Missing Medicine

I never thought I would say this... but I am going to miss medicine in my year off. The realization didn't hit me until finishing up this year, but it's true. I am going to miss seeing patients. I'll miss the challenge and the connection. I'm also a little worried that my brain might turn to mush. All this hard work and I'm sure I'm going to forget at least half of it. The UNC students that stay and do their Masters in Public Health (MPH) often work at SHAC (remember the place we raised money for with that calendar?). They work Wednesday nights there to keep up their skills. I'm going to have to find a place up in Rack City where I can do something similar. Something clinical. Not sure I want to jump back into research again... but we'll see.

Being the planner that I am, I've already been thinking about the clerkships I'll be trying out fourth year. I have the opportunity to start back next June, which is the prime time to do a rotation back at THE BIG HOUSE. First of all, all the fourth years have cleared out, and often there are no third years on the services. So it's your time to shine. It's also a great time because the residents are almost a full year in, so they know what they're doing. July can be a total cluster (never get sick in the summer). The new interns are trying to find their way around, and the residents are figuring out their new roles and responsibilities. So I am considering coming back to THE BIG HOUSE for a surgical rotation, or heading back to Asheville to get back into the swing of things with a Family Medicine - Acting Internship (AI). Since Family Med arguably encompasses the most medicine, this could be a great way of drinking from the fire hose again.

After that, I have some mandatory rotations: Critical Care (back in Asheville), a rural rotation, Clinical Anatomy (time pass the Thorax and Abdomen exam... for the first time), Radiology, and Anesthesia. I think all of these will set me up well for Intern year. After that I want to throw in Palliative Care (surgeons could probably use a strong background here), Dermatology, and/or maybe something else. I just have to back in Rack City during the month of January 2014. Camping for a month with Ronnie is another must. We'll see how it all lays out, but I'm already thinking ahead.

In the meantime, I'll miss medicine.

Don't get me wrong; there are a lot of things that I won't miss too. This year off will be great for a lot of reasons. For starters, I won't have to...

• Wear a short white coat.
• Live on Beaucatcher Road.
• Feel like I should be reading something... anything... UpToDate?
• Study for 8 hour tests.
• Sit for 8 hour tests.
• Perform pap smears.
• Be turned down after telling a patient I will be performing their pap smear.
• Wear "contact" and "airborne" precautions during RSV season.
• Laugh at unfunny jokes.
• Use the word "Shelf," unrelated to something that hangs on a wall.
• Be spotted multiple times at the same coffee shop because being at home is worse than paying $2.11 for a few hours of internet. When studying for 8 hour tests is better than being at home, something is wrong.
• Worry about grades.
• Tell patients my height and what I did instead of playing basketball.
• Dread sitting through 4 hours of lecture every Wednesday.
• Sit through 4 hours of lecture every Wednesday.
• Read about cervical ripening, the vaginal vault, or mature teratomas.

So I guess there are indeed some things I will NOT miss. Feel free to add more.

Step 2 CK

Ahhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhh
hhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhh
hhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhh
hhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhh
hhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhh
hhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhh
hhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhh
hhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhh
hhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhh
hhhhhhhhhhh?

Marion County ER

It's been long enough since the actual occurrence that I'm ready to tell a quick story from the McDowell Emergency Department that was particularly memorable. One of the reasons I am taking this year off is to study not only how we can make patient care better in this country, but how we can make it more efficient and less expensive. The average American racks up over $7,000 in health care costs each year, and for the majority, that is an insurmountable financial burden. With access to care issues and poor understanding of its use, the Emergency Department often turns into a primary care clinic. This causes long wait times, frustration, and increased costs. As a student in the ED, I often wonder how can this be fixed.

My preceptor had asked me to go see young lady (about 15 or 16), who was complaining of right wrist pain. It was a Sunday night in the ED, and there was a long list patients in the waiting room. I walk in the room and she is accompanied by her mother and little brother, who is bouncing off the walls after having waited more than a few hours. I start taking my history. The pain had been going on for about 2 weeks, not really getting worse, and perhaps getting a bit better; however, it was her dominant hand. There was no point tenderness, only a generalized soreness that was worse with use. She cannot think of anything that had caused the pain either. One morning she woke up with a bit of pain, so she saw her pediatrician who had splinted the wrist. She hadn't had fever or symptoms (weight loss, chills, cough, headache, etc.), and she was neurovascularly intact (she had a good pulse, with no numbness, tingling, weakness, or anything worrisome about the nerves in her wrist or hand). Overall her physical exam was rather benign. X-rays two weeks ago were normal.

