Doctor / Detective

Today I spent with Dr. K, who is a female doctor I spent a 1/2 day with the other day. We had some interesting cases today - with unknown answers. I am looking forward to getting some test results back to help us narrow down our differential diagnosis for the issues. I'll just mention a few of them:

1. Female patient 48 yrs old came into the office today for a follow up. A few weeks ago she presented with lower abdominal pain and pressure. They ruled out a UTI with 2 negative urinalysis, next on the docs differential was diverticulosis and she had a CT of the abdomen done. This showed now diverticulosis, but it did reveal a globular uterus and a left ovary that had drifted over to the right side. The patient was prescribed an antibiotic prior to the CT and her abdominal symptoms resolved. The interesting part is that this patient had a hysterectomy and oopherectomy (L ovary removed) a few years ago. So...... one wonders why according to radiology she still has a globular uterus and a L ovary?????
The patient does have a history of endometriosis - which is when the lining of the uterus (endometrium - that is shed every month) proliferates, sometimes in spots where it's not supposed to - like outside the uterus. It usually gets out via the fallopian tubes. Endometriosis can cause irregular bleeding. Well, our patient had irregular bleeding post-hysterectomy which shouldn't happen. She still has her cervix (which they may or may not take w/ a hysterectomy) - and with the abnormal bleeding they used some sort of treatment that basically cauterized her cervix (which is questionable from my and Dr. K's perspective). Anyway - we sent her to see her gynecologist and for an ultrasound to check this out. It could very easily be endometrial tissue that was left after the hysterectomy - that has proliferated. Not sure.

2. Another 48 year old woman presents with a "lump" in the back upper arm, near the axilla, but not in the axilla. It's more the back of the arm rather than in the armpit. This "lump" - is more of a fullness in the back of the arm, it's movable and I describe it as grainy. Dr. K and I are not worried about breast origin because it's more the back of the arm rather than axilla and the patient had a clear mammogram in Jan. The mass is not connected to muscle and does not feel like a swollen lymph node. It has been present for a week and has not grown according to the patient. I was stumped at first, but the current differential is a soft tissue mass - probable lipoma. The next step according to radiology (because Dr. K called to ask what the best imaging studies would be) - 1st step is x-ray to rule out any bony abnormalities and then if that is clear MRI. So we shall see....

So..these cases and a few others (these being the most exciting) - make me feel like a detective trying to figure out what's going on. We slowly gather more evidence for or against our proposed hypothesis.

http://en.wikipedia.org/wiki/Endometriosis
http://en.wikipedia.org/wiki/Lipoma

Loving 3rd year

ok ok - I know it's only day 2 - but so far I'm loving 3rd year. Also, I am probably lucky to start in a family medicine office. I worked from 8-5 today with probably a 15 minute lunch break and... I loved every minute of it.

There are always interesting findings even with a routine physical exam. I truly enjoy just going in and talking with patients. Everyone has an interesting story or history - that they all want to share in addition to whatever is ailing them. And if they are coming in for a routine physical and pretty much everything is normal - that feels good. It's great to see healthy people, because we are surrounded by so much illness and disease in the hospital.

It's hard for me to describe the high lights of my day - because I feel like what I find exciting and interesting is probably not so exciting and interesting by your standards. Today I froze off 2 warts, saw a case of probable gallstones that was textbook. There is a mneumonic for gallstones - the 4 F's - Female, Forty, Fat and Fertile. My patient today was 39, female, I would say pudgy not fat and I'm going to guess still fertile. It's amazing that some of the stuff we learned from the books was right. In a way I feel like I'm learning all over again - starting from scratch.

This is why I went into medicine - to see patients everyday, to interact with them and carry on various conversations on a variety of topics and to help them in whatever way possible.
Sometimes that's just listening. I had a new supervising doc for part of the day Dr. K. and one of her patients came in with a chief complaint of neck / shoulder pain - once she got in there she realized that all she really wanted was an outlet to tell her problems.

Ok - time for me to read a little and then hit the hay! I'm exhausted, but it's a good tired.

