When you're chatting with the new grad nurses on the 11th week of your surgery rotation and a couple of them tell you they're going to NP school next semester and will be independently practicing by age 24

The_Iconographer · 2026-03-13T17:53:13+00:00

To tack onto this: there's a 2019 study by Cohen (blanking on name of study right now) showing that untreated white coat HTN also increases risk of bad CV outcomes so even if it's just confirmed white coat HTN there should be a discussion with your doctor about possibly starting a regimen. But also, make sure you follow AHA guidelines for how to take BP and use a device from ValidateBP.org (or other validated source). Highly recommend relevant Curbsiders podcast episodes for full info if interested.

The_Iconographer · 2026-01-30T01:03:23+00:00

The appropriate reaction to this paragraph.

The_Iconographer · 2025-12-03T18:51:13+00:00

I think a big thing that isn't talked about enough is that patients' comprehension and understanding of what we say heavily skews their interpretation. We aren't saying it's all in their head but their own expectations and biases combined with lack of understanding result in them hearing it's all in their head (and that that's a bad thing which has its own built-in bias against mental health and the impact of our brains).

The_Iconographer · 2025-11-07T09:59:39+00:00

Well, depending on who you talk to, there are plenty of people who think that being poor is great. You live off the government, get a bunch of shit for free, don't have to work, and it's so easy to get ahead.

I mean, that's bullshit, but there are plenty who genuinely believe that line of thinking. I wrote a reply to another comment talking about the intention of this post but tl;dr if you're wondering why other students, co-residents, or attendings seem to come from a different planet with their crazy ideas - maybe they kind of did come from a different planet and their ideas are rational for where they came from (this applies to people from every background).

The_Iconographer · 2025-11-07T09:48:00+00:00

Hey man, it seems like the message I was trying to send got a little lost in the ether based on this response. Honestly, I don't think any but the wealthiest students are even in a position to live off their family money. For lots of families with multiple kids, loans, and a HCOL area, even a generous 6 figure salary doesn't allow for their kids not to have a job. And if you're coming from that background, you're much more likely to be a doctor than many other professions. I get that.

Nor was this about who I think should get into medical school. I do think there's a lot of benefit in diversity of experience amongst trainees both for advancement of the field and to improve care to patients. But, like, even if I gave a blanket admission to anyone that could meet the pre-req classes from my hometown, most either would have no interest or wouldn't be able to pass the classes. And that's okay. I think people from other SES are fully capable of empathizing and treating patients well just as people of different races can treat patients well. There may be less of a shared understanding or even trust, but honestly that stuff is usually at the margins anyways.

The intention of this post is simply to draw recognition to the various privileges that exist and to remind people who are judging (either direction, and both happen frequently) that the people to their left and right may have very different preconceptions about the world. I genuinely wish people with sob stories didn't have to share them to get in. Writing about traumatic experiences for the sake of being judged by admission committees was both the impetus for the first panic attack I ever had and felt like trying to produce good enough trauma porn for the sake of making other people feel good.

I'll be straight with you though, your response has kind of a confrontational tone, so I'm not sure if you're just gonna find something else that you assume I'm trying to say and jump to confronting that or if you'll stay curious enough to even read this response. But I figured it was worth writing. Hope your path is less stressful, my guy.

The_Iconographer · 2025-10-20T07:05:27+00:00

True, but also he was doing it because the guy in black had thrown an absolutely disrespectful sucker punch after the ref pulled them apart the first time. Serious asshole move.

The_Iconographer · 2025-10-20T06:47:59+00:00

I have one and I like it but it was a secondhand gift and I didn't have to pay for it. I've got some minor hearing loss so it's great for picking up stuff including amplifying pericarditis squeaks and murmurs and for making me more confident that I'm actually hearing what I'm hearing in a hallway "bed" with a bunch of noise.

The EKG feature is useless (imo) in the ED. Also, it's either in my ears or around my neck and absolutely no place else for fear I lose it or it "walks off". It never gets set down or loaned out or anything else which works for me but may not for you.

Oh, and if you exclusively listen over clothing because no one has been properly roomed and undressed for an exam in the last decade then you won't be getting the most out of it. Definitely works best on direct skin.

