Be forewarned: this is a rant more than a post. In addition to losing my car keys recently, I've lost my PDA, some notes from my cardiology rotation and who knows what else. Then today we get hit with expenses galore. Santa is bringing us a new refrigerator, new car tires, brake rotors, brake pads and a windshield. Yipee!
The one silver lining is that I've already ordered a new cell phone/PDA that is on the way. My PDA was showing it's age (I bought it used on Ebay) and I found a new T-mobile MDAs on Amazon for $25. I just hope it performs decently. I sure liked the Dash (Becky is getting one of those from Santa), but it wouldn't run most of my medical software (Windows Smartphone vs. Pocket PC). For another $30 I got a 2GB minSD card in case I ever purchase an UpToDate subscription for it.
As usual, my break will be spent (partially) working on choirs, gadgets and computers. It will be nice to have one device to carry around, but it's going to take some time setting up Epocrates, Feri's, Tabers, Netter's Anatomy, Ultimate Anatomy, Shots, Midnight Medical, Medical calculators, Outlook sync and the ones that I don't use on a daily basis. Somehow that seems more enjoyable than tackling the sprinkler system...again.
Monday, December 18, 2006
Sunday, December 17, 2006
Reflecting on a maternal death
While it's fresh, I wanted to post on an important but unpleasant topic. In the U.S. we do a pretty good with average maternal deaths around .01%. One of the top causes is maternal bleeding during labor & delivery. But it can also happen prior to labor due to improper implantation of the placenta.
In this case, the OB/Gyn group I worked with thought their patient had placenta previa where, by ultrasound, the placenta can be seen covering some of the cervix. This is a concern for bleeding but very rarely leads to a fatality. However, this patient had placenta acreta, where the placenta is implanted deep into the uterine muscle and its vasculature. There is currently no test or exam that diagnoses this condition. However, if placenta acreta is found incidentally, delivery is usually scheduled as early as possible (36-37 weeks) before contractions start.
This young lady of 28 was close to term with her second child. Previa bleeding was a concern at prenatal office visits, but she hadn't reported even any spotting. When she was admitted it was estimated that she'd lost almost half her blood volume. This was at 8am, not long after I had left Dr. Mourad in a C-section that ended my 7pm to 7am shift. He and ten or so other physicians from his group and perinatalogy rushed and frantically tried to get blood products into her hypotensive body, but could never gain on her profuse blood loss.
Resuscitation was attempted until 11am when the death of mother and child was called. I arrived that evening as scheduled at 7pm to find the entire labor & delivery unit in grief. Not tears, no one present at the bedside was still around, but real sadness from everyone coming on hearing the news like I did.
I talked to and overheard conversations from many nurses and several attending physicians from my group. I also heard from other physicians who made up a committee investigating the incident. My group even requested that the case be reviewed by an outside group of physicians (OB, perinatology and anesthesia) at a different hospital.
It sounds like the findings will be some minor procedural changes (chain of command, blood product availability) but nothing that would have changed the outcome. Now a five year old is left to be raised by his grandmother surely grieving for her daughter and unborn grandchild.
The whole case was an educational experience to go through, even from the outside. It showed a lot of care, humility and professionalism from my attendings. I don't look forward to experiencing my patient's death, but I feel a little more prepared for handling such an event.
In this case, the OB/Gyn group I worked with thought their patient had placenta previa where, by ultrasound, the placenta can be seen covering some of the cervix. This is a concern for bleeding but very rarely leads to a fatality. However, this patient had placenta acreta, where the placenta is implanted deep into the uterine muscle and its vasculature. There is currently no test or exam that diagnoses this condition. However, if placenta acreta is found incidentally, delivery is usually scheduled as early as possible (36-37 weeks) before contractions start.
This young lady of 28 was close to term with her second child. Previa bleeding was a concern at prenatal office visits, but she hadn't reported even any spotting. When she was admitted it was estimated that she'd lost almost half her blood volume. This was at 8am, not long after I had left Dr. Mourad in a C-section that ended my 7pm to 7am shift. He and ten or so other physicians from his group and perinatalogy rushed and frantically tried to get blood products into her hypotensive body, but could never gain on her profuse blood loss.
Resuscitation was attempted until 11am when the death of mother and child was called. I arrived that evening as scheduled at 7pm to find the entire labor & delivery unit in grief. Not tears, no one present at the bedside was still around, but real sadness from everyone coming on hearing the news like I did.
I talked to and overheard conversations from many nurses and several attending physicians from my group. I also heard from other physicians who made up a committee investigating the incident. My group even requested that the case be reviewed by an outside group of physicians (OB, perinatology and anesthesia) at a different hospital.
It sounds like the findings will be some minor procedural changes (chain of command, blood product availability) but nothing that would have changed the outcome. Now a five year old is left to be raised by his grandmother surely grieving for her daughter and unborn grandchild.
The whole case was an educational experience to go through, even from the outside. It showed a lot of care, humility and professionalism from my attendings. I don't look forward to experiencing my patient's death, but I feel a little more prepared for handling such an event.
Piano Recital
Until Friday I don't think that I had ever seen a piano recital. But after five months of great teaching from a classmates wife, my boys were ready to perform. I should mention that this is no ordinary piano teacher. She taught middle school last year but due to the commute. She quickly filled up her studio hours at home and has over 20 kids on the waiting list! My boys adore her and the recital was very well run.
I helped the boys tie their first real ties. Then all five of us (Becky, her sister, the boys and I) headed over a bit early to get seats and do something about our gitters. Below is a picture we took before the recital started.
Twenty-five kids played and/or sang. Some better than others, but pretty good all in all. Connor and Colton were fantastic. They had two solos each, then a duet performed together which can be seen at Handbell Choir piano duet by Connor and Colton
Christmas shopping is mostly done (thank God for Amazon) so now I have no more excuses to avoid study for the OB/Gyn shelf test on Tuesday. Well maybe one more.... The boys have requested that the four of us go see the new movie Aragorn based on one of their favorite books. That would be a priority over a pass/fail test any day.
I helped the boys tie their first real ties. Then all five of us (Becky, her sister, the boys and I) headed over a bit early to get seats and do something about our gitters. Below is a picture we took before the recital started.
Twenty-five kids played and/or sang. Some better than others, but pretty good all in all. Connor and Colton were fantastic. They had two solos each, then a duet performed together which can be seen at Handbell Choir piano duet by Connor and Colton
Christmas shopping is mostly done (thank God for Amazon) so now I have no more excuses to avoid study for the OB/Gyn shelf test on Tuesday. Well maybe one more.... The boys have requested that the four of us go see the new movie Aragorn based on one of their favorite books. That would be a priority over a pass/fail test any day.
OB/Gyn done!
Well it's been an interesting two weeks. The first week (two weeks ago) was gynecological surgery. It was a fairly easy week, not at all the 6am to 6pm days we were told to expect. It was usually 7:30am to 3 or 4pm with even lighter days on Th and Fr when we only had one long morning surgery each day.
I lucked out in that I was able to scrub for some unusual surgeries. For example, a laparoscopic sacral colpopexy was pretty cool to see. I usually just stood next to the First Assist cutting suture and suctioning blood. Occasionally I got to suture or staple when closing up the patient. But it was still very interesting and I learned a ton.
Last week was days on Labor & Delivery (L&D). The first two days were awful. Nothing happened at all. I got a lot of reading in, but could have done that without the hour plus commute to Desert Banner. Wednesday picked up a lot and was attended by my favorite teacher during the rotation, Dr. Mourad. I had three deliveries and I caught the baby on each one. On the third I was pretty self-sufficient and just needed a little help repairing a couple small tears. It was amazing to see how much better moms push without epidurals. While it is more painful, the moms sure get through the whole process much more quickly. I also got in one C-section with Dr. Mourad where he even let me cauterize some with the bovey. The most amazing thing was that we delivered a healthy (Apgars 7 @ 1m and 8 @5m) 24 week old! The mom had been bleeding, had ruptured membranes and was on steroids for fetal lung development. It's hard to know how well the baby will do over the next few years, but the birth couldn't have gone better.
Fate then decided to play a role in my week. I realized that I lost my last car key in one of the goop bags for the three vaginal deliveries I handled. The nurses were great and helped me look everywhere else. If I had to feel through one garbage bag of used garments and bloody rags I might have considered it. But not three with no guarantee it was in any of them. So I did my Friday 24 hour shift on Wednesday. The bonus was that Dr. Mourad was the attending, it was a relatively easy night and this would allow me to see my boys first piano recital Friday night.
We had one more C-section that night, then I slept in one of the physician sleep rooms until Becky called me at 8am! I actually slept better and more hours than I had been getting at home. When the locksmith was late I called a local Honda dealership. Glad I did because even in 2000, Honda had electric chips in the keys at the locksmith would have had to replace every lock in the car. By 1:30pm I had two new keys and was $270 dollars lighter. I took the rest of the day off.
Friday was pretty uneventful. I make it in time to see observe one delivery which definitely wasn't as much fun after catching half a dozen babies myself. Then I scrubbed in on one C-section that was very messy. At one point we had at least five locking forceps closing squirting arteries. All three of us (surgeon, first assist and myself) were splattered in blood. My two hands were put to good use holding retractors, suction, bovey, etc. I felt fairly useful for a change.
I had a chance to scrub in a twins C-section, but decided to head home early to get ready for the recital. My attending actually encouraged me to go. I turned in my badges, said goodbye to the staff and got home well before traffic started.
I never did get over the dichotomy of old guys with tons of serious conditions and diseases last month at the VA and generally healthy young women having healthy babies this month. If it wasn't for the horrible hours, insane legal atmosphere, stratospheric malpractice insurance ($150k per year) and endless office hours staring at vaginal discharges OB/Gyn would be incredibly cool!
It was a rotation filled some incredible highs with a few great attendings. But it also some of the most mind numbing hours I had with awful attendings, who while good physicians, had no place dealings with students in any capacity. Now it's time to study for the shelf exam on Tuesday and get ready for the Holidays and my long two months in Toledo, OH.
I lucked out in that I was able to scrub for some unusual surgeries. For example, a laparoscopic sacral colpopexy was pretty cool to see. I usually just stood next to the First Assist cutting suture and suctioning blood. Occasionally I got to suture or staple when closing up the patient. But it was still very interesting and I learned a ton.
Last week was days on Labor & Delivery (L&D). The first two days were awful. Nothing happened at all. I got a lot of reading in, but could have done that without the hour plus commute to Desert Banner. Wednesday picked up a lot and was attended by my favorite teacher during the rotation, Dr. Mourad. I had three deliveries and I caught the baby on each one. On the third I was pretty self-sufficient and just needed a little help repairing a couple small tears. It was amazing to see how much better moms push without epidurals. While it is more painful, the moms sure get through the whole process much more quickly. I also got in one C-section with Dr. Mourad where he even let me cauterize some with the bovey. The most amazing thing was that we delivered a healthy (Apgars 7 @ 1m and 8 @5m) 24 week old! The mom had been bleeding, had ruptured membranes and was on steroids for fetal lung development. It's hard to know how well the baby will do over the next few years, but the birth couldn't have gone better.
Fate then decided to play a role in my week. I realized that I lost my last car key in one of the goop bags for the three vaginal deliveries I handled. The nurses were great and helped me look everywhere else. If I had to feel through one garbage bag of used garments and bloody rags I might have considered it. But not three with no guarantee it was in any of them. So I did my Friday 24 hour shift on Wednesday. The bonus was that Dr. Mourad was the attending, it was a relatively easy night and this would allow me to see my boys first piano recital Friday night.
We had one more C-section that night, then I slept in one of the physician sleep rooms until Becky called me at 8am! I actually slept better and more hours than I had been getting at home. When the locksmith was late I called a local Honda dealership. Glad I did because even in 2000, Honda had electric chips in the keys at the locksmith would have had to replace every lock in the car. By 1:30pm I had two new keys and was $270 dollars lighter. I took the rest of the day off.
Friday was pretty uneventful. I make it in time to see observe one delivery which definitely wasn't as much fun after catching half a dozen babies myself. Then I scrubbed in on one C-section that was very messy. At one point we had at least five locking forceps closing squirting arteries. All three of us (surgeon, first assist and myself) were splattered in blood. My two hands were put to good use holding retractors, suction, bovey, etc. I felt fairly useful for a change.
I had a chance to scrub in a twins C-section, but decided to head home early to get ready for the recital. My attending actually encouraged me to go. I turned in my badges, said goodbye to the staff and got home well before traffic started.
I never did get over the dichotomy of old guys with tons of serious conditions and diseases last month at the VA and generally healthy young women having healthy babies this month. If it wasn't for the horrible hours, insane legal atmosphere, stratospheric malpractice insurance ($150k per year) and endless office hours staring at vaginal discharges OB/Gyn would be incredibly cool!
It was a rotation filled some incredible highs with a few great attendings. But it also some of the most mind numbing hours I had with awful attendings, who while good physicians, had no place dealings with students in any capacity. Now it's time to study for the shelf exam on Tuesday and get ready for the Holidays and my long two months in Toledo, OH.
Saturday, December 02, 2006
Labor & Delivery Nights
The OB/Gyn office week was cut short by Thanksgiving. I don't think I missed that much and was able to study my rotation book during the family trip to San Diego for the Holiday.
Things changed a lot this week for Labor & Delivery nights. The first night, Monday 7pm to 7am, was with the worst attending I've been with yet. She was a decent Doc technically, but a stuck-up b**** to the nursing staff, a sourpuss to patients and non-existent as a preceptor. It was the worst rotation shift I had to that point. I had to chase her around and get my bearings of the busiest L & D ward in the SW USA! They deliver 8500+ babies a year at Banner Desert. So she was worthless, but I managed to pick up a few things on my own, watch a C-Section and attend a few deliveries.
Unfortunately I had her again on Thursday night (7pm - 7am). That night was dead so I read a lot and tried to stay out of her way so she could get her "precious" sleep. She didn't have the courtesy to let me know about the one delivery of the night on our service so I did absolutely nothing! That was just about my most worthless 12 hours in medical school and I had to stay up through the night for it.
Tuesday was much better. I scrubbed for two C-Sections and got to cut sutures, hold retractors, etc. I was a little more involved in deliveries and saw some interesting cases. Wednesday was even better with an awesome attending. He let me catch three babies, deliver the placentas and get even more involved in a C-Section. It was a tricky one with fibroids and a lot of bleeding so I learned a lot. Even though I was tired driving an hour and a half through Phoenix rush hour traffic at 7am, I felt awesome having helped with those deliveries. The downer is that I left at 7:10am and learned later that the attending lost a mom shortly afterwards when she bled to death from a placenta accreta. The baby was delivered at 8am, but the Code for the 28 yo mom was called at 11am. The entire staff was shaken up and I heard the attending took it really hard.
Thursday was the let-down I already mentioned, but Friday made up for it. I was with one of PPA's (Phoenix Paranetology Assoc) attendings and she was terrific. We were extremely busy and she didn't get any sleep, but she was still the most gracious attending I've seen at Banner yet. The nurses love her too. I read maybe two paragraphs the whole night but loved it. I caught three babies, wrote lots of notes and started to perform some sutures on my own to repair torn vaginal walls. I need a lot more practice on suturing and started working on my catching technique so I can do single-handed someday.
I learned that the Doc hardly gets to see the baby at all. You deliver his/her head, bulb suction the goop, rotate the shoulders, deliver the body and cradle him/her, clamp the cord, cut the cord and hand the baby off to mom or the nursery folk for a high risk case. You get a few seconds at most to look at the baby when s/he is usually covered with goop and still blue. Then, with amniotic fluid running down your leg, you get to stare at a new mom's privates for an hour or so trying to deliver her placenta and repair any lacerations while the nurses, parents and anyone else present enjoy the infant.
In fact, one of the babies I delivered last night was given a clinical diagnosis of Down's by the nurse that took him from me based on facial features alone. Neither my attending or I had time to notice any of the findings as we were dealing with the placenta, lacerations and cleaning mom up. Afterwards, we spoke to the visibly upset parents (dad had seen his son in the nursery when the nurse talked to him). The attending was great and I appreciated her bedside manner. We had the advantage of having a nurse nearby that had raised a 10 yo daughter with Down's. She talked to the family for quite awhile and gave them lots of information on support groups, web sites, etc. However, we warned the patients the chromosomal studies would take 10-14 days and the baby may be just fine. The weird thing is the baby had pericardial effusions (usually associated with a viral infection) and a level II ultrasound. None of the usual "soft" findings like missing nasal bones, thick nuchal fold, short femur, heart/GI problems, etc. showed up.
