Year-End Newsletter

As I'm writing this, it is quite overcast and there is a flurry of snow breezing past my window, so it is finally starting to look like winter here in unseasonably warm Colorado. About this time last year, I was taking a sailing class in St. Petersburg, Florida. I had a most enjoyable time - if I could make a living of it, sailing would be a strong contender against surgery. Shortly after returning home, I got a scare at the dentist when I went in for a standard check-up. After several visits with that dentist and a periodontist, I was told I have gingivitis and need to get tooth cleanings every three months, get deep cleanings (read: elective torture), and possibly get surgery to graft bone onto my jaw around my tooth sockets. All very unsettling, but after the initial shock wore off, life resumed and my latest appointment was yesterday, seven months after my last cleaning (they weren't happy about the four-month delay). Still doom and gloom on the dental front and I'm going to need a mouth guard at night since I have cracks in my teeth from grinding them.

I started my last lecture-based semester in mid-January and also started going out with one of the librarians at school. She was my first girlfriend and we dated for two months before I decided we weren't as compatible as I had thought, plus I couldn't really handle a relationship being thrown into the med school mix. In some ways, I wish we hadn't started going out to begin with; it throws a twist into the overall flow of my life, but you don't get as much out of life by keeping on the same boring track, and I'm glad for the experience. Regarding the academic aspect of the beginning of the semester, I came across this line I wrote only four days after the semester started: "while starting well, [this semester] has already turned into another sleep-deprived exercise in deciding how best to manage falling behind." I'd say that typifies the med school experience, even now that I'm doing rotations. There is still a lot to read and study. It is more enjoyable getting to work in the "real world" while simultaneously being more stressful since your attending holds you accountable to rigorous daily studying.

The rest of Spring semester was the typical med school roller coaster and ended with a review course for our first board exam. I took both the mandatory DO exam and the MD exam a week apart from each other, which made for a stressful week (more detail on these exams is in the third and fourth paragraphs here). I ended up passing both of them, though, which was not the case for all of my classmates. While my scores fall in the "passing" range, they are not really in the "competitive" range, so I still have my work cut out if I want to keep my residency options open.

After boards, I went to Virginia to see a friend from college. I was glad to be able to catch up and see some sights around the area with him. They were having record high temperatures, which was miserable for a Coloradan, especially with the humidity. In a humorous twist, though, we got to cool off once at the end of our day at Colonial Williamsburg when it started raining in sheets as all the buildings were closing and we had to walk back to the car. It was a good trip overall, but I neglected to keep in mind my 1 to 1.5 week limit when staying in new places with people. By the end, I was a bit of a grump, which was an unfortunate end to the visit.

Third year started with a less than informative prep course for rotations before we actually hit the clinics. My first rotation was Family Medicine, and I was thrilled about it for several days. I have always known I don't want to do primary care, but being in the clinic was great. The novelty quickly wore off, but I still enjoy rotations more than the lecture-based years. I finished off August by doing my third annual Pikes Peak hike with a couple classmates. A brief description is in the fourth paragraph here, with pics at the bottom.

My subsequent rotations have been Cardiology, Family Medicine month 2, Psychiatry, and Internal Medicine. I have enjoyed Psychiatry the most so far. For one, it was focused on one aspect of medicine, and for another, I already had a decent conceptual understanding of psychiatric ailments. Plus, my attending gave me a good deal of responsibility and explained concepts well. This contrasts with Internal Medicine, which was three straight weeks of getting raked over the coals and shown how much I don't know. Thankfully, I was rotating with a classmate, so neither of us was stuck feeling incompetent alone, and our attending let us have this last week of December off.

I start General Surgery this Tuesday, and I'm excited to finally be getting to something more up my alley. I won't be learning many techniques and my main focus has to be all the medicine pertaining to the surgeries, but at least it's closer to my desired field than past rotations.

Have a great 2011! I'll post again at the end of January and hopefully sooner.

Scott

First-Hand Medical Experience

In addition to being really busy, I've had a GI bug since Saturday morning. I made it to work yesterday but decided to skip today and finally saw my old family doctor, who gave me some Cipro. I thought it humorously counterintuitive that his treatment plan includes a medication that can cause severe diarrhea in the form of Clostridium difficile colitis. Oh well - a five-day course should be fine. Plus, he told me to take Imodium and keep taking Pepto, so I should be back to normal in just a few days. Much as I'd like to go into gooey details, I have to read up on systolic dysfunction for tomorrow. It is the main problem in heart failure, which is the final common pathway of just about everything in cardiology, so I'll sign off and hope to post more in-depth and interesting info soon.

Scott

Good Day and Passing with Honors

After yesterday's post, I thought I should follow up to clarify that the world hasn't come to an end. Today was quite good. There was a light patient load, it went well interacting with patients and my preceptor, and we got off early. It's nice to be back on track so quickly after a bad day. It's just tough while you're in the midst of a hard experience to see past it. I'm sure I'm going to have more rough days on this rotation, but things are looking well right now (not that I like internal medicine, but the rotation is looking up). It's been a hard-learned lesson, but I truly do know that I shouldn't base important opinions and decisions on single negative experiences. Anyway, to top off the day, I just learned that I not only passed Psychiatry, but did so with honors. Some classmates and I were thinking it was impossible to get such a score on these Shelf Exams, but apparently it is possible, at least on the reputedly easy psych test.

Updating you on the patient I mentioned yesterday, he eats minimal amounts and GI (short for gastrointestinal, but can refer to gastroenterology) should have placed a PEG (percutaneous endoscopic gastrostomy) tube today to help in the administration food. A PEG tube goes through the skin directly into the stomach and is a last-ditch effort to continue using the gut to digest food when a patient isn't eating enough. Using the gut is greatly preferable to TPN (total parenteral nutrition), since the body has a lot of autoregulatory mechanisms and it's hard to get the nutrient balance just right when sustaining someone solely through an IV tube. Aside from the typical issues with having a tube in the belly, I'm worried about this patient's bed-wetting. He does not have a Foley because of the infection risk, but now he's getting an even more invasive tube in him, and his whole mid-section gets soaked with urine when he urinates. Barring a UTI, urine is sterile, but bacteria love it when they can get it, so he's turning himself into a petri dish a few times per day. His mood was a bit more positive today than yesterday, but still not back to where it was. I'm hoping he can stay positive in the long run with the long hospital stay and the recurrent procedures.

Scott

Bad Day

This past week has definitely been a challenge for me. My preceptor has an odd way of communicating. He has an accent, plus he speaks in partial sentences and uses a lot of imperative statements, so it's hard figuring out what exactly he means even if you understand the words. He sometimes just stares at the patients or at me for seconds on end; these are always uncomfortable times. Plus, he asked one lady how she has been since the recent death of her husband, and after she talked a bit and stopped to cry, he just stared at her, then said, "Don't cry. It'll be all right," and kept staring. There's obviously a cultural gap, but he seems to be somewhat Spock-like at times, expecting people to act solely on reason and practicality rather than emotion and desire. My classmate is mostly amused by him. I tend to be bemused and irritated, but in any case, we both had a rough day today. On my part, it's starting to get to me that our preceptor seems to misunderstand me and respond in ways that indicate that he thinks poorly of me. I feel it's detrimental to be confrontational with him, but since he'll be evaluating me, I also feel it's detrimental to let him misunderstand me and get the wrong impression of my intent. Damned if you do, damned if you don't, I'll just be glad when this damned rotation is over. I hate internal medicine.

