Psychiatry Week 1

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

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

Then the next big events will be the board exams.  

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

Off off and away!

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!  

Internal Medicine...Week 2

Well, I'm still trucking along.  I've started watching Kaplan videos for Step 2 USMLE on my phone in the car - yes, yes, bad I know, but I'm not really "watching" so much as listening and glancing over/laughing when he does some of his very odd antics.  I really like the lecturer - he always brings up references to literature (like fiction and non-fiction non-medical texts) or brings up the greek and latin origins for many of the words.  He also repeats everything about 3 ways, sometimes with funny voices.  Once I stopped looking at it as silly it's really quite useful.  Also, at the end of the day, if I'm too tired to study, at least I know I got 3 hours of decent quality Step 2 studying done, in addition to seeing medicine practiced in real life.

Example of the Kaplan videos coming through for me: Today we had a patient (who I am following) who presented with a million problems, but most concerning today were sharp chest pain.  We are thinking it is unstable angina, however he also has end-stage renal disease and is getting dialysis on a regular basis.  We THINK he may have been getting too much potassium in the dialysis wash, and the level we measured was 6.4 (normal range is 3.5-5).  Just the other day I had finished watching all the nephrology (kidney) lectures, including acid base.  So when we were discussing treatments for hyperkalemia, I was super on top of things.  We also have started seeing some acute coronary syndromes, and I am about halfway through the cardiology lectures, so I'll be prepared for that too.  I'm definitely absorbing the material, that's the most important part.

Lately we've been having a lot of patients who delayed getting medical care for way too long and are suffering pretty bad consequences.

Case 1: Middle aged white man comes in for chest pain - 5 months ago he developed a large mass (about golf-ball sized) in his lower cheek, which he was told was likely cancer and he should have resected at a nearby academic facility.  For some reason or another, he never followed up with that, despite the mass becoming about the size of a tennis ball (NOT exaggerating), ulcerating, and bleeding from time to time.  If I had a tennis-ball sized crater on my face, I would probably be worried.  Anyhow, he comes in for chest pain/shortness of breath, and turns out he has tons and tons of metastases in his lungs and bone (he had an occult rib fracture as well).  Verdict: even without a biopsy, we can tell him it's stage 4, 99.9% incurable, and he probably has a year or less.  

Lesson: If you have a big mass, even without the breaking down and bleeding and oozing, get it removed.  You may have far less time to get around to it than you think.

Case 2: Middle aged black man comes in because he can't see - two weeks ago he lost vision in one of his eyes, and a couple days ago his other eye also lost vision, except just barely at the edge.  You would think losing vision would make someone come into the hospital.  Anyhow, the workup shows he has bilateral acute angle glaucoma - which is very unlikely to happen in both eyes simultaneously, but it DOES happen.  He left it for so long that the build up of fluid within his eyes likely has given him permanent damage to his optic nerve and local structures.

Lesson: If you go blind, don't shrug it off.  Time is of the essence.

Case 3: White female in her 20s (Untreated diabetic type 2, history of drug use, fighting with passerby, and living with boyfriend after another) presents with about two or three months of severe headaches, swollen face on one side, and one eyelid shut.  A month ago she was seen for headaches and her eyelid, and they diagnosed severe sinusitis and gave her antibiotics.  For some reason, she only took 2 or 3 days of the antibiotics (Sinusitis requires at least 2 weeks).  Of course, that didn't do anything.  Now she's back, and the nerves that control her eyelid pass through one of her deeper sinuses in her skull and the fluid/infection has increased the pressure to the point that the nerves are compressed.  Surgical drainage is performed, and we try to beat it into her skull that she has to finish her antibiotics and take her blood sugar medications.  She should regain the ability to open her eyelid on the affected side, but progress will be slow if it ever does come back.

Lesson: Take your medicine

There are a few other interesting cases, but after a while it all feels like work.  I can see why patients complain that doctors don't care about them, but honestly, when you see a person with COPD, you expect them to be on a respirator.  When you see someone with cirrhosis, you expect them to vomit up blood or die from jaundice or develop huge fluid collections and die of heart failure.  You just expect it, and you see it so often, you know what the treatments are, and you know what the percentages are for the different outcomes.  It's hard to be surprised by what happens.  It's even worse when it's a completely preventable cause, such as something caused by drinking, drugs, failure to take medications, obesity, smoking, etc.

Anyhow, time to get back to studying, eating, all the usual stuff.  As far as the group, I am now a 4th or 5th wheel among Indian female interns who have no interest in making friends with me or including me in discussions.  You'd think there'd be small talk even.  Sigh.

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.