Medical School Noise

Yeah, I think It's Medicine I want

2011-12-17T17:07:00.000-08:00

Internal medicine is what I mean. But am I cut out?

That was a recent topic of discussion when I went back to Texas over Thanksgiving, the place where I was raised. My aunt asked, "Are you a good diagnostician?" somewhat too candidly. The question floored me because she really hit the heart of the matter. Becoming an internist takes a great deal of analysis and diagnosis. In honesty, I couldn't answer unequivocally "yes." I have no idea if I'm a good diagnostician. How would I know right now as a third year medical student? I know I'm logical, thorough, and resourceful. But plenty of times during my medicine rotation, I was astounded by the doctor's diagnostic skills.

For example, one evening in the ER, one of Dr. Afsari's patients (Dr. Afsari being my preceptor) came in with an acute abdomen. She was vomiting coffee-bean-like substance, had an acute, diffusely tender abdomen, and leukocytosis. Dr. Afsari said "Looks like ischemic bowel." Huh? I really had no idea. Yeah, she was in the age range, but I was thinking PUD or diverticulitis. Those were on the differentials, but guess what? A few days later, she was diagnosed with acute bowel. Damn. I was slackjawed.

What does it take to be a strong internist? If I were commissioned to write this story, I'd probably research this topic. But I'm not. So I'm moving on to my next, most internally (get it?) pressing issue during this rotation...the experience.

Fantastically mesmerizing. Buoyantly intriguing. Deeply haunting. Mindblowing. No, I'm not giving a movie review. This is what medicine with Dr. Afsari was like. He's an infectious disease specialist and an incredibly straightforward teacher and stable, understanding, and thinking doctor. Most days, we rotated with him for 3-4 hours, then researched the cases, visited our own patients, prepared for our presentations, and caught up on school work.

Most of the patients were really sick or had chronic illnesses. And many, many of our patients died. Not because Dr. Afsari is a poor physician, but because Doctors Medical Center serves a destitute, underserved patient population. Examples: the IV drug user with cirrhosis. The obese male with ischemic bowel. The handyman with pancreatic cancer. The rheumatoid arthritis patient with rheumatoid lung. Death to many of these individuals was unwelcome and shocking. Many weren't ready. And many finished out their lives on the gurney in Doctors, some alone, some with loved ones, and some with loved ones ready for their death.

I bring up the subject of patients who died because it pained me to watch. And I keep those feelings close to me. I want those feelings to stay close to me, to live with me, and to be uprooted again and again during patient encounters.

There's so much to say about internal medicine. Dr. Afsari methodically works up each patient, spending hours reviewing patients' charts, consulting with other practioners, and talking to the patient. His way is thorough and thinking, heartfelt, and real.

On my last day, I nearly buckled. I wanted to stay with Dr. Afsari and continue to learn from my patients. He said his farewell over a glass of champagne, calling us his colleagues, and the future of medicine. I'm humbled by this thought.

A Family Medicine Epitaph

2011-10-04T14:34:00.000-07:00

If I could write my farewells to family medicine, it would have to start with Dr. Mahoney at Brookside. A man of many talents, Dr. Mahoney is a boisterous, larger-than-life man frequently spewing one-up knock-knock jokes, talking about pretty ladies, jostling poor time management skills, and most importantly, engaging and meeting his patients at their level. Family medicine at Brookside is how I envision practicing medicine. The patients are diverse, the staff is friendly, and everyone shows passion and flexibility for their work. I didn't encounter negativity as I did at other sites. Between Dr. Mahoney, who laughs more easily than any other doc I've worked with, and Dr. Villanuevo, who smoothly jumps from task to patient, I learned and loved a lot. It was easy to go in and hard to leave everyday.