Anyway, with that off my chest, we get to go in later tomorrow. Also, tomorrow should be a lighter day with patients. Speaking of patients, the one I've been rounding on this past week has pressure ulcers on both feet as well as his sacral region. The ones on his feet had become infected, so the podiatrist debrided them and in the process discovered that the infection had spread to the bone. So the patient went back for bone debridement yesterday. He is usually chipper and energetic even when I wake him to talk, but today he seemed to just want to go back to sleep and he couldn't remember having had the procedure yesterday. I'm hoping it's just part of the procedure recovery process, but I'll find out tomorrow. The bacterial cultures of his bone came back with Staph and Strep, which are common in osteomyelitis from skin ulcers, as are anaerobes, gram negatives, and mixed infections. Osteomyelitis from a plain skin infection is likely to be Staph aureus or Strep, but when the skin is eroded away by a necrotic ulcer, it's a free-for-all in the unprotected underlying tissue. It's important to keep the skin intact as the first line of defense against invasive organisms.

I mostly needed to vent, but I figured some substantive info would be good, too.

Scott

Preliminary November Newsletter

Sorry, I got distracted at the end of November and today Internal Medicine hit hard with a lot of studying to do for tomorrow. This should be a difficult, but hopefully informative, month. There is much to learn and it's not at all focused, so it'll be a challenge for me.

Psychiatry was great. My interest didn't make a big decline until near the end, versus other rotations, in which I started getting antsy and ready to move on by the end of the second week. My only disappointment with Psych was the lack of interaction with psychotic patients. I saw one adult who seemed to be hearing voices but wouldn't admit it and was quite on edge. Also, there was an adolescent who came to the acute unit from the residential area of the hospital who had been gradually becoming more grandiose and unrealistic with the stories he would tell. For example, he apparently was dead lifting 300 lbs the weekend before coming to acute and tore muscles in his neck and chest and ruptured some blood vessels in his head, causing him to pass out and be rushed to the emergency room. He said this incident is why he was wearing a sling; I never really got a good feel for what parts of his stories were legit, exaggerated, or plain made up. He was pleasant enough to talk to, though.

A classmate and I will be working with the same doctor this month. Thankfully, this is a classmate with whom I enjoy spending time, so it should be a good month being able to confer and just chat with him.

I think the thoroughness and regularity of my posts will be inversely proportional this month (as I mentioned last month, I'll try to post a couple times per week and I'll sum up in the monthly newsletter, but I only send notices of the newsletters).

Scott

Psych is Going Quickly

I just realized with glee the other day that I'm already 3/4 done with this rotation. Then I realized that I've been enjoying it and I'll be somewhat sad to move on. I typically have about a 2-week limit on rotations before they become drudgery, but for psych I've held out this long. Surprisingly, along the way, psychiatry has moved up my ranking of specialties. It's still not at the top, but I would actually consider doing it in an inpatient setting if surgery didn't work out.

Speaking of surgery not working out, I've been in some denial about a tremor I developed this past spring. It started off barely noticeable for an hour or two in the morning, but it's gradually become worse. It's such a slow progression I keep hoping it's plateaued, but I'm not sure. In any case, my psych rotation has somehow made me able to accept the thought of life without surgery and I've been thinking of other specialties I would enjoy. As mentioned, psych is at least on the table, but I'm leaning toward pathology and maybe radiology, both of which require little interaction with people. Ironically, one of the therapists at the hospital says I'm too personable to be a surgeon (and I suppose by extension, a pathologist or radiologist), but the thing is, being personable is not natural to me and it's very draining. Perhaps I should get this tremor checked out, but mumble, mumble, mumble, mumble. I'd probably just get put on a beta-blocker, anyway.

I'll post more case presentations as the week progresses.

Scott

Critical Mass

Apparently, putting a dozen troubled little boys and a couple of adolescents together causes a spontaneous reaction. Between two wards, you can only separate so many volatile patient pairs. There are obvious laws about male and female patients not sharing the same room, but other laws also limit the age difference between roommates to 36 months. Then, there's also a law or hospital policy preventing a patient who has a history of sexual misconduct from even being in the room at the same time as the roommate, so at night they have to take turns sleeping out in the common area. In case you're not adequately disturbed, keep in mind I've been working with kids. On one ward, there's a 9-year-old who has a history of sexual misconduct, and the other ward has a 13-year-old in the same love boat... er, same boat (I'm sure that's an example the type of twisted humor you develop to help cope with the knowledge of what's been done to these kids and what they in turn do to others). The 9-year-old is annoyed with not being allowed in the (single-occupancy) bathrooms at the same time as the 7-year-olds. My preceptor described "insight" as the ability to appreciate the consequences of one's actions and the effect of those actions on others. I'm seeing a lot of patients, even older kids, who are totally clueless about cause and effect of their actions.

Anyway, all this logistic juggling is made worse by the fact that both wards are near capacity. Several kids on the more full one decided to lose their cool today. It was a rough afternoon. I learned I am not naturally gifted with the patience to deal with the loud, outbursting types of patients day in and day out. One little boy had a penchant for loudly screaming a couple octaves higher than should be possible and slamming doors repeatedly. Another decided to make it his personal mission to attack a younger kid who's kind of an outcast and just mopes about all day. Then there is a teenage girl who has borderline personality disorder (alternates between desperately clinging to you and beating the crap out of you, not always figuratively). Bradley, a boy she knows, was admitted today. So, with the aggravation of little boys screaming and the desire to show off for her newly-formed soul mate, she reverted to her coping method of choice: regressing to the maturity level of a three-year-old. On the way back from one of several trips to the seclusion room and after a boat load of meds, she yelled, "It's ok, Bradley, it's ok! I'm calm now! It's ok, Bradley!" She's screaming this, mind you.

While I'm discussing totally odd behavior, there was a certain teenage boy admitted for combative, defiant behavior. He was one of the first patients I saw here, and the doctor said to imprint him in my mind as a classic case of bipolar, which is apparently overdiagnosed these days. During his stay on acute, this guy had one or two run-ins with staff, being physically aggressive and just defiant. I saw the staff bodily drag him to the seclusion room; if all you could have seen was his face, you'd have though he was just enjoying a competitive sport. No wild psychosis glinting in his eye, no hatred seething out of his pores. They asked him at one point why he was acting this way and he said, "I don't know. It's fun." His behavior eventually leveled out, so he was transferred to the residential unit, which allows more freedoms while still providing intensive treatment. Last week, he decided it would be a good idea to fill his toothbrush holder with feces. I'm not sure if that was "fun," or if there was some other driving force. My attending said it was a subconcious way of testing others' acceptance of him. "Here's a part of me, what do you think of it?"

