My Favorite Story

I have one story from my clinical years that I have yet to tell. I must keep some of the details a bit vague (you will see why), but I don't think that takes away from the (ummmmm, explicit?) content.

The tale goes like this...

Once upon a time, I was seeing a seven-year-old boy (we'll call him "Patrick") in one of the specialty pediatrics clinics. He was adorable. Like any normal boy of this age, Patrick was already bouncing off the walls when I walked in the exam room. I let him wear himself out while I sat and took a history from Mom. Patrick had been complaining of headaches, though he certainly was feeling well at the moment. After finishing up some standard questions regarding his birth and past medical history, Patrick finally decided to insert himself into the conversation.

Mommy, can I play on your phone?

Ahh, times have changed. Kids are now born iPad-in-hand. I am unsure how I was able to entertain myself as a kid.

Mom let Patrick play on her phone while I resumed my questioning. Patrick was successfully entertained for perhaps only a half a minute before returning to the adults. He held the "toy" in his outstretched arm, holding the large smartphone screen just a few inches from my face.

Hey! This is a picture of my Dad's car!

It was indeed. Pops apparently was something of a car connoisseur, and though I didn't recognize the make and model, it looked like a restored antique. I smiled at Patrick and affirmed his statement that it was his Dad's car (such a smart kid!). Patrick looked back at the phone and swiped the screen to the right.

This is my Dad's other car!

Again, a true statement. I smiled and told him that it was a very cool looking car. Before I could return my attention to Mom, Patrick again swiped the screen to the right, paused, and a very confused look spread across his face.

I don't know what this is...

Patrick pushed the phone six inches in front of my eyeballs. I wish I could have been a fly on the wall, watching my own reaction. There are few times in my life when I've been left truly speechless, and this was one of them. I felt my face flush.

I was staring at a picture of (someone who I could only assume was) his mother, waist down, naked, and spread eagle on a couch.

A moment of shock and panic. I do remember taking the phone away from Patrick, clicking the "Home" button, and handing the phone back to Mom. Why don't we let your mother hold onto this for now? That didn't last long. He grabbed it out of his mother's hands, sat down on the floor, and went back to perusing photos.

Right on cue, Dad walked into the exam room.

Also right on cue, Patrick showed me another picture that he wasn't quite sure about...

This time I grabbed the phone (again, quickly pressing the home key), and handed it back to Mom. You should really hold on to this. I made the statement as emphatically as I could. I skipped the rest of my questions and went right in for the physical exam. Anything to keep the little guy occupied.

It was a cursory exam.

After I was done, I went straight to my attending's office to discuss what had gone down (a little advice at this point would be nice). I explained the entire situation, but s/he didn't seem to be too concerned. I was told not to worry about it, and we completed the encounter like nothing happened.

Is this a frequent occurrence or something? Ah, another naked parent. Don't worry about it, Robert. It happens all the time.

Fortunately, in my (very short) career as a budding clinician, this is the only time I have been exposed to nude photos of relatives of my patients, and I hope it is my last. This story should illustrate two important points:

       1) Don't take naked pictures of yourself unless you want other people to see them.

       2) Parents, password protect your damn phones!!

Thank goodness Patrick wasn't a wee bit older... now only one of us is scarred for life.

Fridays

Finally it is the last day of the work week. Fridays are something to look forward to for many reasons (the upcoming weekend is an obvious plus), but I also very much enjoy an afternoon in probably my most challenging clinic. Usually the mornings are filled with either Radiology lectures or our "Master Clinician" series (a case-based discussion with many of Asheville's finest physicians). This is followed by a few hours of studying/continuity, and then Psychiatry in the afternoon. Psychiatry has offered some of my most colorful and challenging patients, as well as the best opportunity to really get to know my patients as people. In our initial interview, we (the students) spend an hour listening to the patient's story and asking questions. Only then do we take about ten minutes to discuss the case with our preceptors, and then we all talk as a group for the remaining twenty. So the students actually spend way more time than the physician with each person. And, unlike the outpatient clinics where we may only have ten minutes, there is usually very little pressure to accomplish any "agenda." It is a much more relaxed setting.

However, I must admit that Psychiatry hasn't always been a "relaxing" clerkship for me. I have always strived to get out of my comfort zone, and Psych has offered the best opportunity to do that this year. This is a field I certainly had no experience with prior to our orientation in October. For the first few months, I was almost always nervous before meeting each new patient. I never knew the "chief complaint" before starting the interview, and so every encounter was a surprise. Would the patient be manic? Schizophrenic? Suicidal? Thus, it honestly took me longer than usual to get truly comfortable with asking the important questions... Have you ever attempted suicide? Have you ever thought about hurting yourself? Have you ever harmed someone else? Have you ever felt like you were ever physically or sexually harmed? I usually acknowledge the confidentially of the patient-physician relationship first, but I initially felt uneasy asking the hard questions.

One thing this experience has taught me is to keeping asking and asking until you have an answer. Psychiatry is the ultimate "tell me more about that" specialty. Once I got comfortable asking patients the tough questions, I realized that sometimes I was moving on without getting a true answer.

