Day to Day: Doctor in Training

3rd and 4th Weeks of OBGYN

2012-01-26T23:32:00.000-08:00

Phew, it has been an intense couple weeks. Have barely had time to think. I'll start with my 3rd week (last with Preceptor #1). As far as the clinic days went, we had some interesting cases - an IUD expulsion, a retained tampon, trichomoniasis, and lots of pregnant women with whom I got to practice finding fetal heart sounds. The most recent thing I can remember is my last day there - Thursday which lasted 24 hours. We had clinic during the day, then that evening we had an overnight call shift from 6:30pm-6:30am. I think it was that night that at the start I joined the doctor for a laparoscopic ectopic pregnancy removal. She was somewhere between 12-20 weeks. Apparently it is rather rare for an ectopic to get as far as surgery because they usually catch it early enough to use medical interventions. Anyhow, that was interesting. Then I slept for a while and got woken up for the delivery at the end of the shift. My preceptor let me sit in the front seat for this one and I delivered the baby, handed it to the mother, clamped the cord for the dad to cut, and delivered the placenta. My preceptor sutured up the tears, of which there weren't very many, and we took care of that. There was some retained placenta (I think because he was trying to get it out before it was fully detached, I would have given it more time but that's my side of things), but he got it out with a loop scraper.

A few other things of note - I was following a patient who I had assisted on a delivery for. She was a caesarean section because of a placenta previa. As a result of excessive bleeding that was suspicious for retained placenta or at least failure to clot, we took her back to the OR but in the room the uterus had essentially stopped bleeding so we inserted a 'balloon' to help plug the bleeding via compression. We took that out the next day. There was another patient for who had a urethral sling, vaginal/cervical suspension and anterior and posterior repairs done on the pelvic floor. Her posterior repair (the easy part at the end) wouldn't stop bleeding and she developed a painful hematoma so an hour after taking her out we had to bring her back into the OR to redo the stitching. That was a bit of a pain.

Now onto my 4th week (1st week with Preceptor #2). My new preceptor is very nice, a bit more 'preceptor-like' than my previous ones - a lot more teaching, more presenting, more following patients, more is expected of me but I am rising to the challenge without much problem. It's more mentally stimulating and it's nice to have a little autonomy. The first day I saw one delivery that went well, and then there was another one that ended up being a shoulder dystocia. Shoulder dystocias are one of the most scary complications in obstetrics because a healthy baby manages to get it's head out of the vaginal canal, but one of the shoulders gets caught beneath the woman's pelvic bone. This causes compression of the cord, and compression of the baby - so the baby is getting less oxygenation from the mother, and is doubly unable to expand its lungs to breathe air from the outside. At this point the team starts a timer and begins various maneuvers to free up the shoulder - including hyperflexion of the mother's legs at the hip, suprapubic compression, reaching into the uterus and trying to free up the arm, and various clockwise/counterclockwise rotations. Last resort includes breaking the collarbone and/or humerus. Many complications can occur as a result, one of the most notable ones is a brachial plexus injury which results in nerve damage to the impinged shoulder. The baby comes out with an arm that doesn't rise, it is pinned to the baby's side and it's hand is facing behind it - Erb-Duchenne Palsy (or "Waiter's Tip" palsy). Anyhow...this baby they got out and it ended up having decreased arm movement, it looked like it had some nerve damage. Luckily, even when these signs are present at birth, 85-90% of the time the baby recovers in the first 2 months. By the second day after the delivery, the baby was starting to move its hand and shoulder.

Now onto today - a nice long 24 hour shift from 7am to 7pm. This L&D floor is a lot smaller than the previous department that I was in so there aren't too many active patients, and there's a bit more down time. However, as luck would have it, we had ANOTHER baby with shoulder dystocia today. The first baby ended up being 9 pounds 11 oz, and this one was 10 pounds 1 oz. Needless to say, it is well documented in the literature that large "macrosomic" babies have a higher incidence of shoulder dystocia. This one didn't have any real nerve damage though. The mom was pushing for a good 2.5 hours, it was a little challenging with language barriers but it worked out okay. From what I can tell, shoulder dystocias are not very common occurrences - some previous students haven't even seen a delivery period, so for me to see two dystocias is pretty crazy. I'm glad the outcomes have been relatively good.

We also had an interesting ED consult for gynecology - a woman with a 14cm possible tubo-ovarian abscess. We have started her on empiric antibiotic therapy while we wait for GC/Chlamydia results. There is some concern that it may be a tumor, or have some tumor involvement because she has had significant unintentional weight loss over the past 6 months. No way to know at the moment - just gotta treat. I'm gonna nap now, I'll be woken up if we have any new admits - on the plus side, I get the day off tomorrow. More studying, wooh!

Call Night and Week 2

2012-01-11T21:32:00.000-08:00

OB-GYN is coming along without much of a problem. I had my on-call night, and I thought I had been warming up to the whole baby thing, but I think the first vaginal delivery was kind of the ideal situation, along with ideal family responses, and environment. The call night started out with figuring out logistics essentially - talked to the doctor for the evening, and it was my preceptor and this other female doctor on call that evening. They divide the night into shifts, and so my preceptor slept from 9pm-2am, and the other doctor got to sleep from 2am-7am. Like all medical students, I wanted to show my enthusiasm, so I decided to spend as much time with the other doctor before caving into sleep. We had a couple interesting cases.

First case - fetal demise in an orthodox Jewish woman, 3rd pregnancy (has two living children). A couple things are wrong with this case. First, she was inconsistent with her prenatal care and was taking a lay midwife's advice over going to prenatal checks with her physician. The doctors that I work with at the hospital have made a distinction between the midwife nurses at their hospitals and the lay midwives who are not affiliated - that in the hospital, their threshold for thinking a baby is in trouble (and thus, needing to interfere with the 'natural' progression of a gestation and vaginal birth) is a lot lower. As a result, the hospital midwives are more willing to consult a doctor about a baby's status, or suggest a C-section. Anyway, the woman stopped feeling any fetal movement around 23 weeks and the lay midwife said that was "normal". The woman finally comes into the hospital after a WEEK of her baby not moving and there are no fetal heart tones of course, so it's dead. The second problem is that a lack of prenatal screens/ultrasounds didn't catch what is most likely an anencephaly (or lack of a head) on the baby. It could have been caught a couple weeks earlier, but no. People like to talk up natural traditional methods of health care, but there's a reason we have these tests. The third problem with this case is the orthodox religion - mostly it just makes patient care more difficult, but they need to consult another rabbi (even though her husband is a rabbi) to determine if they can test the placenta (dead baby is definitely off-limits) for chromosomal abnormalities. Often when a woman has a fetal death, it is reassuring and relieves guilt to know that the baby had a chromosomal abnormality or other problems inherent in the baby that would have made it nonviable no matter what.

Next case of the night... this really pretty Asian girl, possibly Filipina, late twenties, on her third child. Her husband was with her, kinda ugly, but I gave him the benefit that maybe he's just a really sweet supportive guy to win a gal like her. She decided to go through the vaginal delivery without any epidural anesthesia, and she barely made a peep - she did a great job, trembled a lot, but delivered the baby pretty quickly. Right after this, the husband essentially ditches his shaking wife and stands with his back to her filming the baby in the warmer with his phone. Once or twice the wife seemed to try to get his attention but he either glanced briefly or didn't respond. This went on for at least 10 minutes, the whole time I was in the room anyway. There also wasn't anyone else in the room, no other family. I never saw him go over and ask her how she was feeling, or tell her she did a great job - made my blood boil.

Next case before I went to bed - 21year old girl, second pregnancy, husband was this short kinda meek white guy - she delivered like a pro too - she did have an epidural, but she basically had no problems. The husband on the other hand just about passed out when he saw the baby crowning - he wasn't intending to look, he was walking around where we were to the other side of her and his face just went white and he just about fell to the ground right there. It was kinda funny, but at least all the family were supportive, smiling, and the husband stayed next to his wife this time.

After that I went to sleep and my preceptor called me when he had a new case - we did a few checks to see if any girls' water was breaking, interesting stuff. Around 8am I was done and in the car.

That was it for that week - yesterday we started in the clinic and I got to do some Pap smears and some prenatal checks where I measured the uterus size (to see if it was consistent with the gestational age) and checked fetal orientation and heart rate. The first one or two were a little challenging to find the heart beat for me, but I think I've started figuring out where the baby's body is oriented, so I was spot on the last 3 heart rate checks. We saw a woman with an expelled IUD - usually that doesn't happen to women who have had pregnancies, but apparently she was told she has a short cervix.

Today had two surgeries - one was a mid-urethral sling insertion, which is to help with incontinence. The woman was awesome - she was a feisty, energetic, humourous elderly woman. It's always reassuring to see older people with such vitality! So that surgery took 35 minutes, no problem. The next one was significantly longer, a laparoscopic vaginal hysterectomy, on a woman with an enlarged uterus and multiple fibroids - had to cut it up a lot and bring it out piece by piece. The doctor my preceptor was assisting actually thanked me at the end for my help because the extra pair of hands made it go a lot better than they were expecting. Yay!

Tomorrow is a morning/afternoon of surgeries, and then another evening of call duty - I think I will try to sleep when my preceptor does this time, since I will not have had all day to relax.

1st Week in OB/GYN

2012-01-08T19:01:00.000-08:00

Well, almost done with my first week in OB/GYN. The first day we were on gynecological duty, so we were seeing patients in the hospital for ovarian cysts, pyelonephritis, etc. However, we did assist on two C-sections and I got to observe a vaginal delivery. It feels very odd to see a family react to a "birth" in scrubs while surgery is still technically taking place (suturing everything up, still have half the environment sterile). The vaginal delivery setting makes a lot more sense - the delivery I saw only took about 40 minutes too so that was a pretty quick delivery. Watching the men is the funniest part because they look terrified and helpless at the same time - after all, it's not like they can relate in any way and they can't really participate in the actual process - she's doing it all herself. Of the two delivery methods, I'd definitely rather do the vaginal one personally (with epidural of course) - it just looks a lot more impressive.

The next time I was in the hospital we were rounding on patients and doing a lot of gynecological surgeries so several hysterectomies and salpingo-oophorectomies (tube/ovary removal). Not the prettiest of surgeries...especially when they do a hysterectomy through the vagina. Before heading into this rotation, I had no idea that OB/GYN doctors do so much surgery. Anyway, tonight we are on-call from 7:30pm to 7:30am, so I best be getting off to that - should be interesting. I like night time, and I'm packing an energy drink - I hear there will be many deliveries. I will post about it next time I have a spare moment!

In other news though, I got my loan disbursement, so money is not a problem for a little while. I emailed my school contact about year 4 rotations and I am still studying for the boards - Feb 4.

Second Week at the AIDS Clinic

2011-12-15T22:51:00.000-08:00

Second week is almost over - it's been interesting. This week he started his inpatient rounds at the hospital, so we've been going to the hospital in the mornings and rounding on whichever of his patients happen to be hospitalized or cases that require his consultation. Had a case of mesenteric venous thrombosis, which apparently is pretty uncommon so they have been doing a full coagulation disorder work up - protein C, protein S, antithrombin III, antiphospholipid antibodies, the works. More and more data have been coming out suggesting that HIV infection in itself produces a hypercoagulable state, and thus people are more likely to suffer a thrombosis or a stroke simply because they are HIV positive. It is not precisely known why, but they are looking into it.

There have been a few altered mental status patients as well, and one who has a recurrence of toxoplasmosis in addition to esophageal candidiasis and other things. Been seeing lots of patients with lipodystrophy, or abnormal lipid deposition due to the HIV medications. A lot of the medications cause fat deposition on the abdomen and the neck, and sucks fat away from the arms, legs, buttocks, and cheeks, so they can end up with a very odd body habitus. A lot of them come in for problems unrelated to the HIV, such as poorly controlled diabetes, or joint pain. The doctor I am shadowing spends 45 minutes or more with most of his patients because he goes through a list of 20 issues, some of them pretty minor. He is definitely very comprehensive - takes his time, makes sure to ask about every aspect of the patient's life. Being a primary care physician for so many patients as well as a specialist looks quite challenging - especially since they don't have medical records so he still does a lot of writing up of charts and has to go to the hospital to sign for things.

On Wednesday morning I got to attend HIV grand rounds at San Francisco General Hospital - the doctor I am shadowing as well as a UCSF HIV pathology researcher/lecturer and the Kaiser Permanente HIV management physician were on a panel to discuss some interesting cases and do some Q&A. It was good that I had had a lot of discussions with the doctor about HIV before the panel, because otherwise some things would have been harder to follow. At the end of this rotation I will definitely know all the combination therapies, as well as which drugs are NRTIs, NNRTIs, and PIs. It's gotten easier already.

Two things I have learned about on this rotation are HIV strain reversion to wild type, and protease inhibitor "boosting". Because patients go on and off drug regimens when they gain and lose insurance, they can develop resistant strains of HIV - however, some of these mutations that develop decrease the fitness of the virus (similar to sickle cell increasing resistance to malaria but decreasing overall fitness/survival in humans). Anyhow, while there are drugs exerting selection pressure, the mutants can survive and overpopulate the wild type, but when the drugs are discontinued the mutants die off and the wild type becomes the dominant strain. Sometimes the mutant type is no longer replicating so genotype tests will not show any resistance patterns. However, because HIV is a drug that integrates and hides in host cell DNA, those resistant mutants are usually still hiding somewhere in a cell in the body and can emerge again if you re-start therapy with the drug that selected for them in the first place. This can make treatment a challenge. As far as protease boosting, we were taught a list of 'protease inhibitors.' One of the protease inhibitors is ritonavir, which I thought was like the other protease inhibitors, but turns out that it is not particularly effective at suppressing the virus, but acts to improve the effectiveness of the other protease inhibitors such as darunavir or fosamprenavir. So that was useful to know - I was wondering why I kept seeing 3 drug regimens that had four drugs listed (including ritonavir, which they don't count as one of the 3 drugs).

Anyhow, one more day tomorrow - just hospital rounds in the morning - and then a 3 day weekend!

First Week at the AIDS clinic

2011-12-07T16:02:00.000-08:00

This week I started shadowing an HIV physician at the AIDS Clinic in the city - the first day I tried driving and quickly discovered it would be a nightmare and is impossible to do for a decent price on a regular basis. I figured out the BART schedule and the next day I came in that way - I have about a 15-20 minute brisk walk to the hospital, so that gives me a little exercise - I may start packing a change of shoes though in my backpack, don't exactly want to be walking several blocks in semi-heels or boots that are more fashionable than functional.

As for the actual rotation - again pretty chill. Most days I don't need to get there until pretty late in the day - 10-ish. Some days even later - this Thursday I don't need to be there til 1:45pm. We also get off relatively early. And I get one day a week completely free, and Fridays he doesn't have patients in the afternoon. The patients are mostly homosexual men with HIV - they are surprisingly compliant with their regimens - I haven't yet heard him give a lecture about how they need to be better about taking their medicines.

Yesterday I got to accompany him to a nearby hospital pharmacy where we met with a drug rep and my preceptor spoke about a new single dose multi-drug pharmaceutical that was FDA approved recently. He says he looks at his main role as a health educator, and doesn't try to push one drug over others, that he doesn't speak for companies that wish him to be more heavy-handed in his talks. At any rate, I got to learn a lot about Complera, and it's predecessor Atripla.

Here's some of the medico-pharmacologic stuff that you may not be interested in but I will talk about nonetheless. One of the major challenges with HIV treatment is that there are a ton of drugs, a lot of them have weird side effects, and a lot of the drugs have to be taken at various times of the day, making for a complicated regimen for patients. Before Complera, there was only one single-dose multiple drug combination pill that could be used in patients with HIV. Single day dosing is pretty rare in a lot of medications, and combination pills can be extremely useful. The disadvantage with combination pills is that the dosages are fixed, so you cannot increase the level of drug A in combination ABC, you have to stick with the set dosages of A, B, and C.

Anyhow, a standard regimen for an HIV patient is two nucleoside reverse transcriptase inhibitor (NRTI) class drugs, plus either a non-nucleoside reverse transcriptase inhibitor (NNRTI) class drug or a protease inhibitor (PI) class drug. Atripla contained two NRTIs and one NNRTI (Efavirenz). Efavirenz has a fair amount of side effects. Anyhow, they came up with a new combination drug Complera, which is the same two NRTIs as in Atripla, but has Rilpivrine in place of Efavirenz - they are both NNRTIs. Physicians also often add a protease inhibitor (plus a booster drug to increase it's effectiveness). It was neat hearing about the differences between them, the restrictions. We also got a free lunch, though apparently there's a new policy that pharmaceutical reps cannot provide catering to their events - another attempt to prevent there from being any "buttering up" to encourage use of the drugs. I understand but if you are presenting during lunch time, it would be advantageous to provide a lunch...

We also had a patient who decided he wanted to stop all his antibiotics that were treating him for Mycobacterium avium complex (a different species from Mycobacterium tuberculosis, which causes tuberculosis, and all species of Mycobacteria are notoriously hard to treat). His reasoning: He has been getting magnetic therapy. I immediately thought of the Penn and Teller episode about magnetic and other kind of hand-waving snake oil type new age medical treatments that masquerade as medical treatments but really just are, like the title of their show, bullshit. I don't particularly object to gullible or desperate people trying alternative treatments, but I do object when these unproven, possibly dangerous, treatments are used in place of evidence-based medicine that WILL work! Hopefully that guy won't have a recurrence of his infection, which may by this time be resistant to the antibiotics he was being treated with before...

Last Day of Actual Surgery and Didactics Presentation

2011-11-29T17:58:00.000-08:00

So today was my last day doing actual surgeries - tomorrow I have my last day of clinic with the orthopedic surgeon. We did two arthroscopic surgery repairs, one of them was a rotator cuff repair which I hadn't seen before. Another was an arthroscopic knee meniscal repair, and the other two were hand surgeries: carpal tunnel release surgery and a ganglion cyst removal. I still get along great with the surgeon and his PA, so I'm not worried about my grade for this rotation. He isn't very book-focused and they always joke when they see me studying so much so I assume they think I am intelligent enough.

Throughout most of today I was reading and rereading my presentation for today. As part of our third year clinical rotations, we have to attend didactic lectures on Tuesday, only an hour usually. Every other Tuesday, one or two of us present, and we each have to do a total of two presentations by ourselves - one on a topic that we can elaborate on, and another on a selected clinical case. My turn was today, and my topic was Psychiatry, so I chose Major Depressive Disorder because it is applicable to everyone. I was worried about a lot of things - whether I would run overtime, whether I would bore everyone by talking about antidepressant medications, whether I was saying too much or too little, whether people would be unresponsive or not know how to answer my quiz questions, and whether people are bored to death with depression, because I remember we had a lot of lectures about that at Touro.

Anyhow, I gave my presentation - I got a slight boost of confidence because I went over it orally beforehand and managed to get it down to 19 minutes and 30 seconds, so I wasn't as worried about going overtime. So I gave my presentation, people seemed to pay attention and like it. Basically everyone was answering my pharmacology quiz questions, so it was definitely sticking. When I got feedback, it was essentially a unanimous response that it was the best presentation all year, was really informative, I sounded confident and knowledgeable, had all the information that everyone had been craving, was varied, kept attention, etc. The physician who attends all the didactic sessions and grades our presentations agreed that it was the best all year and was even at the next caliber level for what he expects from us - that it is the kind of presentation one could expect at the professional level at a real conference.

Needless to say, this was awesome. Honestly, I feel like I'm a decent presenter. I try to convey my enthusiasm for a topic and hopefully drag a few unwilling audience members with me, but it worked out great. I used PowerPoint animations, humor, color coding, quotes... this was exactly the boost I needed to help me keep going on through studying boards and rotations. I think I'm going to be happy and charged up the rest of the night! Man.

Week 2, and Week 3 of Orthopedic Surgery

2011-11-21T23:37:00.000-08:00

Orthopedic surgery is continuing to do well. Since those two hip replacement revision surgeries, which apparently are only done once a year or so, I have assisted on several arthroscopic procedures and today we had 9 hours of surgery - no waiting around - two total knee replacements and two total hip replacements. Apparently I am getting a lot of good experiences, since some of these procedures are not done all that often during a single 4 week rotation period. I definitely feel privileged to be able to handle shards of bone and help drill into patients' dislocated hips.

One of the patients today had had a hip fracture a long time ago and was immobile at his hip joint because his bones had not set properly and had accessory bone growth within the joint socket and around it, essentially cementing his femur into his pelvis. It would be neat to see him in post-op after he realizes he can move his hip again on that side.

Something interesting I found was how the procedures are very step-by-step - everything is cut based on relative positioning and they have a ton of pre-made accessories that they attach to the bone to help guide their cuts. Also, when boring into the shaft of the femur to place the metal rod, they first make a small hole, then start with the smallest metal rod, and then build up incrementally to the size they wish and it is all very precise. It is quite neat.

My preceptor also seems to think I am coming along fine - he and the PA both think I pick up things fast and my preceptor was pleased with my more recent patient presentations and assessments. He is also very relaxed - the PA as well. They both have similar political/religious/cultural views (which I of course let them voice first before chiming in at all - I'd rather not take the risk of striking a bad chord) so that helps make for good conversation in the OR. I have also been allowed to help put respiratory equipment into patients with the anesthesiologists - just the throat dam (not sure the name), but it's still useful to get a little familiarity with the oropharynx.

