Psychiatry Week 1

This rotation is a breath of fresh air compared to the previous one.  First off, our preceptor is a nice middle-aged white chap who I have no trouble understanding and who likes to sit and chat about psychiatry.  Second, it is not a high-stress environment, despite being surrounded by many psychotic patients (in the medical sense). Third, I have a fellow classmate with me on the rotation, so we have each other to hang out with during lunch and on breaks.  The patients are all quite interesting, and we get off relatively early most of the days.  Also I get to wake up at 6:00-ish instead of 5:00-ish, like I did last time.  I still have a 1.5 hour drive each way, but again, plenty of lectures to watch on the way.  

Another nice thing about psychiatry, is I know a fair amount about the topic so it's less stressful, less pressure.  I have another week here, then the week after we have a week of mandatory lectures and sessions at the main campus that everyone in our class has to attend, so I will be making a much shorter commute each day.  The final week I have to fly out to Pennsylvania on Tuesday, take the physical examination portion of the boards on Wednesday, then I fly back on Thursday.  I am most looking forward to finding a really nice restaurant in the area and having a solo celebratory meal after the exam.  It will be an awesome feeling.  

Then the next big events will be the board exams.  

I also cancelled my family medicine rotation up at the hospital I was at previously for internal medicine - it was scheduled for mid-December to mid-January and I do NOT want to be doing a sub-internship with long hours at a program that I really do not want to get into (not the best environment, and word has it that it is a very weak program) and which would require long hours and that 1.5 hour drive.  During the holiday season.  It's not worth it.  I'll fill that time with another elective of some sort.  I should send some requests for those sorts of things now.

Off off and away!

Internal Medicine - first 2 weeks

Internal medicine for the first four weeks is to be outpatient, so I am essentially back in Family Medicine.  The only difference is we see a lot more older patients, and instead of being with one doctor for four weeks and another for four weeks, I am with a total of 4 or 5 different doctors, and usually two different ones in a single day - one for the morning and one for the afternoon.  It's a challenge getting used to what they expect in terms of presentations and their personalities - harder to get a good rhythm going, so it feels more chaotic and stressful.  Also with all the older patients that I see, I can't help but feel a little depressed thinking of myself one day being where they are with lost loved ones, being unable to get up and around, unable to hear, or demented.  Two days a week I work with a doctor or a nurse who each goes to skilled nursing facilities.  I see a lot of demented people there, who are so far gone they can only half-feed themselves, smack their lips, and don't recognize their family members - who wish they would hurry up and die because they are quickly destroying their life savings.  I asked and you are able to stipulate in your advanced directive that if you are unable to recognize family members or have an acceptable quality of life for someone of your age and physical condition (not mental) that you give permission to discontinue all medications, including ones that were being given prior to mental deterioration.  The catch with dementia is you can't stop any treatments once you've started, but you can abstain from starting treatments.  So a patient with palliative care lung cancer patient starts bleeding per rectum, you don't have to go looking for colon cancer, you can just keep doing what you're doing and give narcotics.  It's a tragedy so many families are trapped watching the husk of someone they once loved deteriorate further and drain their finances that could put their grandkids through college, or help pay off debts.

In other news, I've been adhering to a stricter study schedule and trying to make sure to get my quota done each day - if I don't, it means no fun time.  Last week it definitely cut into my fun time, so I have to become a faster reader...  I also have to give a presentation next week, so this coming weekend will probably be spent working on that.  Also been busy trying to get rotations set up for fourth year.  Soon I'll need to call another place in Sacramento, but hopefully after I hear about two other sites because I don't want to be stuck without a rotation...  So much stress.  Wish I could just be done with medschool and onto residency.