Have you ever thought about hurting yourself?
No, not really.

At the beginning of the year, I would move on. But, "No, not really," is not really an answer. Tell me more about that. As I delve further into that line of questioning, I realize that many times patients just don't want to answer outright. Maybe they are scared or uncomfortable. This may be the first time they've admitted such feelings. Often it requires gentle prodding to fully understand the situation. I have found that "No, not really," actually may mean, "I only think about hurting myself when I'm alone. Yes I live by myself, and yes I own a firearm." Continuing to ask questions, and geting the full picture, is something that I have had to work on throughout the year.

Psychiatry has also given me a crash course in crisis management. Numerous patients have called me contemplating suicide, a number of people have called for prescription refills (won't be for a few years!), and some patients have called just to talk. Taking a step back, these are the encounters that remind me what an honor it is to be a physician-in-training, and how great the responsibility of being a doctor will be. My Grandmother once told me, "With great power comes great responsibility." My Psychiatry patients remind me of this constantly.

With the danger of putting too many thoughts into one Post, I will just make "one quick little teaching point, only if you can stand it" about Radiology. This is a field that many medical students get zero medical training in, unless they choose it as an Elective. Fortunately, we have been lucky enough to receive biweekly imaging lectures throughout our longitudinal months. I have spent many half-days sitting in the Radiology reading-room, and I absolutely must do Radiology during a month in fourth year. I doubt I could make a career out of sitting in a dark room most of the day, but it is a field that is constantly expanding and becoming an integral feature of every specialty. So, I've tried my hand at images about once a month since October (hopefully with some improvement).

The other specialty I need to try fourth year is Nephrology. Third year has taught me that I know nothing about the Kidney, probably due to my absence throughout much of Physiology during 1st year. For that, I have Ronnie Milam to blame, and 5 Star Nerve to show for it. 

Thursdays

Thursdays are just such wonderful days here in Asheville. The weekly four-hours-plus of lecture are over; the weekend's in sight. I also get to wake up to the fresh, bright, smiling, young-minds of America (or if they aren't smiling, they're certainly crying/screaming/biting). Thursdays are a double day of Pediatrics in the morning and Neurology in the afternoon, and I swear my Peds preceptor only schedules the cutest kids on these mornings. On several occasions I've left a clinic room hearing: "If you don't want to go into Peds after seeing a kid like that, something's wrong with you!" If I ever drop out of Surgery, this is where my heart lies...

Besides how awesome the kids are, one thing I love about outpatient pediatrics is always being on the look out for something crazy (and I don't mean the parents). Behind the cool, calm, and collected exterior, you're a detective. The vast majority of kids are developing just fine, but it's your job to pick out the subtle anomalies. Amongst the health maintenance exams, flus, and the runny noses are the chronic granulomatous diseases, the Wiskott-Aldrich syndromes, and the one in a million genetic disorders. On the exterior, it looks routine. Ever wonder what the pediatrician is looking for when he or she checks your little one from head to toe? You don't wanna. Using the light to look in the eyes? Retinoblastoma. Squeeze the belly? Wilm's tumor. Moving the legs around? Developmental dysplasia of the hip. Trouble can be found anywhere. My preceptor told me about one mom who really wanted to know what he was looking for with each test. Despite trying to parry the question, she persisted. About halfway through the exam and explanations, she decided not to hear any more!

Probably one of the most important lessons I've learn in Pediatrics, however, has nothing to do with kids. The practice I work in (ABC Pediatrics) has six pediatricians, and they all love each other. They get along so well, and this has such a positive impact on quality of life. In picking a specialty, there are many things to consider. One thing I think it's interesting to ask is, "Who do I want my colleagues to be? Who do I want to wake up and see every day?" Based on my experience this year, both in and out of the hospital, I would want to work with Pediatricians. Laid back, fun, and they know their ish. I'm sure there are uber-intense Pediatricians out there, but they certainly aren't a dime a dozen. In general, finding a great group to work with makes such a difference, and I hope to be as lucky as this practice.

I also think it makes a big difference in patient care. All the parents I've talked to love the practice, and they are willing to see any of the physicians, even if they aren't their primary. All the docs are on the same page, they get along, and they have similar philosophies about approaching care. Because of that, I think there is more consistency for the patients amongst different styles. I have yet to hear from someone who doesn't like the practice, and I can see why.

As for the afternoon, it's off to Neurology. I have written about this clerkship before (see "Death Rate in America"), and will continue to write about it in the future. The patients I've seen in the outpatient clinic (and now on the inpatient service as well), tear me up. More to come on this front.

But now I must get ready for another week of Inpatient Medicine. See you on the other side...

Wednesdays

Hump day. Given our schedule, this was aptly named. Once I get through Wednesday afternoon, the rest of the week is all downhill. The hump, though, is 4 hours of lecture - my worst nightmare (so, why again am I signing up for another year of school?!?). Lecture is what I so strenuously avoided the first two years of medical school. Almost every lecture was video captured, allowing me to watch all our professors at up to two times the speed. Some professors, who had especially slow, monotonous voices, could even get sped up to just under 3x. That saved time and energy (and allowed me to sleep in very often). But, here there is no more lecture capture. One o'clock to 5:30 pm every Wednesday is back in the classroom; and with only eight students, falling asleep is completely out of the question. No dark corners in which to "rest one's eyes."

