For the past week and a half I have been on my 3rd year elective. At LLU, we do a 2 week elective after our Pediatric rotation. It has been interesting. They told us to use the elective to help us to either rule in or to rule out a specialty we are considering.

I ranked Physical Medicine & Rehabilitation (PM&R) as my first choice and was glad when I found out I got it. I chose it because I had heard many people say that it is a good specialty to go into: decent pay & good lifestyle. But I really had no idea what PM&R doctors did.

With my 2 weeks rotating through the PM&R service I hoped tho learn more about what these doctors actually do and explore the specialty as best I could. I’ve learned that these PM&R doctors are called physiatrists and their goal is to improve the quality of life and the function of their patients. Within this specialty doctors manage pain, assist in regaining physical function, deal with amputees, treat spinal injuries, etc. It is a huge field.

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Today I saw a stroke patient. I’ll call her Sharon. Sharon has been in the recovery unit for quite some time. The thing that stuck out to me was that her left side was extremely weak due to the stroke. However, she insisted that it had always been that way. To her, there was no change in her physical abilities and she couldn’t understand why she was still being kept in the rehab facility.

I’d heard about hemineglect before but this was the first time for me seeing it live. And it was very odd to see.

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PM&R doctors also do EMGs like neurologists. I got to chance to observe during one day of EMG clinic. The whole ordeal looked quite uncomfortable. After the first patient finished, one of the medical students asked the attending if he could explain a little bit about EMGs. He took us back into the room and proceeded to perform an EMG on himself.

He took it like a champ. While the patients were squirming and moaning with pain, the attending just fiddled with that needle in his muscle. So I snuck this picture in. If you click on it, a larger version should pop up and you might be able to see the needle.

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Overall, it’s been a good experience. I’m glad I got a chance to see the wide variety of things that happens within the PM&R specialty. At this point, it is still on my list of possibilities.

OSCEs are a great way to test students. Every student sees the same “patient.” The actor might be different, but the case they are given to memorize and act out is the same. It allows for standardization and makes evaluating students all the more easier because everyone is on the same playing field.

The problem is that OSCE patients are there to test us — not figure out what is wrong and get treated. And since the goal of the “patient” is different, they act differently than real ones.

For example, when I have seen real patients who come in sick, I often need to slow them down because they are just spouting off everything under the sun that is wrong with them or their child. So a mother bringing a child in with a chief complaint of diarrhea will tell you that the diarrhea started at such and such a time and the kid also had a fever and threw up a couple times, etc.

An OSCE mother will tell you that the kid is suffering from diarrhea. And when you ask if the kid has any other symptoms, it is likely that she will reply, “No.”

I get why a fake patient does this. They are there for our practice and for us to be evaluated on our clinical skills. We should be pressing for specific symptoms once we have an idea of the diagnosis. So after taking the history we have to go over the “Review of Systems” and ask specifically for different symptoms (i.e., vomiting, diarrhea, fever, headache, etc.).

But it just feels like I’m playing a game, or that my “patient” really isn’t all that interested. Because as a parent, wouldn’t you be listing off all of the symptoms you have noticed if it is as obvious as a fever you personally measured?

And now this rant ends.

I apologized to a patient — for not being a woman. As I walked into the room, and the nervous laughter erupted from both her and her mother, I knew something was up.

“What brings you in today,” I asked after we exchanged the customary introductions.

“She’s shy,” her mother answered as the two of them laughed again. “She was hoping she would get a girl doctor.”

And with that, I drew some conclusions as to why they were in the clinic. The chief complaint, as listed in the chart, was a simple one liner: “abdominal pain.”

The girl — no, the young woman sitting on the exam table in front of me was probably as uncomfortable talking to me as I was talking to her. Because when you’re a brand new 3rd year, you learn pretty quickly that you will have to “fake it” more often than you’d like. You come into situations you have only ever read about. You have to talk to a patient about the most private parts of their lives. Then you have to offer counsel and, hopefully, a plan to fix whatever they came in to have fixed all without sounding like a clueless idiot fumbling with words and eye contact and all that social jazz.