All in all a great week some of the highest highs and lowest lows I've experienced thusfar in med school. I can see the attraction of OB/Gyn for male and female Docs (healthy patients, procedural, gracious parents and continuity of care). It is something that I will definitely consider incorporating into a rural practice. But the concerns of uncontrolled hours, malpractice costs and legal liability are pretty discouraging. Two more weeks to go though and I have to study up on three Gyn surgeries on Monday.
My parting thought is remembering the rural IM/FM doc from Texas I met on a flight coming back from Seattle. He mentioned doing a crash C-Section in one hour and nine minutes. This is how long it took the ambulance he was in to get the 120 miles to the nearest hospital with L & D services. At this point I can't fathom ever having the courage, knowledge and skill to do that. As a classmate told me; "your knees get weak after an intense delivery" - with all the resources of one of the busiest L & D departments in the country a few feet away.
Things changed a lot this week for Labor & Delivery nights. The first night, Monday 7pm to 7am, was with the worst attending I've been with yet. She was a decent Doc technically, but a stuck-up b**** to the nursing staff, a sourpuss to patients and non-existent as a preceptor. It was the worst rotation shift I had to that point. I had to chase her around and get my bearings of the busiest L & D ward in the SW USA! They deliver 8500+ babies a year at Banner Desert. So she was worthless, but I managed to pick up a few things on my own, watch a C-Section and attend a few deliveries.
Unfortunately I had her again on Thursday night (7pm - 7am). That night was dead so I read a lot and tried to stay out of her way so she could get her "precious" sleep. She didn't have the courtesy to let me know about the one delivery of the night on our service so I did absolutely nothing! That was just about my most worthless 12 hours in medical school and I had to stay up through the night for it.
Tuesday was much better. I scrubbed for two C-Sections and got to cut sutures, hold retractors, etc. I was a little more involved in deliveries and saw some interesting cases. Wednesday was even better with an awesome attending. He let me catch three babies, deliver the placentas and get even more involved in a C-Section. It was a tricky one with fibroids and a lot of bleeding so I learned a lot. Even though I was tired driving an hour and a half through Phoenix rush hour traffic at 7am, I felt awesome having helped with those deliveries. The downer is that I left at 7:10am and learned later that the attending lost a mom shortly afterwards when she bled to death from a placenta accreta. The baby was delivered at 8am, but the Code for the 28 yo mom was called at 11am. The entire staff was shaken up and I heard the attending took it really hard.
Thursday was the let-down I already mentioned, but Friday made up for it. I was with one of PPA's (Phoenix Paranetology Assoc) attendings and she was terrific. We were extremely busy and she didn't get any sleep, but she was still the most gracious attending I've seen at Banner yet. The nurses love her too. I read maybe two paragraphs the whole night but loved it. I caught three babies, wrote lots of notes and started to perform some sutures on my own to repair torn vaginal walls. I need a lot more practice on suturing and started working on my catching technique so I can do single-handed someday.
I learned that the Doc hardly gets to see the baby at all. You deliver his/her head, bulb suction the goop, rotate the shoulders, deliver the body and cradle him/her, clamp the cord, cut the cord and hand the baby off to mom or the nursery folk for a high risk case. You get a few seconds at most to look at the baby when s/he is usually covered with goop and still blue. Then, with amniotic fluid running down your leg, you get to stare at a new mom's privates for an hour or so trying to deliver her placenta and repair any lacerations while the nurses, parents and anyone else present enjoy the infant.
In fact, one of the babies I delivered last night was given a clinical diagnosis of Down's by the nurse that took him from me based on facial features alone. Neither my attending or I had time to notice any of the findings as we were dealing with the placenta, lacerations and cleaning mom up. Afterwards, we spoke to the visibly upset parents (dad had seen his son in the nursery when the nurse talked to him). The attending was great and I appreciated her bedside manner. We had the advantage of having a nurse nearby that had raised a 10 yo daughter with Down's. She talked to the family for quite awhile and gave them lots of information on support groups, web sites, etc. However, we warned the patients the chromosomal studies would take 10-14 days and the baby may be just fine. The weird thing is the baby had pericardial effusions (usually associated with a viral infection) and a level II ultrasound. None of the usual "soft" findings like missing nasal bones, thick nuchal fold, short femur, heart/GI problems, etc. showed up.
All in all a great week some of the highest highs and lowest lows I've experienced thusfar in med school. I can see the attraction of OB/Gyn for male and female Docs (healthy patients, procedural, gracious parents and continuity of care). It is something that I will definitely consider incorporating into a rural practice. But the concerns of uncontrolled hours, malpractice costs and legal liability are pretty discouraging. Two more weeks to go though and I have to study up on three Gyn surgeries on Monday.
My parting thought is remembering the rural IM/FM doc from Texas I met on a flight coming back from Seattle. He mentioned doing a crash C-Section in one hour and nine minutes. This is how long it took the ambulance he was in to get the 120 miles to the nearest hospital with L & D services. At this point I can't fathom ever having the courage, knowledge and skill to do that. As a classmate told me; "your knees get weak after an intense delivery" - with all the resources of one of the busiest L & D departments in the country a few feet away.
Tuesday, November 21, 2006
Passed the Medicine Shelf!
Whew, that one was tough. I studied hard Sunday and last night. I was too burned out to study anymore at lunch today, but I don't think the study break hurt my score at all. I did ok passing by a decent margin.
After talking with several of my classmates, I'm pretty happy. It's scary when two other good students get completely different answers to the same questions! Bottom line, that one is over.
OB/Gyn started off a little rough. I had a headache yesterday from getting up at 5am; just not used to starting that early with a long commute and "first day on the job" anxiety. Then there was some confusion with ID cards and where we were supposed to be. Once I got to the office for outpatient Gyn I saw a bunch of patients: echo'd some fetuses, saw a couple cervix and even felt one way off to the patient's right attached to some large fibroids!
I'm hopeful that it's going to be a good month. But it's going to be a lot of work! And somehow I have to survive the awful commute. Hopefully my Kaplan MP3 lectures will settle me down and generate some value from all the hours in the car.
On the residency front, I've been getting some feedback that Ft. Collins is more expensive and yuppie than I realized with less procedural training than I am expecting. Then Ft. Wayne is supposed to be less expensive and even better than I have been reading. It sounds like residents do very well moonlighting, houses are cheap and the training is top notch. I'm glad I will be able to see firsthand what Ft. Wayne is like in April. And I hope to hear back from Ft. Collins on a rotation there in the Fall.
After talking with several of my classmates, I'm pretty happy. It's scary when two other good students get completely different answers to the same questions! Bottom line, that one is over.
OB/Gyn started off a little rough. I had a headache yesterday from getting up at 5am; just not used to starting that early with a long commute and "first day on the job" anxiety. Then there was some confusion with ID cards and where we were supposed to be. Once I got to the office for outpatient Gyn I saw a bunch of patients: echo'd some fetuses, saw a couple cervix and even felt one way off to the patient's right attached to some large fibroids!
I'm hopeful that it's going to be a good month. But it's going to be a lot of work! And somehow I have to survive the awful commute. Hopefully my Kaplan MP3 lectures will settle me down and generate some value from all the hours in the car.
On the residency front, I've been getting some feedback that Ft. Collins is more expensive and yuppie than I realized with less procedural training than I am expecting. Then Ft. Wayne is supposed to be less expensive and even better than I have been reading. It sounds like residents do very well moonlighting, houses are cheap and the training is top notch. I'm glad I will be able to see firsthand what Ft. Wayne is like in April. And I hope to hear back from Ft. Collins on a rotation there in the Fall.
Saturday, November 18, 2006
No More VA!
Well, at least no more VA for MSIII year. I hear they have a great CCU rotation, so I might be back next year. But Medicine there was more than enough time to convince me I could never work there for a living; it's depressing, bureaucratic and decrepid. Not enough to make up for the (mostly) good house staff.
The week ended with more than free time than I expected so I got in some reading and errands. I also finalized my rotations for the rest of the year. The only change from my last post is that I was able to line an audition rotation at my third choice, Ft. Wayne, IN. Since I'll have a lot of surgery under my belt by then, I hope to learn firsthand how much and how they teach family practice Docs procedures and minor surgeries (appies, C-sections, hernia repairs, etc.). I hope to make a weekend trip over to the Memorial program that Tucker is looking at and maybe one more in Indianapolis. Might as well cover my bases while I'm there. However, I'll have to rent a car somehow.
Last night was fun. We had an impromptu dinner with Tucker and his family here so it was a great time unwinding, comparing notes on rotations and joking around with the wives. It sounds like Banner Desert is going to be tough, but a great learning experience. I just have to survive the 5:30am commute to Mesa everyday for the month. Actually, the drive home with probably be the worst part. Lots of time to listen to lectures on my MP3 player.
I had hoped to spend most of today studying for the Medicine shelf on Tuesday, but I spent in until 10am (about 11 hours!) and then have spend the day doing busy work. Tonight Becky and I want to go see the new Bond film, so all my studying may have to come down to tomorrow. It's making me a bit nervous because Medicine is a huge body of knowledge. I have some "remembered questions" from upperclassmen, so I will have to focus on those and hope for the best.
I'm already dreading spending most of the first five months of 2007 away from home, the family and anywhere to swim. Oh, well time to take my HIPPA test for Banner Desert and make sure I'm ready for Monday so I can focus 100% on the Medicine shelf next month.
The week ended with more than free time than I expected so I got in some reading and errands. I also finalized my rotations for the rest of the year. The only change from my last post is that I was able to line an audition rotation at my third choice, Ft. Wayne, IN. Since I'll have a lot of surgery under my belt by then, I hope to learn firsthand how much and how they teach family practice Docs procedures and minor surgeries (appies, C-sections, hernia repairs, etc.). I hope to make a weekend trip over to the Memorial program that Tucker is looking at and maybe one more in Indianapolis. Might as well cover my bases while I'm there. However, I'll have to rent a car somehow.
Last night was fun. We had an impromptu dinner with Tucker and his family here so it was a great time unwinding, comparing notes on rotations and joking around with the wives. It sounds like Banner Desert is going to be tough, but a great learning experience. I just have to survive the 5:30am commute to Mesa everyday for the month. Actually, the drive home with probably be the worst part. Lots of time to listen to lectures on my MP3 player.
I had hoped to spend most of today studying for the Medicine shelf on Tuesday, but I spent in until 10am (about 11 hours!) and then have spend the day doing busy work. Tonight Becky and I want to go see the new Bond film, so all my studying may have to come down to tomorrow. It's making me a bit nervous because Medicine is a huge body of knowledge. I have some "remembered questions" from upperclassmen, so I will have to focus on those and hope for the best.
I'm already dreading spending most of the first five months of 2007 away from home, the family and anywhere to swim. Oh, well time to take my HIPPA test for Banner Desert and make sure I'm ready for Monday so I can focus 100% on the Medicine shelf next month.
Wednesday, November 15, 2006
Last Call at the VA
We just admitted our first patient of the evening. I already have two patients, so the other student is doing the H&P on him now. I'm just counting time by blogging a bit.
I think I finally have all my rotations for MSIII set up. I was up late last night doing paperwork, applications, etc. For January and February I will be in balmy Toledo, OH doing ER Peds and then Surgery with their respective residents. It will be two hard months, but I should learn a ton. Hopefully I can work my schedule such that I have at least two flights back home for a few days to see the family, depending on ticket prices.
In March I'm heading to Show Low, AZ for rural surgery. From everything I've heard, this should be an awesome rotation. Hopefully I can take my shelf test after this rotation so I have two months to learn the material and do lots of procedures firsthand. It's only 4 hours drive from home, so I can drive home every weekend.
April looks like an inpatient month at one of the John C. Lincoln hospitals. It's my elective, so I hope it's the hospital less than two miles from my house. If not, I might have to consider a preceptor rotation close to home. I'm going to need a break and time with the family after five hard rotations.
After that "easy" rotation, I will head back to Show Low, actually Snowflake, AZ, for a rural family rotation. Again, I've heard great things about it and been told I will fall in love with the place. By that time, Becky and the boys may want to come visit me for a mini-vacation. That's the last rotation of MSIII year, so I should be able to find some time to study for the third year final and my Step 2 set of Board tests.
Last night I even got around to filling out an application for an audition rotation to one of my first choice FP residency programs, Ft. Collins, CO. It might be a little early, but it shouldn't hurt to be eager and professional. I'm going to have to start calling my other top choices in UT and IN to try and line up rotations at them next Fall since neither offers online applications.
Well, time to go work-up some new admits to the VA...
I think I finally have all my rotations for MSIII set up. I was up late last night doing paperwork, applications, etc. For January and February I will be in balmy Toledo, OH doing ER Peds and then Surgery with their respective residents. It will be two hard months, but I should learn a ton. Hopefully I can work my schedule such that I have at least two flights back home for a few days to see the family, depending on ticket prices.
In March I'm heading to Show Low, AZ for rural surgery. From everything I've heard, this should be an awesome rotation. Hopefully I can take my shelf test after this rotation so I have two months to learn the material and do lots of procedures firsthand. It's only 4 hours drive from home, so I can drive home every weekend.
April looks like an inpatient month at one of the John C. Lincoln hospitals. It's my elective, so I hope it's the hospital less than two miles from my house. If not, I might have to consider a preceptor rotation close to home. I'm going to need a break and time with the family after five hard rotations.
After that "easy" rotation, I will head back to Show Low, actually Snowflake, AZ, for a rural family rotation. Again, I've heard great things about it and been told I will fall in love with the place. By that time, Becky and the boys may want to come visit me for a mini-vacation. That's the last rotation of MSIII year, so I should be able to find some time to study for the third year final and my Step 2 set of Board tests.
Last night I even got around to filling out an application for an audition rotation to one of my first choice FP residency programs, Ft. Collins, CO. It might be a little early, but it shouldn't hurt to be eager and professional. I'm going to have to start calling my other top choices in UT and IN to try and line up rotations at them next Fall since neither offers online applications.
Well, time to go work-up some new admits to the VA...
Sunday, November 12, 2006
One more week at the VA
The last two weeks have been educational, but it's been hard work. I'm finally getting the hang of H&Ps, the whole ward-based thing and the VA system. I think it's taken me a little longer than it should have because I had very complex patients that I've followed since about Day 1. Usually students handle 1-2 patients that are bread-and-butter cases. They take 3-4 hours to do a thorough physical exam, interview the patient, write it up in a History & Physical note and do the research for the assessment & plan (differential diagnoses, evidence-based care, studies supporters the plan, etc.). Whereas I've been generally doing SOAP (progress) notes on patients who have been here a long time with up to dozen problems, sometimes trying to juggle 6 patients as an MSIII. So my research has been cut pretty short.
Now we have a new Resident who is much more organized. She is giving us appropriate patients and managing logistics tightly. We can't talk to the interns until after morning rounds with the Attending so that they can get their notes in beforehand. We don't pick patients, they are assigned. Stuff like that.
I am actually looking forward to another IM rotation now that I'll have a much better idea how to manage my time and know what's expected. Plus I'd be smarter about working with Attendings. Our team's Attending is a bigwig and he can be pretty intimidating. But if you do the research, read up on your cases and listen to his didactics you can learn a ton.
My biggest time sink in the last week or so has been Maricopa County hospital screwing up my surgery rotation in January. I've had to scramble to find a new January rotation, and basically rearrange my rotation schedule in order to get a ward-based Peds rotation. I really feel I need the academic setting and resident team environment at least once for each core area.
After a zillion phone calls and another spreadsheet, I'm crossing my fingers that a program in Toledo comes through. Free housing, good residency program and a big hospital with lots of patient volume and interesting pathology. January my Peds rotation would be in the ER with Peds residents and February would be surgery in the general surgery residency program. If that works out, I'll still have a March rotation to play with before heading to Show Low, AZ for rural Family and Surgery for the last two four week rotations of MSIII year. Those should be great rotations where I get a lot more freedom to do stuff.
