Interviews: Done

Well, all is complete.  Finished all my interviews, am one week into vacation, and it has been a busy vacation indeed!  After getting my thank you notes all figured out, had a weekend in Monterey to take care of wedding vendor business (Florist, Cake, and Hair/Makeup).  We also have a guest for the month, and another guest coming next week.  It's nice to be busy with only fun things.  Ordered the Save-the-Dates, got the guest list finalized... just riding out the end of the month.  Things are pretty much going awesome, and I feel very confident that I will match at my top choice, and if not then my second choice, both in Sacramento.  I doubt Davis will rank me particularly high, and after that one then Redding and Modesto are perfectly feasible options.  

Not too sure what else to update - I feel very fortunate compared to some of my classmates.  I know what I want, I'm competitive in the field that I want, I'm compatible with the field I want...  Compared to others who don't know what they want or aren't competitive for what they think they want.  I'll probably hold off on any more updates to this blog until I start my Neurology rotation in January, and then the Emergency Department rotation mid-January.

Sub Internship - Week 3

Well, I know I haven't been updating much - it's been busy.  A lot of fun stuff going on - seeing all kinds of patients, getting to know the residents and faculty... it's really enjoyable.  I had almost forgotten how much I enjoyed family medicine - there are so many things you get to do in family medicine that you can't do in other fields of medicine.  A day could involve diagnosing a patient with anorexia, managing a patient with depression, removing a sebaceous cyst, performing maneuvers to treat a patient's vertigo, putting a cast on a 10 year old boy, identifying a rash and prescribing antibiotics to prevent future heart complications, managing a patient with hypertension + diabetes + chronic kidney disease + depression + foot ulcers + macular degeneration, managing a patient with sinusitis, counseling a patient on weight loss, removing an ingrown toenail, identifying a urinary tract infection... and so on.

Essentially any medical problem a patient has, they go to you first.  So much fun.  I'm at the point where I know enough that sometimes it feels like I really have the answers.  There have been many encounters that would be blog-worthy in these past weeks, I just don't know where to start.  A woman at 37 weeks gestation who has gestational diabetes, who also just developed symptomatic gallstones, who has an OB/GYN physician who seems indifferent to the fact her pregnancy is one problem away from becoming an emergency surgery?  Breaking the news to a young skinny girl that she has dieted to the point that she isn't having periods and needs to gain more weight when that's the last thing she wants?  A man with crippling chronic pain from an accident years ago who is allergic to morphine?  

The residents have been great, the attendings have all been great, I feel like I fit in really well.  I love the area, the city, our new place.  I really hope I get into this program.  

Currently my tally is 8 interviews scheduled out of 11 programs I applied to.  I think I'll get an interview with Davis, and I am still hoping for at least one more interview offer.  I'm not holding my breath for one of the programs.  I'm kind of looking forward to interviews as well - two places are covering my lodging.  One of them is letting me stay with a resident, and another is paying for my hotel room.  Tomorrow hopefully I can relax a bit.  I need to get back on my exercise regimen but I strained my calf muscle two weeks ago and it still hurts really bad and I don't want to be impatient and hurt it even more.  After next week I start Pediatric Psychiatry - should be nice.

Sub-Internship Day 1

Things are going well so far - they have EPIC electronic medical records and I have full access, so I have started making my own note forms and am getting on great with everyone I've met.  To make things better, before the end of the day I had an interview request from Merced, called Salinas and confirmed my interview for end of November, and the coordinator I met this morning (at place I am currently doing my sub-internship) sent me an e-mail requesting/confirming an interview date!  So now I have two interviews scheduled, and two I'm waiting for official date scheduling, but 4/11 within 1 week of applying ain't bad!  

I also like my preceptor and hope to get along with everyone super well.  I'm just trying to remember to smile as much as humanly possible, without it looking inhuman.  They seem to think my patient presentations are pretty decent too, even though right now I feel like I'm so scatterbrained.  It's been a LONG time since I did any rotations in a clinic, so my outpatient presentation skills are really rusty.  Shouldn't be long before I'm back in the swing of things, but until then, it's a slightly rocky start.  I'm definitely glad I'd touched base with a couple current residents - it's nice to see familiar faces, who all seem encouraging. 

At any rate, I think I'm going to go and read up on some stuff I saw today and then do some pleasure-reading.  

ICU

Well I just finished a week on ICU.  Definitely more intense than previous rotations, but getting a lot of experience and trying as hard as possible to be a fast learner.  So many sick patients.  Many vegetable or "anoxic encephalopathic" patients, from quadriplegics with huge ulcers who need to get a trachostomy because of recurrent pneumonia, to people with interstitial lung disease who have been in and out of the hospital for many years and just start taking a turn for the worse.  I've assisted in several intubations and central line placements.  Central line placements feel the most natural - intubations are unpleasant.  My second one was aspirating "coffee ground emesis" the entire time and we are still not sure where her upper GI bleed is.  