Not all the patients are so oddly colorful, however. One was a teenage girl who was just dealing with several stressors and started cutting and having some suicidal thoughts. Her family is supportive, and she just needed some quick inpatient therapy before being set up with outpatient follow-up. She had a positive outlook on life in general and got along with people well and should be fine.

Back to cutting and other self-destructive behavior. Cutting and similar actions are distinctly different from suicidality. Cutting is not an action meant to harm or kill; it's like sighing long and hard at a complex problem. It's an emotional release. It's a way of transferring abstract, intangible, inner distress to a tangible, concrete, external locus. It does some other things, too, but that seems to be the consistent theme amongst cutters. They probably won't have thought it out in such detail, though.

As a poor analogy, think of suicidality and cutting as being like flames and smoke. They often coexist, but it depends on what's being heated, and they are two separate entities. Smoke and flames are simply the obvious signs of the combustion process, which is what really needs to be stopped. Similarly, putting an end to the angst and depression leading to suicidal ideation and cutting is the only effective treatment for them. If you want to treat the symptoms, the best action you can take to prevent these thoughts/actions directly is to equip the patient with healthier coping mechanisms. You can't cure suicidality. You can't cure cutting. You can't cure suicidality. You can't cure cutting. Should I say it again? You have to cure the underlying cause. If I seem emphatic on these topics, it's due to personal experience with both. I should specify that's past experience, so don't go locking me up.

Speaking of personal experience, it's both a benefit and a detriment. On the one hand, I'm non-reactive when patients relate suicidality and cutting, which facilitates their sharing, plus I understand their thought processes fairly well. One the other hand, I feel detaining most of these patients is such overkill (no twisted pun intended). I keep thinking, "so they cut themselves and want to die, what's the big deal? I had the same thoughts and I'm still here. (And I walked five miles to school in the dark barefoot in the snow uphill both ways and in my day...)"

So as not to leave on a negative note, consider this: this sentence has seventy-five letters... q.

Scott

Family Medicine Test Results

I found out today I passed the Family Medicine Shelf exam! Aside from the bit of Family Medicine on my next set of boards, I'm done with it forever!!

I'm getting a bit more interaction with patients. I'm still forgetting stupid stuff. I'll remember to ask one thing and forget another. Then remember the other and forget the one. It helps that the place I'm at has interview sheets bearing a separate section for each part of the interview: chief complaint, history of present illness, past medical history, etc. Once I get more experience, I'll know what types of things are relevant to a certain type of presentation, but right now I feel like I'm still rehearsing a script. Poorly.

I'm finding my motivation to study for each rotation lasts about a week and a half. We should switch from monthly rotations to fortnightly ones. I'll pull through, though. I'll be switching doctors for a couple of days next week, so that should mix things up a bit.

Scott

First Real Psych Interview

Well, it finally happened. It wasn't very smooth, but I have greatly improved in my patient interaction skills over the past three months. Back then, I was hesitant and intimidated by a plain old interview with an adult patient. I've now come to the point where I am hesitant and intimidated by a psychiatric interview with a 13-year-old girl. Three biggies there: psychiatric, so emotionally or mentally, things are not ideal; 13yo, and I'm turning into an old fart, so I'm out of touch; and girl, and I obviously have limited firsthand experience dealing with the struggles facing females. I was much better at maintaining cohesion of the interview even during times I knew I was tanking (maintaining cohesion = me not curling up on the floor and weeping silently). I'm sure she would rather pull out her toenails than go through that again, but I was so glad to see the progress I'm making.


I was still able to critique myself, though. I need to work on not letting the mood get down: I'm afraid to minimize their negative experiences and thoughts, but while acknowledging those things, I need to stay upbeat throughout so I don't get the patient in a negatively-focused rut. I need to improve my ability to allow a conversation to flow and direct it so I can simultaneously build rapport and gather info. The doc I'm with asked a patient if she's into texting and Facebook, to which she said yes. In his dictation, he mentioned she's sociable, so he was not only just talking to build rapport, but learning about her interests and evaluating her sociability. I was thinking later that one could also infer a certain amount about her intelligence, technological aptitude, cultural awareness, etc.


I just remembered the last physical I gave last month. I did a prostate exam and totally forgot to give the poor guy some tissue to clean off the lubricant! I did remember once his pants were back in place, but he declined when I finally offered -- A-W-K-W-A-R-D! Live and learn, I guess. Much respect for the patient patients.


Scott

Bipolar and Trauma

I got assigned to a doctor today. We saw an adolescent male with bipolar, which is rare, though is over-diagnosed. His symptoms of mania were bouts of aggression, violence, assertion, not thinking of or caring about consequences (bought a car and drove it around town before having a license), and not needing much sleep. His depression manifested as suicidality and maybe some other stuff (I'm trying to rush through this to get back to studying; I've finally been assigned reading again). He had been put on an anti-depressant, which is the last thing you want to use for bipolar since it can cause wild mood swings, hold the person in mania, or even keep them depressed. The doc switched him to valproic acid, a mood stabilizer.

I was amazed how all the kids we saw were so matter-of-fact and open talking about their experiences such as physical, emotional, sexual abuse; drug use; cutting; suicidal thoughts and attempts. At the same time, one girl had a moment's hesitation when admitting she was sexually active. I'm not sure if they're open talking about their past because it's already been brought to light in previous sessions or if they are able to emotionally detach from those aspects of life in such a way that they can talk about them like everyday topics. As opposed to the one girl's reluctance to admit to a sex life, which she may still hold on to as a private or positive part of her life (or could just feel reluctant to talk about it with two males). It will be interesting seeing what trends like this develop.

I mentioned trauma because almost every kid we saw today had had some sort of emotional trauma. This disillusions them by shattering their basic assumptions of life. The doc said researchers have boiled down the inborn assumptions everyone has: The world is safe, I'm worthy of love, My caretaker is competent, Life is worth living. Most psychiatric disorders can be traced to one or more of these being shattered by negative experiences. But, genetics is a big part of the mix, too, so lots to think about.

Scott

First Day of Psych

That's somewhat misleading, as I didn't really have any exposure to psychiatry today. My two classmates and I met with the HR lady, found out we hadn't been given all the paperwork we needed, waited for a doctor to come meet with us, and were given a tour of the facility. After that, they let us go home, to return tomorrow morning to work out schedules and remaining paperwork. Despite the logistic issues, I'm excited for this rotation. I have no desire to work in psychiatry and I'm rather nervous about interacting with patients, but I find behavioral health fascinating. That and my desire to get better at my interviewing skills should make this a really good month.