The other time sink has been preparing a PowerPoint case presentation for last Tuesday's small group didactics. My presentation went well enough that I tied for "the best" and have to present it to the whole class at the end of the year. I kind of over did it because I had a very interesting CHF case that really got me interested in Diastolic vs. Systolic HF, their relative mortalities and differences in medications. It's pretty current news so my supporting articles were very recent.
Last night the family and I met several of my classmates and their families on campus for dinner. It was fun playing volleyball with the kids while talking shop. OB/Gyn next sounds great month, but an awful commute and a lot of work, again. Everyone seems to be narrowing in on residency options and getting eager for school to be done with.
Feedback on my latest residency thoughts was very positive. Ft. Collins, CO and Ogden, UT are my two top choices atm. Once I get my MSIII rotations squared away, I need to schedule audition rotations at both of these places for next fall. I can't wait to check out the programs and talk to the current residents. I also want to see if it's really possible to have a couple procedure days a week in rural Family for minor surgeries like hernia repair, tubule ligations and C-sections. That feels like the key for an enjoyable Family career.
Now we have a new Resident who is much more organized. She is giving us appropriate patients and managing logistics tightly. We can't talk to the interns until after morning rounds with the Attending so that they can get their notes in beforehand. We don't pick patients, they are assigned. Stuff like that.
I am actually looking forward to another IM rotation now that I'll have a much better idea how to manage my time and know what's expected. Plus I'd be smarter about working with Attendings. Our team's Attending is a bigwig and he can be pretty intimidating. But if you do the research, read up on your cases and listen to his didactics you can learn a ton.
My biggest time sink in the last week or so has been Maricopa County hospital screwing up my surgery rotation in January. I've had to scramble to find a new January rotation, and basically rearrange my rotation schedule in order to get a ward-based Peds rotation. I really feel I need the academic setting and resident team environment at least once for each core area.
After a zillion phone calls and another spreadsheet, I'm crossing my fingers that a program in Toledo comes through. Free housing, good residency program and a big hospital with lots of patient volume and interesting pathology. January my Peds rotation would be in the ER with Peds residents and February would be surgery in the general surgery residency program. If that works out, I'll still have a March rotation to play with before heading to Show Low, AZ for rural Family and Surgery for the last two four week rotations of MSIII year. Those should be great rotations where I get a lot more freedom to do stuff.
The other time sink has been preparing a PowerPoint case presentation for last Tuesday's small group didactics. My presentation went well enough that I tied for "the best" and have to present it to the whole class at the end of the year. I kind of over did it because I had a very interesting CHF case that really got me interested in Diastolic vs. Systolic HF, their relative mortalities and differences in medications. It's pretty current news so my supporting articles were very recent.
Last night the family and I met several of my classmates and their families on campus for dinner. It was fun playing volleyball with the kids while talking shop. OB/Gyn next sounds great month, but an awful commute and a lot of work, again. Everyone seems to be narrowing in on residency options and getting eager for school to be done with.
Feedback on my latest residency thoughts was very positive. Ft. Collins, CO and Ogden, UT are my two top choices atm. Once I get my MSIII rotations squared away, I need to schedule audition rotations at both of these places for next fall. I can't wait to check out the programs and talk to the current residents. I also want to see if it's really possible to have a couple procedure days a week in rural Family for minor surgeries like hernia repair, tubule ligations and C-sections. That feels like the key for an enjoyable Family career.
Wednesday, November 01, 2006
Internal Medicine at the VA Hospital
Well I knew this would be a tough rotation, quite different from the pleasant ones so far. I'm getting to the VA between 6:30am and 7am to read the latest notes (reports, labs, procedures) on my existing patients. Then at 8am we have morning "rounds" which is just a meeting with all the attendings, residents and students. We go over a case in detail (all the DDx) then have a short lecture. The attendings may have some specifics for the group as whole that relate to the lecture topic.
From 9am to 10am, we have to finish seeing any patients we didn't get to before 8am and be ready to present them to our attending. Team meetings from 10am to 11am are a little intimidating because they are when you get pimped to death and it's your primary opportunity to shine in front of the Doc who will write your review and/or LOR.
After you sweat your way through that, it's another hour to do anything that came out of the attending's feedback, then get to work on your SOAP Notes for the day. Depending on the day, you can have new admits come in during this time which require a lot more work: a full physical exam; a detailed history; and a long H&P report.
Lunch for all the residents and students is usually provided by a drug rep. After the rep's 5 minute spiel, we have a lecture or a game of IM knowledge such as team jeopardy. The senior residents obviously dominate the latter, but even students sometimes get to dust of some tidbit we remember from Boards. My team won yesterday because one of our Podiatry students was on our team and she knew the derm symptoms for rheumatology diseases cold.
The afternoon is spent writing up progress notes, handling new patients, following procedures and trying to learn as much medicine about your patients as possible. I'm using WA Manual and UpToDate as my primary sources, but I sure wish it was easier to master this stuff. There's so much to know!
For example: the differential diagnoses, presentation of symptoms for each possible diagnosis, tests for each, accuracy of those, studies proving the accuracy of the tests, treatments, studies on efficacy of treatments, potential side effects/complications, etc.
And this patient population is VERY difficult! "Train wreck" has been used frequently. I have to present on a patient this Friday for Professor Rounds at the VA and then on campus next Tuesday on a typical patient. He was confused about meds and thus non compliant. Volume overload made him short of breath with pleural effusions. Then his pacemaker failed as we watched his EKG. Then before he could get transferred for pacemaker replacement he had an MI!
Of course, he also had diabetes, hypertension, CHF, CAD, stents, renal failure, neuropathy, ulcers, a previous stroke, and the list goes on. I was worried when we got him back after the pacer replacement that he also had in pneumonia, but that's one thing we have been lucky on so far.
It's really a wonder that more patients don't just keel over. The attendings and residents manage to keep them alive. Even when, as one patient told me this morning, they just want to go home and die due to the pain. Usually it's temporary and they aren't serious, but we certainly deal with those kind of issues and questions all the time.
The beneficial aspect of all this is I think I am learning a ton. The patients and the little tidbits I get from residents and attendings are important knowledge that should stick better having seen it in real life. Of course, I'm still supposed to be reading all the time, but a panic attack about residency a week or two ago has me staying up until 2am every night researching programs online instead of reading. I have less than nine months to start sending in applications!!!
And I had call on Saturday so I couldn't study last weekend. Now that my residency program spreadsheet is mostly done, I can focus more on the reading. I also need to hone my reporting skills. Our attending is a real stickler for detail. He is very bright and, in a nice way, can pretty hard on our sr. resident, two interns and two students including myself. Lives are at stake and he's training us to be competent so I appreciate his prodding and relentless pursuit of improvement and learning.
The new patient report, an H&P, is a very complex document, especially for these patients. Getting all the information is difficult enough from complex patients and electronic medical record system at the VA, but then there's researching the findings and the diseases processes and finally tieing everything together so there's no loose ends. Does every drug have an evidence-based purpose and do you know the study proving it? Is every abnormal electrolyte explained by your problems list and addressed by your plan? Is your plan, (tests, meds, procedures, etc.) have evidence to support it as being the most efficacious in terms of patient outcome and dollar value?
I'm pretty sure I don't want to go into medicine. This anal retentiveness for knowing every differential diagnosis, every bizarre disease and every new study that comes along to contradict current methods is a bit too cerebral for me. Reminds me of a lecturer in first year that summed up American medicine as; "make sure your patient dies with their electrolytes in balance". Too true! It makes you miss surgery where you just fix stuff. So I'm probably more committed to rural family practice than ever.
My residency research has cost me a lot of sleep, but I'm getting more comfortable about my options. Becky and I are looking pretty hard at procedure heavy programs in Colorado, Utah, Washington and some fallbacks in San Diego, Phoenix, Indiana, Montana and elsewhere. There's a lot to consider: OMM/DO acceptance, procedural training, operative training (hernias, appies, tonsils, etc.), trauma exposure, climate, patient volume (want 100+ logged scopes), pay, moonlighting, technology, call, cost of living, reputation, etc. I have pretty much excluded opposed programs. This is where there are multiple residency programs, so the Family guy admits a patient and then has to send them to specialists if there's any interesting pathology. As a rural Doc I won't be able to rely on specialists at my beck and call. Plus it's more interesting to handle those cases and do those procedures myself.
Finally, this spreadsheet may help me repair my rotation schedule. I just found out last week that my surgery paperwork for Maricopa County Hospital was needed within two months of scheduling my rotation, not two months of the start. So without telling me, they gave my January spot to someone else! Now I'm waiting to see if they come through with something else. In the meantime, I'm researching which of the programs I'm interested in that have MSIII rotations. All have MSIV "audition rotations" to check out potential applicants. Only some have Peds, Surgery and Family rotations that I need in the next few months. The downside is this is time away from the family, I will incur travel costs and it may put me in front of program directors when I'm not as well trained as they are expecting. The one upside I can see is that it will give me a chance to check out more programs. I really only have 2-3 audition rotations at the beginning of MSIV year.
More scrambling due to errors out of my control! Makes me long for owning my practice. Well, now that the sugar coma from last night's Halloween loot has worn off it's time for some sleep.
From 9am to 10am, we have to finish seeing any patients we didn't get to before 8am and be ready to present them to our attending. Team meetings from 10am to 11am are a little intimidating because they are when you get pimped to death and it's your primary opportunity to shine in front of the Doc who will write your review and/or LOR.
After you sweat your way through that, it's another hour to do anything that came out of the attending's feedback, then get to work on your SOAP Notes for the day. Depending on the day, you can have new admits come in during this time which require a lot more work: a full physical exam; a detailed history; and a long H&P report.
Lunch for all the residents and students is usually provided by a drug rep. After the rep's 5 minute spiel, we have a lecture or a game of IM knowledge such as team jeopardy. The senior residents obviously dominate the latter, but even students sometimes get to dust of some tidbit we remember from Boards. My team won yesterday because one of our Podiatry students was on our team and she knew the derm symptoms for rheumatology diseases cold.
The afternoon is spent writing up progress notes, handling new patients, following procedures and trying to learn as much medicine about your patients as possible. I'm using WA Manual and UpToDate as my primary sources, but I sure wish it was easier to master this stuff. There's so much to know!
For example: the differential diagnoses, presentation of symptoms for each possible diagnosis, tests for each, accuracy of those, studies proving the accuracy of the tests, treatments, studies on efficacy of treatments, potential side effects/complications, etc.
And this patient population is VERY difficult! "Train wreck" has been used frequently. I have to present on a patient this Friday for Professor Rounds at the VA and then on campus next Tuesday on a typical patient. He was confused about meds and thus non compliant. Volume overload made him short of breath with pleural effusions. Then his pacemaker failed as we watched his EKG. Then before he could get transferred for pacemaker replacement he had an MI!
Of course, he also had diabetes, hypertension, CHF, CAD, stents, renal failure, neuropathy, ulcers, a previous stroke, and the list goes on. I was worried when we got him back after the pacer replacement that he also had in pneumonia, but that's one thing we have been lucky on so far.
It's really a wonder that more patients don't just keel over. The attendings and residents manage to keep them alive. Even when, as one patient told me this morning, they just want to go home and die due to the pain. Usually it's temporary and they aren't serious, but we certainly deal with those kind of issues and questions all the time.
The beneficial aspect of all this is I think I am learning a ton. The patients and the little tidbits I get from residents and attendings are important knowledge that should stick better having seen it in real life. Of course, I'm still supposed to be reading all the time, but a panic attack about residency a week or two ago has me staying up until 2am every night researching programs online instead of reading. I have less than nine months to start sending in applications!!!
And I had call on Saturday so I couldn't study last weekend. Now that my residency program spreadsheet is mostly done, I can focus more on the reading. I also need to hone my reporting skills. Our attending is a real stickler for detail. He is very bright and, in a nice way, can pretty hard on our sr. resident, two interns and two students including myself. Lives are at stake and he's training us to be competent so I appreciate his prodding and relentless pursuit of improvement and learning.
The new patient report, an H&P, is a very complex document, especially for these patients. Getting all the information is difficult enough from complex patients and electronic medical record system at the VA, but then there's researching the findings and the diseases processes and finally tieing everything together so there's no loose ends. Does every drug have an evidence-based purpose and do you know the study proving it? Is every abnormal electrolyte explained by your problems list and addressed by your plan? Is your plan, (tests, meds, procedures, etc.) have evidence to support it as being the most efficacious in terms of patient outcome and dollar value?
I'm pretty sure I don't want to go into medicine. This anal retentiveness for knowing every differential diagnosis, every bizarre disease and every new study that comes along to contradict current methods is a bit too cerebral for me. Reminds me of a lecturer in first year that summed up American medicine as; "make sure your patient dies with their electrolytes in balance". Too true! It makes you miss surgery where you just fix stuff. So I'm probably more committed to rural family practice than ever.
My residency research has cost me a lot of sleep, but I'm getting more comfortable about my options. Becky and I are looking pretty hard at procedure heavy programs in Colorado, Utah, Washington and some fallbacks in San Diego, Phoenix, Indiana, Montana and elsewhere. There's a lot to consider: OMM/DO acceptance, procedural training, operative training (hernias, appies, tonsils, etc.), trauma exposure, climate, patient volume (want 100+ logged scopes), pay, moonlighting, technology, call, cost of living, reputation, etc. I have pretty much excluded opposed programs. This is where there are multiple residency programs, so the Family guy admits a patient and then has to send them to specialists if there's any interesting pathology. As a rural Doc I won't be able to rely on specialists at my beck and call. Plus it's more interesting to handle those cases and do those procedures myself.
Finally, this spreadsheet may help me repair my rotation schedule. I just found out last week that my surgery paperwork for Maricopa County Hospital was needed within two months of scheduling my rotation, not two months of the start. So without telling me, they gave my January spot to someone else! Now I'm waiting to see if they come through with something else. In the meantime, I'm researching which of the programs I'm interested in that have MSIII rotations. All have MSIV "audition rotations" to check out potential applicants. Only some have Peds, Surgery and Family rotations that I need in the next few months. The downside is this is time away from the family, I will incur travel costs and it may put me in front of program directors when I'm not as well trained as they are expecting. The one upside I can see is that it will give me a chance to check out more programs. I really only have 2-3 audition rotations at the beginning of MSIV year.
More scrambling due to errors out of my control! Makes me long for owning my practice. Well, now that the sugar coma from last night's Halloween loot has worn off it's time for some sleep.
Saturday, October 21, 2006
Finished Cardiology
Another rotation over and done with. It was a good one that I learned a lot from. As I've said before, the Docs at Cardiovascular Consultants are top notch.
The last week in the office was a lot more of the same except for one CABG I got to see at T-Bird. The patient was a 41 yo with CAD due to radiation therapy 10 years earlier for a large lymphoma. He had no other risk factors and no pertinent family history. I assumed that this would make the surgery and recovery easier for him. Only afterwards did I learn how wrong that idea is.
Opening the chest and harvesting the saphenous vein went well. The first graft even went pretty good with a not abnormally large drop in BP when the coronary artery was tied off before sewing in the graft. However, the second graft didn't go so smoothly. The surgeon kept talking with the anesthesiologist about BP, but as the second vessel was tied off the BP dropped over 30 seconds from about 110 systolic to under 30!! The surgeon started yelling and cussing, especially towards the anesthesiologist. As the nurses frantically rushed to set up the bypass machine and one prepped the defib paddles, the surgeon manually pumped the heart. The pumping kept the blood moving which finally enabled the anesthesiologist's meds (epi) to get back to the heart.
The BP finally returned and the surgeon apologized but asked me to move to the other end of the table so that the anesthesiologist wasn't distracted. The two docs explained that the problem wasn't really communication though. Younger CAD patients don't have time to build up collateral blood flow in the heart. So this BP drop is rare. The other interesting part of this surgery was that we found an additional (reminant) lymphoma on the left side of the chest above the heart. The surgeon wasn't able to remove because the phrenic nerve passed right through it. I don't think the patient wouldn't have appreciated a life with half his diaphragm paralyzed.
The rest of my time in the office was spent seeing spent, reading up on Cardio and watching a few stress tests with nuclear scans. The office staff was great and I got along great with the patients. But I missed not seeing any kids or healthy people.
