see one - do one - teach one

If I were to make New Year Resolutions....

2008-12-17T15:26:00.000-08:00

...They probably wouldn't be all that original.

However, if I pen (type?) them down, no matter how unoriginal, they might have a way of becoming reality.

I know, I know, it isn't even Christmas yet and I am writing these down. This is what comes of being tired of studying and needing to take a break, all the while knowing that taking a nap would not be the best plan. So, instead, a blog post is formed.

These are not going to be in any particular order (other than how they popped into my head).

1. Run. Work up to running about 20-30 miles per week. This number will be more in the month of June, when Mike and I are signed up to do the Rock n' Roll marathon in Seattle.

2. Play a more active roll in household duties. I admit, my involvement in this area has significantly decreased since medical school started. Yes, I did actually do the statistics and the change is, indeed, significant.

3. The all important, eat more "healthy foods." Now, this one is actually somewhat hard for me (and Mike if he is game) because we don't really eat too much "unhealthy" food. Most of our shopping at the grocery store involves the perimeter of the store. I think that the places I particularly need to work on involve cheese (eating less of it, even though it is on the perimeter of the store), fruit (I need to eat more of this. It has definitely been hard to get all the apples and bananas in that I need with this schedule of mine that doesn't not involve a desk or planned lunches), and decreasing portion sizes (hmmmm, how did that meal for 6 turn into a meal for 2?).

4. Keep involved in my rotations and do the best that I can in them. I have no idea when I might find "that" rotation that determines the rest of my career.

5. Help Mike not be so dependent on coffee/caffeine. This can happen in multiple ways, but of course, Mike has to be game first for this to even go anywhere. I could help by doing more things around the house, trying to get him to drink herbal tea instead of another cup of coffee, and making it so he can sleep more.

6. Spend less freaking money on coffee. True, we spend less now that we have an espresso machine at home, but the spending has not gone down to zero. More like 50%.

7. Try to wean myself off of needed/wanting/obsessing about so much sleep. I LOVE sleep (almost as much as I love cheese) and I feel the need to schedule lots of things around sleep. Example: Go to Grand Rounds or sleep? Sleeping usually wins out.

Please note how only 1 of these is really focused on med school. This apparently means that I have more going on in my life than just med school. :)

Opinions. Thrown at the keyboard.

2008-12-08T23:15:00.000-08:00

Where do I start?

For a while, I had been getting frustrated (Mike can back up that statement) with the fact that it felt like "everyone" was complaining about doctors, the education of doctors, and doctors in training.

"Doctors waste valuable healthcare money"

"Doctors only want to pad their pockets. They don't actually care about what is right for the patient."

"Doctors are abuse to those around them. They are just plain rude and think that they own the hospital."

"Doctors don't do any of the hard work anyways. We (the nurses) are the ones that change the bedpans and answer the call buttons."

"Medical students and doctors these days don't care about patients and don't spend the time to listen to them."

"Doctors and medical students aren't even nice to patients."

"I (a patient) always research what I think I have before I go into see the doctor so I know if they are just going to recommend treatment that is more expensive than a cheaper option."

What???

There are two general things that really irk me about all of this. The first is on a more personal level. Is this what people are thinking about me? Am I really that horrible? The second is personal in a different way. Am I just not able to see this attitude in me or those around me? How horrible would it be for me to be training in an area that sometimes banks on "reading" those around you and I can't even understand what my upper levels are thinking?!

I also felt somewhat defensive over this "profession" that I chose. I worked so hard to get where I am at. I work with so many people that are deserving of respect and kindness because they have worked at least as hard as I have. They are here, right beside me, putting up with whatever comes along so we can in turn serve those in this society.

Since writing my two previous posts, I have have two encounters that were somewhat ironic in their timing. The first happened just after my second to last post. I said that I don't really see too many "abusive and destructive" doctors. Well, I still didn't see one, but the doctor I am currently working with told me that he had just thrown a pair of scissors while in the operating room the day before.

And why did he throw them? Because they were the "12th" pair of scissors that weren't sharp. Yes, I understand that not having sharp scissors while operating is really poor form on the part of the hospital, but did he really need to throw them?

The second encounter was today. Grades are a big deal in my line.

Duh.

So, of course, I am gunning for as many honors as possible (so far I have a High Pass and an Honors). Today, somehow the topic of grades came up while I was talking with the doctor who threw the scissors. Apparently, he went to a residency that didn't even look at your application unless you had "honors" in OB/GYN. So, this doctors approach to things is that if you tell him that you are even slightly interested in OB/GYN, he will give you honors (as long as you aren't incompetent). On one hand, this is quite nice for people applying to OB/GYN. It is also nice for people that have followed the "underground" advice of saying that you want to go into whatever field your current rotation is. It sucks, however, for those, like me, that have answered truthfully. When he asked me what I wanted to go into, I said that I didn't know but that OB/GYN was the first rotation that I had tried that was on my list of "possibilities."

Does this mean I will end up with honors or not? I have no freaking clue.

Personally, I would only like to get honors if I KNEW that I EARNED the damn grade. But... It would also be nice to have as many honors as possible for whatever residency I apply to.

(In other news... I will FINALLY be visiting my cousins and family down in Alameda before making my way over to Vegas for New Years! yay!)

An article I can agree with

2008-12-06T23:32:00.000-08:00

Read this.

I mostly agree with her.

Doctors are Horrible...

2008-12-02T19:33:00.000-08:00

... according to most people out there apparently.

I keep finding all of these articles stating experiences with doctors that were less than stellar. I am not sure what is going on here. Many of these people say that "doctors are arrogant, abusive, and disruptive" while another article that I had read earlier says that doctors don't listen to patients at all.

Really?

Come on now.

I have seen doctors be short with patients. I have been on the receiving end of some crap from attendings. I have experienced the "want" to tell patients to "hurry it up" because I want to go home and see Mike and my dogs.

However, I have not seen doctors be so blatantly rude as these people are describing. Yes, I haven't seen everything. That is correct. Can I really have gone this long in this field and not have run into those horrible kinds of doctors? Does this mean that the Pacific Northwest is home to the most awesome and caring doctors?

I just get so frustrated! Why don't people write articles about how awesome these doctors are? It is so disheartening to read all of these things. Why am I putting myself and those around me through this if all of my patients are just going to hate me and think that I am one of the worst people around?

Anyone else want to tell me their thoughts on this?

Life

2008-11-29T21:29:00.000-08:00

Life has been interesting recently. I started OB/GYN at the beginning of November, which is actually why I haven't been posting. My life at Swedish doing OB/GYN is pretty busy. My schedule is working from 8:00 am to 5-6:00 pm without a lunch break usually. I am also on call again every 4th night or so.

I am not sure how excited I am about this rotation as well. I really like it when I am there, depending on with whom I am working with. But when I am at home, I am not sure if I like it so much. I like the mix of "medicine" with "surgery." I like that I get to help someone bring another life into the world. The moment that a child is born is amazing. It is kind of an odd experience being an outsider in a situation that is so momentous.

What do I not like about OB/GYN? The lifestyle is pretty rough. That isn't so bad, but that fact combined with the additional fact that the schedule isn't always predictable is what makes this worse. I don't mind being busy, but I like set schedules more than "random" extra time in the surgery suite because there aren't enough other people to assist.

Other than that, I guess I have been doing alright. I am still excited to be doing what I am doing. We are remodeling our bedroom and that is going well.

Other than that, not much is going on...

Kinda boring.

Life out here

2008-10-15T21:49:00.000-07:00

So... I love Montana. Did I mention that before? I haven't been this excited about a "place" in a long time. I am seriously asking Mike to think about this place as a possible place to call home in 5-6 years after I finish residency. Of course, a lot could change in that 5-6 years.

My rotation is going well. I am in the middle of my 3rd week of this 6 week rotation. I am getting a lot of suture time in! :) It is pretty cool.

