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.

I’ve been meaning to watch Band of Brothers. I have seen a few episodes, but I recently got a hold of the entire mini-series. The above picture shows the characters from the show.

The reason I thought of the show is that I recently had the opportunity to chat with an amazing patient. The patient fought in World War II. He landed in Normandy and fought in Europe until the war ended.

I can’t even begin to imagine the kinds of stories this man could tell. My attending physician told me that in the past, the patient has brought in pictures from the war. I wish I could have sat with him and talked casually about the war. I would have loved to see the pictures and hear him retell the tales. But it was neither the time, nor place for this. We were in clinic. But I still felt like I was in the presence of one our national heroes.

He was so polite and gracious, thanking me — a medical student — for what I was doing. And here I was sitting in front of someone who lived through some of the most violent years in modern history, who fought for his country through the worst of times.

I truly felt honored to have been able to participate, in a very small way, in this veteran’s care. I’ve heard that the ranks of men who came back from the 2nd World War are slowly thinning. It’ll be a sad day when the last of these men finally leaves us.

Note: I realize that I was vague about the time this occurred as well as on details of the patient’s service and case. Again, this is to comply with HIPAA regulations and to protect the patient’s privacy.