I spent a good portion of today looking into joining El Paso County Search and Rescue. After all my research, it looks like I won't be able to hack the time commitment for training with my unpredictable rotation schedule. Also, they basically expect you to stay on for at least several years, but I could only manage another year and a half before I start rotating out of state and eventually move to my residency, which will almost assuredly be out of state and definitely will not be in El Paso county. I wish I hadn't spent all that time looking into this instead of brushing up on psych or reading the volumes of regulations regarding the facility I'll be at. Though, it's good to know what to consider when I finally do have time in life to do this type of thing.

Somehow Mom found out that Grandma has been having belly discomfort; I called Grandma, got a brief history, and urged her to go to the ER if she doesn't improve. We're all hoping for the best here.

Scott

October Newsletter

I'm done with Family Medicine forever! Whooo! Assuming I passed the test, that is. Thing is, the test comprises* retired questions from exams testing knowledge that is, in the case of Family Medicine, five years ahead of my current level of training. I'm just going to keep plugging away and not worry about my score until it's posted. 

My rotation shaped up to be what I was expecting based on my first day: brief patient encounters and too fast-paced for me to think of questions to ask. Recapping from the last newsletter, the doctor only works two days a week, so I spent most of my time with his two PAs. I got along well with them and actually enjoyed my time with them more than with the doctor. He was lenient with me, but usually sounded irritated talking with his staff. I kept thinking, this is not how I would treat the people on whom my livelihood depends. One PA took more time with patients, but in general, all three providers were very fast and were practically looking for an excuse to give patients antibiotics. Thankfully, I was able to induce Stockholm Syndrome and get through it all right.

One highlight of the month is that a little girl hugged me. It made my day. Regarding other memorable patient interactions, I try to keep specifics out of my newsletters since I'm quite verbose when describing them, so I'm hoping to be more detailed about that in the middle of the month, as I was here.

For November, I'm doing Psychiatry, which should be interesting enough, but it's a nuisance being re-fingerprinted, re-background checked, and re-drug tested, which are required steps to be at the facility. Plus, the mandatory reading I've spent hours on this weekend regards the state of Colorado's regulations, and is not specific to the place I'll be working (Cedar Springs Hospital, if you're curious). It's boring, redundant, and half legalese. Oh, well. This should be a good month as long as I see more -iatry than -ology; I don't want to sit around listening to counseling sessions.

Repeating the above, I'm going to try making a habit of writing more detailed posts during the month while keeping the end-of-month newsletters short. To my mailing list folks, I'll continue only announcing the newsletters, but feel free to check http://medstudentscott.blogspot.com/ for the latest. Now it's back to reading "Rules Regulating Residential Child Care Facilities."

Scott

*Comprise: "to be made up of." This is the traditional definition and the one I prefer, but the alternative definition, "to make up," is the way I mostly see this word used. This is a shame, since the original def is basically passive, and therefore sets up such double-passive awesomeness as: "Five hundred members are comprised of our organization." My guess is the original definition requires too much mental dexterity for the common person to understand (said with nose in air).

Mid-October thoughts

It's just past half-way for this Family Medicine rotation. I was a little unsure whether I could handle it, as I mentioned in my September Newsletter. The majority of my time has been spent with the doctor's PAs, which is just as well, since I get along with their personalities better than his. I'm disappointed in the doctor's apparent shortness with his staff. He often uses an impatient, irritated tone of voice with them. Admittedly, this could just be how he speaks with people he knows well. The thing is, he doesn't use those tones with his PAs, and it seems to me he should show more appreciation to the people who are so vital to his practice. I have a greater appreciation for the first family practice doctor with whom I rotated. He would always take time to let his staff know he appreciated them and pull them aside to acknowledge times when they did a bit more than their share. It's funny: the first doctor, Dr. 1, would complain about how specialists are so highly paid and he has to work so much more to earn his living, while the current doctor, Dr. 2, complains about how much harder he has to work relative to Dr. 1 since Dr. 1 has a partner in his practice and brings in so much more money. I guess it just goes to show there's always someone better off and worse off than you.


Aside from needing to induce Stockholm Syndrome when I go to work* so I don't have a meltdown over how quickly they breeze through patients and over-prescribe antibiotics, I'm enjoying myself. I still don't like primary care nor clinic-based practice, but putting that aside, I've had some good patient interactions, and I get along well with the PAs, with whom I spend 2/3 of my time. Plus, I'm glad I'm getting Family Practice out of the way so soon. I'm worried, though, that I have yet to get pimped too hard at any of my rotations. I don't like being put on the spot, but I think I would be learning so much more if I was and if I had someone giving me topics to look up every night to report back on the next day. I'm pretty sure this is how future rotations will be and I just hope I'm ready for that environment.


I've been able to see quite a few non-followup patients before the doctor/PA sees them, which is always a good learning experience and test to see how well I remember to do a history and physical. Two such patients stood out, the first of whom was a 19-year-old Hispanic male with a one-year history of bilateral knee pain and "instability" which has been getting worse. The pain is absent in the morning and gets worse throughout the day. Cold temperature, changes in the weather, and staying on his feet at his job as a restaurant busser make it worse. Aside from staying off his feet, he hasn't found anything to make it better, but has only tried regular-dose ibuprofen and not ice or elevation. He describes the pain as a soreness. There is no radiation of the pain, but he does have other distinct areas that are affected. His ankles are both sore and affected similarly to his knees, except for changes in weather. His upper extremity proximal interphalangeal joints feel stiff, especially in the cold. Both wrists have been affected for several years, being sore and occasionally developing self-limiting "bumps between the bones" on the dorsal surfaces which appear every few months and resolve within a couple weeks.
Social history: as mentioned above, he works as a busser. He drinks alcohol every few weekends at parties, denies tobacco and recreational/street drugs. He moved out of his family home six months ago and has been eating a lot of fast food since then. He stays well-hydrated.
Family history: basically negative, with a grandmother having arthritis in old age.
Physical exam: healthy-appearing young male in no apparent distress. No laxity of knees, ankles, or wrists was noted. McMurray test negative. PIP joints currently non-swollen. Tenderness absent throughout. Heart: regular rate and rhythm with no murmurs. Lungs: clear to auscultation bilaterally in posterosuperior and posteroinferior listening posts.

I wish I had covered: a bit more about sexual history, although gonococcal arthritis would be very unlikely with this presentation; specifically ruling out involvement of the axial skeleton; any fever, nausea/vomiting, weight loss, etc.; and history of illness. I should have checked all his pulses and reflexes, too. Anyway, he's too young and too non-female for this to be a typical case of rheumatoid arthritis, way too young to have have a typical case of osteoarthritis, and just a tad on the old side to have a typical case of juvenile rheumatoid arthritis, although, my friend and I thought JRA to be the best fit with the lack of relevant family history, his age, and gender. The doctor didn't probe much more than I did and ordered an autoimmune workup, checking for rheumatoid arthritis and SLE, and a general blood work panel. I'm not sure if the patient followed through with that; I haven't seen him back or seen any lab results come through and it's been over a week. I was hoping to see him again for the sake of my education, but also because I think with this history, he really needs to follow up and figure out what's going on.