I am getting more and more nervous about choosing a specialty. A lot of doctors say that I don't need to know yet, which is true... I just need to know by March-ish. Below are the many things that have crossed my mind:

Internal Medicine
Pediatrics
Pediatric Cardiology
Cardiology
Orthopedic Surgery
Pediatric Orthopedic Surgery
OB/GYN
Family Medicine (ONLY if in a small area like Whitefish, big city Family Medicine is stupid)

These aren't really in any specific order. The sad thing about all of this is that I have only done my Internal Medicine and part of the Family Medicine rotations. I won't even see Cardiology and Ortho until after I need to figure out what I am doing. The other thing to think about here is that these specialties are all over the map in terms of competitiveness. I would say that Peds is the "easiest" and Orthopedic Surgery is the hardest (and by hardest I mean that my Step 1 score may not be high enough for me to really feel comfy with my chances). Right now, in terms of lifestyle and specialty, Orthopedic Surgery would be my number one choice. The call schedule isn't too challenging (docs here take call by the week instead of day) and the pay-scale is pretty nice as well. I really want to be able to have a family and support the family well (not that I am discounting anything that Mike will be doing) without having to worry about missing a trillion dance recitals or soccer games.

I am just not sure what to do.

Whitefish, MT

2008-10-10T16:16:00.000-07:00

Below is the link to my flickr account with photos of Whitefish. There aren't that many, but I think they are fun! :)

http://www.flickr.com/photos/j1h03hna/sets/72157607910483786/

Oh the frustrations!

2008-10-04T19:39:00.000-07:00

I absolutely love Family Medicine! Just not in big cities.

Argh!

Anyways...

"Things" out here are going well for me. A few patients have said that I seemed better than other medical students they have run into in the clinic. It isn't that I necessarily want to compete with my classmates, but it is nice to hear compliments from people that have worked with other medical students and not just myself. The doctors seem to like me as well.

I still sometimes get that feeling that people will recognize me for who I am and realize that I am a fraud. I wonder when (if?) that feeling will ever decide to leave? Maybe it is good that I have it though; it keeps me honest and keeps my head at a size that my neck can support.

I love working with kids. :) It is so much fun! I have seen quite a few kid things in my first week here: a highly competitive teenage boy be told he can't compete in a tournament over the weekend because of a recently sustained concussion, a boy who came in with a 2 year limp (yeah, they were right on top of things) who ended up having SCFE, a baby that fell down a flight of stairs but WAS COMPLETELY FINE, and a bunch of other things.

I am also missing Mike a ton right now. All of a sudden, spending $280 for a weekend trip to fly back to Seattle isn't seeming too expensive.

Oh, and I haven't uploaded pics of this place because the internet connection is super slow... I don't feel like dealing with it.

Family Medicine in Big Sky Country

2008-09-30T19:04:00.000-07:00

Hello again everyone!

I know you missed me, you don't have to admit it. I just know it.

(Hello? tap tap tap... Is this thing on?)

Family Medicine out here in Whitefish, MT is FREAKING AWESOME! No, I am not exaggerating. The doctors are marvelous, the patients are varied (some good, some bad, some easy, some confusing, some young, some old, some in between), the area is beautiful, and I am 15 minutes away from big city things like Best Buy, Target, Lowes, and Home Depot. I am finding, on my second day of the rotation, that my 6 weeks here might be a lot like my 4 weeks in Red Lodge, MT when I did the RUOP part of my training.

What happened in Red Lodge is that I found I could definitely LOVE Family Medicine, however, I would need to practice in a small town to do so. One of the reasons that I had eschewed (that is right, I said eschewed) Family Medicine before was because in the city, you don't get to do much. You really just have people that have sore throats and things like that, and then they don't always come and see you. Additionally, you don't get to practice in-patient medicine. However, out here, it is an entirely different story! You do everything for everyone (just about). The Family docs out here admit patients, deal with in-patient practice, have patients that range in age from teeny-weeny baby to great-great-great grandma Eloise.

Today, my patients ranged in age from 13 years to 70 years. The challenging part about that is that each age group has its own problems that are common to them. As a doctor, you have to understand that concept.

The problem, however, is that I never thought I would practice in a small town. It was never a plan of mine (or Mike's). The funny thing is that there is this female doctor here who visited this town as a medical student, came back for residency, and then stayed as a practicing physician. Interesting...

So, I am not saying that Mike and I are moving to Whitefish (or Kalispell) anytime soon, but it is weird that it seems like it could at least be a distant option for me. An even bigger surprise to me is that it would mean that Family Medicine is an option for me.

Argh, I hope that 3rd year isn't all like this... That would mean that I would like EVERYTHING and have a HORRIBLE time deciding which field to go into.

(Almost) done with Internal Medicine

2008-09-25T22:27:00.000-07:00

I take my test tomorrow morning...

Then I have Friday afternoon and Saturday to pack.

Then I drive for 8 hours.

Then I start Family Medicine in Whitefish, MT on Monday.

LOTS of time of chill.

LOTS.

Well, I should go get some sleep. Hopefully the sounds of my neighbor blasting Rock Band won't keep me awake for too long.

Almost done with my first rotation

2008-09-21T22:26:00.000-07:00

Wow! I am almost done with my first, and longest, rotation. I will be done with Internal Medicine on Wednesday and take the test for the rotation on Friday. I will then be in Whitefish, Montana next Monday.

(Yes, I will miss Mike)

Even though I have absolutely loved internal med, I will be very happy to be done with this rotation. I am so tired all of the time. I am also tired of changing attendings every two weeks and having to learn how they like presentations and rounds completed. I have learned an AMAZING amount of medicine, I can actually answer questions about healthcare with some authority and know that I am probably right. :) It is a nice feeling.

On this rotation, I have been "pinned" as the following types of doctors: surgeon, pediatric intensivist, and an internal medicine doctor. What do I think about those? I honestly don't know, the only one I have experience in is Internal Med. I think that I could do internal med, but I still have always pictured myself as specializing in something. I like that internal med docs need to know a lot about a lot of things (jack of all trades and a master of none) but I also like knowing a LOT about just a few things.

I am really not sure how I am supposed to "choose" my life-long specialty by March.

I am also not sure how I feel about practicing medicine in an academic setting. By academic, I mean having students on my health care team. I feel like I will never know enough to be able to teach other people about the subject. Also, academic medicine is very demanding (well, for certain specialties). The time spent in the hospital is massive and having a family can be challenging (yes, you have to think about those things at this point).

Minor heart attack... OMG, I am old enough to even THINK about when I would be having kids?!?!

However, practicing at a hospital like UW would put me into constant contact with so many new technologies and procedures, it would be great!

Well, I am going to go to bed now. I am sooo tired.

Ideas do not automatically translate into a blog post

2008-09-14T22:28:00.001-07:00

I have all of these wonderful ideas for blog posts...

Talking about a recent night when Mike and I hung out with guys from Japan (yeah, not medical stuff but still pretty interesting)

Commenting on an article in the NYTimes (and then commenting about the people who made comments in that article)

Talking about my experiences in the hospital

Working through my thoughts about why people somehow think I am nervous when I am giving a talk but I myself do not FEEL nervous

Going over how much being on call every 4th night sucks

Talking about how people, in general, seem to think that as you "get older" your body fails... And so symptoms that are actually worrisome to doctors, people will not go to the doctor about those symptoms because they just assume that it is part of "getting older"

.....

So many ideas! So little time! I don't have the energy right now to really write a good (okay, at least adequate) quality post. I feel like I would just complain about "stuff" but not really get any point across.

This call thing needs to stop. Mike agrees as well. :) He is kind of tired of it himself.

An obstacle called "call"

2008-09-08T20:12:00.000-07:00

So, if you may have noticed (again), I haven't been posting much.

Being on call is kicking my bootie.

Seriously!

No really, I am not that lame...

Being on call sucks.

Want to know what else sucks? Wanting to get honors in just about everything. It is bad because that means I get super worked up about things when I shouldn't. The result is that I look "stupider" in front of the people that I need to impress because I am trying way too hard.

Example: The first presentation that I gave in front of my current attending was pretty horrible. Partly because I was used to the previous attending who liked things VERY brief and partly because I was nervous. So, now that I am doing my normal level of presentations, I all of a sudden have achieved the "most improved" award for presentations.

Sigh.