Week 1 Orthopedic Surgery

2011-11-13T15:08:00.000-08:00

This rotation is pretty cool. The clinic days are generally easy, I shadow him, present the new consults, I get to look at X-rays, and he encourages me to take time to research various conditions on my computer (I get a little work station). I also get a lunch break for an hour and a half sometimes to study for the boards. I can even do practice questions at work. I also ran into my last preceptor (infectious disease) at the main hospital when we were there for surgeries, so I got to visit with him a bit and he updated me on some of the last patients we had seen together.

Surgery days: I get to study in between surgeries - I review through the USMLE First Aid Step 1 in between surgeries, and I am listening to Goljan lectures in the car.

As for the actual surgeries themselves, they are pretty interesting. The laparoscopic procedures remind me of kelp forests because the golden glistening tendrils of intra-articular fat and meniscal tears have this fluffy look to them and they are waving back and forth in the water due to the irrigation. On Friday I got to assist on two total hip revisions - very complicated procedures, the surgeon who is my preceptor was working with the UCSF doctor who was his attending in residency. Apparently the UCSF doctor only assists on surgeries if they are more challenging cases. In these cases, we were 'revising' the prosthesis, as in taking out the prostheses that were implanted in the hip and femur, shaving out the concrete and re-forming the implant sites, and then using a combination of cadaver bone, current bone, new prostheses, metal cables, screws, and cement to reattach them. It's amazing that it produces a functional hip at the end. We have to wear knee-high foot covers over our scrubs (normal surgeries you only need foot covers to the ankle), and also these heavy plastic face shields that you wear like a helmet that circulate air inside your helmet. There's a lot of blood spray, so that's what those are for. Unfortunately, the strap around my head was giving me a pretty bad headache in the second surgery, and this whole weekend I have had a mild-severe tension headache from my neck straining against the weight.

Another week starts tomorrow, hopefully it will be educational as well as productive in terms of board review.

Infectious Disease, Last Week

2011-11-02T22:37:00.000-07:00

Things are going well with Infectious Disease still. We've had a few interesting developments. One of our patients, the homeless young female patient who has had altered mental status and been in full restraints for the past week and has systemic Methicillin-Resistant Staphylococcus Aureus infection has actually started to come out of it. From the start she had altered mental status and we haven't been able to get an MRI to see how her brain is functioning, so we have had no way to know how her brain was doing. Through this we were speculating that she had bacterial vegetations forming throughout her body that could be throwing clots to her brain, and she even grew MRSA in her spinal fluid, so it could have been forming microabscesses in her brain as well. Not to mention the huge abscesses in her iliacus and piriformis muscles (anterior to the spine in the lower back, behind the abdominal viscera) that started the whole deal. I think none of us were really expecting her to ever come back to mental awareness, and we had not seen her in anything resembling a lucid state since we started treating her.

Today she woke up.

For her it almost seemed like nothing ever happened - just saying "I'm hungry," and "I feel tired," like she'd had a really long nap. Calm and tired, not thrashing about or pulling at her tubes or anything like that. No alarm yet, maybe has a little bit of a drugged look (understandably), and we still don't know the extent of the damage of this week of MRSA sepsis, but she's lucky she had my preceptor on the case for her infection and such a good team of ICU specialists. It's amazing - there are some patients who you really don't know if they will recover who somehow bounce back, and then there are others who look fine and are ready for discharge and they die that evening. Definitely drives home how unpredictable medicine can be.

That's not to say that I think we should do everything in our power to keep a human body running when it is beyond what a clinician would estimate is "the point of no return". Some absolutely septic patients, with multi-organ failure, and other comorbidities like diabetes and obesity are still getting specialty bone scans and send out labs even when their lactic acid level is at 14, they are on 5 different pressor medications and their blood pressure is still not in control, their stats are steadily dropping, and they're on a ventilator. There is a time and place for hospice and palliative care. Some points that indicated that perhaps our homeless young woman might recover were the following: she was never on a ventilator, her laboratory values were never all that particularly horrible, she was young, AND she wasn't obese, diabetic, or suffering any other comorbidities that we knew of (aside from drug abuse). It's amazing what diabetes and obesity will do to your survival rates in a hospital.

Infectious Disease, Week 3

2011-10-27T07:35:00.000-07:00

Things are still going well - this week we have another student hanging out with us. He's a fourth year from my school, and apparently one of the top of their class - his board scores are probably 98th percentile and he's getting interviews for residencies in places that are competitive even for MD students, and normally impossible for DO students. Needless to say it's a mixed bag - on the one hand now I have someone who has a ton of information who I can learn from and get tips for fourth year. On the other hand, he's a genius - which is kind of intimidating. On the plus side, he doesn't have an insufferable ego and is pleasant and nice, so that's good. He's also very tall, about as tall as my preceptor and they are both over 6 feet tall, so I feel pretty short compared to the two of them.

We have been talking a lot about rickettsial diseases lately. We had a patient come into clinic who was previously diagnosed with Lyme disease, Batonella, a couple other rickettsial diseases based on a tick bite 20 years ago and some doctor wanted her to go down to Monterey and pay for a 45 day infusion of antibiotics. We all agreed, after the patient left, that she's probably being scammed - it's really a shame, because diseases like Lyme disease CAN have a chronic and nonspecific presentation - occasional fever, joint pain and stiffness, abdominal and cardiac problems. When diseases have nonspecific presentations like that, the rate of false positives and hypochondriasis and money making by shady doctors goes through the roof.

As far as interesting patients - our necrotizing fasciitis patient from the prison had had a surgery to debride his infected arm, but it wasn't enough and the bug was extremely resistant to antibiotics. He developed a classic necrotizing fasciitis rash across his chest, and had tense bullae as well. He died later that day. We had another patient who was brought in for various reasons but one was vancomycin-resistant enterococcus endocarditis complicated by aspiration pneumonia (where you inhale stomach contents along with acid and possible bacteria and it damages your lungs or predisposes to infection). The endocarditis was challenging because it was resistant to vancomycin, as well as a bunch of other major antibiotics. We were treating with linezolid, but the course of treatment for endocarditis requires 6 weeks of antibiotics and we can't use linezolid that long or you start damaging the optic nerves. Also, Daptomycin was considered but it is inactivated by lung surfactant so there wouldn't be good coverage of the possible aspiration pneumonia. That patient also died later.

Today is another round of patients in the ICU, then rounding on inpatients, then we go to another hospital to check up on patients and talk to the pharmacy staff about antibiotics. Yesterday was a long day, hopefully today will go shorter.

Busy Day in ID

2011-10-21T15:57:00.000-07:00

Today started off pretty busy. I was at my morning rounds at 8:30 as is routine, and I wrote down the overnight reports of the patients. One of them caught my attention as being a patient who had been downstairs on the normal inpatient floors. We have been caring for two patients with Clostridium difficile infections and one of them wasn't looking to good and the other was looking better. Unfortunately the one who was looking better yesterday ended up in the ICU overnight and was basically circling the drain. It was really sad because he looked like he was getting better there, and he had been alert and talking and fine the previous day.

Right as my preceptor and I gowned up and went in to our decompensating patient's room, he told me to go to the room two doors over - that the guy had just coded and it would be a good observational experience. So I took off the gown and watched them go through all the Advanced Cardiac Life Saving procedures that I had trained in - they were doing a PEA (Paroxysmal Electrical Activity)/Asystole procedure, where the patient has flatlined and they are doing chest compressions, rescue breaths, and injections of Epinephrine every 2 minutes. It was surprisingly by the books, no one was panicked, but there were definitely a lot of people. There were imaging people in the hallway waiting to come in and do ultrasounds or x-rays of the heart/chest when anyone got tubes placed, and the defibrillator was ready. You don't shock a flatline though, so they were basically going through the cycles of compressions and injections.

By the time the code finished, I turned around to join my preceptor and we ran into the whole family of our C. diff patient, and we discussed his condition, and the family wanted to take him off life support. It was pretty clear her was fading fast - his blood pH was down to 6.85, and the normal range is 7.35-7.45. So, in a very short amount of time two ICU patients in the same area both essentially plummeted.

The rest of the day was spent checking out our other patients and we discussed AIDS regimens and Pneumocystis jiroveci pneumonia. This weekend I am going to check out the infectious disease society website and look up treatment protocols for a few things. We have a fourth year (from my school?) joining us on Monday, so that should be interesting - maybe he will have some helpful hints for rotations and preparing for residencies.

Week 2 Infectious Disease

2011-10-18T17:35:00.000-07:00

Well this week is off to a good start - we had a nice morning where he let me be to look up information on all our patients. I reported sufficient information to him, so that's always good - I hate to come up short. One of our patients who has a history of Chronic Lymphocytic Leukemia has upper lung lobe pneumonia of some kind and when I looked up his information I didn't see the positive quantiferon gold test for tuberculosis (he comes from an endemic region). When I went to check in on him he hadn't yet been transferred to isolation, so then when I learned about the test then 10 minutes later when we went in to see him together he was in isolation and we were wearing our face masks.

My preceptor told a funny-creepy story today. When we were discussing antibiotic therapies with the pharmacists, a patient came up who was 100 years old and in a persistent vegetative state, and the daughter is refusing to let up on aggressive treatment. It reminded my preceptor of a patient he saw some time ago who was brain dead, and had been for months, and the son refused to let them stop treatment, despite the man's mother being on a ventilator, and essentially brain dead. The difference between persistent vegetative state and brain dead is that the former is specifically nonfunctioning of the cerebral hemispheres (higher thinking), while the latter includes the brainstem (basic respiration, reflexes). So one day he was doing a status check on the brain dead patient and saw something on the patient's earlobe - it was a maggot. Apparently somehow a fly had gotten into the mouth and/or ear and laid eggs and there were maggots in the throat/mouth and ear. Kinda adds new meaning to someone being 'brain dead'.

I also had a mini-victory today - we were talking about one patient who had a few trichomonads on her urine analysis and he asked me what the treatment is for that, and as he was adding, "do you have your Sanford guide on you?" (which is our booklet for antimicrobial therapy) I just answered without skipping a beat the first line and second line treatments. I guess he didn't expect me to know off the top of my head, so I was pleased with myself, even if it was a super easy question for me.

California Association of Family Practitioners conference

2011-10-16T23:46:00.000-07:00

Well, this weekend I have been in LA with a friend and attending the CAFP conference. There has been a lot of discussion about how Family Physicians get a bad rap, and how they need to improve their image and reputation for the public, patients, other physicians, etc. They went over the things to do when applying to residencies, went over the timeline for things. The next most beneficial thing was talking to the residency program directors - the things they emphasized the most were...

Doing a sub-internship (Sub-I) at their facility
Choosing rotations that offer good inpatient training
Interviewing well and going with your gut

It was nice to know that they don't emphasize board scores very much, and that your rotations make a bigger impact. I asked around about what programs that are local that they think give good rotations, and so I will be getting in contact with those people and preparing my rotation applications - the good ones fill up fast. I don't want to be stuck with outpatient. Only problem is I may be stuck with really long commutes if we move to Davis in February (e.g. if I want to do Peds at Oakland Children's Hospital). Driving back up to Northern California in a bit - I have my family medicine lectures on hand!

Infectious Disease Elective, Week 1

2011-10-13T16:08:00.000-07:00

I just finished the first week of Infectious Disease - it is pretty neat. I like talking with someone essentially ONLY about bugs and drugs. So much more fun than getting pimped on things I have no clue about - and it is great for finding the holes in my bugs and drugs knowledge. Our day is as such - in the mornings we usually hang out in ICU for their morning rounds, and he chimes in for patients who are on antibiotics - a lot of his job is managing patients on multi-antibiotic regimens to make sure they are all medically necessary so as not to promote bug resistance. After that we round on his personal patients or check out consults. Most of them are pretty standard, but some of them are fevers of unknown origin, and most likely infectious but we can't find the cause so that's always fun.

He gave me a New England Journal of Medicine drug study publication to review and discuss with him. Also I am going to start writing SOAP notes next week, which should be fine - I'm not particularly nervous about that. I've done a lot of SOAPs, and while ID SOAPs will probably be a little different, it should be easy enough to adjust.

Tomorrow I am driving down to LA with my boyfriend to stay at a friend's place while I attend the California Academy of Family Practitioners conference for residencies and education - I should be able to learn more about what is going on in residencies and I can interact with residency directors and talk to them about their programs, their requirements, etc. I'm not sure how it will go, but hopefully I'll have some free time for socializing.

Also I am in the midst of signing up for my Step 2 exams and planning out my study regimen - I've decided to take the USMLE Step 1 sometime between December and February, and I'll be starting questions soon. I was doing Step 2 questions, but if I really want to maximize the chance that I will match somewhere in the Bay Area, then I really need to make myself as competitive as possible. We shall see how it goes but as long as my two digit score is over 80 I will be okay. It's a bit stressful, and money, but it will probably help me prepare for Step 2 and it will give me some focus now. I have two electives and a relatively chill surgery rotation for the rest of this calendar year, so this is a good time to study.

Starting Infectious Disease

2011-10-11T14:58:00.000-07:00

Well, I have started infectious disease - it mostly involves going around to patients with suspected infections and monitoring their antibiotic regimens, laboratory cultures, etc. The doctor is very nice, he is fresh out of his fellowship so he's closer to my age I think. We have another student joining us next week, and he's also lenient about me taking days off (specifically for a doctor's appointment and for driving down to LA for the California Academy of Family Practitioners conference). I spend a lot of time learning bugs and antibiotics, which should be good stuff to know.

In the meantime, I'm checking out residency programs that are nearby - I emailed two of them. One of them said they take both COMLEX and USMLE, no difference between them, they just want a good score, and they look for a two digit score of 80 or higher, and I'm over 80, so that's good. Not MUCH over 80 but hopefully there won't be too much competition - that tends to play a big role. I'm going to try emailing the students who matched there and see if they have any suggestions or are willing to share their scores. Family medicine isn't as popular as other residencies so I'll have a better shot.

Also need to sign up for the physical exam portion of my step 2 exam.

Family Medicine COMAT exam

2011-10-06T18:31:00.000-07:00

Well I took the COMAT exam today for Family Medicine - three of my classmates didn't know the date had been changed so they were lucky I contacted one of them the night before. Kinda funny. Anyhow, took the exam - it was very consistent with what I had been learning - some of the questions may not have been written the best, but I think the USMLE questions will be more challenging. I'll go through those on my question bank soon. The exam took me about an hour and a half, we are given two hours. Other people were staying longer but I think it is because they were Internal Medicine, and that exam is a bit harder than Family Medicine.

I found some good online lectures to listen to for Family Medicine topics, and primary care topics in general. Quite nice. I have a little bit of relaxing in store this weekend, since I am now between rotations. Tomorrow is my last day of Family Medicine, so I need to ask my preceptor about a recommendation. He will almost certainly say yes.

FM 2 Week 4

2011-10-05T11:25:00.000-07:00

This is my last week of Family Medicine, only a couple more days. Thursday is my Family Medicine COMAT exam, so hopefully I'm ready for it - I've been listening to prep lectures. Yesterday we went to a nursing home for my preceptor to catch up on his nursing home patients. It was interesting, though mostly depressing. A good number of the patients are unaware of things, and most have those childlike empty grins of Alzheimers, the nonverbal combativeness of Alzheimers, slow fogginess of normal dementia, shaking and mental confusion of Parkinson's, or if they're lucky a semi-lucid awareness of what is going on. One lady/man (I couldn't tell what gender the patient was, to be quite honest) kept following us down the corridors in his/her wheelchair, calling after the doctor who examined his/her friend asking why we didn't examine him/her. He/she kept grabbing my arm and trying to talk to me, but the person was partly deaf so it was hard to even talk to him/her. The doctor and the chief nurse tried ignoring the person, but he/she was very persistent. Eventually they talked the person down, but it was awkward for a little while there. We also saw one lady who has a big fall risk who feels trapped at the nursing home, because she cannot go out unaccompanied and has no family nearby. That was rather depressing also.

I start Infectious Disease at Fairfield next week, so that should be neat. I checked my rotation schedule again and my second elective is still not arranged, so I re-emailed our coordinator and I guess she just hadn't noticed that I had attached two different forms when I emailed her a month or so ago, and so she tried to blame the IT department on it. She better not cost me a rotation...it'll be a big headache to have to find another place.

FM2 Week 3

2011-09-27T17:55:00.000-07:00

I'm in my second to last week of Family Medicine - things have gotten even more routine feeling, especially since my current preceptor is a little more relaxed even than the first one. He's great, just very chill, so he doesn't really pressure me to make SOAP notes and such. I'm glad all the doctors have such good bedside manner, except that one that I mentioned before who had the difficulty communicating. There was also this other doctor I was with one day who sounded tired/bored the whole time, no real emotional changes in his voice, but that's beside the point.

This week there have been a few interesting cases - we saw a woman who had a gastric bypass who "felt like she had something stuck in her throat" and was feeling nauseous and unable to drink liquids. She ended up having to be sent to the ER to get her esophagus checked and sure enough she had a bolus of food stuck in her lower esophagus. I feel like most of the presentations I am seeing in the office are familiar to me now and I have a pretty good idea of what medications and treatment plans to use.

Today I was with the sports medicine doctor again and confirmed that he will write me a letter of recommendation - I just need to email him my stuff. It had been a while since I saw him (2 weeks), so I was glad our previous dynamic was still intact. This afternoon my current preceptor and I went to do a home visit for a patient we saw previously in the office who is now on hospice care for his metastatic melanoma. As far as terminal patients go, this one is rather fortunate - he is 86 years old, has two great-grandchildren, his wife of 66 years is still mobile and caring for him, and his daughter is helping as well, and he doesn't live in a nursing facility, he is at the home of he and his wife. My preceptor essentially went over the basics for hospice - making sure he's eating and drinking, that he doesn't have any pain, and managing side effects of pain medications (constipation, which can cause secondary pain). The wife talked to me a fair amount, and we did a check up with the patient, who has had a lot of family visits and support. It would be horrible to know you only have a month or two left at best, but if that were the case, his situation is probably one of the more fortunate. At the end they gave my preceptor two bottles of wine (it's Napa) and he ended up giving me one of them - a 2009 Rose Syrah. I imagine as a doctor in Napa he gets a lot of gifts of wine from patients - and for good reason, he's a very nice and thorough physician.

I have finished all the "modules" for my Family Medicine rotation, so now I need to finish the last two quizzes and start reading/preparing for my end of rotation exam. Sometime next week I will ask Dr. Cotter if he is willing to write me a letter of recommendation - I feel like it will be odd having all my recommendations from Kaiser Family Medicine doctors, but since I am considering family medicine and have gotten along great at Kaiser, this will be very helpful. The sports medicine doctor (the associate dean of our clinical education) may also be the one who writes my Dean's letter, which would be good since I actually know him - versus the main dean of clinical education is not very well known to me, aside from his bad advice regarding USMLE vs COMLEX for those on the border. Time to get some light exercise in and eat and study...

Zoster Presentation

2011-09-20T17:48:00.000-07:00

Well today was my presentation, and it went pretty well. My previous preceptor told me just beforehand that we had a really good turnout, that usually not many doctors don't come to the student lectures, and both my preceptors (last one and current one) were sitting to my right as I went through the slides. I got maybe 2-3 questions, 1-2 comments, and my preceptors chimed in when I was asked questions that I couldn't answer, so it was nice having backup. Also there were three fellow students in the audience, so that was nice. Afterwards I got a lot of compliments from them, my preceptors, and the doctor I was with that afternoon - that she learned a lot and that it looked like I had put a lot of time and research into it.

Didn't see too many interesting patients today, as it was a slightly later start and I had my presentation. In the latter half, the doctor I was with today went in with me to see a diabetes patient, and she was kind of stressed because she was getting behind and so she was lapsing into a lot of doctor speak that I had to explain to the patients. I felt kind of bad because it seemed like the doctor and the patients were both having a lot of trouble getting their points across. The doctor was talking too fast and repeating herself a lot, and not answering the questions as the patients intended (as in they would ask something and the doctor would think they were asking something else and answer that other thing). I think I am pretty good at speaking with patients, and my last couple preceptors were pretty good too, so it's interesting to see when a doctor has some trouble.

After that, ran off to didactics to see a student lecture on coronary artery disease. Also handed in the cover letter for my previous preceptor to write a recommendation.

Week 1 FM 2 Complete

2011-09-17T18:50:00.000-07:00

Next week has a fair amount in store - on Tuesday I have to do a lunch time presentation about Herpes Zoster to the whole family medicine department at Napa Kaiser. Yeah, a tad nerve wracking, but hopefully will go okay. They know I'm a student so they probably expect it to have some flaws. I mostly am nervous about their questions. Finished the PowerPoint, now working on a handout. Plan to practice the presentation at some point this weekend, and of course read over it a billion times.

Last night attended a high school football game with my preceptor - saw some muscle spasms and a kid with a possible nerve root impingement that was causing his upper arm muscles to be weak. The kid thought it was kinda funny, but of course, meant he couldn't play the rest of the game. Didn't see any particularly bad accidents, but it was a good time to relax with my preceptor and hang out. He really has a "dad" feel to him - he's 62 and pretty laid back. He has a daughter who is a fourth year in medical school, so I think he transfers a bit of that to students he has now. He also said that I've been doing very well and he sees me being a great family physician. Most of all, I'm relieved that all these doctors who have been teaching students for a while don't have that stressed-out mean attitude I remember from horror stories people tell and Scrubs. I should re-watch some of Scrubs...it's a lot more relevant now that I'm doing rotations.