The other patient who stood out was in just yesterday. It's getting late, so I'll just run through the highlights. 17yo white male, he came in to make sure his healing ingrown toenail was coming along well. He had just been treating it at home. His toe was healing fine, but as I was questioning him, tiny red flags kept popping up that weren't at all related to the toe. Through my questioning and the PA's follow-up questions for things I forgot, we discovered that he had a history of depression and suicidal thoughts in middle school, and currently has some stress at school, at home, and with his best friend; has some knee achiness; and has been hearing a female voice call his name randomly, which he described as paranoia. The whole time we were talking, he was quite respectful, but was fairly non-expressive (mask-like facies of schizophrenia?), but he would smile or chuckle now and then, and his affect lit up as we were walking out making small talk and I happened to mention some of his interests. Physical exam revealed a positive Romberg test (when given a slight push; the PA didn't wait very long to see if he would teeter on his own), and when alternating between touching his nose and the PA's finger, he moved slowly, but it was hard to tell if he was being deliberate with his movements or if he was unable to go faster. With the psychiatric and neurological findings, the PA strongly urged him to see a psychologist at least, and maybe see a psychiatrist if necessary; go in for a head CT to evaluate for any masses in/around the brain; plus go for some blood work to give more info on the knees and neuropsych issues. I most likely won't be at this location when he returns for followup, so I left my contact info with the PA and hopefully I can see what's going on. This patient's case sort of scared me and made me realize how important it can be to follow through with subtle, unrelated things the patient says that clue you in to potential problems. The patient may only be here for a toenail, at least ostensibly, but may have schizophrenia, major depression, suicidal ideation, rheumatoid arthritis, or any number of terrible diseases.


My school recently let us know of an opportunity in February to take another Family Medicine rotation as an elective, which may sound like something that wouldn't interest me at all, except that it's an intensive Spanish education rotation. The first week, the days will be heavy on the Spanish instruction and have a few of Spanish-only clinical hours, the second week will be less classroom and more clinic, etc. I would really like to improve my ability to communicate directly with Spanish-speaking patients, because, all politics aside, I'm going to see a good deal of Spanish-only patients, plus, I've always had high aspirations to learn about a dozen languages, and this would be a good way to learn one. I'm not sure if my Spanish is quite good enough to get in, and I don't know how logistics like housing and commuting would work, since it's at least an hour away, but I'll keep you posted.

In other news, for a few weeks, I've had a profound lack of motivation to be productive when I get home from work* and my wanderlust has been acting up for several days. I've been pining after sailing a lot the last few days, and thinking about driving up to spend a day in the mountains, taking a trip to Europe, just anything spontaneous that gets me away from here. I'm learning this is my cue to take a break, and I hope I can figure out a way to do so without wasting a bunch of money or study time in the process. I think learning your own needs and signals is an essential part of a medical career (and life, for that matter), and I may be a bit slow on the uptake, but I'm getting better at it.


Time for bed. My next post will probably be my monthly newsletter, but we'll see.


Scott


*I've discussed with classmates and family members what to call the time I spend at the rotation site, and "school" seems less accurate than "work," though neither sounds quite right.

September Newsletter

I was just talking with a friend and was reminded I'm a tad late writing this. Cardiology ended Wednesday and we had a wrap-up day Thursday, making today the first day of my second month of family medicine. Cardiology was a good rotation. I got to see patients in the hospital and observe some surgery-like procedures. I saw a good deal of patients in clinic, and I really don't like that type of interaction, but I keep telling myself that's where the bulk of medicine is practiced and that's where people get treated to stay healthy and I need to develop an appreciation for it. I need to learn all this background stuff to be a good surgeon. At least, that's what I'm trying to believe to make these non-surgical rotations bearable. Thankfully, the vast majority of patients are amiable and even glad to be involved in my education process. Some of them are downright pleasant and encouraging. But also, I've been able to practice dealing with patients who aren't easy to talk to, whether because they are angry, just odd, psychotic, or what have you.

For internal medicine and surgery, each of which is two months, my school lets us take a month of the basic specialty and a month of a subspecialty. So, my cardiology rotation, being a subspecialty of internal medicine, is considered my first month of IM and I won't take my basic IM rotation for a while. Sadly, I think I would have learned a lot more during cardio if I had taken two full months of the basics first. Because of this, I plan to take two months of general surgery before doing any subspecialties. Speaking of surgery, I am still set on becoming a trauma surgeon in the end, but I'm not sure if I want to get there through general surgery (and patch up the squishy stuff inside the torso), or through orthopedic surgery (and patch up the bones and ligaments and such). Apparently, general surgeons are the lead surgeons in trauma cases and orthopods just drop in to fix the bones. While it would seem more desirable to be a general surgeon from this standpoint, I've been told the one in charge must handle most of the paperwork, while the ones assisting just get to hop in, fix stuff, and hop out. Unfortunately, it would not be easy once I'm out of med school to start training in one specialty and later switch to the other. Fortunately, I have a good amount of time to decide; a good number of my classmates still don't even know what area they want to go into. I've been told not to worry about it, but I do anyway. On a side note, I thought recently that pediatric trauma would be an interesting niche, but I'm not sure how well I'd handle the abuse cases.

The doctor who owns the family practice office where I just started rotating only works Tuesdays and Thursdays, so I'll be shadowing one of the two physician's assistants who work with him. The PA I worked with today saw probably 24 patients in the six-hour day. He said he can get up to the mid 50s during the really busy seasons. He wants me to do basic physical exam techniques like checking ears and throat and listening to heart and lungs, so I'm thinking of my time with him as a good opportunity to break down my timidity in touching patients since I'll be doing it so much. Must suppress all I've been taught about spending adequate time with a patient...

Sorry this is more disorganized than normal.

Scott

Cardiology, Week 3

It was a rough transition from Family Medicine to Cardiology, as it was also a transition from a private practice clinic to a specialty practice, half in the hospital, half in the cardiology group's office (which, conveniently, happens to be in the hospital building). The first few days I didn't know how to do anything. I finally started getting the hang of how to do rounds and write simple notes on patients' progress each morning. It still takes me at least half an hour per patient, but in my defense, med students haven't been allowed access to the computers, and the majority of patient info is on the computer. I always have to ask nurses and techs to look up lab work for me on the computer, and I'm sure I'll look back on my dependence on them as good practice in interacting with other members of the medical team, but it's such a pain as a shy person to have to interrupt their work flow to ask for things.

An interesting case I saw in the clinic was a patient with an old aortic dissection. This means he got a hole in the inner layer of the biggest artery of his body, the aorta, and blood gushed in between the layers of the aortic wall, tearing them apart from each other. A very painful process and often deadly, but he lived and I got to hear abnormal blood flow sounds. It sounded like an undulating wheezing noise over top of the typical heart sounds. If you've ever heard a prosthetic valve, it sounded like that, starting simultaneously with a normal S1, decreasing through systole, then picking up at S2 and decreasing quickly at the beginning of diastole.

