Elective Rotations and Sports Medicine

After a lot of phone tag with various physicians and emails going unanswered for a week or so, I finally got in contact with two infectious disease specialists - one works at NorthBay Medical Center in Fairfield, and the other works in Oakland.  I got them both on board to do one of my elective rotations each, so I'll be in Fairfield in October, and in Oakland in December.  Another little perk is that the Oakland physician is taking the last week of December off, so I'll have something like a winter break.  It should also be a good variety, since one of the rotations is at an HIV/AIDS clinic and the other is more hospital based.  

As far as Family Medicine, I'm working on a case presentation that I'll be doing on September 20th - it's going to be about 45 minutes long, in front of all the doctors in the family medicine department.  Oie.  I found an interesting case we saw of a woman with a lot of problems coming in for new onset myalgias (neck, hip, arm) and the idea that my preceptor went with was early Herpes Zoster, so she prescribed some prednisone and did some viral assays.  About a week later though, the patient went to the ER for Bell's Palsy, which in the context of Herpes Zoster would be Ramsay Hunt Syndrome type 2.  She still hasn't had a skin eruption yet, but we shall see if we get more information back about her in the next few days.  The overall theme of my presentation will probably be acute myalgias, the workup, likely candidates in a primary care setting, and of course the actual patient case.  The hard part will be organization and fitting it into a 45 minute time slot, since acute myalgias is a huge topic.

Also I think I've figured out what kind of preceptor-student relationship I had had in mind for rotations.  My first preceptor was nice, but not very approachable, hard to read, barely spoke about anything, and wasn't very open to teaching with me asking questions - he was more into the old fashioned pimping style of him asking everything until I don't know.  So, that was the example of the "hard to read" preceptor.  Then my current female preceptor is nice, kinda touchy-feely, a little holistic, so that's a nice contrast.  The sports medicine doctor ( a guy ) is almost too friendly, with a lot of topics of conversation that go outside of the office.  The other male doctor I am with sometimes seems more like I had envisioned it - nice, tolerates some question asking, talkative but mostly about patients or conditions or clinic-related topics without it feeling too "strictly business".  

As for today, I saw a good variety of things - saw a woman with breastfeeding-associated DeQuervain's Tenosynovitis, with the characteristic positive Finkelstein's test.  I also saw two ends of the spectrum of rotator cuff injuries - honestly, it seems like half of the patients (at least) who come into the sports medicine office have rotator cuff problems - makes me want to keep my rotator cuff muscles strong so I don't end up having problems with that.  I feel bad for the older people with those problems.  The one end of the spectrum was someone who kept trying to exercise even while doing physical therapy and ended up coming in with an entirely inflamed shoulder, with subacromial bursitis, biceps tendonitis, and rotator cuff weakness/tenderness.  On the other end, there was a woman with focal pain on her lateral posterior shoulder, and an X-ray showing that her humeral head was about a centimeter higher up than it should be in her glenohumeral joint.  When I did the exam, I got kind of excited about finding a significantly positive sulcus sign - which is elicited when you exert downward traction on a person's humerus by pulling their elbow gently to the floor.  On the uninjured side I didn't get much but on the other side her shoulder went down a ton, had a visible dimple on the shoulder, and a lot of cracking (crepitus) - it almost sounded like I was dislodging it from a stuck position.  That was the first time I had tried that test since our sports medicine practice.  The patient was really surprised, and I think it made it more likely that she would do her physical therapy, since there was a significant, noticeable difference in her joint.  

Slow Day

Today was rather slow by comparison - only saw two patients.  In the morning there were lots of quickies here for some injections (either Supartz or corticosteroids) and one or two who didn't want a student.  Spent a lot of time sitting around reading JAMA articles.  I came across a few interesting tidbits.

1. Onchocerca and Dranunculus, both parasitic roundworms, are in the process of being essentially eliminated from the human population by the World Health Programme.  Onchocerca causes river blindness in South America, and Dranunculus is also known as the Guinea Fire Worm, and if you don't remove it slowly from a person's arteries then it will die and cause a reaction that will kill the person.  You hear about viruses like polio or smallpox being eliminated, or maybe malaria, but rarely about parasitic worms.     

