Thursday, September 29, 2016

Learning, Labor, and Love

For graduation, I asked my parents for customizable diploma frames from 3art. I chose the blue mat for my PhD diploma and green for the MD. In the green one I also put a photo of Dear Husband hooding me at graduation (it was the only professional up-and-down photo we got), as well as my tassel. In the blue one are my MD medals (Alpha Omega Alpha and Honors), as well as my BA tassel, since I lost my PhD tassel when I accidently returned it with my mortar board. These now hang in our living room, over the couch as mementos of 12 (16!) years of learning, labor, and love.

Maybe if I'm ever home again when the sun is up, I'll take better photographs.

Sunday, September 25, 2016

Apple Maple French Toast Bake

1. At 6:30 AM on a Sunday morning, tune the radio to Sunday Baroque, because the last thing you want to hear this morning is election coverage. Pre-heat oven to 375 F.

2. Assemble ingredients for a sweet bread-pudding recipe you found in the East End Co-op mailer. Discover that you forgot to buy bread yesterday.

3. The Co-op doesn't open until 8 AM. Cut up the rest of the bread in the refrigerator, enough for 4 cups instead of 5-6.

4. Adjust the recipe with 2/3 the milk, 3/5 the eggs (they're extra large), 3/4 the butter and apples, and 100% of the cinnamon, ground ginger (really? not nutmeg? weird), brown sugar, and Illinois maple syrup.

5. Whisk eggs, milk, 1/2 the cinnamon, and nutmeg. Fold in bread. Add in the brown sugar you forgot.

6. Melt butter in pan while chopping apples. Dropped pieces of apple belong to the chef (after washing off, of course). Stir in maple syrup and the rest of the cinnamon. Turn off the heat.

7. Butter a glass baking dish. Combine the bread mixture with the apple mixture.

8. Bake for 2/3 the time. Wash dishes. Let sit for 5 minutes.

9. Serve with hot tea, fruit, and yogurt.

The bread was almost too soft, but the apples were still crunchy and tangy. Only needs extra maple syrup if your sweet tooth has already gotten out of bed. We thought it was just fine as it was.


4 cups cubed bread
3 tangy apples, chopped
3 eggs
1 cup milk
1/4 brown sugar
1/4 maple syrup
1 1/2 tablespoons butter
1 teaspoon cinnamon
1/4 teaspoon ground ginger (no judgment if you substitute nutmeg; not sure if you could tell the difference)

Bake for 30 minutes at 375 F.

Do you prefer a savory bread pudding? Try this dinner recipe.
More fun with apples: baking apple pie with immigrants.

Friday, September 23, 2016

The Infectious Disease Borg

"We are the Borg. You will be assimilated. Resistance is futile."

As a fourth-year medical student, I planned to write a series of blog posts about what I had learned from different medical specialties. For a variety of reasons, those never materialized, and the drafts I started are languishing on Blogger. But this week I was inspired to start yet another mini-essay, and having the evening off provided the time to compose it.

This week I had five days of elective; I chose to join the Infectious Disease team. (I was there for the drugs--to learn more about antibiotics, that is.) The way we were treated, one would be forgiven for thinking that I had assimilated to the Borg. Instead, I learned a little something about the best way to utilize consulting services.

Over the course of the week, our attending pointed out repeatedly that the ID fellow or attending on service frequently gets a call from a primary service that goes something like this: "Hi, you know about So-and-So, right? We consulted ID a couple weeks ago. Well, ...." But the fellow or attending does not actually know much if anything about So-and-So, because when the ID team was consulted a couple weeks ago, s/he was not on service. (Primary teams have turnover too, so it's a little unclear why they think consulting teams are any different.) If the person who was on service for ID did not explicitly say to the primary team, "We are signing off," and write that in their consult note, then the primary team often assumes that someone from ID is chart-stalking the patient. There is a department-wide sign out every Monday morning, but every week a new attending and fellow do the consults for the hospital, joined by a rotating gaggle of residents and medical students. The ID department is not the Borg, and they do not share a consciousness.

Lesson #1: When calling a consult, always provide a relevant identification and history.

Lesson #2: When performing consults, don't just fade away. Be clear about when your team is or isn't following a patient.

The experience clarified for me what it means to serve on a consult team. It does not mean that I have any more or special knowledge than most of the people--other physicians, mind you--calling consults. I have not joined the hivemind. What I do have is time, and access to an ID fellow and attending who know more than I do off the top of their heads. Otherwise, the work I do is a careful patient history and a literature review, which a primary team could do, if they weren't caring for so many other patients. This was reinforced for me when I was assigned a very interesting consult with a clear question, interviewed the patient, searched through the medical record, and spent an hour on PubMed. After running the case by the attending, I called the senior resident with my (our) recommendations. "Oh good," he replied, "that's what our research told us too."

