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.