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.

Another Hurdle

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

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

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

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

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

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

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

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

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

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

Week 1 Has Begun!

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

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

I Must Be Crazy

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

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

Faster and Faster

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

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

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

Almost done with Block 2!

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

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

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

Back in the Swing

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

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

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

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

Blocks coming up...

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

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

Another day...

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

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

Nearly Through Another Week

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

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

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