The Book of Mormon

I went to see The Book of Mormon today, which for two weeks is touring through Minneapolis. I¬†fervently enjoy musical theater, and having been blessed/cursed with the pecuniary privilege of a career in retail pharmacy, I can afford kinda just whatever mainstream stuff I want. I went with one of my roommates, although we didn’t sit together because we bought our tickets too late and there weren’t good middle class seats next to each other.

The performance was really good. The players were excellent. The vocals were excellent. The choreography definitely was excellent. The lighting was slightly distracting; the spotlight a couple times seemed to preempt players movements or randomly adjust for a stationary person, maybe a 6-7/10. The audio was a bit too loud, just past the point where it caused distortion, 8/10. But all in all a really good performance that I would heartily recommend to anyone.

It’s written by the South Park guys, so I expected it to have lewd toilet humor, which it does but not as much as I was expecting. I think it really catered to the audience well. It’s funny, randomly funny, structurally funny, and has a lot of heart. Too much heart in the middle, almost gimmicky heart, but the threads come together in the denouement. And of course the spectacle of musical theater is always exciting.

Tickets were about $84 each in our section on the balcony, which is a good price point relative to the closer but more expensive seats ($100-150) and the farther but cheaper seats ($60). The audience was nearly 100% white but fairly divided between retirement-aged and young professionals. Not as much middle-aged representation here.

The audience contained an almost soul-crushing number of strikingly attractive girls. I sat next to two of them, and behind one. They were attractive in the natural sense but also they’d gotten dressed up and hair and makeup and heels and leveraged everything about modern cosmetics in a desire to minmax their appearances. Behind all the spectacle of personal appearance however, were still natural strikingly attractive girls. My roommate, while not unattractive, has kind of an androgynous thing going on and spends lots of time late at night with other androgynous girls.

Downtown Minneapolis isn’t the nicest place at night, so I walked among a horde of well-dressed white people as we exited the theater and walked into a crime-ridden ghetto. A horde of affluence in the dark of the night that no mere mugger dare approach.

I really enjoy musical theater on a variety of levels.

a brief history of pharmacy school: part VII

The worst ten weeks of my life were spent on my acute care rotation. I was in surgical ICU for five weeks, followed by the medical ICU for five weeks. The former was run by an angry masculine woman named K, she had a no-nonsense persona and didn’t hesitate to give you direct criticism to your face. But K’s criticism was at least about your performance on rotation. The medical ICU was run by a madwoman with serious personality flaws whose criticism came behind closed-door sessions where she would attack my personality. I call her Hitler. She appeared nice at first but she actually hated me pretty thoroughly, I guess I remind her of her ex-husband. She looks like a witch with jet black hair and she decorated the walls of her workstation with the art of her gravely untalented child.

I started every day at 6:30 am and left at 3. Then I would go home and try to learn everything about what I saw that day because they grill you every day on every medication on every patient you saw. Then they’d have a topic discussion where they’d talk about some random topic and grill you a bunch about that. So you had a prepare a ton of stuff at home; I was spending 3 to 4 hours a day at home, so this was a 12 hour a day thing. Even when I was at home I’d have so much anxiety about the next day. K’s expectations were high but realistically achievable. Hitler didn’t even grill me on actual useful information; she would grill you about rare zebra shit like famotidine causing thrombocytopenia or penicillins causing acute interstitial nephritis. The student who preceded me shared my opinions on the entire experience as well, see below.

The group dynamic in the surgical ICU was alright. There were several other medical and PA students as well. The critical care nurses were on the floor, one nurse for every two rooms, they were good. The attending physicians were overall good. Some of them were comprehensive at rounds and we went slowly; others walked up to the room, talked for 2 minutes, then moved on with the patient examination. They were respectful and I wouldn’t hesitate to work with any of them again. They also had a jovial PA whose buoyant mood was well accented by his morbid obesity. Standing for the length of rounds was clearly a genocide on his knees so he sat down a lot. The one problem working in the surgical ICU was that I was physically isolated in a little storage room. All the residents and everyone else associated with patient care were in the resident room sitting next to each other. They all could talk and discuss treatment plans among themselves, so the patients I had worked up were based on old information.

