Friday, July 29, 2005
Here I sit with my VERY DRY 1/2 martini, two olives, one onion and some cool jazz playing on my computer. Oops, 1 olive! The other found my mouth a little early.
I just completed my first shelf exam. It is basically the same as the medicine portion of the USMLE step 2 exam. Which means IT'S NOT FUN. This was the fourth and last exam that marks the end of my internal medicine rotation. This rotation (3 months) is the longest and considered the more difficult. Surgery is also very demanding of time and energy, but it's only 2 months. Now, granted, out patient service isn't exactly grueling, but I'm glad to have it all behind me now. At least so long as I passed each of the four exams. Two of the exams were last week and I think I mentioned them already: EKG and Chest X-ray.
This week I had pattern recognition and the shelf. The pattern recognition was 200 questions (1-2 liner) in 120 minutes. Blocks of two questions each block with 20 answers from which to choose. The self exam is 100 question made to be just like the medicine part of the STEP 2. Oh, and 120 min in which to complete them. The worst part, however, is the room they have us take the exam. The seats in the auditorium have these little "desks" the size of a postage stamp! Basically, they are the size of one bubble on the scan-tron. (Yes, they were bubble tests.) So you had to juggle the exam booklet and the answer sheet. Hence, the martini! I need another sip.
In total, I saw almost 100 people. I have 97 documented, but I know there are some that I missed. I got to see two patients in follow-up. That is, more than once. One of them was my patient in cardiology and then again in his first outpatient follow-up. (I think I mentioned that before.) There was also an outpatient that I saw a couple of weeks ago. She had been admitted to the hospital, subsequent to our first visit, for intractable nausea/vomiting. This was her follow-up visit after that admission. She has a bunch of problems going on and I cannot say that any of them are well controlled at the moment. It's a shame because she's really nice, pretty young and smart. She's an artist and a pilot! Right now, she cannot do either. Everyone else was more of a once shot deal, at least for me. I managed to impress at least a couple of doctors including my infectious disease doc and my geriatrics doc. But, we'll see how their grading comes back. For that matter, I have not even received my grades from Cardio. I hope they remember who I am! ;-)
But, more on outpatient med. You are supposed to have very quick encounters with patients, on the order of 15 minutes. I was not ever so good at that. But, I contend that some of that was not my fault. The docs would give me "interesting" patients and they would end up being train wrecks. One of them was so bad off that we had to send him to the ER! He looked like he had been in a bar fight with a bloody nose and two black eyes. I could not get him to tell me any other story than he fell twice and one time he hit the edge of the counter. No WAY dude! But I tried really hard. In the end, we sent him to the ER for a CT and I notified social work to follow up with him. Keep in mind, this guy is in his late 70's. Thus it is called vulnerable adult as opposed to a bar fight. Speaking of which, there goes the end of the martini.
Another interesting thing that happened in out patient was my getting into the electro-physiology (EP) clinic. I was supposed to be in a diabetes clinic and on my first day there I was told that the doctor was out of town that week. I called the medschool person in charge (Mary) and she told me to work with on of the other docs there. There was only one and she was willing to work with me that week but she had specifically requested NOT to have any students for a host of uninteresting reasons. Things went okay. But the next week, I found out that the doc I was supposed to work with was still on vacation, but again, she was supposed to be back the next week. I went to go talk to my alternate doc and she found out the doc I was supposed to work with was off for the entire month! Oops. Next door was the EP clinic and I went to ask the doc if it would be okay to follow him. Then I called Mary and told her what was going on and that it would be okay to follow in the EP-clinic. She hesitated a little, but finally said it was okay. I am, apparently, the ONLY student to have ever served in the EP clinic. Not just the only M3, but the ONLY STUDENT! We had a good couple of weeks together and it was pretty interesting. The doc said I could scrub in for a procedure if I was interested, which I'm going to try to do. These are the guys that put in pace makers and burn various spots on your heart to get it to stop having abnormal rhythms. The cardiologists I worked with said that EP-docs are strange, but I thought this guy was pretty nice and normal.
So all of my outpatients clinics were: Hem/onc (breast cancer genetics counseling) (Mon 1-5p), Infectious disease (Tues 8a-12), Kidney (Tues 1-6p) with ML's boss!!! (Yes, I'm expecting honors, or, at least, hoping! And, yes, I asked Mary if it was a conflict of interest first), VA Geriatrics (Wed 8a-12), EP (Wed 1p-5), and General med X2 (Thurs 8a-12, 1-5p). Yes! I had nothing on Friday! Oh, wait, from 1-5p I had seminars. It was still pretty awesome! The rest of the time I tried to study for all of the exams, which I did. I wish I had spent more time focused on the shelf though.
