Madison County, NC

I literally could not understand the first patient I saw in clinic. His accent was so thick I had to use every ounce of active listening power to comprehend his statements and questions. At one point, I just laughed and nodded because he did. I have been hanging out in the city way too long. A year in Boston will do that to you. Even Chapel Hill (pretty close to the dead center of the map, pictured above) is too far away.

I began my final rotation in primary care last week. After this month, I will spend four months in class and on the interview trail, then finish my MD with four straight rotations: Radiology, Nephrology, Palliative Care, and Neuro Trauma ICU. It's a busy last few months of fourth year, but the goal is to not be an idiot when I start as an intern. This month, though, I want to firm up some of my primary care skills, taking care of patients with the usual array of chronic medical problems: high blood pressure, diabetes, congestive heart failure, depression, anxiety, etc.

While I have done some chronic disease management, I have actually spent most of my time as an urgent care / emergency medicine medical student. Many of my preceptor's patients use his clinic much like I would use urgent cares and EDs. On the average day, one or two patients will roll in with a deep laceration to the leg, hand, or face, and we will just sew them up right in the office. In fact, I've done more sewing in my first two weeks here in Mars Hill than I did during my entire Pediatric Surgery clerkship. I am also sharing time with a third year Family Medicine resident, so we will sew and do procedures while our preceptor works up patients. It's a good gig and super efficient.

Originally, I thought that doing two rural rotations as part of the Asheville Longitudinal Curriculum might be a burden. But these clerkships are turning out to be some of the best hands-on experience I'm getting as a medical student. I spent my first surgical acting internship in Linville, NC, where I truly felt like an intern. I had all the responsibilities that the interns at UNC had on Pediatric Surgery (except for the fact that I could not sign my own orders, which was probably a good thing). And here in Madison County, I'm in a similar boat. See one, do one, teach one.

After finishing up clinic on Wednesday, I flew to New York City for the weekend. My friends were appalled with my "southern accent." Apparently after two weeks here (and another two months in North Carolina), I was speaking reeeeeeaaal slooooow. And yes, I say "y'all" - something I promised my sister I would never do after she came back from Furman University in South Carolina saying it. In New York City, I'm just a country boy.

Funny. Because all my friends at Carolina call me a Yankee.

Surgery vs. Swimming

There is a flag in the surgical intern call-room, pictured left. This sentiment is oddly reminiscent of my swimming days (in fact, I think this is a direct quote from a number of my previous coaches...). Maybe this is why I am drawn to surgery; the similarities are abundant. Either that, or I am just a glutton for punishment. It's never made sense: I love to sleep 10 hours a night and I'm kinda lazy. Nevertheless, I keep choosing activities with horrible hours.

It has been a while since I've posted any countdowns or lists, so I bring to you the 7 reasons surgery and swimming are exactly the same. I encourage you to add to this list...

1. Four in the morning is considered an acceptable time to begin the day. Four is early, five is normal, and six is sleeping in. Three I just refuse to do. When I was in high school, I remember having to wake up at 4:11am to get to the pool exactly on time. Not a minute too early. I've never understood why we have to wake up so freaking early to get stuff done. In Surgery, it's because you have to start operating by 7:30 or 8am. Well, when I'm an attending, we'll start at ten! But getting home at midnight is as equally depressing as the pre-dawn wake-up.

2. Everyone falls asleep during class. If you're going to wake up at 4am or earlier, you aren't getting much sleep. One thing I like about surgery is it's go-go-go. Always moving, always working. But lectures and tutorials are sandwiched in between. The moment I sit down, my eyes start to droop. And I'm not the only one. Five minutes into a presentation, the interns' heads start to bob. The residents are pretty crafty though. In a big lecture hall, it can look like you are reading, but if you listen closely, you can hear a faint snore. The only difference between surgical lectures and college classes is I could straight up just skip the latter.