Next week we will also be doing a couple home visits and maybe a nursing home visit. We saw this poor man and his family come in - the guy had several melanoma metastases to his brain, and essentially a terminal diagnosis. The discussion was about arranging hospice care. Rather depressing. There is also a class or two happening next week that I will attend.

Nearly Done - 1st Week FM2

2011-09-15T21:17:00.000-07:00

Well, almost done with the week - we've seen a lot of different things - it's hard to remember them all. I heard an abnormal heart rhythm, saw a lot of upper respiratory problems and rashes, and there have been a fair few things that my preceptor(s) haven't been 100% sure about. There was a meeting today about some things going on in the departments, such as needing to hire more people, and how to prepare for the CNA (California Nurses Association) sympathy strike on Thursday. They're providing food for staff so they don't have to cross picket lines, on the off-chance that they protest at our clinic (unlikely).

Went over my powerpoint a bit with my preceptor, and we decided to re-do the case a bit and use vignettes instead of a specific case because the original case was a bit complicated and might bog down my presentation. Tomorrow going to help out at a high school football game - hearing about the kinds of injuries young athletes suffer makes me never want to let my kids play sports like football or cheerleading. Falls where they break their necks, or collisions that cause brain bleeds and repeated concussions.... no thanks. It is doubtful I will have kids interested in football though, since they will not grow up with it and their parents certainly will not encourage it.

First Day of FM2

2011-09-12T18:51:00.000-07:00

Since I have been with this doctor before, there is not too much more to report. He's a friendly guy, very open to discussing cases and instructing. We saw a lot of patients today, and it seems like he takes a while with them so I have a feeling we will be running late a lot of the time. Of notable cases, there was a patient with cerebral palsy since he was an infant in for trigger point injections, and a 3 year old boy with recurrent episodes of croup, which had been diagnosed as asthma - it is likely some kind of structural problem so we referred him to a specialist.

In other news, I am still working on my herpes zoster presentation - I just need to hammer out the details, it is essentially organized, and provided that my preceptor approves, it will work out pretty well. There are also online cases to do, quizzes, and plenty of studying - I have to take my family medicine end-of-rotation exam in 4 weeks. Not looking forward to it.

Thursday I will be going to a regional conference in Vallejo (the first 2 hours of it) with my preceptor, there are some lectures on chronic pain management and migraines, so that should be interesting. On Friday I will be assisting him after work at a high school football game. Managing to fit in exercise in my schedule is still a challenge - at least I'm eating healthy. The weekends feel much shorter.

Last Day of FM1

2011-09-09T21:54:00.001-07:00

Day started off with a carpool with my preceptor to a psychiatry discussion about the depression questionnaire and how to approach patient care. It was interesting. On our way back we stopped at her house briefly and she gave me the tour - it's like I pictured: tons of collectible natural items. Jade, ancient Asian artifacts, paintings, a 20 foot anaconda skin along the wall up the stairs, shells, fossils like megalodon teeth, framed insects, tons of fruit trees and vegetables in the back yard, herbs throughout the backyard, a library study with the best books, and an Asian nook in the front yard.

After that, we went back to the clinic and saw patients in the afternoon. We talked about a letter of recommendation, she said sure, so I just gotta send her my CV. Now for a weekend finally. Starting with the next doctor on Monday.

Difficult Patients

2011-09-09T07:30:00.000-07:00

It is interesting seeing some doctor reactions to difficult patients. Yesterday I was with the sports medicine doctor in the morning, he treated me to Starbucks (I just got some tea) and got some cookies for the medical assistants and receptionists. We saw a few patients, but none were particularly vexing diagnoses as I recall. Kind of a slow morning. I'll probably ask him for a recommendation near the end of family medicine, but I'll be asking my main family medicine doctor for one sooner.

With the afternoon doctor, it started out with him relating a difficult patient he had had that day. A middle aged lady had emailed him asking for a refill on her Valium, which he doesn't like to prescribe and it had been a long time since he saw her, so he asked for her to come in to discuss prescriptions. He ended up prescribing it to her since she has been on it for a while and has no history of abuse. He also ordered a thyroid panel because she was obese, and he had told her this, but perhaps not in the clearest phrasing. When we put in a prescription or lab order, we have to also plug in a diagnosis to justify it, and in this case the thyroid was justified with a diagnosis of obesity, which is technically true. The woman called later that day furious that he had written 'obesity' as a diagnosis on her chart - as if this was news to her, and was insulting and she just went ballistic. The doctor of course tried to explain that it is medically true, and it isn't a judgement in any way, but merely an assessment based on BMI, and that Kaiser can offer weight loss classes and counseling. This did nothing to placate her and she just kept going on and shouting she expects someone to come out to her place to bring her healthy meals similar to a Jenny Craig program or something similar - and that she's so angry she might just leave Kaiser (which the doctor would not have a problem with - in private practice, physicians can much more easily drop difficult patients). Because he was so frustrated with it he put something about her being a difficult patient in her chart, but later he knew that'd be just starting a war and added an addendum to change it (sort of like writing an angry letter and then fishing it out of the mailbox).

We also saw a patient with "dizziness" following a fall from a roof, which ended up being benign paroxysmal positional vertigo. We did the dix-hallpike maneuver where you turn a patient's head to one side as they lie back on the table and when you turn their head in the direction of the affected ear, it produces uncontrolled eye movements. It was a pretty positive test with this patient, and so there are Epley maneuvers where you have them roll back on the opposite side to try to dislodge the piece of debris in their inner ear which is causing all the problem. It's a benign condition that usually self-resolves in 2-3 weeks, so that was a relief considering there was concern about concussion in this man initially.

Last Week with FM Preceptor 1

2011-09-06T20:50:00.000-07:00

After this week I will be reporting to a different Family Medicine doctor, but I will still be down the hall from the doctor I have been with these past four weeks. I am going to miss her, as she was a lot of fun and very pleasant to work with. She has a little arrangement of leafy plants in a basket, along with an ornamental bird nest containing eggs, and every time I looked at it I felt like it would be perfect to add a butterfly or two to the arrangement. So, I brought in my box of extra collected insects and I wasn't expecting her to be in today, but she was and I gave her a small brown hopper butterfly and a medium-sized orange butterfly. She was very thrilled, and said that she and her husband (one of the other doctors I am with sometimes) both like mounted insects (she likes butterflies, while he likes beetles) and that she couldn't wait to show her daughter the butterflies I gave her. I wasn't expecting her to be quite so overjoyed, not to mention she kind of has a hippie-streak so I wasn't sure if she would be upset at the idea of killing living creatures, but it worked out great. She and her husband remind me a lot of me and my boyfriend - both of us are interested in collecting natural things and travel - he collects Jade, she does underwater tropical photography, she also has a lot of plants and they like going hiking.

Today I saw a few interesting things - one patient came in with textbook biceps tendonitis, I can diagnose that pretty easily. One woman who came in actually had an ACL tear, so there was a significant amount of laxity when pushing her leg posteriorly. I got to freeze off some seborrheic/actinic keratoses with liquid nitrogen, and the doctor showed me how much those procedures are typically billed (about $500 dollars just to spray 7 or 8 skin tags essentially, taking all of 5 minutes!). When I get them I plan on just buying liquid nitrogen at the store and a box of Q-tips. Another case came in where two elderly men arrived and the doctor told me in advance that the men are a gay couple, but because of the prohibitions on marriage the only way for one of them to stay in the country was for the older man to legally adopt the other one as his son. How horrible is that? Pretty ridiculous...

Anyhow, still trying to work on my Herpes Zoster report - it's hard when you're so tired at the end of the day. Some good news though - my preceptor's husband (the one who is associate dean of clinical education) and I were talking and eventually got onto the topic of preceptors and students and he openly said it would be a pleasure to write me a letter of recommendation at the end of this time. He also looked over one of my SOAP notes and said it was 'excellent. excellent note,' so in all, pretty decent day, minus the 3 hours of sleep...

Preview of Next Preceptor

2011-09-03T11:38:00.000-07:00

On Friday the doctor I am normally with was off sick, I didn't have any notice, so the medical assistants were kind enough to help me arrange to shadow someone else that day. I ended up being with the doctor who will be my preceptor after next week. He's a really nice older guy, almost 60 years old, and he has a nice teaching approach. It was a nice day in that most of the stuff I saw that day I was able to figure out easily enough - one person had crackles in the lung, which I rarely hear these days; another had a bruise that had drained to his foot like I had had in my karate days; and there was one interesting case where a woman came in with large half-golf ball sized swelling in her throat, but they were not hot and soft, they were indurated and firm, which is rather unusual. Neither of us really knew what it could be, we considered abscesses or salivary gland obstruction, but she was sent to visit HEENT and get a CT scan.

I also had a chance to discuss my presentation with him, and he helped me narrow it down and focus it a bit more. Overall the pace of the day was pretty nice, and I had a lot of time to talk to patients.

Elective Rotations and Sports Medicine

2011-09-01T20:17:00.000-07:00

After a lot of phone tag with various physicians and emails going unanswered for a week or so, I finally got in contact with two infectious disease specialists - one works at NorthBay Medical Center in Fairfield, and the other works in Oakland. I got them both on board to do one of my elective rotations each, so I'll be in Fairfield in October, and in Oakland in December. Another little perk is that the Oakland physician is taking the last week of December off, so I'll have something like a winter break. It should also be a good variety, since one of the rotations is at an HIV/AIDS clinic and the other is more hospital based.

As far as Family Medicine, I'm working on a case presentation that I'll be doing on September 20th - it's going to be about 45 minutes long, in front of all the doctors in the family medicine department. Oie. I found an interesting case we saw of a woman with a lot of problems coming in for new onset myalgias (neck, hip, arm) and the idea that my preceptor went with was early Herpes Zoster, so she prescribed some prednisone and did some viral assays. About a week later though, the patient went to the ER for Bell's Palsy, which in the context of Herpes Zoster would be Ramsay Hunt Syndrome type 2. She still hasn't had a skin eruption yet, but we shall see if we get more information back about her in the next few days. The overall theme of my presentation will probably be acute myalgias, the workup, likely candidates in a primary care setting, and of course the actual patient case. The hard part will be organization and fitting it into a 45 minute time slot, since acute myalgias is a huge topic.

Also I think I've figured out what kind of preceptor-student relationship I had had in mind for rotations. My first preceptor was nice, but not very approachable, hard to read, barely spoke about anything, and wasn't very open to teaching with me asking questions - he was more into the old fashioned pimping style of him asking everything until I don't know. So, that was the example of the "hard to read" preceptor. Then my current female preceptor is nice, kinda touchy-feely, a little holistic, so that's a nice contrast. The sports medicine doctor ( a guy ) is almost too friendly, with a lot of topics of conversation that go outside of the office. The other male doctor I am with sometimes seems more like I had envisioned it - nice, tolerates some question asking, talkative but mostly about patients or conditions or clinic-related topics without it feeling too "strictly business".

As for today, I saw a good variety of things - saw a woman with breastfeeding-associated DeQuervain's Tenosynovitis, with the characteristic positive Finkelstein's test. I also saw two ends of the spectrum of rotator cuff injuries - honestly, it seems like half of the patients (at least) who come into the sports medicine office have rotator cuff problems - makes me want to keep my rotator cuff muscles strong so I don't end up having problems with that. I feel bad for the older people with those problems. The one end of the spectrum was someone who kept trying to exercise even while doing physical therapy and ended up coming in with an entirely inflamed shoulder, with subacromial bursitis, biceps tendonitis, and rotator cuff weakness/tenderness. On the other end, there was a woman with focal pain on her lateral posterior shoulder, and an X-ray showing that her humeral head was about a centimeter higher up than it should be in her glenohumeral joint. When I did the exam, I got kind of excited about finding a significantly positive sulcus sign - which is elicited when you exert downward traction on a person's humerus by pulling their elbow gently to the floor. On the uninjured side I didn't get much but on the other side her shoulder went down a ton, had a visible dimple on the shoulder, and a lot of cracking (crepitus) - it almost sounded like I was dislodging it from a stuck position. That was the first time I had tried that test since our sports medicine practice. The patient was really surprised, and I think it made it more likely that she would do her physical therapy, since there was a significant, noticeable difference in her joint.

Slow Day

2011-08-30T18:42:00.000-07:00

Today was rather slow by comparison - only saw two patients. In the morning there were lots of quickies here for some injections (either Supartz or corticosteroids) and one or two who didn't want a student. Spent a lot of time sitting around reading JAMA articles. I came across a few interesting tidbits.

1. Onchocerca and Dranunculus, both parasitic roundworms, are in the process of being essentially eliminated from the human population by the World Health Programme. Onchocerca causes river blindness in South America, and Dranunculus is also known as the Guinea Fire Worm, and if you don't remove it slowly from a person's arteries then it will die and cause a reaction that will kill the person. You hear about viruses like polio or smallpox being eliminated, or maybe malaria, but rarely about parasitic worms.

2. Bladder cancer is higher in men than in women - I hadn't really thought about this before now. Bladder cancer is strongly linked to cigarette smoking, particularly to a chemical in cigarette smoke: naphthylamine, which is also found in certain textile dyes. However, it was previously thought one of the reasons men were more susceptible was because men were more likely to be smokers, have unhealthy lifestyles, and work in environments that expose them to carcinogens. Now that women are working in a lot of the same fields as men, the incidence has not increased an equivalent amount. A study in 2007 showed that mice without the testosterone/androgen receptors who were exposed to chemicals linked to bladder cancer did not get any bladder cancer, compared to mice with the receptors who nearly all got bladder cancer (~90%). It would seem that the same mechanism behind prostate cancer may be involved in development of bladder cancer in men.

3. JAMA includes a previous JAMA article from 100 years ago to the day at the end of each issue. One of the old articles about digitalis/foxglove and its use as a medication for arrhythmias and other heart problems had a very interesting line in it. After going at length about the benefits of high doses of digitalis, the author writes: "For that reason, a daily large dose of digitalis is advocated indefinitely to keep the weary heart a-going on its rapid journey to an eternal standstill." That article was written in 1911, and the last part of that line has a very poetic, almost morbid sound to it. Rather unexpected when I was reading the article.

At the end of the day I had to go to didactics, where a guy who reminded me a lot of Jim Carrey was telling us about Clopidogrel, and how it compares to Aspirin - his main argument was that Clopidogrel (Plavix) is treated like a substitute or necessary adjunct therapy for Aspirin, but in reality there is little evidence it is more efficacious than Aspirin, or that dual therapy would benefit anyone besides those with cardiac vessel stents or in an acute cardiac event. It was interesting, he was going on a bit about drug reps and such - since I studied a lot of that in undergrad for my medical history classes, it wasn't anything that new to me. Anyhow, time to get some reading done and try to recharge for tomorrow.

3rd Week of FM

2011-08-29T22:16:00.000-07:00

It's starting to feel more routine each day - the nice thing is the patients are always different. I don't know why people complain that family medicine is the same old thing - yeah, it's always talking to a patient about what's going on, but at least it's a different thing with each patient usually.

We had a deaf couple come in, and naturally they couldn't speak, so we had to communicate by hand writing back and forth. I've been trying OMM on some patients but usually they are so uncomfortable from whatever it is that is ailing them that I don't feel super comfortable treating them, since touching them or making them move puts them in a painful position. I got to help drain a MRSA (methicillin-resistant staphylococcus aureus) ulcer today on some guy. Perfect example of patients being horrible historians - when I saw the ulcer I specifically asked him "do you have any history of having cellulitis, or MRSA, or other skin infection?" "mm...nope." "Are you immunocompromised, like taking chemotherapy or have HIV?" "nope." So of course when I report back to the doctor he looks in the patient's chart and see's "Yeah, he's had two or three bouts of MRSA, each time was treated in a hospital for it." You would think a patient would remember that sort of thing.

In the meantime, the topic I chose for my presentation is acute myalgia, which is an incredibly broad topic, so it will be hard to narrow it down, and categorize things in a way that covers as much of it as possible. I'm still doing translating here and there, and working on SOAP notes in the office. This was a good weekend but I was up late last night and there was an accident on my way back from Napa so my usual 40 minute drive back turned into 2 hours. Blah.

Translations and Presentations

2011-08-24T22:34:00.000-07:00

Today felt rather long, but it was generally busy at least. Didn't see too many patients in the morning, but the afternoon was packed. One patient in the afternoon who came in had suffered a fall in a Target store and she and her husband/boyfriend were there - both were Spanish speaking. Since the doctor I was with today spoke a modest amount of Spanish I spent a lot of time translating, which was interesting and my head and tongue hurt by the end of the session. I don't know if it's because it is tiring making your mouth say different accents back and forth, or if it's just because I don't use Spanish all that often but it was a good practice session. By the end, the patient and her companion were both very thankful I was there and were glad to have gotten so much attention at last - she had a multitude of problems, like herniated disks, possibly a broken rib, neuropathies.

Also, I discussed my Case Presentation project with my preceptor - during the family medicine rotations, we are to do a presentation on a patient/topic and present it to all the doctors in the family medicine department - it has to be 45 minutes long, powerpoint presentation, with a handout or two. I attended our didactic lectures yesterday and that was a reminder that I have two-20 minute presentations through Touro that I need to do for my fellow students, and get feedback. I'm of course more nervous about the 45 minute one where lots of doctors will be asking me questions and critiquing me, versus the positive feedback/nice constructive criticism of an audience that is mostly people from my class. And unfortunately the 45 minute presentation is the first one I have to do, so I don't even get to warm up with the 20 minute ones. Buuuut - that's not until the third week of September, so I have some time. I am going to come up with the powerpoint this weekend though and have my preceptor go over it.

Another Week of FM

2011-08-23T00:25:00.000-07:00

Today I was supposed to be with this one doctor, but ended up getting sent to a different one who kind of reminds me of George Washington Carver - skinny black guy with the same haircut and mustache. Anyhow, he was nice but he did not seem to interested in any of the patients he saw - maybe he is just jaded or tired or not happy to be back after a weekend but he looked kind of blase or worn out. We saw a couple elderly patients with mild dementia - kind of a harrowing feeling, hoping that your parents or yourself won't end up in that situation.

After that in the morning, I had my lunch but decided the two recipes I had experimented with for my week's cuisine were both rather unappealing. I'll modify them tomorrow after my half-day so that I can still make some use of the ingredients. The cucumber soup is mostly unsalvageable but the root veggies I think I can turn into something edible. In the afternoon today I was back with my main preceptor, and we saw a few interesting cases - a girl for acne, a woman with possible prodrome phase of herpes zoster, and a couple people with gastroenteritis (one Spanish-speaking). I'm keeping my fingers crossed that I don't get a stomach virus - I can't remember the last time I had a really bad gastrointestinal illness, and I'm hoping it won't be for a while yet. I've been taking probiotics daily so I should be covered as far as bacteria, but viruses? I don't know if probiotics help with that at all...

Tomorrow I am back with the sports medicine doctor who is associate dean of clinical education. I need to show him a SOAP note of an interesting patient we saw on Thursday, who had a dorsal expansion hood rupture on her second digit knuckle. It's only a half day so hopefully I'll be able to get home, make some food, and get some decent studying done. Waking up so early is killing me, hopefully I can get through tomorrow.

Also, there is a family medicine conference in LA that I may go to on October 15 and 16 - all the residency programs in California for family medicine should be there, and it would be an opportunity to visit a friend of mine and my boyfriend's, and my boyfriend's family. It would only be for a weekend and we would drive down there, but I think it would work out. Just have to sign up.

End of the First Week

2011-08-20T14:35:00.000-07:00

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.

More Family Medicine

2011-08-18T15:26:00.000-07:00

Family Medicine is still going pretty well - the patients all seem to like me, and I have gotten to see a good range of ages, from kids 3 years old to adults 91 years old. I have spent time with two general family medicine physicians and one sports medicine doctor (who also happens to be associate dean of clinical education at our school). I've been trying to do readings on the stuff I see in the clinic, and stay engaging with the physicians. I get along with all three of them really well, and I get the sense they do not mind having me around. We had a little snag up with the scheduling so the dean was not quite expecting to see me today, but it worked out fine. I talked to him a little more about some stuff, and near the end he said he was glad that I'm going to be with him two days a week instead of just one. I also asked him if my timing on patient interviews was okay and he said that he would have let me know if I was going too fast or too slow, so I'll take that as a good sign.

Yesterday was good as far as patient interactions - a middle aged man came in yesterday and we diagnosed him with an inguinal hernia, and I was able to palpate bilaterally and up the inguinal canal - first time on an actual patient and not an actor. Also one of the patients, a real talker who probably held me up a bit longer than I'd have liked, complimented me to the physician that day, saying that I was going to be a great doctor and was really good at talking to patients. The more positive things said, the better - I just have to keep doing well and not let anything negative creep up. I still feel pretty tired at the end of each day, and it's looking more and more like my drive is an hour each day - I have started listening to German audio lessons in the car. Today I got off earlier than usual because the doctor I was going to be with this afternoon was not around and most of the other doctors in the office were not there this afternoon. Time to catch up on my studies!

