physician | Elbrecht's Corpuscle

the one percent

Posted on June 22, 2015 by Elbrecht

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In the Fall of 2011, while in the midst of studying for my first medical licensing exam, a time period in which most students become so immersed in learning the filtration properties of the proximal convoluted tubule of the kidney that they can’t tell you the day of the week, I managed to catch a glance of the New York Times every once in a while.

What I saw was amazing; the type of social uprising with which Stalin would have thought intriguing. My interest in Occupy Wall Street, bristling in nYc’s Zuccotti Park, stemmed more from an educated curiosity than a support of the movement, but its occurrence and my observance provided a daily reprieve from the mind-numbing studying.

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And perhaps more importantly, if everything went as planned, if all of my hard work, hours of memorization, and time spent differentiating between the etiologies of monocular glaucoma and retinal detachment, I would become part of a different one percent.

The Occupy Movement, as it became known, was an example of the age-old battle between the “haves” and “have nots”, except on a grander scale, as the “have nots” were meant to be representative of the 99% of American’s who do not possess the majority of our Nation’s private wealth. Wall Street, with it’s perceived “fat cat” mentality, was the optimal target, emblematic of the wide gulf between wealth and poverty in our country.

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My curiosity was piqued for multiple reasons, not only because of the precipice on which I found myself, but because I believed our immediately digital world was bringing this tale directly into anyone’s home who was willing to log on to the internet, click a link on YouTube, or haphazardly skim a front page article in any leading newspaper.

It’s not as if I was surprised by the willingness of many Americans to embrace the Occupy Movement (until it descended into mass chaos); most Americans long for the financial independence they feel has been squelched by the One Percent.

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Given my education and opportunities I have been and will be afforded because of it, I have a hard time agreeing with that mentality. The economy does not work in a way that is “understandable” to most Americans; I don’t mean to belittle the knowledge of most Americans, but I truly believe it.

The economy on which America was founded basically depends on such a massive inequality between the 99% and their villainous opposition.

Yet, I digress, as the One Percent I associate myself is not the behemoths of industry, finance, and politics embodied in the fervor of the Occupy Movement. Instead, my access point to the One Percent is my profession: a physician in America.

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When I awoke from the immersed slumber of studying for the aforementioned medical licensing exam, which once passed allows medical students to participate in patient care in a hospital setting, I had ample time to re-acclimate myself to the goings-on of America. At the forefront was the Occupy Movement, which in Boston where I resided, was taking place not far from South Station.

While awaiting my 3rd year of medical school schedule, I decided to journey to several major cities on the East Coast and Midwest where I might be placed in order to investigate the hospitals at which I might train; or choose not to train at, depending on what I concluded.

Included in this whirlwind was New York City, the birthplace of the Occupy Movement.

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My association with the One Percent is not one I am “excited by”, as in, I am not looking forward to the day when I am afforded financial independence because I am a well-compensated physician. In fact, at no time in the entire process of deciding to reverse course on my entire professional career and become a physician was I motivated by the idea of making money.

This is due in most part to the reality of having a much more lucrative career in any number of other fields without incurring such massive financial debt in the process. Despite such a fact, the average income of a physician, even when including paying off said debt, will afford a comfortable salary and lifestyle (idiotic purchasing habits and tendency to live outside of exorbitant means, notwithstanding).

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https://youtube.com/watch?v=akiVi1sR2rM

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And so it is this fact, the one in which I possess an education which allows me to be well-compensated, that puts me in an overlying bracket of the One Percent.

I certainly do not anticipate accruing the assets necessary to be part of the 1% of Americans who possess >50% of the individual wealth in this country, the scourge of the Occupy Movement, but I do possess an education far more in-line with the ability to do so than a massive majority of people.

Yet, within my colleagues, I have experienced a disconnect with these facts. Even in my current physician standing as a Resident, in which my salary is fixed despite the hours I practice, my income is larger than the average American family of four.

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I repeat, my income as a single, white, male is larger than the typical American family income.

An example of this disconnect arose when my fellow Residents and I were gathered together to sign new contracts for the up-coming year. Our Program Director made a quick joke about our slight increase in pay, which was lamented by one of my colleagues.

She noted how awkward it was that hourly employees of the hospital could be rewarded with an end of the year bonus, but our current status as Residents, prevented us from any such potentiality.

Our program director quickly pointed out how despite our “low-wage” we still made significantly more than an hourly employee who was eligible for an end-of-the-year bonus.

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Such a disconnect is not uncommon within the Resident physician echelon, as I have been hearing about it from every friend and colleague in the medical field since long before I joined their ranks.