3. BEEEEEP, BEEEEEEP, BEEEEP!! Pagers beep, swimming clocks beep. They are both loud and annoying.

4. Everyone around you is just as crazy as you are. Swimmers are their own breed. I could walk onto any college campus right now and pick out who the swimmers are walking to class. Athletic gear, slightly slower pace, broad shoulders. The women have damp hair; the men have just bleached disgustingness going on. Med students are their own breed too, but surgeons are a cult. I shouldn't say too much, but spend enough time in the hospital and you'll know exactly what I mean.

5. You are always doing something incorrectly. I once talked to a sports psychologist who told me I was the quintessential trained rat in a maze. If you put a piece of cheese in the middle, I would run around the maze until I found it. Once I found the cheese, I would go back to that spot every time I was put in the maze. Even if there was no cheese, I would keep running to that spot, over and over again. So long as a piece of cheese was put in there once in a blue moon, I would keep running. She told me this is how I am with positive feedback and praise. I'll keep working for it. I'll bitch and moan when I don't have it, but I want that one piece of cheese, and I'll keep working for it, even if it's only thrown out every once in a while. This is the best way to get me to perform. All my best swim coaches understood this. This mentality is perfect for surgery. Most of the time you are meant to feel barely adequate, but every once in a while...

6. Everything is a competition. Whether its knot-tying or taco bell burritos, you want to be number one. Either the best surgeon, the fastest swimmer, or the burrito eating champion. And it's not just in the OR or the pool. Our annual swim team beer pong tournament at UNC was just as fierce as ACC Championships.

7. Nothing is more rewarding, but the grass is always greener on the other side. "I should've played tennis." I used to say that constantly (in fact, I still do). Swimming is like the worst sport ever. The hours are terrible, there's no career in it, chicks don't really dig it, and you completely lose out on a college experience.  But at its best, there's nothing better. Beating UVA is still one of the greatest experiences of my life. A number of surgeons have told me that if they could go back and do it all over again, they'd be radiologists or dermatologists. But then you see them when a life is on the line, and they love it. They love the rush. They would quit if they could, but they can't. Addiction.

To the Big House!

Rebekah likes to tell the story of our first day on Obstetrics and Gynecology (OB/GYN) as third year med students. There were three of us traveling up the elevator at Mission Hospitals: Rebekah, Blake Pemberton, and me. The ride up four flights from the parking garage was pin-drop silent. It was the first time she'd seen me with my mouth shut. She also says that I looked a new shade of pale, but I think that was just the lighting.

Truth be told, I was overly apprehensive. OB/GYN was the one rotation I was not looking forward to. It was my second clerkship, and though I was definitely nervous for Surgery six weeks prior, it was a different type of nervous. Everyone is nervy when they start third year. The comfort of the classroom is gone. Patients bite. Doctors bite. Nurses bite. Snakes bite. You realize you know nothing. For OB/GYN it was different. It was the kind of nervous I hope most 20-something males have when they realize that for the next six weeks they are going to be completely surrounded by female parts (in a clinical way). Lots of female parts, and they don't really know how they work...

Ma'am, I understand you are going through a lot of pain right now.
YOU DO NOT UNDERSTAND MY PAIN. YOU WILL NEVER HAVE A BABY AND YOU WILL NEVER MENSTRUATE!!!

This is how I imagined most conversations would go. Also I would have to not smile when people would say the words "penis" and "vagina" (I made it the entire six weeks without giggling by the way - Mom, I'm so grown up!).

Anywho, I tell you that story to help you understand how nervous I was for this Monday (and by "you" I mean future Robby who will change the story in his mind about how cool, calm, and collected I really was). Here, as a fourth year, I was starting perhaps my most important rotation in medical school, and I had never even been to UNC Hospitals, my home institution. I didn't know where anything was, didn't know if my badge would work, didn't know if I would be able to eat (i.e. where would I steal food from?!), etc. Pediatric Surgery will be my only UNC rotation on my transcript, and I also need to garner a letter of recommendation (LOR) from a surgical faculty member. The pressure was on.

