:

Um, and out in practice it’s more like 30-40.

Specialist: When do you do your notes?!

Wayfaring: In between patients and at home and after work. 

Specialist: You guys amaze me. That’s too much work. I can barely manage work and a baby and I only work 4 days a week.

Wayfaring: Well that’s why they pay us…the little bucks. 

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Asker Anonymous Asks:
Are you or any of your colleagues considering concierge care? What's your opinion on that and is it going to die down due to the ACA?
wayfaringmd wayfaringmd Said:

I actually do have a friend who graduated a few years ago who is considering starting their own concierge practice. There is some confusion with the term “concierge practice”, because it makes it sound like those doctors are catering to rich people. Some of those practices do operate that way. But the one that my friend is starting is basically just a cash pay business for people of all walks of life.

They will offer a cash price for walk-in visits, and will also offer a monthly membership fee for individuals, families, and small businesses. My friend lives in a very poor area of the country, where most people do not have insurance. So this design of a practice would actually be helpful in a place like that. It would actually be cheaper for families to pay her membership fee then it would be for them to buy insurance. Of course this membership is only going to cover outpatient costs and not inpatient costs, so there’s a tradeoff there.

I really don’t think any of us really know what is going to happen with the ACA. We’ll just have to wait and see. 

Asker Anonymous Asks:
Can you be a doctor still if you developed depression and BPD in med school? I'm scared to get help in case I'm kicked out...
wayfaringmd wayfaringmd Said:

Yes. 

Your diagnosis is technically your business alone. But if your school notices that your work is being affected by your illness, they may ask you to take some time off to get better before you start back. 

Please get help. NOT getting help will do much more damage to your schoolwork and career than actually getting help. 

Asker Anonymous Asks:
Can I go to my family doctor and ask to get a rabies vaccine? I know the universal "back off or die" signs most animals give out, but I still wanna be safe. I keep my Tetanus up to date but i've never heard anything about rabies for people. And is there an minimum age on it? ( And plus It'd feel nice being the person to go help something that's injured somewhere and being able the scream IT'S OKAY IM VACCINATED)
wayfaringmd wayfaringmd Said:

Before I get to the meat of your question, let me say this: being vaccinated doesn’t necessarily confer 100% protection against a virus. Immunity can wane after vaccination, which is why boosters are sometimes recommended, or your body may not build up appropriate immunity to a virus. Just because you are vaccinated doesn’t mean you should take unnecessary risks of exposure to ANY virus. For example, healthcare workers are generally vaccinated against Hepatitis B, but we still wear gloves and other protective equipment when blood exposure is possible. We still wear masks around flu patients, even when we’ve had the flu shot. 

So don’t go out there thinking you’re untouchable! Be safe!

Now back to your question: 

Actually, the rabies vaccine is not recommended for most people because the chances of the average person being exposed to rabies are fairly low, and human-human transmission of rabies is exceedingly rare.

There are 2 types of rabies protection. One is pre-exposure “active” immunization, where the traditional type vaccine is given and the body builds immunity to it over time (and after several booster shots). The other is post-exposure “passive” immunization in which a person who has been exposed is administered rabies immunoglobulin (aka the stuff your body makes to fight off viruses, just in a synthetic form) to help protect against active rabies infection.

The only people who are recommended to get PRE-exposure prophylaxis are: 

  • rabies research workers*
  • people who make rabies vaccines and are around the live virus*
  • people who frequently handle bats*
  • cave workers*
  • animal control and wildlife workers** 
  • veterinarians and staff**
  • travellers***

*: requires primary series and boosters if titers are low

**:Requires primary series without boosters if working in an area where rabies is uncommon to rare. If living in rabies enzootic area, they require titers and boosters as well.

***: only required if traveling to a rabies enzootic area with reasonable risk of exposure and limited access to rabies immunoglobulin.

If you don’t fit one of those categories, then you’re like the vast majority of us who will only get a shot if an angry animal bites us. Also, if you do get bitten, go to an ER. Your family doctor will likely not have rabies vaccines, as they are given pretty infrequently and are costly to keep around.