I would add, that for these last two exam I focused more on sleeping than on studying. So, we'll see how that pans out for me!
Back to outpatient. Really the story won't be told fully until the grades come back, but the person that I liked the least (at first) I think I impressed a lot. She and I got into a really good rhythm together and I actually helped her get through her patients faster. In part because she would send me in for 10 min, come in and have me do a bed-side summary, and then finish up. It quickly got to the point where they would put two patients in a two rooms, she'd go into one and I the other, and when she was done with hers (often I would just be finishing too) she'd pop over, ask any additional questions she wants, and write the scripts. One of the things that she was amazed about was that in almost every room she walked into, the patient was laughing! She had never seen a student able to do that before. (It was really easy: I'd introduce myself, ask if it was okay to speak with them, and then tell them that I'd go through everything with them and the doc would, no doubt come in before I was finished and take over. So, each time I heard the knock of the doc, no matter what I or the patient was saying, I'd say, "well, that concludes our time together!" Hence, the laughter.)The other strange thing, (and I had nothing to do with this!!), was that almost all of the patients in her clinic that I saw, complemented on how nice of a person I was as we were all leaving the room! Actually, what I also found out later was that she (the doctor) would normally ask each of her patients before sending a student into the room. But, after that first day when she found out how well I was able to establish rapport she let me go in on my own. Actually, I just started doing it the second day and she basically didn't stop me. But she told me about that at the end.
The clinic that I liked the most was the Gen med morning clinic because he just fed me all of the "good" patients and let me do whatever I wanted. Which was the way he had always dealt with students. So, it was very educational for me. I'd get to go and talk to his strangest patients for a good 20-30 min while he saw other patients. Although, I don't think I made as good an impression on him as I did that afternoon doctor. Again, the grades will tell all.
Oh! Back to the VA. Well, actually, at the ID clinic! They ID docs were talking about some of the patients at the VA and they mentioned someone's last name. I turned around and said, "you're not talking about Mr. So-and-so?!" They were! He was one of the guys I admitted when I was at the VA and he was STILL there! I kept meaning to see him after the morning VA clinic, but it always ran long so my last clinic day I went in 30 min early to say hello. He was actually going home that! (And last I heard he had actually gone home!) Anyway, he still was doing well. He had a procedure to help with his liver cirrhosis and had gotten a blood infection that we were having a difficult time curing. He was never very ill, we just couldn't get rid of the infection and it was important to have him on IV antibiotics. Each time he'd get close to going home, he's spike a fever (usually associated with going outside). In other VA clinic news, I discovered a patient with some massive depression which had resulted in a 50 pound weight loss over two years. The doc had not really picked up on it because she sees him so often. It was kinda' interesting though because I was following a bunch of cancer red flags. I was staffing the patient with the doctor (that's telling the doc what all I found in a specific organized fashion) and I was throwing out all of the cancer red flags: loss of appetite, weight loss, increased back pain...I got her all worked up and we were planning all sorts of screens and then I looked at her and, "what if he's really just depressed?!" Right then, the chief chimed in from across the room and started asking me about all of these questions to screen for depression. I answered the first two as, I don't know. Then I stopped him and said, "Wait, I don't think you understand that I JUST considered depression as an explanation while I was staffing because I was thinking cancer. So I have not asked him any questions about depression." I had asked all of the cancer questions and, yes, there is a surprising amount of overlap between the two. The chief went in and he screened (which kinda' pissed me off because I wanted to do it) and he, that patient, scored VERY high for depression. So we cut back to just a pelvic X-ray just to rule out an underlying malignancy, started some short term antidepressant (which for him was justified since, once he because mobile again much of his depression would resolve) and made an appointment for him with psychology. Oh, have I ever mentioned that I was very good at picking up depression at the VA. It was always pretty easy, you just ASK!!!! But, apparently, that does not happen. Really, there are some specific screening questions you can ask, but once you have some semblance of rapport, you can just ask them. You I don't think much of my interpersonal skills, but it is apparently lacking in the field. Who knew?!?!