2. Bladder cancer is higher in men than in women - I hadn't really thought about this before now.  Bladder cancer is strongly linked to cigarette smoking, particularly to a chemical in cigarette smoke: naphthylamine, which  is also found in certain textile dyes.  However, it was previously thought one of the reasons men were more susceptible was because men were more likely to be smokers, have unhealthy lifestyles, and work in environments that expose them to carcinogens.  Now that women are working in a lot of the same fields as men, the incidence has not increased an equivalent amount.  A study in 2007 showed that mice without the testosterone/androgen receptors who were exposed to chemicals linked to bladder cancer did not get any bladder cancer, compared to mice with the receptors who nearly all got bladder cancer (~90%).  It would seem that the same mechanism behind prostate cancer may be involved in development of bladder cancer in men.

3. JAMA includes a previous JAMA article from 100 years ago to the day at the end of each issue.  One of the old articles about digitalis/foxglove and its use as a medication for arrhythmias and other heart problems had a very interesting line in it.  After going at length about the benefits of high doses of digitalis, the author writes: "For that reason, a daily large dose of digitalis is advocated indefinitely to keep the weary heart a-going on its rapid journey to an eternal standstill."  That article was written in 1911, and the last part of that line has a very poetic, almost morbid sound to it.  Rather unexpected when I was reading the article.

At the end of the day I had to go to didactics, where a guy who reminded me a lot of Jim Carrey was telling us about Clopidogrel, and how it compares to Aspirin - his main argument was that Clopidogrel (Plavix) is treated like a substitute or necessary adjunct therapy for Aspirin, but in reality there is little evidence it is more efficacious than Aspirin, or that dual therapy would benefit anyone besides those with cardiac vessel stents or in an acute cardiac event.  It was interesting, he was going on a bit about drug reps and such - since I studied a lot of that in undergrad for my medical history classes, it wasn't anything that new to me.  Anyhow, time to get some reading done and try to recharge for tomorrow.

3rd Week of FM

It's starting to feel more routine each day - the nice thing is the patients are always different.  I don't know why people complain that family medicine is the same old thing - yeah, it's always talking to a patient about what's going on, but at least it's a different thing with each patient usually.  

We had a deaf couple come in, and naturally they couldn't speak, so we had to communicate by hand writing back and forth.  I've been trying OMM on some patients but usually they are so uncomfortable from whatever it is that is ailing them that I don't feel super comfortable treating them, since touching them or making them move puts them in a painful position.  I got to help drain a MRSA (methicillin-resistant staphylococcus aureus) ulcer today on some guy.  Perfect example of patients being horrible historians - when I saw the ulcer I specifically asked him "do you have any history of having cellulitis, or MRSA, or other skin infection?" "mm...nope."  "Are you immunocompromised, like taking chemotherapy or have HIV?" "nope."  So of course when I report back to the doctor he looks in the patient's chart and see's "Yeah, he's had two or three bouts of MRSA, each time was treated in a hospital for it."  You would think a patient would remember that sort of thing.  

In the meantime, the topic I chose for my presentation is acute myalgia, which is an incredibly broad topic, so it will be hard to narrow it down, and categorize things in a way that covers as much of it as possible.  I'm still doing translating here and there, and working on SOAP notes in the office.  This was a good weekend but I was up late last night and there was an accident on my way back from Napa so my usual 40 minute drive back turned into 2 hours.  Blah. 

Translations and Presentations

Today felt rather long, but it was generally busy at least.  Didn't see too many patients in the morning, but the afternoon was packed.  One patient in the afternoon who came in had suffered a fall in a Target store and she and her husband/boyfriend were there - both were Spanish speaking.  Since the doctor I was with today spoke a modest amount of Spanish I spent a lot of time translating, which was interesting and my head and tongue hurt by the end of the session.  I don't know if it's because it is tiring making your mouth say different accents back and forth, or if it's just because I don't use Spanish all that often but it was a good practice session.  By the end, the patient and her companion were both very thankful I was there and were glad to have gotten so much attention at last - she had a multitude of problems, like herniated disks, possibly a broken rib, neuropathies.  