Last Day in Peds

Last day - it's been a fair 6 weeks.  Aside from being sick for one of the weeks, it's gone really well.  My preceptor thinks very highly of me and I've gotten my timing, writing, and presentation skills down as far as history and physicals go.  I'm looking forward to seeing adults again - kids are fun, but honestly, only if they can talk.  Babies are kinda boring.  Either way, seen a few good cases, gotten a couple challenging things to diagnose, but for the most part I refined my examination and presenting skills.  I have the test tomorrow and then it's off to Internal Medicine. 

In other news, I finally went to the other hospital and downloaded the case information for the patient who I want to present to my classmates.  I have a presentation in mid-April that I need to prepare.  Trying to get my rotations for fourth year all set up.  Our school's 4th year coordinator is apparently really bogged down with doing these, so I don't know how soon they will be out - I'm a bit anxious about getting the information out in time.  Hopefully it'll all work out and my rotations will fall into place without a problem.  Thank goodness UC Davis does an online application.  I should schedule my flight and hotel for my Step 2 exam - the part where we have to do 10 full patient visits in a row somewhere on the east coast.  Studying for the Step 2 written exam hasn't quite revved up, I'll need to get my butt on that.  This weekend I get a bit of a vacation, then it's back to work.

Pediatrics, Week 5

Okay, it's been a while since I updated - various things have happened - boyfriend had surgery, we had a friend visit and stay with us for a week, oh yeah, and I got a really bad cold after not being sick with anything of any kind for over a year.  Anyhow, pediatrics is going well, even if it is still pretty boring by my standards.  I like patients that can actually talk to you, and the majority of our visits seem to either be under 24 month well checks or kids with runny noses and ear infections.  Occasionally we get older kids, ADHD kids, and the like.  I got to hang out with a pediatric cardiologist, a pediatric behavioralist, and a pediatric endocrinologist.  I'll stick to the highlights...

As far as my preceptor goes, he seems to think I'm pretty smart and capable - he constantly comments that I am really good at writing up history and physical notes and write really quickly and well.  Basically I have them done at Step 2 Board Physical speed - get in the room, start writing, and by the time I'm out I have the history written and am halfway through the physical, already having discussed the assessment and plan with the patient to some degree.  I also have Step 1 USMLE studying to thank for having a reputation now as a medical dictionary.  It's funny, but I'm glad he thinks highly of me.  Even though I'm not particularly interested in pediatrics, I'm considering asking him for a letter of recommendation - simply because he would probably write a very complimentary one and has said on many occasions that I will be a great primary care doctor.

The only real complaint I have about him is that he won't let me interview Spanish-speaking patients, he insists on us just getting an interpreter and not letting me have a try at it.  I'm not sure why, I suspect it's for medical-legal reasons, perhaps he doesn't want to end up relying on what I say and then if something goes wrong then he can't refer back to interpreter #### who misinterpreted for him.

Still going to my didactic sessions, been mostly working on getting my applications together for my year 4 rotations.  I found several places I want to go for - my list of possible good places has increased from 2-3 to 3-4, and my list of total feasible options from 4 to a bit over 10.  It helps that I am going for family medicine, which is more receptive to DO students.

Next month around this time I will have to do case presentation - I'm planning on doing it on that young homeless woman who came in with abscesses in her muscles that we thought at first was meningitis or endocarditis.  It was a really interesting case and is a good way to talk about diagnosing meningitis, which is an important thing to understand.

Good news: I also got back my board exam score and not only did I pass, but I scored the average for all 4th years who go into family medicine residencies.  While it is just barely over the cutoff for one of the programs in Sacramento that I wanted, I can do better on my Step 2 and hopefully that cutoff was more for COMLEX scores and not USMLE.  Either way, I passed that and am essentially caught up to where I should be.  Now to study for Step 2 and get my fourth year figured out.

