Dictations of a "Drelf"

I was told I would fail my Pediatrics clerkship if I didn't have a ballin' costume for my first day of inpatient Peds, which just so happened to be Halloween. Throughout the year, each of us spends four weeks on inpatient medicine: two weeks on Internal Medicine, and two weeks on Pediatrics. Since nine months of our curriculum is spent in the outpatient setting, these four weeks help us garner the inpatient experience necessary to function in a teaching-style hospital. It is our time to learn how to admit patients, formally round with the team, present, and dictate admissions and discharges. And what better way to start on Pediatrics than on Halloween.

Since I had been given my charge through a game of Telephone, I was left to figure out whether I needed to go balls-to-the-wall, or whether Julia Brant was playing tricks on me. Since it was for the kids, and I'll do anything for the kids, I tried to find a middle ground. Rebekah Macfie and I went to a costume store on our way back from Chapel Hill, and we decided that I should probably work within the confines of my green scrubs. As much as I would have liked to purchase an adult-sized Superman outfit, or perhaps "Sexy Nurse," I didn't want to be the only member of the team garbed in "French Maid" (and, what would the parents think!). So, what goes with green scrubs? First thought was Gumby; we have a similar physique. But, as we perused the store, it appeared that Gumby masks were completely sold out. Go figure. Ninja turtle was option number two, but we settled on something we found in the Christmas section. There before me were elf boots, an elf hat (complete with ringing bells), and a finely crafted elven belt. After a quick stop at the dollar store to find my elf tools (which ended up being a giant pair of plastic elf scissors and some snowflakes to pin on my scrub pants), I was ready.

Turns out not showing up in a mask from Scream VI was probably a good idea. My residents went the classy route: a cow and a lady bug, tail and wings included, both working well with their medicine-business attire. Our attending rounded as a witch, and we all were big hits with the chillens. The last patient we rounded on was a kid about 6 years old who was as adorable as can be. We all lined up in the room and watched patiently as our attending examined him and set forth the plan. Meanwhile, our little one decided to play the "Guess What I Am!" game with our costumes:

What do you think I am?
A cow!

What do you think she is?
A ladybug!

And what do you think he is?!
Ummmm... a dragon?

My heart sank. I was being discriminated against because of my height! No elf can be 6 foot 5. Clearly my proportions are closer in approximation to a dragon than a tiny elf. Henceforth, I was no longer "Robby the Elf." I was a Dragon-Elf. The "Drelf."

Later that day I had the opportunity to "admit" my first patient (still wearing my elf gear, obvi). "Admitting" means that a patient comes to the hospital, usually from the Emergency Department or a private practice, and needs to be in the hospital for an extended period of time. There is an entire History and Physical (H&P) form to fill out in order to get the patient into the system. This entails taking the history (chief complaint, history of present illness, family history, social history, etc.), doing a physical exam, and writing an assessment and plan. I presented to my attending, and then did my first "dictation," which was a complete and utter disaster.

If you listen to an experienced physician dictate, it is a blur of words. ThisisDr.TomArnold-A-R-N-O-L-DdictatinganH&Ponpatientnumber34243243285dateofbirth5/2/2000for... They have the entire format memorized, and they can bang out the whole plan in two minutes or less. It is a skill. A couple hours later, a typed up report pops up in the electronic medical record (EMR), fully visible for all to see. Like most things a medical student does for the first time, my first dictation was a train wreck. If I hadn't known how to "press 2 to pause," I would be still attempting to dictate that first H&P today. The whole thing is supposed to flow like a story; a beautiful soliloquy that anyone can read and follow. It should be chronological and orderly. Instead, my first history went something like this:

Um, yeah. So this patient, um, is being admitted for abdominal pain? So 6 months ago he sneezed, um, and then again a couple weeks later. He sneezed that is. But yesterday he started cramping up. In his abdominals, that is. But I'm not sure if that was a new finding because he gets that all the time, like once the week before. And oh yeah, he's lactose intolerant and he ate a lot of cheese. But not yesterday. Shoot! Did I mention the sneezing? Um.