One thing I've noticed as I've gotten older is that I can no longer sit still. I honestly think my attention span was a better when I was in 1st grade than it is now. I'm very fidgety in a lecture setting. I tap my foot. I move around. I rub my neighbor's shoulders. Maybe I rub my neighbor's thighs (at least Dan's). I struggle to pay attention. It takes all of my concentration to keep-on-keeping-on (which has gotten more difficult as the year has progressed). The good thing, though, is that most of our lectures are "case-based." This means that the discussion revolves around the presentation of a patient's illness, and we work though the evaluation and management together. That keeps me involved and engaged. PowerPoint, on the other hand, is a different story.

On another note, I spend each Wednesday morning in Internal Medicine (IM). IM is the backbone of medicine, and it's one of the most important third year clerkships (if not the most important). Every specialty, no matter which one we chose, needs to know their medicine. Makes sense, since that is the field of study for physicians. Therefore, it is the broadest in scope. I actually work in a practice that is Medicine and Pediatrics, so I get to add kids into the mix. Prevention, growth and development, diagnosis, and management: IM is all-inclusive.

IM is also the clinic where I get the most outside continuity. I have followed patients to psychiatric appointments, to surgery, and met a number of them in the Emergency Department. This has been particularly rewarding, since I get to spend quite a bit of time with them in the clinic as well. I only see a handful of patients each morning, which has given me the opportunity to get to know each patient personally. I have specifically worked on developing my skills for weight management, smoking cessation, counseling about lab results, and developing a differential diagnosis.

One of my patients, in particular, shows how the continuity experience is extremely satisfying. Over the past several months, this individual has stopped smoking, lost weight, improved his/her liver and cholesterol profile, and has accomplished all these lifestyle modifications without the help of pharmacotherapy. It has been a true pleasure working with this person, continuing to motivate and being so impressed with my patient's drive. Of course, this is not the course with many (or most?) patients, but it is wonderful seeing a patient reach their personal goals, with or without medication. You don't see this if you only spend 4-8 weeks in a clinic or in the hospital; there's not enough time for real improvement. I've seen this patient at least 4-5 times since the beginning of the year, and I always look forward to seeing him/her on my schedule. If I didn't participate in a longitudinal curriculum, would I ever get to have this experience in medical school?

The Champagne Tap

According to some random website that I found on the internet, a champagne tap is defined as "a successful lumbar puncture with no red blood cells found, which means it is as clean as possible. Upon completion of the maneuver, the supervising resident has to, by custom, buy the student a bottle of champagne." I am gloating today because, by custom, my attending Emergency Medicine physician just bought me a bottle of champagne. (Insert huge smiley face here).

For those of you not of the medical persuasion, a "lumbar puncture" (or "spinal tap") is a procedure usually done to assess a patient's cerebrospinal fluid (CSF). This is the clear/yellowish liquid that encases your brain and spinal cord. A needle is inserted into a patient's lower back, just between two vertebra of the spine, and right below where the spinal cord ends. Fluid is extracted, and then analyzed in the lab. There are a number of reasons to perform an "LP," but one common example is testing for meningitis. This is a very serious medical condition caused by inflammation of the protective coverings of your brain and spinal cord. An LP can determine whether this infection may be due to a bacterium or a virus, among other etiologies.

As you might have gathered from the description above, an LP is not an atraumatic procedure. The patient curls into a ball to open up the vertebral bodies, the area is prepped with antimicrobrial ointment, and a large needle is stuck through the skin and spinal ligaments until you hit the space with all the fluid. There are plenty of opportunities to cause bleeding along the way. The champange tap then, is when there is no blood in your sample. Usually that means there was no blood in the cerebrospinal fluid (CSF), and none encountered along the way. So it's not impossible to get a clear tap, but apparently it's not always routine. And thus when you get your first one, the doc in charge buys you a bottle o' bubbly.

So my bottle of Jaume Serra Christalino is now sitting proudly on my desk at home.

It was beginners' luck; I have to admit that. It certainly wasn't perfect technique or years of experience. I just simply got lucky, but I'll take it! And as Dr. Mitchell told me, hopefully I can earn myself another bottle during residency (if I don't tell them I already popped my first during medical school).

The Emergency Department (ED) is where we get to do most of our procedures. Here, we learn to start IVs, do lumbar punctures, and intubate, among other things. We see a ton of patients and a ton of pathology. This is where I remember seeing my first case of shingles, and my first necrotizing fasciitis. It is a very interesting place. Some of you might be wondering whatever happened to my interest in Emergency Medicine. I have to admit, it certainly was number one on my list of potential specialities going into this year (Surgery wasn't even in my top 3!). With my experiences in EMS, it seemed like a plausible next step. I guess three things happened, 1) I fell in love with Surgery; 2) I always find myself wanting to follow my patients one step further after the ED; and 3) the pace in the ED is a wee bit faster than at which I want to operate.