This weekend I have one day free, so I'll be hopefully using it to work on my personal statement for residency and setting up my applications online.  Also hopefully spend some time with the fiance.  We get a few hours every evening but now we are both working until essentially 8pm each day.  At least we are both busy.  

I don't know that I could work in a field where most of the people do not get better, or they get slightly better and then you see them a month or two later nearly brain-dead with family refusing to accept that this might be the time they don't come back.  It's hard hearing the explanations for patients who are vegetables, where patients' families will swear that they were looking at them, or had tears coming down their face, or squeezed their hand.  Bad news every day is very depressing.  We actually had a family that was rather quick about it today - Three hours after we intubated an old woman who had severe pneumonia and many other comorbidities, her family arrived to remove it and let her die in peace.  This compared to three others on the ward which will probably not get better.  

Anyway, another three weeks of this.  I have heard that the preceptor next week (they alternate weeks) is easier than my current one, which is fine since it might be nice to have a reprieve.  It's funny, my current preceptor talks about how he doesn't want to be anyone's boss, so he joined a physician group, would never join Kaiser because they own your life, and yet he is constantly taking calls about patients, staying beyond 12 hour days, etc.  I find it hard to believe he has more of a life than a lot of the doctors I talked to at Kaiser, where they can actually leave a lot of their work at work.  We'll see - he's given me more to think about as far as potential work environments.  I will definitely have to thoroughly investigate the different options for practice.  Short of solo practice.  

USMLE Step 2

It has been a while since my last post.  I've been busy studying.  Questions every day and whatnot.  Instead of Neurology, there was a scheduling conflict and I got switched to another Radiologist.  Luckily, this guy has a lot more to see during the day than the first guy, so I got a lot of experience seeing different plain films, CTs, MRIs, ultrasounds, etc.  Some of it will hopefully help on the exam tomorrow.  After this week I head on to ICU, which will likely be intense, have long hours, and be rather stressful.  Probably will have some weekend call days.  

After tomorrow's exam, there won't be any more standardized future-of-medical-career exams until Step 3, which will probably be after I get into a residency program.  In the meantime, I have to work on my application to residency - write some personal statements, research programs, etc.  It will be stress of a different nature.  We move to Davis in September, and then near the end of September I start the Sub-Internship at my number one potential spot for residency, so hopefully that will go well...   Yet more stressful stuff to worry about.

Tonight hopefully I can put most of that out of my head and try to relax a little bit.  After tomorrow, no more endless practice questions for a while.  Oh yeah, my 6-year anniversary of having been dating my fiance is tomorrow as well, and I should also be getting my COMLEX Step 2 written exam score back as well.  We aren't celebrating our anniversary until Friday, but either way, lots of stuff going on.  

COMLEX PE

Well, today I had the COMLEX PE exam - it's a pass/fail exam where you have to have 12 standardized patient visits and then do a write-up.  You have 14 minutes to see the patient, and 9 minutes to do the write-up.  For DOs it is only offered on the east coast in Pennsylvania, so of course, off to Pennsylvania I had to go.  So jetlagged...  Anyhow, things were starting out fine, ironed my white coat, did some spot cleaning, looked great.  Then when I put it on after carrying it over one arm to the test center, I realize I got blood on it somehow - I nicked my knuckle somehow.  So I had to cover it up with something, first I just had clear tape, next I had an actual white paper cover, which was better.  Hopefully it won't count against me too much in the exam - I think it'll all average out okay, but it was really disappointing.  

As far as the patient encounters, they all went about as expected - and I was surprised that I never really found myself running out of time for either the visit or the write-up.  I feel like I always got through it, was able to ask them if they had any questions or concerns or if I can help them with anything else, etc.  Super exhausted though.  Treated myself to a nice dinner, and now just debating how much sleep I want to try to get before my 6am flight.  This time we get to change flights in Chicago, but at least the second leg will have Wi-Fi, so I won't be as bored out of my mind as I was for the first flight.  My stomach has felt funky the whole time I've been here, so I'm looking forward to getting back to my normal food.

Another bummer today was I got an email saying I didn't get a rotation spot at one of the programs I wanted to do a sub-Internship at.  It sucks that they took so long to figure that out because now I can't really make any other arrangements - I have to just scrounge for some other rotation.  Hopefully our department at school will be working through rotation requests a lot faster now that they got some extra people to take care of student health.  

As far as Psychiatry, it went well overall.  The preceptor was great, the patients were interesting, and the hours were very reasonable.  I was not too happy that I had to cut a lot of the days out because of mandatory lectures at school and this trip to take the exam, but at least I made the most of my time there.  The end-of-rotation exam is Friday and then I'm on vacation for two weeks.  Got some nice activities queued up, and I need to start seriously planning my wedding.  

