EDITOR’S NOTE: Only when you think you know a lot about medicine does something happen that makes you realize how little that amount actually is. There Bot for the grace of God go I.
I was a third-year medical student and he was a third-year OB-GYN resident when we crossed paths at the large county hospital in Texas. No, this is not a love story. There will not be an ending where we gazed into each other's eyes after a long night on call and fell into each other's arms in some sort of homo-erotic fantasy. No, this is a story of how someone with low self-esteem immersed himself in the medical field, probably to gain power and pump up his ego and subsequently came very close to getting beaten to death - by me.
The obstetric rotation at this hospital had its good and bad points. The bad part was that the teaching wasn't the best because there was too much work to do. The good part, for medical students, was that even though they were going to kick your ass, you still would get a lot of deliveries. I chose this rotation because I liked the hands-on work. This place was nuts. I remember one time a resident delivering twins right in the triage room and one of them was breech. This was not malpractice because it was survival. Many of these patients were immigrants who would come into the country at the end of their pregnancy with no prenatal care and deliver their children on United States soil. It was a way, we assumed, that they could stay in the country. For a student, it was paradise. You could see anything and everything as long as you mentally survived the torture of the rotation.
The torture consisted of 5 a.m. rounds followed by watching surgical procedures or doing deliveries as they came. The work was endless and intermingled with it were lectures and pimping. The call, even for med students, was horrific and it was common to stay up all night and go 36 hours in a row. When you found a moment to rest, you either studied or slept. You never got enough of either.
The attendings were good old boys and rough. This is not to say that there weren't any female attendings. In fact, there were – they were rougher. They all had the same cowboy mentality as the men and usually beat up on students even harder.
That wasn't as bad as it sounds because you only interacted with attendings an hour or so a day. The bad part was that they really brutalized the residents. Since sh%t rolls downhill, each resident subsequently beat up on the person one rung below him or her. This is where I come in.
The rotation was going well for me until the last two weeks. Now I may not be an easy guy to boss around because, I admit, I don't take orders that well. I knew, however, that to survive I needed to put my head down and suck it up. Joe, the third-year resident, was a pretty boy. That is the best way to explain him, plain and simple. He was 6′ 2″ tall, good looking, and married. Rumors about his affairs with other women were rampant. At first I didn't mind him or his attitude. I even tried to befriend him one late night on-call. Nothing worked because, for some reason, Joe just didn't like me.
Any night on-call with me, Joe would make me do unbelievable amounts of what we like to call “scut” work. This may be cleaning gross things up, doing blood draws on anyone and everyone, doing extra rounds, etc. It was obvious that he was singling me out, but I put up with it. It got worse. Mature people wouldn't do this and if I was smart, I would have talked to him about his motives. The problem was that this attempt also could make things worse and kill my grade. So, I put up with it.
On one of my last nights on-call for the rotation, I was again paired up with my buddy Joe. He decided on his own to lay it on thick. He was full of himself and loved the power. Like the military, he had the hierarchy that was unbreakable. He beat me up with scut work and I couldn't do anything about it. I remember trying to catch a few minutes of sleep in the call room and each time he would overhead page me or beep me 10 minutes after I got into the room. He did that all night. The next day he laughed and laughed. There was nothing I could do as he just stared me down as I walked by to go home. He was the “man” – in his own mind.
At the end of the rotation I spoke with the head attending and chief of obstetrics at the hospital. I wanted to feel him out about my predicament without giving any names. He told me that if it was him, in this hypothetical situation, he would speak to the resident man-to-man, and lay it on the line. I knew what he was inferring. I told you these guys were cowboys.
The end finally came and luckily enough, I made it through the rotation and even got a decent grade. I was done with Joe. Unfortunately, my next rotation was in surgery at that same county hospital. This was an even better learning experience than the OB-GYN rotation but I knew I would have to run into the egomaniac again. It was early in the surgery rotation when we were rounding as a large group and walked by the obstetric floor. Out from the doors from the delivery area came Joe. He immediately saw me and stopped and started to stare. Pretty soon, like a 9-year-old kid, he started taunting me. “Hey, buddy, how are you doing? They're not working you too hard are they? Are you tired?”
I ignored him and looked away. He started in again, “Come on, don't ignore me. Is my little friend tired? Why don't you do another OB rotation with me?”
Finally the surgical group walked away. He was a dead man. I could tolerate his bullshit on the OB service because I had to, but now that I was off his rotation I felt I had no reason to take his crap. I needed a plan.
Okay, it wasn't a great plan. I decided I needed to tell him a few things in private. Though he was a big guy I wasn't afraid of him at all. I am only 57″ tall but I was a collegiate wrestler and an all-American collegiate boxer. The funny thing is that Joe had known my history but I guess he didn't think it would come into play on his rotation. He was right - sort of.
By luck, a few days later I found Joe on the OB floor in a secluded hallway. All right, I admit it; I stalked him until I found him in the right place. As I walked toward him he chimed right in with the mocking. “Hey, what are you doing here? Didn't you have enough last time?”