Starting Family Medicine

2011-08-16T23:01:00.000-07:00

First let me say...wow. Family Medicine is such a far cry from surgery. The preceptors are so much more talkative, nice, and helpful - the interactions feel so much more normal. We have been seeing a good variety of patients, including patients with asthma, bladder infections, osteoarthritis of the shoulder, palmar psoriasis, cirrhosis of the liver, and doing plenty of patient education also. I've been grilling most of them about how they like working for Kaiser, since I am very interested in working for Kaiser one day - and all three pretty much love it. Two of them are a married couple (though with different last names) and they used to have a private practice and she says they made more money in private practice, but it was much more stressful, and they could never take vacations, and had no life, compared to now. Also, watching them deal with the electronic medical record system looks very appealing - they can finish encounter notes so quickly. I told them I came from surgery and they chuckled, saying that I'll have the briefest notes of all of them after that, since surgeons are really brief.

The biggest difference is in the question-answer feel - when I ask questions, I feel like they acknowledge that I am a student and have no problem telling me things. When I tried that with the surgeon, he seemed more of the attitude of not wanting to teach me about stuff like that, that he would rather have me self-study and just quiz me when he felt like it. Maybe it's because Family Medicine doctors are more relaxed and used to doing patient education. It's a fairly stress-free rotation, so far. I finished my first weekly quiz, most of it was either easy to look up or easy to discuss. We have a quiz every week or two on blackboard, so we have to go through those. I also need to be working on some readings and doing practice questions I think, but it's tough to get to everything when I get home at 6pm and have been up since 6:30am or so.

Last Day of Surgery

2011-08-14T09:55:00.000-07:00

Friday was my last day doing general surgery - we started out that morning at 8:30am with a patient with swelling of the left leg of unknown etiology - they had already ruled out DVT, osteomyelitis, and had essentially ruled out infectious agent, since there was no gas visible on any of the X-rays, and there was no surface involvement. When we went in to get a muscle biopsy, his leg fat was swollen with fluid, just watery fluid - so there's a chance it was severe lymphedema or venous stasis due to CHF or another underlying problem.

Anyhow, I got to stitch that guy up and then ran off to find the doctor at his clinic, where we saw a few clinic patients, I helped dress some wounds, etc. At the end he met with me to discuss my review, which consisted of him mostly asking me questions about how I liked the rotation. He also asked me to grade myself, and I was a little on the humble side, so he gave me a little talk about not selling myself short and to focus more on selling myself and recognizing where I am doing well - especially for residency applications. But other than that, he said I have done very well and that if I continue to perform like this in my later rotations, I will be successful.

Second to Last Day of Surgery

2011-08-11T19:35:00.000-07:00

Today was fairly interesting. Our first patient took 3 hours. She was a morbidly obese wheel-chair ridden woman with diabetes and she had a major ulcer (about as big as my palm) on her lower buttock by her vagina and one of her labia had a lot of sores, from when she has self-catheterized herself. The surgical solution was to remove the middle portion of both labia (they have to match) and cut a flap, cauterize the big sore, and cover it with skin. Her labia were gigantic, each one was about as wide as my arm. This was, again, due to extreme obesity. After three hours everyone was pretty sick of the case.

The second one was a gallbladder surgery, open (not laparoscopic) because the gallbladder was actually a "porcelain" gallbladder, a term to mean that the gallbladder has calcified. There were also significant stones in it, and it was chalk white (hence the name). Normally it is rather radiopaque, but the radiologist make any major comments about it, so it was missed initially until the first attempt at a laparoscopic repair. Once it was out, it was rock hard - and the walls were pretty thick. Inside instead of the typical greenish-yellow bile, there was this light yellow fluid, probably mostly cholesterol.

The next two cases were lumpectomies for breast cancer, not much to say about that. Didn't really get to do any suturing today, but tomorrow there is one surgery - a leg incision and drainage, because it is a cellulitis case (most likely). Had to buy some thank you cards today, and should get some studying, but a friend is coming to stay with us for a week so I shall be very preoccupied with fun social stuff.

Long Day of Surgery

2011-08-09T19:11:00.000-07:00

Well, another surgery day is at an end. I was first-assist for a cholecystectomy and a thoracotomy plus decortication. The cholecystectomy was fine, went about as expected - and I sutured up two of the short incisions and they looked quite nice. The thoracotomy is where it starts getting interesting - it was on this 22 year old obese autistic individual, very obese. We had to go through 4 or 5 inches of fat to get to his ribcage where we had previously inserted a chest tube to drain pleural effusion. The guy had a really bad pneumonia infection and it had caused empyema, so we needed to go in, break a rib, spread his rib cage a bit, and detach as much of the pus-covered fibrinous exudate as we could - it was really remarkable how much there was. Imagine peeling really glued on labels off a glass beer bottle, except instead of glass it's lung tissue and the label is dense clotted blood, pus, exudate, and fibrin material. It took a total of 2 hours to do the surgery.

After that I observed a cholecystectomy, but this was kind of an odd case because the woman had a standalone piece of liver, about 2 inches by 1 inch by 0.5 inches, living by itself on her gallbladder. It was really weird, it had it's own blood supply and everything. At any rate, same procedure took place - removed the gallbladder along with that tiny chunk of free-living liver, and stitched the woman up. She took a half hour to come out of anesthesia and even then she was too weak to do much so they decided to intubate and let her sleep and recover overnight.

In other news, my car needed to be repaired, battery/alternator trouble and the cost is gonna be about $2,000 - really painful to think about. At least I have loan money for this sort of thing - unfortunately they still haven't disbursed the majority of my loan money because there is some problem with my stafford loans over at the main university headquarters on the east coast and they are waiting to hear back from them. If I don't hear anything tomorrow, I'll bug them again.

Also, I contacted an infectious disease specialist who works with AIDS patients and he told me to email him so we could set up the rotation - I haven't heard back yet, but hopefully tonight or tomorrow he will respond and I'll know if/when my infectious disease rotation will be. I'd really like to do that, we shall see.

Starting the Last Week

2011-08-08T17:08:00.001-07:00

Well, after a nice weekend with friends, boyfriend and family, time to get back to work. Today I helped drain a cyst, and dress a wound, as well as finishing up the suturing on a VAP placement. It worked out pretty well, the suturing looked good, and the doctor seemed to be in a decent mood. Got out at a decent time, but ended up having to take the car into the shop. I have a rental at the moment, which is kind of a hassle, but at least it's getting stuff fixed and I'm getting a detail, so it should be nice and pretty when it gets back.

Later this week there are a few other surgeries, nothing particularly radical, but it looks like a nice load, nothing too stressful. On Thursday a mutual friend is coming to stay with me and my boyfriend for a bit and there should be some nice social fun going on this coming weekend. Next week on Monday I start my Family Medicine rotation at Kaiser Permanente - here's hoping it works out all right.

Connecting with Patients

2011-08-02T17:17:00.000-07:00

Despite this being a surgery rotation, where you spend most of your time cutting into unconscious people, I'm getting to connect with quite a few patients in unexpected ways.

First off, yesterday during clinic hours I was interviewing a 34 year old Hispanic woman and getting information about her concerns about a benign lump in her breast. However, as we were talking about her allergies (raw onions) and I asked if anything else made her throat swell up like that, she said that the last couple weeks her throat has felt more swollen - like there was more fullness. She also felt like the back of her tongue was swelling more. Considering her race, age, gender, and that symptom, I thought I'd ask her a little bit about thyroid problems - turned out she was having cold intolerance lately, extreme fatigue, difficulty sleeping, palpitations/chest pain/anxiety, and her father and aunt on her father's side both have thyroid disorders. I asked her if she had talked to her primary care physician about this and she said no, that her PCP doesn't really talk to her about that much - that she's really rushed. I told her that I was thinking it could be a thyroid problem, that if I were her doctor I would want to check it out but that I would run it by the surgeon and see if he was willing to look into that. I mentioned it to the surgeon, as humbly as possible since I am terrified of sounding like a know-it-all medstudent who tries to diagnose a million things, and he immediately said "Sure, we can order a thyroid panel."

I don't know if it was the fact that I had actually made a physician-like decision in a patient's health, was suddenly afraid that I might be wrong or out of my mind, or just that the surgeon had actually taken my concerns seriously - but I was baffled for a moment. Of course, it could be that she is just tired from having two young children, maybe she is anxious from having a breast lump, maybe the chest pain is related to muscle pain in the breast, maybe the throat swelling is just an incidental finding, or maybe her cold intolerance is just in her head but it was exciting to actually have a tiny feeling of what it is like to be a physician.

In another situation, today after we finished what we thought was the last surgery for the day, it turned out that we were going to see an appendectomy patient. There was a 9 year old girl in the emergency department with acute appendicitis. Before I knew anything about the case, the surgeon told me to go to the ED to check out the patient and wait for him there. When I got there, I found an adorable teary eyed 9-year old Hispanic girl and her father, grandmother and uncle. Her father spoke pretty fluent English, but her grandmother and uncle both did not. Since they seemed to understand me when I spoke Spanish, I carried on a conversation with them, telling them a little bit about the surgery, that she would be put to sleep for it, that I would be there in the OR with her. The grandmother was keeping it together pretty well but when the little girl started to cry she started crying too, saying to me (in Spanish) "Since we cannot be there, can you please speak to her on the way to the room and in the room until she falls asleep so she isn't so afraid? Since you speak Spanish..." I almost started tearing up there and told her I would.

Since I was taking on the task of guiding this little girl to the OR, I took a moment there to talk to her a little, tried to get her mind off the impending operation by asking about brothers or sisters, about pets or anything. I remembered a story about Madeleine and how she actually had her appendix out and asked her if she knew the story and she said she did so we talked about that a little bit before the Anesthesiologist came. He was very nice as well and spoke very broken Spanish so that helped too.

When we got everything in the OR set up, we got the laparoscopic tools set up and the surgeon let me staple/cut the appendix out, as well as bag it in the collapse-able bag and pull it out through one of the tubes. He was getting a little antsy to get out of the OR near the end, probably since it was an unplanned surgery, so it was a little nerve-wracking but my fellow PA student reassured me that I did a great job and that it was really exciting to watch. Quite a fun filled past couple of days. We were going to discuss how I have been doing on this rotation, but he said we could do it tomorrow, so tomorrow morning I'm to remind him about that. No clue what he will say, but hopefully it'll be good. I'm glad my Spanish-speaking skills are coming in useful these days - now that I think of it, one of the other Spanish-speaking patients' daughter (middle aged) who was translating for me in the room on a clinic day complimented my Spanish skills in front of the surgeon. I wonder if he sent me to the room early today so that I could talk to the family with that in mind.

Either way, tomorrow is another clinic day, and hopefully constructive feedback from him about my performance, and maybe that woman got her thyroid function panel done for me to check on it. It'd be exciting if I successfully diagnosed someone with something that other doctors hadn't identified yet.

Colectomies Galore

2011-08-01T07:54:00.000-07:00

One of the days last week that I was shadowing surgery had two Colectomies in a row, in which a portion of large intestine needed to be removed and reconnected (anastamosed). It was interesting because I got to see two very different approaches to anastamosis.

The first case was a patient who had a very large volvulus, or twist, in the ascending colon. A volvulus can occur in the ascending or descending colon, because those portions are fixed at the hepatic and splenic flexures (respectively) and the lower portion is hanging freely, with the potential to get twisted about itself. The volvulus was pretty big, about a foot long and 1/3 of a foot in diameter. After it was clipped off on both sides and removed, there were two pieces of colon that needed to be anastamosed and those were connected the same way I mentioned in the previous entry.

The second case was a patient who had had an emergent colectomy and colostomy bag put in, without a reanastamosis, so in this case they were going back in to finish up the colectomy, and anastamose the pieces to the rectum. The difference in this case is there is not enough room by the rectum for a surgeon to work very easily with his hands and clips, so instead they did the majority of the procedure laparoscopically. Once they had prepared the colon end that they wished to connect to the rectum, they inserted a circular disk with a metal male port perpendicularly. This produced an end of intestine that had a circular disk within the very end, and through the center (where the lumen would be) the male prong was sticking out. They then took another circular disk, except with a female port, and pushed it up the rectum to the point that they wished to create the new lumen and pushed the prong through the wall of the intestine at that point. They laparoscopically connected the two ports, producing a metal connecting rod between the two disks. The metal connector then approximated the two disks, to the point that there was a seal between the two parts of the intestine. The disks then cauterized the area and the entire apparatus was removed, leaving in its place a new lumen created between the sigmoid and the rectum for bowel contents to bypass the area that had been removed. I had never heard of this type of procedure before, so I was kind of clueless as to what was going on for the first half hour of the procedure. Mental note: Find a page later to link to procedures so that it's easier to understand what I am describing...

Well, more surgery clinic appointments today - I should also be meeting the new PA student from Touro who will be sharing my preceptor for the rest of my rotation.

Loooong Day

2011-07-27T20:28:00.000-07:00

Well today was extremely long. Kinda surprised it didn't FEEL longer. Got to the clinic at 8:30am, expecting a short clinic day getting out around 12:30 or 1:00 - instead, the doctor was about 20 minutes late so we had a lot of catch up most of the day, and I didn't have the PA student with me so I had more patients to see than usual. I also did some injections and assisted with a skin nodule extraction - outpatient minor surgery at the clinic. Mostly stressful just because I wasn't sure how to do any of it, not that it was difficult. By the time the patients were gone it was probably 1:30, and I was trying to finish up my SOAP notes. In the meantime, the doctor was trying to get a bed in the OR for a patient with an ulceration in his intestines and was having trouble. Eventually it was scheduled for 3:00 PM, so we drove over to the other hospital around 2:15pm, I got dressed, checked the OR list of procedures to see how on time they were, and then rushed to the physician lounge to get something to eat or drink. Found an energy drink, elected to use the zero carb one, downed that while I waited for 3:00 to roll around, around 4:00 maybe the surgery started.

Today we cut into the first patient's abdomen, and pulled the intestines out of the abdomen and onto the patient's belly so we could look for any perforations that were causing the patient to lose fluid into her peritoneal space. This consisted of cutting away the connective tissue holding the intestines coiled and going through it at length to find stuff. It really looked like an evisceration. Got to see a bunch of new anatomy, and it was an interesting exploration - didn't find a perforation and the fluid was all clear, so it was probably from the pleural space. After that, the doctor had to do ANOTHER one, except this time the guy almost certainly had a perforation in his gut somewhere - he was in a lot of pain. We did the same thing as for the first patient, except we found the hole in the guy's sigmoid colon and the fluid in his abdomen was brownish. Yeah, pleasant. Anyhow, I got to see how you cut out a segment of colon and reconnect it. There are a lot of specialty clipping tools and ways of doing it that I hadn't thought of - it was very interesting. I mean, when you think about it, how do you get a piece of large intestine out and connect the tubes without spilling fecal matter all over the place? With lots of nifty tools and tricks, that's how.

Anyway, got through all that, by the time all this was over and the patient was back in his hospital gurney, it was 8:00pm. SO..... basically a 12 hour day. A few pluses: Saw some new procedures, assisted in new procedures, talked more with the surgeon, and people (including the surgeon) were addressing me by name for the first time. Guess they're starting to get more used to me.

As an aside, for anyone who has played RPGs, I started feeling like a total NPC today - following him around, if I lingered and he got away from me a bit I would jog to catch up, I'd be stuck in doorways or be hindering things (but honestly mostly helpful). When I got that thought in my head it was hard to not laugh. Another day of surgeries tomorrow, hopefully just the three that I know are scheduled. Time to take some ibuprofen for my aching feet - I didn't know we'd have surgery so I stayed in my dress shoes all day and my feet are KILLING me!

General Surgery Rotation - Week 2

2011-07-26T17:19:00.001-07:00

So far the week is going well. Monday we started out with some clinic cases, and then we headed to do a thoracic surgery - removal of the lower left lobe of the guy's lung. It was pretty interesting - had to break open the ribs, and then slowly remove the lung - it was pretty involved. Amazing that lungs, which seem so delicate when you read about them and such, can handle a person shoving them around with their hand. I got to feel the diaphragm, descending aorta, lung tissue, saw the heart beating in the guy's chest - feel pretty privileged to be able to partake in things of that sort. Few people can say they've had their hands inside a living person's rib cage.

Today went well also, had a few surgeries, this was the last day the PA student was there, so for the next few days it'll just be me and the surgeon until the next PA student arrives. I assisted in a neck lumpectomy and a breast lumpectomy - it's amazing how vascularized fat is. With the neck fat there were sprays coming out here and there - with the breast tissue I've come to expect that. Had to find the lymph node, and I did an essentially complete final suture - the surgeon actually said it looked good, so that felt really good - all I really want is to not look like a complete idiot. Anyhow, tomorrow is more clinic patients - maybe I will be done by 1:00 or 1:30pm - that would be nice, since today I was done at 4:30, and I want to get more of my studying done.

In other news, my boyfriend and I have our 5 year anniversary coming up - we'll be dining somewhere in San Francisco - should be nice.

Day 3 and 4 General Surgery

2011-07-21T19:18:00.000-07:00

Yesterday I went in and took histories most of the morning, tried taking a thorough history, then tried to make them more focused. My notes are looking more proper, I think it helps that we didn't have any minor procedures that day, which are not quite surgery, not quite a normal visit, so those are a little challenging to document. Starting to talk more to the surgeon, which is good. He's warming up to me, I suppose. His 1:00pm surgery ended up getting pushed to 3:30pm, so me, the surgeon and the other student mostly sat in the physician lounge chatting for a while. It was nice, getting a bit more comfortable. Then we went to the surgery, it was an exploratory laparoscopy, which was interesting to observe. Ended up extracting an ovary and ovarian cyst (benign).

Today he had a hernia repair in the morning, during which I assisted. I got a few pimping-type questions, which was fun, and the anesthesiologist joined in as well and he was impressed that I seemed to know stuff - "It's refreshing having bright students come through." I don't know if it helps that I'm a girl, but at any rate, it was nice to get a little positive feedback during the experience. I also lucked out that the questions I got were rather infectious-disease related, which of course is one of my main interests. I still got to make the first incision on this, and also tied off the last suture for the mesh.

The next surgery I observed, it was a fistulotomy repair. The scrub nurse looked like Dr. Chase from House (teehee). After that we went to a different hospital and I assisted with a VAP insertion (Venous Access Port), in which we insert a tube into a vein and there is a subdermal port attached to it which is used to make it easier to administer chemotherapy and such. So, my part in it was identifying the trajectory of vein via syringe needle, then inserting a guide wire about 2-feet through the jugular vein, guiding a plastic tube around the guide wire, and then removing stuff after we got the port connected. I also got to do the subcutaneous suturing. Final surgery was observing another hernia repair and that's the end of the day. We were expecting to do a thoracotomy, but that guy got postponed to another day. I also got to watch a chest tube insertion on a guy with pneumothorax and lung cancer. Interesting, for sure.

Oddly enough, I find that doing the surgeries themselves is a lot more interesting than meeting with patients and writing SOAP notes after the encounters. I guess because it feels like a lot of busy work and they don't feel like regular patients since they are all referrals for surgery it feels like a pointless exercise. Also, in surgery you aren't dealing with people, you're just dealing with their flesh - it's like a mini-crafts project almost. You have cutting, pasting (I guess cautery can count as pasting - or cooking, haha), sewing, organizing, sculpting... I duno. It's interesting. I still highly doubt I would go into surgery, considering the years of training, the unpredictable hours, and constant standing and high risk of lawsuits, but this rotation is turning out to be a lot better than I was expecting.

Day 2 General Surgery

2011-07-19T17:17:00.000-07:00

Today I had my first actual scrub-in surgeries. The first surgery was an umbilical hernia repair - I scrubbed in a bit early but got some of the awkward "what do I do" stuff out of the way at least. When you are 'scrubbed in' the scrub nurse fits you with your sterile drape and gloves that you will wear for the rest of the surgery - after that you cannot touch anything that isn't within the sterile zone. So they were still prepping a bit and I had to stand by - beginner's mistake, and at least the surgeon wasn't there yet to notice.

Me and the other student are alternating in assisting, so I was first in assisting, and got to make the first incision. The surgeon was a bit more relaxed and talkative today, maybe because he is in his element and not having to worry about patients (interacting with the person, I mean, not the body). After that I mostly held clamps, dabbed gauze, and tied off a few stitches. We inserted a mesh to prevent the herniation from protruding. The next surgery was in a different hospital so we sped over there in our respective cars and this time the other student scrubbed in, so I observed. It was rather short, another hernia, so that wasn't too bad.

During the lunch hour, there was a cancer session where radiologists, surgeons, and others meet to discuss particular cancer patients and approaches to diagnosis and treatment. We got free lunch, so that was nice - the doctor's lounge also has regularly stocked varieties of drinks, including energy drinks, so that's pretty awesome - on surgery days I get free energy drinks ^_^

After that we observed half of a double mastectomy and I assisted with the second half - this time both the surgeon I am following and another surgeon were working, and I was mostly assisting the latter. They are both nice, were chatting with each other about their residency experiences in various places, etc. At the first hospital there were eye shields, and I was really wishing I had an eye shield for that mastectomy, since there were a lot of small blood vessels getting cut here and there, and a few times it barely missed my face. Again, mostly holding, snipping, or dabbing. Got out about 4:30 PM so all in all not a particularly long or troublesome day. Tomorrow I report to the clinic around 8:20 AM and we have a surgery in the afternoon around 1:00pm so we shall see how that goes, whatever it is.