So why, exactly, did they consult ID? This was not a question my attending knew off the top of her head. We are all physicians with the ability to read and synthesize medical literature. There is nothing more special about the ID intern's ability to read and understand than about the primary team intern's ability. As much fun as I had researching and answering the question, I felt disappointed and redundant. I worked long hours during this "easy" week of elective and perhaps could have used that time doing something else. I guess I'm glad the primary team attempted to answer the question on their own without reflexively calling a consult, but I wanted to feel more...special.

Lesson #3: When you call a consult, have a clear question in mind that you can't answer yourself.

Our ID attending also told us about the time a surgeon paged her while she was driving home from the hospital to ask the dose for an antibiotic. When she refused to stop driving to look it up, they accused her of not doing her job. She shot back they weren't doing their job. As, you know, physicians with the ability to read and synthesize.

Lesson #4: When you call a consult, don't do it because you're lazy.

I once "consulted" another intern about a renal question her first day on the service. Of course she couldn't answer it. She hadn't assimilated to the renal-pulm borg any more than I had assimilated to the ID borg and could answer a senior resident's impromptu question about what drug(s) to start for a recently transplanted patient with a fever. Because I had already signed off for the day and would otherwise have had to look up an answer myself, I referred her to the ID fellow, who at least would have had a little more experience with the issue. Because I am still just an intern, the ID team isn't the borg, and they don't share a consciousness. They just have a little more time to focus on one piece of the patient puzzle.

So I was less than thrilled to discover that another intern had copied and pasted the recommendations I had made as the primary plan for a patient, with minor updates. Forget intellectual pride and ownership over that text (ownership doesn't exist in an EMR), I wasn't charged with seeing the patient as a whole, just the ID part. In using my recs as the plan, this intern missed out on the rest of the patient's problems and systems. Recommendations are always just that, as it is the primary team's responsibility to decide whether and how to enact them.

Lesson #5: Don't blindly follow recommendations; rather, incorporate them into your plan of care for the patient.

Lesson #6: Always thank your consultant(s) for their time and effort!

Saturday, September 17, 2016

Marriage Metaphors from Cheat Lake

The metaphors practically wrote themselves.

Dear Husband and I had decided to go canoeing on Cheat Lake*, West Virginia, after my pediatrics intern retreat had concluded. Renting a canoe for an hour was $5 cheaper, but the rental guy warned us there was a slow leak in the boat that would let on about a gallon of water in the time we would have it on the lake. With 80-degree weather, an overcast sky, and gentle rain when we started, neither of us was interested in getting particularly wet, so we opted for the kayak. After clipping on our life jackets, I volunteered to sit in the back and steer (of course), while Dear Husband folded himself into the bow of the kayak. And off we went.

The last six months of cancer, Matching, graduation, moving, and internship have been stressful, but DH and I have tried hard to stay positive and connected. That fell apart the last two weeks, as I changed to a very busy in-patient service on which there were only "long-call days"--no one went home early because there was too much to do. After seeing me only long enough to serve me dinner and tuck me into bed three days in a row, DH asked that if I had to work late on Wednesday, could I please do it from home, so at least I would be ignoring him from the same room. (!) My senior resident and co-intern agreed to send me home from the hospital "early"--whereupon I proceeded to spend the evening (sans an hour for dinner), writing notes and discharge summaries in one corner of the study, while he worked in the other. Thursday was a busy half day at the hospital followed by a quick 45 minutes of changing and packing before my ride picked me up for the retreat. Friday DH drove down to join us, and a late lunch was the first time we got to have uninterrupted time together in nearly a week.

So the state of our relationship was at the forefront of my mind this weekend, and you know where I'm going with this kayak metaphor, right? Unsurprisingly, paddling together and steering were intermittent problems for us to solve on the lake today. Occasionally we found a rhythm and stroked together with power and efficiency. Other times I hit his oar or life jacket with my oar. Or one of us was pulling us to one side or the other. Just as in our relationship, we had to communicate our desires to each other with patience and without blame.

It occurred to me at one point that I might be more of a canoer than a kayaker. Kayaking requires you to make even, shallow strokes well-timed with your partner. Canoeing allows you to paddle deeply, now on onside, then on the other, as the situation demands. Two nights before, the first exercise the interns did on our retreat was to rate ourselves according to personality traits: I scored myself highly on curiosity and analysis and was surprised at how accurately the text description of this personality (for whom the worst thing is to be wrong) fit me. When DH heard the categories later (curiosity, empathy, order, and spontaneity), he pointed out that I probably wanted to be a “methodical planner” (aka a kayaker), but that this rarely worked out in real life.