So we met at 6am in the PICU on Monday, and my resident tells me to go print off a "list" (list of all the patients that are on our service). Zero clue how to do this. When I sit down at the computer, I realize I don't even know how to log-on to a generic UNC computer. I ask the nurse. Ohhhhh, so you are like "new-new." Here ya go, honey.

I am not a "honey." I'm just new-new.

The administrative mayhem this week went from bad to worse. Absolutely nothing worked. My badge didn't open any doors until I got a new OneCard, and spent 20 minutes on the phone with the hospital IT people. My parking badge was an epic fail, and I accumulated two parking tickets along the path to fixing that disaster. I couldn't view radiology images, and I couldn't find my way to the operating rooms. Oh, and there are two third year med students with me that know a heck of a lot more about the UNC computer system than I do. #FourthYearFailure

But the OR is the OR, no matter where you go. Clean, sterile, precise. The rules are the same everywhere. So, for the first case I scrubbed in on with the attending and chief resident, I was ready. It was a laparoscopic case, so I was able to operate the camera. I did not induce motion sickness in anyone. I held the trocars in place when they were inserting instruments. I knew when to turn the lights away. I knew how to scrub. And when the attending asked, I told him I was a fourth year going into General Surgery. He replied, "Oh, that makes sense. I thought you knew what you were doing in here..."

FOR THE WIN!!!

Unfortunately, I think that was my only victory of the week. There is a steep learning curve that I have to climb on this rotation, and as my resident says, "Our goal in Surgery is to make sure you always feel barely adequate." Excellent.

Family Medicine - Acting Internship

Yes, Meredith, but it is good to be happy every once in a while. And today was a very good day for happiness. Today I had a case where everything went right (although it helped that it was a bread 'n butter General Surgery case!). I had plenty of time to read about the condition before I saw him, I was able to do a leisurely admit, the resident and attending physicians told me I had a "great" presentation and plan, and then the patient himself told my superiors that I was going to be a great doctor. It doesn't get much better than that. I told my patient that I would slip him a check for saying nice things about me...

There's nothing more satisfying than when an entire encounter goes well. Obviously, this is not the norm, but it is wonderful when everything clicks.

So, this month I am in "Block 0." It is a four week rotation before the beginning of the medical calendar year. Everything starts on July 1 in medicine. The new interns arrive at the hospital, the residents become a year older, and the chiefs graduate and become fellows/attending physicians. Third year med students hit the wards, eager and scared shitless (I certainly was - "Today I was called doctor and that was scary..."). After a year off, I really wanted to do a Block 0 clerkship before starting on a surgical service at UNC. Family Medicine in Asheville was a perfect choice. I could re-train in internal medicine, pediatrics, OB/GYN, and admit surgical cases. Family Medicine is the specialty with the broadest spectrum (which in my mind, makes it the most difficult to practice well), and I certainly still need a lot of work relearning the knowledge that I've lost. There are quite a few axons that need to be rewired.

The schedule isn't too bad. Each morning we meet on the 7th floor to check out with the night float resident. We hear about any complaints or calls that the resident had to field the night before, and any new admissions. Typically, our service runs about 10-15 patients, although today we had six. Last Friday we had 25. After sign out, we divvy up who to see, and then we round on all our "peeps." Depending on the census, I see between two and five patients. I get a history of the nights events, perform a focused physical, then write up the encounter with an assessment and plan. Then it's off to rounds, where we discuss each patient individually as a team. I present my patients, but a resident and attending have generally already seen them as well. Finally, I spend the rest of the day helping to manage the issues on the floor and admitting new patients to the service.

Then I'm off in time for dinner. Rinse and repeat.