What the heck does most improved mean? And really, the attending and the R2 have both said that I have "improved" a lot. In my mind, this means that I pretty much sucked at first. The next step in this interpretation is that did I just go from "horrible" to "okay" or did I go from "okay" to "pretty darn good damn it?"

Argh. I just want to do well! I want to have my choice basically of where I go for residency (which will probably be somewhere in Washington or Oregon). However, even though I know that I can do alright, I feel like I am coming across to my superiors as a "flighty" girlie-girl at first and I am pretty sure that is putting me at a disadvantage at first. I have to work harder to prove that I can handle the hard work.

Anywho...

I have seen some pretty cool things recently. Right now, one of my patients has a gangrenous toe that is going to be amputated tomorrow. My other patient just had a COPD exacerbation but he is still in the hospital because he uses cocaine and we have to rule out heart and other lung problems.

There is now another med school student on my team in addition to moi. I have known him for a while, but my competitiveness is kicking in. Also, a sense of loss. I have noticed that other medical school students are very good at playing smart when they really have no idea about what they are talking about. This skill works well when you have an attending that doesn't really question you all that deeply. I am realizing that I don't have this skill and I think that is working against me.

Some people might not see this as a skill. You would be amazed, however, to see how much this skill comes in handy when you only spend about 2 hours per day with your attending and you need to impress the hell out of her. I always wonder how much my attendings really pick up. Do they know that my classmate is faking it? Do they see that I might not know but I always look up the answer? I hope so.

I also think that I am a little too honest sometimes. If someone asks me how I am doing, or how well I am doing with the current attending, I want to answer the truth. But I am seeing (somewhat at a later stage) that most people around me just say that things are "fine." So that makes me look like I am whining. (Side note... The things that I bring up as "issues" I know are valid because EVERYONE else on my team complains about them in private.)

Well, hopefully I can adapt a little more quickly. I leave for Montana on the 27th or something like that so I only have a little bit more time. I am questioning why I feel like I am behind the ball game all of the time. I get feedback from people who say that I am doing well, but I still have this voice in the back of my mind that says, "They are just saying that so you don't feel horribly."

Pyoderma Gangrenosum

2008-08-28T18:41:00.001-07:00

An informative post for those that feel the need to learn about skin conditions.

This is a quote from an awesome resource called, "UpToDate."

Pyoderma gangrenosum — Pyoderma gangrenosum occurs in up to 5 percent of patients with ulcerative colitis and 2 percent of those with Crohn's disease [5,6] . Despite its relatively infrequent occurrence, it often has more serious consequences than erythema nodosum such as persistence of the lesions and local discomfort even with appropriate therapy.

The lesions initially may appear as single or multiple erythematous papules or pustules that are often preceded by trauma to the skin (show picture 2). They occur most commonly on the legs, but can develop in any area of the body, including the abdominal wall adjacent to the stoma after colectomy as well as in other surgical scars or areas of trauma [7] . Subsequent necrosis of the dermis leads to the development of deep ulcerations that contain purulent material which is usually sterile on culture (show picture 3). Biopsy reveals nonspecific findings consistent with a sterile abscess (show histology 1).

Pyoderma gangrenosum lesions parallel IBD activity in only about 50 percent of cases [8] . Therapy directed at the underlying IBD usually results in healing in these instances, although treatment often needs to include a several week course of high dose prednisone (60 to 80 mg/day) or pulse methylprednisolone (1 g/day IV for three days) [9] . Other potential therapies include topical and intralesional steroids [7] , 6-mercaptopurine or azathioprine, topical cromoglycate, dapsone, clofazimine, granulocytapheresis, cyclosporine, and hyperbaric oxygen for those who are intolerant or resistant to high-dose systemic steroids [9-14] . In addition, infliximab was effective in case series and a small placebo-controlled trial [15-17] . Topical or systemic antibiotics should be added if bacterial superinfection is documented or suspected. (See "Neutrophilic dermatoses").

The (expected) unfairness of it all

2008-08-28T18:34:00.000-07:00

Quick note: being on call has its ups and downs. On my last call I got to sleep for 5 hours, the call before that I didn't sleep at all. And finally, I am on call this weekend --> Labor Day weekend! Gah!

On my last post-call day, I had to present one of my patients to this super hard attending in the Intensive Care Unit. That is fine and all, I had time to prepare. So, being the good med student that I am, I researched everything and went over my findings with my R2. The R2 agreed with me and so I thought that I was golden. :)

I presented...

and...

was shot down.

By both my "normal" attending and the intensive care unit attending. The crappy thing was that when the ICU attending began explaining what the answer might be, the R2 totally acted like the plan was all my idea and she knew it was wrong all along.

You could say it made me feel kind of stupid.

Unfair? Probably. Unexpected? Not at all. Am I going to do anything about it? No.

At least I will learn from this experience.

Another quick note: My specialty "flavor of the month" now is Cardiology.

Remember when I said I wouldn't post much?

2008-08-24T21:56:00.000-07:00

Yup. That would be right about now!

This rotation is kicking my behind. Being on call every 4th night is nothing to scoff at.

Here is what my schedule is while I am on call:
-Get to hospital at 8:00 am
-Go to required seminars and presentations
-Take care of current patients
-Begin admitting patients at about 1:00 pm
-Work up patients admitted to my intern (the resident who is my kind of "direct boss")
-If I am lucky, get about 2-3 hours of sleep at some point in the night
-If I am not lucky, like on Friday night, get absolutely no sleep
-Present patients to attending (my big boss) at about 7:00 or 8:00 am THE NEXT DAY
-Go home around 12:00-3:00 pm
-Sleep

I basically stay at the hospital the entire time. Because I am a medical student, my hours are not limited and I could actually end up staying until 5:00 pm or so the following day.

Needless to say, working a straight 30-40 hours is kicking my behind. And making it so I don't post that often.

I am currently at the Seattle VA hospital doing my rotation. This is interesting because in addition to the "normal" health problems, veterans have additional problems to deal with. And the population is mostly male.

Working at the VA has given me some laughs. A certain patient kept trying to call me "youngin" and would argue with me when I would tell him what the treatment was going to be. He talked down to me and basically made me feel like s***. So I laid down the law (so to speak) in two different ways. First, I said that I would answer to my name and that is it. And second, it so happens that as part of his work up he needed a prostate exam, so I was the one to give it. I normally don't enjoy doing these things, but since he really didn't want one and he was being a jerk to me, I enjoyed the fact that he was really uncomfortable with the fact that I was going to do the exam.

Payback is a b**** sometimes.

I am having to learn how to focus and think after being up for 20+ hours. It is definitely hard to do. The worst for me is driving home after being on call. It is a little like driving buzzed. Kind of scary, I know. But the awesome thing is that I have this SUPER DUPER COOL boyfriend who will come and pick me up if I need it. :)

A normal day (not on call) at the VA entails me getting to the hospital between 6:00-7:00 am and leaving between 3:00-5:00 pm. So that isn't too bad.

Well, that is a quick update on what is going on.

A lot of news

2008-08-19T21:02:00.000-07:00

I know, I know.

I haven't been posting that much. I have been a bit busy and a lot of things have happened in regards to my "medical education."

In regards to finishing up my first 6-week rotation... Sigh. This is an interesting problem. According to the main doctor at the site, I did clinically and analytically well. Patients liked me and I genuinely cared for the patients. However, I wasn't told until my last feedback session (after I was done with the rotation) that the main doctor was having a personality conflict with me. There are a lot of details about this that I don't feel like posting because it is a sore subject with me. If you would like to know, please go ahead and email me. Just know that it will be somewhat of a "rant" email which is why I am not posting that "rant" on here.

Your time is worth more than that (unless my neighbor tries some funny business with another tree, then your time is worth a rant).

Moving on...

I started the second half of my Internal Medicine rotation yesterday. Holy gebeezus! My first day (that would be Monday the 18th) I was on call with my team. So, I got there at 7:30 am YESTERDAY morning and didn't leave until 3:00 pm TODAY. I got a total of about 2.5 hours of sleep while I was there. It was pretty cool because I got to do a lot of things already. I was first-assist on a paracentesis. I helped work up a patient with a GI bleed. And now that I am at a big teaching hospital, I got to do LOTS of rounds and didactic sessions.