Also, I discussed my Case Presentation project with my preceptor - during the family medicine rotations, we are to do a presentation on a patient/topic and present it to all the doctors in the family medicine department - it has to be 45 minutes long, powerpoint presentation, with a handout or two.  I attended our didactic lectures yesterday and that was a reminder that I have two-20 minute presentations through Touro that I need to do for my fellow students, and get feedback.  I'm of course more nervous about the 45 minute one where lots of doctors will be asking me questions and critiquing me, versus the positive feedback/nice constructive criticism of an audience that is mostly people from my class.  And unfortunately the 45 minute presentation is the first one I have to do, so I don't even get to warm up with the 20 minute ones.  Buuuut - that's not until the third week of September, so I have some time.  I am going to come up with the powerpoint this weekend though and have my preceptor go over it.  

Another Week of FM

Today I was supposed to be with this one doctor, but ended up getting sent to a different one who kind of reminds me of George Washington Carver - skinny black guy with the same haircut and mustache.  Anyhow, he was nice but he did not seem to interested in any of the patients he saw - maybe he is just jaded or tired or not happy to be back after a weekend but he looked kind of blase or worn out.  We saw a couple elderly patients with mild dementia - kind of a harrowing feeling, hoping that your parents or yourself won't end up in that situation.  

After that in the morning, I had my lunch but decided the two recipes I had experimented with for my week's cuisine were both rather unappealing.  I'll modify them tomorrow after my half-day so that I can still make some use of the ingredients.  The cucumber soup is mostly unsalvageable but the root veggies I think I can turn into something edible.  In the afternoon today I was back with my main preceptor, and we saw a few interesting cases - a girl for acne, a woman with possible prodrome phase of herpes zoster, and a couple people with gastroenteritis (one Spanish-speaking).  I'm keeping my fingers crossed that I don't get a stomach virus - I can't remember the last time I had a really bad gastrointestinal illness, and I'm hoping it won't be for a while yet.  I've been taking probiotics daily so I should be covered as far as bacteria, but viruses?  I don't know if probiotics help with that at all...  

Tomorrow I am back with the sports medicine doctor who is associate dean of clinical education.  I need to show him a SOAP note of an interesting patient we saw on Thursday, who had a dorsal expansion hood rupture on her second digit knuckle.  It's only a half day so hopefully I'll be able to get home, make some food, and get some decent studying done.  Waking up so early is killing me, hopefully I can get through tomorrow.  

Also, there is a family medicine conference in LA that I may go to on October 15 and 16 - all the residency programs in California for family medicine should be there, and it would be an opportunity to visit a friend of mine and my boyfriend's, and my boyfriend's family.  It would only be for a weekend and we would drive down there, but I think it would work out.  Just have to sign up.

End of the First Week

Family Medicine is off to a good start - I've seen a few patients multiple times.  One example - I saw an elderly man with the sports medicine doctor, then I saw his wife with another doctor, and then I saw both of them with the man's primary care doctor.  I have also been practicing writing SOAP notes and trying to refine that practice.  I still have good rapport with all the doctors, and am getting a better sense of how to conduct patient history and physical exams.  One gray area that I was a little nervous about was doing a basic physical exam on someone - I didn't know how thorough I should be when my preceptor is not there (mostly as far as having the patient disrobe, doing genital exams, etc).  The first time I came across this, I decided to do a thorough history, do some health education, and then wait and see how she conducted the 'complete physical'.  I went through everything, and included information about doing monthly self-checks for testicular cancer (highest rates in men in their 20s, 30s, and 40s, unlike prostate cancer which is highest in men over 50).  After the doctor did the exam (which didn't include a genital exam), she mentioned that normally she does that if the patient has complaints and I told her I did some patient education on that topic and she was very pleased.  She also seemed satisfied with my SOAP note that I did that day.

