On the Wards – Thrown to the Wolves

I missed the deadline to submit my preference for where I wanted to do my Family Medicine clerkship. Fortunately, though, my first choice was an away rotation at a hospital near my parents’ house.

On my first day of Family Medicine clinic, I was scheduled to work with Dr. C, a senior resident. Before seeing my first patient, we talked about how things were done in clinic. We looked at the list of patients scheduled for the afternoon. We discussed the chief complaints that these patients had reported when making the appointment.

Dr. C asked me what rotations I had already been on. He asked me if I was familiar with different physical exam maneuvers. He graduated from a different school than I attend so he wasn’t too sure how much to expect of me.

While we were talking the medical assistant roomed a patient. I didn’t notice this. I didn’t even know what to look for. But Dr. C did. And as he wrapped up, he finished with, “Well the best way to find out where you are and how much you know is to just send you in. So go see the first patient.”

And that was that. I went to see the patient. I took a history and performed a physical exam. When I came out I told Dr. C what the chief complaint was and what my physical exam findings were. He asked me questions about the patient. I apologized for not thinking of asking for that information.

I’ve decided that the third year is full of these moments where I feel like I’m just thrown into the deep end of the pool. It is a state of almost constant unpreparedness. It was the same way when I started my Pediatrics rotation. I started on the Pediatric Pulmonary team. During our first full week the service was swamped with patients. They gave each student 5 patients to take care of.

Two weeks into Pediatrics I was sitting at lunch with 3 other classmates. Every single one of us felt overwhelmed. We each felt like we didn’t know what we were doing; it was like a mean prank where they throw you into a game without the instruction booklet.

But maybe it works. Maybe the constant feeling of not knowing quite enough is what pushes us through the fatigue and the strain to keep reading. Maybe we have to feel like we know nothing in order to push harder. Maybe this is one of those “refiner’s fire” types of situations that will mold is into competent physicians.

Sure. I can accept that. Why not?

Bring on the wolves.


So What Do You Wanna Do About It?

“Overnight, Mrs. Blake had 650 cc of emesis,” I reported to my senior resident.

“So what do you wanna do about it,” he asked me.

Unprepared for the question, I paused. I was expecting him to tell me what he wanted to do about it. I’m still trying to get used to this whole 3rd-year-medical-student-thing.

As I continue in my training, I have to transition from someone who collects data to someone who interprets data and comes up with a plan for what to do next. Anyone can collect data. But I’m going to be a doctor. At least that’s what my senior resident said to me.

Fine. I have to learn to do something about the data I collect. It’s tough, though. I don’t want to do something wrong. It’s comfortable to “just” collect data without having to do something with it.

I suppose it is fitting, then, that the last two years of medical school revolve around the question of “what is the next step in management?” This is in contrast to the emphasis in the first two years where the question that haunts medical students is “what is the diagnosis?”

Change is hard. But change, I must.


Jumping Out Of Bed

I remember one occasion when I was sitting in on a patient visit. I was there just as an observer. The attending was giving his elderly patient instructions about a new medication he was about to receive. The conversation went something like this:

Doctor: Make sure you don’t jump out of bed. Go slow; take your time. Sit up, get your bearings, and then stand.

Patient: Don’t worry. I haven’t jumped out of bed since I was in my 20s. And that was because her husband came home!

I don’t know if he was being serious or if it was only a joke. But I liked that patient.


On the Wards – A Book and Its Cover

One isn’t supposed to judge a book by it’s cover. Everyone knows that. Kids learn this saying in elementary school. But it’s just too easy to do so. In my opinion, this is because we humans are “lumpers.” That’s how we learn. We lump things that are similar into categories and when we encounter something new, we try to see which category it best fits into. Or perhaps I am a lumper and I am lumping you all into the same category as I am.

But back to books and their covers. I remember being on call while assigned to the Pediatrics service one night. As I pulled my vibrating pager off my hip and read the message, I learned that I would be going down to the Emergency Department (ED) to do an admission. There was a young girl who was presenting with what seemed to be an asthma exacerbation. I went into the resident call room, discussed what I needed to do with the senior resident on call, and headed down 6 floors to the ED. I chose the elevator, of course.

In the room, I saw the little girl. She was sitting on her bed playing with an older relative while a TV program ran in the background; well maybe I should say it ran in the foreground because it was pretty loud.

I turned to the child’s father. Since the child was in no apparent distress — she was, after all, playful and breathing well — I began taking the history from him. Her father, whom I will just refer to as “Dad” for brevity, remained in the chair, his eyes affixed to the television.

We talked. I asked. He answered. Our eyes rarely made contact. Most of the time Dad kept his head tilted upwards towards TV set. He didn’t even bother turning it down.

I felt like he was disconnected — like he didn’t really care or feel this was a big deal. I didn’t make this conclusion based on his continued TV watching alone. Other things felt odd. Details were sketchy. Some of my questions regarding the timeline of the girl’s asthma just didn’t make sense. I wondered to myself if he was actually very involved his child’s care. But I plugged on through the interview like a good 3rd year medical student.

At the end, because I had forgotten to do it earlier, I asked him if his daughter had any exposure to tobacco smoke at home. “Yes,” he answered.

“Who smokes,” I asked.

“Me,” came the reply. He only momentarily looked at me before averting his gaze.

I said alright and left it at that. I was eager to leave. I was tired of dealing with a parent who obviously didn’t appreciate the significance of being admitted into the hospital from the ED. Did I bother suggesting that his daughter should avoid 2nd hand smoke? Did I take time to suggest he quit? Did I offer help?

No. I left.

A couple days passed and I was sitting in the Physician’s Workroom with other students and residents working on our progress notes. Our attending came in and announced that she had talked to Dad about his smoking and he had expressed interest in quitting. One of us (the resident or I) would be in charge of getting Dad in touch with the tobacco cessation program people.

I was stunned. Dad wanted to quit?!? The same Dad that seemed more interested in the television show than his daughter’s admission?

It was something I should have caught. It was something I should have offered. But to me, he looked like he wouldn’t be interested. And that was my mistake.

“They” say never to judge a book by its cover. I’m inclined to say that this is one lesson I’m still trying to learn.


On The Wards – PM&R

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.

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.

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.

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.


On the Wards – I Apologized To A Patient

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.


On the Wards – Outpatient Pediatrics

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.