This accident-in-slow-motion went on for about 45 minutes. When it finally popped up on the computer, I decided to rewrite the entire thing before my attending discovered my total incompetence (thank God for the ability to revise history). It would have been much quicker for me to write it all out in the first place, but time and practice are key to acquiring a new skill. By the end of the week, my dictations were a million times better. The biggest question is always whether the dictation will be transcribed correctly. This is an exact copy of the last line of one of my dictations:

"Dr. T and rhythm position him Mary it would go to feel with the transcriptionist the name of the game to straight Liza Young tube Mary Elizabeth Young. Thank you very much for this transcription in this wound."

Fortunately, this was the only word vomit of the week, but I now try to enunciate my words more clearly. I guess that particular transcriptionist didn't speak Elvish...

Monday Mornings

Well, I never have a case of the Mondays; that's for sure. As I look at the first few months here in Asheville, I realize how lucky I've been to have this opportunity. Everyone in our class is receiving a wonderful education; UNC is known for having some of the strongest clinical years out there. But I've especially lucked out with my preceptors. So as I go through this year, I want to say a few things about each clinic. Thus, we must begin at the beginning: Monday mornings. Every first of the week I head over to the Family Health Center to spend a morning as a Family Medicine doc. I am really as close as you can get to a doctor in this clinic, and probably have more autonomy here than in any of my other clerkships. So, I especially look forward to Monday mornings.

The goal for the year is to be able to operate as closely as possible to Intern status. I am set up with the Electronic Medical Record (EMR) with a username and password so I can log on as a provider. For each patient I see enter their chief complaint, take the history, perform a physical exam, and then quickly type up my assessment and plan before consulting with my attending physician. I am learning to ePrescribe and order lab tests. In Family Medicine, I get to see the patient before the real doctor does. Some patients are wary about seeing someone who looks like a teenager, but they are usually calmed by the fact that the real doctor will be there in just a minute.

Actually (and I know this certainly a biased view), I think most patients enjoy seeing both a student and the doctor. It's like having a "team" attending to their care (which is semi-true, although I certainly don't pull any weight). I've had very few patients hold back information or fail to divulge pertinent details to me when giving the history. When my preceptor and I see the patient together after my presentation, patients usually have moved from curious skeptics to excited participants in the patient-centered experience. Many are used to seeing students and are happy to help; of course a few others think I'm a waste of time.

Every week I get to the clinic at 8am (it is amazing to sleep in - no more 4:45am wake up for a while!). and we start with a brief oral quiz. At the end of each session, my preceptor identifies a "learning issue" to research and prepare for next Monday. These are traditionally bread and butter topics that all clinicians should be familiar with: diagnosis and treatment of hypertension, medications used in diabetes, goals for cholesterol and statin therapy, etc. Julia and I both work with the same preceptor, so we get to learn from each other in the process. Then it's off to our computers to get started on the day's patients. We usually "open" the notes the night before so we are extra ready to see our peeps, and then it's "knock knock" let's begin! After seeing the patient and presenting my plan, I return to the exam room with my doc. Sometimes my plan is right, often it's wrong. Fortunately, during the wrap up I can edit the details on the EMR, making sure everything's entered accurately. That way when we leave the patient's room, I am ready for round #2. Typically I see 3-4 patients each morning, but that will pick up as the year goes on.

The other thing I love about Family Med clinic is that many of my longitudinal patients are starting to return for follow up. When prescribed a new medication, patients often need to be seen again in 2 weeks or a month to check in. So, now I'm starting to see the same faces again, which is one of the big bonuses of this program. Keep learning, keep reinforcing. Recognize a name and face; it's what makes it all worth it (although, I guess it depends on the name or face). In between, I see plenty of acute and urgent issues as well.

When the clinic is over, I have the rest of the day off. I try to keep Monday afternoons open for work (gotta do it while the week is fresh). My other free half-days are Tuesday and Friday mornings, and that's the time I try to use to schedule other clinics, meetings, and continuity visits. Usually I frequent one of the local coffee shops, but I recently, in the evenings, I've taken to studying at the Grove Park Inn, reading Harrison's with a beer in hand. I watch the sunset through the clouds and over the city, with the mountains looming in the distance...

And, that's why I never have a case of the Mondays.