Interesting article I read this morning while eating b-fast - in case you're interested

http://www.bbc.co.uk/blogs/thereporters/jamesreynolds/2008/07/a_tale_of_two_beijings.html

Day 1

So 1st day down. Even though it really was a half day. I had orientation this morning which was boring and I will spare you the details.

This afternoon was fun though. The doctor who is in charge of me didn't have too many patients this afternoon, but that gave us some time to chat and for him to show me around. The place I'm working at is quite a big outpatient center - with a number of family docs, a pediatric cardiac center, and a lab, etc.

I feel like there is so much to tell and it's only been the first day. It's partly because Dr. R and I talked about Family Medicine in general and where the practice and role of family physicians is going. We also discussed briefly his feelings about pharm reps, etc. The Pharm thing is hard - because it is ridiculous the amount of money people pay for drugs and how much the pharm reps spend feeding doctors, trying to get them to prescribe their brand. But....the free samples help patients. Docs can give out a months supply of meds at time to help a patient get the meds they need. Penn State is going Pharm free soon which means pharm reps won't be allowed to give presentations, etc. Dr. R (my advisor for the next 2 weeks) - says that he morally understands going pharm free, but there needs to be data backing it up. There are many docs out there - probably too many that prescribe based off of the pharm reps or just out of lack of knowledge or time to look into their patient's monetary situation and prescribe brand names at will. Dr. R says that his history shows him prescribing at a cost that is 43% less than his peers. He's not saying that he's never been influenced by a pharm rep, but that he's doing a pretty good job and in a way he and his patients are being hurt with this movement to pharm free.
It's a tough battle and no easy answer.

He loves his job and has been through some rough times with family medicine earlier in his career - not being able to survive on his own or with a group and that's why he's with the med center. But...he loves his job and can never see himself retiring. He works about 12 hours a day - by choice. He'd choose it again if given the chance.

This year is my year to find out what I will be so passionate about 15-20 years down the road. I feel family medicine is a good place to start. I have a lot to accomplish in the next four weeks. They give us a list of procedures and exams along with a few homework assignments that must be done by the end of the rotation. I'm excited - still a little nervous, but extremely happy to be with patients and people.


Picture: Vail

4th of July and the start of 3rd year

I was lucky enough to spend the 4th of July with one of my best buds. This past week I got to spend a few days with Ryann. It was great to see her - her life and meet her friends. We caught up and hung out - like old times. Even though our lives have changed and we've grown in the last few years - our friendship still feels the same - I guess it's grown with us.
We shopped, talked, and went up to Vail to hear the Rochester Philharmonic orchestra play on the 4th of July. Then we had a wonderful dinner, before heading back down to Denver to watch the fireworks. It was a short, but wonderful trip. My fingers are crossed that she'll be able to come out and visit for New Years.

As for tomorrow - it's the start of a new school year. 3rd year - I'm halfway done. I consider tomorrow the official start of 3rd year. Clinical skills week was sort of a warm up. My morning starts off with orientation and then I head out to the clinic to start my family medicine rotation. I feel like I'm pretending to be a doctor. Sort of like dress up when your a kid. I have knowledge, but I have very little practice or ability in applying that knowledge. Skills? Maybe a few, but not many. My learning curve is going to increase dramatically in the next few months. It's exciting and unnerving at the same time. I guess that's how it's always been with the first day of school. I have my outfit picked out and my lunch is pretty much packed in the fridge.

I'll fill you in tomorrow.... wish me luck!

random

I know it's been a while since I've written. I guess I've been busy enjoying my vacation. Heading to Colorado tomorrow to visit Ry Ry - my old roommate and one of my best friends. Can't wait. I spent this evening sitting around playing games with my family - being loud and laughing - A LOT. The way it's supposed to be. I love how even though I'm gone most of the year - that never changes. I come home and I'm exactly that - home, where everything seems to fit just so, even though we're all growing and changing, so much is still the same.

So here's a post I've been meaning to write for a while and just didn't get around to it. This is about our last week in clinical skills and I was talking with my fam about some of this tonight. Well - we were talking about being a standardized patient and getting pap smears. We heard these patients get paid $1000 / day.