I like it there, it is pretty busy and I actually get to work with residents and fellows so I can see how my education will progress.

Oh, and did I mention that I am on call every 4th night? So, my next call day is Friday. I will get there at about 8:00 am and then leave on Saturday between 12:00 and 3:00 pm. Life will suck for a bit. :)

This year will suck...

2008-08-12T21:56:00.000-07:00

...

Not because of anything really negative, but I think that I will end up liking ALMOST all of my rotations. I liked just about everything I did in Internal Medicine. Since Internal Medicine is kind of a compilation of a ton of fields in medicine, that makes applying for residency that much more confusing.

Sigh.

I was supposed to only like one field and get into that one field.

Another dilemma...

Seattle? No Seattle? Yes, it is a conundrum. On one hand, I want to get into a residency in Seattle for obvious reasons. On the other hand, I want to go where the good programs are (in whatever I go into). What if that isn't Seattle?

Mike has said he will go where ever; but lets be honest, Seattle would be so much easier.

On another note... I got to remove 3 moles from a guy's back today because they bothered his wife. Amazing. I didn't know that "wives" have that much control.

Another day of learning

2008-08-11T21:04:00.000-07:00

Today was chock full of new knowledge. Not the medical type, but the useful type that will help me be a better doctor type.

I did another one of those "shadow a specialist" things today. I am not going to tell you what specialty it was; mostly because there really aren't that many in this area so it would be too easy to pinpoint who I am talking about.

Hmmm, how is that for a build-up for a post that has a bunch of not nice things to say?

I am actually pretty conflicted about the doctor that I saw today. I know that I don't want to do his specialty. I am learning that I really need some kind of specialty that allows me to do in-patient care. I really like that aspect of medicine.

On one hand, the patients seemed to like the doctor. Two of the patients actually felt comfortable enough around him and I to start crying. (Yeah, some people would find that odd but think about that the next time you visit your doctor. Would you feel comfortable enough to cry?) Patients also told me that they really liked him. Those two points really impressed me.

On the other hand, get him into his office, and you see a different side. He complained about DOs, bragged about his MCAT score (that was a while ago), told me (and reiterated) that he was "competent" at what he did, and is a drug-rep doctor. He also gave me some "advice" that he learned from a family doctor (a doctor that even he said was bad), "Follow the 3 A's: availability, affability, and ability; in that order."

Oi.

He just confirmed the "thing" that I didn't want to be! I don't want to be "affable" but stupid.

I also learned that this area really needs doctors. I am surprised. I would think that being this close to the state capital would mean something, but apparently that is wrong. It really makes me think about why I took this path. I have always wanted to help where it was needed, right? But, when I left Shores, I swore off anything that reminded me of a small town. Could I deal with a place like this again (not Shores, never Shores)? I know that Mike wouldn't mind.

But then again... I like being in Seattle. I like going somewhere at 11:00pm knowing that it will be open that late.

Argh!

All of these damn decisions!

Internal Medicine

2008-08-09T16:26:00.000-07:00

I finished my 5th week of my 12 week rotation in Internal Medicine this week. After the 6th week I will go back to the big city to be at the VA hospital.

I really liked my two weeks with the "really crazy busy doctor." I don't want to be as busy as he is, but it is because of him that I would really consider Internal Medicine as a field option for me. He had a good combination of hospitalist work and clinic work. While I was there I got to see a wide variety of things. Some patients had very complicated cases while others were just fine.

If I had only done this part of the rotation at the first site, I would not have added Internal Med to my "possibles" list.

Isn't that amazing!?

I could have possibly written something of "for forever" if I hadn't done this two week stint in this location. I wonder what that means for my other rotations.

THE Experience

2008-08-07T19:23:00.001-07:00

This is going to be somewhat of a long post. Just thought you ought to know.

I know nothing.

My classmates and I have been told numerous times about this certain experience. I have read about it in different books as well. However, no matter how many times you are told about this type of experience, you can never (EVER!) be prepared for it. You just recognize it while it is happening and realize that all you can do is learn from it.

I felt utterly, completely, and universally inadequate today. I mean jaw-dropped-on-floor, want to cry and run home inadequate.

I will give you the general version of this experience followed with a specific description of what I wen through if you want to know the medical details. I will deviate from my normal way of writing and not create links for every medical term, it would take too long. If you really want to know, Wikipedia is there to help.

General Description:
I knew that at some point, all of my book-learned knowledge would be useless. It would go into hiding behind some lead-lined wall in my head right when I needed it. I was told that I would be put into some emergency situation and two things would happen: the first was that I wouldn't realize it was an emergency situation and the second was that I wouldn't know how to react (thanks to that lead-lined wall). This is what happened today. I walked into a patient's room with a doctor, the doctor realized that the patient was not doing well at all (READ: If we had walked in about 10 minutes later, we would have had a scene from ER running at the hospital). To my credit, I would have realized the same thing, only about 30 seconds later. The doctor began firing off orders in a completely calm and orderly fashion, while I stood on the sidelines trying to be useful by not getting in anyones way.

What a way to learn.

Specific Description:
At about 7:30 this morning, I was pre-rounding on a patient. This patient was morbidly obese (weighed about 170 kg - kilos people, not pounds) and had a history of: aortic stenosis, COPD, CHF, diabetes, and electrolyte abnormalities. Basically, she was not a "simple" patient by any means. I spoke with this patient for about 45 minutes, and she was mostly fine (as fine as can be expected) at that point. She was able to hold a conversation with me and coherently answer all of my questions. In fact, she had even been mad at me for waking her up and asking her a bunch of "stupid" questions. To move the story along, I did the physical exam and got her history. Out of all of the things that were wrong with her, there was one that didn't fit: her respiratory rate was somewhere around 30 per minute. Most physicians really wouldn't like this number. I understood it to be high, but I didn't realize that it was high enough to set off alarm bells. When I was presenting this case to an attending it was about 1.5 hours after I had interviewed her. After I mentioned the little tidbit about the respiratory rate, I was peppered with more questions and we decided to see the patient.

When we walked into the room, the patient looked sleepy. "No big deal," I thought, "She was like this earlier." Oi. The no-big-deal part didn't last that long. After trying to wake her up by saying hello, and her not really responding, the attending determined that she was crashing. (Enter the part where I hopefully would have realized that she was crashing about 30 seconds later if I had found her on my own.) After that, there was a flurry of action. The attending set a trillion things into action: and ABG was ordered, stat xray, stat EKG, 40mg of lasix, 2mcg of morphine, 125 (I forgot the units) of methylprednisolone, respiratory treatment, and stat labs.

And what was my job?

Attending: Stay here and watch what they do.

Me: Okay.

I did my job really, really well.

I had this horrible sense of helplessness and inadequacy. It is almost like watching someone die that you know and realizing that you almost know how to save them, but you can't pull that information to the front of your brain.

If I had discovered her by myself, the situation would have been different. I would have realized a little bit later something was wrong, then I would have either yelled for help for went to get the attending, and then the same scene would have played out.

Now that I have had a chance to think about all of this stuff, I realize that I am not completely useless. I understood all of the life-threatening things that could have been causing her shortness of breath. I just didn't know what to do acutely for them.

Medicine is a scary thing people! The nurse for that patient had just seen her 30 MINUTES before all of this had happened and she had been just fine. That is insane! 30 freaking minutes went by and this patient's body went from 'dealing with the problem' to 'f*** it, I don't care.' This was a shocking experience for me. I seriously called Mike after it was all done almost crying. I was just so moved by the whole experience.

I must try to get as much experience in anything that I can. I just feel so inadequate.

And to make my day even more interesting, I saw a sex offender today as a patient. I was instructed to leave the exam room door barely open, just in case.

Wow, talk about an interesting day.

Too close to see the growth

2008-08-06T19:42:00.000-07:00

I am pretty sure that I have learned at least SOMETHING in the past 5 weeks or so. I am sure that it is measurable in some manner.

But I couldn't be the one to judge that.

This experience, I am sure, is somewhat like watching my puppy, Tesla, grow. At first, I could tell that she was growing even though I was around her almost all of the time. But now, the reason I can tell that she is growing is because I am gone the whole week and I only see her on the weekends.