Last Week of OB/GYN

Here I am, in my final week of OB/GYN.  Surprisingly little has happened between my last post and now.  There have been very few deliveries that I have been around to see.  I didn't do any 24 hour shifts last week because I was studying for my USMLE Step 1 exam (Feb 4).  I am also not doing any 24 hour shifts this week because I have my COMAT exam this Friday, which I take at the end of a block of rotations (e.g. OB/GYN, pediatrics).  As far as the USMLE goes, I think it went well, I am pretty confident I passed, and fairly confident I got around an average score.  It's hard for me to gauge because I took only one practice assessment and a lot of the questions that were on that test weren't very representative of the most commonly tested items.  Also, unlike practice questions, this test did not have very many of my weak spots on there; so, there were very few questions about CV/Respiratory physiology, elaborate equations, or complicated mechanisms about adrenergic receptors and drug combinations.  There were some endocrine questions which I may or may not have gotten right, and a few complicated ethical questions, but aside from those, I think I did decently well.  Only one or two questions were asking me about things I had no idea about.

Now onto this week - the most interesting thing that has happened was a woman in her mid-30s came in (she is in her late 2nd or early 3rd trimester) and she has profuse sweating, 102 degree fever, mild chest congestion, tachycardia, very fatigued.  She was kicked out of her house by the baby's father (likely because of her drug problems) and she was brought to the hospital by the homeless shelter people.  One of the more perplexing things about this case was that her white blood cell count was within normal range, and the ratios of cells was all practically normal - only up or down in a couple areas by 1 percentage point.  Also, her chest x-ray did not look very concerning - only some mild opacities along the central portion of her thorax and slightly on the left (mediastinum).  Her lung sounded pretty clear.  We also got a report from her past medical history that she has no asthma history, but she was diagnosed with hyperthyroidism back in the year 2000 and she said she hasn't taken any medications.  So of course the first thing I'm thinking is exacerbation of her thyroid disorder, possibly thyroid storm, because hyperthyroidism can cause all of her symptoms.  So my preceptor thought I might be onto something and ordered a stat TSH - it came back < 0.01 - in other words, something is suppressing her thyroid stimulating hormone production, this is most commonly caused by an excess amount of thyroid hormone causing feedback inhibition.  We ordered free T4 and free T3, as well as a thyroid hormone receptor antibody test to see if she has an autoimmune cause of hyperthyroidism (common in women 20-40) called Grave's disease.  My preceptor was very excited about me making a call she probably wouldn't have thought of - so hopefully that will reflect in my evaluation a bit - I haven't had any reviews yet that were particularly complimentary about my medical knowledge.  

At the moment I am keeping an eye on that patient from yesterday - her fever has resolved somewhat since starting the antibiotics for possible pneumonia, so maybe we just caught a really early pneumonia and the hyperthyroidism is just a longstanding comorbid condition.  Either way, hyperthyroidism is something really important to deal with in general, and in pregnancy especially.  I also have a presentation tomorrow about intrapartum anesthesia - emphasis on some of the lesser used modalities, such as nitrous oxide (commonly used outside the US), acupressure, and osteopathic medicine (mostly because my preceptor expressed interest).  I'll work on that when I get home probably, it's a little hard to focus here - I kinda need a break but I'm gonna stay at least a couple more hours.  My preceptor isn't here and we only have the one patient who probably isn't due for several weeks - and who knows if any other pregnant women will be coming in within the next few hours.  Even if they do, the odds that they will be imminently entering active labor are slim.

After my COMAT exam on Friday, I get to enjoy Valentine's Day weekend and then Monday I start Pediatrics after my Accutane appointment.  Wooh, fun times.

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 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.  

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.  

Post-COMLEX Step 1

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

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

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

The surgeries I can expect to see performed include:

Inguinal hernia

Umbilical hernia

Lap Chole (Laparoscopic Cholecystectomy)

Excisional breast biopsy

Appendectomy

Injecting hemorrhoids with a sclerocing agent

Port a cath placements

Pilonidal cyst excisions

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

One more week to go...

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

Finished BLS and ACLS

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

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

3 main things to know for CPR

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

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

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

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

Another take-away note about Strokes...

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

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

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

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

Nearing the End of 2nd Year

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

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

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

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