Last Day of Internal Medicine

It's a shame that I have to leave Internal Medicine right when it started getting enjoyable - mostly because of the preceptor.  I walked the team through a New England Journal of Medicine case and my preceptor and one of the interns commended me on my presentation of it.  My preceptor also seemed pretty impressed with my patient presentations, so that was reassuring.  I also started getting into the habit of picking up patients who had Hispanic-sounding names, since most of the people on the team speak little-no Spanish and it's a good opportunity to make a difference and look impressive.  Today we were shorter on prep time and I actually was the only person who had seen this one patient (Spanish-speaking) at the time we presented, so that was pretty cool.  My preceptor then gave me the rest of the day off to study - I ended up mostly sleeping because the last two days I've gotten about 3-4 hours of sleep each night.  

Tomorrow I have my Internal Medicine exam - going to go through practice questions.  As long as I pass it that's all I need.  I also got a "Medical Spanish made Ridiculously Simple" because while I speak Spanish decently, if I want to use it as a bullet point on my CV I'd rather have it be a little more honed.  Especially since my rotation in September at my #1 spot for possible residency will have me working with a preceptor who likes to emphasize Spanish-speaking patients and I suspect he is not a native speaker either.  

Anyhow, this weekend will be a bit relaxing - Friday and Saturday just for me and the boyfriend, then going out on Sunday to a dim sum brunch in SF with my best friend who will be leaving for Seattle in a couple short weeks for a new job... then possibly watching the eclipse with my family.  Next week I start Psychiatry - last one for a week and then, as luck would have it, I will have a 2 week vacation.  I had intended to fill this spot with Radiology, but the doctor could only take me for the first two weeks of July, not from mid June-mid July as I had wanted.  More time to study at least!  

Inpatient Medicine - Finally

Well, I have finally started my inpatient medicine internal medicine rotation at a teaching hospital.  The first day was pretty exciting - we rounded on patients, I got to know my team, we hung out in the emergency department and admitted people, ran to catch a code blue, etc.  It had a very "Scrubs in India" feeling to it because the residents and the attending are all from India (except one woman from Bosnia?).  They are nice, but one challenge is they have very thick accents and are kind of clique-y.  One of them in particular has a very thick accent that I have a lot of trouble understanding, and I know he has trouble enunciating so I feel a little bad asking him to repeat himself all the time.  They all talk softly too, mumbling, so it is hard to tell what they are discussing unless I am super close.  

It's gotten a bit more negative as time goes on - first day I thought things were going to be good: I would follow a patient, the attending told me to pick a patient and a topic to research, and then I'd discuss it with them and present the patient.  My first day I wanted to follow a patient with COPD, but then she was going to be transferred to ICU where we don't really round or follow patients.  This was after I had already done a writeup and was preparing on that topic.  It was then suggested that I follow another patient - so I picked a man with liver cirrhosis and varices.  So that's two writeups and two topics I needed to look over that night, on the off-chance we went to the ICU.  When I finally try to present the next day, the attending corrects me on the order in which I was giving information, the standard form that were taught and how I've been doing it over the last year with no complaints from any of my preceptors.  After I do half a presentation,  then the resident I was working with filled in the physical exam portion (which was essentially what I would have said, minus two small findings), and another resident presented the next patient.  That person did the EXACT format of presentation that I did, but of course without being called on it.

To make things a bit worse, today the resident who has a thick accent wanted me to look up some information - how a medicine is connected to a condition.  I figured it was a "this is a good topic to know, look it up and we'll discuss it" type task, similar to what attendings have done in the past, and he didn't give me any indication it was otherwise.  After a 30 minute search on my usual online textbooks, all reputable sources like Harrison's and Current Medical Dx and Tx, I couldn't find anything linking the two.  I come back, told them what I found out about the topic and medication, and they tell me to just google it or search on pubmed.  I got pretty annoyed because I didn't know he was just scouting possibilities for research projects and there WASN'T an established link between the two things.  I go back to pubmed, which they spelled out to me as if I had no clue what it was even though I've used it a million times, and I still couldn't find a single article linking the two conditions.  Everything was consistent with what I had previously reported.  

Ultimately I found an article about use for the medication in the condition in general (which I had already described) and there was another medication he was curious about so I found a couple token articles about that, but I left in a rather sour mood after having to do almost 2 hours of busywork for no real payoff and reviewing an esoteric topic that I already knew.  

The topic I'm reading up on for the attending currently, bacterial meningitis, was something I read through yesterday - I must have read through 3 different full-length UpToDate articles, and where I thought there were holes in my knowledge I continued to investigate.  Wrote everything out, went and checked out the pertinent sections in my review books, and today he still wanted to give me more time because he said UpToDate isn't the best source and kept asking about random textbooks that they used back in India.  At least he approves of Harrison's and CMDT, but I read over the meningitis information in those texts, and it was verbatim what I found in the UTD articles, and actually was less detailed.  I understand that UTD is a quick reference and half the articles are short and to the point, but I went for the full-length meaty articles.  

