Interview Schedule

I'll keep this post updated with the interviews I get and when they'll be happening.

Univ of Nebraska (Omaha) - November 6th -- New!
Univ of Wisconsin (Madison) - November 16th
Univ of Utah (Salt Lake City) - November 20th
Univ of Iowa (Iowa City) - December 21st

Internal Medicine Programs

Ok, here's my list. And why. For the interested.

1. U of Iowa (Iowa City). Already have good relationship with staff. Love the hospitals. Very good pay. Free health benefits. They keep residents for fellowships. Iowa City is pretty laid back town to live in. Good elementary schools/family environment. Cheap cost of living. One of the best programs. My research work is ongoing here. They offer a Masters in Clinical Education degree to residents, which fits my long term goals.

2. U of Wisconsin. (Madison). Nice place to visit I hear, and it’s close. Just an interview I can drive to and make me feel better about staying at Iowa. Family trip if I get an interview.

3. U of Nebraska (Omaha). Same as above. Drive to the interview, good to compare just for the experience. Very low interest, but hey . . . supposed to have an awesome Zoo there.

4. U of Utah. I’ll go and just verify that all the bad things I hear are true. Who knows, maybe I'll like it. There are a few positives about the program. I would actually like working with the LDS population as patients, the more I think about it. Probably warrants at least an application, if I feel strongly about not interviewing there I won’t.

5. Oregon University (Portland). Very good program, friends in residency there seem to like it. Portland could be fun.

6. University of Washington. One of the best top programs. Probably won’t get an interview, but I indicated I’d be interested a program where you do your 2nd-3rd year in Boise. We’ll see.

7. University of Colorado (Aurora/Denver). One of the best/top programs. Closer to home. Might be bad to their residents, need to check it out. Actually a contender for residency.

8. UC San Diego. One of the best programs. Too expensive to live, but I might be able to do this and UC Irvine at the same time. I doubt I will even get an interview. But if I do, also an excuse to take a trip to San Diego.

9. UC Irvine (Irvine/Orange County). As above. Not a particularly strong program. Also, home of In&Out burgers.

10. Stanford. One of the best programs, has a good clinician-educator program. Too expensive to live, but if I got an interview there it would be worth the experience to see Stanford.

Screwed

This was shared with me by a patient. It's a true story. I hope you'll read and enjoy taking pause at how out-of-touch medicine can be. I hope I hear stories like this constantly to keep my focused and grounded in what's important in patient care.

This story is called "Screwed."

The phone call came on a Wednesday evening in the middle of September. I knew from my sister-in-law's voice there was a problem. "Bill needs to talk with you," she said.

My brother got on the line. "Hi," he said. "I have something to tell you, but I don't want anyone to make any fuss."

"What is it?" I answered.

"I'm screwed," he said.

"What?"

"I'm screwed. My doctor told me I have cancer and it's too late to do anything about it."

My brother's message caught me totally unprepared. Six months before he’d had his annual checkup and all was well. I grabbed a pad and pencil.

"Bill," I said "when did you see the doctor and what tests were done?”

"I first went three months ago. We were getting ready to go on vacation and I hadn't been feeling good for about two months. I was having trouble sleeping and I didn't feel much like eating. I had lost some weight. The PA at my doc's office examined me and couldn't find anything wrong. He jokingly said that maybe the problem was my wife's cooking. I told him that since retiring a few years ago, I did most of the cooking.

“I spent the vacation lying around, feeling tired. I didn't have much of an appetite. A couple of weeks after we got back I still didn't feel any better. I called my doctor's office and made an appointment. The PA asked me a bunch of questions, did another exam, didn't find anything wrong and drew some blood for tests. I went home with a prescription for some sleeping medication. I got a call two days later that the tests didn't show anything abnormal.

"When I didn't feel any better after two more weeks, I called and made another appointment. I went in last Tuesday and this time my doctor saw me. He did an exam and took some urine and blood for more tests. He asked if I felt depressed since retiring. I told him I had felt fine until just before I went on vacation. Then on Thursday morning he called and said he wanted me to have some radiology tests done. I went in Monday and had the tests. And then yesterday afternoon his office called and asked me to come in today and, if possible, have my wife also come. When we got there he told us that the radiology tests showed a tumor in my right kidney. Then we met the urologist who works in that group. He said the cancer had spread outside of the kidney and was too large to treat by surgery. They scheduled me for a biopsy this Friday. So that's what I know, and I decided to call you."

My brother lived in a suburb of a large city. He was a retired Professor of English who had taught courses on contemporary American films. His family physician practiced in a multi-specialty group connected to a small community hospital. A large academic medical center with an NCI-designated Comprehensive Cancer Center was located in the city. Thursday, the day after my brother's call, I phoned his physician and got some additional information. It was uncertain whether and what kind of treatment was going to be recommended. They needed to get a biopsy to be sure, but everything pointed to a renal cancer. I phoned a colleague I knew at the nearby large academic medical center to gather more information. When I mentioned the name of my brother's hospital, I was advised to get him transferred. My colleague said, "That place has a poor reputation." My colleague put me in touch with a medical oncologist at the cancer center who specialized in urologic cancers.

The following day I got another phone call from my sister-in-law.

"Bill went in for his biopsy this morning but while they were doing it he became

confused and agitated, so they kept him there. His doctor is gone for the weekend

and a different doctor is in charge. I talked with that doctor but he didn't seem to know much about Bill's situation. He said he ordered some sedative for Bill to calm him down. I'm really worried. Something's wrong. I'm not sure Bill recognizes me. They have his arms tied to the bed and they put a catheter in his bladder."