Let me back up and explain. During clinical skills week, one of the skills we practice is giving a female pelvic exam. We have standardized patients that are paid to do this for us. They are supposed to help guide us through this along with a doctor who is also there to guide us through. We don't actually perform a pap smear, but we do the speculum and bi-manual exam (where you insert 2 fingers into the vagina and use your other hand on the abdomen to feel for the uterus and ovaries)

First I must say that I feel at an advantage being a woman and having experienced a pelvic exam before. Naturally, I think most of the guys in my class are much more nervous about the entire process. The best story I have out of this experience was one of my guy friends who has rather large hands. He walks in and shakes the patient's hand and she says - Oh my gosh, you have huge fingers! He chuckles and tells her that he'll be gentle. The exam proceeds, but when the bi-manual exam rolls around the patient requests that he only use one finger instead of the standard two!

Transition to Clinical Medicine

This is a longer post, but I promise it is worth the read.

Last night we had our Transition to Clinical Medicine Ceremony. The class of 2010 gathered in the hospital auditorium, once again wearing our white coats listened to a few speeches, and retook the Hippocratic Oath. It was a time for us to reflect on the past two years and look ahead at the next two. We're halfway there - M. - 2 more years and it'll be the full M.D.

One of my best friends, Mr. Richard Tran - was nominated by our class to speak last night. As is Rich's style - he kept it real, down to earth, and was thoughtful as always. Someday he will make a wonderful physician. I will let you judge for yourself - below is a copy of an inspiring speech!



We've decided that the picture below - should be used as Rich's campaign photo should he ever decide to go into politics.

I was trying to think of a word to summarize what these last two years—these preclinical years--have been about. And the word that I came up with is…information. So much information. Too much information even…that almost makes you feel ashamed to know it. For example, it makes me sad that I know what smegma is.

But information on its own is a lifeless thing; it’s not organic. Yes, we can learn in a vacuum; we can gain a lot of knowledge when we’re apart from the world as we’ve been these last two years. But we didn’t sign up for this to be strictly learners or to know it all; we signed up to become doers and practitioners. And you can’t practice in a vacuum. You can’t do anything that matters when you’re insulated in a classroom or a library cubby. Today marks an occasion when we take a step toward becoming doers.

Just a couple months ago, our daily routine was looking at Powerpoints and pdf files over and over. A few weeks from now, you might find yourself looking into the face of someone’s daughter instead. That’s quite a change…and one might ask, how can we expect to be prepared for this re-entry of real life into our world? How do you go from studying in quiet to performing out there, where anything can happen?

Here’s the secret…we’ve been preparing for this our entire lives, not just the past two years. All of the things that built you into the person that you are today will equip you with much of what you’ll need. I look into this crowd—I look at all your pretty and handsome faces--and I don’t necessarily see med students. I see mothers. I see fathers. I see people who hustled to get here, and people that have been through struggle. Medical school is only the latest chapter in our life stories; we’ve had many, many chapters written prior to this one.

So when you look into a patient’s eyes and see that they’re scared, you’ll be ready for that moment. Not because you’ve had a lecture on sympathy and empathy—which we have--but because YOU’VE BEEN scared. You know how that feels, and you know what you can do. When you’re trying to figure out the right thing to do in a situation this year, remember that you’ve spent the past 20, 30, 40 years of your life doing the right thing. You’ll KNOW what the right thing is.

When you’re put on the spot and you have to step up, that’s not going to be new either. Because you’ve had to step up many times before. We are all grown, experienced men and women, who have seen a lot of life, and all that life has readied us.

Now that we’re ready, we have a lot of things to look forward to in the coming year—some good, some maybe not as good. We’ve heard the stories about the hours, the work, the stress, the patients, attendings, and…what do they call it…pimping? And we hear all of that. We acknowledge that not everything will be sweet all the time. In spite of this, there is one truly BEAUTIFUL thing that we can ALL look forward to.

If you close your eyes and indulge me a little, think about the best moments of your life. I’m talking about the truly best moments of your life, not when you got your first Nintendo. I’m talking about those times when you were the most proud of yourself, and when you felt the highest. When I think about those moments, they have a common thread. They happened when I accomplished something that I DIDN’T know I had in me. It’s a sweet feeling when you rise to the occasion and go beyond what you thought your limits were.