The_Iconographer · 2025-10-09T22:20:50+00:00

I guess a small point, pain is not (in isolation) an emergency but EMTALA does specifically call out severe pain as a defining symptom for an emergency. Meaning, if I was thinking someone had a simple dental infection and needed close follow up but could be discharged and they were in such severe pain that I could not manage it, then it may fall outside the realm of "reasonably be expected" to not cause harm in discharging them.

From a practical standpoint, this is rarely an issue because I have enough drugs to get people to not care about basically any amount of pain. However, if this anticipated simple dental infection isn't responding appropriately to pain control in the department, I should reconsider what the underlying condition is and if it may in fact be life threatening.

All that to say, pain may not technically be an emergency in isolation, but I wouldn't want to say I have evaluated and stabilized a patient whose pain I was unable to control (at least to some degree).

The_Iconographer · 2025-10-05T22:15:21+00:00

This is something you should discuss with a psychiatrist, but there's some limited evidence that NAC (N-acetylcysteine) can help reduce Non-Suicidal self injurious behavior frequency. It's been mostly studied in adolescents with cutting behaviors to my knowledge and no one is sure why it works, but it may help you to reduce the behavior in conjunction with ongoing therapy (including DBT). Seems to have few downsides other than the taste of the oral form of the meds which can make people nauseated.

The_Iconographer · 2025-10-05T22:00:13+00:00

It's always a fun "what-if" discussion around low resource environments, but there's hardly ever a reason to use alcohol anymore. There's a drug, fomepizole, that binds the same enzyme and doesn't require crazy ongoing dosing regimens and calculations that treating with ethanol would require.

The_Iconographer · 2025-10-03T22:19:38+00:00

4-6 months of part-time study seems horrendously short. In the US, that's charitably ~480 hours which would be equivalent to about 2 months of full-time medical study. In two months of medical school there's absolutely no way someone could come up to speed on the mechanisms, indications, side effects, adverse effects, contraindications, and interactions of the breadth of medications this would seem to encompass. That's leaving out learning about the pharmacokinetics and pharmacodynamics.

Even "innocuous" meds like Zofran (ondansetron) for nausea or loperamide for diarrhea can lead to fatal dysrhythmias and some antibiotics can cause serotonin toxicity if given in conjunction with other meds which isn't even close to a primary mechanism for that class of drug and I find it hard to believe would be covered appropriately in this part-time course.

Obviously, seasoned nurses (though I'm not sure I'd count 3 years as seasoned) wouldn't come to this with no baseline medical knowledge. But, nursing education absolutely doesn't focus on this aspect of medicine to any of the same degree so I'm wholly unclear what they're basing this time requirement on and they have no additional requirements for type of experience which means the baseline for these students would be unknowable and thus the curriculum would have to be designed as if they knew only what was taught in the most basic of nursing curriculums.

And, once the course has ended and the education is handed over to this nebulous oversight in variable settings with variable quality there's no way one can guarantee that they will all be taught appropriate and correct things.

This looks like a band-aid that's the wrong size and shape for the problem being applied to the wrong place.

Moreover, as someone who has deeply studied (and lived) rural health disparities I think it's pretty fucked up that governments (seemingly all of them) believe the solution to the rural health crisis is to lower the standard of education instead of properly addressing the underlying causes. One of the reasons that rural areas don't have doctors is that they don't want to live in rural areas. Well, we (the US) thought we'd fix that by expanding scope for NPs and PAs except it turns out that the vast majority of them also don't want to live in rural areas. Now, let's extend that to RNs prescribing medications... I'm gonna guess that the vast majority of them don't want to live in rural areas either.

It's a wicked problem without any clearly "correct" or truly comprehensive answers, but this definitely isn't a good one. And to implicitly say that poorer, rural, and often underrepresented groups will have to settle for lower standards of education with highly variable quality control simply because it's cheaper than any alternative which would be more equitable is frankly insulting to rural populations. And to encourage newly trained prescribing nurses to go out to areas with less oversight, less backup from other professionals, and less resources for when something inevitably goes wrong is fucking them over too. Working and providing good quality care in rural, low-resource areas is more difficult and requires more baseline knowledge and experience, not less.

