This thing I refer to as My Life

HME...

Who knew NOT working your fingers to the bone could make you so busy. I suppose it was all of the other chores that I had been ignoring taking up the "extra" time. As of yesterday, all (or at least most) of the M3 class took their final shelf exam of their last M3 rotation and thus the M3's become M4's. The real change (other than the opportunity to have some control over our own schedule) is that the e-mail address the school uses to address the class changes from M3 to M4. That's really not true. The M4 year is longed-for by every student trapped in M3.

Family Medicine was my last rotation of M3. It seemed like a good choice when I was selecting from my choice of rotations in that FM is known for being more relaxed, and, students are usually quite burned out by the end of M3. (Which was true.) The other train of thought is that you don't want to rotate in something that you're interested in when you're burned out. Now, I'm only willing to put that suggestive line there because of this following sentence. I really thought the field of Family Medicine was pretty cool! Part of that comes from by bias towards outpatient environments--that was something I learned this last year. And the other part comes from the observation that everyone was happy. Well, almost everyone. It has a very nice lifestyle in that your clinic starts at 8a and, if you do not have a student slowing you down, you're finished seeing patients by 4:30p and can probably get through most of the paperwork by 5. There were some evenings where the docs stay until 7, but that is way better than all-night call.

Almost every time you meet a patient during your M3 year, it is the first time you're meeting them. That comes with a significant amount of baggage in that you have to establish rapport, learn about their history and then try to get the patient to actually tell you what's going on.

Aside: I'm talking with my neighbor yesterday (enjoying the nice weather) after my exam and discussing her experience with students in her clinic visits. I was describing to her what went on behind the scenes which I was surprised to find out she did not know. So, I'll mention it here (or at least what I do): I walk in and introduce myself as the student working with Dr. X (actually, several times I would blank out on which doctor I was working with during FM because we work with so many). I continue to explain that we'd meet first, I'd take the history and perform a general physical exam (we're not allowed to perform breast or genital exams without the attending present, which will be another story). I would tell them that I would go tell Dr. X what is going on and that we'd both come back together, some of the exam would be repeated and we'd complete the physical exam if there was more to be done. Of course the speech was tailored to the context of the visit, but I tell you that to tell you this: after explaining what goes on to my neighbor she looks at me and says, "Oh! So I should be telling the 'student' all of the things that are going on? I usually just save most of it for the doctor…" Doh!

In FM, one of the big selling points is continuity of care which is why a 15 minute visit can actually work. The doctor knows the patient's history and does not have to have the full picture painted each time. Not that everyone likes that, but I think it's pretty nice.

The personality conflicts were minimal in FM much like during surgery. The attendings are "normal" and, contrary to some of the rumors out there, they're pretty damn smart, too. At least that was true for the doctors I worked with. I will single one of them out in that this attending had a collection of the world's most complicated patients. Whereas many of the visits with the other doctors were straight forward (aches, pains, colds, infections), this attending had patients that had enormous, complicated problem lists. Our last day together, virtually every description of the patient that was given during the patient-overview-debriefing started with "this patient has a complicated past medical history…" These patients just seem to gravitate to this attending.

Okay, it's time for one of those observations of mine: there are two kinds of attendings out there when it comes to students in these clinics. There is the kind that wants the student to see every patient within the given time-slot and there is the kind that allows the student to work at their own pace and they see other patients around the student to keep things on time. Of the two, I much prefer the latter because I think it is much more educational and valuable for me to be able to perform a first visit and to be able to investigate the disease process(es) in greater detail than to pretend that I know the patient, run in, find out why they're here, make sure that I can hear their heart and breathing through my stethoscope and that they have gas in their colon (most of which I know already because I've been talking to them) and run out to the attending with a diagnosis. I was first introduced to these two types of attendings during my outpatient internal medicine month and it does continue here. Fortunately, most of the attendings in FM ascribe to this latter method, too. Or, at least they figured out that was what I was going to do. I suppose I will find out what they thought of it when I read my evaluations.

Now that the love-affair is over, let's talk about some of the "moments" in FM. As one might expect, there are a lot of health maintenance exams (HME). During my month, there were only two male HME and a slew of female HME. To be honest, I am much more nervous about the prospect of performing an over 50 male HME because I have yet to do one and I can say I have now watched only one. (I have only performed one prostate exam and that was on a standardized patient interaction (a (well paid) actor/instructor.) I was going to perform one after I watched that first one, but the patient refused the student. (That happened much more to me in FM than it did during my outpatient internal medicine.) With that said, I still get plenty nervous performing a speculum exam: although I'm okay with the bimanual pelvic because I did a ton of those during my Gyn-Onc rotation, but the patients were unconscious at the time. That, obviously, is another story. So, what is so difficult about a speculum exam you ask? Aside from the awkward language one has to use to describe what is taking place and that you don't want to hurt the patient, it's the damn cervix! That beast can be next to impossible to find especially when you're learning. You try to move the speculum around--correctly--to capture the cervix between the "bills" but it frequently does not work. And, the longer it does not work, the more nervous the student becomes.