Sources: cdc.gov, uptodate.com

1930: Checkout. I am warned about Mr. CCU. I admitted him last night with a massive, un-stentable MI that took out his entire right ventricle. Tonight he is intubated and is on 2 pressors, and his BP is still 70s/40s. Keep a close eye on him, they say. Wear a gown and mask if you code him. C. Diff. AIDS. Hepatitis.

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1945: I am warned about Mr. ICU. He came in after a major overdose and continued to endorse suicidal ideation with a plan. He’s medically stable, but mentally unwell.

2000: Checkout over. Peruse the computer and look over everyone’s vitals and labs. Not a big census, but a sick one.

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2020: Head up to check in on Mr. CCU. Oh by the way, his potassium is 6 and his creatinine has tripled. Dialysis just got started. BP 80/60. Ask dialysis tech not to take off any extra fluid.

2040: Check on Mrs. Recently-stepped down from ICU. She’s fluid overloaded. A spot of Lasix for you, my dear.

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2100: CCU: “Will you check on Mr. CCU’s pupils? They seem to be fixed and dilated.” Crap. Pupils as big as saucers. Scleral edema. No doll’s eyes. Guess the brainstem is gone. He’s not breathing over the vent anymore either. Great. No reflexes. Not stable enough for brain imaging. Let’s call the family. Oh there is no family. Emergency contact is a friend with a disconnected phone number. Still a full code. Write a note.

2120: Intern and I make a nest in CCU. Preparing for a long night ahead. We got iPads, reading materials, pagers, and beverages. Better order Chinese for me and the intern and the CCU nurse. 

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2130: Chinese already delivered, piping hot. How do they do that? The restaurant is 5 minutes from here!

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2200: CCU smells like egg rolls. Peruse the ER census to find my least favorite patient’s name on the list. She has been there 4 times since she was discharged from the hospital 5 days ago. Awaiting a call from the ER to admit her.

2230: Dialysis over. He got albumin and more fluid during dialysis. BP still 80/60. At least it’s holding steady. Going up and down on the pressors. Write a note.

2330: Things seem to be stabilizing. Change of strategy: retreat to the call room. Wow, no calls for admissions yet? I’m shocked. Let me refresh my knowledge of pressors.

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0002: ER: “Mrs. Supratentorial is here again and says she can’t breathe. All her labs are black. Her physical exam, x ray, and EKG are normal. I wanted to send her home but she’s refusing to leave. Will you guys come talk to her?”

0004: Send intern into the fire with Mrs. Supratentorial. If she is not sick, send her home! Do not admit her, I say. Make her leave, I say. She can follow up in clinic in 8 hours. 

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0101: Haven’t heard from intern. “You still in ER?” “Just sent Mrs. Supratentorial home. Just finishing up the documentation now.” “You’re a freaking rockstar.” I trot back to CCU. One more check and then maybe I’ll try for a nap.

0110: Mr. CCU’s belly is bruised and firm now. He’s bleeding freely from the mouth and rectum. BP 70s/40s. Glad cards didn’t put him on heparin. Let’s get coags, not that it really matters at this point. Write another note.

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0130: Paged by intern: Mr. ICU trying to leave AMA. What do I do?

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0135: Chatting with Mr. ICU. Nothing is wrong with me, he says. I was just kidding when I said I was going to kill myself, he says. Those 50 pills I took are no indication of my current mental state, he says. And why are you trying to trick me by changing your clothes and putting on a wig? I know you’re all the same person that keeps coming in here. I’m not crazy, he says. I’m leaving.

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0150: Intern informs me she has turned down an unassigned admission from the ED. This is not something we ever do. Technically we are open for another one. “Ain’t nobody got time for an admission when everyone’s trying to die and leave AMA on us,” she says. Agreed. We will take the next one.

0220: Involuntary commitment papers done. Geodon flowing. Patient resting quietly on the bed. Back to CCU for us.

0225: Everything kosher in the CCU? Pupils still blown. Belly getting harder. ABG says the bicarb is improving his acidosis just a smidge. Awaiting other labs. 

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0330: Mr. DKA’s potassium is 5.8. Mrs. Step-down + Lasix’s potassium is 2.7. Is the lab having issues with potassiums? Everyone was normal this afternoon. Someone give Mrs. Step-down some K. Recheck in the AM. Is it naptime yet?.