The medical ICU was a different beast. I had to deal with Hitler there, whom I shall eternally loathe. The first week was neutral; everything was about the same as the SICU, but only because I didn’t realize how it was fucked up. The most senior resident was a cool Indian dude who liked Prince and acted really outgoing and friendly. They also had a nurse practitioner on staff, a youngish blonde girl who seemed wholesome at first glance. I mention these two in particular because I suspect they are backstabbing informants who demonstrate no loyalty to their peers. Stuff that I said to the group as a joke or in confidence was reported to Hitler who had a fun discussion with me about my personality. Something to the effect of “Stop having fun, stop being sarcastic, nobody likes you, I can fail you for lack of professionalism.” When you were getting grilled while presenting patients, she would just randomly go hostile on you if she didn’t like what you had to say. That made it really hard to continue presenting.

During this section of my rotation, I cried for 4 hours at home and 1 hour at the hospital. The hour I cried at the hospital, one of the attending physicians was in the room writing a note. His back was turned and I was crying really quietly so he didn’t notice anything I think. One of the most important skills is to realize when you’ve left reality to stumble into the legacy of totalitarianism. Like you thought you were just talking to your friends, but then a policeman comes and takes you to a baffling court where the charges against you are absurd and inscrutable. The ability to recognize which office has Kafkaesque politics is needed to identify where you must remain silent. Anything you say can be used as evidence at your trial; silence is the only logical behavior in this situation. I stopped talking to everyone else on the team; enforced silence turned my stressful situation into an alienating and frightening experience. I needed a good cry at lunch when the residents had left.

All I did after that was work hard and keep to myself. When I moved to the next care team, the group dynamics were better, but I had committed to silence so I remained silent. I feel like their members were genuinely nice people, but I couldn’t open up because then I would gamble on Hitler’s wrath. Hitler also had the fun habit of insulting me just randomly. Like I was presenting a patient and going through the chart when she was just like, “Apathyfactory, I feel like you don’t care.” That actually was unnerving because I was spending something like 75% of my waking hours on this stupid fucking rotation.

Towards the last week, it got a little better. I had good working relationships with the people on my care team and got to meaningfully participate in patient care. Hitler lightened up a little bit, but I didn’t trust her at all so I still did my gargoyle impression the whole time. I couldn’t tell whether she warmed up or whether she entirely gave up on me. She tried starting a few conversations along the lines of “Are you interested in hospital pharmacy now? Aren’t I a great preceptor?” My responses were always prevarications that students are forced into returning as feedback in a small insular pharmacy community to the effect of “Thanks, I learned a lot.”

The following was written over several months by the student who preceded me, which I present with minimal editing. I corresponded at length with her because of how uniquely isolating the experience was, and how much we both suffered at the cause of it.

FYI – I’m straight up gonna KILL [Hitler], and I don’t mean that in a haha sort of way…I am literally going to stop her heart!! She is so nitpicky, overbearing, is a control freak of the highest magnitude, and does not take well to others not accepting her recommendations. I think she is so used to the residents and interns and med student kissing the ground she walks on, that she freaks out if her recommendation isn’t accepted.

Not the be the bearer of awful news, but MICU is 100 times worse than SICU, and, honestly, it’s because of [Hitler]. I have awesome days whenever she isn’t there and I am working with a reasonable pharmacist…you’ll see what I mean in 2 short weeks. She is obnoxious. I only tell you so you can prepare yourself. [Hitler] acts all nice and smiley on the outside, but she is bat shit crazy.

K isn’t going to make you go to the team and recommend that they TKO the patient’s fluids, because many patients get fluid overloaded in the ICU….that is the level of nit picky. She goes far beyond a pharmacist’s scope of practice. She even pulled up a CXR today and started saying that there is no reason to be suspicious of PNA, because, despite what the radiologist said, there weren’t infiltrates visible on the X-ray.

Also, if someone doesn’t want to take her recommendation, she harasses the shit out of them until they give in. Fortunately for her, most of the people she is dealing with directly are the residents/interns/students, who are easily bullied.