The best example I can use to illustrate point #2 is a recent case I saw on the A side (where the crazy-ish goes down). A 50-60 year old man was transported to the ED after having an episode that his friends described as a grand mal seizure with a substantial post-ictal period. He meandered in on his own two feet with a temperature of 105 degrees F, heart rate of 150 beats per minute (that's fast), and a normal blood pressure. All his labs were normal. No evidence of infection (CBC was within normal limits), drug toxicology screen was negative, and LP was clean. He had never had a seizure before. It was just a peculiar story.

The patient was admitted to the hospital after I left, but I desperately wanted to know what was going on with him. I ended up following this patient to his story's conclusion, which was very satisfying, but I just don't like letting these cases go. I want to be on the other side of the coin: either being the one to figure out what's wrong, or fixing it.

I don't know. Maybe that's not a good reason, but I'm often left wanting more. If that isn't a good reason, loving Surgery is. So I'll stick to that.

Pop a bottle to that notion.

Tuesdays

This picture really has nothing to do with medicine (or Tuesdays for that matter), but it's one of the first pictures that pops up on Google Images when you search the word, "Tuesdays." I thought it was cute, so there we go. Anywho, before I start weighing in on last week's ethical dilemma, I want to get back to some of my bread and butter. Two things that I've been behind on are 1) profiling my fellow medical school classmates, and 2) going through a typical week to talk about our program's design. I'll start with the latter today, but since my post about Dan "The Man" White, I haven't done any in depth investigative reporting on my Asheville compatriots. We'll get there.

Onto Tuesdays. These are my "lite" days. Every other week I work the afternoon in Cardiology, but I'm scheduled to have the whole morning off each week. This works well for continuity clinics and spending half-days in other offices. I've had the opportunity to sit in the Radiology reading room looking at pretty (and not so pretty...) pictures, as well as drilling holes in people's femurs in the OR. Here is a brief list of a few of the specialties I've seen:

• Cardiology - Every other week I try my hand at "Cards." From 1pm to 3pm, we rotate through different aspects of cardiology, then hop on over to an hour and a half of "heart" lectures. I have spent a few hours with the Echo techs (they take souped-up images of a person's heart using ultrasound), a day working with the EKG techs in the Emergency Department obtaining bedside heart graphs (looking for MIs, arrhythmias, etc.), and working in the clinic taking care of outpatients. This latter experience is my favorite, because I get to hear a whole bunch of different "murmurs." These are extra heart sounds in the cardiac cycle that I can hear whilst listening to someone's chest through my stethoscope. Usually, one should only hear the classic "lub-dub, lub-dub, lub-dub." But sometimes I can hear "KEN-tuck-eee, KEN-tuck-eee, KEN-tuck-eee" or "lub-WOOOOSH-dub, lub-WOOOOSH-dub." Weird, huh? Now you wonder what your heart sounds like...
• Radiology - Pretty pictures. This is always a very satisfying half-day. What's awesome is that I get to see each image, come up with my own impression of said image, and then immediately have the answer presented by the attending. This is what I see when I look at this abdomen; see this [insert pathology here]? You can't miss that! I get to see appendicitis after appendicitis, chest x-ray after chest x-ray. It's the repetition, as I try to build a catalog of images in my brain for future reference. Picture, impression, answer. Picture, impression, answer. The radiologist immediately dictates his or her report on vocal recognition software, so I can hear exactly how the picture should be interpreted. Like I said, very satisfying.
• Orthopaedic Trauma Surgery - Another very satisfying field, because in this one I get to put screws in people's bones. Literally. I had the opportunity to take electric drills and screw in plates of steel (or some kind of metal) into broken femurs and elbows and ribs and clavicles. It is very meticulous for a specialty notorious for its brute strength. Everything is so precise: there has to be a certain amount of strain this way, and a little bit of stress that-a-way to make sure the patient's leg isn't turned 90 degrees when the patient wakes up the next morning. I also like Ortho because, instead of just wearing the shoes' coverings, I wear the moon-space boots that cover my scrubs all the way up to my knees. It makes me look uber-cool when I waltz into the cafeteria...
• ENT - "Ears, Nose, and Throat." It's an awesome field with a great mix of outpatient and surgery, pediatrics and geriatrics. Ultimately though, I just don't like the ears all that much. Too much wax...
• Neurosurgery - A very interesting specialty that I am definitely going to have to spend more time in. One of the docs I worked with does "deep brain stimulation," which means he actually inserts an electrical device into someone's brain and then it sends out all these stimuli. I've mostly seen it used in patients with Parkinson Disease, but I think there are a lot of indications for it. I've only seen a couple chronic neck pain cases, so I'm definitely going to have to go back for some brain drilling. Ultimately, I think I enjoy the abdomen much more, but it's worth a second look.
• Continuity - same old, same old. Taking two patients from the ER straight to the OR was the latest and greatest I've done.

I also have half-days in Pediatric Endocrinology and rural General Surgery to look forward to (I hope!) in the near future. So next we'll tackle the ethics issue presented last week, and then hopefully some class profiles to follow.