0500: Mr. CCU is maxed out on 2 pressors. BP 70/30. Now with a heart rate in the 40s. Here, have some atropine. Intern has already pushed more fluids. Let’s get as far as humanly possible away from our comfort zone and put on a third pressor. Sure, why not. Gotta keep him alive until the attending rounds in the AM.

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0510: Back to the CCU. 2 nurses, intern, and I are gowned in preparation for the inevitable code that is coming. His ABG is in the toilet. O2 sat in the 60s. Acidotic out the wazoo. Here’s another amp of bicarb. Potassium’s back up to 6, even after normalizing after last night’s dialysis. Still bleeding. Intern writes another note.

0520: Mr. ICU is awake again and just punched a nurse. Intern and security to the rescue with 2 point restraints.

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0545: Mr. CCU is tanking quickly. One epi in, and oh look, we have a blood pressure again for about 15 minutes. Now he’s in and out A-fib. Great.

0700: The slow-code continues. We’re on epi number 4 now. Coags are back. As suspected, he’s in DIC. Hemoglobin has dropped 4 points overnight. He’s out of platelets. This is futile. Brain gone, heart gone, lungs gone, liver gone, immune system gone, kidneys gone. Attending makes him DNR since there is no next of kin. Finally got in touch with his home health aide. She will go get the emergency contact friend and bring them here.

0720: Friend arrives and agrees that DNR is what he would have wanted. Excellent. No fighting. Give them some time alone with him.

0800: Inhaled breakfast and headed back to CCU. Day backup is there now, stopping the pressors.”You guys wrote a lot of notes last night, he says.” Yes we did.

0815: Potassiums have been jacked up in the lab all night. Everyone’s K is actually OK. Except Mr. CCU’s, of course.

0830: On-call intern is a no-show to rounds. He is pronouncing Mr. CCU.

Asker Anonymous Asks:
Hi Wayfaring! I work for an answering service and we answer for a lot of doctors. Sometimes we get calls for doctors who have pregnant patients where the message to pass on is "APGARS 8 & 9" or some other two numbers, after a baby is born. Do you know what this means?
wayfaringmd wayfaringmd Said:

I assume these docs are passing the message on so they can include the info in their dictations and delivery documentation. 

So the APGAR score is both an acronym and the name of the person who invented it. It’s a quick test used to assess an infant at 1 and 5 minutes after birth. The maximum score is 10. If the score is low at 5 minutes, it is usually repeated every 5 minutes until >7. 

It stands for:

  • Appearance: 0 points for blue or dusky color, 1 point for blue only on hands and feet (called acrocyanosis), and 2 points for pink all over.
  • Pulse: 0 points for absent, 1 point for <100, 2 points for >100.
  • Grimace: assess primitive reflexes. 0 points for no response to stimulation, 1 point for a grimace or feeble cry, 2 points for lusty crying or pulling away with stimulation
  • Activity: 0 points for none, 1 for flexed arms or legs, 2 points for flexed arms and legs that resist extension
  • Respiration: 0 points for not breathing, 1 for weak or irregular breaths, 2 points for lusty cry.

Of note, APGAR scores haven’t been shown to have any correlation with longer-term health outcomes in babies. It’s mainly used as an assessment a birth to direct initial resuscitation efforts (including giving oxygen, suctioning fluids from the mouth/nose, physical stimulation to raise the heart rate). A score of 10 is not common (and pretty unheard of in my hospital. I think the nurses are superstitious against giving 10s. Basically all babies that come out crying get an 8&9.) because most babies have some acrocyanosis that persists for hours after birth. 

Asker Anonymous Asks:
Hey Wayfaring! I'm an emergency room scribe, and I was just wondering what your opinion is on the whole scribe program, writing/typing charts, and family medicine charting. What is your charting like as a family medicine resident? Is the amount/complexity/thoroughness different than what would be seen in an ER?
wayfaringmd wayfaringmd Said:

On scribes: Never worked with one. I think it would be nice to have one, but at the same time I worry about the fact that there’s no standard training for scribes. I worry that my documentation (and billing) would initially suffer with a scribe while I trained them. But I definitely like the idea.