In other news, I'm typing on my new computer! Well, actually, it's just a new motherboard and processor. I know, I just replaced the mother board with my old CPU but the something was still flaky and I didn't have time to figure out what it was. I think it was just another defective motherboard. I went with a different brand cause I thought it would be good. Actually, it was mostly the RAID function (RAID=two duplicate drives running in tandem so there is always a backup if one of them fails) would drop the drive speed by a factor of 10. (Too slow to even burn a DVD.) So, I got a new mother board (well, yes, a different brand than my usual but I wanted to try to broaden my horizons) and a new processor that is almost 1 GHz faster than my other one but there is really little difference over my original set up. Except it has passed all of my stress tests which my original board was not. I still don't know what happened to it! The intermediate motherboard also never crashed, but I could not put up with the slow drive speed. More over, this processor will run Windows XP 64 bit even though it is not supposed to. AMD started shipping out the 64bit enabled Sempron 3300+ processors before they projected date. Unfortunately, my wireless card will not work with WinXP64, so I can boot into it, but I cannot do much more than work process. It seems to work pretty well and it does seem a bit faster. If they every make a driver for my wireless card I will switch, but I doubt they ever will.
Okay, time to clean my office!!! Maybe I'll do the dishes too! (I'm such a nice husband...NOT!)
I just completed my first shelf exam. It is basically the same as the medicine portion of the USMLE step 2 exam. Which means IT'S NOT FUN. This was the fourth and last exam that marks the end of my internal medicine rotation. This rotation (3 months) is the longest and considered the more difficult. Surgery is also very demanding of time and energy, but it's only 2 months. Now, granted, out patient service isn't exactly grueling, but I'm glad to have it all behind me now. At least so long as I passed each of the four exams. Two of the exams were last week and I think I mentioned them already: EKG and Chest X-ray.
This week I had pattern recognition and the shelf. The pattern recognition was 200 questions (1-2 liner) in 120 minutes. Blocks of two questions each block with 20 answers from which to choose. The self exam is 100 question made to be just like the medicine part of the STEP 2. Oh, and 120 min in which to complete them. The worst part, however, is the room they have us take the exam. The seats in the auditorium have these little "desks" the size of a postage stamp! Basically, they are the size of one bubble on the scan-tron. (Yes, they were bubble tests.) So you had to juggle the exam booklet and the answer sheet. Hence, the martini! I need another sip.
In total, I saw almost 100 people. I have 97 documented, but I know there are some that I missed. I got to see two patients in follow-up. That is, more than once. One of them was my patient in cardiology and then again in his first outpatient follow-up. (I think I mentioned that before.) There was also an outpatient that I saw a couple of weeks ago. She had been admitted to the hospital, subsequent to our first visit, for intractable nausea/vomiting. This was her follow-up visit after that admission. She has a bunch of problems going on and I cannot say that any of them are well controlled at the moment. It's a shame because she's really nice, pretty young and smart. She's an artist and a pilot! Right now, she cannot do either. Everyone else was more of a once shot deal, at least for me. I managed to impress at least a couple of doctors including my infectious disease doc and my geriatrics doc. But, we'll see how their grading comes back. For that matter, I have not even received my grades from Cardio. I hope they remember who I am! ;-)
But, more on outpatient med. You are supposed to have very quick encounters with patients, on the order of 15 minutes. I was not ever so good at that. But, I contend that some of that was not my fault. The docs would give me "interesting" patients and they would end up being train wrecks. One of them was so bad off that we had to send him to the ER! He looked like he had been in a bar fight with a bloody nose and two black eyes. I could not get him to tell me any other story than he fell twice and one time he hit the edge of the counter. No WAY dude! But I tried really hard. In the end, we sent him to the ER for a CT and I notified social work to follow up with him. Keep in mind, this guy is in his late 70's. Thus it is called vulnerable adult as opposed to a bar fight. Speaking of which, there goes the end of the martini.
Another interesting thing that happened in out patient was my getting into the electro-physiology (EP) clinic. I was supposed to be in a diabetes clinic and on my first day there I was told that the doctor was out of town that week. I called the medschool person in charge (Mary) and she told me to work with on of the other docs there. There was only one and she was willing to work with me that week but she had specifically requested NOT to have any students for a host of uninteresting reasons. Things went okay. But the next week, I found out that the doc I was supposed to work with was still on vacation, but again, she was supposed to be back the next week. I went to go talk to my alternate doc and she found out the doc I was supposed to work with was off for the entire month! Oops. Next door was the EP clinic and I went to ask the doc if it would be okay to follow him. Then I called Mary and told her what was going on and that it would be okay to follow in the EP-clinic. She hesitated a little, but finally said it was okay. I am, apparently, the ONLY student to have ever served in the EP clinic. Not just the only M3, but the ONLY STUDENT! We had a good couple of weeks together and it was pretty interesting. The doc said I could scrub in for a procedure if I was interested, which I'm going to try to do. These are the guys that put in pace makers and burn various spots on your heart to get it to stop having abnormal rhythms. The cardiologists I worked with said that EP-docs are strange, but I thought this guy was pretty nice and normal.