One of the questions that I have learned to ask is, "So what brought you back in to clinic today? As opposed to yesterday or a week ago." There's usually a reason, especially for a prolonged issue. When I asked Mom, she stated that the pain had been going on for a couple weeks, and now was a "convenient" time to come in. The young lady had insurance and a pediatrician. Mom worked, and she actually was not working the next day (Monday). I left the room sure I was missing something.

During the actual report to my preceptor, I told him that I must be missing something crucial. I was running down the differential, thinking about the worst it could be. Fracture? Osteomyelitis? Osteosarcoma? I didn't know what I was forgetting. So we go back in the room together. In the meantime, the X-ray came back from triage (normal, of course). My preceptor probed a little bit more into what was going on. Apparently for the months prior, the patient had been doing a lot of typing on the computer (term papers, really? why are we still doing those), and sending thousands of text messages a month. She texts with her right hand. It had been getting more sore for a while, but then slept on it funny one night, causing her symptoms. The splint was for an overuse injury (originally, neither of them could remember the diagnosis she was given). We resplinted her, gave her some Motrin and advice, and sent them on their way.

I know this is a pretty mundane story, but that is kind of the point. The cost of an ED visit is sky-rocketing. Depending on your sources, median/average costs can range from $600 to over $1300 (and that's using 2009 numbers). Taking a ride in the back of an ambulance may cost you and equal amount (the flat rate at one of the companies I was working for was $600 for a drive to the hospital, plus the cost of care). So here we have a patient who does have insurance, does have a pediatrician, has a mother who is able to take her to her pediatric appointments, and doesn't have an acute injury. It just leaves me with such a disconnect. We are not educating our patients how much health care costs. We don't have enough transparency. And perhaps we aren't teaching enough common sense.

It is easy to blame patients; it's harder to ask ourselves where we can improve. But at times, I admit I'm frustrated.

Because wait times are long, we also aren't educating our patients when is an appropriate time to come to the Emergency Department, when they are in the Emergency Department. It seems like a perfect time. But that night we had several very sick patients taking up most of the ED physicians time and resources, and there just wasn't time to tell this patient, "This could have waited until tomorrow morning. Probably you would have only had to pay a copay, and that would be it. This is not an emergency." I think this requires a conversation, not a brusque remark.

I left the room that night wishing this was a part of every visit.

One More Quotation

On the heels of a post with humorous (and often concerning) quotes from throughout the year, I wanted to add one last statement that really made an impression on me. Obviously the core clinical clerkships are not all fun and games. As many of our preceptors say, the third year of medical school is probably the time in our lives when the greatest amount of learning happens. Perhaps even more than as an intern in residency, this year encompasses a vast expanse of knowledge that we are expected to acquire. Thus, it is important for me to reflect also on some of the other lessons learned since last July.

There were many sage words spoken by the great physicians we worked with, but we only remember about 5% of what we learn throughout the day (and I probably am remembering that quote incorrectly as well - and 47% of all statistics are made up on the spot). So, as I look back, there is one specific piece of advise that I will hold onto for the rest of my career. During one of our psychiatry didactics, we were discussing suicide and patients with suicide risk. One of my cohorts stated that (s)he was greatly worried about a patient because, even though there was no reason to commit the patient to inpatient therapy, (s)he was concerned that this patient might end their life. This is a sentiment I have often referred to in this blog, one of helplessness. It is something we have all felt throughout the year, but with suicide, the stakes are often higher. Our preceptor acknowledged this concern, but also tried to add some perspective...

"My goal as a provider is not to make sure that no one commits suicide."

This really struck me as a unique way of looking at our roles as clinicians. For me, it helps contain the feeling of helplessness that many of us hold. I can't go to a patient's house and make sure she takes her blood pressure medicine. I can't make my patients exercise. And, I can't hold a patient down and make sure he doesn't harm himself. This statement addresses one of the fallacies of the goals of medicine. We often think we should be able to "fix" everything and everyone, but in reality, that's not our job. Our job is not to make sure that no one commits suicide; our job is to try to make each day in the lives of our patients a little bit better. Whether that means prescribing an SSRI, taking out a gallbladder, or even by just sitting and listening. Sometimes we can prevent a suicide from occurring. Sometimes we can't.

Now this may not be the lesson that our preceptor was attempting to provide, but I think priorities are very important in the medical profession. Understanding one's goals, and accepting one's limitations is imperative. We are all human, and we are all going to make mistakes. We are going to succeed, and we are going to fail. However, we must define "failure." Success and failure are not about how many patients are cured and how many patients die. I'm not sure I know what those two terms mean in the context of medicine, but I'm sure I will experience both throughout my career. For now, I'll keep concentrating on each patient in each moment.

Did I make my patient's day better?