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On charting: In the office, our notes are pretty thorough. There are a lot of little tricks and specificities we have to pay attention to maintain our clinic’s PCMH status, which is kind of annoying. Unlike most doctors, I actually generally like our EMR. It does what I want it to without being unnecessarily complicated. Personally, I’m a writer, not a box-clicker. I’m not a big fan of clicky boxes for history taking, because in the end none of it makes sense. I like that our EMR makes us write out the HPI and assessment/plan. I’ve been told in the past by multiple attendings that my notes are really thorough. Once you’ve been sued and complimented by lawyers on your thorough documentation, it becomes even more of a habit ;). 

In the hospital, we have the option to hand-write or type our notes and print them on the chart. For floor patients, we’re only required to write one note a day, but we do AM and PM notes on ICU patients. And of course, any time you go see the patient again during the day or if their status changes, you write another brief note.

On complexity: Given that our ER charts are terrible and nothing but clicky-box meaningless nonsense, I’d say that our notes are a lot more complex and thorough than ER notes.  Plus our ER docs are lazy and half the time don’t even document a proper physical exam.

Definitely not the message I was expecting when my pager went off at 1 AM. 

Spoiler alert: It’s never a parasite. 

**After a family medicine patient unexpectedly codes in front of L and L has to lead the ultimately unsuccessful code, she goes home feeling a little down**

OB-GYN friend on phone: Hey L, why don’t you come over for dinner tonight?

L: Nah, I really just wanna go home and lay around in my PJs.

OB-GYN: aw come on, come over!

L: No, I’m really tired! I don’t wanna be around people tonight.

OB-GYN: Ugh. Well I have something for you that I’ve been meaning to give you for a while. Just stop by on your way home and pick it up.

L: Ugh ok I guess.

**L shows up at OB’s house to find OB and his wife, Pediatricia, in the kitchen with a smorgasbord of ice cream, sprinkles, syrups, whipped cream, and toppings**

L: What is this?!

Pediatricia: We have a rule in our house. Run a code, eat an ice cream sundae for dinner. Eat up!

L: This is the greatest. 

Asker Anonymous Asks:
Hi! So I've been reading your answers to questions about what family med doctors do. It's cool that you can do so much, but I was wondering if you end up making a good amount of referrals because you can't be highly trained in everything. For example, if a woman came in and she was, say pregnant with twins or triplets, would you refer her to an ob who had training with more complex pregnancies?
wayfaringmd wayfaringmd Said:

I don’t do tons and tons of referrals, but I do them when they are warranted. I’ve seen some family doctors that do nothing but refer all day. They even send all of their diabetics to endocrinologists because they don’t know how to manage diabetes. That’s pretty sad to me.

The point of a referral is to get the opinion or skills of someone who has more training than you do once you have exhausted your capabilities. We also refer out for procedures or treatments that are outside of our comfort zone or scope of practice. Laziness is not a good reason to refer people to specialists.

For example, I might refer a patient to G.I. if I think they need endoscopy or to cardiology for an echo. But I am comfortable managing diverticulitis or heart failure without their help in most cases. I am very comfortable cutting off moles off of arms, legs, and abdomens, but if it’s huge or super deep or on the face I send them to dermatology or plastic surgery. If I think a patient has a complex or uncommon medical problem, I will begin the work up and order the appropriate labs before I refer them out. 

I may also refer out when I have exhausted all the options I am trained in or am comfortable with. I can manage a patients knee osteoarthritis (or back/neck pain) for years with medication, therapy, and injections before I send them to ortho (or neuro) surgery.

I definitely refer out high-risk pregnancies, which would include multiple gestations, severe preeclampsia and gestational diabetes (though I do manage these frequently if they are not severe), moms with multiple complex comorbidities, and certain fetal defects, to name a few.

Sometimes you also need to refer out because a patient requires a drug that is outside your scope of practice to prescribe, like chemo or certain DMARDs for rheumatologic conditions or certain narcotic pain medications. 

Occasionally you get a patient who doesn’t trust you or who has read too much on WebMD and has already diagnosed themselves and they request to be referred to a specialist. Generally I will comply with the request but I will also tell them what I expect the specialist will tell them.