But for my salary, in two years it will double. Or triple. Or quadruple. Or quintuple… or… whatever I want it to do depending on the number of hours I want to work, the type of physician practice I join or don’t join, the geographic area in which I live, and any number of other factors I chose to include.

To have those options almost seems ludicrous to me. But they are true.

And at times, the possibility of making a salary more recompense with my education and expertise enters my mind when I glance at my bank account and calculate how much goes towards paying school loans.

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Another colleague, after visiting the home of one of our faculty, remarked to me how humble her home was. This was despite the fact it was located in a well-to-do neighborhood and the obvious investment evidenced by the interior of the home. He wondered why a physician would choose to live in such a place, “unless she’s not really into money.”

I was not alarmed at his callous miscalculation; it’s incredibly common amongst the One Percent I will soon join.

Even now, when my salary is a little egg, waiting to hatch after a few more years of incubation, I can appreciate the gulf between the 99% and the 1% as it was laid out during the Occupy Movement. The “have-nots” will always want to be a “have”.

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By the time my sojourn across the Midwest and East Coast landed me in nYc there had been rumbles of the approaching demise of the Occupy Movement. Story after story, video after video, documented how it had lost its initial intention, but I needed to see it for myself.

The evening I arrived I slept on the couch of some close friends. I awoke the next morning, jumped on the train and headed straight for Zuccotti Park.

I stormed up the subway stairs ready to embrace the chaos I had heard so much about, but it was gone.

All of it. In the midst of my previous day’s travels and late arrival, a plan had been put in place and executed to end Occupy Wall Street.

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The end of a movement. The end of my curiosity? It all enhanced my desire to not be a member of the One Percent, despite a plotted collision course with exactly that mentality.

Life Sustains Us

Posted on May 3, 2015 by Elbrecht

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Part of the training to become a Family Medicine physician requires the Resident to have the ability to successfully assist a woman in the delivery her child. Depending on your religion, culture, and/or understanding of human biology, when the baby exits the vaginal canal and lets out its first cry, its life has begun.

Being a part of this experience has led Family Medicine to adopt a credo of “from the cradle to the grave”, as we have the unique blessing to care for patients from the beginning of life until death becomes us.

Nearing the end of my Intern year as a Family Medicine physician, I have now had the opportunity to train as a physician on the Obstetrics and Gynecology (OB/Gyn) service two times. The first four weeks occurred in the first half of my year and were a whirlwind of stress and re-introduction to a field of medicine which I had barely survived as a student.

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During those four weeks, I constantly found myself on edge, not only because of my experiences as a student, but because I found myself as the least seasoned member of a team responsible for making sure each and every baby let out its first cry.

While a sense of relief and pride would wash over me when each baby boy or girl let out its first little squeal, most often while I was still holding it in my gloved hands, I was still tasked with several steps to assess the health of the mother after handing off the baby to the pediatrician who stood awaiting my delivery.

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Those additional steps were the cumbersome parts I would rehearse in my head while staring intently at the woman’s vagina as I used my fingers to create the space needed to assist the baby’s head from tearing perineal tissue. Often times, my mind would go blank as soon as the baby made its way into my arms.

After what seemed like an eternity, which properly calculated only totaled 4-5 seconds, I would begin assessing the mother’s health, including any vaginal lacerations which may need repair, massaging the fundus of her uterus to determine the likelihood of a postpartum hemorrhage, and carefully tugging at the umbilical cord still attached to the indwelling placenta.

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Typically within 10 minutes I would have transitioned from the foot of the bed, having delivered the newborn and the placenta, as well as completing the necessary postpartum assessments, to clickety-clacking away at the computer to document the successful delivery.

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My second go-around on the OB/Gyn service was nearly identical in substance to the first four weeks: women of different stages of pregnancy coming into Labor and Delivery Triage to be told if they were or were not in labor, often requiring me to perform speculum checks and cervical exams; actively laboring women begging for epidurals and anxiously awaiting their newborn while I paid hawk-like attention to the monitors assessing fetal heart tones and uterine contractions; rounding before the crack-of-dawn on women post-delivery, assessing their postpartum needs; and imparting my seemingly minimal medical and clinical knowledge of Obstetrics and Gynecology to the even less-knowledgeable medical students I was tasked with teaching.

But while the substance of the second four weeks was nearly identical, my experience as a physician training in this foreign world was markedly different. By the time I showed up for the second-go-around I was a substantially different physician; it is utterly unconscionable how much things had changed in five months…

how much things had changed in me…

how much things had changed in me as a physician…

how much things had changed in me as a physician responsible for the care of a pregnant woman and her unborn baby…

how much things had changed in me as a physician responsible for the care of a pregnant woman and her unborn baby while being the leader of the medical team.