Inpatient Medicine

As I've mentioned before, four weeks of this year are on the inpatient service: two on Pediatrics and two on Internal Medicine. I already completed my first week with the kids, so in my final three weeks of the semester I am spending seven full days on "Medicine." This week of Medicine is the closest we get to the hours that we'll work during residency. Morning report starts at 6:30am, and sign out occurs somewhere around 8:30pm (usually a 14 hour day). Wednesdays we have a slight break because we have lecture from 1pm to 5:30pm, and then have the rest of the night off. We work the weekends, with no break going into the next week of continuity clinics. Basically it's a long week, but I better get used to it. I'll be doing this for years and years to come. The 80-hour plus week is upon me.

The morning for the med student is usually fairly relaxed. At 6:30am we get the scoop from the night residents, hoping that nothing crazy happened the night before. Usually it's a lot of patients asking for more pain medication, and it seems that pain control often dominates the discussion during morning report (and rounds later). At 7am we get going on seeing patients. I generally see 3-4 patients, each of the Interns sees six patients, and the Chief Resident checks in on everyone. The Attending also sees all 18 peeps, and somehow keeps them all straight (I can barely keep track of the three patients I see daily - I hope this is a skill that improves over time). I've had the opportunity this week to read about all of my patients before rounds, which helps me know what I'm talking about when we're all together.

At 10am we "round." Rounds are where the whole team gets together and discusses the treatment strategy for each patient. On many services, Pharmacy, PT/OT, nursing, social work, and chaplaincy will also be present to discuss patients, but on Internal Medicine we have only had Pharmacists with us. All 18 patients are presented in a very systematic format (subjective, objective, assessment, and plan or "SOAP"), with specific attention to the overnight events. How long the presentation lasts depends on the Attending and the service. For example, my presentations in Surgery needed to be 15 seconds or less (surgeons are go, go, go); in Pediatrics they were between 1-2 minutes (peds is always a little more chill). Medicine is notorious for longer presentations, greater detail, and tedious rounds. While we rounded on six pediatric patients in 20 minutes, our Medicine rounds will last three hours - three times as long per patient. Needless to say, a second cup of coffee is mandatory. However, I actually have found that I enjoy rounding, although it is very Attending specific. The demeanor of the Attending physician makes or breaks those three hours, and I have been lucky to have very good teachers this week.

Everything is discussed in the rounding round, from medications to social issues. Pain control is the biggest topic covered though. There are an amazing number of patients who enter the hospital already addicted to prescription medications, and so many more patients who are in severe pain. Deciding whether to use NSAIDs (like aspirin), or the best pain-killers available such as narcotics (morphine, etc.), can be a tricky choice. The goal is to use the least amount of medication to keep the patient comfortable and the pain controlled, but balancing use vs. abuse is difficult. Sometimes it really comes down to a gestalt or gut feeling from the physician, and some docs are more willing to sign off on narcotics than others. How much a patient needs may also depend on how much time the physician actually spends with that person. Some people joke that in the future we'll all be out of jobs because machines will take over the world, but these are the types of decisions that a computer can't make. Dealing with pain is part of the Art of Medicine; a very difficult and subjective choice.

After rounds we start admitting patients. The Interns discharge any people ready to go, and then fill up the beds so we always have 18 on our service. Most of our admissions come from the Emergency Department, so I find myself constantly running down to the ED to take a history, do a physical, and then present to the Intern and the Attending. Here again, how you a present a patient totally depends on who you are talking to. Sometimes I just want to ask, "Do you want 5 seconds or 5 minutes? Just tell me and it'll make this all go smoother." But you're expected to get to know the individual docs and figure out what they want to hear. I do my best. If the physician starts looking bored, it's time to wrap it up. If they're snoring, just quit. Everyone gets interrupted, but ultimately if you move quickly and confidently, I've found the results are generally good. Some Attendings you will never please.

Admit, admit, admit, and then time to sign out, turning the patients over to the night residents! I have to be honest, being here over the weekend is depressing. Everyone else is enjoying the time off to catch up on work and sleep, and here I am back at the hospital (where the weekend meals are just terrible - Sunday is by far the worst...). But I better get used to it; welcome to residency. I'll just have to keep counting the days until Winter Break.

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.

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.

The Miracle of Life

9:51pm. It all started with a high-five. I would have preferred the classic 8 mile Eminem opening scene: I can hear the crowd in the other room as I retch over the bathroom sink; I look up at myself in the dirty mirror, breathing heavy and wiping the vomitus off my chapped lips. Lose yourself in the moment, you own it... However, beggars can't be choosers, and this is my first baby. Well, not mine, obviously. This is my first delivery. Legs spread across stirrups; baby crowning in front of my eyes. I had practiced over and over on the "fake baby, fake pelvis" at the rounding table. Left hand, perineal support. Right hand, two fingers on baby's occiput. Control the head. Pushing slows. Use both hands to guide the head, fingers point in the direction of the baby's mouth. Check for a nuchal. Birth the anterior shoulder. Grab the neck with superior hand and control. Pull up and out to deliver posterior shoulder, supporting the arms from arbitrary extension. Deliver the lower extremities. CATCH and HOLD. Untangle the cord. Turn. Present to mother. Clamp the cord. I knew the progression; I just hoped the birth would be easy and slow. These multiparous women can pop out an infant quick. Perineal support. Two fingers on occiput. Control the... "Robert! Let's go birth a baby. You can do this (insert noise of proverbial high-five slap here); I'll coach you through." We enter 391 quickly, disinfecting our hands in stride, pushing through the wide swinging door. This will all go just fine, as long as I don't drop the baby...

