Sunday, December 29, 2013

Half way through Intern Year

Well, I'm still here, still doing the doctor thing.  It's been exhausting of course, but still trying to find time to do fun stuff.  I'm about ready to make my New Year's resolution list, usually I choose 10 things, but that will go on the other blog.  Recently I've done more Obstetrics, Medicine, and Pediatrics.  A recent development in the last couple weeks - I had heard whispers that some of the second and third year residents were concerned about one of the first years' readiness for night float, where we are the only one on the service without a second or third year helping us.  As it turns out, they all met and discussed the readiness of the interns, and they decided to swap me into this intern's slot and rearrange things so that that intern would be going last, to allow more time to be ready.  It actually works out well for me because now I get to have my two weeks on Medicine at night right before my two week vacation, instead of right after.  Also is nice to know that the residents think I'm doing well. 

Coming up for me is a week on psych, so I should be able to get a little bit of a break before I start on night float.  There have been difficult patients, challenging patients, all that, but it's hard to know when something is interesting enough to report.  Seen a lot of drama in the hospitals, luckily I'm staying out of all that.  Anyhow, I'll try to think of something good to write about... just working and working and working for now!

Sunday, October 27, 2013

Night on Call

Well, here I am, another night in the hospital. I decided to plan ahead and took about an hour nap, maybe slightly longer, before coming to work at 7pm, and took a 100mg caffeine tablet. Just took my second 100mg tablet now, at 12:45am. I was anticipating it being a nonstop night, however everything is all organized now, did a vaginal delivery, my notes, etc. and now... just waiting for admits or for all hell to break loose. This is just a weekend call though, 7pm to 11am the next day (at most). OB and Pediatrics. This past week and this coming week I am on surgery. It's been a nice change of pace, and getting home at a more reasonable hour as well. My attending looks and sounds exactly like Hugh Laurie on House. It's rather uncanny. One of his patients even pulled me aside and asked, "Does Dr. so-and-so look like Dr. House to you?" I don't know if it's surgeons in general, but he also has a lot of interesting stories. My previous surgery rotations were also filled with story telling. I wonder if it's because sewing, cutting, spreading, etc. isn't super cerebral and you can just chat while doing it. I had my in-training exam last week - I kinda just rushed through it... I know I probably should have taken it more seriously but...meh. Just wasn't in the mood, and at this point I feel like either I know it or I don't. Well, next weekend I get both days off, yay! I'll be driving over to my parents for my dad and sister's birthday - should be fun! Anyhow... guess I'll go back to studying random stuff... what to study, what to study...

Tuesday, September 24, 2013

Starting on Obstetrics

Well, after having four nightmares in a row about starting Obstetrics and hearing horror stories about staying horribly late and being super busy and stressed all day charting, I wasn't expecting this OB rotation to be as enjoyable as it is.  It's fairly relaxed, the Attendings are nice, and the first day I got to deliver two babies in a row, delivery times were 11:44am and 12:07pm, and they were in rooms across the hall from each other!  Felt pretty exciting.  I also have all the notes I need to write prepared in templates, so I can get things written a lot faster.  Today I delivered another baby and the family wanted me to take a picture with them - it's definitely a different environment than Medicine or ICU.  

Vacation was great, though I was sick for the first few days - back to the grind.  The weather is getting cool and routine is returning after a lack of much of a schedule for two weeks.  A few things I still have to get around to are my loans, which will be due December 7th, and I need to schedule my Step 3 exam.  For now though, things are quite peachy.  After this, is Pediatrics.

Wednesday, September 4, 2013

Medicine and ICU

Phew, it's been exhausting!  I had a month on internal medicine service where basically every day for 12-15 hours I'd be at the hospital managing a panel of patients and admitting new ones from the emergency department.  It was rough, and there was plenty of weekend hours put in as well.  I had an easier time of it compared to some of my colleagues because, again, I'm pretty comfortable with electronic medical records and working with computers in general.  I didn't have any real time to do readings, however, so now that I'm on ICU which is more about learning than having any intense responsibility for patients, I'm finally able to catch up on all the stuff I wanted to review.