An interesting patient in the hospital was one whose kidneys decided to stop working. He was on Coumadin (you may know it as a "blood thinner"), and when he came in, his blood was a few times "thinner" than it should have been (INR ~5, if you're wondering). They decided to do a kidney biopsy to see what's going on since he had none of the typical risk factors leading to kidney failure. Since a biopsy entails cutting a small piece from an organ, the patient needs to be able to stop bleeding when it's performed. They were only able to get his blood thickened a little bit (INR 3.1), so he ended up bleeding when they did the biopsy, and he went from mostly alert right after the procedure to being barely able to open his eyes and reliant on a ventilator the next morning. Granted, a good deal of his decline was probably due to pain medication, but it was a good reminder that patients can go downhill and even die at any time. I'm glad to say that he was alert and conversive again today, but he could still die before getting out of the hospital.

I have been trying to avoid free food from drug reps, who are basically salesmen trying to pitch their company's products to physicians. For the most part, I eat my own lunch every day, but the last two nights, I've been to fancy restaurants to listen to discussions on medical topics, and the dinners were totally sponsored by pharmaceutical and medical device companies. My dinner total for the two nights was probably over $100, at no cost to me. Ridiculous.

I've got to study; hopefully I can write more later.

Scott

August Newsletter

Finally, I'm posting right at the end of the month! August has been a good month. It has been my first of two (non-consecutive) months of Family Medicine. I've been working with a doctor who was sort of grandfathered into FM after doing just a year-long internship out of med school, then getting a bunch of continuing medical education credits. He's had just over 30 years experience, so I figure he's a good one to learn from. The hands-on nature of this part of med school is just about what I had hoped and expected it to be. I've learned so much more of the practical side of medicine, as opposed to the minutiae of cellular and chemical processes.


I had the school's first needle-stick incident while assisting the doctor remove a bump in a patient's mouth. The patient said he has Hepatitis C but does not have HIV, but in any case I still needed to get blood drawn to get a baseline reading for my virus levels. Since I didn't have hep C, my levels were 0, but they need that baseline so they can compare the virus levels at 6 weeks and 6 months out, just to make sure the virus didn't take hold. The annoying thing is that, being at a new school, plus using a clinical rotation system in which all the students are spread out at different clinical sites instead of at one hospital, no one quite knew how to handle the incident. I called our clinical coordinator, who said to go to the ER of the principal hospital we work with in the area. Since this was not the principal site for all our students, and since I was coming in from another clinical location, I was treated like any other ER patient and wasn't brought back to a treatment room until at least an hour later. In the next several hours, I had blood drawn and waited, talked to nurses and doctors sporadically and waited, got some juice, and waited. Along the way, I was told that the prophylactic treatment for hep C hasn't proven to be very useful, so I wasn't started on that, and since there was a low chance that I was exposed to HIV, I wasn't started on the treatment for that, either. So, I spent 7 hours just to get some blood drawn, and was released at half-past midnight. Subsequently, we have brought the patient back in to have his blood tested, and his active hep C viral load was undetectable, so my 1.8% chance of contracting the disease drops even lower, and he is indeed HIV-free, so that's a relief. I've been reassured that the school is working on making sure this prolonged response doesn't happen again, but the bulk of the response is dependent on the specific site's established protocols and smaller, private practice clinics don't necessarily deal with this type of thing very often. Anyway, like I mentioned above, I'll have blood drawn in a few weeks, then again in several months, and I'm not expecting any hepatitis to show up.


This month of primary care has further confirmed that my skills and interests lie in more acute care than in long-term health management and disease prevention, but it has also further demonstrated how important the primary care is. I still want to be a trauma surgeon, and this rotation has been good at showing me what sort of long-term health issues people deal with. Things like diabetes, hyperlipidemia, depression, hypertension, etc. don't just go away when someone has a traumatic incident, so it's good to have a feel for how their medical care is going to have to continue alongside their surgical care.

To finish off the month, some friends and I hiked up Pikes Peak last Saturday (pics below). We planned on hiking up and riding the Cog Railway down, but we ended up going at a slightly slower pace than I expected, missed the train, and had to have a friend drive up and get us. We lucked out that we had cell service to call our friend near the top of the mountain, because in my experience it's rather patchy up there. A couple of us had dinner with the knight-in-shining-armor friend and her mom on Sunday, then went to Seven Falls, a local attraction. I'm not sure if I had some lingering electrolyte imbalance from Saturday or got food poisoning Sunday night, but yesterday, on the second-to-last day of my rotation, I woke up with some mild stomach distress and diarrhea, which progressed by late morning to nausea to the point that I almost had to run out on a patient lest I throw up in front of her. The doctor said I could go home, and I had to bum a ride from an MA because my car was in the shop (racking up an $87 bill to tell me I simply needed a new gas cap). Anyway, I spent the afternoon emptying the entirety of my digestive tract out both ends, but by the end of the day I was able to sip some Gatorade and water, then even have some noodles for dinner. Today, I decided to take it easy, so I've been doing some simple things around the house, getting ready for my next rotation in Cardiology, and making sure I'm ok to go back to my Family Medicine rotation for the last half day.


I've had plenty of fun patient interactions, but I feel this is long enough already, so hopefully next month I can focus more on the patient side of things.


Scott

Fun on boulders.

7 miles in and still pretty happy.

11 miles in; only 2 to go!

We made it!

Poof we were at the top.

July Newsletter

July brought an end to my trip to VA to see my friend Stephen. I enjoyed spending time with him, seeing the attractions in the area and just seeing what his life is like there. I realized on the trip that our ACLS (reviving people from heart attacks and such) course would be more intense than I had expected. By that, I mean it was completely an independent study with a series of online tests and an almost perfunctory skills test at the end. I got through it all right, but don't come running to me if your heart stops. Before the skills test for our ACLS certification, we had started our Capstone course, which I thought was going to be a crash course on life in the clinical settings in which we would be rotating. It ended up being more of the same type of lectures we have been receiving for two years. We got through it and I started my first rotation, Family Medicine, at the beginning of August.

I almost forgot the most important news: I'm officially a third-year! I passed both of the board tests I mentioned earlier, so I was allowed to progress to where I'm at now in my third year.
Anyway, I have enjoyed the last four days immensely. At least, I've enjoyed finally being in the real world of medicine and dealing with real patients, which is exciting, because I don't even want to do anything primary care-related. I can't wait to get into the hospital and see more specialized medicine, but I'm in no hurry to leave where I'm at now. I am disheartened by my lack of efficiency in studying. The doc I'm with gives me a simple topic to research each night, and I can barely read and retain enough to carry out a brief conversation about it the next day. This concerns me that I may not be able to keep up with the study load when I have to do in-depth studying on multiple patients' multiple maladies when I'm in the hospital. But for now, I've fairly well fallen into a groove.
Consider this my attempt to get back on track with monthly updates. More to come in a month.
Scott

Pseudo May/June Newsletter

There's no reason for this to be so late. I didn't write an update at the end of May because I was thinking about boards, which I took the 1st and 8th of June and elaborated on here when I couldn't sleep one night in late May. (The third and fourth paragraphs in the linked-to post explain the tests).

