One of the students working with me on L&D recently complained that she wasn't getting…
Why I stopped asking so many questions
As a generally curious and inquisitive person, I tend to ask a lot of questions. The learning curve as an intern in steep, and time to read and research is often limited. It’s hard to find the answers that you need quickly, and you have a to-do list at least a mile long. As a new intern, I fell into a bad and dangerous habit: asking my chief.
As an intern, it’s easy to feel like your chiefs know everything. It’s easy to treat them like walking reference libraries, and I found myself just asking them things instead of looking them up for myself. Recently, however, one of my graduating chiefs pointed out what a bad habit this is, for two reasons.
First, what am I going to do when I graduate? When I don’t have an attending looking over my shoulder every minute, who I can ask questions? I don’t want to get in the habit of asking someone else what to do all the time.
Second, how do I know whether the person who I’m asking has any idea what they’re talking about?
I had a recent experience that really drove this home for me. I ordered a TSH on a patient in the first trimester of pregnancy. She had a history of hypothyroidism and had previously been on synthroid, but stopped when her primary care doctor retired. The TSH came back at about 4, which is normal outside of pregnancy. I asked one of the PGY-3s what to do, and she said “Nothing, that’s normal.” “Do I need to repeat it next trimester, or something?” “No, it’s normal.”
When I read the practice bulletin on thyroid disease several weeks later, I realized that I had made a mistake. According to the practice bulletin, her TSH was above the goal for the first trimester. By the time I realized this, nearly 10 weeks had passed and she was solidly into the second trimester. S***! My stomach sank into my pelvis somewhere.
Other things I learned from the practice bulletin? People with hypothyroidism often require regular dosage increases of up to 25% during pregnancy, and TSH levels should be monitored at least every trimester. (Double s***!)
At her next visit, two months after the original TSH was drawn, I ordered a repeat TSH. (This patient also happens to be a type 2 diabetic on insulin, and is apparently very attached to me, so I see her every week.)
The repeat TSH was six, WAY above the target range for pregnancy. S*** cubed.
How much synthroid should I start her on? Lesson learned, I looked it up in the practice bulletin. The answer? 1-2mcg/kg/day, or 100mcg. She happens to weigh 100kg, so I started her on 100mcg/day. When should I re-check her TSH? Again, I looked it up. (The answer, by the way, is 4-6 weeks, but don’t take my word for it!)
The moral of the story? It’s easy to ask someone else what to do, and it’s faster than looking it up, but sometimes it means you do the wrong thing for your patient.
I’m pretty sure my stomach is going to stay knotted up until this kid is born. We’ve got a whole trimester to go. It’s going to be a long trimester for all of us…