And I’ve tried ignoring some of her questions before and hoping she will forget, but she hounds the shit out of me. Woman is obsessive. She writes about 5-10 recommendations for you to approach the team with on rounds, and I would say 50% of them are necessary, but she makes you recommend it anyway.

She also may harass me more, because I give her some pushback, which she doesn’t like, and I don’t know all of the details she does. You may know all of the details she expects (liken at Keppra has a 28% risk of causing irritability, and famotidine causes thrombocytopenia). If she thinks you know all the details, she may back off.

Why does the patient has bradycardia? Well, it must be because in some rare subpopulation of humans, famotidine causes bradycardia. Gaaaawwwwwd.

 

Whatever. Be happy I know it is renally dosed. And isn’t necessary after extubation, unless the patient has baseline GERD or something. I will leave you with one of her favorite quotes: “every drug every day”…in reference to knowing the dosing, all adverse effects, and possible d/d interactions… As if we have time to do an interaction check on every patient and all of their 20 plus medications every day. I’m gonna go ahead and assume that the pharmacist who approved this order knew what they were doing, and didn’t disregard any interactions that the computer alerted him or her to.

Can you imagine that being your job full-time? How can I fuck with their sedation today, wen though they are perfectly fine where they are at?

[Apathyfactory], don’t get me wrong, I can be dramatic, but I am on par with my assessment of this lady… Not trying to stress you, just want you to be forewarned, because maybe it won’t be so bad if you go in thinking the worst.

I feel really bad for [the pharmacy resident]. I agree that she is definitely intelligent, it’s too bad that [Hitler] makes everyone feel so uncomfortable and nervous. Watching her go through this residency crap made me realize I would not want a residency, and especially not at [this hospital].

“It’s ironic that the patients in the ICU are dying because we’re getting killed by acute care.” – Me, to the other student

 

a brief history of pharmacy school, part VI

My next rotation was ostensibly to learn about research in the pharmaceutical industry. I emailed the preceptor and he’s a half-retired Jewish gentleman who seemed like he more wanted an audience than a student. He lacked an office so we met 3 hours a day, 3 days a week at a Caribou Coffee, where I acquainted myself in detail with their thoroughly mediocre menu and eventually settled my order as Northern Lights Mocha with Dark Chocolate, Medium, with Ice, Blended. My preceptor spent a career dealing with FDA regulation, so his little consulting gig was to help small organizations with the regulatory aspects of the market. The task of reading FDA guidance documents is profoundly dull.

His expectations were mercifully low, and I spent most of the five weeks playing League of Legends. He let me grade myself and I gave myself a B. So much for that experience.


Then something both unfortunate and wonderful happened. I rotated through a Walgreens and realized that it was where I belonged, which is a sad indictment of my character (and in turn a startling sign that I’m an unreliable narrator). The store itself was cramped and dusty, but everyone working there was young and relatively cool. So long as you showed up and you were working hard, you were respected. Nobody cared if you made off-color jokes and everyone at least knows how to treat people decently because it’s a service industry. It helped that the pharmacists were smoking hot. Nobody is so inept and so abhorrent they would rely exclusively on office politics to maintain their jobs. The unfortunate part is that Walgreens does not treat its employees well. It’s a big faceless corporation and its number one concern is the stock price. That takes precedence over the employees, the customers, pretty much anything is expendable so long as Wall Street approves.

I went to several flu clinics, which is where corporate demands you go out into the community and attempt to immunize people. Corporate doesn’t actually care, it’s just that flu vaccination reimburses very well so the hassle of going off-site is worth it. The manager there hired me after the five week rotation. I asked, “So if I eventually wanna be a grad intern do I just apply online?” and she was like, “You wanna work for Walgreens?” half incredulously, and I was like “Yes”. So that’s why I work for Walgreens. That manager is one of the greatest people I’ve ever had the privilege of meeting and I probably wouldn’t have otherwise bothered with pharmacy practice at all if she weren’t there. Hiring me makes managerial sense – I showed up on time and worked hard but more importantly I received five weeks of training for free. I don’t have the best attitude, but for however little I respect the corporate structure, they have really good and honest people working there and if you pull your weight they respect you back. I started working a shift a week and picking up shifts when people were sick.