Day 1 General Surgery

2011-07-18T16:07:00.001-07:00

Back from vacation, time to hit the ground running -

So, started my surgery rotation today around 9:00am - I knew the doctor would not be there until around 10:30am due to a previous surgery so I reviewed the patients who were coming in that day, and then did patient interviews. After doing an interview, once the doctor got there, I would follow him into the room and he would examine the patient. The two nurses/PAs are quite nice, and there is a PA student from my school who is there with me for the next few days so they all showed me the ropes a bit - what is disposed, what is washed, etc.

At the end of the day I wrote up SOAP notes of the various patients, which includes their history, observations, the assessment, and plan for their treatment. Spent about two hours doing that, hopefully I'll go faster next time. Tomorrow we have an inguinal hernia surgery and possibly a bilateral mastectomy - there's also a cancer meeting about one of the Dr's patients but I don't know if I get to go to that.

For the rest of the evening, going to look up information about inguinal hernia surgeries, mastectomies, and other surgeries that I saw today, and get started on my reading assignments. One observation about the surgery rotation - I basically have to have as much initiative as possible, so suggest helping with things, follow the doctor into rooms - no waiting to be told what to do or asked to do this or that. Good training, requires a lot of energy though. We'll see where this goes.

Post-COMLEX Step 1

2011-07-12T10:00:00.000-07:00

Well, that was a long test, that's for sure. So, I took COMLEX on Monday, it is a 400 question test, separated into sections of 50, no real theme to the sections, they feel like pretty much random collections of topics, and you get 60 minutes per section and a 40 minute break for lunch after the first 200 questions. Took BART into San Francisco, arrived at the Prometric testing center at 7:30am, started the exam around 8:15am after everyone got checked in, pockets checked, scanned with metal detectors... at least cheaters have a difficult time. They also do rounds in the testing area every 10 minutes.

Anyhow, there were quite a few repeat questions - what bug is causing this infection, what does this slide indicate, it's all a bit of a blur right now. I kept tabs of how many I was "guessing" on, and by the end it felt like maybe 40% of the test was my best estimate? But the questions are each weighted between 0.5 and 5 points, so it's really hard to know about how many you need to get right to pass or get a proper score. My practice COMLEX exam had me at slightly above average, and my question bank percentages were fairly respectable, so I almost certainly passed and most likely have a score acceptable to most Family Medicine, maybe some Internal Medicine, residencies.

I also got some information about my General Surgery rotation which I am starting on 7/18/11 - clinic days are Monday, Wednesday, and Friday - where he will have me practice taking patient histories and then we will do physical exams together; Tuesday and Thursday are surgery days.

The surgeries I can expect to see performed include:

Inguinal hernia

Umbilical hernia

Lap Chole (Laparoscopic Cholecystectomy)

Excisional breast biopsy

Appendectomy

Injecting hemorrhoids with a sclerocing agent

Port a cath placements

Pilonidal cyst excisions

So... lots of stuff in the future! I'm glad the clinic days are so short, as it'll leave me a lot of extra time for studying and personal time =)

One more week to go...

2011-07-03T14:26:00.001-07:00

One more week until I take COMLEX, going to have to step up and really study. Took a break the last day or two, just been stressed out. Plus after I take the test it is off to Oregon, then the day after I get back it's time to jump into the general surgery rotation and patient interviews and scrubbing-in and all that fun stuff. I've gotten my badges for the two hospitals I'll be at for now, and have a surgery rotations book to review while I'm in Oregon. It's getting really hot now in the bay area, so it's getting harder to focus. Must stay strong! Time to do some practice questions...

Finished BLS and ACLS

2011-05-10T15:11:00.001-07:00

Since I shall soon be starting rotations in hospitals, I had to go through BLS (Basic Life Support) and ACLS (Advanced Cardiac Life Support) training and certification. Didn't take too long, and BLS was a recertification so that was no challenge - ACLS was a lot of new material and new sequences of information, along with a refresher course on EKG reading so that was fun! I particularly liked the instructor, as he had 42 years of experience as a paramedic and emergency department (ED) technician so he had lots of case examples to share with us.

Some take-away points for normal people which I feel I should mention - as it may save you or a loved one one day:

3 main things to know for CPR

1. Are they breathing? Do they have a pulse? (if no...)

2. Have someone call 911 and tell them to try to find an AED (often in hospitals, schools, major office buildings, gymnasiums) - no use doing CPR if no one is coming to help.

3. Chest compressions - fast and hard - at a rate of at LEAST 100/minute, so we're talking about 2 compressions per second. When you do compressions, middle of the chest (approximately between where the nipples are), compress about 2 inches into the chest. On kids, 1/3 of the way. *FYI: If you are doing compressions properly, you may very well end up breaking their ribs - don't let that stop you - keeping heart circulation going is much more important than a broken rib or two*

If you are comfortable doing mouth-to-mouth on this person (child, husband, etc.) do only 2 breaths, head tilted back, covering nose, and then go straight back to compressions -compressions are WAY more important, so alternate 30 compressions then 2 breaths.

Another take-away note about Strokes...

If you or someone else starts having signs of a stroke (one sided muscle weakness, face drooping on one side, difficulty speaking) - CALL 911 - DO NOT DRIVE THE PERSON OR YOURSELF (unless you are less than a block from a hospital MAYBE). Reason? You may feel well enough to drive yourself, or you may think you can drive your family member, but if an ambulance picks them up, then not only will they get en-route care, the hospital they deliver the person to will be completely prepared, with the neurologist, cardiologists, etc. all notified and ready to take care of the patient. It can take 45 minutes of assessment and evaluation once you get to the hospital before they decide it's a stroke and can do any therapy - by then, it may be too late.

Why is this so important? Fibrinolytics - you basically have a 3 hour window where you can be given a medicine that will essentially dissolve the clot in your brain. I have known people who drove themselves while having a stroke, or who started having a stroke in the middle of a golf course and played through to the end before going to the hospital - if you want that shot at a Fibrinolytic, which will GREATLY INCREASE your chance of restoring brain circulation, get to the hospital ASAP.

Bottom line: If you have a loved one, pass on this information so they get the fastest possible care, or so they know what to do if this happens to you. Time makes a MAJOR difference when it comes to blood not getting to your brain.

Enough with the public service announcements though - time to get back to studying for board exams! Wooh! Diuretic medications.

Mostly done with 2nd year

2011-04-23T14:55:00.000-07:00

Finished all our normal curriculum classes - feels like it's time for a break but alas, must start really hankering down on preparing for boards. I moved my board exams to later, since I will be doing a vacation first, so I have a bit more time but my prep program has a live lecture series that begins at the end of May so I need to get cracking!

As far as the last few weeks of school, they went by rather quickly, with lots of studying and crossing fingers that I wouldn't have to re-mediate anything. It's getting warmer, so perhaps I can take a break to collect insects again soon, but a medical career sure does eat up your time. I'm also trying to adopt a healthier lifestyle, incorporating more exercise and diet changes. We'll see how long that lasts.

Got back from Monterey recently, went for a week-long vacation with most of the family - I say most because my dad recently had a hernia repair complication and had to stay home to recover from that. Funny how you learn things in practical settings that they don't really discuss in medschool - like how to approach a patient who comes in with an internal bleed. Solution? If their H&H doesn't drop too low, and if the bleeding stops on its own, even with tons of swelling, you can expect the body to resorb a certain amount, and it is usually less risky than surgically draining the fluid or going in to repair a small bleed.

On another note, I've discovered I have a very particular allergy, to two products produced by the Estee Lauder parent company (Brands are Origins and Clinique). The brands are significantly different and the two moisturizers I used only share a handful of ingredients - I've narrowed it down to butyloctyl salicylate (but this is common in a lot of sunscreens that I think I have been exposed to before) and micrococcus lysate (an ocean-microbe's dissolving organ enzyme). My money is on the micrococcus lysate, because it is used in very few products and is relatively new on the market (2009) so I am curious to see if that's what it is. There is one more product out there that I know of that contains the micrococcus lysate but not the other compound, so if i test that on some skin it should produce a reaction if I have the right compound isolated. Kinda fun to experiment on oneself, but I kinda want my face and neck to stop being all inflamed and itchy. And my test arm.

Nearing the End of 2nd Year

2011-03-13T23:56:00.001-07:00

Well, in a few short weeks my core classes will be finished and I will be mostly studying for Board Exams (USMLE, COMLEX) and gearing up for rotations. My third year rotations will mostly be taking place around Fairfield and Napa, with two rotations out in Stockton (psychiatry and hospital-internal medicine). That isn't until the end of year 3. My schedule only permits one month of vacation, which I intend to take right at the beginning so I can extend the time that Itake USMLE and COMLEX by a month - an extra month of studying will make a big difference, especially since that is ALL I will be doing. I am leaving a week between the COMLEX and the start of rotations to go on a vacation though - it's my only vacation, I should try to do something!

The unfortunate thing about Touro University is they do not let us finish school very early. We are in actual classes up to April/May, many mandatory, while other schools have already finished second year to give students time to study for boards! No wonder Touro students perform more poorly on boards. It's hard to keep up with boards and classes at the same time. Luckily a lot of the boards review is starting to overlap with what we are currently studying, so hopefully that'll help out a bit.

I also had an interesting extra-clinical experience - we are required to do a visit and then 6 month follow-up with a geriatric patient at a nearby retirement community. When I went to visit, it so happened that my patient had fallen in a parking lot that day and did not feel up to visiting the clinic, so the head nurse told me to make a house call. In a way, it's kind of ironic that my first "house call," once a traditional type of doctor visit, is probably the only one I shall make in my career. It was a little awkward, but kind of cool to examine a patient with an acute injury in the comfort of her home (in case you were concerned, she was barely injured - extremely lucky considering she is an 83 year old female with history of osteoporosis and is on anti-coagulation medications - she could have easily broken her hip, leg, or wrist, or ended up bleeding a ton).

On another "fun" note, we get to do rectal, breast, and vaginal exams on paid "patients" this week...not particularly looking forward to it, but at least I have experienced all three, so it's not an entirely foreign concept. We are getting into the genitourinary and pediatrics sections now so ... time to race to the finish line. I still have some fun stuff planned - next week double date to Sattui Winery for complimentary tastings, thanks to being wine club members. Anyhow, back to boards review...

Spring Semester and Boards

2011-01-22T21:37:00.000-08:00

Well, just finished the 3rd week of Spring Semester - this unit is gastrointestinal, endocrine, reproductive, and dermatology - or GERD. Just signed up for our "Project Prepare" time slots, where we get to practice breast, prostate, and vaginal exams on hired "actors". We always kind of wonder what kind of people choose to do this sort of work, but hey, in this economy, why wouldn't they?

At any rate, the first week we covered mostly dermatology, and the second and third weeks have been focused on the endocrine system (so the pituitary, adrenal glands, pancreas, etc.). I am also getting geared up with my boards review program. I am taking Boards Bootcamp, where we get video lectures, as well as a study plan in the mean time. Near the end of the program we attend some live lectures locally. We got a super discount because at first we committed to the comprehensive program which was supposed to have weekly live lectures and cost 1700 or so, but we were going to get it for about 1300, then when we didn't get the minimum number of students to sign up, they upgraded those who did sign up to the elite program which normally costs 2200 (but we still only paid 1300). It's a lot to work on, but frankly I enjoy studying for boards more than Touro material - it just feels like it's better organized and more relevant. Anyway, I devote my Sundays to studying Boards material - works out well because my boyfriend works essentially all day on Sunday, and Monday-Thursday, so I don't feel like I'm neglecting him too much.

I have been managing to have a little fun on the side - spending time with my boyfriend, hosting a New Year's Party, heading out to a brewery here and there, a movie or two, played nearly all the way through Fallout: New Vegas. Even trying my hand at some new dinner recipes. Now I just have to re-incorporate an exercise regimen...

Oh, I also got all two of my wisdom teeth out a couple days ago - first time going under anesthesia. But there was barely any after-effect and I'm recovering quite quickly. It sucks not being able to eat much solid food, but because I only had wisdom teeth on my left side, I can still chew a little bit on my right without disturbing my stitches. The whole procedure was only about 25 minutes, I was surprised.

Fall Semester: Finished

2010-12-25T21:52:00.001-08:00

Well, the Fall semester of OMS 2 has come and gone - it was rather intense, neuro-musculoskeletal-other stuff. Next up is Dermatology, Gastrointestinal, Genitourinary, etc. Should be interesting - this is all the neat stuff. I think I will actually attend lecture this time because a lot of it is interesting stuff to me and I'd kinda like to get back into that. Right now it is Christmas time, and I'm home for a bit but mostly school is still on my mind. Board exams are coming up, so I have to take a diagnostic Step 1 for my boards prep course, which starts in January. Also, our 3rd year we start rotations so we had to rank and send in our requests for certain rotation locations. I'm trying to stay local, but so is most everyone else - most people are in relationships or have kids so it is a challenging position. We hear the results shortly after class starts again.

So...what with rotations, boards, end of fall semester, board prep courses, and trying to have some semblance of a social life, been quite busy. My other blog has been sorely neglected of late...hopefully I can get back to it soon. It seems I never have a spare moment to think even. For now, just trying to enjoy a few days off and plan a New Year's Party.

Season's greeting, everyone - stay warm and safe this holiday season!

Fourth Week In...

2010-08-25T22:02:00.001-07:00

Posting has been lacking due to the insane amount of stuff I have been up to - being a second year is no simple matter. Nor is moving. Anyhow, I am finally settled in the new place - which has a gorgeous view and is pretty darn spacious and awesome - because it is "technically" within Vallejo's city limits, it makes the property values a lot lower, so the rent is surprisingly affordable.

The start of this year has been centered on Neurohistology, Psychiatry, Cranial OMM stuff, and learning how to do more focused Physical Exams. We will be also doing an extra clinical experience at a retirement home to learn more about geriatrics and the problems that face that particular demographic. Neurophysiology is very detailed, so that has been taking up most of my time. Money is also super tight. However, our living area is great, my friends are close enough for us to visit regularly and for us to host things every so often, and school is closer, and I have a lot of time to study in the evenings. Not to mention the occasional social events like LAN parties or themed parties. Still have time to do a half-hour or hour of games a day - I need a nice way to de-stress, and the latest one, plants vs zombies, can be played with just a mouse, leaving my other hand free.

Almost time for school...

2010-07-31T18:45:00.000-07:00

Well, my 2nd year is coming swiftly upon me - apologizes for the lack of updates, these last few weeks have been crazy. After Bolivia I went to the Galapagos Islands for a week with my family, then I came home and my boyfriend and I sorted stuff out and plan to move in together this fall. It'll be nice having him there, after a year of long distance. We had to look for apartments and budget my financial aid money, since I took out a bit less than I probably should have and so we don't have much breathing room.

Our first unit will be Neurology - so we get to learn brain functions, nerve stuff, etc. It is supposed to be really hard, so I'm glad I've had a sequence of Cognitive Science courses at UCSD. I have at least two textbooks I can refer to if things get too complicated. I am also reviewing old material from Semester 1 - I want to review old material and make flashcards for it at least once a week, since it'll be good practice for the USMLE/COMLEX when that comes around in the Summer (shudder).

I may continue my research on bacteriophages, I would like to, but we shall see. Also, since I took Medical Spanish last year and went to Bolivia, I now have a spot for an elective for fun, so I am curious what will be offered. Anyhow, tonight I drive back up to Northern California after spending the rest of the summer in San Diego - Kit will be following me up in a few days, but I have some meetings at school on Monday and that was our assigned moving day, so I have to get up there. I got a new phone too, a Droid Incredible, which is, indeed, quite incredible - I love some of the medical apps - particularly the drug interactions app. Really cool. It'll even tell you the details and why.

Third Week in Bolivia

2010-07-09T10:19:00.000-07:00

Rather late update, I know, but I figure I shall update for the third week when I went in the mobile medical units. The first day I went up to a school where we did general health exams on the classes of kids - most were under 10 years old. They all had horrible teeth, some were malnourished and had herpes skin outbreaks, a few had upper respiratory problems, and we were checking their fingernails since parasites in fingernails is a big way they enter food. We dispensed two de-worming pills per student, and returned the next day to extract broken teeth beyond hope of repair. I even have pictures this time! Since I had been watching the examinations closely the previous day, I volunteered to help conduct the exams the next day, so I got to do essentially half of the kids. I hope they understood my accent well enough.

Another point about their teeth - a lot of them had teeth so bad that they also had abscesses...poor kids. A few less typical cases include...tonsillitis and bronchitis. All in all, it was a very interesting experience and gave me a chance to get some hands on experience. I listened to the kids with stethoscopes and was able to discern bronchitis (and we were just listening through clothing too...you definitely let a lot of things slide when you're on the go in a third world country).

The next day in the ambulances was our last day doing hospital stuff and I went in the mobile unit that parks at various street locations and takes walk-ins for treatment. Most of them were all alcoholics or pregnant ladies, and the guys would stay and talk for 10-30 minutes at a time about their problems...got really boring, and I could understand what they were saying too. The stories just all sound the same after a while, and so we did very little actual medicine that day. The only good thing that came out of it was a female patient came by who had a mitral valve defect - mitral regurgitation - and we were able to hear the valve defect in the flesh so to speak. It was definitely more pronounced than the audio clips we had been given to listen to during our last examination.

That's about it for medical stuff in Bolivia - the next day we went to Lake Titicaca until Saturday, then I just hung around until Wednesday, when I got to leave for the Galapagos Islands with my family! I was so happy to return to the US when I finally got back - after being in Bolivia for 3 weeks, seeing familiar food, familiar settings, stores, etc. felt great. Anyhow, I shall soon begin posting on the various medical conditions I saw or heard about in Bolivia. Until then, off I go.

Second Week In Bolivia

2010-06-14T14:55:00.000-07:00

Well I am into my third week now, but this post shall mostly be about last week. Last week was...interesting. I will briefly describe the weekend - we went first on this crazy hike up to the Muela del Diablo. It was quite neat. The next day we went on a bike ride, something like 55km down the Worlds Most Dangerous Road. Ended up going down from bout 14k feet to 3.5k feet into the rainforest where there was an animal sanctuary so there were lots of really friendly monkeys, birds, etc. Some insects too. No pics, alas, since these computers dont have memory card readers.

Anyway, Monday was fine, I followed Dr. Fernandez around for a while. Tuesday was more of the same. Wednesday I shadowed in Obstetrics and Gynecology, since we were all switching locations on Wednesday and I was absolutely miserable. Cannot stand OBGYN. First off, the sight of pregnant women, babies, breast feeding, etc. is definitely NOT my thing. Next, I know very little about pregnancy and complications. Finally, all the doctors spoke super quietly so it was near impossible to understand anyway. Then Thursday I tried to hang out mostly in ER but that got kinda boring, since it was mostly UTIs and women with abdominal pain. Friday we were going to leave early to go to Lake Titicaca for the weekend, but one of the guys in our group was feeling pretty ill from some bacteria, so had pretty bad GI upset... so we ended up not going. Me, the doctor, and the other girl in our group went shopping for souvenirs and went to the Coca museum, which had a lot of interesting information about the history of Coca in Bolivia and the world. Saturday...three was more souvenir shopping. As was Sunday, but we also watched a lot of partidos de futbol! Wednesday we had gone also, but it was just a local game and there was not as much skill as in the world cup. It is a pretty big deal here.

Anyway, this week we are spending mostly in the mobile units, checking out schools and kids in the streets. It is pretty neato, but I will do a full report later, since we have only done this for one day so far!

First Week in Bolivia

2010-06-04T09:16:00.000-07:00

I would have written sooner but it's a little difficult to find time among all the things we are doing. We got in on Sunday morning at about 6am after flying to Miami and then La Paz. A lot of flying. Very long flights. We were met by Mr. Gonzalo who is our liason/coordinator for the volunteering we are doing. He helped us get a taxi which took us to our homestay. We are on the fifth floor of an apartment complex and staying with a woman named Olga. She speaks essentially no English but among our group of three (Nourah, Me, and John), Nourah and I usually are able to make sense of things. We were considering taking Spanish lessons, but we placed as intermediate/advanced so we weren't sure it'd be worth our money. Anyway, we napped that first day, then met Nathalie, one of our professors, at a coffee place in one of the plazas. We then explored the area a bit, did some shopping, that sort of thing.

The next two days were kind of a blur of meeting with Gonzalo to discuss the cultural and social climate here in Bolivia, discuss our role in the hospital, how we can contribute, that sort of thing. We also were joined by a physician from Touro, Dr. Mokari, who is hanging out at the hospital with us. We visited the hospital and were introduced to people but didn't stay long enough to do much else. Then we returned, have been eating out a lot and getting drinks, that sort of thing. We saw Prince of Persia the other day in Spanish, have gone on two bus tours, and the like. We're starting to get a pretty good feel of the city, including which taxis and minibuses are sketchy.

First day in the hospital I chose to follow an infectious disease epidemiology specialist - of course - and we saw four cases of Dengue fever (apparently really unusual for this time of year), a case of gallbladder stones, and then discussed the etiology, causes, diagnostics, treatments, etc. Today I saw a patient with tuberculosis, got to look at his X-Rays and auscultate his chest. It was really interesting. I was also shown around the SUMI office, which is insurance for low income individuals and they keep tabs on the most significant infectious diseases or conditions including yellow fever, leishmaniasis, rabies, influenza, tuberculosis, dengue, AIDS, hanta virus, polio, rubella, measles, etc. We're going to do a survey on Monday, and this weekend our group is going to do a biking trip to the rainforest, hopefully! Until then!