This month, I've been relaxing, catching up on housework, getting things ready for next semester, and most recently, spending time with a friend from college who lives in Virginia. We've seen colonial Williamsburg, swum in the James River (runs through Richmond), been to DC, and a few other things. It's been good seeing him again.


As I mention in the blog post about the boards, my plan after I graduate med school is to do a residency in La Jolla, California, near where much of my extended family is. I'm still not sure it will be possible, but that's what I'm hoping for right now; I mention it now because it's been on my mind since I have to start planning and preparing well in advance for residency, especially if I want to apply for one that will be at all competitive.


I'll get back on track with monthly newsletters soon.


Scott

Late Night, Late May Update

I was lying in bed not sleeping and realized I haven't written anything aside from the monthly newsletters in a while. The semester has ended, but I don't think I'll consider myself a real third year until after I pass the boards. The fact that we're reviewing everything doesn't help: we're taking a review course covering the last two years' information to prepare for said boards. This review isn't helping with my academic drive, either, with two years of graduate-level information crammed into three weeks. Oh, well. I keep tending toward getting stressed out about how much I don't know, but I tell myself to relax and try to learn a few things from this review instead of trying to cram everything in and forget it all.

I hadn't done any sort of physical activity for a couple weeks, so I've somewhat fallen into an every-other-day workout schedule. When I feel lazy on the "other" days, I figure I can let myself slide since beating myself up over not holding to a rigorous exercise schedule isn't going to help. Yesterday (Friday), I went for a good bike ride in the afternoon and later a classmate who's been wanting to go hiking for probably several months now texted me to see if I'd go today after class (yes, we have class this weekend). At the time I thought it would work, so I said yes, if we could keep it under an hour. This morning, though, I started to get irked that it takes around half an hour just to get to the place and the hike would take at least 45 minutes. After the first hour and a half of class, I was feeling overwhelmed again by what the instructor was covering and by the additional topics I plan to go over on my own. I decided the best thing would be to bow out of hiking, despite the fact that, knowing myself, I would probably be fairly unproductive anyway if I stayed home and tried to study. I figured not resenting my classmate for dragging me on the hike would be better in the long run, and hopefully he doesn't resent me for canceling. I said I would definitely go after June 8th (when I'm done with boards), so hopefully that will work out. He wasn't in class today, thus the text instead of talking to him, and he didn't text back, so I'll have to see.

Speaking of boards, I should explain how they work and my specific situation. I'm training to become a Doctor of Osteopathic Medicine, or D.O., as opposed to a Doctor of Medicine, or M.D. Since I'm explaining the boards, I'll just highlight the main differences between an MD and DO, which are the manipulation training (think massage therapy, physical therapy, and chiropractic rolled up together) and a whole-person approach on the osteopathic side. These days, though, the entire medical field is focusing more on the person who has a disease than on the disease in isolation. In any case, an MD and DO have the same practice privileges and career opportunities available to them, aside from the manipulative treatment. But, since there are two distinct routes to become a medical doctor, there are two different series of three-part tests, or boards, students must pass to become certified. Level One (DO) and Step One (MD) is what we're all worried about now and they cover the first two years of medical school. Level Two and Step Two are during the second two years and Step Three is taken within a year of graduating med school.

Since the MD degree has been around longer and its boards test the same type of information (again, aside from the manipulation), osteopathic students have the option of taking the MD boards in addition to their mandatory DO boards. Since many MD residencies only consider MD board scores, the only reason a student would put himself through more than one full-day test in rapid succession is if he wanted to apply to MD-based residencies in addition to/instead of DO-based residencies (residency is the next part of training after the four years of medical school). I want to apply to MD residencies (particularly one in La Jolla, for those family members who might be interested), so I'll be taking my Level One DO board June 1st, then the Step One MD board on June 8th. While the two are fairly similar, I wanted to get the manipulative medicine out of the way first and be able to focus on everything else for the second test. However, the MD board is more academically rigorous, so the order probably doesn't really matter (on the spectrum from working in the lab with beakers to working in the clinic with patients, MD training tends slightly toward the lab and DO training tends slightly toward the clinic, and this is evident in the boards). I'm just hoping I won't be totally burned out in a week, since our school is making us take a full practice board test on Thursday, the day after we finish our marathon sprint through this review.

Well, that's probably more than you wanted to know and I've accomplished my goal of being tired enough to fall asleep, so good night.

Scott

April Newsletter

Not a lot to report for this month. April has been our Women's Health block and the last new material before we start reviewing for the boards. I've done well on the first two thirds of the course and I'm still going strong, so I think I'll have a good finish to the semester. This is despite being quite antsy to be done with the semester, wanting to go sailing, and wanting to get into residency right now. I think everyone's ready to be done with school, so it's good the semester's closing out soon. I don't feel like we're reaching a milestone with finishing our first two years, because we still have to take our board review course, the boards, and a capstone course to introduce us to the hospitals. I think I'll feel like a third year med student after I finish the boards successfully.

I'm working on a hand-held sail for on-land windsurfing on my skateboard. I still need to cut and sew the material for the sail, but I've made the frame, a picture of which is shown below. The other pictures are of some of the trees I noticed blooming lately. It's neat to see the flowers back on the trees.

Scott

Sail frame. Yes, it's basically a big kite.

Tree at the road by my apartment complex.

Tree right outside my window. Looks better in person.

March's Newsletter

This may be a couple days late, but I can claim that was intentional so I could not only experience the entirety of March, but also allow myself time to think and write a thoughtful reflection. Right. Also, sorry about the length, but there's a lot of news.

March 1st found me in the midst of our first Renal test, showing off all my knowledge of the functioning of the kidneys. I say that partly in jest, but for the first segment of Renal, ending the day of that first test, I felt quite on top of the course material. I'm not sure what happened, but for the rest of Renal, I barely kept my head above water. In fact, it was my score on the first test that carried me through the abysmal scores on the second test and final. The good news on that front: I passed the course even without the curve on the final exam, which we just took a week ago. I felt like I picked up the pace a bit for the last leg of the course to have a strong finish, but I ended up doing poorly on the final anyway. The disappointment from that is alleviated by knowing that only half of the final was on the new material and especially by the relief of not needing to retake the course this summer.