For example, while on medicine service I saw at least 3 cases of "acute pancreatitis," with two legit cases and one (maybe more) case of not-so-legit pancreatitis.  I finally had time to go to the American Gastroenterological Association website and find their guidelines for acute pancreatitis and read up on the latest "word" from the experts.  We definitely weren't managing the patients ideally, we were managing them fine but not particularly ideally.  That's one of the challenges in medicine is that it's a constantly evolving field and you have to stay super up to date on the latest treatment protocols and what the studies are saying.  We even have a website that is essentially a wikipedia for physicians, called "UpToDate" - the name says it all, it's where doctors go to stay up to date on information.  However, UpToDate isn't always the best organized website and I don't particularly like how it's structured, plus the articles aren't necessarily peer reviewed by experts in the field based on only the best, most solid, studies.  That's where specialty society guidelines come into the picture.

In ICU, we actually had a pretty 'exciting' semi-TV moment of emergency patient care - an older woman currently on a ventilator suddenly started having blood come up her nasogastric tube, so essentially she suddenly developed bleeding and her vital signs showed she was in distress.  The rooms in ICU should be bigger than they are, and this one felt particularly cramped.  The crash-cart was between the end of the bed and the opposite wall, and I was on the inside half of the room and my attending (a very intelligent younger doctor who looks more like a college student than a seasoned ICU doctor) literally ran over the bed to get to my side so we could insert a chest tube - he didn't have a gown on (just a white coat with the sleeves rolled up to his elbows) and ended up getting sprayed with some of the fluid when the tube was in - he had eye guards in place at least (aka glasses).  Then we immediately pulled from the other cart a fiber optic cable to see where the bleeding was coming from and it was essentially seeping from every surface in her lungs - diffuse alveolar hemorrhage as they call it.  No source to suture, cauterize, or slap a bandage on - just have to keep giving her suction, oxygen, and start steroids.  She had developed a chronic lung condition over the past year and it was not going well.

Heroics aside, ICU can be a very difficult place.  We had a young girl come in and die within hours, and it shook the ICU physicians and staff for the next several days, and it made news in the community.  It's not part of the plan for young, otherwise healthy people to suddenly die of overwhelming bacterial sepsis, but it happens and there's very little you can do to stop it.  Also, one of my patients who I had been managing a week prior on the normal hospital floors for a pneumonia and fluid in her lungs, a very sweet older woman with mild Alzheimer's dementia, ended up choking on her morning breakfast and ended up in the ICU on a ventilator, likely with brain damage from lack of oxygen.  She had been on a dysphagia diet, but hadn't been officially evaluated for her swallow by a speech therapist - her eating challenge wasn't obviously apparent, it was more that she would eat too fast and choke slightly on her food rather than any physical deficit.  I hadn't seen her since, and she was probably going to be discharged from the hospital that day or the next to a rehab facility and then an assisted living home.  I don't know if it would have made a difference to have that swallow evaluation or not, part of me thinks it would have gotten her out of the hospital, home, and then maybe a little longer in this world, but on the other hand, it may have only been a matter of time before something like that happened.  If she'd been switched to a liquid only diet, would it have changed anything, or would she have developed an aspiration pneumonia later and ended up in ICU in a month anyway?  She died that night - no code was called, so it's likely the neurologic findings were dismal and the family agreed to withdraw life support.

On the more positive side of things, I've been appreciating more how much patients like seeing their doctor in the hospital, even if it's a resident physician.  It's still hard for me to see myself as a REAL doctor, but we are making decisions for the patients and know them better than the attendings.  We check on them two or more times a day, not including all the calls to the nurses, reading up on previous visit notes, calling their physicians and specialists, and checking and ordering labs and radiographs, which patients don't get to see.  After I moved to ICU service, I went back and checked on one of my other patients from medicine a few times, as she was an especially complicated case, and helped the new team manage her discharge a bit.  She was really appreciative that I was still coming and managing her - she had had a somewhat 'flat' affect and wasn't all that talkative or cheerful so I wasn't sure initially if she even liked seeing me, but she made it clear later that she was glad I was still involved in her care.  Another patient I had discharged a couple weeks ago, a young person who had gotten frustrated several times while in the hospital about being kept there for treatment and had landed himself there by some fault of his own, came back today to get some paperwork filled out and actually said of the doctors who were coming to see him he liked me the most and was glad to see me.  I was his regular doctor, and when people are in pain and are grumpy it's hard to tell if they're mad at you or if they think you should be doing something that you're not doing.  I'm glad to know that even the patients that I think are not satisfied with their care do actually appreciate the work we do.