So, I'm hunting around for the cervix during my one of my first pelvic exams since OB/Gyn (which was about 9 months ago, oddly) and I look up at my attending for help. She provides some instruction which I follow, but it does not work. She offers to try after what seemed like 2 hours, but was probably more like 2 minutes. After several more minutes she says to the patient, "you have a rather difficult cervix to locate!" She decided to perform the bimanual exam first to locate the cervix. Over the rest of the month I had about a 50% success at finding the cervix. I just wish I could get training wheels for the exam. Who knew the cervix could be such an elusive creature?

On the less-stress-inducing side, there were several patients with shoulder, back and knee pain. There was one patient, a little girl with her mother, which I saw with concerns over an upper respiratory infection just before lunch. After lunch, while working with a different doctor, I walk into the room to introduce myself to a woman who is about to have a colposcopy exam and when I go to introduce myself I stop with, "I'm the med…" when I realized it was the mother of the last patient. It was weird at first, but also really nice when you consider how much time it takes to go to a doctor's appointment. (For those of you wondering, a colposcopy is an exam of the cervix for neoplastic changes using a device that is basically a pair of binoculars on a tripod. Of course it looks much more official than a pair of binoculars on a tripod, but that is really what it is. Oh, it has a flashlight, too. That's the difference. Okay, this colposcope had TV output so the patient could also see her cervix, but you get the point.

I think those are the cases that stand out and are amenable to the written word. I also saw bunches of other patients with diabetes, depression, rashes, colds, infections, and more. I did get to cut off a skin tag! That rocked! But, then, I'm easily amused by the end of M3.

The med-student blog is supposed to be featured in the AMA newsletter next week (a national new letter). I took it upon myself to ask ML to proofread all of those posting, which she lovingly did and now they're all corrected. Too bad I'm too lazy to fix them over here, too. I was speaking with the dean of admissions yesterday, who is one of the people in charge of the blog, about how I'm a corporate tool. He said, "no, you're a very effective corporate tool!" And then he said that he will put that into my Dean's letter. Great! That's just what I needed.

The professor who is in charge of the family medicine just found out about the blog from a friend of his in Jersey! Kinda' scary already! I think I'm going to have ML edit the posting before I post. I was originally going to do that, but never did.

Today, we participated in an egg roll with our neighbors. For those of you that don't know (which I did not): you color an egg and then roll it into someone else's and the one that breaks, looses. But, then you get to eat your egg so it really depends on how hungry you are as to whether you consider it a loss or not. All of the children when through their elimination rounds and then the adults. I made it to the semi-finals when someone noted that I roll my egg oddly, to which I replied, "well I'm Jewish! I have no idea how to do this, but it seems to be going pretty well." Moments later my egg broke. It was yummy! I win for my tummy if not my cholesterol.

I forgot to cross-post this one....
Also, in more personal news, I have found yet another prof. I don't particularly like. I think a common theme with this is prof. that like to hear themselves talk more than I like to hear myself talk. Ahh, the things we learn in medical school

Don't Stroke in Your Sleep
04/09/06

Ive hit something of a writers block.

Let me start with the last post. I have never had so much feedback (read responses or complaints) about a story in all of my blogging. Understand that is the way consults often work. You know what I know. That patient was admitted and I had to move on to the next one. Since he was admitted to neurology, the consult service does not follow. There is not always continuity of care in medicine. ER docs never have it and neither to Anesthesiologists. But, it was so interesting that I will tell you this: the evidence does not point to any acute structural damage to the brain. And, unlike so many have speculated, there was no drug abuse involved at all.

Neurology has come and gone and while I walked away with many lessons, this is probably the most important: Dont have a stroke while you are asleep! Awesome advice, right? It turns out that tPA, the clot-buster they use for ischemic type strokes, is dangerous enough that the benefits outweigh the risks only if the stroke was in the last three hours from the time they stick the stuff in the IV. So, if you cannot provide a definitive time as to when the stroke took place, you are out of luck. What is worse is the system is set up against information gathering, which is the most important part of this equation. The second nugget of information is stick to your story. You see there was a person that was brought in to the ER with a report of stroke symptoms onset shortly after waking up. When we (the neurology consult team) questioned him, the first story we got was that he was normal when he first woke up. However, they person has had a few strokes before and he already had some cognitive deficits that further hampered communication. When we questioned him for a little more detail about the events of that morning, it became less and less clear that he was normal when he woke. Even more unfortunately, the patient said that he did not have a roommate. But, we would find out later that afternoon that the patient did have a room mate and that the patient was normal first thing in the morning. We could have administered tPA if the patient would have wanted. In all fairness, the patient did not seem too thrilled with the idea anyway, but that may have been partly due to the way it was presented. There is apparently some regulation that EMS is not supposed to spend time gathering information. (I can see both sides of that coin.) So what we need is a bunch of volunteers to be The tPA Stroke Information Gathering Team! A team of premeds and students who are contacted immediately when EMS thinks a person has had a stroke. The team can swoop to the location, gather the precise story and contact the ER to relay the information. Of course that only works if the stroke happens close enough to the team location that someone can get there quickly. But still, it would be better than nothing. In any case, people do get better from strokes without tPA and it is only appropriate in a narrow window of non-hemorrhagic strokes.

Now I am in my family med rotation working in an outpatient clinic. The people are really nice, that patients are nice and almost everyone has a viral illness thats going around. I saw four of the largest tonsils I have ever seen! They were like elephants!