Instead of continuing the previous week's great work-put regimen, I got very little sleep and couldn't stop thinking about residencies. I was up until 2am every night researching programs around the country, looking at other specialties and reading discussion threads on StudentDoctor.net. While the money in other specialties like Cardio is appealing, I'm even more convinced that Family Medicine is the right place for me. There's a few programs in the Northwest and Phoenix that look good, but the Midwest programs have the best pay and benefits. However, a few Colorado programs have a pretty unbeatable combination of teaching and lifestyle.
I have my list of program attributes and tons of book-marked sites. Becky is teasing to get going on my spreadsheets. And even bumped in Tucker this morning at the campus cafeteria and we ended up discussing our last rotations and residency searches for a couple hours. Seeing him and comparing notes was a great excuse to put off studying for my Cardio shelf test on Tuesday. If I had to choose today, I think Scottsdale Healthcare would be my first choice with a couple Colorado programs coming close behind. Becky and I are going to John C. Lincoln's residency program Open House this week, so that provide some additional insight on local programs and my decision process.
Lastly, I managed to return a few things last night and purchase a couple dress shirts and ties at Fashion Square (the only Nordstrom's in all of Phoenix!). It was more than I wanted to spend, but now I have several more interchangeable outfits for the clinics that look good with or without a tie.
The last week in the office was a lot more of the same except for one CABG I got to see at T-Bird. The patient was a 41 yo with CAD due to radiation therapy 10 years earlier for a large lymphoma. He had no other risk factors and no pertinent family history. I assumed that this would make the surgery and recovery easier for him. Only afterwards did I learn how wrong that idea is.
Opening the chest and harvesting the saphenous vein went well. The first graft even went pretty good with a not abnormally large drop in BP when the coronary artery was tied off before sewing in the graft. However, the second graft didn't go so smoothly. The surgeon kept talking with the anesthesiologist about BP, but as the second vessel was tied off the BP dropped over 30 seconds from about 110 systolic to under 30!! The surgeon started yelling and cussing, especially towards the anesthesiologist. As the nurses frantically rushed to set up the bypass machine and one prepped the defib paddles, the surgeon manually pumped the heart. The pumping kept the blood moving which finally enabled the anesthesiologist's meds (epi) to get back to the heart.
The BP finally returned and the surgeon apologized but asked me to move to the other end of the table so that the anesthesiologist wasn't distracted. The two docs explained that the problem wasn't really communication though. Younger CAD patients don't have time to build up collateral blood flow in the heart. So this BP drop is rare. The other interesting part of this surgery was that we found an additional (reminant) lymphoma on the left side of the chest above the heart. The surgeon wasn't able to remove because the phrenic nerve passed right through it. I don't think the patient wouldn't have appreciated a life with half his diaphragm paralyzed.
The rest of my time in the office was spent seeing spent, reading up on Cardio and watching a few stress tests with nuclear scans. The office staff was great and I got along great with the patients. But I missed not seeing any kids or healthy people.
Instead of continuing the previous week's great work-put regimen, I got very little sleep and couldn't stop thinking about residencies. I was up until 2am every night researching programs around the country, looking at other specialties and reading discussion threads on StudentDoctor.net. While the money in other specialties like Cardio is appealing, I'm even more convinced that Family Medicine is the right place for me. There's a few programs in the Northwest and Phoenix that look good, but the Midwest programs have the best pay and benefits. However, a few Colorado programs have a pretty unbeatable combination of teaching and lifestyle.
I have my list of program attributes and tons of book-marked sites. Becky is teasing to get going on my spreadsheets. And even bumped in Tucker this morning at the campus cafeteria and we ended up discussing our last rotations and residency searches for a couple hours. Seeing him and comparing notes was a great excuse to put off studying for my Cardio shelf test on Tuesday. If I had to choose today, I think Scottsdale Healthcare would be my first choice with a couple Colorado programs coming close behind. Becky and I are going to John C. Lincoln's residency program Open House this week, so that provide some additional insight on local programs and my decision process.
Lastly, I managed to return a few things last night and purchase a couple dress shirts and ties at Fashion Square (the only Nordstrom's in all of Phoenix!). It was more than I wanted to spend, but now I have several more interchangeable outfits for the clinics that look good with or without a tie.
Tuesday, October 10, 2006
Interesting weekend...
Saturday I finally got in some decent study hours. I went back to campus and owned a familiar study table in the cafeteria (my old study lounge one was take!). I took a break to see the boys' soccer game and get some lunch, but it felt good to cover some testable Cardiology material.
On the way home I picked up some pizza for the family and while waiting for it get cooked I decided to peek at the latest in bikes at the nearby cycle store. Well, I found a full carbon bike for $995! And it was a pretty nice one with Ultegra and 105 components, good geometry and a perfect fit for me. Well, I had been planning a getting a really nice bike for graduation, but why lose 18 months of incredible Phoenix biking weather? It was the last of 40 or so bikes at this price among four stores and while I was looking at it we got a call that someone at another store wanted it.
I had them hold it and went to talk to Becky and talk it over. Well, we decided that a little more debt wasn't going to break the bank (thank goodness for home appreciation) and the bike would a long overdue 40th B-day present for me. I also planned to get Becky some diamond earrings for her B-day on the 11th. We also decided to look into refinancing the home to pay for some long overdue improvements (fence, A/C, carpets, garage storage). I stayed up way too late looking at bike reviews, comparisons and deals on the Internet (Ebay, Craigslist, etc.) to make sure it was a good deal, and except for the wheels, which I'll have to replace soon, it was a great deal.
Sunday we cleaned house and did some chores. I picked up my new carbon bike at 11am after a thorough test ride and then patiently went grocery shopping with Becky. As soon as I got home I rode around the block with boys and then went a nice 20 miler or so that felt terrific. I can't wait to ride with folks from school or other locals now. Sunday night I did some more diamond shopping for Becky, but not before hearing that Julie is quitting her nanny job.
Becky's sister Julie has helped watch the kids for about two years now. But she wants to start her own career in Seattle and the boys are just about old enough to watch themselves for an hour here or there. It was coming, but the timing is more than a bit strange. So while I was bidding on Ebay today Becky was lining up childcare and school transportation in case Julie leaves soon.
Today was fine in the cardiology office. Not as exciting as the hospital, but I'm sure there's a lot learn in outpatient to. I went for a swim this evening and have spent the couple hours trying to finally finish the Gamma Knife paper I've been working on forever. The guilt was nagging at me for not completing it, plus Becky's mom has decided to stay with us for two weeks so I lose my office tomorrow!
We knew her brothers were coming for Becky's 40th, but Marge was a surprise. We are both pretty sure it's more to support Julie than to experience Becky's 40th. As usual I had no say in the matter, but now have to figure out how to function for the next two weeks of chaos.
On the way home I picked up some pizza for the family and while waiting for it get cooked I decided to peek at the latest in bikes at the nearby cycle store. Well, I found a full carbon bike for $995! And it was a pretty nice one with Ultegra and 105 components, good geometry and a perfect fit for me. Well, I had been planning a getting a really nice bike for graduation, but why lose 18 months of incredible Phoenix biking weather? It was the last of 40 or so bikes at this price among four stores and while I was looking at it we got a call that someone at another store wanted it.
I had them hold it and went to talk to Becky and talk it over. Well, we decided that a little more debt wasn't going to break the bank (thank goodness for home appreciation) and the bike would a long overdue 40th B-day present for me. I also planned to get Becky some diamond earrings for her B-day on the 11th. We also decided to look into refinancing the home to pay for some long overdue improvements (fence, A/C, carpets, garage storage). I stayed up way too late looking at bike reviews, comparisons and deals on the Internet (Ebay, Craigslist, etc.) to make sure it was a good deal, and except for the wheels, which I'll have to replace soon, it was a great deal.
Sunday we cleaned house and did some chores. I picked up my new carbon bike at 11am after a thorough test ride and then patiently went grocery shopping with Becky. As soon as I got home I rode around the block with boys and then went a nice 20 miler or so that felt terrific. I can't wait to ride with folks from school or other locals now. Sunday night I did some more diamond shopping for Becky, but not before hearing that Julie is quitting her nanny job.
Becky's sister Julie has helped watch the kids for about two years now. But she wants to start her own career in Seattle and the boys are just about old enough to watch themselves for an hour here or there. It was coming, but the timing is more than a bit strange. So while I was bidding on Ebay today Becky was lining up childcare and school transportation in case Julie leaves soon.
Today was fine in the cardiology office. Not as exciting as the hospital, but I'm sure there's a lot learn in outpatient to. I went for a swim this evening and have spent the couple hours trying to finally finish the Gamma Knife paper I've been working on forever. The guilt was nagging at me for not completing it, plus Becky's mom has decided to stay with us for two weeks so I lose my office tomorrow!
We knew her brothers were coming for Becky's 40th, but Marge was a surprise. We are both pretty sure it's more to support Julie than to experience Becky's 40th. As usual I had no say in the matter, but now have to figure out how to function for the next two weeks of chaos.
Saturday, October 07, 2006
Cardio Inpatient Done
The last two weeks have been much better than I expected. I am really enjoying the group I'm working with, Cardiovascular Consultants (CVC). And my "team" of preceptors are just outstanding. They have my admiration as professionals and teachers.
It's not that I've been sold on Cardiology myself, but I certainly appreciate what the Docs offer and what they do to earn a VERY nice living. They all spent seven to eight years in residency AFTER medical school. But in a pinch they can: handle a patient's overall medical needs; diagnose life threatening conditions invasively and non-invasively; and FIX many patients' heart short of an open-heart CABG surgery. It's not a bad job for those dedicated enough to get the training.
I haven't finished my logs, but in the past two weeks I've seen about thirty patients on my own. Half were new patients requiring H&Ps and half existing patients requiring Progress Notes. I reviewed the patients charts, questioned (the ones that could talk) and examined them, wrote up the notes and put them into the charts. That was most of my mornings.
Afternoons consisted of watching lots of procedures and revisiting patients and their charts with the cardiologists. The latter is where my education really took place. I learned the questions and examination tests I forgot. I received feedback on my notes, especially the Assessment and Plan sections where I'm still very uneducated. Some of my most noteworthy patients included:
1) Young mother of two who had her first pacemaker at 8 yrs old (congenital heart block) and needs a) leads from her first of three, non-functional pacer removed and b) a new Bi-ventricular pacer with ICD (defibrillation) capability installed.
2) A young man with Osteogenesis Imperfecta (blue sclera and lots of broken bones!) that had a frustratingly intermittent A-fib interfering with his job and lifestyle. Our EP (electrophysiologist) manipulated his heart very aggressively with drugs and four intravenous catheters but we still couldn't find any structural abnormalities.
3) A middle-aged female diabetic and smoker that had two CABGs (six vessels total) and an angioplasty (two stents).
4) Several older post-AMI patients with poor cardiac output (low EF) who needed complicated drug regimens complicated by conditions like ARF (acute renal failure), COPD and PVD (peripheral vascular disease). I learned what rhythm vs. rate control really means and its implications.
The procedures I got to see up close and personal included right and left heart catheterization, angioplasty, electrophysiology, defibrillation/conversion, stress testing, angiograms and echocardiology. The stress testing is noteworthy because if I do end up going rural Family that is something I will probably do in the office before sending patients to the "big city" cardiologist.
The procedures I would have liked to see include open heart CABG, stenting an AMI, balloon valvuloplasty and closure of intracardiac shunts like patent VSDs. Patti, the awesome NP I worked with a lot, is going to call me if one of our patients goes in for a CABG, so I still have a good shot to run across the street in the next two weeks and see one of those.
I even managed to maintain a life and get in some swimming. I just ordered an indoor trainer so I can watch Board review lectures while stationary biking a couple mornings a week. But that did get me a little envious of a couple of the cardiologists. Between patients they planned trips to Hawaii and Switzerland, traded notes on their Computrainer stationary bike sessions (on custom Trek Madones of course), discussed upcoming triathlons and offered advice on expensive cars, food, wine, etc. They definately live in a different socio-economic spot than I've been around.
My fear now is the next two weeks of outpatient cardiolgy in the office are going to be boring. I just hope that I can continue to improve on my charting and examination skills by seeing patients on my own followed by review and feedback.
It's not that I've been sold on Cardiology myself, but I certainly appreciate what the Docs offer and what they do to earn a VERY nice living. They all spent seven to eight years in residency AFTER medical school. But in a pinch they can: handle a patient's overall medical needs; diagnose life threatening conditions invasively and non-invasively; and FIX many patients' heart short of an open-heart CABG surgery. It's not a bad job for those dedicated enough to get the training.
I haven't finished my logs, but in the past two weeks I've seen about thirty patients on my own. Half were new patients requiring H&Ps and half existing patients requiring Progress Notes. I reviewed the patients charts, questioned (the ones that could talk) and examined them, wrote up the notes and put them into the charts. That was most of my mornings.
Afternoons consisted of watching lots of procedures and revisiting patients and their charts with the cardiologists. The latter is where my education really took place. I learned the questions and examination tests I forgot. I received feedback on my notes, especially the Assessment and Plan sections where I'm still very uneducated. Some of my most noteworthy patients included:
1) Young mother of two who had her first pacemaker at 8 yrs old (congenital heart block) and needs a) leads from her first of three, non-functional pacer removed and b) a new Bi-ventricular pacer with ICD (defibrillation) capability installed.
2) A young man with Osteogenesis Imperfecta (blue sclera and lots of broken bones!) that had a frustratingly intermittent A-fib interfering with his job and lifestyle. Our EP (electrophysiologist) manipulated his heart very aggressively with drugs and four intravenous catheters but we still couldn't find any structural abnormalities.
3) A middle-aged female diabetic and smoker that had two CABGs (six vessels total) and an angioplasty (two stents).
4) Several older post-AMI patients with poor cardiac output (low EF) who needed complicated drug regimens complicated by conditions like ARF (acute renal failure), COPD and PVD (peripheral vascular disease). I learned what rhythm vs. rate control really means and its implications.
The procedures I got to see up close and personal included right and left heart catheterization, angioplasty, electrophysiology, defibrillation/conversion, stress testing, angiograms and echocardiology. The stress testing is noteworthy because if I do end up going rural Family that is something I will probably do in the office before sending patients to the "big city" cardiologist.
The procedures I would have liked to see include open heart CABG, stenting an AMI, balloon valvuloplasty and closure of intracardiac shunts like patent VSDs. Patti, the awesome NP I worked with a lot, is going to call me if one of our patients goes in for a CABG, so I still have a good shot to run across the street in the next two weeks and see one of those.
I even managed to maintain a life and get in some swimming. I just ordered an indoor trainer so I can watch Board review lectures while stationary biking a couple mornings a week. But that did get me a little envious of a couple of the cardiologists. Between patients they planned trips to Hawaii and Switzerland, traded notes on their Computrainer stationary bike sessions (on custom Trek Madones of course), discussed upcoming triathlons and offered advice on expensive cars, food, wine, etc. They definately live in a different socio-economic spot than I've been around.
My fear now is the next two weeks of outpatient cardiolgy in the office are going to be boring. I just hope that I can continue to improve on my charting and examination skills by seeing patients on my own followed by review and feedback.
Sunday, October 01, 2006
Cardio Week One
The hospital isn't as addictive and cardiology isn't as specialized as I presumed. The hospital has it benefits, like lots of resources, but it is a large complex organism with some parts dysfunctional at any given time. And you rarely have any control over those parts.
Cardiology seems more like primary care for large percentage of the geriatric population with cardio problems. Internal medicine rounds our patients and QB's the other specialties, but it sure seems like we run the show on the majority of cases.
I'm still way too slow on H&Ps, but doing well as usual with the patients. My studying is better than previous rotations but still has room to improve. It's difficult this weekend because I'm at home watching the boys while Becky and her sister are in Spokane for their grandmother's 90 B-day.
The boys had a sleep-over Friday with a couple friends and secretly stayed up until about 3am. That made for a great Saturday morning and soccer game. Picking up their friends was kinda fun though because we "magic schoolbus" night at the boys' school. Connor's M&M model of planet earth was a big hit. I got to meet Colton's new buddy and his parents. We even discussed get togethers for them finally. We also cleared up some of the drama with Colton and Becca's long-term "relationship". They never even held hands, but "dated" for almost two years :-). Colton wasn't very nice with the break-up so Colton got some early lessons in polite social behavior and friendship.