So all of my outpatients clinics were: Hem/onc (breast cancer genetics counseling) (Mon 1-5p), Infectious disease (Tues 8a-12), Kidney (Tues 1-6p) with ML's boss!!! (Yes, I'm expecting honors, or, at least, hoping! And, yes, I asked Mary if it was a conflict of interest first), VA Geriatrics (Wed 8a-12), EP (Wed 1p-5), and General med X2 (Thurs 8a-12, 1-5p). Yes! I had nothing on Friday! Oh, wait, from 1-5p I had seminars. It was still pretty awesome! The rest of the time I tried to study for all of the exams, which I did. I wish I had spent more time focused on the shelf though.
I would add, that for these last two exam I focused more on sleeping than on studying. So, we'll see how that pans out for me!
Back to outpatient. Really the story won't be told fully until the grades come back, but the person that I liked the least (at first) I think I impressed a lot. She and I got into a really good rhythm together and I actually helped her get through her patients faster. In part because she would send me in for 10 min, come in and have me do a bed-side summary, and then finish up. It quickly got to the point where they would put two patients in a two rooms, she'd go into one and I the other, and when she was done with hers (often I would just be finishing too) she'd pop over, ask any additional questions she wants, and write the scripts. One of the things that she was amazed about was that in almost every room she walked into, the patient was laughing! She had never seen a student able to do that before. (It was really easy: I'd introduce myself, ask if it was okay to speak with them, and then tell them that I'd go through everything with them and the doc would, no doubt come in before I was finished and take over. So, each time I heard the knock of the doc, no matter what I or the patient was saying, I'd say, "well, that concludes our time together!" Hence, the laughter.)The other strange thing, (and I had nothing to do with this!!), was that almost all of the patients in her clinic that I saw, complemented on how nice of a person I was as we were all leaving the room! Actually, what I also found out later was that she (the doctor) would normally ask each of her patients before sending a student into the room. But, after that first day when she found out how well I was able to establish rapport she let me go in on my own. Actually, I just started doing it the second day and she basically didn't stop me. But she told me about that at the end.
The clinic that I liked the most was the Gen med morning clinic because he just fed me all of the "good" patients and let me do whatever I wanted. Which was the way he had always dealt with students. So, it was very educational for me. I'd get to go and talk to his strangest patients for a good 20-30 min while he saw other patients. Although, I don't think I made as good an impression on him as I did that afternoon doctor. Again, the grades will tell all.
Oh! Back to the VA. Well, actually, at the ID clinic! They ID docs were talking about some of the patients at the VA and they mentioned someone's last name. I turned around and said, "you're not talking about Mr. So-and-so?!" They were! He was one of the guys I admitted when I was at the VA and he was STILL there! I kept meaning to see him after the morning VA clinic, but it always ran long so my last clinic day I went in 30 min early to say hello. He was actually going home that! (And last I heard he had actually gone home!) Anyway, he still was doing well. He had a procedure to help with his liver cirrhosis and had gotten a blood infection that we were having a difficult time curing. He was never very ill, we just couldn't get rid of the infection and it was important to have him on IV antibiotics. Each time he'd get close to going home, he's spike a fever (usually associated with going outside). In other VA clinic news, I discovered a patient with some massive depression which had resulted in a 50 pound weight loss over two years. The doc had not really picked up on it because she sees him so often. It was kinda' interesting though because I was following a bunch of cancer red flags. I was staffing the patient with the doctor (that's telling the doc what all I found in a specific organized fashion) and I was throwing out all of the cancer red flags: loss of appetite, weight loss, increased back pain...I got her all worked up and we were planning all sorts of screens and then I looked at her and, "what if he's really just depressed?!" Right then, the chief chimed in from across the room and started asking me about all of these questions to screen for depression. I answered the first two as, I don't know. Then I stopped him and said, "Wait, I don't think you understand that I JUST considered depression as an explanation while I was staffing because I was thinking cancer. So I have not asked him any questions about depression." I had asked all of the cancer questions and, yes, there is a surprising amount of overlap between the two. The chief went in and he screened (which kinda' pissed me off because I wanted to do it) and he, that patient, scored VERY high for depression. So we cut back to just a pelvic X-ray just to rule out an underlying malignancy, started some short term antidepressant (which for him was justified since, once he because mobile again much of his depression would resolve) and made an appointment for him with psychology. Oh, have I ever mentioned that I was very good at picking up depression at the VA. It was always pretty easy, you just ASK!!!! But, apparently, that does not happen. Really, there are some specific screening questions you can ask, but once you have some semblance of rapport, you can just ask them. You I don't think much of my interpersonal skills, but it is apparently lacking in the field. Who knew?!?!