First of the Last Tests

2010-05-17T17:07:00.000-07:00

Well, today we had our last anatomy test - yesterday I went to the Bay to Breakers event in San Francisco, so my head wasn't quite as into the test today as I'd have liked, and I wasn't nearly as prepared as I could have been. If I pass, I'll be satisfied.

In the meantime, we have three days of Jewish holidays this week AND on Friday's we're not allowed to be tested so we don't have any tests until Monday. They will be rather intense, and I'll need to do some practicing of various techniques for OMM and doctoring, among all the basic science and medicine studying, but at least I don't have too much exciting stuff planned, besides maybe watching a video or two and study breaks to hike. Gotta mix it up a bit or I'll go insane, after all.

Anyway, I need to rest my head - yesterday was insane, and I wish I were updating things more...there will probably be a decent number of updates once I go to Bolivia - leaving on May 29. I got my vaccinations, but I do need to fill my prescriptions...hmm...

Another Hurdle

2010-04-30T10:01:00.000-07:00

Well, just finished a pseudo-midterm - feels like I've been doing nothing but study lately - and in my spare time, computer games. I really need to get out more and exercise... Feels like I'm trying to do a million things at once, but I guess that's nothing all that new. I can't believe I'm almost done with my first year of medical school. It's rather intimidating because sometimes I feel like I've learned a lot, and other times I feel like I haven't learned anything. Now with the midterm done, I plan to just relax as much as humanly possible between now and Saturday night - Saturday we have a semi-dance thing on campus, it's a fundraiser for the group that is going abroad to Ethiopia and Tanzania. Unfortunately they're more established, better organized, and have the Global Health program director in charge of their group, so they have been putting on a lot more events than my group (Bolivia) and the Taiwan and Israel group.

The latest stuff we have been studying is all the respiratory illnesses - mostly those that cause pneumonia, bronchitis, that sort of thing. There was a section on pediatric illnesses and upper respiratory problems, which was okay. I'm not a fan of babies in general, and learning about the millions of ways that babies can turn out wrong frustrates me, since there are no laws permitting parents to relinquish their responsibilities for an incredibly unfit offspring. Definitely a controversial view, which as far as I'm concerned will only apply to myself and my future offspring, not the patients for whom I care (so don't worry), but human societies have practiced infanticide since before they were even humans - all animals practice infanticide if they do not have the resources or the animal is too unfit to survive and care for itself. It seems a crime to force parents to spend say, 5 years of their lives caring for a child that is 99.99% doomed to die - that's 5 years in which the child will be suffering, becoming progressively more mentally retarded, and slowly wasting away until its inevitable demise. It's an emotional drain for sure, not to mention a financial drain on the parents.

Like I said, I know it is my duty as a physician do everything in my power to keep a patient alive, and I will do that wholeheartedly - I just don't want to end up a slave to any offspring I produce with conditions that are incompatible with life for which medicine can offer no acceptable end.

In other news, still doing bacteriophage research. My medical Spanish classes have picked up again, so we're practicing those and we have our practicals next week. The trip to Bolivia is essentially ready, though I still need to get all my vaccinations...mental note: call the travel center. OMM is going well, I suppose - we're learning the high velocity, low amplitude techniques (the cracking techniques). I've had mixed success with them, so I definitely need more practice. Thank goodness we don't need to make an audible crack for it to be 'treated' - otherwise I don't know how we could get anything to treat during a practical after we've been practicing on each other for days.

Still working on balancing personal life with school, but everything's a work in progress these days... Now for the joy of computer games!

Spring Break

2010-04-04T16:48:00.000-07:00

Hooray for spring break and being done with blocks exams for the time being. I ended up going to Monterey for a week, and then down to San Diego for the remainder of the passover time we have off. I have done essentially no medicine-related stuff all break - a welcome change and break for my brain. Looks like we get to start out with venipuncture and the respiratory system next block. Makes sense, as we just covered the cardiovascular system. It should be interesting.

In other news, we're needing to raise some money for the Bolivia trip (as in, get money to buy supplies for the hospital, mobile unit, and for the impoverished down there). I'll be returning to my research soon enough, and want to exercise a bit more so I'll join in the weekly karate class and do pilates on the side. I also got a LASIK checkup and my eyes are still healing perfectly and there are no complications. I also need to start making my own food more often - as much as I like letting my parents cook everything, sometimes I really prefer my own cooking. Anyhow, back to enjoying the last couple days of leisure that I have...

Spring Semester, Block 2

2010-03-17T14:48:00.001-07:00

Next week is our second block of exams for spring semester - it will mainly focus on the heart and related diseases. So...that includes hypertension, angina, valve disorders, congestive heart failure, arrhythmias, pericarditis, cardiomyopathy, etc. AND their pathologies, drugs, treatments, and more. Fun times...over a hundred drugs to learn, again. There's some OMM stuff to learn in there as well, specifically tender points and some cranial technique theory. I'm interested to learn cranial - supposedly it's really good for headaches (among other things...). Here is the first 1/4 I have completed of my study board:

Today is St. Patrick's day, so it won't be long before we medical students, once again, imbibe alcohol and kill our livers and brains counter to the advice we're required to give our patients. I guess alcohol isn't quite as bad as the McDonald's lunch I had, but hey, my BMI is 21, my system can take a few hits for the greater good. (Hears Dr. Clearfield's voice in my head..."Even people in their 20's, who look perfectly healthy, can have early and even middle-stage coronary artery disease and atheromas in their arteries"...oooooo...scary).

More and more, I realize how much I want to specialize in Infectious Disease. The fact that the thought of a lecture on anything related to bacteria, viruses, fungi, or parasites is enough to brighten my week is sure sign enough. I'm really amazed at how little surgery or other superspecialties appeal to me - cardiology? Meh. ER? Nah. Surgery? Too many hours standing over someone's guts while nurses wipe sweat off your face. I have the hand dexterity, focus, and attention to detail to be a surgeon, as I've been told many times, but it just holds no interest. Gimmie someone with a bug in them! I'm going to send a letter to an Infectious Disease DO to see about shadowing - as much as I love infectious diseases, I know very little about what an ID specialist would actually DO. Hopefully I'll mail that out and hear from her soon!

Bolivia and Research

2010-03-10T01:47:00.001-08:00

Things are progressing as usual at school. We're studying drugs for treating hypertension, dyslipidemias, arrhythmias, angina, etc. Essentially this is the phase where we learn how to treat the diseases in the renal, cardiac, and respiratory systems, which we learned about last block.

In the meantime, I've gotten started on some research, fortunately with the same professor who is going to Bolivia with us. I'm glad I am on good terms with all the faculty so far - I have heard of a few students who think certain professors dislike them, and I haven't gotten that vibe from anyone yet, so hopefully I won't. The research is related to bacteriophages, as I mentioned before, and we will be growing bacteria (Salmonella) and determining under what conditions their bacteriophages become most activated to the lytic phase (where they reproduce themselves and lyse their host cell, looking for more hosts, compared to the lyosgenic phase where they lay dormant in the host cell's DNA). The professor I am working with, as well as others in the lab, seem to be really laid back, It's kind of a "when you can help out, come on in - put your studies first" situation. After the high-stress environment of working in a hospital laboratory, and even the strict environment at UCSD, this is a welcome change.

Also, the Bolivia trip is beginning to materialize more. We are about ready to book our flight to La Paz, are going to put together a presentation of pre-research about Bolivia, and are getting materials ready for the trip. I'm very much looking forward to the experience - Spanish immersion, health education, learning how to diagnose and possibly treat diseases we rarely will see here in the US. Anyhow, back to studying.

Fun and the Future

2010-03-04T00:00:00.000-08:00

Even with so much to do, medical students can still have a little fun. The last weekend I went to a house party, with drinking and silly stuff, then to a shooting range, then a BBQ and a turkey dinner, and then played computer games all night. It's nice to know that we can kick back occasionally, but we better enjoy it now, because it's going to get a lot worse. The number of drugs we need to memorize is steadily adding up - I wish I knew them all as well as I know drugs like tylenol or omeprazole, typical OTC drugs that I've known about most of my life.

We're getting into hypertension lectures, angina, coronary artery disease (CAD), congestive heart failure (CHF) and similar problems. It's funny, with all the talk about eating healthy, and how CAD can be seen as early as in teenagers or people in their twenties - the food I'm craving the most right now is fast food. I haven't craved it in ages, but here we are.

Every so often, the curriculum at our school throws in a "Managing Stress" class, where we are told ways to deal with stress, as well as the kinds of stress we are going to encounter (which of course gives us a lot of stress right then and there). Today, the doctor teaching the class was talking about how the first two years of medical school are a breeze compared to third and fourth years when you begin your clinical rotations and have to use whole different sets of skills (communcation versus booksmarts). Then she went on to say you think rotations are bad, wait til residency - where there will be hallways or stairwells essentially devoted to hiding and crying when your attending shouts the crap out of you. I imagine something like Dr. Cox from Scrubs, except no one is laughing. She then added how even then, you start your internship somewhere and it's just as bad - with more power comes more responsibility, which comes with more and more work. It's like being spider man except that everyone knows where you live and you're expected to work 16 hours straight.

As she talked about us being on rotations or in residencies, I couldn't help picturing how some of my classmates would be during rotations - getting picked on by the attending, or stepping into a patient room with an air of authority and asking them what the problem is and trying to help. Now that I know more about a doctor's thought processes, and my classmates' strengths and weaknesses, it is hard to picture myself as a patient of theirs - putting my problem in their hands and trusting their judgment. Though, in my mind at least, I always picture my classmates looking very proper, professional, and knowledgeable in these situations. I suppose that means I have a good amount of respect for my peers as future physicians and human beings (well, most of them - there's always a couple you wouldn't want as your doctor). Hopefully I'll pull everything together and become as awesome a physician as I picture most of my peers becoming.

Studying, Advocating, Consoling...so much to do

2010-02-10T02:13:00.000-08:00

Well, spring semester has been coming on fast and furious - been extremely busy. Have also had tests every other week, essentially, and our first Block exams of the semester are next week. We have had two standardized patient encounters with our small group - where we must take histories and perform a physical exam. It's amazing the things you notice yourself and your classmates doing when interacting with patients - strengths and weaknesses, the importance of listening... We have also practiced doing SOAP note write-ups (subjective, objective, assessment, plan) and worked on differential diagnoses. The ailments of the patients are in line with what we are learning, so we can apply what we learn clinically.

Tomorrow we get to explore a new aspect of the physician-patient relationship - breaking bad news. We will have 12 minutes to break bad news to a standardized patient who has been trained on how to react convincingly to the news, including shouting or crying. We will be faced with one of these: a son whose father unexpectedly died, a woman with a suspicious breast lump who needs a biopsy, a man with inoperable pancreatic cancer, a childless woman who just had a miscarriage, and a man with an STD from an affair. Should be interesting and nerve-wracking - but I imagine it will be more difficult for some of my colleagues than for me. Working in the lab, I definitely got to deal with very angry patients, and one woman I drew as a trainee had just learned her husband was going to die - that was a difficult one. You really don't know what to say to a stranger who suddenly starts crying, especially when they're still holding back so much pain and you know almost nothing about their situation. I almost cried myself that time - but sometimes all you can do is squeeze a person's hand to let them know you're there with them, even if it's for just a moment. I'm usually someone who insists on a 3 foot personal space bubble and never hugs people unless they're family (and even then not so much), but somehow I was able to recognize that at that moment, she really needed to feel physically that someone was there with her. If you're really with them, and not just going through the motion, time almost seems to stand still for you both in a good, or at least meaningful, way. They say, "You can touch patients during a bad news situation if you think they would be okay with it," and you kind of wonder, "How will I know if they would be okay with it?" Well, that was one of those moments, and I could definitely tell even with no experience - though my rule is that if in doubt, it's better NOT to touch.

On a more positive note, last Thursday we were bussed by the Osteopathic Physicians and Surgeons of California (OPSC) to the state capitol to speak with assembly members and fellows about the recent merger between the Doctor of Osteopathy and Doctor of Naturopathy boards. Essentially, bill AB X4 20 merged the boards because the governor wanted to make it look like he was cleaning up the government - busting excess bureaucracy and saving money. However, both our boards are funded by those in the profession, no tax money is involved, and they approve licenses as well as oversee malpractice issues. NDs do not prescribe medications without supervision (and even then, no category 2 drugs) nor do they perform surgeries - so having them oversee us, or even have us oversee them, is not fair to either profession. I was the designated group leader to the assembly member whose fellow we spoke to because apparently I live within the district (14). Definitely nerve wracking, but everyone seemed to think I made a very eloquent case. The fellow we spoke to seemed very supportive of our cause. One of the senators (Lee) has submitted two goldenrod bills to his boss for approval, which we need in order to get numbers on them, support, and signatures. It was really enlightening to see how the process works in state government, and that people in the offices actually will listen to you and you can make a difference. We also got to speak to one of the governor's aids right before he was going to a meeting with Mr. Schwarzenegger himself, with the promise of at least mentioning the issue with him, so that was exciting. There were a bunch of school children outside of the governor's offices as we walked in and they were all asking us to say "Hi" to the governor for them, ask for more money for schools, it was adorable. All in all, a very exciting day - here we all are in front of the capitol building!

Also, on one final note, the founder of Touro University, Bernard Lander, last night at the age of 94. All the Touro campuses were closed out of respect. I don't really know what to say about it, as I never met him or knew much about him before now, but I am kind of wondering how it will affect the universities. At the least, I was productive and used the day to get more caught up on classes.

Latest in Whiteboarding

2010-01-24T23:59:00.000-08:00

Well, I'm trying to catch up on all my anatomy, but more will certainly follow - I need to work on respiratory material that we're starting to learn, put up some OMM diagrams, and maybe some useful doctoring notes. As we go, though, I feel like there's material we already learned that is slipping away from me! It is so much material, I'm definitely going to have to do some studying over the summer somehow - I hate that I try to remember stuff from first semester and some of it is already disappearing. Tomorrow is Monday, which means 8 hours of lectures, so I have to be sure to bring a decent sized lunch. Also, there's a basketball game between our class (2013) and the second years (2012) - hopefully it will end better than the last game between our classes...

Apologizes for the quality - I have not yet found a decent way to photograph my whiteboard

Post-Mini CVRR Exam...

2010-01-20T23:52:00.000-08:00

Well, since the last post, so much has been going on that I haven't had the right state of mind to study...what with the first week of school and seeing everyone, coming back from winter break, and having a party/Gala packed weekend. So, alas, my studying last week was essentially nonexistent and very little studying was accomplished when I visited Kit over the weekend, so I ended up doing an all-nighter last night and I am feeling the pain right now. Anyhow, hopefully tomorrow I'll wake up feeling more energized and be able to charge back into studying!

We've been getting into more detailed cardiovascular exams, dissecting the heart, learning about the heart and various ways of looking at circulation. We're starting the respiratory system now but I want to go back over the circulation stuff a bit since I feel like I probably missed some of the details during my rabid speed studying last night. Hopefully will be having some normal fun this weekend, make some headway on my studies, and feel all prepared for next week.

Awesome Anatomy Lab!

2010-01-07T19:13:00.000-08:00

Sometimes you have a really fun time learning things - when you get quality time with professors, they don't seem rushed, and you have prepared, you can get really involved in the active learning process. We had small groups today, and were examining the inner thorax, mediastinum, the lungs, and the heart. There are so many knowledgeable professors, it's great! Also, all the information was being absorbed in my head like a sponge, and becoming more cohesive.

Some of the highlights include finding essentially all of the key terms we needed, learning how to insert a tube through the rib cage to remove air or fluid, following the arteries and veins into and out of the heart, and getting information about x-ray films of the chest. This was quite a fun lab. It also helped my studying - I updated my whiteboard. I barely have any room left for tomorrow's material, or the heart stuff from today, but nothing we focused on today was particularly new. Unfortunately there were a lot of graphs, so I probably need to memorize and understand those...

Week 1 Has Begun!

2010-01-05T23:16:00.000-08:00

Well, Week 1 is well underway, starting the cardiovascular system. We opened up the thorax on Monday, peeled away the skin on the chest, saw the pectoralis major, pectoralis minor, serratus anterior, external intercostales, deltoid, subclavian muscle. Also the rib cage, the sternum, manubrium, clavicles, etc. I also dug around and found the subclavian vein, cephalic vein, axillary vein, axillary artery, and brachial plexus. Next we took out the ribs (bone saw) and observed the lungs, heart (still in pericardium), a bit of the trachea, etc. One of the other cadavers had severe lung cancer - he had bulges the size of golf balls on his lungs and the interior of his ribs were black on that side. There was also a male cadaver with breast cancer. On one of the cadavers I was able to see the right and left vagus nerves and the left phrenic nerve also.

I have been making good use of my new giant blackboard - as for OMM we have started the pelvic area, learning landmarks, anatomy, and lateralization tests. I'm glad I had a girl partner for the first one - I'd rather not feel stuff for the first time on a guy - least now I know what to look for and won't feel like I'm groping around their crotch and butt aimlessly. The science lectures are all about how the heart works, mostly action potentials right now - which I have learned multiple times - AP biology, then cognitive science 1, 10 and 11, then in some biochemistry classes as well, and now here. At least I have some fun stuff planned for the end of the week - a party and the shooting range. Seriously, medical school is way more fun than undergrad was! Oh, and also my disbursement check is ready at the financial aid office - I need to get it tomorrow and figure out my budget for the Bolivia trip - if I have some extra money, I may go to Convocation. If not...well, there's always next year.

Spring Semester...

2010-01-02T14:29:00.000-08:00

Monday is the first day back at school, and I am not particularly looking forward to it. I just got rid of my year-long writing block so now I want to work on that! Alas, it will have to be put aside. It looks like we're starting in on the cardiovascular system, and will be dissecting the chest wall, the heart, etc. I don't really want to go back to the anatomy lab... One more weekend to enjoy freedom before entering the grind of school again. I won't have a break again until spring break, and then not until I get back from Bolivia. I think I'm going to pass on Convocation this year, simply because I already have one expensive trip planned. Maybe next year I'll go. Anyhow back to enjoying the last break I have for months...

Tis the Season!

2009-12-25T13:22:00.000-08:00

Christmas/Yule/Winter Solstice/etc. is here, and I am quite happy with the spoils. Relevant items include a 6 foot by 4 foot whiteboard, with which I can write all the drugs, pathways, etc. that I need to know. I also got a leather executive-style black chair to sit in - a huge improvement over my old chair - a lightweight thin wooden plank-type chair that would fall over every time I stood to go somewhere. Also, I bought myself a new mechanical pencil, a brand new five-star college-ruled perforated page notebook, and I have my highlighter, computer, and USMLE Step 1 prep book ready.

In other news, I got a new portable hard drive which trumps my other two in several ways. My first external hard drive was a portable 50 GB drive with two USB connections, one for power and the other for transferring data. This has worked out well as a storage for documents, pictures, etc. My next external hard drive was a 500 GB LaCie model, with a large external casing, a single USB connection, and a wall socket power cord. This third one has a capacity of 1 TB (1000 GB), it has a single USB connection, a soft case, and is less bulky than both of the others. All in all, I am tempted to scratch my old ones and just use this one, but I think I'll keep the others as backup devices. Why have one when you can have three, after all? I definitely need the space, even for medical school data. All together, the first semester at Touro University has yielded 4 GB of powerpoints, videos, documents, PDFs, pictures, and more.

I Must Be Crazy

2009-12-24T16:23:00.000-08:00

Just got back from Tahoe, had a wonderful time of course. It was nice being away from the grind of studying medicine, but all the same I found myself missing Principles of Internal Medicine, especially while watching Outbreak. Infectious disease is one of my biggest interests, and I felt so bad watching that small town doctor flipping desperately through his medical books trying to understand why everyone in town is becoming ill. I definitely do not want that to be me. I do not want to miss something vital, I know I inevitably will, but I definitely do not look forward to it.

Anyway, now that I am back I feel the urge to read through Principles and work on studying for the USMLE. This is as good a time as any to start reviewing. Less to learn later. Just reviewing everything we have already covered, and trying to fill in the gaps. One thing about osteopathic schools, which is a tad unfortunate, is we do not get quite the detail on genetics and pharmacology of allopathic schools. Luckily for me, I like genetics and pharmacology stuff, as well as microbiology, which I think is also treated a bit more lightly. Anyway, back to the unnecessary studying.

OMS1 Fall Semester: Complete!

2009-12-18T13:35:00.002-08:00

Well, this was an interesting first semester, but I am content with the results. Next quarter the goal is to get 90% or higher in Fundamentals in every section - OMM/Doctoring I don't particularly care about as long as I pass above an 80%. The tests are all over, hopefully we'll get some challenges that will improve my fundamentals score a tad.

Also, as far as the LASIK is going, I have come to the conclusion that I am not seeing halos at night, and everything is still nice and clear. Leaving for Tahoe tomorrow, and other than that, not too much to tell. Next semester we are starting on a bunch of stuff, so that will be rather stressful. But we shall see - my followup for LASIK is January 8 so hopefully I'll have more good news by then.