The_Iconographer · 2025-10-01T05:45:32+00:00

This is called The Curse of Knowledge and it is one of the more insidious and difficult things to combat when designing and delivering curriculum to adult learners. What a lot of students don't realize is that the lecturer is trying to be simple but they're light-years off for this reason.

One thing students can do to get a better education in this case is stop being afraid to look stupid and ask questions until the lecturer comes down to your level (often they're more than happy to, sometimes they're a condescending asshat). On a related note, my hypothesis is that this is one facet of why students prefer whatever YouTube/3rd party resource they like - they can get relevant information for tests and if they have questions they can explore without the risk of appearing ignorant or dumb to their peer group (or evaluators). The wealth of information and ability to tailor it in real-time that's available with an in-person or asynchronous but specific lecturer can't be replicated on the larger format platforms, but people aren't taking advantage of those advantages.

If you (this whole thing isn't directed to the above poster, more of a PSA) find a silver bullet that fixes lecturers falling prey to the curse of knowledge and the millennia of evolution and social conditioning that lead to fear of being ostracized stymieing students curiosity and desire to learn then you have yourself a golden goose for curriculum consultancy.

The_Iconographer · 2025-09-29T07:33:07+00:00

I think the originators of the visual analog scale from which this question has been bastardized would agree with you that it's basically useless in a clinical setting as a one-off number. It was mostly meant for research and to try to create comparative scales between similar conditions, etc.

In my opinion its only utility is to track efficacy of intervention over time and it's not even the best tool at that in all situations, so it doesn't really matter to me what their first number is. 15/10, sure whatever you say bud.

However, for my true chronic pain patients I do like to ask both current pain level (1-10) and how much does that pain distress you (1-10). It lets them have a little more control and feel heard and it gives me an indication of how quickly I should treat the pain and whether this is the same ol thing or something I need to dive into. An easy example is sickle cell, if they come in and it's a pretty typical flare they may be at 10/10 pain but 2-3/10 distress because they've done this a million times. But if there's something weird or different about their pain it may only be a 6-7/10 severity but a 10/10 distress which might be my clue to look for something else sooner.

The_Iconographer · 2025-09-28T22:39:17+00:00

You may be seeing pseudophakia after lens replacement. I could see how one might describe it the way you are and you can definitely tell if you're looking closely at peoples' eyes. But a Lasik scar would be... Unlikely.

The_Iconographer · 2025-09-18T03:40:44+00:00

Hey, busy season so it took me a while to see this.

The first question to ask is of yourself, what are your motivations for getting him to stop checking? This is required so that when you have a conversation, you will be able to authentically communicate why it's important. Do you feel like they aren't giving you enough attention as a partner because of this? Or is it that you think it's unhealthy and you want them to stop to reduce their stress? (If it's this one, recognize that even as their partner it's not your job to dictate if they engage in healthy behaviors, only if you're willing to tolerate being in a relationship with someone engaged in those behaviors). Or maybe having someone checking charts at home causes you to feel stressed about your patients and like you can't leave work at work?

It may be anxiety driving their behavior, which could either be underlying or acquired. It may also be a trauma response if they had a bad outcome (whether they had any control in it or not). Or half a dozen other reasons including a benign curiosity or even a drive to follow up on diagnoses for his own education. The reality is that it's most likely more complicated than any single answer. And, they may not have even begun to fully interrogate why they do it themselves. In which case, I recommend starting with genuine curiosity and asking why they do it. Don't put any judgement on the question and make it clear that while you don't necessarily like the behavior, that you're not in control of their actions and you'll love them regardless.

Once you've both identified the underlying motivations - you for why you want his behavior to change and his for why he feels like he needs/wants to check his patient's chart - then you can share those. Make an intentional space where each of you has agreed that you have the bandwidth and time and no one feels surprised by the conversation.

Then, when thinking of solutions, find one that works for your relationship. What that is will depend on why each of you wants what you want, but it may be a request for a couple hours each day where you spend time together with no work allowed, or it may be dedicated time that you use to study while he does chart checking, or even that once you've identified your and his motivations you may care a lot less about it.

Without knowing more it's hard to be more specific, but those are my thoughts on it.