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Suffice it to say, it was an overwhelmingly different four weeks. And by no means was I the lone physician paying excruciating attention to the women and their unborn babies, as I was assisted/supervised by a 2nd or 3rd year OB/Gyn resident and Attending physician, but the knowledge and experience I acquired during the initial four weeks allowed me a level of comfort in my own capabilities that I had not anticipated.

The knowledge and experience in regards to the medical aspects of physiology, biochemistry, and anatomy involved in OB/Gyn were certainly at the forefront of increasing my comfort level, but it was actually my knowledge and experience of the other members of the care team that proved to be my greatest asset.

Not that other medical services in the hospital don’t have exquisitely trained nursing staff, but the OB nurses are in a class all by themselves… and if you don’t respect that, they will bury you. Bury you in a world of cervical checks, bleeding vaginas, and spasming uteri.

Think about that for a second… spasming uteri. It used to give me chills even thinking about it… but that was way back when… when I was still learning about how life sustains us. Now I know to give some gentle uterine fundal massage. And run the pitocin wide open.

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Gray’s Anatomy

Posted on January 18, 2015 by Elbrecht

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The most prominent book on my mantle is Gray’s Anatomy, a text I received from a colleague with whom I worked at Man’s Greatest Hospital. After many hours spent working side-by-side in the Gastrointestinal Cancer Center, she felt it was a fitting gift as I embarked on my mission to becoming a physician.

Nearly six years later, I’m an Intern in a Family Medicine residency program, trying to learn how to become the quintessential doctor.

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I spent the first six months of Residency filling many different roles, each of them markedly different from the one before or after. I have been an Internist, Clinician, Gynecologist, Primary Care Provider, Nocturnist, Infectious Disease specialist, Pediatrician, Teacher, Obstetrician, Podiatrist, and Trauma Surgeon. I have also become an even bigger fan of sleep than I ever could have imagined.

The copy of Gray’s Anatomy which I received is a facsimile of the 1901 version, the 15th edition of Henry Gray’s medical masterpiece of the human body. Not much has changed in human biology in the past 113 years, but Gray’s experiences as a physician and lecturer at the Royal College of Surgeons is probably somewhat different from what I experienced in the past six months… or perhaps not.

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Day 1 of Residency I was assigned to our Internal Medicine service, responsible for running around the hospital admitting patients, providing them care, discharging them home, all while hoping I’d done a serviceable enough job teaching them about their medical ailment to prevent a hasty return to the Emergency Department.

Of the services we staff as Residents (service = four-week stint as a physician of a specific branch of medicine), Internal Medicine at my Residency is the most labor intensive, sleep-depriving, nerve-wracking, hair-splitting service of them all. The official name is Clinical Medicine, or Clin Med for short (or Clin Dred when you know the next four weeks are about to evaporate into the ether).

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Somehow I became one of the two “lucky” lottery winners to be a first-year Resident assigned to Clin Med. My partner was a friend from medical school whom I had known since the beginning. We were paired with two senior Residents, who ostensibly had been the highest functioning first-year Residents on the Clin Med service the previous year and were thus chosen to be our medical mentors.

The ensuing four weeks were so busy that I spoke to my friend for exactly 8 minutes and 11 seconds during the entire month (that includes the time it took to type text messages).

I was told being chosen to start on the Clin Med service should be considered an honor… basically meaning that during my time as a student at the same program the previous year, they had come to the conclusion I would not be responsible for the early demise of any patients who would be placed under my care.

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I thought it comparable to being told I would be allowed to be the first person to jump out of an airplane without a
parachute. Low and behold, not a single patient died under my care; or really had any significant downturn in their medical malady.

The days were filled with trying to learn how to navigate the choppy waters of a medical institution and its systems, and the computer programs which allowed me to chart on my patients, along with a physician’s responsibility of percussing my patients’ backs, feeling for pedal pulses, listening to a heart beat while gently pressing along a radial artery, writing perpetually changing orders, and allowing for my own bodily functions to occur when I had a moment.

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At the end of the month, I took a deep breath, realized I had survived my first service as a Resident, glanced at the
Gray’s sitting on my mantle, and wondered aloud, “what the hell just happened.”

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After a month of learning on the fly about how to be a functional physician in a fast-paced hospital environment, the following two weeks were a nice respite, a smattering of out-patient visits to social service providers in Columbus, office visits by established patients in our out-patient office… and a couple of shifts in the Gyn Clinic.

My experience as a medical student during the six week rotation of Obstetrics and Gynecology were by far the worst of my clinical training. I only survived it by forming a bond with two other colleagues who were equally averse to the responsibilities therein. After that rotation I spent the next two weeks traversing around the Eastern half of the US, visiting old friends, drinking away the memories on an adventure I called “The Journey to Reclaim My Soul.” Sticking a speculum, or even worse, my sterile-gloved fingers, inside women I had met only moments prior wasn’t exactly why I had decided to become a physician.