Hooray for Eyes

2009-12-11T23:39:00.001-08:00

Here's the latest from Dr. Auker. I can now stop putting the Vigamox (the antibiotic) into my eyes! I still have to do the Vexol for another two weeks, but only twice a day, down from four. He did seem concerned that my eyes were rather dry, but my eyes have been dry before I got the surgery, so I know it's not associated with LASIK. After years of contacts, I'm not a very good judge of when my eyes are dry, so I probably wasn't putting the moisture drops in regularly enough. He put tear duct plugs in each eye, so that it will slow the drainage of my eye/lacrimal fluid. He also gave me more moisture drops - I was running low. The girl who got the low down from me before Dr. Auker came in checked my eyes again and I'm still seeing better than 20/20 - I am able to see 20/15 in both eyes, but it's slightly more difficult in my left, so my right may be slightly better than 20/15.

In other news, after dressing up "professionally" and wearing a white coat with a patient again, my mind is drifting to my dearth of decent clothing. I have no nice suits beyond the suit I bought for interviewing, I have no professional tops except a single blue blouse, and the only dress shoes I have are heels and uncomfortable. I wore tennis shoes to the patient encounter because a lot of the doctors I've shadowed wear tennis/sports shoes and it is only logical - if you're on your feet all day, you need durable, comfortable shoes, not ones that are just for show. I should probably invest in two pairs of "professional tennis shoes" - a white and a black pair. Ones that look like professional shoes but are actually really comfortable. But then there's the issue of body fluids getting on my nice shoes during rotations and residency...oh the scutwork shall be wonderful. Either way, no one commented on my wearing tennis shoes, though I think I was the only one in my group who did. I am painfully wardrobe-challenged.

Standardized Patient Encounter

2009-12-10T18:08:00.000-08:00

Well, could have gone a lot worse, but I didn't leave feeling particularly confident. I practiced all day, had done 6 people in the past 24 hours, the last two times before I did the real thing I got under 15 minutes (the cutoff point). I did the exam exactly as I had practiced, maybe had a couple nervous pauses here and there that would have added about 45 seconds to my exam time had I been allowed to continue past 15 minutes. So, on the plus side - all the criticisms I got were things that I needed to incorporate into my already fine-tuned routine, rather than things that I simply "forgot" - except for one that I had asked another professor about earlier that he said was okay, but that my grader did not, so that was kind of annoying. The negative though, is that since I did everything exactly as I had planned, I thought I had done pretty well, so the amount of criticism I received was not expected.

On the plus side, if those fine-tuning things are the only thing I need to fix, that's reassuring. Also, the standardized patient and I got along quiet well, she seemed to think I was a nice student doctor and did not have any complaints about my examination. She reminded me a little of my aunt. A few of the other grading doctors gave students their scores, but people who had mine (one of the more in-charge doctors) and a couple others were not told. I am assuming it is because we are not supposed to know but a few docs bent the rules.

There was one thing I did that seemed to impress my grader - a lot of students are pretty nervous about approaching a patient's pelvis, so whenever we are told to find the femoral arteries everyone is very gingerly with their fingers. The correct method, as the teaching doctors demonstrated a few times, is to locate the ASIS and the pubis bone - around the middle of that diagonal is where the femoral should be - but almost no one does that. So I had a feeling they'd be pleasantly surprised if I located the femorals properly, which was the case (I was of course careful to explain to the patient before I did it, so she didn't think I was trying to grab her crotch, haha). I mentioned that to one or two other students before I did my exam, but with any luck they didn't incorporate it. Since it was pretty close to exam time, it's hard to add new techniques without messing up your routine, so hopefully I was one of the few students who did that and stood out a tad.

Tomorrow I have my followup with Dr. Auker about my eyes, which are still seeing nice and clear. Occasionally if they are dry it might be ever so slightly hazy, but it doesn't last long. Still using my eye drops all the time, too. Speaking of which, it's time already - now to get back to studying lymphomas, leukemias, tropical diseases, coagulopathies, anemias, and all the things that come with them.

LASIK Complete!

2009-12-05T15:03:00.000-08:00

Well, I got my LASIK done yesterday - and I'm sure everyone is curious about the medical procedure. My first appointment was a while ago where they checked my eyes to determine whether I was a good candidate. Some of the criteria include nearsightedness less than -10.00, sufficient corneal thickness, no severe eye dryness, and little or no astigmatism or other eye problems. My eyes are somewhat dry, both were around -3.00, unnoticeable asigmatism, and a slightly thicker cornea than average, so I was a good candidate.

The second visit, they dilated my eyes and did other tests to get exact readings on my eyes, we discussed payments, methods of going about the laser eye stuff, etc. I went with the laser system for cutting the flap in the eye (instead of a hand held microtome) and LASIK (laser-assisted in situ keratomileusis). After a couple reschedules, my LASIK date was finally set for Dec. 4.

I was instructed to wear glasses (no contacts) for the week prior to the surgery, I had to take a Valium (5mg) 1 hour before the surgery, and have someone drive me to and from the surgery center. When I arrived, they took me into a room to analyze my eyes, I forget what the first test was for, but the second one was to map my iris (similar to iris-recognition for security) so that the laser could lock onto my eye. This was part of the "Custom Vue" LASIK, where they use Wavefront, WaveScan, and WavePrint technology to get a very accurate fingerprint of the eye, so to speak. Supposedly, it can also measure flaws in the eye 25x more precisely than traditional methods. Then they cleaned the area around my eyes, put in numbing drops and antibiotics, and we headed to the first station - the intralase machine (the laser which cuts the corneal flap).

This was the most uncomfortable part - they had to prop my eyes open clockwork orange-style, then attach a plastic fixture to my eyeball with suction, so it was completely fitted to my eye. Then the other end was attached to the intralase machine, and basically my eye saw those gray/white/black patterns you see in your eye when you press on it. Then I had to hold still for a moment and it cut the flap; I couldn't feel it, maybe there was a slight warmth. Then we repeated for the other eye and I went to another room for the LASIK laser procedure. They propped my eyes open again, taped my eyelashes back, added more numbing drops, and had me look up at the laser. The doctor folded back the flap on my eye. The laser itself was a green color, but there were bright dentist-like lights on either side, which were painfully blinding. As they focused the laser's position, there was a grid of red light that I saw pass over my eye. Then I held my focus on the green laser point for a few seconds as it did its work. I could smell flesh burning...not too pleasant. Afterward, the doctor replaced the flap on the eye and smoothed the lines of the incision to make sure it was firmly back in place. Then we repeated with the other eye and I sat aside for a bit while someone else had the same procedure done. Afterwards, my eyes hurt quite a bit - like there was sand in them and some of the chemicals made it difficult to open my lids. The doctor rechecked the eyes, said that the procedure went perfectly and the flap was back in place. About 2 or 3 hours after being back home the pain had gone away and I could open my eyes for brief periods of time.

As far as post-op care, I cannot use eye makeup, wash my eyes, do any strenuous activities or go swimming, and must put one drop each of Vigamox (Moxifloxacin hydrochloride) and Vexol (Rimexolone) into each eye four times per day, and use Systane (preservative-free) eye drops as needed for dryness. I also cannot rub my eyes and must wear goggles at night and sunglasses outside. I also have to be careful when doing activities that tend to cause less blinking, such as working on the computer, reading, or watching TV - essentially, I have to remember to blink or hold my eyes shut every so often. I have to keep up this post-op care for 1 week, but I have a blackberry app that lets me do as many different alarms as I want, so I have 1 wake-up alarm, 4 eye drop alarms, and 1 birth control pill alarm. I can make it play whatever song I want as the alarm, too, and change it for each alarm - if anyone's curious, this is the app.

The next day (today) I went back in the morning for him to check how my vision had changed, and I am 20/15 in both eyes - so better than 20/20 (standard). I have a followup in a week to make sure things are healing correctly, and other than that it went off without a hitch. It's great being able to see without contacts or glasses! It feels so weird that such a short procedure, which doesn't look or feel like anything changed with my eyes (currently, anyway) could suddenly make it possible to see super-perfectly clear.

As for the breakdown, Dr. Auker's costs for examination and supervision of the procedure were $2,350, use of the LASIK machine was $2,150, and the intralase machine was $600. My mom had originally offered to cover $3,000 as a gift to me, and when it turned out to be more, I covered the excess. So in total, $5,100 dollars for both eyes, $2,100 out of my own pocket, but I got 20/15 vision out of it so I'd say that's money well spent. I should point out that Dr. Auker and the laser center are more pricey than other options out there, and I do not know whether there is a substantial difference in quality - Dr. Auker treated my mom's eyes about 10 years ago when he was still with Kaiser and she is still happy with the results - he now has a private practice. Considering his experience, and the fact that he was performing LASIK successfully when it was brand new with good long-term results, made me feel more confident in his skills/knowledge and more likely to choose him over a cheaper alternative. To see his website, click here.

Bolivia! It's ON!

2009-12-01T21:43:00.001-08:00

Today was fairly straight-forward, though I forgot to drink any caffeine so the day started dragging down during the myelosuppressive disorders lecture. My group had two OMM sessions to get through today - the first we had a short quiz (easy) on muscle attachments and worked on some rib muscle energy techniques, then after lunch I had a semi-practical where I had to demonstrate upper thoracic vertebra muscle energy techniques - passed without a hitch.

Now for the good stuff - we had a Bolivia information session today with the coordinator, Dr. Garcia-Russell. I really cannot wait to go - we'll be staying in La Paz with a local family, two or three people per family, and the overall price of the trip looks like it'll be $2,000 - broken down, about $1,000 for air fare, $100 for entry visa because Bolivia hates America (no entry cost for non-Americans), $150 for accelerated Spanish course (50 hours), $100 preceptor fee that goes to the hospital hosting us, $270 for the room and board for 3-4 weeks, and a few miscellaneous costs here and there. It's amazing how cheap everything sounds like it will be - and some local attractions include Lake Titicaca, nature preserves, etc. I was expecting to be staying in a very rural area, so being in La Paz a surprise. Here is a picture of the hospital: Arco Iris.

Check the link above for information about Arco Iris. It looks like it'll be exactly what I was hoping for - a place in South America where they speak almost only Spanish (and a couple indigenous languages, like Amaya), in a climate that is perfectly tolerable to me (it should be cold and sunny at 12,000 feet), and I get to learn more medicine and get a valuable experience. We will be leaving at the end of May, right as our block exams finish, and be in Bolivia for 3-4 weeks, the last week being reserved for social work with an orphanage. Our clinical experience will be rather basic, but we spend a week in Obstetrics, Pediatrics, and Emergency medicine, as well as accompany a Mobile Medical unit that goes through the streets and to schools. Some of my family may come down at the end of my internship to spend time in Bolivia or a neighboring country. I'll bring more news later! Now to do more studying...

Oh right, and LASIK is happening, for real this time, third time's the charm - this FRIDAY!

Faster and Faster

2009-11-29T23:38:00.000-08:00

I used to be more on the side of patients when it came to doctor visits, but now I'm feeling a lot worse for the doctors... We have gone through the general screening exam, which includes neuromuscular, cardiac, respiratory, gastrointestinal, HEENT and taking vitals thus far. If we are allowed to do it at our own pace, no rushing, talking sweetly to the patient, etc. it takes us about 30-40 minutes to do it at this point. We are expected to speed it up to 15 minutes. I have been able to do it all in about 15:45 minutes, but it feels so rushed as far as barking orders and telling the patient to jump and sit that I can see even more clearly how a patient would feel like a physician doesn't care about them. Unfortunately, when we're expected to cram exams into a tiny amount of time...it's hard to do it in a way that makes a patient feel happy.

Of course, I'm betting that's where the magic of experience and bedside manner kick in. I'm going to try to practice the exam in 15 minutes but also practice my tone of voice and memorize concise, simple instructions so that I don't feel like I need to cram my words together. That, and I need to get a really good feel for the order and routine, as well as the phrases...ugh! So much to remember! We are required to say specific "lines" when we do examinations, such as "Patient is breathing easily, quietly, and regularly" or "Patient presents with no edema and is not diaphoretic or cyanotic." It really feels like being an actor/actress almost, since they really are lines.

In other news, I got a massage table, which I plan to use for massages, OMM, and exams - so that should help a lot. Also, we're focusing on hemostasis and hematological diseases at the moment - all very interesting and familiar since I worked in the laboratory for 3 years and I've seen all the lab tests before. Goal for this is to memorize the clotting cascade, the diseases, and the treatments, as well as go back over all the stuff I've already learned and try to commit it to memory.

Almost done with Block 2!

2009-11-10T11:53:00.000-08:00

Just finished as much studying for Doctoring as I think will make any difference at this point. After the FOOM test on Friday, I was burnt out on studying until Sunday - so I was not very productive until then. Monday morning I practiced OMM techniques with a bunch of different classmates for about 4 hours before the practical exam, and I know for sure I aced two of the three portions. I only know because those two professors gave me feedback, and the third kept a nice poker-face the whole time - but I think I did satisfactorily at that station too. Then this morning we had our OMM written exam, where they describe positions, techniques, and segmental findings and we have to know the type of technique, what the diagnosis is, etc. We also have some "softer" portions, like history of osteopathy, particularly in California. I think they overdid it a tad on that, since our professor didn't finish the lecture on California, but should be good either way.

The Doctoring exam coming up in half an hour is going to test on portions of the screening exams - so far we have covered general, HEENT (head, eyes, ears, nose throat), Cardiovascular, Respiratory, Abdominal, and Neuromuscular. Since we're osteopaths, we also throw in a TART screen at each step, but the way it's integrated it almost feels "tacked on." The test is also going to cover Medical Jurispridence, a lecture I missed where we got to hear about all the ways we can get sued, how getting sued works, and how to try to avoid it.

We recently saw a video about Convocation too - it's essentially a DO Seminar/Convention where everyone from experts to first years goes to see different techniques, hear what's new for Osteopathy, etc. It's a little pricey, but I requested a bit more loan money this year than I needed, and it's being held at Colorado Springs resort this year, so I might as well take advantage of that. It is held on a weekend in March, but we shall see if I can attend - I might be on a vacation. Anyway, enough distracting myself - I should get focused for doctoring and then fun and relaxation for a few hours before I realize I have to start prepping for Midblock 3 that is happening in 13 days...

Block 2 Fundamentals - Done!

2009-11-07T18:41:00.000-08:00

Well, I finished my Block 2 exam for FOOM, but I still have two written exams (Doctoring and OMM) and a practical OMM exam. I slept through my alarm on the morning of my Block 2 test, so I didn't have time to review virology, mycology, or pathology - if I had woken up early enough I probably would have reviewed material that would have given me 3 or 4 extra correct answers on the test. Either way, I don't think this exam will affect my percentages much...unfortunately. I'll just have to try a little harder this next block! Also I took a few pictures of the campus - it was a nice sunny day, so here they are:

In other news, my LASIK is finally scheduled for good - December 4th. After that - no more contacts! Hooray! Next week after the tests should be very nice - hopefully seeing a movie or two with a classmate, Kit's coming up to visit on Thursday, and I'll have a rather relaxed weekend. Next block we will be covering diseases of the immune system including HIV/AIDS, immunopharmacology, and blood.

I feel like I've been slacking off on the USMLE First Aid book - in the sense that I have not opened it yet. I haven't been using my books enough in general. This final third block I swear I will do all the assigned readings before the lectures! I double swear! And I will cut down on the Left 4 Dead playing a little. During weekdays. If I have to wake up early. And have a short day also. Maybe.

Classes and Weekly Routine

2009-11-02T09:03:00.000-08:00

Comparing my two blogs, I'm relieved that despite the uneven posting habits, I've essentially posted the same number of posts - go me. We're starting to get into the virus lectures, which is of course one of my main interests. I never really described our general weekly curriculum, so I'll delve into that briefly - I'm not sure how they do it at other schools, but I have a feeling we're somewhere in the middle as far as weekly hours. We also get an hour for lunch from noon to 1am.

Monday - usually a long day of lectures that set the tone for the week, lasting from 8am until 3pm-5pm. Tuesday through Thursday we have small group sessions in the morning and afternoon, and 2 hours of lecture each day. There are 3 divisions for the small group sessions, groups A, B, and C - I am group A, so I'll describe that arrangement. Tuesday we have morning small-group OMM lab, where we practice techniques, diagnostics, etc. from 8-10. From 10-12, we have lecture as a whole class. From 1-3, we sometimes have no class/independent study, it depends on how many classes are slated for that slot for those three days (2 classes, we have one afternoon off, 3 classes we have something each day). Usually it is a class-related workshop, working with new equations, concepts, etc. On Wednesday, we have morning "independent study" so we don't come in until 10, for the 10-12 whole class lecture. Our afternoon class is usually doctoring, where we practice clinical diagnostic techniques, examinations, etc. On Thursday, we have histology or pathology in the morning, and in the afternoon we either have more histology/pathology or another class-related workshop. Fridays we have lectures that may end as early as noon or as late as 5pm.

A few more observations as of late - one might think that after four years of undergraduate, some masters/higher level education, and clinical work, we would be desensitized to "sensitive" medical material, like genital warts or hypospadias. Nonetheless, I still catch a few students giggling at the mention of herpes and genital conditions. I'm sure by our second year most of the gigglers will have gotten used to it - or pelvic examinations will be extremely awkward for them (moreso than us non-gigglers).

Back in the Swing

2009-11-01T17:39:00.000-08:00

Well, after getting sick, dealing with the second midblock, and finally partying it up for Halloween, it is back to the grind. Lately we have been focusing on antibiotics, bacteria, etc. - which is fine by me, being interested in infectious disease. We are starting to get our clinical experiences set up - I've signed up for my first one for December 3rd. From what I hear, we get to take histories from actual patients!

Also I have touched base with a professor who is researching lysogenic bacteriophages in Salmonella, and will be starting a project to determine the actual contents of probiotics, and to determine a useful way of checking their claims. I always wondered how dry pills could contain as many active bacteria as they claim. So, either probiotics/supplements or bacteriophage research - both of which I find extremely interesting. She is also the same professor in charge of the Bolivia trip, so I have communicated to her my intent to go with them next summer. The only concern I have is that they are doing a lot of PCR and I have never actually done PCR, since in our class labs, the TAs always ran those. Not too worry - it can't take that long to learn how to do.

We have a string of exams coming up, which should be interesting. I'll be practicing OMM all next week. One of the great things about going to a DO school is that if you have a muscle/bone/joint problem, you can ask a professor to take a look, and within 5 minutes you can be feeling much better. I had some hyperextended ribs/vertebrae, and when I inhaled it compressed my nerves and sent joits around my ribcage - usually it happens transiently, but this time it stuck around the next two hours of class. I went to my adviser's office to see if he could spare a couple minutes, and when I left I was breathing painlessly - as well as having had my shoulders, neck, and arms aligned.

Also, for any possible MDs reading this, I would like to add that at Touro, our professors are very adamant about not demonizing MDs. One of our lead DO professors, every few lectures when he speaks about the development of the DO profession, always makes very clear that MDs and DOs each have their faults and that neither is wholly responsible for the clashes between the professions. I know at other DO schools there is a strong sense of rivalry, but I don't get that sense at Touro, for which I must applaud them.

One Month Later...

2009-10-27T16:34:00.001-07:00

It is a shame I haven't posted for a while, not that too many people follow this blog, but it is so easy to get wrapped up in medical school! I did well on the last Block exam, after which I had a Fall Break and went to visit my boyfriend in San Diego for a week. My LASIK still has not happened, due to endless rescheduling - the latest hiccup occurred 24 hours after I received the live intranasal flu vaccine (not H1N1). I was told I would experience some runny nose, maybe some tiredness, etc. - nothing too unreasonable. By lunch the next day I was ready to crash - I had a 101 degree fever, sensitivity/aches, chills, chest congestion, headache, fatigue. Essentially the flu - except more likely a reaction to the vaccine - all those symptoms were listed as 'mild side effects' for my age group. Symptoms lasted from Thursday to Tuesday, essentially destroying my weekend, and 4 extra days during which I could have studied for the second midblock exam that I had three days later. So much for that.

Now, I must explain a few things, as it is my duty to my profession. First, one cannot get the flu from the vaccine - whether it be intranasal or the injection. The intranasal vaccine contains live attenuated virus, an adenovirus that has been altered so that it can only thrive at temperatures below that of the human body. It has the antigenic markers of flu viruses so it can confer immunity when the immune system reacts. Second, the reactions most people experience with regard to the flu vaccine are an immune response to the adjuvant, derived from eggs (a common allergen even outside the context of a vaccine). Third, from what I understand from my immune system professor and the lectures, people tend to show symptoms to a virus like the flu within 24 hours.

Keeping all these things in mind, there is a slight possibility that I encountered someone who had the flu between the morning that I got my flu vaccine and the following day. However, I think it is much more likely, then, that I had a reaction to the attenuated live virus. I know this reaction is supposedly not typical, and I had the nurse file an Adverse Event Report, but I know it will be difficult for me to recommend live intranasal flu vaccines to any future patients of mine. I won't have much trouble recommending the flu shot, but unless a patient is in a high risk group, then I won't be recommending anything but the flu shot. For all practical purposes, the vaccine put me out of commission for 5 solid days during which I could not do anything productive. Trust me, a medical student with an upcoming exam will not easily be dissuaded from studying, no matter how bad they feel. It was miserable, I was pissed and frustrated, but at least I got my flu season illness out of the way - I better not get sick again...

Anyway, now I am focusing on learning tons of drugs - NSAIDs, antibiotics, chemotherapeutics, etc. Our recent topics have been pathology, neoplasia, antibiotics, immune system, NSAIDs, and inflammation. A friend of mine also recently got accepted to Touro, though she applied to some MD schools too and I know if she gets into one of those she'll matriculate there. Back to studies - will include more doctory stuff next time.

