Internal Medicine: Parts 2 and 3

Oh, hi.  Remember me?  Time has completely slipped away from me these past few months.  Case in point, my desktop calendar still reads March.

I spent 2 months on the medicine wards (I believe this term refers back to the olden days when all the patients resided on the same floor, but nowadays our patients are spread throughout several buildings) at MCV and the VA hospital.  It was, how shall I say, enlightening.  Six days a week, 11-15 hour days, many of those hours spent in a drab team room typing notes and calling consults with less than enthusiastic residents.  There was complaining, a few tears, anger and resentment on my part.  I did not like myself in this environ.  And more importantly, there was no one inspiring me enough to turn my frown around.  The attendings were great physicians, don't get me wrong.  I learned so much these past few months.  But I always love coming to work knowing there will be someone invigorating and excited to teach me something.  That rarely happened these past few months.

The patients were never a problem.  I got quite close to a few.  I helped one gentleman work through end of life decisions.  He literally begged for us to let him die as he had developed a colitis that left him sitting in a pool of his own bloody diarrhea for weeks.  Another young man I related to all too well, was fighting a brainstem tumor.  That kid was mentally and physically tough and easily became one of my favorites.  I even got to see him a week out from his discharge and all the progress he had made.  Then there were the GI patients, a meek lady with Crohn's disease and a motherly figure with cirrhosis.  And the devastatingly sad nursing home patients, many suffering from neglect and malnourishment.  What. the. heck.  The flirtatious old men at the VA hospital.  So, so many of them.  They all taught me something.

Towards the middle of the two months, I started to think about an internal medicine residency: nearly 3 years of wards and ICUs and scattered clinics that none of the residents seem to enjoy, even those that claim they are pursuing primary care careers.   It got me down.  I don't like the hospital much or the confines of the team room or the depressed attitudes.  Residency seemed like such a forlorn experience and I lost hope for myself and my happiness over the next few years.  But then I started to talk to friends and mentors about it and began to realize I may have been so mentally committed to internal medicine that I was suppressing my inner family physician!  And since making that realization I have been so much happier.   I admitted to myself that I don't hate pediatrics as much as I have said (I definitely enjoyed my peds rotation).  And I love outpatient medicine, that much I knew already.  I love that family docs to be get to train in a variety of settings, including a little bit of surgery and ob/gyn.   And as my mentor put it, when he goes on a medical mission trip they press the internal medicine and pediatrics folks to see what ages of patients they are willing/capable of seeing, whereas with him they simply show him to his chair.  He can see anyone and be of great service in many settings.  Since I am pretty sure I want to work in a rural or underserved area, this just makes the most sense to me.

Internal Medicine: Outpatient month

And just like that my outpatient medicine month is almost over! I spent the first two weeks in a primary care clinic and now I am finishing my two weeks in the ER at the Veteran's hospital.

The primary care clinic was stressful. The way I see it, the 3rd year of medical school is all about refining our history and physical skills and improving our differential diagnoses. In this block, I was thrown into the deep end of the swimming pool and I was forced to learn how to swim. My attending treated me like an intern: I saw the patients, wrote their visit note, ordered their prescriptions and any tests or consults they might need, and scheduled the follow-up visit. All the while being hammered with questions and criticism by the attending. Needless to say, I grew some thicker skin on this rotation. But in the end, I appreciate the experience because this is how things are going to be: am I going to sink or swim...the answer is definitely swim!

Next I moved over the world of emergency medicine. And I LOVE it! The thing I was missing in the primary care clinics was being able to DO things for my patients. If they have a pre-cancerous skin lesion, I want to freeze it off. If they come in with a laceration, I want to sew it. If someone has a possible AAA (abdominal aortic aneurysm) or ascites (fluid in the abdomen due to a failing liver), I can wheel the ultrasound into the room and look for myself! And I have been getting more and more freedom in the ER. The attendings and residents have gotten more confident in my abilities (or maybe it's just that I am more confident) and I find I am getting to drive more. It's like having that learner's permit all over again. I am in the driver's seat but thank goodness the instructor has his own set of breaks just in case I muck things up. I finally feel like an almost-doc!