Stepping foot inside the Gyn clinic was a bit of a flash-back to days of yore. Days I would rather forget. But, I chose to become a Family Medicine physician because I wanted to experience a full-scope of practice, so I needed to use those memories to help the new women I would have asking me about their privates.

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In the midst of those two weeks, there were a smattering of half-days in the office, where patients would come to their appointment expecting to see me; not some doctor who happened to be available. They had formally been told I would be their physician. It was a bit of a culture shock unlike what I experienced on the In-Patient service, where people arrived in the hospital hoping for someone with a medical background to cure their ails.

This time, they were expecting “Dr. B.” Whether or not they liked me or thought I was helpful would determine if they would think of me as “Dr. Bullshit” or “Dr. Badass.”

Two short weeks of community clinic visits, office appointments, and speculum insertions were followed by flipping my schedule and going on night-call for two weeks.

It evoked memories of my life for the six months prior to Residency, when I had worked overnight; Except I was traversing the ED, the emotional rollercoaster of my equally sleep-deprived senior Resident, and the perils of septic shocks and intubations at 3am, rather than deciding which return bin to toss some junk into at Amazon.

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It had not started smoothly, as my transition back to nocturnal life stymied my brain’s ability to function on the level necessary for a physician. By the end of the second night (by night I mean at 6am, 12 hours into our shift), my senior Resident, 9 years my junior in age, and I had a tit-for-tat critique of each others performance.

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And when I say “tit-for-tat” and “each others”, I mean, I got my ass handed to me and had to sit there and take it like a man. By the end of those two weeks though, he and I were having a nice breakfast reminiscing about all the crap we had successfully lived through together.

Gray certainly didn’t write anything about that in his book; I checked.

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The first two months of Residency seemed to last forever, but at the same time, it seemed to be over before I knew it. The next two months were spent down the street at the nationally recognized Children’s Hospital, where it is customary for the Interns of my Residency to spend back-to-back months there learning the medical art of Pediatrics.

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I was only starting to get the hang of being a Resident by that time, making the transition a bit of a shock to the system as I needed to learn all new faces and an all new electronic medical record; all while assimilating to the hierarchy of a whole new medical specialty.

The Residents of Children’s Hospital learn the ins and outs of treating babies, children, adolescents, teenagers, and the occasional grown adult still suffering from their pediatric medical maladies… I needed to become one of them quickly. The assimilation process when you are a physician is expected to occur over the course of a couple of hours; not a few days or weeks.

So of course I started on the Infectious Disease service right as a never-before experienced scourge affectionately known as “Asthmageddon” swept the Midwest.

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Asthmagedden was a region-wide exposure to a newly recognized virus, Enterovirus D68, which was causing babies and children of all ages, with and without previous asthma afflictions, to show up in the Emergency Department in Status Asthmaticus, a diagnosis indicating the inability of the respiratory tract to respond to front-line medical therapy, causing a constant difficulty in breathing.

http://www.wcpo.com/news/health/healthy-living/watch-respiratory-illness-ev-d68-found-in-ohio

Enterovirus typically affects the gastrointestinal tract, causing horrible diarrhea and concomitant dehydration, but as evolution has shown us, a few changes to a gene here or there and all of a sudden a new Enterovirus emerges, now equipped to attack the lower respiratory tract.

Children who had never wheezed, the most common sign of asthma, were having their bronchi inflamed by the virus, making it difficult for air to pass. As somebody who grew up with asthma, I can attest that this is a terrifying feeling.

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http://www.youtube.com/watch?v=7EDo9pUYvPE

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Some of these children were so sick they were immediately admitted to the Intensive Care Unit to receive the most minute-by-minute care to assure they would not suffocate from a blocked airway. These critically sick children by-passed our normal Infectious Disease unit, but as their symptoms resolved, they would be shuttled to our unit to continue their care alongside the children who were not as severely afflicted.

Of course, a Pediatrics Infectious Disease unit is also full of little tykes with butt abscesses, whooping-cough, diarrheal illnesses, crusty eyes, and non-remitting otitis media (ear infections); and a whole host of anxious parents, who typically become the biggest concern of Residents.

After seeing all of this, I’m re-thinking my plan of having children one day, if at least so I don’t need any psychotropic medications when my kids get sick.

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The first three services were a whirlwind of cognitive adventure, psychological daring, and physical extremes. When I hung up my scrubs on the last day of Pediatric Infectious Disease, it was with the knowledge I was only a quarter of the way through Intern Year.

Gray’s Anatomy… continued