The point...

I feel like I haven't grown or learned much in the past 5 weeks. What I have noticed are things that I don't feel are important. For example, I definitely feel more confident walking into a patient's room and FEELING like I am supposed to be there.

To me, important things deal with knowledge. I wish that I could remember something from just hearing it once and be able to apply it to situations as needed. I would like more confidence in my abilities (this last statement is kind of funny if you think about the fact that I have been talking about having learned nothing yet).

Well, this post is just kind of "blah." I really like the doctor that I am working with right now and I don't want to go back to the other one. Not that the other one is bad, but I like this pace better.

Did I choose you? Or did you choose me?

2008-08-04T21:19:00.000-07:00

While being out here, I have worked with a total of 6 different doctors. It is great to be able to see the different ways that each practices medicine.

What I have come to notice is that eventually, patients and doctors match in personality and "style." For example, the doctor that I followed today has a reputation for getting extremely agitated if she gets behind even a few minutes. Also, even though she has 3 patient rooms, she only wants 2 filled at once because 3 makes her edgy. Interestingly, most of her patients are quick and to the point about why they are there. They get right down to talking about their symptoms, how they are feeling, and what they are worried about. All of this happens without the doctor seeming like she is pushy or trying to get her patients out of the door.

Another one of the doctors will listen to almost everything you have to talk about, even if it isn't the reason that you came in to see him in the first place. As you may have guessed, a lot of his patients talk a lot and he is usually running about 30-60 minutes behind schedule. That may sound frustrating to some of you (maybe you would work better with the other female doctor I mentioned...) but his patients know that when he finally gets to them, he will also give them all the time they need.

It goes on and on. So I guess that means that if someone recommends a doctor to you, you should ask that person more questions about how the practice goes. For example, if you really wanted a doctor that spent as much time with you as necessary and didn't mind being late, the person recommending the doctor to you would need to give you more details about how much time the doctor spends in the room with the patient.

My point is that how did the patients and doctor end up together? These types of things aren't really advertised anywhere but most of the patients seem to work well with the doctor's style.

At this point, I think I am leaning more towards the female doctor in this post. I wouldn't be exactly like her, I don't think I would flip out about 3 patient rooms being full. But I would like to keep things on schedule as much as possible.

My Weekend On-Call

2008-08-03T21:37:00.000-07:00

This weekend had its ups and downs.

I got to help do a thoracentesis as I mentioned earlier. I saw how admission to a hospital works. However I really don't think that I learned much. My attending was trying to expose me to as many things as possible so that I would be prepared when I went to the "big hospital" up here. What ended up happening was that I was overwhelmed by all of the things, I didn't get a good grasp of any single thing. I will only know later if this experience has helped me.

Another bad thing was that my attending and I got on each other's nerves by the end of the weekend. This is partially due to my personality and partially due to his. He had mentioned earlier that usually by the end of his weekends on-call, he gets annoyed at people constantly needing something from him. Our housing situation was setup so that I stayed with him in a house that the hospital owned. Of course, we had our own bedrooms but it was weird staying with him. It also meant that we spent more time together (probably a bit too much). By the end of the weekend, I was feeling pretty crappy because I felt like I wasn't doing well with anything.

So, together, it didn't make for a good combination. Which sucks when I am the medical student and he is giving me my grade.

I guess my overall feeling is, "eh." I could have only done the call for one day and had gotten the same thing out of it. Kind of sad because I would have enjoyed spending the time with Mike instead.

It was the non-hospital experiences this weekend that I really liked. My attending thinks that I will become a pediatric intensivist. Interestingly, this is a field that I have considered and really like. But, who knows. I like lots of things. Cardiology is also pretty interesting to me. What I have figured out is that I am going to specialize in "something."

Editor's note: As I read back over this post, I realize that it sounds very negative. I am not changing it because I want to be able to read back over it at a much later time and see if I still think the same thing. So, dear readers, please don't think that nothing good came of this and it was a waste of time. As I get into a better mood, or as I enter the "big hospital," I may realize all of the good things that I had while I was on-call with him.

Non-medical school related rant (just a warning)

2008-08-03T21:12:00.000-07:00

We have this neighbor.

Oh, and this will be a long post.

Sigh.

She is somewhat nosy and very picky about having things done her way.

Which is fine and all, as long as she is only picky about her stuff.

We have this tree.

Wait, back up. SHE has this tree. Most of this tree has berries that fall on our side. It is a Mountain Ash tree.

It produces fruit in spring and then the fruit fall off. Into our yard. We don't like these berries for a few reasons: the dogs eat them, the dogs track the berries into our house, and we track the berries into our house. Granted, the berries aren't poisonous to our dogs, but I still don't want them eating things that they shouldn't.

We have spoken with out neighbor a few times about this tree. She just keeps telling us, "Well, the berries aren't poisonous. You should just keep outside shoes and inside shoes. "

We aren't sure how the shoe recommendation would work for our dogs.

She was nice a few months ago and somewhat trimmed the branches (with a professional service).

Oh yeah. ALL OF THE BRANCHES ARE ON OUR SIDE OF THE FENCE. So she has the trunk on her side, and the berries on our side.

Mike spoke with her earlier this week and asked if we could remove some of the branches that had berries on it. She agreed to let him do that. But there was a miscommunication. She assumed that we only meant the tiny branches that directly held the berries. Mike meant the big branches that held branches and branches and branches of berries.

So we cut one down this evening. And while our neighbor was staring out of her window down into our yard, she realized that something was happening that she didn't like.

To make a long and annoying conversation shorter, the result was this:
-Neighbor doesn't want us taking down any branches, she acknowledged on her own that all of the branches are on our side, and she thinks that this is a malicious attack on her (side note on that one... She had her tree pruning service out earlier in July and when they trimmed some other trees of hers and some branches fell on our property. No biggie. What happened was that when the pruning people came onto our property to clean up the branches without asking permission, they removed one of Mike's broccoli plants. One plant isn't a big deal. But was kind of crappy that they didn't even try and pay attention to his vegetable garden when cleaning up. Our neighbor was told about this, because we wanted to say that if they prune branches WE would clean it up. She made the pruning service buy Mike new seeds. Not what we were going after.) So when she went inside her house, she muttered, "One broccoli plant, one branch. I see."
-Neighbor complained about one of our trees that was completely on our property and said that it blocked light on her property so that she couldn't grow what she wanted there. She then offered to remove the tree with the berries if we removed that tree. We agreed.

She didn't like that response. She put herself between a rock and a hard place because she made an offer that she needs to follow through with. We have already started removing big branches from our tree.

The only thing that we could have done differently was pay a professional pruning service to remove the branches that have berries on our yard. But, as she pointed out, that would make it so she basically has no tree there.

We have spoken with her for months about this. We have tried to be very nice about it. But tonight it came down to saying that it is our property and we don't want them there. Mike and I don't want to piss off our neighbors, but you can only do so much.

Argh!

Sorry for the super long rant about nothing related to medicine. I just cannot believe how amazing this is. It really makes me mad that she thinks Mike would do this just to "get back" at her about a stupid broccoli plant. Are you kidding?

Yay!

2008-08-02T16:39:00.000-07:00

I got to help do a thoracentesis! My attending did the first "poke" for guidance, then I did the second poke for draining a bunch of fluid from the guy's chest.

Nice.

This weekend

2008-08-01T15:09:00.000-07:00

I am on call this weekend. So, no posts. Hopefully I will write one on Sunday about all of my adventures.

:)

To the Owens-eese

2008-07-29T22:07:00.000-07:00

Okay, so life with the super-crazy-busy doc....

Has been...

Odd?

It isn't hard in the ways that I thought it would be hard. However, I am learning that I am incredibly sucky (yes, that is an official term) at writing prescriptions and hospital orders right now. Of course, some would say that I shouldn't be worried about it. They are probably true seeing how this is only my second day trying to write them.

But damn it!

I am supposed to know everything! Right...