Brookside specializes in adult, underserved care, especially for a hispanic culture. Mostly, we encountered diabetics and hypertensive patients. But there was also the guy with the skin tag, the young man who went through a slew of tests before finding a pancreatic mass, the hispanic elder who lost a ton of weight in mexico because he became insulin-intolerant, the female with PID who got three speculum exams that day, the IV drug user with a new-onset stroke, two or three PPD-positive patients, two patients with toenail removals, and the young lady with heavy periods and 6.0 Hb.

Looking back, I realize that Brookside was a special place where the right patient population meets the right doctors. For Brookside, your memory uproots feelings of warmth, spirit, care, and diversity.

I finish my FM rotation at the Touro Medical clinic, a more structured, stuffy facility that still maintains hand-written charts. Structure hasn't been a bad thing. I go in, see a few patients, present the patients, then write 4 SOAP notes daily. Weekly, I given presentations -- from topics to journal presentations. My professors expect technical perfection in physical exams and SOAP note linguistics. I've risen to the challenge, and although somewhat gruelling, my note taking ability and neuro exam have seen vast improvements. And I can finally explain relative risk, odds ratios, and the number-needed-to-treat like a pro.

There were also, of course, the patients. Vastly different setting than Brookside, Touro Medical Clinic serves a mostly Caucasian population. Also underserved and mostly medical. What is it with osteopaths and the underserved? not that I'm complaining. That's the population I strive to work with. We saw plenty of interesting cases, along with the normal hypertensives and Diabetics. There was the young woman with Turner's syndrome and menorrhagia. The 48-year-old male with corneal ulcerations, back pain, and GI upset (AI infection perhaps?), the COPD patient who just wanted to be "fixed," the teenagers who wanted to know everything about the male genital anatomy (including the color of a testes), and the cases of lower back pain which required four injections by yours truly.

Between Brookside, my love, and Touro, my challenger, I've thrived in Family Medicine. Probably because I like the world of variety and diversity. A much needed break from the rigors and monotony of surgery.

Acute Abdomen, Farewell

2011-07-16T11:46:00.000-07:00

I finished my last day of general surgery yesterday. Kind of sad to say goodbye to Dr. Gourlay and Julie, his secretary. Gourlay has a great way of putting people at ease and anticipating questions. Key takeaways:

- Always maintain a sense of humor, even if you're about to drain someone's abscess by sticking a knife in 'em.
- Talk kindly of other docs, even if you don't agree with their decisions. This is a Gourlayism, and I like it.
- Lead the conversation and don't let the patient lead you, such as if they're about to tell you a story about being in the roller derby.
- Say yes to anything a preceptor asks you to do even if you don't want to.
- Know more about the patient than the preceptor knows.
- Follow your attending's lead
- Stay human, even if that means you gotta cry every once in a while.
- People are tough. Take the 49-year old obese male who had perianal abscess. When the doctor said, "I'm just gonna knife you and drain it" the patient replied, "did you say knife me, Doc?" To which the doctor said with a smile, "Yes, because I think a local would be just as painful as just sticking a knife in it," the patient said, "OK. Do it doc." The knife went in, pus and blood emerged, and it was done that fast. The patient left smiling and thanking the doctor. What!? Like I said, people are tough.

In the last two weeks, I scrubbed in to see:
- 1 partial mastectomy
- 1 lumpectomy and sentinel node biopsy
- 2 ventral hernia repairs
- a few more cholecystectomies
- 2 colonectomies

I also saw several hemorrhoid cases, 1 abscess drainage, generalized lymphadenopathy, sebaceous cyst, inguinal hernia, and lots of post-op follow-ups.

I'm constantly learning about the doctor-patient relationship, how bad docs can make a patient feel like a specimen, and how good docs can make her feel like a human again. For example, I helped one of the ICU doctors put in a central line (on the same patient I helped put in a trachea tube). The doctor didn't explain shit. He didn't consider any opioid until the nurse suggested it. I felt sick for the patient who took the procedure without any conception of what was happening.