"I'll be there as soon as I can," I said. "It's about a 16-hour drive. I'll stay in touch on the way."

When my wife and I arrived at the hospital late Saturday, we found my brother alone in his room, confused, agitated and fully restrained to his bed. His wife had been at the hospital most of the day but had left earlier because she had a severely autistic teenage son at home and no caretaker for the evening. One nurse and an orderly -- a community college student who had only started working at the hospital that week -- were responsible for a very busy patient floor. The nurse told me that because my brother was confused and kept trying to get out of bed, he had to be restrained. The covering doctor had ordered the restraints and the catheter. I asked to see the doctor, but he never came or called.

I spent all day Sunday sitting at my brother’s bedside. He remained restless and poorly oriented. I requested to get him transferred to the university hospital. When a bed became available at the Comprehensive Cancer Center Sunday evening, my brother was transferred from the community hospital. As the ambulance moved down the expressway, I sat next to him stroking his head and listening to his wandering incoherence. In spite of the dismal prognosis, I felt a smattering of relief. I knew he was headed to a first rate facility.

The first hospital had read the biopsy as undifferentiated carcinoma, likely of renal origin. The university hospital did some additional studies on the biopsy material and confirmed a renal origin. On Monday morning an oncology professor arrived in my brother's room along with fellows, house staff and students. The professor told one of the fellows to get the x-ray films from the other hospital. That afternoon the films arrived. Tuesday morning the professor and his team returned. There seemed to be a problem with the x-ray films. They had my brother's name on them, but the abdominal image showed a previous surgical procedure. My brother had never had abdominal surgery. An official assessment by radiologists at the cancer center revealed that the x-ray films were of a female patient. On Wednesday my brother's films were delivered, and they showed that he had a large renal tumor.

My brother's mental status continued to wander between somnolence, confusion, and agitation. His orders read NPO and he had an IV drip. I kept his lips moistened with a wet face cloth. Three times a day a person from dietary arrived and placed a tray of solid food on the table next to the bed. About two hours later a clerk arrived and removed the tray with the food untouched. After three days in the cancer center, my brother had yet to receive any nutrition. I spoke to the nursing staff and they told me he had to remain NPO until he had been given a swallow test. The test had been ordered when he was admitted. They would check to see why it hadn't been done yet. A patient with his mental status was a risk for aspiration and hospital protocol required a swallow test before allowing oral intake. I told them that dietary was delivering meals to him three times a day. They would look into that.

I learned from the oncology professor who visited my brother’s bedside on rounds each morning that my brother had been admitted to the cancer center because he was a candidate for a clinical trial testing a new agent that targeted the blood vessels of tumors and had showed some promise in the treatment of renal cancer. The professor had published an article on the preliminary results and now had a grant to conduct a large clinical trial. Each morning the professor and entourage appeared briefly.

About seven o'clock on the fourth evening an orderly arrived with a gurney to take my brother, who was still confused and intermittently agitated, for a CT scan. I told the orderly that I would go along with my brother to the radiology suite. After securing Bill onto the gurney, we rode an elevator to the basement of the hospital and made our way through narrow hallways with low ceilings strewn with pipes and cables and reached a large empty waiting room with a sign over the entrance that read Department of Radiology.

"I'm going to leave you here," said the orderly. "Someone from radiology will be with you right away." Then he left. I stood next to the gurney holding my brother's hand and stroking his brow. "They're going to take some pictures, Bill," I said. "It's not going to be uncomfortable." Bill gave no clue that he heard what I said or knew who was standing next to him. Each time I said something or touched him it stimulated a response. Without opening his eyes or appearing to be speaking to anyone in particular, he would smile and in fragmented, slurred sentences talk about Louie, the manager of the movie theatre where as a teenager Bill had worked as an user, or mumble some lines from an Edward G. Robinson movie.

After forty five minutes without seeing another person, I began to wonder whether anybody in radiology knew we were waiting. Then a different orderly arrived pushing a gurney carrying a woman who appeared to be in her early twenties. The orderly left the gurney in the middle of the room and left without saying anything. Restless, the young woman continuously scanned the room. I could hear the sounds of people moving inside of the radiology suite and told her that I thought someone would be with us soon.

Just then a door opened, a technician appeared and without saying a word to the young woman, pushed Bill's gurney into the suite. I helped the technician situate my brother for the procedure and then joined her at the viewing console behind the protective barrier. As I watched the CT scanner probe my brother's body, my thoughts kept returning to the anxious young woman on the gurney out in the waiting room alone with her fears, and without a hand to hold.

On his fifth day in the cancer center my brother became delirious and more agitated. He remained that way for the next three days. The food trays continued to arrive and depart three times a day. On morning rounds the discussion centered around whether my brother’s mental state reflected meningeal carcinomatosus, metabolic encephalopathy or a drug reaction.

Nobody ever came to do a swallow test. I began going to the cafeteria and purchasing orange juice and yogurt to feed to my brother. He took them avidly and swallowed without difficulty.

On the three days after my brother became delirious, the rounding team walked past Bill's room each morning without stopping in. I wanted to know if a plan had been made for Bill's treatment and I asked to see one of the fellows. He told me that my brother's mental status had made him ineligible for the clinical trial and that he was going to be discharged. As I looked into the fellow's face I could tell that he was uncomfortable having to tell me this. He knew that I knew. They needed the bed. They did clinical trials.

I never saw the professor again.

My brother went home and died within the week.

I still think about the young woman.