In another example of networking and working as a team, I talked to a nurse who had semi-challenged me on a medication decision.  Long story short, I thanked her for voicing her concerns, because after the fact I went and re-examined the data behind the study that a senior resident had very emphatically told me was going to be the new standard of care, and decided that the risks do not outweigh the benefits.  Initially she may have thought I was blowing her off because I told her my justifications for wanting to prescribe the medicine which, don't worry folks, never ended up getting taken by the patient because he felt like refusing meds and even if he had gotten that one dose before I discontinued it, it's the kind of medication that takes time to build up to a therapeutic level.  I didn't HAVE to talk to her about it, as it wasn't really an issue, but I elected to for a number of reasons.

First, it's important for nurses to feel respected and not marginalized in a very hierarchical system where doctors are traditionally seen as their opponents, not partners.  We rely on them for patient care and we want them on our side and voicing concerns, when legitimate.

Second, nurses talk - if she thought I had blown off her concerns, she probably would have gone complaining to all the other nurses that I'm a bad doctor and endangering a patient, or that I'm one of "those doctors who think they are better than nurses," and I have to work here for the next three years.

Third, if nurses think their patients are in danger and that physicians aren't listening to their concerns, they will start doing things on their own - which in rare cases does help patients, and in many other cases doesn't, like times when nurses think a doctor has prescribed too high an insulin dose, pretend or abstain from giving it to the patient, and in the morning the patient has blood glucose > 300.

Fourth, good karma.

Well, at the end of this week, I'm free for two weeks to do whatever - my first vacation of intern year.  When I get back I get to jump into OB/GYN... Not looking forward to it very much.  On the plus side, I got my call schedule for next month and I won't have to do a weekend shift for the first two weekends, which is great since on the first weekend there is a Cardiovascular Symposium I'd really like to attend!  I've got a bunch of nice stuff planned for my vacation, and can't wait to get started, but I'm also really liking the pace and learning opportunities in ICU.  Having an attending who likes discussing the latest care guidelines and is passionate about evidence-based medicine is always very invigorating - it's the most academic we get, as clinicians.  Time to go read more stuff!

Sunday, July 21, 2013

A Couple Weeks In...

Well, still at it - doing the whole doctor thing.  It's fun, though I still gotta say I like clinic the most.  Clinic is where I see myself practicing most of the time.  Right now, though, I've got another week of Emergency left.  It's fun, it's interesting - a fair few procedures and such.  Only thing about it though is it's all very short term - essentially putting a bandage on someone's problem.  I would find that very demoralizing after a while.  I guess it has the same appeal as surgery - there's a problem, and you fix what you see in front of you.  Maybe it was my education at an osteopathic school, but I just don't see the appeal.  Or at least it doesn't really feel like being a 'doctor.'  You don't even get to do elaborate labs when you have an interesting case - it's just 'not our problem, they'll work that up later.'  The lifestyle is somewhat appealing, a few long shifts then a few days off, but still - doesn't have the same appeal in terms of feeling fulfilled.  

Right now trying to figure out what I should focus on learning on my own - there's so much stuff to learn more about, and it's hard to know what to focus on.  

Also enjoying being employed - getting paychecks is great.  Once I get used to the schedule of how things work I'll feel better about everything and a little less stressed - scheduling in enough sleep is the biggest challenge.  I want to get more out of my day when I've been gone a long time, and end up cutting into sleep.  Almost how time flies.  Well, I think I'll try to read up on one medical topic and one medication each day.  Or every other day.  Whichever I can accomplish.  I'd really like to at least know what receptors everything acts upon - some of them I know but some I just memorized what you use them for.  The nuances count the most...

As far as my crusade against poor management of mental health in outpatient medicine, I'm still not backing down.  Still using my PHQ-9s, documenting them, discussing it with patients... it would be really hard to manage some patients if I were limited by time the way the real doctors are.  I'm given a lot of time to see patients and hear their stories, and I'm really thankful for that.  It'll be a challenge in the future when I have to boil down a 45 minute psychiatric visit into a 15-20 minute visit that includes their other problems.  Gotta pick the battles where you can...