Work Hurts

There are certain patients I know I will never forget. Several people from my years in EMS have made such an indelible mark. I'll never forget one of the first calls I ever was a part of: a man in his mid-30s who had stabbed himself five times with a kitchen knife. I can still see the blood stains all over the carpet as we rushed through the front door. The mixed smell of blood and sweat. I was sitting in the airway seat in the back of the ambulance, leaning over him, trying to keep him awake and talking... "Why won't you just let me die??"

I remember the first time I did CPR. I remember the first time I got duped by a drug-seeker (and the second time). Each of these experiences will stay with me, some perhaps longer than others. I always had a moment of detachment, just a brief second, when I was acutely aware that this encounter was different from others. For the patient with multiple stab wounds, it was right after he asked us why we were trying to save him. It was a real "wow" moment: "Wow. This man really wants to die."

As always, I have to change most/all of the patient identifiers for obvious reasons, but I recently saw a patient who will stay with me for a long time. A couple weeks ago, a young Hispanic lady, maybe upper-30s to mid-40s, presented to the clinic with a chief complaint of elbow pain. She sat quietly in gray sweatpants and a navy hoodie sweatshirt, hands folded in her lap. She was unassuming, and maybe a little embarrassed that she had to see a doctor. She told me her the pain started a couple weeks prior, but now it was interfering with work. When I say "she told me," I mean she wrote all this down on a piece of notebook paper. She was deaf. The history and physical were all communicated via a sheet of yellow, wide-ruled notebook paper. Each question was asked individually.

When did your pain start?
Three weeks ago.

What brings you into the clinic today?
Work hurts.

Work hurts. I asked her where she worked. I put toys in boxes. How many hours do you work? There and at my second job. She was working every single day, Monday through Sunday. Packing and sewing, sewing and packing. She was averaging about 12 hours on a good day, and her symptoms were getting worse. She had tried taking pain-killers, but when I asked how many, the lady had only tried to take one pill here or there. There was a clear lack of education. After going back and forth trying to gather the history, I wrote that I was going to take a look at her elbow. I put the pen down and mimed the motions I wanted her to make. I inspected, palpated areas of point tenderness, looked for good pulse and sensation, and tested her full range of motion. She squeezed my hands. They were coarse and calloused. They were working hands. The exam was almost universally benign, but she did have pain when I pressed on certain areas of bone, as well as during pronation of the wrist.

I'm going to go and get doctor in charge. I will be right back.
Ok.

My preceptor joined us after talking quickly about the case. There was no need for X-rays. He did a full examination on the joint, and then wrote out the diagnosis. There was clearly an inflammatory process present, but nothing immediately concerning. As we had discussed outside the room, a trial of 800 mg of ibuprofen 3-4x a day with light duty at work would be a good trial, with follow-up in a month. If it got worse, she might need to see a specialist. This was all communicated via computer paper now, each instruction carefully written down.

Four 200mg tablets at a time. You can take these 3-4 times a day for 1 week, and then use them as needed.
Ok.

She had just one more question. I need a note for work. Just for this morning. She wasn't even asking for the whole day off. With just a signature she could have had the entire week off. I thought, "Fly to a beach somewhere! Do you need a stronger pain medication? Rest! Come back and everything will be fine and dandy! Please." But she needed to work. The note was written for the morning.

I got lost daydreaming in the room. I'm a wonderfully good complainer, an expert really, and I had been agonizing over a couple assignments that I had been putting off. That afternoon I had to have my nose in Harrison's Internal Medicine, scrolling through UpToDate, writing and learning about a couple of diseases I would report on later that week. I would have to sit in some fancy coffee shop with an overpriced decaf Americano and my laptop as I bunkered down and studied. I would have to eat a home-cooked meal, and then spend an entire hour ironing my dress-shirts. Ironing. That was what my terrible evening would be filled with. Ironing. Whoa me, what a terrible and tough life I live! I felt sick. This woman may not know when her next meal would be, and I spent the night before talking with friends about which new restaurant we would try next weekend. I realized I was tearing up as I was daydreaming.