He actually used a line from "50 ways to break up with your lover" on Becca and then ran away so Jacob could interrupt; "you're dumped!" Even in 3rd grade, the kids need to be nicer. Just as importantly many of us parents discussed where the 6th graders are going next year. Challenge Charter is only K-6 and deadlines for many of the best Junoir Highs are in December.
This morning the boys have in much better moods. We chores done relatively quickly and now I'm procrastinating from putting together (I hope) the final draft on my Gamma Knife paper for Matt. If Gigi got me the correct graphs and stats, I should be able to just plug them in. It will be so nice to get that off my table.
Parting thoughts on Cardiology. I like the Docs and job is pretty cool. But they do work hard and average about 8 years of residency. The payoff just isn't there for me. But I this is very good rotation and I'm going to learn a ton. I can't wait to see my first CABG operation.
Cardiology seems more like primary care for large percentage of the geriatric population with cardio problems. Internal medicine rounds our patients and QB's the other specialties, but it sure seems like we run the show on the majority of cases.
I'm still way too slow on H&Ps, but doing well as usual with the patients. My studying is better than previous rotations but still has room to improve. It's difficult this weekend because I'm at home watching the boys while Becky and her sister are in Spokane for their grandmother's 90 B-day.
The boys had a sleep-over Friday with a couple friends and secretly stayed up until about 3am. That made for a great Saturday morning and soccer game. Picking up their friends was kinda fun though because we "magic schoolbus" night at the boys' school. Connor's M&M model of planet earth was a big hit. I got to meet Colton's new buddy and his parents. We even discussed get togethers for them finally. We also cleared up some of the drama with Colton and Becca's long-term "relationship". They never even held hands, but "dated" for almost two years :-). Colton wasn't very nice with the break-up so Colton got some early lessons in polite social behavior and friendship.
He actually used a line from "50 ways to break up with your lover" on Becca and then ran away so Jacob could interrupt; "you're dumped!" Even in 3rd grade, the kids need to be nicer. Just as importantly many of us parents discussed where the 6th graders are going next year. Challenge Charter is only K-6 and deadlines for many of the best Junoir Highs are in December.
This morning the boys have in much better moods. We chores done relatively quickly and now I'm procrastinating from putting together (I hope) the final draft on my Gamma Knife paper for Matt. If Gigi got me the correct graphs and stats, I should be able to just plug them in. It will be so nice to get that off my table.
Parting thoughts on Cardiology. I like the Docs and job is pretty cool. But they do work hard and average about 8 years of residency. The payoff just isn't there for me. But I this is very good rotation and I'm going to learn a ton. I can't wait to see my first CABG operation.
Wednesday, September 27, 2006
First days in the hospital
Cardiology started by me getting assigned the first two weeks of this rotation in the hospital (inpatient) and the last two weeks at group's office across the street (outpatient). So the last three days have been my first experience seeing patients in the hospital setting.
It's been interesting and not nearly as intimidating as I expected. The H&P's are long and tedious, but I'm not as rushed as I probably will be next month on the Internal Medicine rotation. The first day I followed the group's Nurse Practitioner, two cardiologists and two intervention cardiologists around. I saw several patients, a couple catheterization/stent procedures and then a bunch of echocardiogram reviews at 6pm.
Yesterday was mostly didactics on campus, but I made it back to the hospital for some more stents and a nice meeting with one of the interventionists on establishing a gameplan for the rotation.
Today I started at 7am by seeing four patients myself and working (struggling) my way through Cardio Service progress notes that went into the patients' charts. Right after lunch I worked up a new patient and wrote a full H&P. That took about 2 hours. Finally, I rounded on about 15 patients including the ones I wrote up with my primary preceptor. He read my notes and seemed to like them! He also seemed to like my presentation of my H&P patient which was pretty complicated.
The hospital isn't as addicting as I imagined, nor is the cath lab. But I'm still having fun working as a team member, learning cardiology and integrating in the hospital environment. It will be great preparation for next month's rotation. I just hope I get some time to read and listen to lectures.
It's been interesting and not nearly as intimidating as I expected. The H&P's are long and tedious, but I'm not as rushed as I probably will be next month on the Internal Medicine rotation. The first day I followed the group's Nurse Practitioner, two cardiologists and two intervention cardiologists around. I saw several patients, a couple catheterization/stent procedures and then a bunch of echocardiogram reviews at 6pm.
Yesterday was mostly didactics on campus, but I made it back to the hospital for some more stents and a nice meeting with one of the interventionists on establishing a gameplan for the rotation.
Today I started at 7am by seeing four patients myself and working (struggling) my way through Cardio Service progress notes that went into the patients' charts. Right after lunch I worked up a new patient and wrote a full H&P. That took about 2 hours. Finally, I rounded on about 15 patients including the ones I wrote up with my primary preceptor. He read my notes and seemed to like them! He also seemed to like my presentation of my H&P patient which was pretty complicated.
The hospital isn't as addicting as I imagined, nor is the cath lab. But I'm still having fun working as a team member, learning cardiology and integrating in the hospital environment. It will be great preparation for next month's rotation. I just hope I get some time to read and listen to lectures.
Sunday, September 24, 2006
15th Anniversary
Just realized I totally forgot to mention my attempt to make up for working through our 15th Anniversary. Saturday the 16th (a day late) after I attended the OBEX osteopathic disciplinary board, Becky and I went on a date.
We had a really nice dinner at a quaint Scottsdale Americana restaurant. The seafood was excellent and the atmosphere was great. Prices weren't bad either. And Becky explained the background of a lot of the artwork. One of her former co-workers was the artist of some interesting and unique paintings covering most of the walls.
Finally we headed to our movie, Little Miss Sunshine. I thought is was excellent, but Becky laughed so hard she had tears through most of it. It was like National Lampoon's Vacation movies, but done right. The acting, script and story were really good. I can't remember the last time we saw a movie so good that we continued throwing one-liners from it back at eachother two days later.
Not hugely romantic, but we did have a great time. Now I have to start thinking ahead towards her big 4-0 B-day next month...
We had a really nice dinner at a quaint Scottsdale Americana restaurant. The seafood was excellent and the atmosphere was great. Prices weren't bad either. And Becky explained the background of a lot of the artwork. One of her former co-workers was the artist of some interesting and unique paintings covering most of the walls.
Finally we headed to our movie, Little Miss Sunshine. I thought is was excellent, but Becky laughed so hard she had tears through most of it. It was like National Lampoon's Vacation movies, but done right. The acting, script and story were really good. I can't remember the last time we saw a movie so good that we continued throwing one-liners from it back at eachother two days later.
Not hugely romantic, but we did have a great time. Now I have to start thinking ahead towards her big 4-0 B-day next month...
Friday, September 22, 2006
Third Rotation Down
Finished Urgent Care today without much fanfare. I suppose I got what I wanted out of this rotation, lots of basic Family Medicine, charting, SOAP notes and patient exposure. But I am a bit disappointed by the lack of procedures. I wonder if IM will be much more interesting in that aspect.
So just finished my Preceptor eval, my logs (ugh!) and now my Blog. And it made me think that if I had to do it over again, I might choose a more rural rotation where I was free to do more even if the volume of URIs, UTIs and rashes was less.
Dr. Weiler was decent preceptor. In my eval he gave high marks for patient communication (heck, I got a bunch of compliments) but "meets expectations" for most of the medicine categories. He said that "Exceeds" is a student who presents a case in a very organized fashion, lists the differential, the desired tests and the meds with dosages. In other words, an MSIV or something with prior clinical training. I realize that I need to spend a lot more time on my FP objectives and reading, but he and I agreed that I couldn't meet those expectations with essentially two weeks of clinical exposure under my belt (Psych and OMM not really relevant).
He also said my Cardiology preceptors, who are just on other side of Banner Thunderbird Hospital, are very good. So I'm looking forward to that. I managed to get some reading in this week on the subject and listened to a CD on heart/lung sounds.
On the personal front, we had some good ClinEd lectures on Tuesday. Tucker and I then had lunch and talked in theoretical terms about starting a practice together in White Salmon. Who knows where that will go, but it's fun to visualize running a rural partnership.
Outside of that, I'm not swimming or exercising enough and playing too much Oblivion. I'm in the process of signing up for some tutoring which will be a little spending dough and a good impetus to get me out of the house and studying/reviewing something.
Onto my fourth rotation...
So just finished my Preceptor eval, my logs (ugh!) and now my Blog. And it made me think that if I had to do it over again, I might choose a more rural rotation where I was free to do more even if the volume of URIs, UTIs and rashes was less.
Dr. Weiler was decent preceptor. In my eval he gave high marks for patient communication (heck, I got a bunch of compliments) but "meets expectations" for most of the medicine categories. He said that "Exceeds" is a student who presents a case in a very organized fashion, lists the differential, the desired tests and the meds with dosages. In other words, an MSIV or something with prior clinical training. I realize that I need to spend a lot more time on my FP objectives and reading, but he and I agreed that I couldn't meet those expectations with essentially two weeks of clinical exposure under my belt (Psych and OMM not really relevant).
He also said my Cardiology preceptors, who are just on other side of Banner Thunderbird Hospital, are very good. So I'm looking forward to that. I managed to get some reading in this week on the subject and listened to a CD on heart/lung sounds.
On the personal front, we had some good ClinEd lectures on Tuesday. Tucker and I then had lunch and talked in theoretical terms about starting a practice together in White Salmon. Who knows where that will go, but it's fun to visualize running a rural partnership.
Outside of that, I'm not swimming or exercising enough and playing too much Oblivion. I'm in the process of signing up for some tutoring which will be a little spending dough and a good impetus to get me out of the house and studying/reviewing something.
Onto my fourth rotation...
Sunday, September 17, 2006
OBEX and Urgent Care
Spent my 15th wedding anniversary Friday taking a 4-hour neonatal resuscitation class from 8 until noon at school. Then said hello to a bunch of my MSII friends, checked out Cardio books in the bookstore and headed to Cigna Urgent Care. I expected a wild evening with my Preceptor and hoped for a bunch of procedures. But it was slow night and I ended up getting home at 10pm instead of midnight. This was still long past Becky's 9pm bedtime.
Saturday Tucker and I car-pooled over to OBEX, the Osteopathic disciplinary board hearings. We are all required to spend a day there, and there was at least 25 of us from AZCOM. It was very interesting and I completely agree that every medical student should be required to attend. We saw malpractice, substance abuse and licensing issues mostly. But it was great to see how the process worked and where Docs fail in documentation, staff management, judgment, etc.
My MSII summer Preceptor, Dr. Steinway, was even the President presiding over the board. We ended a bit early at 1pm so he gave us a chance to ask a bunch of questions directly to the board. Overall, it was a very informative 5 hours.
My rotation is going pretty well. I haven't written in couple weeks because not too much has changed. My charting is getting much better according to the attendings, but that should be expected since I'm seeing 20+ patients a day. I haven't seen a lot of ER crisis stuff. But I'm getting good at the basics: URIs, UTIs, sprains & strains, abdominal pain, chronic pain, etc.
UC isn't something I would want to do as a career, but I do think I'm getting the experience I had hoped for, as well as skills that will pay off in upcoming rotations.
It's down to my last week. And I'm at the point where I'm comfortable getting the history and doing the physical. I miss a test or two (e.g. Homan's Sign, Rovsing's sign) but I'm not quite ready to make diagnoses and write orders/prescriptions yet. I generally have some ideas, but there's always something to factor in: pregnancy, DM, warfarin usage, etc.
Finally, I'm really interested in learning more about the Scottsdale Healthcare FP residency program. It's unapposed and highly regarded in the area. The kids could stay in schools with their friends and Becky could stay at her position with St.Mary's. So I have to do some networking to learn more about it. I've tried unsuccessfully to reach one of our Fellows there, but I hope I can meet some residents at an AzAFP Journal Club. I met a bunch of local IM residents at their ACP Journal Club and was told its pretty similar with the AzAFP, but we'll see.
Oops, I have to mention that I'm not doing near enough studying. The boys and I went in together and got an Xbox 360, so I'm way behind on the objectives for Family and now it's time to bone up on Cardiology! Luckily Pass/Fail is very low stress compared to MSI & MSII :-).
Saturday Tucker and I car-pooled over to OBEX, the Osteopathic disciplinary board hearings. We are all required to spend a day there, and there was at least 25 of us from AZCOM. It was very interesting and I completely agree that every medical student should be required to attend. We saw malpractice, substance abuse and licensing issues mostly. But it was great to see how the process worked and where Docs fail in documentation, staff management, judgment, etc.
My MSII summer Preceptor, Dr. Steinway, was even the President presiding over the board. We ended a bit early at 1pm so he gave us a chance to ask a bunch of questions directly to the board. Overall, it was a very informative 5 hours.
My rotation is going pretty well. I haven't written in couple weeks because not too much has changed. My charting is getting much better according to the attendings, but that should be expected since I'm seeing 20+ patients a day. I haven't seen a lot of ER crisis stuff. But I'm getting good at the basics: URIs, UTIs, sprains & strains, abdominal pain, chronic pain, etc.
UC isn't something I would want to do as a career, but I do think I'm getting the experience I had hoped for, as well as skills that will pay off in upcoming rotations.
It's down to my last week. And I'm at the point where I'm comfortable getting the history and doing the physical. I miss a test or two (e.g. Homan's Sign, Rovsing's sign) but I'm not quite ready to make diagnoses and write orders/prescriptions yet. I generally have some ideas, but there's always something to factor in: pregnancy, DM, warfarin usage, etc.
Finally, I'm really interested in learning more about the Scottsdale Healthcare FP residency program. It's unapposed and highly regarded in the area. The kids could stay in schools with their friends and Becky could stay at her position with St.Mary's. So I have to do some networking to learn more about it. I've tried unsuccessfully to reach one of our Fellows there, but I hope I can meet some residents at an AzAFP Journal Club. I met a bunch of local IM residents at their ACP Journal Club and was told its pretty similar with the AzAFP, but we'll see.
Oops, I have to mention that I'm not doing near enough studying. The boys and I went in together and got an Xbox 360, so I'm way behind on the objectives for Family and now it's time to bone up on Cardiology! Luckily Pass/Fail is very low stress compared to MSI & MSII :-).
Thursday, August 31, 2006
Urgent Care
So far my first week in Urgent Care is going pretty well. I would have liked more procedures, but I did get to remove some stitches and help remove a FB (foreign body) from a guy's eye.
The docs that work there are more laid back than I expected. They really like their freetime and typically only work about 32 hours a week, with no call, swing shift or the stress of the ER.
They are also pretty knowledgeable about medicine. I'm getting MUCH better at my charting and learning a fair amount along the way. Once I get done reading Problem-based Microbiology (a great book!) I need to focus more on the medicine: start reading Step-up to Medicine and watching the Kaplan Step 2 videos again. However, all of this is slightly delayed now that the boys and I just purchased a used Xbox 360. The newness of it will wear off on me, but I need to give a few days.
Until then, I'm going to be working through a nasty viral URI and seeing tons of patients in a great setting for learning.
The docs that work there are more laid back than I expected. They really like their freetime and typically only work about 32 hours a week, with no call, swing shift or the stress of the ER.
They are also pretty knowledgeable about medicine. I'm getting MUCH better at my charting and learning a fair amount along the way. Once I get done reading Problem-based Microbiology (a great book!) I need to focus more on the medicine: start reading Step-up to Medicine and watching the Kaplan Step 2 videos again. However, all of this is slightly delayed now that the boys and I just purchased a used Xbox 360. The newness of it will wear off on me, but I need to give a few days.
Until then, I'm going to be working through a nasty viral URI and seeing tons of patients in a great setting for learning.
Saturday, August 26, 2006
Mountains Beyond Mountains
The couple of weeks I've had some free time. So I watched the 2nd season of Sopranos (terrific) and read some. After finishing Hostile Takeover and a bunch of magazines, I read Tracy Kidder's Mountains Beyond Mountains.
It's a fantastic book with great prose and an in depth study into a fascinating character. Paul Farmer is a Harvard MD who has battled TB in Haiti and Peru for most of his life. He is brilliant and willing to endure a lifestyle most people would call torture, but he's been very effective.