9:52pm. Knock, knock. "Robert, go ahead and gown up. What's your glove size?" I put on the face shield first, careful to make sure the clear plastic is miles from my face. Can't birth a baby if you diaphorese (is that a word?), or sweat all over your view. Gown next, then gloves. This is where I put on a show for everyone in the room. Ever seen a med student try to put on a pair of latex in the usual sterile fashion? It's like watching your seven year old kid try to ride a bike for the first time. Do you just let her fall over and over again? It's like putting socks over your hands and then trying to put on a pair of mittens in minus 40 degree weather, barefoot. Cut me some slack. It doesn't help that I have a mother screaming on the other side of the room as I continue my awkward display of incompetence. The little one waited 38 weeks; it can wait another minute and a half. I say a little prayer. Please God, whatever happens, don't let me drop this baby. That's what happened to me, and see how I turned out?

9:53pm. I'm still fumbling with these damn gloves. Where's the scrub tech when you need him?! "Robert! Hurry up!" Just a minute dammit. I'm going to need my gloves on if I'm going to keep from dropping this baby!

9:54pm. By now I'm standing in front of the mom. She's got her legs in the stirrups, and her pelvis is at my knee level. Ergonomically, at 6'5", this is a problem, but I'm used to it. The med student doesn't make the rules, nor does he or she set the table height. So if I D.F.O. ("done fall out"), then I get to blame it on back spasms. I lean over the introitus and begin the progression. Left hand gives perineal support, right index and middle finger control the baby's head. My coach "J" is on my right; Chief stands approvingly at stage left. It's my first birth; anything and everything can go wrong. We already know that the baby is head down via ultrasound, but the rest is completely unpredictable. Who knows, maybe the baby is reaching for the light and a hand will pop out first. Maybe the baby was doing crunches to work on its abs in utero, and the feet will present next after the head. What if the umbilical cord is wrapped five times around the baby's neck? What if there are twins? Or triplets?? And what if I drop this damn baby on its head?!

9:55pm. This is when all hell breaks loose and the shit hits the fan (NB: although defecation is a common occurrence during delivery, no "shit" hit the fan during this delivery). I have my two fingers controlling the head, and then out of nowhere the baby starts shooting out of the mom's vagina. Doesn't it know this is my first time?! Four hands come flying in. I try to get my hands in place to grab the neck, but I had forgotten to check for a nuchal. My coach gets her fingers in first. The umbilical cord isn't wrapped around the baby's neck, but I have no time to switch my hands to deliver the anterior shoulder. "STOP PUSHING!" Any more pushing and this baby is going by using my chest as a backboard. Bank shot! At least thirty fingers are now controlling its progression. I finally get my right hand firmly around the nape of its neck, my left arm rigid beneath this miracle of life. Okay, so this delivery has not been perfect so far, but I WILL NOT DROP THIS BABY. In any case, there are now two pairs of mitts lurking underneath mine, spotting expectantly. All are ready to catch if the med student turns into Mr. Butterfingers. Abdomen, thighs, knees, toes: the entire lower half of this kid slips out in half a second. And there I am in my moment of glory, the moment of truth. The baby has left its warm, comfortable habitat, and entered the real world in majestic fashion: through the vagina and into the arms of a novice, as nature intended. My eyes narrow because I realize now is the time for utmost concentration. If this baby gets dropped, now is when that would happen.

9:56pm. The cord is untangled, and I'm ready to present the infant to its mother. "NOO! HOLD ON!!" I am a little over-exuberant I guess. The cord isn't long enough yet, so my coach leans in to gently lengthen it in order to prevent avulsion from its owner. "Now, you're ready. Go ahead." I spin the baby carefully in my arms and rest its body on mom. Smiles and grins all around. "It was worth all that work, huh?" Internally, I think this question should be directed to mom and me both, but I realize attention has shifted to the new addition to the room. The cord is clamped and cut; the baby cries as fluid is sunctioned from its newly opened lungs. All is right in the world. I rest in my moment of satisfaction. Mainly because I didn't drop the baby!

9:57pm. I stand and watch. At least one minute is dedicated to joy of birth instead of the science of delivery.

9:58pm. "Alright, Robert. Go ahead and deliver the placenta." My reflection is cut short as I realize that after the birth is the afterbirth. I start at the beginning with a gentle fundal massage. A familiar thought creeps into my consciousness... whatever you do, Robert. Don't drop the placenta.