One small snag I have noticed is that my preceptor leans toward holistic/natural medicine.  That is perfectly fine with me, since I like the idea of combining lesser-known but similarly efficacious remedies for various diseases.  Also, according to our review forms, we are graded on whether we make references to medical studies and readings.  I thought a good way to combine the two would be to pick one or two things that she talks about that I am interested in and then look up articles that go into more detail.  On my first day with her, she cautioned a patient to get refrigerated probiotics because it was her understanding that ambient temperature probiotics are not effective.  Since I myself have some ambient temperature probiotics, I wanted to see exactly how poorly they fared against refrigerated ones - and despite going in with the expectation that she would be right, the study I found (from 2010, a pediatric medicine publication) found that they were equally efficacious in reducing the length of bacterial diarrhea compared to placebo.  I mentioned this to her as nicely as possible and she didn't seem to have a problem with it, which was good.  However, the next thing I thought I chose to look up had to do with how glucose levels exacerbate atopic dermatitis (AD), because she cautioned a patient to avoid food with high carbohydrate content in order decrease her overactive immune response.  I started looking up information on PubMed today about that and the first article on the topic that I found stated there was no change in symptoms in patients with AD when they were placed on sugar-free diets.  I only have partial access to PubMed at the moment, but I emailed our library director about how to gain access remotely (I know I can access it from school computers).  She expects me to have looked into this topic and I really really don't want to have to contradict her again - I want her to be right about these things, and I really like her too, so I want to keep her looking favorably on me.  If I really can't find any studies in favor of her sugar free diet, I will at least try to find a few on other factors that may increase AD (she also mentioned caffeine, antibiotics).  She is an MD for what it is worth, as are all the other Family Medicine doctors I am rotating with at Kaiser.

A final note on OMT - I have decided that I want to find ways to practice a little more OMM in the clinic, since it was part of my training, it can provide relief for some patients, and it will be included in my Step 2 board exam practical.  Considering this, I have made a goal to treat at least one patient each day with some form of OMM - most patients are very open to trying it.  The first patient I tried it on was suffering from low back pain and was a Spanish speaker, so it was a little challenging to communicate what I wanted him to do, and he was also in pain, so that was a little intimidating.  The next patient I tried it on was a middle-aged woman who had some neck/shoulder pain, which seemed muscular in origin, so I decided to do some occipital release, muscle inhibition, and long cervical muscle stretches - I was still doing some treatments when my preceptor came in and she was very approving.  The patient did report some decrease in pain, but again, I need more practice with patients.  Since I'm a little nervous about treating patients with real complaints (I don't want to make things WORSE) I am considering doing an OMM elective rotation.  I am still trying to schedule an ID rotation, but the guy hasn't emailed me back and it is really difficult to get anyone on the phone - I'm always transferred to voice mail or some department that doesn't know how to handle my request.  I'll try again next week, but the time I have left to schedule it before getting randomly assigned is ticking down...

I have also started listening to German audio lessons and audio books on my way to and from the clinic - it takes me 45-60 minutes each way.  I was looking for some audio books for Harrison's Principles of Internal Medicine (a huuuuge reference book) but none that were free.  I already have a hard copy of the book and online access, so I'll have to do that during my non-driving time.

More Family Medicine

Family Medicine is still going pretty well - the patients all seem to like me, and I have gotten to see a good range of ages, from kids 3 years old to adults 91 years old.  I have spent time with two general family medicine physicians and one sports medicine doctor (who also happens to be associate dean of clinical education at our school).  I've been trying to do readings on the stuff I see in the clinic, and stay engaging with the physicians.  I get along with all three of them really well, and I get the sense they do not mind having me around.  We had a little snag up with the scheduling so the dean was not quite expecting to see me today, but it worked out fine.  I talked to him a little more about some stuff, and near the end he said he was glad that I'm going to be with him two days a week instead of just one.  I also asked him if my timing on patient interviews was okay and he said that he would have let me know if I was going too fast or too slow, so I'll take that as a good sign.

Yesterday was good as far as patient interactions - a middle aged man came in yesterday and we diagnosed him with an inguinal hernia, and I was able to palpate bilaterally and up the inguinal canal - first time on an actual patient and not an actor.  Also one of the patients, a real talker who probably held me up a bit longer than I'd have liked, complimented me to the physician that day, saying that I was going to be a great doctor and was really good at talking to patients.  The more positive things said, the better - I just have to keep doing well and not let anything negative creep up.  I still feel pretty tired at the end of each day, and it's looking more and more like my drive is an hour each day - I have started listening to German audio lessons in the car.  Today I got off earlier than usual because the doctor I was going to be with this afternoon was not around and most of the other doctors in the office were not there this afternoon.  Time to catch up on my studies!