It has added even more appeal to running my own rural practice. Becky and I are now seriously considering staying in Phoenix for residency then heading to the Northwest after Connor graduates from High School. If she gets a promotion as has been discussed it will be even more appealing. I'll have one extra year to start practicing after residency or to finish a fellowship. Scottsdale Healthcare seems to have the best program, but I can't rotate there until 4th year. So for now, I'm putting out feelers and doing as much research as I can online.
The biggest obstacle is that Colton, Mr. Social, would have to move from a suburban High School before Junior year to a rural one. He wouldn't have his brother around, and I'd be pretty busy trying to start my practice or get a handle on one I purchase.
To hedge my bets, I'd like to learn procedures that are useful in both suburban and rural areas like OMM and Derm. GI and OB stuff are probably more suited to rural areas due to insurance and malpractice risk. Well plenty of time to make those decisions. But not too soon to plan my last elective rotation of this year and start thinking of my MSIV schedule. In fact, I should check how soon I can schedule an audition rotation at Scottsdale Healthcare.
The two most inspirational medical books I've read are outstanding character studies about two of the most obsessed physicians ever. Robert Mee, a pediatric thoracic surgeon at the Cleveland Clinic and Paul Farmer, an infectious disease IM physician at Harvard and Haiti. It's good for us students to have some heroes.
It's a fantastic book with great prose and an in depth study into a fascinating character. Paul Farmer is a Harvard MD who has battled TB in Haiti and Peru for most of his life. He is brilliant and willing to endure a lifestyle most people would call torture, but he's been very effective.
It has added even more appeal to running my own rural practice. Becky and I are now seriously considering staying in Phoenix for residency then heading to the Northwest after Connor graduates from High School. If she gets a promotion as has been discussed it will be even more appealing. I'll have one extra year to start practicing after residency or to finish a fellowship. Scottsdale Healthcare seems to have the best program, but I can't rotate there until 4th year. So for now, I'm putting out feelers and doing as much research as I can online.
The biggest obstacle is that Colton, Mr. Social, would have to move from a suburban High School before Junior year to a rural one. He wouldn't have his brother around, and I'd be pretty busy trying to start my practice or get a handle on one I purchase.
To hedge my bets, I'd like to learn procedures that are useful in both suburban and rural areas like OMM and Derm. GI and OB stuff are probably more suited to rural areas due to insurance and malpractice risk. Well plenty of time to make those decisions. But not too soon to plan my last elective rotation of this year and start thinking of my MSIV schedule. In fact, I should check how soon I can schedule an audition rotation at Scottsdale Healthcare.
The two most inspirational medical books I've read are outstanding character studies about two of the most obsessed physicians ever. Robert Mee, a pediatric thoracic surgeon at the Cleveland Clinic and Paul Farmer, an infectious disease IM physician at Harvard and Haiti. It's good for us students to have some heroes.
Finished second rotation
Yesterday was my last day with Dr. Will for my Family Practice/OMM rotation. The last two weeks I don't think the learning curve was quite as steep, but I honed some skills and really enjoyed getting to know patients.
The last two days were some of the most interesting medically. Thursday, on FP, I saw one of the worst movement disorders any of the physicians had ever seen. Worse, the patient's vocal cords were spasming making her voice and expressions look like something from the Poltergiest. She was nice, but a very complicated case. She'd had these symptoms for a year and a half with only Demerol (huge amounts!) for relief since she was allergic to 32 drugs! Plus she already on 15 for a dozen or so medical conditions like hypothyroidism, IBS, CAD, severe L3-L5 DJD, spondolysthesis, etc, Her husband was a perfect presentation of clinical depression. He obviously had no life other than treating his invalid wife.
It was my first time on rotation actually thinking if I could live in her condition. I can't imagine doing nothing about it for a year and a half. It almost seemed like she was trying to slowly do herself in with huge amounts of Demerol.
Friday at Dr. Will's OMM practice we saw two Arnold-Chiari cases! Both women had serious operations for spinal cord compression, but both were otherwise perfectly normal. Not at all like the Pathology slides I remember describing all the associated neurological conditions.
My review was excellent and I gave Dr. Will equally high marks. He really reminded me how FP can be noble as well as rewarding and fun. I don't expect next months' Urgent Care rotation will seem as attractive, but I hope I will have a chance to do more procedures and hone my patient charting.
Finally, I had a nice conversation with our Clinical Education Dept. Instead of scheduling my rural rotation later this year as an IM rotation like I had planned, I signed up for a rural FP rotation in Snowflake, AZ. It's supposed to be a great rotation with lots of patients, pathology and procedures (my "three P's"). Becky and I even bumped into a classmate at Costco who just finished the rotation yesterday. He spoke very highly of it. Sounds like a beautiful area only four hours away.
The last two days were some of the most interesting medically. Thursday, on FP, I saw one of the worst movement disorders any of the physicians had ever seen. Worse, the patient's vocal cords were spasming making her voice and expressions look like something from the Poltergiest. She was nice, but a very complicated case. She'd had these symptoms for a year and a half with only Demerol (huge amounts!) for relief since she was allergic to 32 drugs! Plus she already on 15 for a dozen or so medical conditions like hypothyroidism, IBS, CAD, severe L3-L5 DJD, spondolysthesis, etc, Her husband was a perfect presentation of clinical depression. He obviously had no life other than treating his invalid wife.
It was my first time on rotation actually thinking if I could live in her condition. I can't imagine doing nothing about it for a year and a half. It almost seemed like she was trying to slowly do herself in with huge amounts of Demerol.
Friday at Dr. Will's OMM practice we saw two Arnold-Chiari cases! Both women had serious operations for spinal cord compression, but both were otherwise perfectly normal. Not at all like the Pathology slides I remember describing all the associated neurological conditions.
My review was excellent and I gave Dr. Will equally high marks. He really reminded me how FP can be noble as well as rewarding and fun. I don't expect next months' Urgent Care rotation will seem as attractive, but I hope I will have a chance to do more procedures and hone my patient charting.
Finally, I had a nice conversation with our Clinical Education Dept. Instead of scheduling my rural rotation later this year as an IM rotation like I had planned, I signed up for a rural FP rotation in Snowflake, AZ. It's supposed to be a great rotation with lots of patients, pathology and procedures (my "three P's"). Becky and I even bumped into a classmate at Costco who just finished the rotation yesterday. He spoke very highly of it. Sounds like a beautiful area only four hours away.
Sunday, August 13, 2006
Dad's B-day
Last week ended well. Nothing major at the clinic, but I'm slowly gaining confidence with patients and learning how to treat patients with basic OMM solutions. If I go the FP route, OMM is looking more interesting than the OB fellowship at the moment. It's fun, but we'll see how I fell after getting back in the OR.
Becky had a good week. She learned that she is going to be groomed to be next in line at her work to run the place. While nothing is for certain, it is pretty exciting. I started asking around about FP residencies in the area and got a few ideas that I shared with Becky. We may just end up staying here for another 5+ years. That would be a surprise. But I think Becky would enjoy finally getting her chance to be called President :-).
This weekend, the family went to San Diego to see my father. It was the first time I've seen him since his stroke over three months ago. He is doing pretty well. His right hand is functional for only the most basic tasks, but he walks with very little limp and his face and voice are just about back to normal. Recover is slowing down which is hard on him I think. But he enjoyed seeing the boys for his 64th B-day.
My concern isn't so much about the stroke, but his underlying mycosis fungoides. It's not clear that his radiation treatment (TBI) really put it into remission. I don't know if his immune system is back to 100% after the stroke. It's frustrating not being able to do anything or have any ideas.
Being my first time back to S.D. since MSII started I also got to see the low-milage car he purchased eight months ago, an Infiniti G35. It was a blast to drive and is my favorite car at the moment. A very reasonably priced luxury car and a respectable doctor's car!
Going to be a busy week with the boys starting 3rd and 6th Grades tomorrow, so it's time to get some rest.
Becky had a good week. She learned that she is going to be groomed to be next in line at her work to run the place. While nothing is for certain, it is pretty exciting. I started asking around about FP residencies in the area and got a few ideas that I shared with Becky. We may just end up staying here for another 5+ years. That would be a surprise. But I think Becky would enjoy finally getting her chance to be called President :-).
This weekend, the family went to San Diego to see my father. It was the first time I've seen him since his stroke over three months ago. He is doing pretty well. His right hand is functional for only the most basic tasks, but he walks with very little limp and his face and voice are just about back to normal. Recover is slowing down which is hard on him I think. But he enjoyed seeing the boys for his 64th B-day.
My concern isn't so much about the stroke, but his underlying mycosis fungoides. It's not clear that his radiation treatment (TBI) really put it into remission. I don't know if his immune system is back to 100% after the stroke. It's frustrating not being able to do anything or have any ideas.
Being my first time back to S.D. since MSII started I also got to see the low-milage car he purchased eight months ago, an Infiniti G35. It was a blast to drive and is my favorite car at the moment. A very reasonably priced luxury car and a respectable doctor's car!
Going to be a busy week with the boys starting 3rd and 6th Grades tomorrow, so it's time to get some rest.
Tuesday, August 08, 2006
Family Practice routine
Life is pretty comfortable in this rotation. I work my hours, do a little reading at lunch and/or the evening. I go in an interview patients. Then I either discuss diagnosis and treatment (FP days) or start team manipulation (OMM days) with Dr. Will. I'm getting decent at charting and scripting and my OMM skills are definitely improving.
The rural family guy life is looking more and more attractive. It's not as prestigious or high paying as the more specialized or academic practices. But the freedom, hours, lifestyle and potential for procedures (especially in a rural town) sure sound better than struggling to get a competitive residency in some grimy East Coast town, working long hours for many years, then moving the family again to some expensive West Coast city where even a Doc's salary barely pays the mortgage. And then you have to deal with bureaucrats in the hospital or soap operas in partnerships.
It's probably time to dive into FP residency research. I also need to install Google Maps and do some fly-bys of Northwest rural areas and start to get some ideas of where the family would be happy.
Oh, the weekend was fun. Saturday I mowed, edged, pooper-scooped and blew the yard in 110 degree heat. After collapsing I relaxed most of the day until it was time to go see the Diamondbacks get spanked by the Astros (9-3). Clemens is still dangerous. It was an ok date night, but the sushi at Ra was horrible. We heard reviews that it was the best in Phoenix, but I thought it was slightly better than Costco!
Sunday we had Tucker and his family over for some 'real' salmon; King salmon caught wild. It was delicious - the tastiest fish in the world IMHO. And a far cry from the over-priced, dyed, farm salmon advertised as 'top shelf Atlantic salmon'. Yuck. Tucker and I also had some time to discuss residencies and practices in the Northwest. It was great to see his family, have great food and wine and then knock around ideas about the next five or so years with a fellow student.
The rural family guy life is looking more and more attractive. It's not as prestigious or high paying as the more specialized or academic practices. But the freedom, hours, lifestyle and potential for procedures (especially in a rural town) sure sound better than struggling to get a competitive residency in some grimy East Coast town, working long hours for many years, then moving the family again to some expensive West Coast city where even a Doc's salary barely pays the mortgage. And then you have to deal with bureaucrats in the hospital or soap operas in partnerships.
It's probably time to dive into FP residency research. I also need to install Google Maps and do some fly-bys of Northwest rural areas and start to get some ideas of where the family would be happy.
Oh, the weekend was fun. Saturday I mowed, edged, pooper-scooped and blew the yard in 110 degree heat. After collapsing I relaxed most of the day until it was time to go see the Diamondbacks get spanked by the Astros (9-3). Clemens is still dangerous. It was an ok date night, but the sushi at Ra was horrible. We heard reviews that it was the best in Phoenix, but I thought it was slightly better than Costco!
Sunday we had Tucker and his family over for some 'real' salmon; King salmon caught wild. It was delicious - the tastiest fish in the world IMHO. And a far cry from the over-priced, dyed, farm salmon advertised as 'top shelf Atlantic salmon'. Yuck. Tucker and I also had some time to discuss residencies and practices in the Northwest. It was great to see his family, have great food and wine and then knock around ideas about the next five or so years with a fellow student.
Friday, August 04, 2006
First Week of Family
Like I said yesterday, Family is looking pretty good. And if you keep up the OMM, you can always build up your patient base to do OMM full-time and increase your income $20-$50k per year from reduced insurance and overhead. In a rural environment, that wouldn't be too shabby. I could even take two hour lunches to get in a good swim or bike workout if there's no hospital bureaucrat babysitting.
Oh, got do to my first nerve block today. Injected some anesthetic into a patient's SI joint. Other than that, it was Fibromyalgia day. Lots of soft tissue OMM with myofascial release and counterstrain. Like asthma, there's a huge variation in severity, so some patients winced at the lightest touch while others handled muscle energy without any complaints. As you'd expect, these patients were using a fair amount of psychiatry drugs, so it was a little review from my last rotation.
Another weekend of chores, playing with the kids and cleaning up - but no studying for a Monday morning test!
Oh, got do to my first nerve block today. Injected some anesthetic into a patient's SI joint. Other than that, it was Fibromyalgia day. Lots of soft tissue OMM with myofascial release and counterstrain. Like asthma, there's a huge variation in severity, so some patients winced at the lightest touch while others handled muscle energy without any complaints. As you'd expect, these patients were using a fair amount of psychiatry drugs, so it was a little review from my last rotation.
Another weekend of chores, playing with the kids and cleaning up - but no studying for a Monday morning test!
Thursday, August 03, 2006
Day four and Family looks pretty good
It's weird, but I'm really starting to enjoy the pace of Family Practice. Maybe it's the way Dr. Will runs his practice, but it doesn't feel like the treadmill I've seen from preceptors in the past. There's little rushing around, and the OMM days are a great break from medicine; you get to work with your hands on patients over 30 minutes so it's very relaxing. And frequently it's very rewarding. I've seen patients come back with long-lasting improvement after no benefit from chiropractors, orthopods or pain management folks.
We are even getting MD residents from Mayo and Good Sam that will be training at the clinic for 6 months. The result with be more acceptance of manual medicine in the Allopathic world and more rotations for us at those institutions.
Today I also had a chance to treat one of our science professors. It was a little weird and really reminded me to pay attention to patient privacy.
Finally, I'm starting to feel more like a doc all the time. I'm going in and working up patients myself, charting them and then writing up the scripts. I'm learning a lot but more importantly, I'm getting comfortable with the role as the Doc.
We are even getting MD residents from Mayo and Good Sam that will be training at the clinic for 6 months. The result with be more acceptance of manual medicine in the Allopathic world and more rotations for us at those institutions.
Today I also had a chance to treat one of our science professors. It was a little weird and really reminded me to pay attention to patient privacy.
Finally, I'm starting to feel more like a doc all the time. I'm going in and working up patients myself, charting them and then writing up the scripts. I'm learning a lot but more importantly, I'm getting comfortable with the role as the Doc.
Wednesday, August 02, 2006
Starting OMM
Day 1
Monday my Preceptor spends at the campus clinic doing OMM. So I got to shake off the rust and do some muscle energy, counterstrain and myofascial release techniques. I even hit a couple HVLAs on the first try! It was fun and Dr. Will seemed very willing to let me talk to patients alone, chart stuff, do OMM, etc. It looks like I'll be doing injections soon for nerve blocks.
The only downside to the day was auto repairs. New minivan tires and our new 'pre-owned' Sante Fe had blown a timing belt. I even enjoyed having a homework assignment to read up on Fibromyalgia, which is about 20% of Dr. Will's OMM patients. I had absolutely zero stress about the next day's Psychiatry shelf exam which was a nice change. Gotta love Pass-Fail.
Day 2
Tuesday I had large and small group didactic group lectures in the morning. It was really nice to see many of my classmates again and catch-up on everyone's first rotation. I was also surprised by some USMLE scores. A few people scored really high like Tucker, but many scored below my expectations. At lunch I finally did a little studying for the Psych test, but I relied on my drug charts and FirstAid for Psychiatry totally. I just don't like our Prof's notes at all. I think I did very well on the test. It was even easier than already low expectations.
After biting the bullet on the car and agreeing to $1300 for the timing belt and related damage, I headed to the clinic. On Tuesdays, Dr. Will works on the family practice side of the clinic. I made it in time to see a few patients myself and practice some physical exam skills (shaking off more rust). I hope I can do whole physicals and blood draws soon, but I got a taste of it. Tonight's homework was Metabolic Syndrome and I was pleasantly surprised to find the best info on it in my PDA version of Ferri's Guide, not Harrison's, Robbin's or Netter's.