Long story short: Feels like they underestimate how much I know without even testing me, or letting me go on when I try to engage in a discussion.  

Plus sides: There is night call twice a week, 8pm to 8am, and then morning rounds, usually get off around 11am the next day - meaning I get to sleep in the day before, study, eat at home, and then spend the night in the hospital, knowing I have the entire next day off.  Essentially reduces my number of shifts by two.  I am not sure if I have weekend duty, but if I can get by with just 3 shifts per week, I'll be pretty stoked.  

As far as rotations go, I got sub-internship at the program I plan to rank #1 - the guy who called was I think a rank higher than the lady who actually does the coordinating and he went over my application.  He commended my USMLE Step 1 score and grades, and liked my personal statement - tried to connect a bit with some things he's done as well.  It almost felt like an interview - which, in a sense, it was, but it felt almost like a residency-screening interview.  I'll assume that his positive feedback about my application indicates I have a good chance of getting an interview for the residency program (provided I don't screw up my boards and rotations between now and then).  

Called a few more places today, starting to get a few more things on board - I'm going to see about doing some easy rotations while studying for my Step 2's so that I can have more vacation left over for a potential trip to Europe.  I think I have ER and Surgery in the bag, and ICU and a Medicine Subspecialties should be easy enough to arrange since Touro has a few exclusive arrangements.  Still waiting on Davis to get back to me, but I'm not really holding my breath too much for them.  Also waiting on another program out there, but they just updated me that they're looking over the application and I should hear from them any day now.

Perhaps time to take a nap and then read up on more meningitis and do some practice questions.......

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.

Pediatrics, Week 1

Well, I have started pediatrics.  It is generally not the most interesting rotation, but there is a lot of stuff to memorize and it requires more participation.  Also, since it is a regular schedule, where I have to leave at 8:15 and end up back here around 6pm, I am finding my energy levels waning quite noticeably.  I've decided I'm just going to have to bring an energy drink every day to drink between 8 and 12, and that'll keep me going decently well for the whole day.  Luckily they don't cost much more than a cup of coffee, so it won't break my bank.  

As far as pediatrics goes, the most common visits involve a kid with a bad cold - usually with "sinusitis" or a possible ear infection associated with it.  If it's more than 2 weeks or the kid has strong symptoms, we prescribe antibiotics.  Personally, I think we are prescribing antibiotics too much and if it were me then I would not prescribe them, but right now I'm the student and I don't want to rock the boat.  We also see a bunch of kids for their ADHD, or monitoring their doses.  I still don't quite know what to make of it yet, as I've never attended a group session where the kids are seen interacting with each other and I don't know from experience what "normal" child behavior is.  Then there are the endless well-child checks, at 2 months, 4 or 5 or 6 months, 9 months, 12 months, etc.  We check their developmental milestones, answer parental questions, prepare the parent for the next stage of development and what to expect.  We haven't had any crying kids yet, so I'm kind of surprised - they are all really compliant with the exam, especially with the ear exam.  They've also let me examine them without much problem, they're all pretty nice.  I'm sure we'll have some combative screamers eventually, but so far so good.  

In other news, I finally got my isotretinoin medications today - better known as Accutane, though I have the generic version.  The process is extremely involved, especially if you are a female.  First you consult with a qualified physician who is familiar with isotretinoin, the indications, etc. and you discuss whether it is the right option - you are supposed to have exhausted every other treatment first.  Next, you get this packet for "females who have the potential to become pregnant."  You are required to read through everything, sign and initial tons of papers, and register and answer questions online swearing that you will use two forms of birth control (primary method such as hormones, an implantable device, or injections, and a secondary barrier method like a condom).  You must then wait for 30 days, and get a blood test within 7 days of your next appointment.  At that appointment the doctor makes sure you've done everything you're supposed to and that your blood tests check out, and they give you the prescription.  Once you have that, you have to take your special ID card, after having filled out the questionnaire online and registered, and go to your pharmacy to fill the prescription - if they do not have the medication on hand, then you have to wait until the next day when they will have it.  So...today was that day, and I now have it.  Side effects (aside from pregnancy) include skin sensitivity, depression, stomach upset, liver problems, skin dryness.  

I have seen some uncommon things though, which is cool - like Henoch-Schonlein Purpura and Roseola.  Also saw a case of Fetal Alcohol Syndrome, which is horribly tragic.  

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.

3rd and 4th Weeks of OBGYN

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

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

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

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

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

Call Night and Week 2

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

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

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

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

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

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

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

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

1st Week in OB/GYN

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

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

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

Second Week at the AIDS Clinic

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...  

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.