Next up: inpatient wards!!

Pediatrics: Part 3

So it seems that I have failed to update in quite a while! Since my last peds post, I completed the final outpatient week on newborn nursery and an entire month of inpatient pediatrics (including night float, hematology/oncology and general inpatient pediatrics). I am going to briefly summarize each experience.

1. Newborn nursery: A great week indeed. My team consisted of an attending physician, one intern and three medical students. By mid-week the nursery was booming and that meant we med students actually got to do useful work, filling out new charts for the babies and scanning their mother's charts for pertinent prenatal information, examining our tiny patients, and giving parent talks (anticipatory guidance for new parents, signs of dangerous infections in an infant, and newborn safety information). This was actually a great experience: carrying up to 6 patients, using translator phones to speak to patients, and gaining some confidence in my physical exam skills.

2. Night float: This was an easy rotation to start the new year on since I trained myself to stay up late the week prior. I had a great time working with a small team of residents and would follow them to see any interesting cases that came in overnight. I was assigned to one of the general medicine teams so I also interviewed and examined patients we admitted to my team and I presented them to the day-team on rounds the next morning. The best part was chasing around the intern assigned to the newborn nursery. One night an infant was crashing because his blood sugar was less than 10 (normally we keep our blood sugar level between 80-100) and I got to participate in his resuscitation! Saving lives, people!

3. Heme/onc: My teammate and I started heme/onc on an unusually slow week for that service, so we initially spent our time following patients who were just chilling, for lack of a more appropriate medical term. Later in the week things picked up and we took part in a new diagnosis of leukemia including the bone marrow biopsy and enrolling the patient in a clinical trial. The moment that stuck with me was when my patient and her mom told me her hair had started to fall out one day so they decided to braid a section of hair and cut it off so they would remember what it looked like. Through the course of their treatments, these kids go through hell, but typically they do quite well.

4. Inpatient pediatrics: I lucked out during these weeks and got to follow two very interesting patients. One was in a traumatic accident and had suffered every possible complication thereafter. The other was being evaluated for a rare cancer syndrome. Though I can't say I developed a great relationship with the patients themselves (who can blame them, I was part of the team of strangers who was inflicting a great deal of their pain), I did enjoy working with their parents more than I thought I would. For the first time I understood what everyone has been saying all along, that we med students have more time than the rest of the team and we can really make a difference in patient care. I spent hours walking the halls with one patient who suffered a terrible drug reaction that caused widespread edema (fluid in her tissues) and I was able to participate in a great deal of the other patient's care including a family meeting to discuss his diagnosis and helping to create a family tree for genetic analysis.

Overall, I found I ended up enjoying pediatrics. Though I still don't think it will make my list of considered specialties, I learned a great deal and I feel more prepared for the coming months of internal medicine.

Speaking of, this was my first week on internal medicine (which means adult medicine). I am starting on outpatient medicine with 2 weeks in a primary care clinic and 2 weeks in the Veteran's hospital emergency department. More on that to come.

2012!

And here we are, just one calendar year away from graduation! This year will bring residency field selection, more Boards, and actually applying and interviewing for chosen residency. But that's OK, because we're not going to panic.

I've actually been pleasantly surprised with my lack of panic of late. Early in the year when I was liking my surgery rotation, I felt a tiny panic. Opening more doors meant decisions would be harder to make and there were still so many doors to peep through this year! But then Family Medicine came along and showed me the way (oddly enough, it showed me the way to adult primary care). The deal was more or less sealed when I started my pediatrics rotation last month. It was rough at first in my 2 weeks of community practice, and then things got better in specialties and newborn nursery (a very busy, fun week of mostly healthy infants). But even though I found myself liking Pediatrics and the practitioners thereof, it just doesn't feel right (again I said it!). And Family Medicine is out because it seems like a waste of time, time that would be better spent learning more in depth about the population I do want to see, training for a population I'd really rather not see in my practice (sorry, kiddos). So, even though I haven't actually-officially done my internal medicine rotation, it is pretty much decided--sigh of relief--.