Then began my rotation in the ICU of a large teaching hospital and it was the worst ten weeks of my life.

a brief history of pharmacy school, part V

You spend a full year on rotation. You go around to various places where pharmacists are and follow them around. You have a limited amount of input as to where you are placed and if you rank thirty or so sites, you’ll probably have enough ground covered to pick up those sites. I was interested in the insurance side of pharmacy so I worked there first.

Working for insurance was a disaster but not the kind of readily apparently disaster. The disasters of pharmacy workplaces are usually more subtle than a dumpster fire. Sometimes you can tell the moment you walk in as you’re beset by the scent of burning garbage that your work environment will be terrible. I worked for a company with close ties to Blue Cross / Blue Shield. I was in the department where they do formulary stuff, so basically the people who decide which drugs the policy will or will not cover. It sounds important but actually it’s fucking simple and they don’t need dozens of employees to do it. Just a couple employees who aren’t retarded could do it but there’s this toxic corporate culture so people hang on even though the culture is toxic. It’s very obvious which drugs you need to cover 99% of the time.

It seemed pretty chill at first, I had my own little cubicle and very little to do. So I did four hours of work in an eight hour period and just kinda read the internet the rest of the time. I get the impression that most of their employees are like this based on how much people “work” from home and leave early. The pharmacist in charge of me didn’t seem to like me at all. She had this goofy face where she looked like she was always smiling and excited but really she’s from the midwest so she’s an asshole but doesn’t want to express herself to your face. I remember we had very few conversations but one of them was about how she didn’t like the way I write citations because I don’t include the volume or page numbers of the journal articles. Literally you can google the title but some people live in a kind of permanent delusion where they think seniority makes them correct.

She also had a friend who has half in charge of me, and her friend was even worse. Her friend was a skinny blonde middle aged woman who always had a foul attitude when she spoke to me. My running hypothesis is that I remind divorced women of their ex-husbands, which will be a recurring theme throughout the year. Divorced women dislike men who are irrefutably correct; something about men being correct really angers women who have been publicly spurned by other men. We had a resident and she liked the resident. We also had another student and they both treated him well. Just they really didn’t like me I guess and eventually I saw the writing on the wall and I #checkedout. Like, they were going to a meeting with BCBS and they take the other student but not me. I was eating with the other student, and they come over and dump a bunch of praise on him and ignore me like I wasn’t even there. They had revisions of a document I made with some very shallow “corrections”. They’ll make whatever corrections they want, and that’s basically what they think of you as a person.

One time, they gave me some flowchart-type document that their prior authorization office uses to make approval decisions for individual patients. They asked me what I thought of it and I returned it with revisions, just quality of life revisions that made the text clearer and cleaned up some logic. I didn’t think anything of it but I get an email two days later from a completely different person saying that they’ve incorporated some of the changes. Based on the email header I get the impression that the correct answer was “this document is so amazing!” and not “this document is mediocre but serviceable, let me help you with that”. The intervening two days was spent with emails bouncing back and forth because I must have stepped on some toes. The office politics here is extreme, which is corroborated by several other people who also used to work there. Basically they didn’t like me and decided to use whatever they could dredge up about my work to dislike it. They showed up prepared to hate me, so they hated me.

I learned a lot of lessons here, a little about insurance and a lot about corporate culture and interpersonal communication.

On Burnout

I was going back and forth with a nurse today on a prior authorization. She asked me about what the insurance was saying and as I was looking it up, she then asks quietly in a little mouse voice “Do you like being a pharmacist?” and I quietly respond “No” followed by “I think there’s a lot of burnout across both our professions.” We shared a little moment between us both calling the insurance company and hearing two different things.

I think the structure of the US healthcare system is fucked for most people who use it. Patients place money in the system that they’ll never see and trust in a system that lets them down. Sickness is a commodity in our society, something to be consumed by a top-heavy medical apparatus that burns out professionals. Medicine let businesspeople run the show and that’s when it started getting fucked. People in business have no idea how to take care of people, patients or employees.