I like being a hospitalist. I only do it right now for 2 hours of the day, but I really like it. The pace of working in a hospital (as compared to a clinic) is much faster. Problems are more acute and more interesting. I actually get to see people a few days in a row and see how they are progressing instead of just seeing them for 30 minutes or so and knowing that I won't see them again.

I got to help diagnose this woman who came in vomiting blood (Mallory-Weiss tear), look at a {DON'T click the next link if you are squeamish about gross looking feet} diabetic foot ulcer, and take care of a woman who tore her labral cartilage in her hip joint. Trust me, these things are so much better than what I had been seeing.

I also was told again that I am one of the "better" medical students. Bah. I still don't believe them. I always think that people are just being nice. One of my biggest fears is that I will become one of those doctors that patients like because I am nice (yes, that is right, I am NICE) and easy to get along with but they won't realize (and I won't realize) that I am actually a stupid doctor.

I mean, geez, at this point I can't even convince my bestest friend of 12 YEARS THAT SHE SHOULD REALLY GET A PRIMARY CARE DOCTOR WITH HER NEWLY ESTABLISHED HEALTH INSURANCE.

Whew.

Where did that come from?

Slow on the uptake

2008-07-27T22:39:00.000-07:00

Okay, so I am a bit slow on the uptake here. Mike has been telling me about this lecture for a few months now. If any of you have not watched this, you MUST do it. I am not kidding.

This talk with change your life. It is an hour and sixteen minutes of your time well used. Please watch and listen to it by giving it your entire attention. No multi-tasking. No putting on a podcast either, you need the visual.

Randy Pausch Last Lecture: Achieving Your Childhood Dreams

The professor just died two days ago.

Trepidation

2008-07-27T20:17:00.000-07:00

This next week may be interesting. I start with a different doctor in a different clinic and also add on some time in the local hospital. This doctor seems to be a bit more challenging (in that I-am-going-to-pimp-you-and-remind-you-of-the-med-student-that-you-are kind of way) and busy than the other physicians that I have been working with. I also have to drive about 30 minutes each way to the clinic and I am on call for the entire weekend next weekend.

Now, if anyone reading this is currently on his or her surgery rotation, they would be playing me the violin at this point. This schedule is nothing compared to what I will get when I am on my surgery rotation.

But.

I am not on that rotation yet, and so this is "bad" compared to what I have been going through.

I really just don't want to mess up and feel like an idiot. (Little voice inside my head: So why did you become a medical student again?)

Anyways, I will post as I get the chance. Hopefully it isn't too bad.

Oh, and in case you are interested, internal medicine as a specialty is still an option for me, but in no way would I do it in a small town. I am pretty sure that I would need to be a hospitalist. I am just not doing well with living in a small town and seeing "medication refill" patients most of the time. No kidding... A lot of the patients I have been seeing are in for a 4 month follow up appointment to make sure that they are doing okay on medications and that there are no new health problems. Don't get me wrong, these check ups are important for catching things that patients may not think of as important. Because of that, it is imperative that I like what I do and not get bored by it.

So yes, those visits are boring most of the time.

The specialists

2008-07-24T16:56:00.000-07:00

For the past two days I have shadowed (followed around) two different specialists. The point of this is to expose me to areas that I wouldn't normally get to see unless I did an elective in it during 4th year. Yesterday, I spent my day split between a Hematologist-Oncologist and a Radiation-Oncologist.

A Hematologist/Oncologist is a doctor that specializes in blood and cancer diseases. The doctor I followed was awesome! She was good at listening to patients and explaining what they had. She was practiced and very adept at giving bad news and handling it when patients and their families cried. Yes, that is part of that job. Pros of the field: treatment changes a lot, there is always something to learn, docs practice is larger areas, you see some pretty cool (cool as in you don't want to be cool if you are a patient because that usually means bad) things. One "cool" thing that I saw was a breast cancer that had actually ulcerated out of the breast and was a 1.5x1.5 inch mass. Beneath her skin it was about 6 inches long and a few inches wide. The sad part was that this woman "wasn't all there in the head." She had actually thought that this growth was there because she had lifted her Christmas tree the wrong way. Can you imagine? She had an ulcerating mass that had completely destroyed her nipple and was bleeding, but she thought it was from lifting her Christmas tree the wrong way.... Another cool thing was an AML diagnosis. The patient came into the emergency room with a bad sinus infection and petechiae on his legs. Those were his only presenting symptoms! Crazy! Now, this doesn't mean that everyone who has this has AML, but it is crazy to think that those were the only things to pick up on. Cons: who wants to tell someone they will die in a few months or years, dealing with rightfully depressed people is hard, lots of drug reps. While I am not discounting this specialty fully, I doubt I will go into it.

Radiation-Oncology - this field has the technology, but lacks the "doctory" feel. You hardly see patients. You memorize anatomy like no other. You get paid A TON. And the lifestyle is a piece of cake. Yes, that sounds awesome, but it isn't what I imagined myself doing. I will not be a radiologist, I like seeing patients too much to do that.

Today, I shadowed a gastroenterologist (otherwise known as a GI doctor). I saw a lot of butts today. Yeah, not my thing either. I like the fact that there were a lot of procedures, but I don't want to do those kinds of procedures. Also, the doctor kind of sucked with patients. He was rushed and didn't seem to listen to the patients. I am sure that the patients picked up on this because at some point, a patient began speaking with me more than him. He also seemed somewhat disgusted with the fact that he was seeing patients in this area. To give him the benefit of the doubt, this hospital is run pretty poorly. Organization and communication are really bad, I know this from seeing it myself and from hearing it from other docs that I meet.

Another thing about the GI doc today was his attitude toward me. Overall, it was nice and fair. There were a few times that he would ask me questions and be surprised that I knew the answer. I am not sure if he was surprised because usually third year medical students don't know the answer OR because I just didn't seem like the kind of student that would know the answer. I would like to think it was because of the first reason, but I wouldn't put it past him to "judge" me and it be the second reason. He also said that I didn't seem like a typical first rotation student, but again, because of what I saw him do with patients and because of his attitude, I don't know if I can believe him. Really, I would like to because that is a boost to my ego, but geez. Do I really want a doctor who is the type I DO NOT want to become (both in specialty and personality) to think that I am good at what I do? Maybe it doesn't matter and I am reading too much into it, but that is what I am thinking.

That GI doc also tried to give me lots of advice. Some of it I would listen to because I have heard it from other sources before, others I will take with a truck-load of salt. Good advice: pick a specialty that allows you to have the lifestyle you want; whether it is being crazy busy all of the time or wanting to have a family and be there for them. Truck-load of salt advice: do radiation-oncology because it gives you the money and the lifestyle.

Make that a semi-truck-load of salt.

The importance of the other one

2008-07-22T18:33:00.000-07:00

It began
in high school.
"I hate you" were some of the first words
Only to be repeated back as if you were a mirror.

We moved on
One with an aspiring poison dart assassin to call her own
One with a somewhat colder mistress who spoke in bits, bytes, and GHz
Or was it MHz at that point?

I lost my assassin
You kept your mistress
One that I would learn to work around.

The winding and tortuous paths crossed
And we found each other in the murky soup of hormones and "indefinite groundings"
And almost lost each
Other to the Beastie Boys and their Girls.

But we made our paths stay together
You sacrificing your weekends to a town that held nothing for the both of us
Continually putting me and your family and friends ahead of your needs
O! Do I feel something serious beginning to develop?

Since then, there has been: 5 marriages, 3 divorces, 1 death, a variety of new and rotating siblings, 9 moves, 1 house, 2 dogs, 2 college degrees, and 4 cats.

You still have your same mistress
I have a new drug
One to rule them all.

That drug committed us both to a life that meant possible change
Every few years.
That drug made previously voiced goals a realization
Only for half of us.

The drug has ravished our lives
But has given us the solidarity to know that
Whatever life throws at us
Our paths are solid enough to laugh at the challenges.

It is mostly because of you

You pushed me when I could no longer pen down the 3 virtues that qualified me to gain entrance

It is your fault that I hold my schooling and goals to higher standards

You are to blame for the support that I get when I am in my fiery pit of ignorance

I hold you responsible for all of those times that my computer was miraculously fixed

And I wonder...

How many other people are as lucky as I am?

