Saturday, August 20, 2011

End of the First Week

Family Medicine is off to a good start - I've seen a few patients multiple times.  One example - I saw an elderly man with the sports medicine doctor, then I saw his wife with another doctor, and then I saw both of them with the man's primary care doctor.  I have also been practicing writing SOAP notes and trying to refine that practice.  I still have good rapport with all the doctors, and am getting a better sense of how to conduct patient history and physical exams.  One gray area that I was a little nervous about was doing a basic physical exam on someone - I didn't know how thorough I should be when my preceptor is not there (mostly as far as having the patient disrobe, doing genital exams, etc).  The first time I came across this, I decided to do a thorough history, do some health education, and then wait and see how she conducted the 'complete physical'.  I went through everything, and included information about doing monthly self-checks for testicular cancer (highest rates in men in their 20s, 30s, and 40s, unlike prostate cancer which is highest in men over 50).  After the doctor did the exam (which didn't include a genital exam), she mentioned that normally she does that if the patient has complaints and I told her I did some patient education on that topic and she was very pleased.  She also seemed satisfied with my SOAP note that I did that day.

One small snag I have noticed is that my preceptor leans toward holistic/natural medicine.  That is perfectly fine with me, since I like the idea of combining lesser-known but similarly efficacious remedies for various diseases.  Also, according to our review forms, we are graded on whether we make references to medical studies and readings.  I thought a good way to combine the two would be to pick one or two things that she talks about that I am interested in and then look up articles that go into more detail.  On my first day with her, she cautioned a patient to get refrigerated probiotics because it was her understanding that ambient temperature probiotics are not effective.  Since I myself have some ambient temperature probiotics, I wanted to see exactly how poorly they fared against refrigerated ones - and despite going in with the expectation that she would be right, the study I found (from 2010, a pediatric medicine publication) found that they were equally efficacious in reducing the length of bacterial diarrhea compared to placebo.  I mentioned this to her as nicely as possible and she didn't seem to have a problem with it, which was good.  However, the next thing I thought I chose to look up had to do with how glucose levels exacerbate atopic dermatitis (AD), because she cautioned a patient to avoid food with high carbohydrate content in order decrease her overactive immune response.  I started looking up information on PubMed today about that and the first article on the topic that I found stated there was no change in symptoms in patients with AD when they were placed on sugar-free diets.  I only have partial access to PubMed at the moment, but I emailed our library director about how to gain access remotely (I know I can access it from school computers).  She expects me to have looked into this topic and I really really don't want to have to contradict her again - I want her to be right about these things, and I really like her too, so I want to keep her looking favorably on me.  If I really can't find any studies in favor of her sugar free diet, I will at least try to find a few on other factors that may increase AD (she also mentioned caffeine, antibiotics).  She is an MD for what it is worth, as are all the other Family Medicine doctors I am rotating with at Kaiser.

A final note on OMT - I have decided that I want to find ways to practice a little more OMM in the clinic, since it was part of my training, it can provide relief for some patients, and it will be included in my Step 2 board exam practical.  Considering this, I have made a goal to treat at least one patient each day with some form of OMM - most patients are very open to trying it.  The first patient I tried it on was suffering from low back pain and was a Spanish speaker, so it was a little challenging to communicate what I wanted him to do, and he was also in pain, so that was a little intimidating.  The next patient I tried it on was a middle-aged woman who had some neck/shoulder pain, which seemed muscular in origin, so I decided to do some occipital release, muscle inhibition, and long cervical muscle stretches - I was still doing some treatments when my preceptor came in and she was very approving.  The patient did report some decrease in pain, but again, I need more practice with patients.  Since I'm a little nervous about treating patients with real complaints (I don't want to make things WORSE) I am considering doing an OMM elective rotation.  I am still trying to schedule an ID rotation, but the guy hasn't emailed me back and it is really difficult to get anyone on the phone - I'm always transferred to voice mail or some department that doesn't know how to handle my request.  I'll try again next week, but the time I have left to schedule it before getting randomly assigned is ticking down...

I have also started listening to German audio lessons and audio books on my way to and from the clinic - it takes me 45-60 minutes each way.  I was looking for some audio books for Harrison's Principles of Internal Medicine (a huuuuge reference book) but none that were free.  I already have a hard copy of the book and online access, so I'll have to do that during my non-driving time.

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