Mr. Aldea, an 81-year old Asian man, underwent a colonectomy for stage III colon cancer. The surgery went successfully but the patient slipped into SIRS (systemic inflammatory response syndrome). He already suffered from kidney failure and several other complications. After 7 days in the ICU and many docs trying to figure out how to treat him, his end prognosis didn't look good.

Then there was the 82-year old man with parkinson's, CABG, and a large inguinal hernia. His wife, a recovered colon cancer patient, was his sole support and only learned of his growing testicle a few days ago.

Those patients and all the interactions did me in. I had a good cry and felt human again. It's easy to forget that the patients in the hospital and in the clinics are suffering human beings, scared and desparate for life. I hope I never forget.

General Surgery Rotation

2011-06-30T11:17:00.000-07:00

On my way home after observing and partially assisting a tracheostomy this morning, I felt an incredible sense of honor for the ability to view the human body in this way. I got to insert my finger into the patient's trachea, feel the isthums of her thyroid, view the pulsation of her internal thyroid artery, and suction the little blood that escaped from the incisions. Anatomy books don't cover this stuff. A living, breathing human being with bubbling fat, warm tissue, and throbbing vasculature dwarfs the cartoon drawings in Netter.

Like my preceptor of 30 years in the surgery business said, "It's still an honor and privilege to perform my job every day."

I started general surgery two weeks ago. Since then, I've seen:
- 4 cholecystectomies
- 1 hemmorhoidectomy
- 1 bennett's fracture
- 1 basal cell carcinoma and benign nodule removal
- 1 umbilical hernia
- 1 tracheostomy (today)

Next week, we're scheduled for a mastectomy, colostomy, inguinal hernia, and hemmoroidectomy.

What's general surgery like? Thrilling. Humiliating. Humbling. Scary. Being a medical student in general surgery is like being a videographer filming a lion attacking its prey. You keep pretty quiet, try to stay out of the way of the techs and nurses, and take in everything that's going on around you. And it's almost deathly when you mess up. First day, I put my mask on backwards AND nearly passed out. Addressing the first mistake, my glasses kept clouding up like I was in a dishwasher. Couldn't see a lot. As to the passing out, I asked to sit down (luckily) before I took a nose dive onto the ground, or worse, into the sterile field. The nurses hate that.

Since then, I've been pretty unassuming. Just slip in and out, say lots of "thank yous," "sorries," and "oh, wows." I only blew my scrub-in once, when I starting tying my gown before putting on the gloves. Oops.

Other than the nurses scowling at you at all times, and realizing that you're the lowest man on the totem poll, being a medical student is surgery has its definite advantages. For one, you get to suture. My step-in preceptor let me suture the entire bennett fracture incision from the lateral thumb to the scaphoid. You also get to stand right next to or across from the surgeon so you can see every bit of anatomy, incision, and probing. Other than that, you sit around a lot, try to make small talk, and formulate good questions and answers to pimping.

How about the preceptor I'm following? Best description for him: knowledgeable, charismatic old kook. He's a character. Always talking, sharing some story about the past or the current, remembering every little detail from names and dates to history and circumstances. He can tell you why every instrument is named like it is. The pathophysiology of most diseases, and even give you a blow by blow of the American Civil War, recounting the Battle of Gettsyburg to the Second Battle of Bull Run. Night time remains difficult for me. When we stop seeing patients at night, he wants to talk politics, NPR news, and the history of medicine for hours. How do you leave that?

Over these past few weeks, I've also had the opportunity to be self-reflective. I'm strong enough for this profession, but it takes some serious self confidence and guidance. I feel like I know jack right now, my information tied up somewhere in different brain compartments. I'm learning how to retrieve the information, but I'm dealing with an antiquated system here. Everyone says H&Ps, Dx, and understanding comes after the third year.

Right now, I'm just putting things together like a puzzle.