Monday, July 8, 2013

First Week of Residency Year 1

Well, I've had about a week of being a resident - I have to say, parking in "Doctor's Only" spots, getting all the free cafeteria food I want, introducing myself as a Doctor so-and-so, it's been pretty great!  It's taking a little getting used to, but it's fun!  I'm finally having a part in patient care and I think the confidence that comes from having decent decision making skills is making me better with my patient interactions.  Also, I have electronic medical records down almost like a second language after only a day or two.  I haven't used this system before, but I've always been good with computers so...after two years of gritting my teeth while watching my attendings attempt to chart patient visits, finally I am the one doing that!  

I've started out with clinic and homeless medicine - which is very interesting and it's a pretty easy way to start out.  The hours aren't that long and I get to do a lot of reading and videos.  I like that I get noon conferences - kind of a daily lecture on random stuff.  Also the commute from my place is less than 15 minutes no matter where I have to go so far!  For emergency, which I start next week, it gets a little more tricky - I might end up driving 30 minutes each way.  My first call is this weekend, luckily it's 7pm to 7am, starting on Saturday, so I get to sleep in and get both days to hang out and do stuff.  

Pretty much all moved in up here - our place is all settled, wedding and honeymoon are all done for now, time to get back to work...  I'm trying to start out with good habits - always taking care of things on time, staying organized, you know.  The things everyone says they'll do but usually don't do.  Well, I'm hoping to do them!  Anyhow, time to enjoy my evening... after a long day running around trying to keep a bunch of things straight in my head...

As a PS:  I keep seeing emails from recent medical graduates, international, caribbean and domestic, all sending us their applications hoping we've had a vacancy or to get started for the next round of residency applications.  All I can say is I am sooooo thankful to be done with that and finally I can stay put for three years and get paid money!  MONEY!  It's not much but it's something!  

Monday, May 20, 2013

Next Steps...

The last day of fourth year/rotations was last Friday - my last two rotations were allergy/immunology and forensic pathology.  It was quite neat seeing how they track bullets through people and the various gross findings in freshly deceased persons.  At any rate, I'm finally done and I am looking forward to putting Touro behind me and moving onto better things, with my excessively high 300k debt following behind me.  We have our apartments in Davis and Redding secured, and soon I'll have to do some PALS training, computer training, ACLS, BLS, etc.  That won't be until June 19 though, so until then I get to relax and do some prep work for those things, and the wedding.  The wedding is the last hurdle - I'm half excited and half wishing it would just be over already, since we've been planning it for months and the Bora Bora honeymoon awaits us...  

Wish I had more to say.  I'm sure some of my experiences on the rotations are worth reporting but all I can think about is wanting to get away from Touro and start earning money.  I'm tired of just racking up debt in an overpriced institution (when you look at the national averages...) and standing in rooms while doctors and patients interact.  I'm tired of waiting and watching and want to start DOING.  Yes, it comes with responsibility, stress, and long hours, but I want to start moving forward in my life.  This is a big year in terms of moving forward, and I want to get on with it!  Graduation is June 2, tomorrow I'm picking up my regalia.  Soon...  soon...

Wednesday, March 20, 2013

Match Day: Redding

Well, the results are in and my match is Redding - specifically the new Shasta Community Health Center program for Family Medicine up in Redding, which shares its first year training curriculum with the Redding Family Medicine program.  Basically I am looking at 3 years of training and I should get a well-rounded family medicine education, considering the community-based nature of the program and the resources available.  

What this means is that now my fiance and I must change our current living arrangement - while we had really hoped to stay in the Sacramento area, in many ways Redding may be a better fit for me.  It emphasizes clinical medicine more than one of the Sacramento programs, UC Davis definitely wasn't a real "fit" for me, and the other Sacramento program would have been a close tie with Redding.  However, the fact that the Shasta program wants me makes them all the more desirable.  Currently we are looking for two bedroom/two bath cat-friendly places in Redding, and tomorrow will investigate a one bedroom/one bath place in Davis.  Hopefully schedules will work out so we can spend maximum amount of time with each other.  The other two residents in my program so far (they are still interviewing for a second PGY-2 spot) are both married with children, as are most of the previous years' Redding residents, which hopefully will foster a supportive environment for married individuals.  

I am starting to get excited about checking out the Redding area - see what the local area has in store for us. Our current landlord let us out of our lease agreement, since we signed without knowing we would be moving.  Didn't even charge us for backing out of the lease, which I definitely appreciated.  Hopefully we can sign a lease tomorrow and get that element squared away.  Heading to Monterey for a bit then going to start an Allergy/Immunology rotation.