Asheville's Five Star Dining

If you haven't figured it out yet, food is very important to me. Whether it's sneaking into the Physician's Lounge to grab a quick bite, or making a New Year's Resolution to learn how to cook some new dishes, my world revolves around food. How I am going to obtain my next meal is an ever-present preoccupation, but I think that's just human instinct. Asheville is known for its fine dining and hole-in-the-walls with exquisite plates, so of course over the year I have been taking careful notes of the most notables. I wanted to share my Top 5 (or six as you'll see) favorite restaurants in Asheville. Some will disagree with a few of my choices, but each has its own cornucopia of reasons for making the list (whether for sentimental value or unabashed delectable-ness). In any case, I recommend sampling all of these if you're ever in town...

5. Thai Orchid ($) - Okay, okay. You're already asking, "Why the hell would you put this on this list?!?" but give me a minute to explain! Thai Orchid is one of the first restaurants I sampled in Asheville, and I was not disappointed. For starters, it is one of the only Asian restaurants I've ever been to that has an appropriate variety of spice levels. There's "Mild," "Medium," "Hot," "Thai Hot," and the infamous, "Make Me Cry Hot." This latter sauce is made every morning by the manager of the restaurant, and is not recommended for the faint of heart. I found my perfect combination with Thai Hot Drunken Noodles, with a side order of the Make Me Cry Hot sauce. That way I can put as much kick as I want into my own dish. The manager gave me a funny look the first time I tried to order the spiciest of the spices, so we settled on an appropriate alternative. But don't be afraid to hold your ground! If you like Asian, and you like it hot, this is the place to go.

4. White Duck Taco ($$) - This little outdoor staple near the river is a true gem. Located just west of downtown, its picnic-style bench seating and cheese queso will leave you feeling warm from the inside out. White Duck Taco offers you a myriad of different taco choices, each with its own unique ingredients. I always order 3 different plates, and my combinations/permutations are never the same. Try the Bangkok Shrimp, Roasted Duck Confit w/ Mole, Lamb Gyro, Lump Crab, or my personal favorite, the Fish Taco. Don't forget to pick up the unreal chips and queso, and then wash it down with one of Asheville's local beers. Tecate bottles are only $2 if you're feeling the summer heat.

3. Zambras / Curate ($$$) - Now putting these two restaurants together is a total cop out, and I'm sorry (but, I'm not sorry). I only had the opportunity to dine at each of these tasty locations once or twice, and thus I cannot rate one better than the other. Both are amazing tapas restaurants that (if you don't have reservations) you may have to wait hours for a table. They feature unique combinations that will leave your palate satisfied, confuzzled, and yearning for more. At Zambras try the char-grilled octopus with arugula, blackberries, and balsamic vinegar, or the grilled scallops. At Curate I recommend the trout (if it is on the menu) or the rossejat. A bottle of nice Spanish wine will only add to the gaiety of the evening.

2. Sunny Point Cafe ($) - Now we're talking, you say! Sunny Point is legendary in West Asheville, and for some, weekly dining is not only compulsory, but a religion. One of the residents at MAHEC actually went there almost every Saturday morning for 4 years. If you sleep in late on Saturday, expect a wait, but just grab a cup of coffee and frolic with the other patient patrons on the porch, and the time will pass quickly. Two of the best plates in the world are made here: the huevos rancheros and the breakfast burrito are TO DIE FOR. Come hungry, leave happy; you won't have to eat again until dinner time. Make sure to add a biscuit to the entree, as their warm/fluffy/doughy insides will make even the most stringent vegan a Saturday-brunch-sinner (cough, cough, Kelly). It's worth the gluttony though; seven Sunday morning Hail Marys and you're scot-free until next weekend.

1. The Admiral ($$$) - This place takes the cake in my mind; if only I could afford it more often! I took my parents here when they came to visit, and warned them that it's a total dive. An inauspicious brick building with zero fanfare hosts the most exquisite dishes in Buncombe County. Whether you're a displaced Northerner looking to sample expensive bottles of wine and a variety of small plates, or you're like me and have to sit at the bar drinking PBRs while scraping every last calorie off the beef tartare cutting board (pictured above), don't go home without trying this place once. The flank steak with pesto seasoning is another one of my favorites (which by the way also tastes great paired with PBR). The place is very Asheville, and you can feel like a local eating there... even though you probably aren't.

Some might ask, "What about Limones? Where is Mela or 12 Bones?" Well, they're in Asheville, but they aren't on this list. So take it or leave it. My final week in Asheville will include eating at three of these six locales (capping the year off with real reservations at The Admiral!). The food is one of the things I will truly miss about Asheville. But I'll have my list when I return.


$ - cheap, expect to pay around 10 bucks for dinner
$$ - under 20 bones total, but if you have a big appetite you won't pay under 10
$$$ - yeeeah, wait til your parents are in town so they pick up the check