I’ve been looking at the NHSC scholarship, and they distinguish between regular family practice and family practice with OB. If a FP does OB care, is the residency longer, or is that included in the regular FP residency? I don’t want to be an OB/GYN, but I’d like to do low-risk OB care along with my FP practice. -drveebs2b

 ALL family doctors are required to do a minimum number of deliveries and learn prenatal care. The minimum number of required deliveries just dropped from 50 to 25 because so many family docs end up not practicing OB once they finish residency (hence the plain FP). Some programs will offer an OB track that affords more opportunities for deliveries, OB/GYN procedures, and prenatal care training. To practice FP/OB, you do not have to have any special training beyond your normal 3 years of family medicine residency. Once you graduate, you are considered capable of managing low-risk pregnancies and deliveries. But some people WILL opt to do an extra 1 year OB fellowship after residency to get more experience and to learn to do C-sections (also, a few FP residency programs still teach C-sections). 

I really like the idea of having “long term relationships” with patients, so I’m leaning toward Family Med. BUT I also really like kids and women’s health so I guess I was wondering how often family practitioners see kids since there’s pediatrics or do lady stuff because of OB/GYN. -goldroadtonowhere

On an average day in the office, if I see 10 patients, 1 or 2 are there for an OB or GYN issue, and 2 are kids. Some days are more OB and Peds heavy than others, though. Today I saw 1 pregnant lady, 1 recently post-partum lady, 1 lady who was miscarrying, 2 kids, and 5 adults medicine patients.

Family medicine is great because you can sort of tailor your practice toward what you’re interested in and still practice broad medicine. Once you graduate, if you decide you love caring for women and children primarily (as do I), you may join a practice and make a deal that this is the population you will mostly see. Or you can just decide to accept more of a certain demographic of patient into your practice so that you can do more of the medicine you like doing. And after a few years, you’ll also develop a reputation in the community as having a certain niche, and those patients will find you. 

Family medicine residency programs also vary a lot on how much of each patient type you see. There are requirements from the accreditation organizations about how many pediatric and OB encounters and procedures you are supposed to have during your residency, so everyone has the same minimum training. But you will find that some programs are more sports medicine heavy, or geriatrics heavy, or OB heavy, for example. I liked mine because it was very solid all across the board. But if you prefer peds/OB, you may be interested to find a program that has extra strong Peds and OB teaching or even special tracks as mentioned above. 

Asker queenstales Asks:
so when you have graduated from residency and passed the boards you have to start looking for a job or does the hospital just hire you ? i hope this isn't a silly question :(
wayfaringmd wayfaringmd Said:

Not a silly question at all!

You start your job search early in your last year of residency (oh look at the time…). It’s sort of expected that you will pass your boards.

The hospital where you do your residency often does try to recruit you for various jobs within the organization (doing hospitalist, hospital employed outpatient clinic, or locum tenens work), but they’re not always available, and you may not always be interested in the jobs. In the last few years, my residency program, which graduates 10 residents per year, averages 1-2 that stay within the system.

I love getting these from my mom. 

In the fall I’ll be a high school senior and I’m really looking to become a doctor. I know I have awhile before I have to pick my specialty but I was just wondering what you do specifically in family medicine? Do you work in a hospital? How long were you in school? Etc and how do you like if so far? - running-to-be-fit

To be a family doctor, I went to 4 years of regular college, 4 years of medical school, and now I’m in my 3rd (of 3 total) year of residency. At the end of this year I will take Family Medicine Boards, pass, and be a board certified family doctor. 

Family docs do ALL THE THINGS.

We work in hospitals, clinics, urgent cares, and ERs.

We take care of babies, pregnant ladies, kids, grown ups, and old people.

We manage contraception, pregnancy, post partum care, GYN issues, and erectile dysfunction. 

We focus on both preventive care and acute & chronic disease management.

We manage heart failure, liver failure, and kidney failure. All the failures.

We take care of patients with heart attacks and bad lung function and strokes and infections and endocrine and rheumatic disorders.

We treat psychiatric disorders, tackle complex social environments, and deal with law enforcement and social services regularly.

We cut off moles, lance abscesses, sew lacerations, remove toenails, splint breaks and sprains, inject vaccines and steroids, do Pap smears and colposcopies, and sometimes do colonoscopies and minor surgeries.

It’s hard to narrow down to specifics because family medicine is, by definition, a broad specialty. It is a super great specialty and I wouldn’t want to do any other.

Anyone see any issues here?