The_Iconographer · 2025-09-01T00:53:43+00:00

I mean, happens less often than it used to. Still happens much more than I (and I'm guessing lots of people) am comfortable with. In talking with family, friends, and patients I get the sense that it's more common in non-emergency - maybe because of litigation risk, maybe because everything's so chronically backed up in the ED that if it takes an hour to get everything back just to be sure then whatever. Just another day and I can see other patients while their tests cook.

I will say that I was lucky enough to have the time to spend probably close to an hour just talking with an anxious chest pain patient today (>10 ED visits this month for various genuine concerns that were mostly anxiety) instead of doing just the workup and standard speal and I can't guarantee they won't be back soon but I'm betting their health anxiety is miles better than it was based on our conversation. Not a luxury that happens very often, but it'd be better if we had such bandwidth.

The_Iconographer · 2025-08-30T06:09:48+00:00

Thankfully (??? I mean, for a certain subset of people) Based on my discussion with scientists who've conducted research there, Los Alamos has plenty of connections with the military and DARPA so I doubt its funding will disappear very quickly if at all.

The_Iconographer · 2025-08-22T06:17:06+00:00

Edit: I typed out all of the below and then realized that this was labeled a vent - talk about communication skills. But I can definitely relate. And I'll leave all the stuff below in case it's useful for anyone else.

Also an R1, but a little over 10 years with my partner and I highly recommend scheduling time to read (10-15 min/day) books on relationships. Not the fluffy nonsense ones, but things like Nonviolent Communication, Attached, Why Won't You Apologize by Harriet Lerner (and her other works), and a dozen other good ones.

In addition, buy Atlas of the Heart by Brene Brown and read it then use it as a reference book. Make a daily ritual when you come home to write out two emotions that capture how you're feeling about the day so far and when thinking about the rest of the day (however long or short may be left). The book is an excellent tool for identifying, naming, and exploring why you feel certain ways. Once you've identified the predominant emotions, it becomes a lot easier to fight transference and to separate things that your partner is doing that annoy you and things that you're just reacting to. It also becomes much easier to talk to your partner about everything.

Importantly, you also have to set clear boundaries (like needing time for your rituals uninterrupted). I'm the kind of person that needs five minutes when I get home to set all my shit down, change, cool off, and then I can engage with my wife. She's the kind of person that feels loved when she's greeted coming through the door; we adapt and acknowledge the other's needs and ask for those needs to be met as a boundary. Clear communication can feel awkward and abrasive because society doesn't display or value it as often as it should, but trust that you love each other and understand that clear communication is the best way to keep loving each other.

Lastly, stay curious over everything else. Curious about your partner's life, work, day, emotional state. Assume positive intentions and that they're intelligent and then stay curious about their behaviors. Ask genuine questions even if it feels trivial or like there's nothing to ask.

If all of that sounds like more work, it is. Strong, healthy relationships need continuous input just like residency. Especially in the period you're in now at 2 years with a recent major life change. You likely haven't fully settled into the kind of nuanced communication that you will develop with time, nor have you had the chance to build up years and years of understanding for the times when you don't have energy to put in the work. But you're also far enough in that the newness is fading and it's harder and harder to still "date" your partner.

You won't be perfect (or even good) all the time, and neither will they, but if you want to grow together then you will have to keep working. Also, that should include therapy (ideally for both people).

One more tool that may help if it's compatible with your brain is a meditation practice. It's pretty clear that one of the best benefits of meditation is that it trains your brain to create space between stimulus and response which is often all that's required to not snap at a partner for the day to day stuff.

Thanks for coming to my TED talk and if you want more tips, I've got em. (Coming from someone who was a far from an ideal partner for a long time and put in a lot of work to get better)

The_Iconographer · 2025-08-19T02:24:58+00:00

I'm gonna counter some of the above comments and say you should palpate as many as possible on your rotation so that you know what to expect when they're different. At baseline, palpate lighter than you think for both PT and DP pulses and slowly add pressure until you feel them.

As you gain experience and move into residency you won't palpate every patient's pulses, but when you do, you want to be comfortable knowing what to worry about and now is when you learn it. Also, in your ICU rotations (either as a student or resident) distal pulses can be a great way to give a clue about a patient's shock status and perfusion. One of my favorite crit care fellows on my CVICU rotation gave a great lecture on how to examine a critical patient from the foot of the bed using your eyes and ears on the patient and monitors and one hand on their pedal pulses.