Residents and Retractors

It's time to let you in on a little secret... I haven't had a completely "normal" third year experience so far in Asheville. That begs the question, "What's normal?" In the first six weeks on Surgery, we worked one-on-one with attending surgeons, sometimes as their first assistant. We scrubbed, we questioned, we joked. Now this is blasphemy. This is not how things are supposed to be.

I'm supposed to show up in my cute little white coat that's stuffed full of books, notes, and pocket tools at 0400. I'm supposed to report only to residents, because the attending is to be awed and feared. He/she is the omnipotent, omniscient, omnipresent being who strides onto the floor confidently, a few inches off the ground. Eye contact must not be made, and it is proper to cower just a little bit in his/her sight. If true fear is not inspired, a good grovel should be thrown in every few hours. If groveling is not ergonomic, you just have to hope they catch you in solemn prayer (praying to their divine-ness, of course). When the attending asks you to present a patient, beware! You will be interrupted quickly, and dismissed even quicker. Your saving grace will be the resident physicians, who are the buffer zone between you and the attending. They are supposed to be terse, possibly flustered, and always running out of time. You, the medical student, are an added chore. Go put a Foley in 17. What?? You really don't know how to put a Foley Catheter in? Get someone else to teach you. I'm busy. Follow resident physicians like lemmings, and, even though they aren't attendings just yet, cower if appropriate. These are the horror stories we students heard from the class above us. Fresh meat, we are.

I must say with a sigh of relief that this is not how OB-GYN really is in Asheville! But I'm not going to lie; of all the rotations this year, this is the only one that gives me a bit of the shakes thinking about it. It's uncharted territory (especially for the young, nulliparous male). Yeah, I'm sure the residents get a kick out of some of my patient care suggestions and butchering of common medical abbreviations (apparently "R+R" means "resection and reanastomosis," not "remove and repair" - but close!), but I'm always pleasantly corrected later. Thus, the next morning I won't act such a fool in front of the omnipotent one on rounds. The residents always have time for me; they teach and don't appear flustered (at least not that I can tell). My chief even helped me horde numerous packets of needless 2.0 Vicryl, so I could tie two-handed knots over and over and over again. I think I picked it up quickly afterwards, but in the OR I'm sure it was like watching a 15 year old behind the wheel for the first time... you grit your teeth, and want to rip the wheel out of their clumsy hands, but you know it's their first time.... they need the practice. After a couple days of trial and error, I can now challenge my Eagle Scout Pops to a "knot-off." And the attendings? I may still have a little bit of healthy fear, and perhaps they do walk a few sonometers off the ground, but there's less grovelling, cowering, and praying than I expected. They don't even blink an eye when I "remove and repair" someone's small bowel. Actually, they've been downright great. It was a great week one, and I'm shaking just a little bit less.

I was also shocked when I made it through 6 weeks of Surgery without doing any serious "retracting." You see that bad boy up in the top left? Now that's a retractor. Med students are bottom of the totem pole in the medical community, so if we get to scrub in, we're supposed to be pulling on these cumbersome tools to hold the patient's skin back. The residents and attendings do all the cool stuff obviously, but most of the cases on Trauma and General Surgery didn't require any heavy lifting. We've been replaced by this tool called the "Bookwalter," which hovers over the patient's belly and secures multiple retractors at the same time (sorry, I can't grow hands either). But finally in Gynecology-Oncology, I got to do my due duty! I got to grab my Deavers and Army-Navies and pull up 'n away. Sure I had retracted here and there in Gen Surg, but now I got a chance to hold back skin flaps for hours and hours at a time (or that's what I'll tell my kids). Don't worry, Robert's ready to retract! And I am. I like being helpful in the OR if I can, and if I play by the rules... do we remember our rules?

Rule #1 - Don't Get in the Way; Rule #2 - Don't Touch the Mayo; Rule #3 - Don't Get in the Way, and Don't Touch the Mayo!

We're there to learn, but I also think that the patient always comes first. Pestering the attending into a fit of rage is not going to make the surgery go smoothly. Queries at the proper times, and struggling to pull back Goelets to help him/her visualize is going to make the attending happy. And believe me, a happy surgeon is a good thing. So I try to find a good balance between learning and helping (so long as I don't touch the Mayo, of course). We had a wonderful case this week that tested the hours I'm putting in the gym. A few minutes into retracting above the liver my left arm starting shaking as I flexed backward. It was a monster piece of metal, and for the life of me I can never remember it's name. But I know what she looks like, and we will do battle again...

This is our only taste of "real" medical education in our third year, but I'm glad for it. This gives us a chance to  better understand a few things: like how much we will know at different levels in our training, what the medical hierarchy is and how it works, and what our lives are going to be like as residents. We also get the opportunity to learn from physicians not far out from medical school; those who perhaps understand our inadequacies a bit better, having walked our shoes just a few years before. It is also an important reminder that the people make all the difference in a residency program. I can't stress this enough. If I'm going to be spending 80 hours a week with just a few colleagues, they better be pretty chill. Fortunately, Asheville attracts that kind of person, I think. We're lucky here.

Now, back to the OR to defeat my nemesis.