Not just lotto lucky, but four-leaf clover lucky!

I chuckle at those that have arguments about Christmas Ham vs. Christmas Turkey
And question why the vows were said
In the first place
Only to be broken at a later date.

Oh other one!
You (and your mistress) are one of the best things that has happened to me!
To those that can't see it, they must be blind
Or shrouded in pessimism.

Thank you for putting faith in my goals
Thank you for putting faith in me
Thank you for understanding
Thank you for putting up with Christmas time
Thank you for making super yummy shrimp
Thank you for re-arranging the bedroom for the eleventeenth time
Thank you for helping my family
Thank you for making family important
Thank you for loving me.
(Oh, and my stupid wireless access point is all fuggered up)

Slowing down

2008-07-22T18:22:00.000-07:00

Is this really my third week in this rotation? It seems like it just started yesterday!

I feel like I haven't learned anything. The rational part of me knows this is not true. I have learned "loads" and I have "loads" yet to learn. However, I still feel useless. Well, honors useless. Yes, I really want honors in this rotation. I am just not sure how to get there. I start a presentation about a patient very strong, but then I hit a little snag and I feel like it all comes crashing down. I am burning in a fiery pit of my own ignorance. True, better ignorance than stupidity, but still.

I think that part of my problem is that I don't get a chance to work out my "brain" muscle outside of studying from books. At this stage, I am seeing a bunch of patients who are in for "follow up." What does this mean? It means that the new part of the care was established a while ago and the patient is in just to say how things are going. Most of the time, things are fine. What did I learn here? Nothing new.

I must emphasize, however, that those interactions are not losses at all. I get the chance to interact with patients and build on my communication skills with patients. General communication I have always had down pat. But paying attention to the little nuances that the people around you have is the golden ticket. That is one of the differences between good doctors and awesome doctors.

Gosh darn it though! I want to learn something new in the clinic! I am tired of learning all of the time through books.

The other problem is that I don't get a lot of time to interview a patient, digest the information and formulate a plan, and then present it to the attending. I would like a bit more time to figure out what is wrong with the patient before I have to present the info to the attending. However, I don't get that luxury in an outpatient setting. Patient appointments are set to 15 minutes each. That doesn't give me a lot of time. In the inpatient setting, I will get more time because I won't have as many patients (and I will be on call all night with "nothing" to do but study my patient and sleep).

Oh, and I start the "intense" part of this rotation next week. That means lots of hours and not as much down time. Should be interesting!

A small percentage, a big problem (oh, and good news)

2008-07-17T22:49:00.000-07:00

One of the most frustrating things in medicine are the tests that come back showing that a symptom can be one of two things. The first "thing" may be "sucky" but it won't kill you. The second "thing" is both "sucky" and can kill you. Hmmmm. There are diseases and situations in medicine that come up that are horrible to miss in a patient. An obvious example would be missing a heart attack in someone who shows up to the emergency room with chest pain. My example from today? A woman had sudden onset pleuritic chest pain, shortness of breath, and coughing. Later, she developed hemoptysis.

The two things at the top of my differential are: pneumonia (sucky) and pulmonary embolism (sucky and can kill you).

So, we order a chest xray. And what comes back? A pattern that could either be pneumonia or a pulmonary embolism. Sheesh. And, may I reiterate, missing a pulmonary embolism would be very ungood. The problem here is that the chance of pneumonia is MUCH higher than a pulmonary embolism. Statistically, this woman has a higher probability of having pneumonia. But since I can't rule out a pulmonary embolism, her higher probability isn't doing much for her right now.

I'll let you know what happens. The tests come back tomorrow.

Good news from me? I did pretty well on my USMLE Step 1. Not stellar, as in I won't get into plastic surgery (lucky for me I don't want to do face lifts all of the time). However, the score is pretty competitive. I wanted a 230.... But I got a 229. So close damn it! But, I am still happy with the score. Of course, a freaking 260 would have been awesome, but you know, not many people ever are able to score that high.

In case you are curious, below is a graph of fourth year students from 2007 who matched (matching just means that the students were placed into that specialty) into different fields and what their Step 1 scores were. The numbers on the graph represent the median score of those who matched into that specialty. The bars represent the two middle quartiles. The two extreme quartiles were excluded from the graph. (yes, the graph looks like crap... Click here for the link to the original .pdf that has the info. This graph is Chart 10 on page 11. Or, you can just click on the chart in this post and it will open in a new window as a bigger picture.)

I know that I DO NOT want to do plastic surgery, otolaryngology (anyone who knows me will know that this would be the LAST field I would EVER do), dermatology, radiation oncology, or radiology. I don't need to worry about those high scores... I am somewhat interested in orthopedic surgery, so that could be in the running.

Anywhoo, I should go off to slumberland.

Nothing too new...

2008-07-15T21:28:00.000-07:00

Today was another day. Not boring by any means, but just another day. I burned off two warts from a guy's arm (purposely). Exciting, yes. I know you are jealous! :D

Something that I have noticed today (more so than any other time) is the weirdness and sometimes frank offensiveness of medical terms. A common occurrence in my teaching here is talking about the patient, in front of the patient, but not actually talking to the patient. This happens only because the attending is trying to teach me something. This isn't the offensive part; the patient is warned that this is going to happen and invited to ask any questions that they would like. The offensive part is when the attending asks me to name a finding on a person. Here are some of the things that I have named/pointed out that I am sure caused some discomfort or at least wonder in the patient: buffalo hump, Cushingoid facies, moon facies, male-pattern balding (on a female), meaty appearance (of the genital area of a female with a yeast infection), and a few others...

I always hesitate when I have to answer these questions. I hesitate because I know that the answers might bother the patients. My concern for the patient then turns into my attending thinking that I don't know the answer because of my hesitation. Sheesh. They have been in the practice for so long that they just don't remember when things are weird. I hope I never get to that point. However, since I have seen many good doctors get to that point, it means that I have to shoot for being a great/excellent/awesome/super/cool/brilliant doctor.

No pressure.

The depressing side of medicine...

2008-07-14T19:55:00.000-07:00

Sorry for the brief hiatus... No medicine on the weekend means that I have more time to spend with Mike and I don't really blog. :)

So, today. Hm. The beginning of the day was okay. I am still learning medicine (go figure) and am still really frustrated that I don't know everything (go figure). I did have a typical small town clinic experience today. Just about right when my attending and I were going to go to lunch (literally) the nurse comes back to tell us that a guy just walked into the clinic with chest pain and wanted to know if the doctor could see him (instead of taking the drive to the ER which is a ways away). Le sigh. Of course, we saw the guy. He wasn't having a heart attack, but it looks like he MIGHT have had a heart attack a long time ago that he didn't know about. So the attending and I used that to try and scare him into quitting smoking. :) Yes, scare tactics are used everywhere, especially in medicine. How many people are going to respond to, "You should really quit, it will harm your health?"

The depressing part of the day was after clinic was done with. I did a home visit with the doctor to a woman who will probably die in about a week. If that isn't bad enough... Her story is super sad. About 1.5 months ago, she showed up to the clinic because of shoulder pain. The attending sent her to get an MRI and it showed that she tore her rotator cuff. When the orthopedic surgeon went to operate, he found the cause of the tear. A bone tumor that had grown into the rotator cuff. (The person reading the MRI had missed the tumor, but that is a different story and a detail that doesn't really matter) After the surgery, the patient came back to the attending with lower back and hip pain. Guess what? She had tumors in her spine and hip. She got an xray. It showed a tumor in her lungs (probably small cell lung cancer -- if you were to pick lung cancers, you would not want this one.... survival is measured in months). This patient had an even worse prognosis because of all the places that the cancer traveled to (officially called "metastasis" of the tumor). She was walking just fine until about 2 weeks ago when she fell and broke her leg (due to a tumor in her leg). So, she is now bed ridden and will really probably die within a week.

This is sad. The only nice thing about this story is that for some reason this woman had setup her "health affairs" ahead of time. Even before she had shoulder pain. So, it made caring for her a lot easier. Her power of attorney was picked out... She had told her power of attorney general things that she would want. And the family was very supportive. It just makes me wonder why all families don't have their sh*t together like that. It is like our own mortality is a taboo subject. We all know we are going to die at some point, so why not try and make it easier for yourself and for those that will need to take care of you.