At one point I was asked if the sporadic pain and the irregularity between menses is normal. I laughed and said I obviously didn’t have any firsthand knowledge about it, but I knew it was normal.

She said she had no other symptoms. But I asked if she had back pain and the answer was yes. I had her move around and palpated her stomach. There were no masses; it caused no pain. I reassured her that it was not appendicitis. It was just normal, young-woman, growing-up pains. She’s growing up.

And I think I am too.

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Today was my first day at a new location. After one month doing Pediatrics inpatient, I have been sent to do Pediatrics Outpatient at a hospital in East LA. Picture 3 shows a view of downtown LA from the hospital.

On a number of occasions, my attending made reference to the fact that many kids to the west of here have those totally organic diets, but not “here.” East LA has a population that is of a lower socioeconomic background than the west side (this would include Beverly Hills, Santa Monica, Bel Air, etc…). So at least there is a perception that the patients I am seeing have a need to be seen — which is a plus for me, personally.

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Junior orientation began on Wednesday this week. Wednesday began with a review of school policies — especially pertaining to 3rd year issues. I also went to the office and picked up my new pager. The pager is the reason I was so excited for orientation. And I know perfectly well that I will probably soon hate being tied down with one. But please, let me wallow in delusional excitement for the time being.

Wednesday afternoon I took a 2 hour course in accessing the hospital’s computer system. Hopefully I will remember the important stuff. Today we had some more sessions. One of the sessions included making sure that we could properly wear the N95 masks. These masks are supposed to be able to keep us safe from catching things like Tuberculosis or SARS.

In the pictures above, the hood was used to check if the mask created an adequate seal around our face. After we put on the masks, we put on the hoods and a bitter tasting substance was pumped into the mask. If we could not taste it, then we knew that the mask was sealed correctly. (And that bitter tasting stuff is really bitter! No bueno.)

We had to try two different masks since the hospital uses two different kinds. Both do the same thing. Those are 3 of my classmates. I figured that their identities are pretty safe unless you already know who they are.

At this point, there is not much studying to do. We just go back and forth to different sessions making sure we are set up to rotate through the neighboring hospitals. The hard work will begin next week. I start my 3rd year with Pediatrics. I really don’t know how much I will be able to continue to blog during the upcoming school year. I’m sure that with more hands-on training, I will have more things to write about. But I also need to make sure that HIPAA regulations are not violated. So in addition to other measures taken to protect privacy, I may end up writing up posts and waiting a while instead of posting things immediately.

Yesterday I had my Pathophysiology final exam. The policy is that as long as you pass the final with a 65%, then you pass the course. If you don’t get below 65% on the final, then they will average all the scores, with the final weighing 40% of your grade and the average must be above 65%

The test was 120 questions and we were given 5 hours. It started at 9:00 AM and we were given 60 questions and 2.5 hours to complete it. We had to come back at 1:00 PM for the second.

After the test my brain was a wreck. I couldn’t think and it was hard for me to get studying for the next exam (Pharmacology). Well the posted the scores later that night and I passed it.

Today I messaged mom on Yahoo:

Me: so i passed the hardest class in 2nd year
Mom: thank GOd

 
Yeah.. So I guess she was worried about it.

Me: How’re you doing today?
Patient: Oh, can’t complain.
Me: That’s good.
Patient: No one listens to me!
Me: Oh… well that’s not good.

I love patients with a sense of humor. Well, I hope my patient was just joking…

Kind of freaking out over exams. They start in a little over a week. Exams will take two weeks. Then I’ll have 2 weeks to study for Step 1, which is one of the licensing exams.

The Pathophysiology exam is on the 18th. It’s a cumulative exam with part one in the morning and part two after lunch. The picture above is the course syllabus. Close to 600 pages of the mechanism of diseases. I flipped through it and found a page that had zero markings. No highlighting, no annotations.

It freaked me out cause I thought I should know something about that topic. So I quickly turned to look at other marked up pages like the one pictured above.

Blah.. back to studying.