In other news, I'm typing on my new computer! Well, actually, it's just a new motherboard and processor. I know, I just replaced the mother board with my old CPU but the something was still flaky and I didn't have time to figure out what it was. I think it was just another defective motherboard. I went with a different brand cause I thought it would be good. Actually, it was mostly the RAID function (RAID=two duplicate drives running in tandem so there is always a backup if one of them fails) would drop the drive speed by a factor of 10. (Too slow to even burn a DVD.) So, I got a new mother board (well, yes, a different brand than my usual but I wanted to try to broaden my horizons) and a new processor that is almost 1 GHz faster than my other one but there is really little difference over my original set up. Except it has passed all of my stress tests which my original board was not. I still don't know what happened to it! The intermediate motherboard also never crashed, but I could not put up with the slow drive speed. More over, this processor will run Windows XP 64 bit even though it is not supposed to. AMD started shipping out the 64bit enabled Sempron 3300+ processors before they projected date. Unfortunately, my wireless card will not work with WinXP64, so I can boot into it, but I cannot do much more than work process. It seems to work pretty well and it does seem a bit faster. If they every make a driver for my wireless card I will switch, but I doubt they ever will.
Okay, time to clean my office!!! Maybe I'll do the dishes too! (I'm such a nice husband...NOT!)
Monday, July 25, 2005
Here we are at the last week of outpatient--not enough time to post any of the stories but hopefully I'll get caught up soon. Although there was less frank work during this month, it turned out to be quite busy! I have two exams at the end of the weeks which I have been trying to get ready for--with mixed success. And, I should get back to studying just a little bit more before going to sleep. This weekend will be a switch weekend (off). And next week I will start my month-and-a-half of psychiatry!
Saturday, July 16, 2005
Lots of thunderstorms over us all this morning. Lightening went on from about 6a until 11a continuously-the storms seem to be moving very slowly. Made it difficult to sleep! Sad thing is I have lots of on-line studying to do. Oh well, I'll have to do it between the lightening bolts. Here comes the next round so I better shut down before I kill this computer!
E-
PS. I did get one great/funny/odd compliment from one of my outpatient docs: "It's amazing! Every time I walk into a room you always have the patients laughing. Even the grumpy ones! I've never seen that before."
E-
PS. I did get one great/funny/odd compliment from one of my outpatient docs: "It's amazing! Every time I walk into a room you always have the patients laughing. Even the grumpy ones! I've never seen that before."
Wednesday, July 13, 2005
Sorry for the long delay. My main computer has been giving me problems so I have been trying to figure it out in my "free" time. As such, I have not had the opportunity to post. Actually, since I started my out patient month there has not been too much to post. Most of it that is interesting is probably too complex to explain other than meeting a woman (who is doing well) who was in a coma for 4 months from disseminated histoplasmosis from sweeping up a dead bat from her garage. See! Coma part is cool but I bet a lot of you were lost a histoplasmosis. :) I did also see a patient going through, what we think, was narcotic withdrawal. That was interesting. We sent her to the ER since the clinic is NOT the place for that kind of help.
Computer-wise, I have taken over ML's desktop. A touch slower than mine, but hers works and she has actually NEVER used it! In reality, the computer is plenty fast enough however, mine is (was) much quieter! I had a lot of special low-noise fans put into mine big one but, keep in mind it had like 5 fans at one point. I managed to get it down to just two but the certainly blow (blew) warm air.
In family news, last weekend ML and I drove down to Chicago for a family reunion. It was a great time with much of my father's side of the family. Most of all, I got to see my grandma' and her sisters! I'll probable have pictures to post some day but seeing how I have not even gotten to Hawaii yet...oh well, that's M3 for you!
Computer-wise, I have taken over ML's desktop. A touch slower than mine, but hers works and she has actually NEVER used it! In reality, the computer is plenty fast enough however, mine is (was) much quieter! I had a lot of special low-noise fans put into mine big one but, keep in mind it had like 5 fans at one point. I managed to get it down to just two but the certainly blow (blew) warm air.
In family news, last weekend ML and I drove down to Chicago for a family reunion. It was a great time with much of my father's side of the family. Most of all, I got to see my grandma' and her sisters! I'll probable have pictures to post some day but seeing how I have not even gotten to Hawaii yet...oh well, that's M3 for you!