“I just wanted to tell you a couple of things,” I said. He actually stopped and listened inquisitively. “When I was on your rotation you could haze me all you wanted. Now that I am on surgery you need to stop.”
His pompous facial expression showed that he didn't care. I continued, “Because if you don't stop, I'm going to beat the living sh%t out of you!” His expression turned to fear. “And I'm not talking about a little beating either. I'm going to find you and beat you so bad that you won't be recognizable to anyone you know. You'd better have someone to help you, because once I start I'm not going to stop - until you're dead - you motherf cker!”
I thought the last part was a nice touch.
Joe's face turned to horror. Like a little boy, he almost started to cry and said “Why what did I do?” I guess he wasn't so tough after all. “You know what you did. Don't talk to me or look at me again because you are going to pay with your life!”
With that statement another OB resident walked through the double-doors, which tipped me off that it was time to leave. As I went past him through those same doors, I heard Joe almost crying “I can't believe this! I can't believe this!” As I walked down and got to the end of the hallway, I heard the other resident pop his head out of the double-doors and scream (and this is no lie),
“HEY! HEY! SHOW SOME RESPECT!”
Respect? I just continued to walk and laugh to myself. Respect is earned. Crying in the hallway after torturing poor medical students doesn't get respect. You need to respect others in order for them to respect you. Both of those residents were losers. They are the stereotypical cocky doctors that give all of us a bad name. I am sure they never changed.
The next day in the Dean of Medicine's office (You didn't think I got away with it?), I thought to myself, Maybe this wasn't the best plan. I apologized to the dean and said what I had to so as not to get into too much trouble. I was made to see another bigwig in OB who demanded I get counseling for anger control.
I agreed, at the moment, to everything and have never gotten any permanent blotches on my record. I s
hortened this part of the story because it isn't as fun as the rest. The truth is that they wanted me to screw up again so they could run my ass out of the school. I never did. What I did do was this. Every time I saw Joe, whether in the parking lot or the hall, I would just stand there and stare at him. Turning the tables on him was worth it all. For all he knew, I was psychotic. Suffice it to say, he never said a word to me again. In fact, he would just put his head down and walk away. I should have, but never did, scream,
HEY! HEY! SHOW SOME RESPECT!
Perc or Drip?
During my emergency department rotations as a PA (physician assistant) student, I was working with my preceptor in a small, rural town.
A short 30-year-old female and her significant other walked into the center of this little ER and she announced “I have chest pain!” This is big news in a small hospital and everybody around began to get their game faces on. After I looked at the patient, I turned to one of the nurses next to me and in my inner-city sarcastic “expertise” said “Not!” I was a little jaded since I had been an RN in a Level I trauma center for a long time and acquired what you would call a sixth sense of suspicion.
The patient proceeded to tell us that they were traveling through Arizona from California and she had taken two “nitros” about four hours apart without any relief of the pain. She had a past medical history of a neurological problem as her only significant marker. Her EKG, however, did look markedly abnormal but without the tombstone ST elevations that would make us start grabbing the throm bolytics.
My preceptor happened by at this time while I was muttering doubt about this patient's history. She also noticed my skepticism. She was a wonderful teacher and very compassionate. Obviously this is a quality I needed to acquire. Unlearning some of my old baggage is not that easy She subsequently helped me work up the patient and soon I began to feel very ashamed of my “attitude.”
The funny thing is that even though we gave the patient an appropriate amount of morphine to quell her cardiac pain, our lady kept requesting some Percodan.
The couple kept mumbling the whole time how “stupid” we were when she wasn't getting her “drug of choice.” I guess they thought it was a restaurant where they could order off the menu. When we finished the workup, my preceptor determined that she had to be admitted to rule out a potential myocardial infarction. In order to get a better grasp of her “neurologic disorder,” attempts were made to reach her physician in California.
During this time the patient kept insisting that she needed the Percodan for her pain.
“I NEED MY MEDS!” she would scream. We had a heck of a time getting that complaint under control. On a personal level, I kept admonishing myself that I was no longer an inner-city nurse but a PA now and therefore had to view patient's complaints in a more professional manner.
I finished up the entire history and physical exam and then went off to a separate room to dictate it.
When I returned to the ER, my preceptor as well as the entire ER staff began laughing and bowing to me. It seems that while I was off dictating, the patient had become more agitated and grew angry while demanding more Percodan. Not getting the drug fast enough for her liking, she totally lost control. With one swift move, she finally tore out her IV and walked out of the hospital dripping blood. You could follow her trail like bread crumbs and probably find her and her husband at the next hospital a few towns away. The truth finally came out when her neurologist in California called back and promptly filled us in on how this patient travels to small towns using her abnormal EKG as her calling card. Since she had had heart surgery as a child her EKG was always abnormal. She would throw in a neurological disorder hoping to make her case sound more serious and subsequently convince small town doctors to snow her with narcotics.
There are some things that my past experience has shown me. First, never get too excited even if it is chest pain and second, always trust your sixth sense. In a complete about-face, my preceptor told me I taught her a lesson and that she would never doubt my call about drug-seeking patients again.
What can I say, it's a gift.