Setbacks and Progress

2009-10-01T01:03:00.000-07:00

Alas, a few unexpected setbacks occurred recently - first, the LAN party was cancelled...blah. Next, my ophthalmologist had to reschedule my surgery since he got a short-notice need to go out of town, so I'm trying to schedule it for the Friday after I get back from San Diego. On the plus side, I just started my Medical Spanish elective, which of course reminds me of the fact I'm going to go to Bolivia hopefully, and I met with my faculty adviser just to make sure I'm on track. My performance on the last exams was above average - and that's saying something when the average is 89%. My goal is to be in the top 25%, so that will be difficult...but hopefully doable! If I knew the standard deviation that would be more helpful, but you do what you can.

We're also learning more about doing histories and general survey exams, so HEENT, vitals, etc. It's fun - feels like we're really becoming doctors. I am anxious to update my insect blog, I have at least two insects to take pictures of and write about, one of which isn't even pinned yet, so hopefully I'll do that tomorrow or during the weekend. Wicked is still happening, and I'm probably going to the Renaissance Faire with the family, so that's good! Anyway, I still have some reading to do tonight, then sleep!

Hooray for Tools

2009-09-21T21:05:00.000-07:00

I'm watching the House premiere, got all my test results back (beat the average, that's what matters), and have a pretty easy week ahead of me. We're starting pharmacology, cell death, immune system, etc. and we also are starting to learn how to use all these nifty items we got from various companies. Here's a picture of them all assembled in their glory:

Golly gee, what else am I up to...next week we only have three days of class, since there are two Jewish holidays. Friday's my last face zap, Saturday night I'm going to a Touro student LAN party for Left 4 Dead at a friend's house (hey, we gotta have some fun), then Monday pre-op and Friday operation. I know I keep mentioning it, but it's exciting - finally I will have clear vision! No more being a slave to contacts. By the way, our professors this week are better than the last couple weeks' professors - both are very well-educated and decent lecturers (with decent powerpoints) so this shall be good. Anyhow, back to House!

Almost...Almost...

2009-09-17T11:23:00.000-07:00

Man, such a week. On the plus side, I keep overestimating how difficult all the tests will be. I suppose I should be glad they don't want to torture and weed us out - they do need our money, after all. Just came out of my FOOM exam about... 2 hours ago. I took my time, and out of 64 questions I think I missed 4 (after careful review and conferring with others). I really wish the FOOM and anatomy practical exam were not so spaced apart though...it was scheduled to end at 10 and my anatomy exam time, the earliest of the 3 times, is not until 1pm. I live too far away for it to be worth driving home, so I'm just hanging out at school.

In about 20 minutes or so I'll start cramming for the anatomy exam - there's a list of 30 or 40 things we need to be able to recognize - shouldn't be too hard. Between 12 and 1 I get to pick up a parking decal, so I won't get ticketed in the future. After my exam, I get to pick up my medical equipment - that is going to be cool. If I had more energy, or were staying home this weekend and not going to San Diego, I would totally play with all these things and look in/at my family's ears, noses, eyes, hearts, valves, and lungs. When you get the stethoscope, you know you're on track to be a doctor.

Anyway, this weekend shall be fun and relaxation. Then I can look forward to my 5th and final face treatment on Friday, my pre-op appointment for LASIK on the following Monday, and my actual LASIK surgery on the Friday after that. That weekend I go to see Wicked with the family, and then on the 5th I'm off to San Diego again, but for a week! Good times ahead.

Blocks coming up...

2009-09-11T15:34:00.001-07:00

Here I go off studying again - after which I fly down to San Diego for the weekend and then come back for Pharmacology. On the plus side, we should all be getting our medical equipment soon, so we will start learning how to use all the common doctor tools! In the meantime though, it's study study study! I'll have to corner my parents at some point this weekend and do all the techniques on them. I'll have a checklist and practice them all!

A friend of mine also made a program that I can load with a word bank to self quiz - I'll probably make a few versions of it - one that quizzes on anatomical stuff, another for actual disease names, etc. I'll also probably distribute it to my classmates, see if any of them would like to try it out. So...self-quizzing and practice quizzes; drawing out the muscles, landmarks, and the nervous system; reviewing histology slides; and practicing OMM seem like a decent way to study for this thing. So, until further notice, I am locked in my room studying with my study buddy:

Tests again...

2009-09-10T00:55:00.000-07:00

Just when the Mid-Blocks finish, the week after the next it is time for the 1st true Block exam. Thanks to my more efficient note-taking strategy, I feel less stressed about it at least. And I have a 3-day weekend visit down to San Diego to look forward to when it is finished, but I feel like I need to step up a gear or two. The last two weeks we've been focusing on the nervous system and genetics - both pretty familiar to me. The osteopathic doctoring stuff and OMM questions will be the challenging ones - there is a lot of terminology that I haven't forced myself to learn yet. Also the anatomy lab will probably be a challenge.

Today in our team-based learning groups, we had a session on the autonomic nervous system, and the detail we were expected to know seemed much more sufficient, but the reading material we were given as prep was sorely lacking, in my opinion. As far as clarity and ease of understanding...it was just not very good. I need to look through my old UCSD textbooks to see better discussions of the nervous system. I hate to make any negative comparisons, but I definitely appreciate the caliber of my science lectures at UCSD more now that I have seen another school's. It's not just the faculty, I think there are some really smart faculty here, it's just the presentation, the accompanying texts, the organization, and the powerpoints that seem to be lacking. Course, the school is a lot newer, with many new faculty, and UCSD WAS recently ranked #2 university by the Washington Monthly magazine, so it's not a fair comparison.

Anyhow, this weekend will be a lot of studying - good old-fashioned writing stuff down and trying to put it into memory, rather than my last bout of studying where I was frantically typing up answers to questions and hoping I would remember the answers 60 pages of typing later.

Getting in the Grooooove

2009-09-03T18:07:00.001-07:00

Today was quite productive - I turned in this autonomic read-and-answer-Q's packet, filled in and turned in the "Meditation" sheet, attended my classes very attentively, worked on my objectives, and talked to classmates and professors a decent amount. The meditation sheet was an assignment from our "Managing Stress" class, designed to keep medical students from freaking out or dropping out or going postal. I just put lying with my kitty on my chest - she purrs so nicely! She even massages me half the time.

Anyhoo, I'm renewing my studying zeal - finding a new way to focus, study, attend lecture, etc. It's working out pretty well so far - it's even helping in my absorption of my Japanese audio lessons. Say what you will, but I think I'm decently proficient now - Japanese is pretty easy anyway, since the language is so vague you can get by without knowing much vocabulary. It's the writing system that'll take me a while to get used to...

Now for some good old studying! Again! Kit comes down this weekend, and after next week is the first block exam, including an anatomy and OMM practical.

Another test down the hatch

2009-09-01T14:41:00.000-07:00

Today was the practical for OMM techniques - mostly soft-tissue type techniques. I managed to do the technique satisfactorily as well as diagnose where treatment was needed - the latter part was not necessary, but kinda looked good at least. We also had a lecture on membrane potential, which I personally think was really helter-skelter and poorly explained. Maybe I've just learned about membrane and action potentials a lot, but I feel like the professor had really poor diagrams and was not getting the message across effectively.

At any rate, I really cannot wait until Friday - we get a three day weekend on account of Labor Day, I'm getting my 4th face treatment, and Kit's coming up to visit. This week we are essentially learning the basics of neural biology and learning a little more about surface anatomy. We do get to look at nerves in histology, which should be interesting. I really should study some more for the block exams that are coming up - September 14-18.

First test: Pass!

2009-08-31T17:34:00.000-07:00

First test went pretty well - certainly passed. Studied all weekend. I have a better study method now, so hopefully next time the cramming won't be quite so intense. I'm finally able to relax...a tad. Tomorrow I have a mini-practical in OMM, so I have to review those techniques, practice on my family, and then hopefully do a decent job tomorrow. The techniques we have learned so far are soft tissue techniques, inhibition mostly.

In addition to the midterm today, we also had several lectures. The woman who taught our neurohistology course was one of the two faculty who interviewed me, and she is definitely a cool lady. The other professor is one of the jolly OMM doctors. I think I really lucked out on my faculty interviewers - neither of them was much of a hardball.

Also, we had a lecture on lymphatics today, and there were a few interesting factoids presented. The one that caught my eye the most was the statistic that ~20 million people in the US caught the Spanish Flu, and of them 500,000 died. ~100,000 were treated by DOs with a mortality rate of 0.25%, whereas the portion treated by MDs had a 6% mortality rate. I think it probably had most to do with the fact that MDs were probably experimenting with a ton of medicines to try to determine their efficacy - not necessarily a bad thing. Yes, it was unfortunate for those who were given dangerous medicine, but there was so much quacky medicine out in the early days of the profession that it had to be ruled out somehow. DOs probably stuck with lymph-facilitating techniques, which at worst are harmless and at best a catalyst for recovery.

Gone Studyin'

2009-08-28T15:23:00.001-07:00

Another day...

2009-08-26T17:49:00.000-07:00

Well, the white coat ceremony was on Sunday - it went well enough. We all went out to lunch afterward. Very little to say about it, except that I am glad they did not make it longer than they had to. The pictures are up on facebook, for those of you I permit to see my profile stuff. Interesting little tidbit though - being a Jewish sponsored school, the rabbi did a talk at the very beginning and blew a shofar, or ram's horn instrument used for Jewish services. I've been steadily working through our class objectives - have to get through them all by Monday, as that is when our first major exams are - the midblock exams.

We also just started learning some actual OMM techniques in lab - this week we are focusing on soft-tissue techniques. I need to practice on my family a bit before Monday, I think we have a practical portion of the exam. The details about what is being tested is a little hazy. Also, today was Club Day, and there was a blood donation bus, so I donated and checked out what clubs there are on campus. I joined Internal Medicine, Osteopathic Physicians and Surgeons of California, the CMA/SCMA (free, otherwise I wouldn't have), and Undergraduate Osteopathic Student Association of some kind - I don't remember exactly the abbreviation. I was considering SOMA, but it's a bit pricey compared to the others. All in all, it was nice to hang around and see what clubs there are.

Radiation, oh my!

2009-08-21T13:59:00.000-07:00

In our radiology lecture today, we were discussing how x-ray machines work, from traditional film x-rays to angiograms and radioactive dyes. There was a chart I thought was interesting that compared the chances of getting cancer from a typical dose of radiation to the chances of other life-endangering conditions:

So basically, getting a chest x-ray is about as risky as spending 3 days in the US, or eating several spoonfuls of peanut butter. I definitely did not think peanut butter was so dangerous... Apparently there is a mold that grows on plants such as corn and peanuts, and it produces a toxin that can be highly carcinogenic. The bacterium is named Aspergillus flavus, A. flavus, and thus its toxin was named Aflatoxin. There is another species in the same genus that also produces the toxin, but A. flavus was discovered first so its name was used. I'm not saying we shouldn't eat peanut butter, I'm just surprised that there was such a risk.

Sunday is the white coat ceremony, and in the meantime I'll be hanging out with Kit - he's visiting for the weekend. We have been going over a lot of biochemistry, but most people in class are having some trouble with our professor's lecture style. I imagine it would be very difficult to understand the jumps from one cycle to another and the brevity of his explanations if one had never taken biochemistry. Lucky for me, most of this is old hat. I'll spend most of next week working on those objectives, and hopefully the first exam (August 31) will go well. I also got my approval to take the Medical Spanish elective, which doesn't start until September 31. On Monday I'll be finding the professor who is teaching the advanced nutrition course so I can take that, and also I'll make an appointment to get another tuberculosis test - the physician who did my physical doesn't think the stuff I sent from Kaiser is official enough, and I can't get the records unless I go to San Diego in person, so screw it - I don't mind getting a bubble in my arm if it'll finally end this ordeal. Besides, if I don't have all my immunization stuff in, then my grades won't be disclosed and I'll be left out of clinical activities.

Nearly Through Another Week

2009-08-19T00:31:00.000-07:00

Amazing how much less reading it feels like I have this week compared to last. I got some OMM treatment today for my lower back, but apparently there is something going on by my left scapula that one of the doctors think I should get checked out. Alas, there was not enough time today, but perhaps next week. We had our third back dissection the other day, where we sawed open the spinal column to view the spinal cord. We're beginning to finesse the dissection a little better, after doing a rather poor job on the back muscles. We're in the middle of biochemistry, so lucky for me it should all be review. Our first exams are the week after next, and next week has a lot of short days! All the better for studying!

I'm sure it's different at other medical schools, but here all of our courses have "objectives," certain topics we are expected to master. For example: Know what an allosteric enzyme is, understand how it functions in Hb. There are lists for each class and I am going to go through them all and answer them as fully as possible. Also, for the record, birth control pills really mess with your head. Long story short, I was forced to go back to an old prescription and it sunk me into depression for about a week. I wanted to wait until my new health insurance came in, since the cost for the pills under my Anthem Blue Cross coverage is 70% the retail price, as opposed to a single copay. I decided I couldn't take much more of it, so I got a month's worth and started, and every day I feel better. I really understand the meaning of the symptom "no longer enjoys things that used to bring joy" - particularly now that I can enjoy them again. Also, if anyone's curious, Microgestin FE 1.5/30 was bad for me, Yasmin/Ocella was good. Though I've heard mixed opinions about both.

Anyhoo, this weekend will be packed - Kit is coming up for the weekend, my sister is getting back from camp, the white coat ceremony is on Sunday morning, and I'm going to go see Ponyo in theaters. On another note - I'm 1/3 of the way through my Japanese audio lessons! Sleep time now.

Good News

2009-08-12T19:21:00.000-07:00

One of the programs offered at Touro, and many other medical schools, is the opportunity to go abroad and learn about foreign cultures, diseases, languages, and train as a physician. It was described vaguely by one of the directors of the Global Health Program, and it sounded like it would be the entire summer - two months or so. Anyhow, I met up today with a second year who I knew back in high school and she and her roommate both did the program and their internships only lasted 3-4 weeks - which is much more conducive to my particular goals. Also, they said the medical spanish program does not require very much fluency, so once I take that and the global health elective in spring, I should be all set! Hopefully I will have worked through most of my spanish audio lessons by then, so I'll be prepared! I'm excited, hopefully it'll all work out! I should bring some jars with me...I'll bet the insects there will be amazing.

Today we also had a stress management course, which seemed to try to prepare us to expect and prepare for the worst. I think I'm a little better off than some other students, who are either living by themselves or have families, and those who are type A individuals. I am definitely not a perfectionist, and in medical school it sounds like perfectionism is a bit of a curse. Anyway, I did not get much studying done last night, so hopefully I'll be more productive tonight. Plus, tomorrow we start Histology, which I'm worried will be a bit challenging.

More OMM and BLS

2009-08-11T18:34:00.000-07:00

Today was my appointed 'basic life saving' skills course time. So, I got to spend a super fun 5 hours or so learning CPR... I wish they didn't have to train people in it every two years - maybe every five unless some drastic change is made to the procedure. We also got to do more OMM today - basically just palpated our randomly assigned partner on the back, neck, chest, hips, and legs. Tomorrow should be a decently easy day, since the only other course besides embryology is "Stress Management." I think I'm doing pretty well, to be honest - I seem to be more on top of reading than the average person here. It probably helps to have come almost straight from college.

We were assigned to watch a movie for one of the osteopathic classes - "The Doctor." I haven't watched it yet, but it'll be nice to watch in some down time. Other than True Blood, House MD, and a couple animes, I don't have much on my list to watch. I've been relying on caffeine a lot these days... One thing recommended by other students is to follow along in the USMLE First Aid as we go through certain topics in class, so that we know to what we should pay attention. Our embryology professor also mentioned that we don't need to memorize stages, that it's more important to understand disease and treatments. I don't know that I trust that though - I would want my doctor to remember how a zygote or embryo differentiates. Maybe I just hold myself to a higher standard than the boards. I find that unlikely. After a few more minutes of relaxing, it's back to the books!

The Fruits of my Labors

2009-08-10T20:04:00.000-07:00

I felt so much more prepared for anatomy lab today after all that COA cramming. I'm sure it would be easier if I had been exposed to anatomy before this, but the last time I studied muscles was my middle school's health education segment of PE. Also, they gave us more guidance about what to do today, which I felt they should have done the previous day too. It's interesting, by the time you've worked through a lot of the fat, your hands are covered in slick yellowish oil, since the fat has essentially liquefied a bit. I am in the A group, and we lucked out in that we do not start more than one new unit each day - tomorrow we start embryology, and on Friday we start histology lab. As a result, we have sufficient time to get used to embryology before we have histology. For the time being this is my new favorite book...

I also signed up for some electives - there are a few decent ones to choose from. I was tempted to take medical biochemistry, since it goes into laboratory tests, but it is a two unit class and I really wanted to take advanced nutrition and medical spanish (each worth one unit). In the spring it'll be more medical spanish and global heath care. I'm looking forward to doing more OMM tomorrow - it's great to have pseudo-patient encounters, even if they are our classmates. Speaking of osteopathy, we had another one of the "pep-talk" type lectures today where we are told what is so unique about osteopathy, how it is a philosophy that will change our lives, how important it is that we're becoming doctors, etc. I wonder if MD students get similar pep talk classes? I was considering taking pictures of the campus today, but reconsidered. I think there are sufficient pictures on the website if anyone wants to browse through them.

Nose Deep in Clinically Oriented Anatomy

2009-08-08T23:23:00.000-07:00

One of our largest, densest texts is Clinically Oriented Anatomy, which our anatomy professor, during his very informal first class, told us we didn't really need to read in much depth. I think that was very misleading (he just wants us to read the easier beginning anatomy text he wrote himself). Also, they put up a lecture powerpoint for the anatomy lab, and even have a section on the schedule which logically is the lecture for the lab, but apparently we are not being lectured on the anatomy lab lecture powerpoints, so we have to go over them in depth beforehand by ourselves if we want to know what's going on in lab. I also know I wasn't the only one - no one else in my group knew what to do either. I don't think they were very clear with us about that, so I feel a little betrayed, but what can I do.

...except go into insane overdrive. Now I'm taking it upon myself to learn all human anatomy without the aid of lectures. Since we're also starting embryology and histology next week, I feel a pressing need to memorize the anatomy stuff before we start those subjects. I wish I had taken physiology or embryology as an undergrad - it would have made things easier for me now, and probably next week. I also dropped my phone in the toilet recently, so I went to Verizon and got a new phone - a PDA since there are some medical apps which are apparently crucial during rotations 3rd year. I ended up getting the Blackberry Storm - 8gb, all touch. I can't stand those little roller balls on the traditional Blackberries. Anyway...back to COA.

Last of the "Day X" Entries

2009-08-07T19:20:00.000-07:00

My entries will start having more of a topic format than a daily routine format, since accounts of daily activities can get rather dull, even if it is about medical school. Today we had history of osteopathic medicine, cultural competency, and interviewing, which explains certain strategies and considerations when interviewing a patient at a doctor's visit. After lunch, we all went to the anatomy lab and started on the back dissection. Our cadaver is a 96-year-old woman who died in a curled position from dementia. Unfortunately a lot of her muscles were deteriorated when she died, so muscles like the latissimus are very thin and fragile. It's a lot to memorize, and I'm going to devote most of my studying this weekend to learning all the names of the back muscles and review dissection techniques.

Next week we start on embryology, patient interviews, and basic life saving techniques. Hopefully I'll be meeting up with a friend of mine from high school who happens to be a second year here. It's exciting. I'm still waiting on the form from the doctor down south so that I can enroll in student health insurance, but I guess I'm not in much of a hurry. There was a party tonight but I guess I just don't feel like being social after a long week of meeting dozens of people. I think I've been doing a pretty decent job remembering everyone though. Also, Non-Sequitur had a cute comic today about patient noncompliance.

First Day

2009-08-06T18:29:00.000-07:00

Today was the first official day of classes. It went well, and I am trying to be very thorough with my notes so they will be a good reference for later when I'm studying for the COMLEX and USMLE. Every now and then I'll hear someone say COMPLEX instead of COMLEX and it kinda grates on my nerves...I can tell when professors hear someone say it that they are annoyed, thinking "If you knew what the acronym stood for you'd say it right." For those who are curious, it is "Comprehensive Osteopathic Medical Licensing EXam" - I don't see a "P" between Medical and Licensing. At any rate, we started out with an introduction to the study of anatomy. It was interesting because Dr. Hartwig is a fan of Latin, so he was giving us all the Latin roots of words and making cracks about how PhDs are teachers, not doers. I only wish I had taken some caffeine this morning - there was a slump of extreme sleepiness I had to fight through around 10:00am - 11:00am. The two morning classes were both part of the Fundamentals of Osteopathic Medicine course (FOOM).

After those classes, we went to lunch and I got my library card, changed my computer access code from the default, and checked in with SHS again to see if the doctor had sent in the forms yet. Negatory. After lunch we started in on Osteopathic Manipulative Medicine (OMM) and got to start familiarizing ourselves with our classmates' backs. We're doing a back dissection tomorrow - interesting stuff. After that, we went to Osteopathic Doctoring class (OD) where we discussed ethical situations in which professionalism is the heart of the issue. We also discussed the different methods of doctoring.

I finally got some caffeine and a day planner - that'll come in useful. Now I need to get some reading done, plan out lunch for tomorrow, organize notes, etc.