Now I just have to get Boards Part II under my belt, a solid team of advisers, a few good letters of recommendation, and I think I'll be on my way: ready to apply for residency, that is.

Those things aside, I'm not much into resolving to do things this year. I could improve/fine-tune some personality traits like projecting confidence and remembering to be a "yes" woman. I would love to find more time for exercise and healthy eating. But you know how those types of resolutions go...

Anyway, I wanted to wish you all (how ever few of you there are) a Happy, Healthy New Year!

Pediatrics: Part 2

This week I completed the subspecialty portion of my Pediatrics rotation. Though I still maintain that Pediatrics is just not for me, it gave me some insight into the world of subspecialties (something we don't get a lot of exposure to this year....naturally, we have to learn the basics first after all).

It was definitely a whirlwind tour. In 5 days I rotated through Endocrinology, Gastroenterology, Pulmonology, Cardiology, Adolescent medicine, and a clinical research clinic looking at childhood obesity. I spent half days in some of the clinics, but fortunately we had the opportunity to spend more time in a few areas of interest (I chose to focus on Endocrine and GI).

And I realized a couple of things:

1. Specialists see a lot of unusual cases. Pediatricians in particular have the cornerstone on congenital disorders (problems that are present at birth). This week I saw kids with syndromes I had never heard of, and one case that most would not have heard of because it is so rare. What I had not realized about pediatrics was that some of these kids may stay with their pediatrician for life since they are more experienced in this area(I am a total sucker for continuity of care!).

2. Specialists see a lot of redundancy too. This wasn't exactly a surprise, but I was somewhat amazed that in 2 days of Gastroenterology I saw little variation on the themes of abdominal pain and failure to thrive. And in my morning of Pulmonology we only saw Asthma cases.

My insights are not groundbreaking by any means, but personally this was a helpful experience since these concepts apply to adult subspecialities as well. First, I did enjoy seeing some of the more unusual cases. I could tell that my attendings' years of experience made them well equipped to handle both usual and unusual presentations. I like the idea of becoming an "expert" in a field and not having to defer to someone else to make clinical decisions as primary care docs often have to. Naturally that leads to some redundancy. These doctors are able to tease out difficult diagnoses because they see the same things over and over again. I found that I liked the variety of cases I saw in Family Medicine (though there is certainly plenty of redundancy there too), so specializing might come at a cost for me. And perhaps many specialists temper the redundancy in their differential diagnoses by partaking in other things like research and clinical trials?

Next week I am headed back to the hospital to work in the Newborn nursery! Stay tuned...

Pediatrics: Part 1

I just completed my 2-week community pediatrics rotation. Well, really it was a short 2 weeks because Thanksgiving break was right in the middle. I was placed in a small practice (2 doctors and one nurse practitioner) in a Richmond suburb, about 20 minutes outside the city.

The first week was kind of a wash since we had orientation on Monday and my preceptor works a half day on Tuesdays and I was a bad(!) medical student and asked for some time off on Wednesday to pick up my bestie from the airport....so I only worked one full day in total. Heh.

And Thanksgiving was marvelous! I hope yours was too! Not to mention, I turned another year older last week.

This week I had to get serious and make up for lost time. I am pretty sure my preceptor thought I was an idiot (and I probably was one), but in my defense I have pretty much never seen pediatric patients before (see my previous post on family medicine in which I almost never saw kiddos, or see way way early posts on my first 2 years' family medicine preceptorships in which I also basically never saw kids).