Munchausen Syndrome was named after Baron Von Munchausen who always lied and told tall tales (John Neville, Uma Thurman, and Eric Idle starred in The Adventures of Baron Munchausen). The Baron has many stories, he even has his own websites.
NOTE: The editors find the Munchausen Syndrome intriguing in an odd way. Publishing these stories may aid some physicians to diagnose these patients with a factitious disorder. We in no way want to make fun of people with psychiatric disorders. Munchausen By Proxy is child abuse and we will not use or publish any of those stories for that reason.
This MY FAVORITE MUNCHAUSEN comes from the February 2001 edition of the Annals of Plastic Surgery.
A 26-year-old whom we will call “Lymphe-dema Lucy,” to give her a personality, kept coming into hospitals I for repeat edisodes of ! septicemia for a huge ulceration on her left lower leg. After being seen by at least five or six different hospitals during the past five years, it was apparent that no one could find the cause of Lucy's problem. No matter what treatment was given, her ulcerations would never heal. Her leg became massive in size and she could no longer ambulate.
Multiple invasive diagnostic procedures were performed, but Lucy could find no help. Interestingly enough, the lymphedema always kept starting around 10 cm from the groin region. Lucy was getting frustrated and began requesting amputation of the entire limb to solve all her problems. Astute physicians had factitious disorder in their differential all along. With a team of psychiatrists now involved, Lucy fessed up. It is amazing what secretly placing a plastic cord around your leg for five years can do to your skin.
We will never know exactly why “Lymphe-dema Lucy” felt so inclined to put a tourniquet around her thigh and make her leg look like an old duffel bag. The authors felt maybe the pressure of adulthood and the need to lead an independent life may have been the cause. Or maybe the care of her ailing father years earlier and then his eventually death played a part? Nonetheless, Lucy received major reconstruction of her leg, which only added to the incredible financial strain that she had placed on the medical system for her care.
De Fontaine S, Van Geertruyden, Preudí-homme X, et al. “Munchausen Syndrome.” Ann Plast Surg 2001;46:153-58.
MOODY
So there I was, a third-year medical student on my psychiatry rotation. Psychiatry seemed to come easy to me, and I found myself actually enjoying it. I was assigned once a week to a doctor that worked with geriatric psychiatric issues. He was a very pleasant individual, but a little difficult to understand at times. He was of Asian descent (I am not really sure where exactly) and he had a rather thick accent. He worked closely with one of the local nursing homes and had to do rounds one week. I worked with him.
So there we were, the patient was not eating and having homicidal ideations. The doctor asked the nurse to bring her into the lunchroom, as she had a roommate. The doctor, the third-year resident, the nursing home resident, and I sat at a small table on the side of the room farthest from the door. The room echoed terribly, and to make matters worse, there was the noise of the air conditioning and the ice machine.
“Sally” was in her late eighties, pleasant, in a wheelchair, and of course, very hard of hearing. We asked her a few questions, and after repeating multiple times, tried writing. We got some mumbled answers, and eventually got her to talk without us having to write our questions. We went on asking her questions about what was wrong, etc.
“How's your mood?” asked the doctor, in his thick accent.
“HUH?” she replied.
“How's your mood?” he replied, leaning in closer to her.
There was a pause, and Sally got this very puzzled look on her face. The doctor starts talking to the resident when Sally blurts out, “I don't eat wood.” At that point, I couldn't help it and I let out a muffled laugh. The resident and doctor both must not have heard her because I got the weirdest look from bot
h of them. I quickly explained what had happened, and both the resident and doctor laughed before continuing with the interview. I just couldn't help but try to put myself in Sally's position. Here are three strangers, and one is asking her if she eats wood.
Patients in teaching hospitals are seen and evaluated by so many doctors and other health professionals on a daily basis that it's understandable that they get some of us mixed up. As a medical student, I've come to accept this. The most frequent misnomer applied to me (typically by an older, male patient) is “nurse” (which wouldn't bother me at all if I'd ever heard of a male student being addressed this way). Some of my patients, however, have gotten even more creative.
One patient that I took care of on an internal medicine service decided that I was her “special angel” – in part because of my blond hair and in part, I'm guessing, because the resident had grown bored with her days before her discharge, rendering me her primary caregiver. While I was doing my psychiatry rotation, another patient announced that I looked like a “magical elf,” and wanted to know where my wand was. At that point I guess I should have taken out my penlight and waved it over his head. Maybe I could have “cured” him.
By far the most amusing case of mistaken identity occurred during my day seeing patients at the county jail. This was located on the top few floors of a tall municipal building outside Boston. The infirmary was a bleak, institutional room with one space walled off for seeing patients. Toward the end of the morning, I was wandering around the room trying not to touch anything (the electrostatic shocks from the plastic and metal furniture were almost enough to defibrillate me), waiting for the doctor to emerge from the exam area. Across the room from me, the next patient was waiting. He was a big, heavyset African-American man in his prison-issued jumpsuit. At one point I saw him motion the nurse toward him, but I couldn't hear their conversation. Later, the nurse filled me in:
The Placebo Chronicles: Strange but True Tales From the Doctors' Lounge Page 4