I snapped out of it. I don't know why this visit affected me like it did. For some reason she just hit a nerve. There are many patients who are just as desperate and deserving; so many who make me realize I'm a piece of shit for ever taking my situation for granted. I don't know why this was different. I get to be a doctor. I get to do something that is so well-respected, so well paid, such an honor... the fact that I ever forget this is just disturbing. I'm too busy being caught up in myself to realize the world doesn't revolve around my Google calendar.

As she got up to leave, all I could think to do was write, "It was so nice to meet you!" in my little black notebook, scrawled quickly over the last page. It was so inadequate; a pathetic attempt to show that I cared. I mustered up the best smile I could. All I wanted to do was hug her.

She smiled and walked out the door, off to work. I realized I probably wouldn't see her again.

Priority #1: Just Show Up... Hopefully On Time

And so it begins! This week marked the beginning of "longitudinal" learning, and it did not disappoint. I flipped from Family Medicine on Monday morning, to sewing pigs' feet in our Emergency Medicine orientation on Tuesday. I raced from Internal Medicine in Arden, NC, to lectures on the liver and chronic diarrhea back in Asheville on Wednesday. An afternoon of Neurology here, Psychiatry there, and somehow peppered in library literature searching, meetings, didactics, and reading reading reading. As I drove back and forth from clinics to the hospital to the coffee shop and back to clinic, I did put a couple holes in the ozone layer; but hey, that's why I bought a manual Corolla. It was an exhausting five days, but extremely rewarding. I finally understand how "continuity" works, and I've started accumulating a cohort of patients to follow. Pamphlets explaining who I am, why I should be your personal medical student, what exactly that means, and how to contact me, were handed out to my "continuities" (although I reminded everyone that in the case of a medical emergency, CALL 911! - and same goes for the rest of you...).

"How does continuity work?" you might ask. Each preceptor has identified certain patients who would be extremely high yield to follow-up on throughout the year. Three reasons: 1) they said "yes" to having a med student, 2) they typically have chronic conditions or medical problems requiring multiple follow-ups, and 3) there is a lot to be learned (although every patient is a learning opportunity! - score brownie points to me for appropriate medical student response!). I, also, will identify patients throughout the year that would be good to follow. To ensure the continuity aspect, I typically walk patients to the front desk after our encounter is completed, and ask to schedule the next appointment for a day when I will be back in clinic. For example, if I see a patient Monday morning in Family Medicine, I try to make sure his or her 2 month follow-up is on a Monday morning when I will be there. My name is tacked onto their chart and BOOM! Continuity.

Additionally, I met a patient this week who needed an appointment with another service (NB: details have been changed to ensure privacy, as always). After our encounter in Internal Medicine, my preceptor and I needed to refer our patient to Neurology. Since I am on outpatient Neurology every Thursday afternoon, we scheduled the patient for a work up a few weeks later when I would be in Neuro clinic. Everyone wins: I can act as a advocate on the patient's behalf, the docs have better coordination of care, and I learn lots of medicine. The trifecta.

The big challenge will be keeping all these continuity patients straight (especially when answering phone calls... Ms. Jones who?). Per suggestions by former Asheville program students, I keep note cards on all my continuity patients, hole-punched into a ring, filed in alphabetical order. With a name, age, and quick notes to remind myself about specifics of each patient (e.g. "works at Carolina Cafe"), I can keep everyone straight. As the list grows, so will my roladex.

It may sound overwhelming, but I've found peace. The only way to cope with the new schedule is to make my own "weekly calendar" on an 8.5'' by 11'' standard sheet of paper with a template of the week's events. Each Sunday I print a new copy of the template, add my ED shifts, extra clinic times, meetings, and didactics. It keeps me on track so I know when I'm going to read for Family, Internal, Neurology, etc., when to lift, run, grocery shop, and do laundry. I happily express my OCPD with this sheet of paper folded and tucked safely into my shirt pocket. I will need this organization even more when I add Pediatrics (my preceptor was saving lives in Haiti this week), Cardiology (our first session!), and possible OR time with Ortho Trauma next week.

I had only one goal as we eased into conintuity... show up on time. If I could do that, the rest would be gravy. Ninety percent of life is just showing up, so I'm happy to say that I accomplished 100% of what I wanted to do during our first 5 days of chaos.

Next week's goal? Smile, and don't look so damn new.