So I had to learn quickly how to examine babies, toddlers and adolescents. And trust me, they all require a different type of exam. It was also hysterical to me when I would listen to a 2 week old infant's heart and lungs with my adult sized stethoscope and it would basically cover their entire chest (hyperbole intended). In addition, kids have different types of medical problems than adults: ear infections, asthma/allergies/eczema, and tons of upper respiratory infections. Sure, adults have some of those problems too, but usually it's one of the above plus hypertension plus diabetes plus osteoarthritis, etc. Dare I say I got bored. I also might add, I got sick! All those kids are just running around incubating viral disease! Ew!

I will try not to run this conclusion into the ground over the next 2 months of my peds rotation (though it might happen), but I think pediatrics is just not for me. I sort of knew this going into the rotation, and I tried not to let my lack of experience and interest cloud my judgement (though it still may have). In the last 2 weeks, it seemed that the parent was the patient more than their kid (reassurance, reassurance, reassurance). The medical problems were not very complex nor the diagnoses/treatments. There were almost no procedures (though this is likely the choice of the practitioners and not a generalized truth). There is always someone screaming/crying -somewhere- in the office and it caused me a constant, mild amount of stress. It makes me really uncomfortable to cause distress in a small child (even if I know I am not hurting them and they are just scared). Ok, one positive: some of them are pretty gosh darn cute.

Next week I will rotate through a bunch of different pediatric specialty clinics (endocrinology, gastroenterology, cardiology, pulmonology, and adolescent clinic) and the following week I will be in the newborn nursery at the hospital! Until then...

Family Medicine: Part 2

My one month stint in rural family medicine has sadly come and gone. In fact, I've already moved on to the world of Pediatrics. More on that later...I have been having trouble putting my experience in words (hence why I'm here 2 weeks late!).

So, way back last spring the department of family medicine asked us to write a wish list of sorts of things we would like to get out of our family medicine rotation. Many folks probably left the section blank or had a particular location in mind (ie, they could go home for the month). But if you know anything about the breadth of family medicine, from rural family docs to hospitalists to Emergency Room doctors to docs who deliver babies to your run of the mill suburban family practitioner to your urban underserved practice....the list goes on and on! Family doctors can do a variety of procedures too, like simple surgeries on the skin (for a large or deep biopsy, for example), joint injections, cryotherapy, delivering babies...there are probably many more, but you get the picture. Family docs do it all!

I knew that I was interested in family medicine back then, so I figured in order to experience a broad scope of family medicine I would have to land a rural rotation. When not too many doctors and large hospitals are around, doctors (hopefully) tend to do more for their patients to avoid having to send them out for many referrals and fancy diagnostic tests. Not to say that they are bad doctors, they just have to be more creative and use their diagnostic skills to save their patients time and money (shouldn't all doctors practice that way, really?).

I marked up my "wish list" with various procedures and rural practices and a few months later I was matched with the Crewe Medical Center! Crewe is only an hour and a half from Richmond, but it is definitely rural. The population for the entire county is only 15,000 and the nearest hospital was 30 minutes away in Farmville. Perfect, I thought!

As I said in my last post, there is a division of labor at CMC. The 2 nurse practitioners see all the well child visits, medication refills, and gynecological visits (basically, all the routine visits). That frees up the 3 doctors to see acute cases and uncontrolled chronic disease. Since I only worked with the doctors, that narrowed the scope for me quite a bit (I mostly only saw adults with acute and chronic disease), but it worked out for the best I think. I learned a lot of medicine in those 4 weeks! Dr. Hall (who I worked with most days) liked to joke that I was X patient's endocrinologist or Y patient's cardiologist. Perhaps a bit of a stretch, but fun nonetheless.

I could go on and on singing the praises of my month in Crewe, but I think I'll stop here. In short, I learned a ton, I loved the practitioners and patients, and I even narrowed down my list of specialties to one. See, I loved family medicine, but it wasn't really family medicine in my eyes. I saw acute and chronic adult medicine (internal medicine...right?). It will take more soul searching to be sure, but I don't see why the extra training in pediatrics would be of benefit to me if I really just want to see adults. Family medicine opens many doors since you can practice in so many settings, but I think Internal Medicine has many, if not more doors. It just narrows the patient population a bit.