On March 5th, I and a classmate, Paul, flew to New Jersey for the student surgery club spring national convention. Friday consisted of several surgeons taking more time than allotted to tell us about various aspects of surgical careers. I didn't pull much out of that evening. That night, most of the students went to a bowling alley and stayed there, apparently getting quite tipsy, until after midnight. Paul and I missed the experience because we had been up for so long and just wanted to go to the hotel and sleep. The next day consisted of a lot of hands-on experiences. We ran through how to gown and glove (maintaining a sterile environment while donning surgical garb), laparoscopic maneuvers (abdominal surgery using small holes instead of a big incision), and several other procedures. It was a lot of fun. During lunch, I was sitting with some first years from another school and they were talking about their drinking experiences of the previous night and plans for that night. It made me wonder how much maturation happens between our first and second year. Yes, many of my classmates still like hanging out downtown in clubs and bars, and while I'm not into the drinking scene myself, I still feel like my class has become more responsible and mellowed out somewhat in regard to drinking. They have definitely made strides in the interpersonal drama that kept the gossip fires well-stoked. First year, I felt like we had regressed all the way back to high school, the immaturity was so ridiculous. This year, I have still been bothered by some classmates' immaturity, but overall, we've come a long way. Sorry, I'm waxing philosophical; I'll wax anecdotal again.

The second night's activity was going to Atlantic City, with the idea of more drinking and maybe some gambling on the side. Neither Paul nor I wanted to go drinking, especially not 'til 3am, so we decided to take our rental car instead of the provided bus. If you've not been to Atlantic City, the Strip, a boardwalk on the beach, is like a mixture of Las Vegas and a carnival, so it would be a fun place to walk during the day with casinos, carnival games, and eateries on one side and the ocean on the other. After dark, be sure to stay on the boardwalk, on the east side of the casinos. Even then, we were hit on by a hooker, then once we crossed back to the west side of the casinos, we truly thought a mugging was inevitable.

The last day, we did a community service event in a church in an area in which every other house was either condemned or enclosed in security bars. We were told not to leave the building unless we were with someone and left our white coats behind. We took blood pressure and blood sugar readings for people and provided food and informational packets about various health topics. It was good to do that; it's been a long time since I did any service activities and I appreciated the reminder of the conditions some people are dealing with. We had enough time after that to try every bridge in southern Jersey back to the airport in Philadelphia, looking for one without tolls. After an hour of getting off and on freeways and trying three bridges, we found out it was just a one-time toll of $4, and we happened to have $4.06 on hand. We just had enough time to run through the Liberty Hall and Liberty Bell area. It was nice to see parts of US history, even if only briefly. See pictures below.

We have been on spring break this week (yeah, I know, there's absolutely no excuse to be writing this late), so I've worked on a project I thought of the night before the final. It was a real strain making myself go to bed for a good night's sleep instead of starting on the project that night. I was watching a gardening show which showed several gardens with hand-laid brick and stone walkways and walls. This made me want to do some sort of similar project and I thought of making a mosaic. I like glass and especially mirrors, so I decided on starting with a mirror tile, etching a compass rose onto it, breaking it, and using the shards to make a mosaic. It's not quite what I expected, but I'm still working on it and it turned out a lot better than it could have considering it was my first time working with anything like this. It's currently mounted in a frame of foam board and balsa wood with plaster of Paris. I tried using grout sealer to seal the plaster, but I guess grout sealer means grout sealer, because it serves only to dissolve a bit of plaster and smudge it around. Next is to use acrylic sealer on the plaster and clean up the glass, then outline the edges of the frame with blue foam rubber, finishing by figuring out how to hang it. See pictures below.

In personal news, Liz and I broke up early this month. Since everyone seems to find it important, it was my idea, but that doesn't really make it easier. I didn't feel like I could give her the time or attention she deserved; basically, I wasn't very invested in the relationship. She, on the other hand, was willing to do almost whatever was needed to work around my schedule and do what I wanted to do. There's a bit more to it, but that's the gist. I'm glad for the opportunity to get to know her better, learn about relationships, and learn about myself, too. I don't know how I'll feel down the road, but right now I'm content being single, and feel like any relationship I would be in right now would have to be all about me since I don't really want to change, and that doesn't seem healthy or desirable.

A positive outcome of the breakup is that I finally started thinking about various personal issues and, with some urging from a friend, I set up an appointment to start counseling April 6th. I've struggled with depression and sundry things I'd like to finally get straightened out, so this is a really good thing. Also, because of the way I'm going about getting counseling, I don't have to worry about negative repercussions on my future career.

I'm anxiously awaiting August, when lectures and board exams will be over and I'll finally be in the hospitals, but for now, I'm setting my sights on the end of May, when our last block, Women's Health, will be over and board review will start. Hopefully I'll post the next newsletter a few days before then.

Scott

Proof we were in Atlantic City. As you can see, the sign says, "Welcome to Atlantic City." Or "Shocking Upscale Presbyterian Party." Maybe "Passing Through Mississippi Ping"?

Atlantic Ocean at night. I really like the depth of color in this shot.

It was tricky dodging other people and their photo ops to get this. My expression conveys something like, "Oops, I hope I'm not in their picture! Hey, don't get in mine! Geez, has he taken it yet? Wait, am I smiling?"

Liberty Hall.

Mirror after etching. It's one foot square in dimension.

Mirror after breaking.

Framed and mounted with plaster of Paris.

Grout sealer smears.

Bonus pic. Is it a ship? Is it a kite? It's a ship kite! Mom gave me this a while ago and a recent windy day inspired me to give it a fly try.

Update on Relationship with Liz

Liz and I broke up last week. I felt like I wasn't able to give her the time and attention she deserved, plus I've seen some issues I need to sort out so I can be able to contribute to a healthy relationship, so I thought it would be best to break up now instead of getting closer and just end up having a harder separation in the future. I was talking with a friend about the breakup and based on my reasoning and some things I've shared with her in the past, she suggested I talk with the school counselor to see if she would have any advice about what kind of professional counseling I could pursue. I decided to follow through with that suggestion, but the counselor was out of town last week through the weekend. If I do end up getting some sort of counseling, I suppose this will have been a positive event in my life. In any event, it was a positive thing having gotten to know Liz, and we plan on remaining friends and maybe in the future seeing if things will work out better.

Little else to report.

Scott

34 Minutes to Spare

Thought I better write another newsletter in the last few moments of February so it wouldn't technically be late. The last few weeks have seen a decline in my motivation to study, but that seems to be the general attitude at school, so hopefully tomorrow's test will end up with a hefty curve (oops, they don't curve tests, they statistically analyze them). We are in our Renal block, so we're studying the kidneys, and I think the hype about the difficulty of this subject is somewhat justified. It's four more weeks of renal, then Women's Health, then a month-long board review course, then I'm taking the boards and taking a few weeks off before starting rotations in the hospitals. I am assigned to the Colorado Springs and Pueblo hospitals for my rotations, but I won't know any more than that for a month or so. I've been looking forward to rotations, but the last couple of days I've realized that what I really need is those few weeks off. We get a spring break at the end of renal, so I just have to stick it out a month and I'll get a breather.


Liz and I are still going out. I'm discovering the difficulty of managing a relationship around two peoples' schedules. I met her mom and step-dad Friday night at the ballet her mom took us to, so now I've met all of her immediate family, and in mid-March, she'll have met all of mine when we go to Body Worlds at the museum with my dad.


This seems pretty short, but I should get going, and I think this pretty much sums up the last month of my life anyway.


Scott