Maybe twenty minutes into our trip, I observed that the heels of my sneakers were sitting in puddles of water, and that my socks were wet. Leaning forward to see if I could bail some of the water out, I realized it was coming in and out of the kayak through holes in the hull. I sang,

“There’s a hole in the kayak, Dear Husband, Dear Husband, there’s a hole in the kayak, Dear Husband, a hole!”

But unlike Liza and Henry, nobody demanded that the other “fix it.” Instead, we rested in the middle of the lake and admired the mountains. At this point we met up with the other canoe in our party and agreed to paddle to the bridge crossing the lake before turning around. Then I realized that the person at the front of the kayak sets the rhythm; unlike canoeing, steering in kayaking has a lot less to do with anything. An excellent reminder that it takes two to paddle both literally and metaphorically.

On the way back, it rained again, and I picked the wrong landmark to follow. When I realized my error, we redoubled our efforts to work together, so as to make it back to the marina before incurring a late charge. Not to mention that DH was wet, top and bottom, and my shorts were soaked through. (So much for picking the "dry" boat.) Plus, it was nearly lunchtime. Like the end date for each period of long-distance relationship in our 18 years together, we were glad to have a concrete goal in front of us, something on which to concentrate rather than the vast expanse of lake. By contrast, marriage seems open ended. With no particular goal in sight, maybe that permits us to try to get by on inertia. Hopefully chances to re-charge like this mini-vacation remind us to actively work on our relationship with each other, to set short-term goals, and always to be kind and flexible.

Back on shore, we changed into dry clothes and shared a burger and fries at the lakehouse before hopping in the car for the 1.5-hour return journey home. One of us even got a bit of a nap in. All in all, a worthwhile adventure. The best part was that we did it together.

*Officially named Lake Lynn after West Penn Power president Albert Lynn from 1925-1976, Cheat Lake got its moniker from the locals, either because of the surrounding "cheatgrass," because the treacherous river/lake "cheated" people out of their lives, or because they didn't like having the dammed lake named after a corporate bigwig.

Saturday, September 10, 2016

What Internship Looks Like XIII: Picnicking in front of the tv

Sometimes internship looks like picnicking in front of the television on your day off.

Because we can't get our couch up the narrow stairs in the townhouse we are renting, there's no good place to sit to watch television except the floor.

This is the first dinner I have prepared since I can remember. Literally. If I'm not working late call (home at 8pm), I like to go for a swim, or else I have continuity clinic; in both cases I get home just in time to eat. Dear Husband has been so wonderful about planning a weekly menu, shopping, cooking, and cleaning up. I'm spoiled so rotten I've already lost two toes to gangrene.

Tonight we had Italian wedding soup, kohlrabi slaw, tomatoes, and crackers. The feature was Pittsburgh From the Air II: Seasons of Change. This hour-long WQED documentary DH checked out of the local library featured scenes from Western Pennsylvania in autumn and spring, accompanied by minimal narration and a jazzy, easy-listening soundtrack. It's the kind of thing that plays on loop in tourist centers, or that runs on public television during pledge time. The library apparently doesn't have a copy of the summer/winter episode; maybe we'll buy one and donate it. At any rate, the shots were a postcard-perfect introduction to this new place where we live. See also Monday's post for hilltop vistas of the Burgh.


Monday, September 5, 2016

That's So Pittsburgh: Hilltop Vistas

For Labor Day, Dear Husband and I picked up the foreign housemates of a friend who was out of town and brought them to a pinko picnic in Schenley Park. But first, DH wanted us to take a detour to a nearby hilltop for a view of downtown Pittsburgh.

From Bigelow and Lydia Streets.

This is Oakland from the hill above Phipps Conservatory in Schenley Park.

On our way from Greenfield back to Point Breeze, I asked to stop and get this shot
from Beechwood Blvd over Duck Hollow and the Monongahela River to The Waterfront.

You might also like: That's So Pittsburgh: Hills.

Thursday, September 1, 2016

What Internship Looks Like XII: Not This Way

Internship is rarely as clear as this sign. There is plenty of medicine I am learning on the job, whether based on evidence, rules of thumb, or gut feeling, but nothing prepares you for all the little questions (Can the girl with hand foot and mouth disease go to the teen room? Does every diaper from this patient need to be checked for blood? Could you fill out this form for me?). Sometimes I very much wish there were more signs like this one.