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