Monday my Preceptor spends at the campus clinic doing OMM. So I got to shake off the rust and do some muscle energy, counterstrain and myofascial release techniques. I even hit a couple HVLAs on the first try! It was fun and Dr. Will seemed very willing to let me talk to patients alone, chart stuff, do OMM, etc. It looks like I'll be doing injections soon for nerve blocks.
The only downside to the day was auto repairs. New minivan tires and our new 'pre-owned' Sante Fe had blown a timing belt. I even enjoyed having a homework assignment to read up on Fibromyalgia, which is about 20% of Dr. Will's OMM patients. I had absolutely zero stress about the next day's Psychiatry shelf exam which was a nice change. Gotta love Pass-Fail.
Day 2
Tuesday I had large and small group didactic group lectures in the morning. It was really nice to see many of my classmates again and catch-up on everyone's first rotation. I was also surprised by some USMLE scores. A few people scored really high like Tucker, but many scored below my expectations. At lunch I finally did a little studying for the Psych test, but I relied on my drug charts and FirstAid for Psychiatry totally. I just don't like our Prof's notes at all. I think I did very well on the test. It was even easier than already low expectations.
After biting the bullet on the car and agreeing to $1300 for the timing belt and related damage, I headed to the clinic. On Tuesdays, Dr. Will works on the family practice side of the clinic. I made it in time to see a few patients myself and practice some physical exam skills (shaking off more rust). I hope I can do whole physicals and blood draws soon, but I got a taste of it. Tonight's homework was Metabolic Syndrome and I was pleasantly surprised to find the best info on it in my PDA version of Ferri's Guide, not Harrison's, Robbin's or Netter's.
Back to Arizona
Colton's Party on Saturday was fun. We had a bigger group of relatives than I expected, and it made for a really fun day. I also had the chance to share of a little of my 'front line' experience with a cousin starting med school this year at the UW. Of course Colton got way more cash than any child should have, but what do you give a boy with everything (except that Xbox 360 we are making them save up for).
After everyone left, it was time to pack up for the trip back. Becky, Julie and the boys headed back early the next morning. I flew back in the afternoon to arrive in time to prepare for new rotation starting at 8am Monday morning. It ended up that the boys were a handful and the women decided to pull an all nighter anyway, but I did sleep better in my bed than I would have in the back of the van.
My flight was fine. I purchased a book called Hostile Takeover I heard about on NPR that is taking me further left and more in the middle than ever before. The book makes some well documented points that being fiscally conservative today is as much anti-Republican (i.e. anti-Big Business) as anti-Democrat. It highlighted three disappointments:
1) Bush has betrayed the Reagan Republicans and squandered his legacy
2) Bush has given in to Big Business more than anyone in recent memory, at great cost to Americans freedom, privacy, financial and military security
3) What the heck happened to the Contract With America?
Anyway, I certainly don't trust the Demos more. Giving in to the NEA, labor and big, centralized government is no better. Time to get off the soapbox...
I met an incredibly interesting Doc on the flight back. He was an Air Force fighter pilot for 23 years, got his MBA, started Med School and 48, then went on to get Boarded in IM and EM! He's 68 and working 24x7 (8 days off in the last year!) as the only physician in a rural 16 bed hospital. The nearest Doc is 120 miles away! He's done a ton of interesting procedures and is making a bundle. Not only does he have incredible energy for a 68 yo, he said that if he knew his hands would still be so good, he would have gone into surgery.
So now I have a couple more specialty ideas to add to the mix. I don't think that I've ever been this unfocused in my interests. Ah well, I've still got a year to figure it out.
I arrived to some very happy dogs and a very green pool. I had also learned that my brother and sister had finally married their significant others. My brother was in town picking up his stuff, so he and Miho stopped by to make dinner and hang out with me. Dan and I stayed up until 1am playing Xbox together and talking. It was fun, but left me feeling a little unprepared for my OMM rotation in the morning.
After everyone left, it was time to pack up for the trip back. Becky, Julie and the boys headed back early the next morning. I flew back in the afternoon to arrive in time to prepare for new rotation starting at 8am Monday morning. It ended up that the boys were a handful and the women decided to pull an all nighter anyway, but I did sleep better in my bed than I would have in the back of the van.
My flight was fine. I purchased a book called Hostile Takeover I heard about on NPR that is taking me further left and more in the middle than ever before. The book makes some well documented points that being fiscally conservative today is as much anti-Republican (i.e. anti-Big Business) as anti-Democrat. It highlighted three disappointments:
1) Bush has betrayed the Reagan Republicans and squandered his legacy
2) Bush has given in to Big Business more than anyone in recent memory, at great cost to Americans freedom, privacy, financial and military security
3) What the heck happened to the Contract With America?
Anyway, I certainly don't trust the Demos more. Giving in to the NEA, labor and big, centralized government is no better. Time to get off the soapbox...
I met an incredibly interesting Doc on the flight back. He was an Air Force fighter pilot for 23 years, got his MBA, started Med School and 48, then went on to get Boarded in IM and EM! He's 68 and working 24x7 (8 days off in the last year!) as the only physician in a rural 16 bed hospital. The nearest Doc is 120 miles away! He's done a ton of interesting procedures and is making a bundle. Not only does he have incredible energy for a 68 yo, he said that if he knew his hands would still be so good, he would have gone into surgery.
So now I have a couple more specialty ideas to add to the mix. I don't think that I've ever been this unfocused in my interests. Ah well, I've still got a year to figure it out.
I arrived to some very happy dogs and a very green pool. I had also learned that my brother and sister had finally married their significant others. My brother was in town picking up his stuff, so he and Miho stopped by to make dinner and hang out with me. Dan and I stayed up until 1am playing Xbox together and talking. It was fun, but left me feeling a little unprepared for my OMM rotation in the morning.
Saturday, July 29, 2006
Psychiatry Rotation Over
Thursday
The homeless clinic was pretty cool because I was able to conduct six new client evals. And the last one was one of the most interesting cases I've seen all month. He had lots of Axis II stuff going on, like Borderline and Histrionic. He wanted an excessive amount of meds, that someone had previously prescribed, and threatened that if he didn't get it he would wind up in jail as a sex offender which would be OK because then he could get some and quiet to finish writing his book. He also had a creepy of saying "sugar" and "honey" to the NP, weird gyrations and some very grandiose expressions. Oh, did I mention he had been in jail because a "kangaroo court" charged him with possession of folding stock tactical weapons? He made for a great finale to my psych rotation.
Friday
Well after a long two hour commute from Herron Island I finally found the community clinic where I worked with a PA all day. It was slower than we expected and a couple patients didn't want me in the room. But I did see a couple STDs, a pre-leukemia anemic patient and general check-ups. The PA and I ended up having a fair amount of time to talk about careers and such as well. The long commutes and Herron Island ferry rides also gave me time for career contemplation.
At this point, rural medicine is sounding pretty good. I've sure gotten positive feedback from Becky, family and all the Docs, NPs, PAs, etc. that I've talked to. It is a bit a of gamble, but what isn't? Finding a community to help with loans and start-up costs while being attractive enough for us and hiring staff may be a bit tricky but there are a lot of opportunities in the Northwest.
Herron Island
Becky and kids sure loved this place. The idea of living in a scenic, quiet place with lots nature around for the kids sure appealed to her. The boys loved exploring the beach with their cousins and soaking most of their clothes every day. They rode bikes, collected shells, hiked around the 1.5 mile wide island and just had a good time. Other than the long commute and my ribs not giving me much sleep on the beds we were provided with, I like it as well.
I can definitely envision being a country Doc driving a short distance to work in my SUV (so I can tow toys and make rural house calls), working for myself with a small staff and then enjoying bike riding, hikes with the dogs, cross country skiing, etc. The kids would miss suburban services like the YMCA and I might have to invest in a pool, but I think they enjoy there their high school years in this kind of environment. Schools though are probably the biggest question at this point.
At this point I need to reevaluate my elective rotation options at the end of the year. I would still like to check out HemeOnc, RadOnc, Rads, etc. but I might be better off with a rural FP rotation (someone who does some of the procedures I'm interested in like C-sections) and another IM rotation (rural if possible).
B-day
Today is Colton's B-day, so it's time for the big event here in WA with all the family and friends. Then packing and the flight back to AZ tomorrow. I'm already trying to mentally prepare for my FP/OMM rotation starting Monday. I think I'm going to need to study a lot more, including many hours of Kaplan Step 2 review lectures and reading Step-up for Medicine. Oh, and I really need to go over all the OMM I've forgotten to!
The homeless clinic was pretty cool because I was able to conduct six new client evals. And the last one was one of the most interesting cases I've seen all month. He had lots of Axis II stuff going on, like Borderline and Histrionic. He wanted an excessive amount of meds, that someone had previously prescribed, and threatened that if he didn't get it he would wind up in jail as a sex offender which would be OK because then he could get some and quiet to finish writing his book. He also had a creepy of saying "sugar" and "honey" to the NP, weird gyrations and some very grandiose expressions. Oh, did I mention he had been in jail because a "kangaroo court" charged him with possession of folding stock tactical weapons? He made for a great finale to my psych rotation.
Friday
Well after a long two hour commute from Herron Island I finally found the community clinic where I worked with a PA all day. It was slower than we expected and a couple patients didn't want me in the room. But I did see a couple STDs, a pre-leukemia anemic patient and general check-ups. The PA and I ended up having a fair amount of time to talk about careers and such as well. The long commutes and Herron Island ferry rides also gave me time for career contemplation.
At this point, rural medicine is sounding pretty good. I've sure gotten positive feedback from Becky, family and all the Docs, NPs, PAs, etc. that I've talked to. It is a bit a of gamble, but what isn't? Finding a community to help with loans and start-up costs while being attractive enough for us and hiring staff may be a bit tricky but there are a lot of opportunities in the Northwest.
Herron Island
Becky and kids sure loved this place. The idea of living in a scenic, quiet place with lots nature around for the kids sure appealed to her. The boys loved exploring the beach with their cousins and soaking most of their clothes every day. They rode bikes, collected shells, hiked around the 1.5 mile wide island and just had a good time. Other than the long commute and my ribs not giving me much sleep on the beds we were provided with, I like it as well.
I can definitely envision being a country Doc driving a short distance to work in my SUV (so I can tow toys and make rural house calls), working for myself with a small staff and then enjoying bike riding, hikes with the dogs, cross country skiing, etc. The kids would miss suburban services like the YMCA and I might have to invest in a pool, but I think they enjoy there their high school years in this kind of environment. Schools though are probably the biggest question at this point.
At this point I need to reevaluate my elective rotation options at the end of the year. I would still like to check out HemeOnc, RadOnc, Rads, etc. but I might be better off with a rural FP rotation (someone who does some of the procedures I'm interested in like C-sections) and another IM rotation (rural if possible).
B-day
Today is Colton's B-day, so it's time for the big event here in WA with all the family and friends. Then packing and the flight back to AZ tomorrow. I'm already trying to mentally prepare for my FP/OMM rotation starting Monday. I think I'm going to need to study a lot more, including many hours of Kaplan Step 2 review lectures and reading Step-up for Medicine. Oh, and I really need to go over all the OMM I've forgotten to!
Wednesday, July 26, 2006
Last day at Greater Lakes
I spent the morning visit a couple of the adult residences run by Greater Lakes. The way it seems to work is that a client gets picked up and sent to Western State or Puget Sound Mental Health. When they are stable they go to a managed facility like Seely Lake Lodge. Then to a more independent facility with little supervision. Anywhere along the way they can decompensate though and cycle back through the system.
Many clients are long-term patients with medication non-compliance and illicit drug use being the two most common causes. Meth (i.e. crystal meth) seems to be an epidemic around here. WA is by some reports the manufacturing capital of the world for meth, with some reservations in the area have evidence of production in over 25% of the homes!
Meth is just about the worst drug these providers have seen thusfar. It can kill you with the first dose (esp. with pre-existing heart problems). It is almost 100% addictive after the first dose. It is cheap and easy to make. Oh, and it has this wonderful effect of permanently creating psychoses in many users! Want schizophrenia, voices telling you to do stuff or the ability to empathize with vegetable matter? Just use Meth for awhile. Scary stuff for our society, but I'm sure there are newer chemicals just around the corner.
This afternoon I sat in on my first therapy session with an insurance client. Until now, clients have pretty much been Medicare or Medicaid patients. So she was very normal with some relationship issues and anxiety. Not to belittle these very real problems, but they seemed so miniscule compared to the permanently compromised individuals I've been seeing for three weeks now. It was a nice break and a chance to actually provide some input from my own personal experience.
Many clients are long-term patients with medication non-compliance and illicit drug use being the two most common causes. Meth (i.e. crystal meth) seems to be an epidemic around here. WA is by some reports the manufacturing capital of the world for meth, with some reservations in the area have evidence of production in over 25% of the homes!
Meth is just about the worst drug these providers have seen thusfar. It can kill you with the first dose (esp. with pre-existing heart problems). It is almost 100% addictive after the first dose. It is cheap and easy to make. Oh, and it has this wonderful effect of permanently creating psychoses in many users! Want schizophrenia, voices telling you to do stuff or the ability to empathize with vegetable matter? Just use Meth for awhile. Scary stuff for our society, but I'm sure there are newer chemicals just around the corner.
This afternoon I sat in on my first therapy session with an insurance client. Until now, clients have pretty much been Medicare or Medicaid patients. So she was very normal with some relationship issues and anxiety. Not to belittle these very real problems, but they seemed so miniscule compared to the permanently compromised individuals I've been seeing for three weeks now. It was a nice break and a chance to actually provide some input from my own personal experience.
Tuesday, July 25, 2006
Rotation Evals
Monday was pretty straightforward. I got to sit in on couple interesting therapy sessions that gave me some insight into family therapy. I don't feel like I've had much exposure to behavioral or cognitive therapy, but I now understand it better. The day ended early so I got to enjoy a little extra time playing with the boys.
Today was my last day with my official preceptor, Dr. Karakus. We saw some interesting patients, including the most interesting Borderline one I've seen to date. He was hearing "helpful", repeatedly trying to kill himself (but somehow surviving each time) and involved in intense relationships. The Doc and I also had some time to talk about our personal lives, the profession and my decision making process as far as residency goes.
She basically recommended the rural Doc route with some procedures to supplement my income. She doesn't have children, but her thought was that moving during the boys' high school educations wouldn't be too bad. In separate conversations later in the evening my father, brother and mother-in-law all agreed. I just don't know. Going 100% for RadOnc (my fav still) or IM with a fellowship in HemeOnc are still attractive. I sure hope a more solid direction develops over the next few months.
Dr. Karakus gave me top marks on the evaluation of course. I hope we can stay in contact.
Becky, Julie and the boys headed to Heron Island near Gig Harbor to hook up with Paul, Susie and their kids. I hope to meet up with them tomorrow night and Thursday night after work. It's only about an hour from Lakewood including the 7-minute ferry boat ride to the 1.5 mile wide island. Sounds like the place is beautiful and the kids are beachcombing through multiple sets of soaked clothes.
I also learned that my brother and sister got married over the weekend; Dan to his long-term on-again off-again fiance Hiroko and Joanne to "committed" partner and father of three of her four children.
Oh, I tried to do some lap swimming at the YMCA during a break but barely managed 1k yards. I could only kick or breast stroke without pain so bad I caught my breath. I'm pretty convinced that I'm experiencing my first cracked ribs, since bruising or inflammation would have lessened by now. Plus I know my swimming anatomy/biomechanics pretty well. I can't envision anything else producing sharp, focal pain on the costochondral margins of ribs 7, 8 and possibly 9. I still hurt with deep inspiration, valsalva maneuvers, blowing my nose or using my rectus abdominus muscles.
Today was my last day with my official preceptor, Dr. Karakus. We saw some interesting patients, including the most interesting Borderline one I've seen to date. He was hearing "helpful", repeatedly trying to kill himself (but somehow surviving each time) and involved in intense relationships. The Doc and I also had some time to talk about our personal lives, the profession and my decision making process as far as residency goes.