That is my schedule during the week. On the weekends, I just have two nights of call during the month. This is when I'm at the hospital with the night float resident. Sometimes the call schedule will be every third or fourth night ("Q3" or "Q4"), so having a Q14 call schedule here is not bad at all! I expect to take call Q3 on Peds Surgery next month, and some preceptors have even suggested I try to take Q2 call so I can impress my attendings.

Being back in Asheville is also wonderful. I have already been to White Duck Taco twice, and the Bywater once for a (very brief) happy hour. Rebekah and I have a dinner scheduled for Sunday night at the Admiral, thanks to Mom and Dad. At Christmas, they realized how much I missed NC and I received a lovely gift basket of Carolina stuffings, gift certs included. So we will cash-in this weekend with some beef tartare.

It's going to be an intense month. I am also trying to spend some time in the OR to get comfortable again, and I will have to re-learn how to tie knots. But it is indeed exciting (I don't know if you could tell).

AHEC 425: Acting Internship in Surgery, Rural Western NC

Welcome to Linville, North Carolina! In my first clerkship as a fourth year medical student (damn it feels good to say "MS4" at the end of my dictations), I decided to grab a one month rotation in Western NC before heading north. What better place to go than the area where I spent my five community weeks my first two years (Linville is very close to Boone)? In fact, I am actually working at the hospital where my community week preceptor has a satellite office. Here, I will spend four weeks working with two general surgeons, learning how medicine is practiced away from THE BIG HOUSE (i.e., Chapel Hill or Mission). One of the surgeons is the third in his family to serve this area as a general surgeon in a practice established before the turn of the century. And by turn of the century, I don't mean the year 2000...

The best way to describe my experience so far is through a short vignette. The only place in Linville where I can get good cell phone service is in the Cannon Memorial Hospital parking lot (burn in hell, AT&T!). I don't have service at home or in the coffee shop I now frequent. So, after we finish rounding in the evenings, I may often be found sitting in my car catching up on phone calls. One night this week I left the door open, welcoming the cool mountain breeze. Mid-conversation, a police officer walks up to the car and starts messing with me a bit...

Dispatch, we have a 10-87-12 going on in the Cannon parking lot. Send 2 units back-up.

I put the caller on hold and start chatting pleasantly. Suddenly he realizes I'm on the phone and says, "Son, I just came by to see if you were going to take that lady back for a C-section." I was a little taken aback (one, because I don't take anyone back for sections; two, how did he know?; and three, HIPAA?). The doctors had only been discussing whether or not this patient would need to go to the OR less than 30 minutes ago. He says, "She's my cousin; I was just curious. Heard you might be in there."

News travels fast.

That gives you an idea of how small and tight-knit the community is where I have the privilege of working. It seems that the lines of HIPAA are a little blurred. Before leaving Asheville, one of the surgeons asked me what my plans were for the year. I told him that I was on my way to Boston, via Linville. He said, "Well, Linville is just sliiightly different than Boston, so good luck." I can imagine. To which our great and wise ethicist replied (in her usual, sage manner),

In the words of psychologist/philosopher Harry Stack Sullivan, "We're all more alike than we are different."

Agreed. It is a different ball game here, though. Because there are only two surgeons for the whole area, we are always on call. If something happens in the middle of the night, I am expected to be there. Morning, noon, night, and weekends. Now, given that it is a small town, emergencies occur less frequently. But the responsibilities are greater. We pre-round on our patients in the morning, see patients and take cases all day, and then round again at night. I have been the first-assist on cases that first year residents don't even get to take (I don't think it happens like that in THE BIG HOUSE). There is less "see one, do one, teach one," and more "go do one." It's fantastic. Mind you I don't "do one" if I'm not comfortable or don't know what I'm doing. I feel a responsibility for my patients here. I also feel a bit like a real practitioner.

I think I'm going to miss the medicine in my year off. I will leave you with my quote of the week:

"My dad used to say, 'If you take a son-of-a-bitch and educate him, what do you get? You get an educated son-of-a-bitch."