A couple weeks ago I had to do an OSCE where I interview a “patient” (actor) and conduct a short physical and then discuss what I think the problem is and what I want to do with the patient.

These “patient interactions,” as they call them, are recorded and we are required to come back and watch them and evaluate ourselves.

I hate watching myself on video. And today I just saw the video of me interviewing a patient who had a complaint of frequent falling. Got that? She came in complaining of falling.

Well I do the interview, asking about when the problem started and blah blah blah. Her three episodes of falling were sporadic, occurring at different times of the day and in different places. And it wasn’t because of any injuries.

Ten minutes later before I move on to the physical exam, I ask the patient, “Have you noticed any changes in balance?”

What the heck, Jeff?!? She has been complaining about falling and you ask if she has had a change in balance?!?

The patient sat silently and just stared — totally confused, I’m sure. And I, realizing what I had just asked her, quickly recovered and pretended like I was clarifying myself and asked if she had felt any dizziness, headaches, or nausea.

Some time ago I saw a patient that came into the clinic with a complaint of cough and congestion that had lasted for longer than the patient was comfortable with. I’ll call this patient, Gloria. Before seeing the patient, I spoke with the attending¹ regarding Gloria.

He asked me for my thoughts regarding the differential², but I didn’t really have a good answer. My first thought was that the symptoms were due to an infection. However, I was already told that this was not the most likely etiology for her symptoms for a couple of reasons: 1) symptoms started about a month ago, 2) blood pressure, temperature, respiratory rate were all within normal range 3) the chest x-ray came back normal, and 4) Gloria’s file showed that she had come in annually around the same time of the year with similar complaints.

At this point, the attending told me that the most likely cause of the symptoms was allergies. And, looking into Gloria’s file I saw that she had a history of allergic rhinitis³. Mentally, I chastised myself for not thinking of allergies. The attending, though, just moved on and ignored my ignorance.

The good thing about being a lowly 2nd year medical student attending clinic is the low expectations — expectations that you probably won’t even be held to. The doctors know that you are still just going through your basic sciences and know that your clinical knowledge/skills still have a ton of room for improvement.

I went to the waiting room, called Gloria inside, and walked her to the exam room. She explained that she had been congested for a month and also had a cough. Her symptoms had a seasonal pattern, occurring around the same time each year. They had also worsened in the days leading up to her clinic visit. This had coincided with the increased winds.

I proceeded to ask for specific symptoms. I asked Gloria about her eyes. I asked if she had any pain. I asked if there was a change in vision. I asked if she had any problems with her eyes. Each time I asked she said, “no.” And so I moved on to other organ systems.

When I finished the interview I listen to Gloria’s lungs. The lung fields were clear with normal breath sounds. Feeling pretty sure it was allergies (and not something more serious like a pneumonia), I left the patient in the exam room and waited for my attending so that we could discuss Gloria’s case.

After reporting my findings to the doctor, he asked if I had done a HEENT exam⁴. Sheepishly, I told him I hadn’t. Another thing had slipped my mind. He then asked if the patient had any problems with dry, itchy, red, and/or watery eyes since those are common with allergies.

I hadn’t thought about asking specifically, but I told him that I had asked the patient about eye problems in general, and more specifically, about pain and visual acuity changes. She told me she had no complaints about her eye.

Well a few minutes later when the attending pulled Gloria in to see her for himself, he asked her if she had experienced and itching or redness in her eyes. Her eyes lit up. “Why, yes,” she exclaimed.

And I, standing in the corner, shook my head — mentally. Physically, I just kind of looked straight ahead.

Sometimes patients just won’t give you the answers.

1. An attending physician is a doctor who as completed his or her residency. See here for more details. [↩]
2. I like to compare a differential diagnosis to a lineup of suspects that may be causing the patient’s complaint(s). Click here for Wikipedia entry. [↩]
3. Medline Plus: Allergic rhinitis is a collection of symptoms, mostly in the nose and eyes, which occur when you breathe in something you are allergic to, such as dust, dander, or pollen. [↩]
4. Head, eyes, ears, nose & throat exam [↩]