I think that some people believe that as soon as they sign a medical durable power of attorney (or just a power of attorney) form, they are handing over their control to someone else and admitting that they are going to die soon. That isn't the case! It is there for those instances that you can't predict and that you wouldn't be able to plan for (yes, I just used a double negative).

Argh!

So enough about death... I need to go study.

Finally!

2008-07-10T22:02:00.000-07:00

I have been put in my place!

I never knew I would be so excited about being knocked down.

It wasn't really all that bad anyways. So, basically what happened is that I started being pimped more by both the really important doctor and the regular doctor that I have been following. This doesn't really bother me because I am expecting pimping. However, this pimping resulted in me feeling two different things. One, stupidity (inadequacy as well). I feel like I should know these answers! And sometimes, I do know the answers but I don't say them because I don't think I am write, and yeah, I end up being correct. Two, more confidence. What?!? Yes, more confidence. They think that I have stuff down enough to even want to ask me about these diseases and processes.

I definitely showed my frustration with being pimped and not knowing the answer. I shouldn't have let it show though... We were in patients' rooms, which is normally how these things work. The doctor that I follow even asked me if I was frustrated with it later... I had to tell him that I was frustrated with myself because I didn't know the answer. For some reason, my brain seems to think that I should know all of the answers already, even though it is only my 4th day into the clerkship.

The nice part about today is that I got some cool feedback from both of them saying that they think I am definitely above average. :-0 Yay! I will take that for now... I am not yet honors level, but if I keep improving I might get there.

Now I am a bit nervous

2008-07-09T21:13:00.000-07:00

So.... Today went well, again. Seriously! I need something to go wrong (not horribly, just enough though) so that I can learn it really well. Or maybe I just think I need something to go wrong because that is just how I think things should happen. Who knows.

Today, another procedure! I helped remove skin tags from a woman's neck. Yes, all of these procedures aren't glamorous or super cool to write home about, but I keep doing them. The part that I like the most is that I am not as nervous doing them as I thought I would be. They tell me to help or do something, and I do it. I really do think that my lack of anxiety is due to their abundance of confidence in me. When I did my RUOP over summer, it felt like although Dr. Oley wanted me there, he didn't have confidence in any skills that I could have had or may have developed. In turn, that made me doubt what I could and could not do.

I had kind of a cool experience today... I was listening to this older gentleman's lungs (and by older, I mean 94) and I was pretty sure that I heard crackles at the base of both of his lungs. When I presented this information to the doctor I was with today, she listened to his lungs and said that she didn't hear any crackles. I then listened again with her stethoscope and pointed her to the exact place that I heard the crackles. She then agreed with me! That was soooo awesome! I am in no way bragging, but it is just nice to know that I wasn't imagining the crackles. :)

So, why am I nervous? I have to see patients with head of the UWMC General Internal Medicine Department. And, of course, they aren't just "normal" patients... Apparently, the clinic saves the really "complicated" patients for this guy. Great. Oh, and I am the only med school student here at this point, so I get all of his attention. Is that good? I will let you know later!

I am learning so much already. I am not sure how I can keep cramming all of this information into my head! I have 11.5 more weeks of this rotation!

Another day, another procedure

2008-07-08T21:41:00.001-07:00

Today was pretty cool, again.

I am just waiting for this bubble to burst. I mean, I need to really mess up soon, don't I?

I got to do/help with two procedures. In the first, I did sutures on a person's finger. The last time I did sutures was about 1.5 years ago on a dead pig's foot. It is amazing how similar this guy's skin was to a dead pig's... Not exactly sure what that means, but there you have it. The sutures weren't the best, but there were only two and it was on his finger. Also, this guy didn't really mind what was going on. He apparently has had over 700 stitches throughout his lifetime. It was a good first suture patient. :)

The second procedure was to help remove a little skin tag from the inside of a woman's nose. I injected the lidocaine solution to numb up the area and then the doctor removed the skin tag. That was an odd location.

I also got to see my first patient that had a new problem that was quite possibly very serious. It seems like he was in the beginning of congestive heart failure. Unfortunately, I will not be a part of any final diagnosis this guy has because it will be made by a cardiologist. It was disturbing to me to realize what this patient probably has and what his course might be like. It is not disturbing to me because of the physical course of the disease, it is disturbing because I actually had the knowledge to be able to make the possible diagnosis.

One of the other highlights of today was a patient who thanked me for my caring attitude. She also said that she "knew" I was going to be a good doctor because I actually was listening to her. She told me not to lose that art (active listening) and that she wished me good luck in the remainder of my schooling. I really wished that I could fold her up and stash her away in my pocket for the day sometime in the future where I make a mistake and wonder what the heck I was doing.

I am still continually being amazed at how much I learned over the past two years. What keeps happening is that I feel like I won't know a diagnosis or the name of a certain feature, but when I am told what it is, the information is dredged up out of the recesses of my mind and dusted off. It turns out that I have been exposed to (in at least a verbal manner) many of my daily encounters. I didn't remember them, however, because I didn't have an experience to tie the name to (like a patient encounter). Now that I am seeing patients, the names are sticking soooo much better!

My first day...

2008-07-07T18:58:00.000-07:00

...wasn't all that bad!

But, I don't want to get ahead of myself. I went pretty slowly, I only saw 5 patients. Some of the patients that I saw didn't have anything wrong with them, so talking with them and updating their records was a bit easy.

I did get to help in a procedure though! I helped remove someone's in-grown toenail. Yes, you may laugh, but I finally got to do something. :)

This is definitely a different experience from my RUOP. At my RUOP, if a patient didn't want to see me, I didn't get to see them. In this situation, I am introduced as the person that is going to talk with the patient first, without question. Of course, the patient is never seen by only me at this stage. So the only thing that the patient has to endure is telling their story about 1.5x.

I am also getting things right at this site. Of course, not everything, but there were a few times that I was able to answer a question that the doctor didn't think I would know. That gave me the warm and fuzzy feeling.

I also am realizing where I falter in confidence. There were 2 times today that I had the correct diagnosis, but I didn't think that it would be it (only because I was questioning myself). And, it turned out, I was correct. So frustrating! I guess that I am so worried that I will be labeled as arrogant and egotistical that I am pushed into the other direction of seeming like I am just not sure of myself and that I have to make apologies for everything that I do.

I should work on that.

My favorite patient of the day was actually my first patient. He came in with his wife because he fell asleep while driving and they were trying to figure out why (It is slightly more complicated than that but I can't really go into the details, of course). When he was informed that he was my first patient as a 3rd year medical student, he genuinely seemed interested in how I was doing and he was happy to be a part of my education. Are you kidding? I am about to put him through questioning twice, be all nervous in front of him, and give him an awkward physical exam but yet he was still happy to be a part of it all.

I LOVE working with patients! This is why I went into medical school. After the hell, otherwise known as second year, that I went through, I am reminded what I signed up for. I only hope that I don't lose that excitement.

The beginning of the adventure...

2008-07-06T22:01:00.000-07:00

So. I am here. I am in Montesano, WA about 1 block from the local correctional facility. A sign?

Nothing much has happened since I arrived (shocking, I know). I am nervous, excited, sad that I am not at home, hoping that I do well, hoping that I at least "don't suck," and wondering why I feel so incredibly unprepared when all I have done for the past two years is be in class.

Would you like a tour of the house I am in? You would?! Awww, shucks. I just happened to have taken pictures.

Yea.... I was going to put the photos in this blog and write captions, but then what would I do with my Flickr account? :)

A more substantial and interesting post will probably be made tomorrow.

I leave today

2008-07-06T10:25:00.000-07:00

Let me start by saying that this won't be updated all that much.

There. I set the bar incredibly low.

Whew.

I have grandiose ideas of how often I will update this blog, but you know, life gets in the way sometimes. That life will actually be the whole point of this blog (I see a vicious circle coming on).

I want to use this blog to keep my friends and family updated on how my third year of medical school goes. I will not be able to call or email all of you as often as I would like, so this is a token offering.