All of us are GUARANTEED those moments in the coming year. They say there are no guarantees in life? Well, I guarantee this one, personally; double your money back if I’m wrong. At some point, every single one of us will pause, smile, and think, “Did I just do that?” That’s the beauty of our field. We work at the extremes of the human condition—with its excitement, emotion, and uncertainty. There’s no way that you can be where we’re going to be…in the wards and clinics…and not be tested. Every day we walk into work, we are being given a chance—at least a chance, if nothing more--to step up and do something beyond the ordinary everyday. And we’ll be new and maybe naive enough that none of it will have become routine yet. A challenge is not something to be scared of; it’s a privilege to be enjoyed.

That means, at any point this year—whether high or low--some of the proudest moments of your life will always be around the corner. Get ready to create and enjoy some of the best moments of your life starting in a few weeks. We’ll be here to share them with you.

I’d like to close by asking a favor from all of you. From here on out—not just for the duration of our time here, but for life—let’s look out for each other. Let’s look out for each other. Collectively, we’ve chosen a path in life that is not the easiest; there are going to be some hard times when you could use an angel, and then there will be times when you can be somebody’s angel. As medical students, as doctors, we are…weird. But we can understand and support each other in ways that even our friends and family can’t.

With that said, there’s one of us who needs to be looked out for especially, because she couldn’t be here with us today. Christina has been eulogized properly by people far more worthy than I; I’m not here to do that. Going forward, I feel like the best way to honor someone’s memory is to do it through action and to keep acting year after year. When we get out there—again not just for our remaining time here, but for life--our work doesn’t end when we’ve finished everything we’ve been assigned. The world lost something when they took Christina away from us. We need to do a little more, a little extra—with her in mind—to not only make up for that loss, but to gain it back in multiples. If fate cheated us by taking Christina away, we need to cheat fate right back by not letting her go. We do that by carrying out together what she would have done if she was still here.

Class of 2010, it makes me so proud to be here with you in this moment. We’re at an uncertain stage—kind of a no man’s land—between student and doctor. This year will likely be a time of heavy uncertainty as well. But if we trust in our own strength, and we work hard for the right people and for the right reasons, everything’s going to be all right. Thank you and I love you all. Let’s go!

In case you were wondering what smegma is: http://en.wikipedia.org/wiki/Smegma

Plan B = phlebotomy

Yesterday, we learned to do venous blood draws and place an IV catheter. As I mentioned before we practiced on each other. We first watched a video and then went into a room to practice the placing the IV catheters. There's a needle that has a catheter (which is just a little tube over the top) on it. You stick the person's vein with the needle and the catheter over the top and then while the needle is in you slide the catheter farther into the vessel and pull the needle out.

Our first station was to practice the IV's on a fake hand, then we did the venous blood draw, which wasn't too bad. Lucky me - I have big veins that are hard to miss. Poor Carrie (my partner) - whose veins like to hide out. I got blood on the first try though! Then next was IV's. This scared me the most because we do it in the back of the hands and you know it's painful. Success, once again! This is why if being a doc doesn't work out then I could always go into phlebotomy.

Let's see what else have I learned? We learned to place Foley catheter's yesterday. That's a tube up the urethra. It was rather painful to watch on the video. Wouldn't be the most fun thing to have done. We didn't practice these on each other. We have mannequins for that with a fake bladder and pee - the whole works.

Lumbar punctures were today. Again practiced on a mannequin with fake spinal fluid. Note to self: definitely do not want to have one of those done. That is one BIG needle that is going very very far into one's back and they take more fluid than you would think.

ABGs (arterial blood gases) - this is where take blood from an artery and send it off to get the concentration of oxygen, carbon dioxide, pH, etc from the arterial blood. Here you feel for the radial pulse and then keep one hand on the pulse and with the other - aim the needle and hope you hit it! Again with a mannequin.

Tomorrow morning is practice pelvic exams. I've done a pelvic before, but these are standardized patients who will be able to tell you if you are feeling certain things or not. I've never felt an ovary - so hopefully by tomorrow.

The motto for our learning is: See one, do one, teach one.

As a patient would that scare you?