A New Old

2011-02-22T17:26:00.000-08:00

Medical school makes you feel old. I'm 35 and old for medical school but young for the world. It's spring semester of year two. Hanging around people 10 years younger than me for almost two years has confused me. They're my equals mentally, but emotionally and physically, I'm different. But I only started out different. Hanging around these 20-somethings has put us closer to equal playing fields.

Example: Before medical school, I'm pretty sure I addressed problems straight on. Now I find myself complaining about teachers and school work. Aren't I past this yet.

Example 2: Before medical school, I read the news, went to fancy wine parties, and cared about politics. Now, I watch top chef for study breaks and occassional peer into what the other medical students did last weekend via facebook.

On this last point, though, I gotta defend myself. Medical school takes all of your mental power. 100%. When I'm done studying, I don't want to engage in anything requiring an IQ over 100. Luckily in this world with all the unchallenging and self-absorbed nuissance out there, I can easily plug in to dumbness.

Speaking of self-absorbed, I'm studying the GI system. I was in the anatomy lab today reviewing the GI organs, vessels, nerves, and fascia. Indirect and direct hernias are difficult to understand. The entire inguinal canal baffles me. It's made from the aponeurosis of three muscle layers (external, internal, and transversalis muscles) and their communication with the rectus femoral muscle. A quandrangle is made in this small space that penetrates lateral to the inguinal region. It's difficult to digest because the tube is made from multiple muscle layers joining together, creating pockets and weak points in the area. Hernias evolve here, and are names just as confusingly: indirect hernia means through the deep ring (shouldn't that be direct)? whereas direct hernias are formed outside the ring.

Something to ponder later. Now, I'm off to suitcase clinic in Berkeley. In the meantime, I'll continue wondering when I'll ever have time to study for boards and carry on a life with my friends and husband for the next few years.

Another Stab

2010-08-02T11:01:00.000-07:00

Here I am again, writing in my blog after a few months of neglect. I passed the first year in good standing, won the Russell C. McCaughan, D.O., Education Scholarship, and just returned from a medical internship trip to Ethiopia.

In the second year, we focused on cardiovascular, respiratory, and renal pathologies, pharmacology, histology, and physiology. Throughout the year, I wanted to become a hematologist, then an oncologist, and lastly a nephrologist. Renal captured my attention the most, and right now, I can still remember most nephritic and nephrotic diseases.

I wrote a book about Ethiopia while I was there, so I only need to highlight the experience here. Four students -- I among them -- traveled to Ethiopia for a medical internship. We worked in Jimma University Hospital during the week, splitting up into two groups rotating OB, internal medicine, surgery, and pediatrics wards. On the weekend, we worked in Asendabo, a community 50 km outside Jimma. We gave talks on family planning and malarial prevention techniques.

Ethiopia encapsulated first year in review. We saw valvular heart diseases, COPD cases, chronic kidney diseases, and many other pathologies that we'd studied in first semester.

Emotionally, I think we were all a bit depressed in Ethiopia. I slept sometimes up to 12 hours, ate poorly, and felt downcast on many days. Was it the sights and atmosphere that brought me down? Most likely, yeah. I'm still fit for this stuff, but the hospital environment was devastating -- bloody gauze, needles, razors on the floor; doctors dispassionate about their patients; and patients in misery. On two occasions, I felt quesy: when a young women was screaming out in pain during an abdomen excise; and in the maternity ward. I chalk both up as patient emotion overcoming my scientific equilibrium.

Future DO

2010-04-10T17:39:00.000-07:00

Year 1: Almost over. I have one more block left and I just started this damn blog. So much missed. Oh well. I'll start from present day.

Present day: Just returned from spring break, and we're into the respiratory system. I'm trying to wrap my head around the difference between obstructive and restrictive pulmonary diseases. Obstructive diseases, I'm slowing figuring out, affect exhalation and are more prevalent. COPD, one form of obstructive disease includes emphysema and chronic bronchitis, which are both degenerative diseases.

I'm just spitting information out right now -- trying to make up for the first 9 months of missed communication.