Surgery: In Review

After a quick 6 weeks, I am moving on from Surgery into the world of Obstetrics and Gynecology (OB-GYN). It is a tearful farewell, as I put hernias and fasciotomies behind me, but by this time next week I might have caught my own baby (there will be a detailed play-by-play when/if I do some serious baby-catching).

I did very much enjoy my time in the operating room (OR) over the past month and a half, though. One of the very few disadvantages of this longitudinal program is only having 6 weeks on Surgery instead of 8 or 12 weeks. My compatriots back in Chapel Hill and Charlotte have a solid two months, but from my understanding, we pack in more hands-on training during our shorter clerkship. When I asked one of my friends from another medical school how he found Surgery and working in the OR, he replied: "Oh, I had a blast. As the medical student, I watched the intern, who was watching the resident, who was watching the fellow, who was watching the attending perform surgery on the patient! I got very good at watching." This is probably a gross exaggeration, but the nice thing about our Surgery block is the ability to work one-on-one with attendings. A number of the services have surgical physician assistants (PAs) on all cases, but that didn't stop me from being "first assist" on quite a few operations. After practicing my suturing on pig's feet, dish towels, and bananas (bananas, by the way, are a horrible excuse for fake human skin), I had the opportunity to sew in tons of cases. I can vertical mattress, horizontal mattress, subcutic, and simply interrupt. I stapled, two-handed knotted, retracted with "Army-Navies," pulled on "Weitlaners," and cauterized with "Bovies." I saw a spleen get taken out ("splenectomy"), a clavicle get plated, and a stomach get wrapped around an esophagus to prevent acid-reflux and reduce a hernia (a "Nissen"). Overall, it's hard to complain.

I'm not surprised that a lot of athletes fall in love with Surgery (as did I). Each case is its own match/meet/game/(insert generic name for sporting event here). It's the ultimate team sport. Each person in the OR plays his or her own very important role, and of course we're all wearing the same blue uniform (mask, googles, hat):

• There's the "scrub tech," who is in charge of the massive number of tools, towels, knives, needles, sutures, machinery, etc. Needle driver? Boom. It's in your hand. DeBakey? Forceps? 10 Blade? Just open your palm and say the magic word. As a medical student, you just get out of the scrub's way. Don't touch the Mayo, and don't try to hand off instruments. You're ass will be grass.
• The "rep" helps the scrub tech if it's a very complicated case with new tools. The rep is from the surgical instrument company, and knows the product inside and out to help in a pinch. But, just like a defenseman in lacrosse, he or she can't cross mid line (lax players please correct me if I'm getting this rule wrong). A rep is forbidden to hand anything to the scrub tech, only the "circulating nurse" can (every sport has their own arcane rules). 
• The "circulator" is master organizer, charting the progress of the surgery, grabbing anything not in the room in an emergency, and is usually in charge of the general ambiance of the room (i.e., the iPod). 
• The "anesthetist" constantly monitors the patient, basically making sure the patient doesn't wake up during the match. The players are constantly being tagged in and out, or "subbed," for shift breaks to stay fresh. The new line comes in, and no one misses a beat. 
• The surgeon and the PA run the offense. The surgeon is the ultimate captain. The surgeon leads the team, directing the troops to victory. When it goes well, the surgeon takes the accolades; when it goes wrong, it's the surgeon's fault. But it really is a "team" in the OR: every person is critical to patient care and success. Surgery is re-living your sports career over and over (including the 5am wake-ups, yuck). Oh, and if needed, a nurse might come in late to be a "closer," both in the metaphorical and literal sense: the nurse will actually close the incisions on the patient to end the match.

And then of course you have the random med student slowing everyone down...

As a medical student, it's all about the little victories. Did I go an entire surgery without getting in anyone's way? (Harder than it may seem). Did I suction at the appropriate time without being asked? Did I not get scolded? Did the attending not have to adjust the way I was holding the laparoscopic camera? You won't get praise for doing any of these properly, only corrected when you mess up. And, thus at night, I dream of the perfect case...

I was scrubbed in first, ready and waiting for the attending to glide into the OR and prep the patient in the desired fashion. No one asked me to move out of the way because I stood in the corner expectantly, then moved to the azure blue field and placed my hands neatly next to the Mayo. I did what I was told, answered all queries immediately and effectively. I drove the camera expertly throughout the case, drawing back during every irrigation and cleaning the scope on the liver when needed. I "followed" without being prompted on every fascial suture. I was then left alone to close the abdomen, which was done beautifully with nylon and steri-strips. The anesthetist didn't even need to give more laughing gas to get us through the final stretch. I was the perfect medical student: polite, crisp, undaunted... and never in the way.

What else did I learn? Orthopedists put in a lot of screws. They give new meaning to "drill, baby, drill!" Lots of plates, lots of screws, lots of drilling (and I got to drill!). For the general surgeon, pooping and passing gas ("flatus") is more important than anything... for the patient, that is. The SHELF exam was impossible; studying any more for it wouldn't have helped. And I think I might want to do Surgery.

So yeah, I learned a lot. Drill, baby, drill.