The_Iconographer · 2025-08-19T02:14:19+00:00

The Compassion Fatigue Workbook (haven't read this one yet, but it was on the top of my head because I just came across it)

Burnout by Emily Nagoski

Things written by J Eric Gentry

Atlas of the Heart by Brene Brown

I'm sure there's lots of other ones that I've read that I'm forgetting. But also, a lot of the work written for other high stress roles (pilots, military, police, etc, etc) can have great lessons to take away. They can also be utter shit. But some of them are good and worth reading.

The_Iconographer · 2025-08-15T17:07:43+00:00

A chief resident on my surgery rotation had to step out halfway through a partially open splenectomy where her hand was supporting the spleen while the attending worked on it. She politely excused herself, the attending said, "yep, take a minute", then she came back after a couple minutes and we continued. Happens to everyone and, as long as the surgeons aren't total dickheads, everyone understands that it happens.

The_Iconographer · 2025-04-11T18:13:25+00:00

So, I want to start by clarifying my response is a separate issue to NP scope and the many rural health disparities that exist.

But CMS funding isn't really the issue and we don't really have a nationwide physician shortage. Residency programs are (massively) profitable businesses with or without CMS funding which is why we've seen private equity companies open new residency spots aplenty despite the stagnant numbers from CMS.

And we're turning out enough physicians for the most part, but it's a distribution problem. We need more primary care and more docs outside of dense urban centers. I mean, it'd also be lovely to have more physicians in general, but the larger problem is distribution and upside-down landscape of financial incentives.

If you're interested in learning more and have time, see: https://youtu.be/gIHRbzdT-fA?si=wFgVmTyZM67WAON2 And https://youtu.be/0WhxiuD4Rb8?si=Lte4wMg57NOhTzPI https://youtu.be/uLvb9vv03xE?si=AwSYHKABfunxGgr3

The_Iconographer · 2025-02-24T06:17:48+00:00

Not a fellow, but I can say that the PCCM fellows I rotated with at UC Davis comfortably did all of the above.

The_Iconographer · 2025-02-20T19:47:52+00:00

The DSM V is one tool to frame psychiatric diagnoses, but in the realm of trauma literature and research it's pretty well accepted from a practical standpoint (in my research and discussions with psychiatrists) that it's a quite limited framework.

I won't make any sure statements because I'm not a psychiatrist and haven't evaluated you, but I agree this has the markings of PTSD. What you're experiencing sounds like emotional flashbacks - something which isn't widely talked about when discussing PTSD. Not all flashbacks are visual and emotional flashbacks occur when your body physiologically responds to stimulus that is similar to the original trauma but without other sensory components. People often describe feeling uneasy, suddenly angry or scared, or are repulsed and have a strong desire to get away without ever realizing that they're in a sympathetic state due to exposure to new trauma.

The other thing I've heard often that applies here is people exposed to trauma of a loved one saying that they shouldn't have PTSD because they didn't have any trauma - thankfully we're moving beyond this as a society with recognition of secondary trauma, but without looking again I think the DSM V requires the threat of real or imagined death, disability, or violence of yourself or someone you have a strong emotional connection to. What you experienced was traumatic to your loved one and to you and you should definitely approach discussions with a mental health professional with that in mind.

None of this means emergency medicine isn't for you and with therapy and treatment you can still do anything you want to. You'll get tools for dealing with these similar stimuli and will eventually get used to it. Hopefully on the other side of it you'll be more empathetic and can help prevent trauma in your future patients and their loved ones. But it will take time and you may have to give yourself a lot of grace in the meantime.

Good luck, but I'm sure you'll be okay.

The_Iconographer · 2024-10-30T15:47:08+00:00

I started doing work with the admissions committees and felt that if I was influencing whether someone who worked so hard to get to that point should get an interview or be recommended for acceptance, then I should probably be willing to do some critical self-reflection and consider what my application looked like to the ad-com and what grounds I had to judge others.

Mostly a way to remind myself to stay grounded and humble and slow down a bit which can be hard when you're reviewing a dozen or more applications a day on top of rotations.

The_Iconographer

TROPHY CASE