Second Week at the AIDS Clinic

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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.