She basically recommended the rural Doc route with some procedures to supplement my income. She doesn't have children, but her thought was that moving during the boys' high school educations wouldn't be too bad. In separate conversations later in the evening my father, brother and mother-in-law all agreed. I just don't know. Going 100% for RadOnc (my fav still) or IM with a fellowship in HemeOnc are still attractive. I sure hope a more solid direction develops over the next few months.
Dr. Karakus gave me top marks on the evaluation of course. I hope we can stay in contact.
Becky, Julie and the boys headed to Heron Island near Gig Harbor to hook up with Paul, Susie and their kids. I hope to meet up with them tomorrow night and Thursday night after work. It's only about an hour from Lakewood including the 7-minute ferry boat ride to the 1.5 mile wide island. Sounds like the place is beautiful and the kids are beachcombing through multiple sets of soaked clothes.
I also learned that my brother and sister got married over the weekend; Dan to his long-term on-again off-again fiance Hiroko and Joanne to "committed" partner and father of three of her four children.
Oh, I tried to do some lap swimming at the YMCA during a break but barely managed 1k yards. I could only kick or breast stroke without pain so bad I caught my breath. I'm pretty convinced that I'm experiencing my first cracked ribs, since bruising or inflammation would have lessened by now. Plus I know my swimming anatomy/biomechanics pretty well. I can't envision anything else producing sharp, focal pain on the costochondral margins of ribs 7, 8 and possibly 9. I still hurt with deep inspiration, valsalva maneuvers, blowing my nose or using my rectus abdominus muscles.
Weekend on Lake Entiat
Lake Entiat is actually the Columbia River damned up in between Wenatchee and Chelan. Becky's older brother owns a vacation home in a planned community there and we were invited for an (almost annual) get together there over the weekend. So after a pretty normal Friday at Greater Lakes Mental Healthcare (and saying goodbye to Po), the boys and I headed to SeaTac to pick up Becky. Then the four of us made the 3 hour drive over the passes.
Saturday the boys had a great time intertubing with their cousins on a huge 4-person hotdog-in-a-bun shaped tube. I goofed around on it with Colton and Kyle and paid the price with a nasty fall at 30mph at we got whipped around a corner. The boys skipped like rocks while I slammed into the 'pavement'. At the time I thought I just had the wind knocked out and some bruises.
Later we did a little cliff jumping. Colton was ready to be a daredevil with his cousin . I felt up to helping him in the current and jumped off a 10-footer with them. But the that little dude then decided to jump off the 20 to 25 foot one! I was too sore for that, so I stayed below for a great view of 7 year old terror.
We then relaxed to some of Dave's great cooking, reading and generally hanging out while the kids played pingpong and video games.
Sunday Dave and I rode about 25 miles with a couple fun hills that proved how out of shape I still am. After breakfast we headed for the boat again and we greeted with some very smooth water. The wake boarding was great, but Colton was disappointed that he only got. He couldn't maintain his balance so he kept falling down until his hands were sore. Becky had almost the exact same experience (and it was her best progress to date to). Connor wasn't feeling well. Chills with the temperature over 105 isn't normal. He was also very disappointed that he was in no shape to keep up with his younger brother and cousin. I managed to get up on the wake board just fine, but Dave and Trish's new Boat's much larger wake was intimidating. After a couple successful toe-side turns I bit it good on my already sore ribs. At this point I starting think cracked ribs was a real possibility.
Kyle and Trish showed us some real wake boarding. Dave took a break from driving and had a bit of fun too. But Katie chose demonstrate knee boarding. By the end, the water was choppy and lunch called. Colton requested a last minute cliff dive and repeated his earlier performance. But not before Kyle tried to demo for him and got injured with a rough landing. Luckily it looked like he would only have a sore back for a day or two.
We ate lunch then napped and relaxed for the rest of the day until it was time to pack up and head back to Lakewood. Not a bad weekend mini-vacation for medical school.
Saturday the boys had a great time intertubing with their cousins on a huge 4-person hotdog-in-a-bun shaped tube. I goofed around on it with Colton and Kyle and paid the price with a nasty fall at 30mph at we got whipped around a corner. The boys skipped like rocks while I slammed into the 'pavement'. At the time I thought I just had the wind knocked out and some bruises.
Later we did a little cliff jumping. Colton was ready to be a daredevil with his cousin . I felt up to helping him in the current and jumped off a 10-footer with them. But the that little dude then decided to jump off the 20 to 25 foot one! I was too sore for that, so I stayed below for a great view of 7 year old terror.
We then relaxed to some of Dave's great cooking, reading and generally hanging out while the kids played pingpong and video games.
Sunday Dave and I rode about 25 miles with a couple fun hills that proved how out of shape I still am. After breakfast we headed for the boat again and we greeted with some very smooth water. The wake boarding was great, but Colton was disappointed that he only got. He couldn't maintain his balance so he kept falling down until his hands were sore. Becky had almost the exact same experience (and it was her best progress to date to). Connor wasn't feeling well. Chills with the temperature over 105 isn't normal. He was also very disappointed that he was in no shape to keep up with his younger brother and cousin. I managed to get up on the wake board just fine, but Dave and Trish's new Boat's much larger wake was intimidating. After a couple successful toe-side turns I bit it good on my already sore ribs. At this point I starting think cracked ribs was a real possibility.
Kyle and Trish showed us some real wake boarding. Dave took a break from driving and had a bit of fun too. But Katie chose demonstrate knee boarding. By the end, the water was choppy and lunch called. Colton requested a last minute cliff dive and repeated his earlier performance. But not before Kyle tried to demo for him and got injured with a rough landing. Luckily it looked like he would only have a sore back for a day or two.
We ate lunch then napped and relaxed for the rest of the day until it was time to pack up and head back to Lakewood. Not a bad weekend mini-vacation for medical school.
Thursday, July 20, 2006
Homeless Clinic
Today was a good today at the homeless clinic Greater Lakes Mental Healthcare is contracted to run (the Psych part). First, I saw one of the clients from last week. This Hispanic guy has symptomatic dilated cardiomyopathy at 42. I thought of Chaga's dz after the meeting last week, so I asked him where he's from. Nicaragua! So I immediately asked the PA I work with how we can order a bleed screen. I may have just made my first save :-).
I also got to run through several evaluations with new patients, including typing in all the notes. The ARNP (nurse practionerer) I'm working with changed a few things and then we agreed on medication plan. Pretty cool. Of there were some hard luck stories, but I hope we are helping them improve their lives.
The afternoon went kinda slow, so I worked with the PA on the medical side of the building and helped unpack and repack a nasty injection site abscess that was drained a couple days ago. I then got to inject lidocaine and cut open a guy's ear that had a large, nasty sebaceous cyst. He had "popped" out most of the gunk, so it was inflamed and refilled with mostly blood. A pretty messy hematoma, but a great experience for me. Looks like I'll be spending my last day of this rotation, next Friday, with the PA. Should be great!
Tomorrow is the last day for me to spend with NP I've been shadowing (the meds team lead) since he's on vacation next week. Hopefully I can get the rest of the week scheduled. Right after work it's off to the airport to pick up Becky. Then it's off to my brother-in-law's vacation house on the Columbia River, actually a portion of it that is damned up so it's basically a large water-ski lake in Eastern Washington.
I also got to run through several evaluations with new patients, including typing in all the notes. The ARNP (nurse practionerer) I'm working with changed a few things and then we agreed on medication plan. Pretty cool. Of there were some hard luck stories, but I hope we are helping them improve their lives.
The afternoon went kinda slow, so I worked with the PA on the medical side of the building and helped unpack and repack a nasty injection site abscess that was drained a couple days ago. I then got to inject lidocaine and cut open a guy's ear that had a large, nasty sebaceous cyst. He had "popped" out most of the gunk, so it was inflamed and refilled with mostly blood. A pretty messy hematoma, but a great experience for me. Looks like I'll be spending my last day of this rotation, next Friday, with the PA. Should be great!
Tomorrow is the last day for me to spend with NP I've been shadowing (the meds team lead) since he's on vacation next week. Hopefully I can get the rest of the week scheduled. Right after work it's off to the airport to pick up Becky. Then it's off to my brother-in-law's vacation house on the Columbia River, actually a portion of it that is damned up so it's basically a large water-ski lake in Eastern Washington.
Wednesday, July 19, 2006
USMLE Score
Last night Becky read my score to me over the phone. It's a decent score, but not quite as high as I hoped. It's high enough to get me into all but most competitive specialties and programs. It's also right about where I thought I'd end up, and interestingly about the same percentile as my GPA.
Given family responsibilities, a lack of recent science coursework and the number of really smart med students out there, I'm pretty happy to be at about the 80% mark. Not surprising, I was strongest on the conceptual stuff like Phys and weakest on the molecular, biochem, micro and immuo sections. The former two aren't taught as in depth at Osteopathic schools and the latter two were just taught horribly at our school. I studied the most in these areas knowing they were weak and memorization of obscure pathways isn't strong suit. But I always seem to do best (even with the least amount of studying) on the conceptual stuff. Once I have the map, table or shape/pattern in my brain, I can manipulate it as well as just about anybody.
Now it's the wait for my COMLEX score. It is no where near as important in my mind, but I need to pass it for my degree and it will be interesting how well the scores correlate.
Given family responsibilities, a lack of recent science coursework and the number of really smart med students out there, I'm pretty happy to be at about the 80% mark. Not surprising, I was strongest on the conceptual stuff like Phys and weakest on the molecular, biochem, micro and immuo sections. The former two aren't taught as in depth at Osteopathic schools and the latter two were just taught horribly at our school. I studied the most in these areas knowing they were weak and memorization of obscure pathways isn't strong suit. But I always seem to do best (even with the least amount of studying) on the conceptual stuff. Once I have the map, table or shape/pattern in my brain, I can manipulate it as well as just about anybody.
Now it's the wait for my COMLEX score. It is no where near as important in my mind, but I need to pass it for my degree and it will be interesting how well the scores correlate.
Experiences in Therapy
Today was fairly interesting. I spent the morning in the injection lab mosting talking with the nurse (a cool guy names Amos) about motorcycles, ATVs and fun outside of work. The weird was how normal these folks are when they stay on their Consta injections every 2 weeks. It's a pretty heavy antipsychotic, so they must need it. But you wouldn't pick them out of any crowd.
The afternoon was my first chance to sit in on some pure therapy sessions and a peds group session for boys 8-9 yrs old. It was nothing like the sterotypical Psychiatrist asking about childhood experiences or freudian analysis. Lots of basic coping skills and relationship tools. My last apt of the evening was with a charming, pretty girl who seemed just like any other teenager on the surface. However, she came from a traffic background and has fetal alcohol syndrome (she looked more like a model than the Path pictures of FAS that I remember). While she can't read or write well, she's made great strides in improving her self-confidence, independance, positive attitude and relationship boundries. You couldn't help but be charmed by her personality and strength of character given what she's been through.
Yesterday, I spent the day mostly talking meds with my Preceptor. Most of the cases were existing clients doing pretty well that needed minor adjustments to meds if anything. We also had a couple evaluations for new clients. These were like peeling the layers off the onion. Broken homes, distrustful relationships with guardians and poor anger management. Both cases ended up being diagnosed with ADHD and started on low dose Strattera. Definitely no quick fixes in most of these cases.
Back to the homeless shelter tomorrow...
The afternoon was my first chance to sit in on some pure therapy sessions and a peds group session for boys 8-9 yrs old. It was nothing like the sterotypical Psychiatrist asking about childhood experiences or freudian analysis. Lots of basic coping skills and relationship tools. My last apt of the evening was with a charming, pretty girl who seemed just like any other teenager on the surface. However, she came from a traffic background and has fetal alcohol syndrome (she looked more like a model than the Path pictures of FAS that I remember). While she can't read or write well, she's made great strides in improving her self-confidence, independance, positive attitude and relationship boundries. You couldn't help but be charmed by her personality and strength of character given what she's been through.
Yesterday, I spent the day mostly talking meds with my Preceptor. Most of the cases were existing clients doing pretty well that needed minor adjustments to meds if anything. We also had a couple evaluations for new clients. These were like peeling the layers off the onion. Broken homes, distrustful relationships with guardians and poor anger management. Both cases ended up being diagnosed with ADHD and started on low dose Strattera. Definitely no quick fixes in most of these cases.
Back to the homeless shelter tomorrow...
Monday, July 17, 2006
On a roll
Two days in a row! Actually not that much interesting happened today, but enough for a quick note.
I saw a real 'cutter' today. Her forearms were covered with more scar tissue than normal skin. One self-mutilation from a few days ago was still open, deep and oozing, but she kept mentioning how nicely it was closing up. Yikes.
I then spent the afternoon visiting several wards at Western State Hospital. That is one bizarre and gigantic place. There are thousands of 'clients' at that place and probably twice as many employees. I have a lot or respect for those people that go into that depressing environment everyday and try to manage that population. I'm realizing that I would rather deal with the terminally ill than the demented and delirious.
On the plus side, most of our clients that were willing to see us were very lucid and alert. A couple should be ready for discharge soon.
I saw a real 'cutter' today. Her forearms were covered with more scar tissue than normal skin. One self-mutilation from a few days ago was still open, deep and oozing, but she kept mentioning how nicely it was closing up. Yikes.
I then spent the afternoon visiting several wards at Western State Hospital. That is one bizarre and gigantic place. There are thousands of 'clients' at that place and probably twice as many employees. I have a lot or respect for those people that go into that depressing environment everyday and try to manage that population. I'm realizing that I would rather deal with the terminally ill than the demented and delirious.
On the plus side, most of our clients that were willing to see us were very lucid and alert. A couple should be ready for discharge soon.
Sunday, July 16, 2006
Psych halfway point
This Psych rotation is so different from what I expected. For starters:
-We have clients (not patients) and providers (not practionerers)
-Psych meds are much more complex than we learned and GPs generally don't do well in this area
-Nurse Practioners handle most of the outpatient Psych meds (I don't think it's just WA either)
-Psychologists handle most of the therapy
-It's 1% housewives seeking valium and 99% IVDAs needing antipsychotics (that's only a slight exaggeration)
-No couches
I only spend one day a week with my psychiatrist 'preceptor' but she's awesome. She's a German neurosurgeon turned psychiatrist after marrying a Turkish neurosurgeon and relocating here since neither one could speak the other's native tongue!
Then I typically spend one day a week with NPs on meds management; one with psychologists on therapy; one at a homeless shelter we're contracted to provide for; and one shadowing our liaison to visit clients at inpatient hospitals after they've been picked up for going off Meds or onto street drugs.
Peds is the most interesting and tragic part I've seen. One young man had a high fever requiring resuscitation that led to seizures at 10 and psychosis later. A family understandibly had the mom in counseling after three of her four kids acquired mental health issues and the father is an uninvolved soldier recently returned from Iraq. Being near Ft. Lewis, we get many less extreme cases related to the war in Iraq. Besides PTSD, soldiers' families frequently have major depression, ADHD and other mental health issues.
Next week I hope to get more directly involved. I'm supposed to spend a day working on wound managment for medicaid clients which will mostly consist of I&Ds on drug injection abscesses. Then I'm going to use my laptop to write my own client notes and scripts since everything here is computerized. Monday I should get to see some really interesting clients committed at Western State just a few miles away. That place is fascinating and scary. It's an old Civil War era Army base the size of some towns converted into one of the country's largest mental hospitals. The hospital has 983 beds! It has a jail for the criminally insane. It even has a farm that inmates used to raise crops on. It also includes a lake and park for the public to use.
The fact that the boys and I have to enjoy the sunny weather, greenery and 75 degree temperature doesn't hurt either :-). Becky is back in Phoenix working and understandably jealous.
This is going to be a great year, regardlesss of the Board scores I get this week. I just love learning with realy patients. Textbooks do not teach the craft of healing.
-We have clients (not patients) and providers (not practionerers)
-Psych meds are much more complex than we learned and GPs generally don't do well in this area
-Nurse Practioners handle most of the outpatient Psych meds (I don't think it's just WA either)
-Psychologists handle most of the therapy
-It's 1% housewives seeking valium and 99% IVDAs needing antipsychotics (that's only a slight exaggeration)
-No couches
I only spend one day a week with my psychiatrist 'preceptor' but she's awesome. She's a German neurosurgeon turned psychiatrist after marrying a Turkish neurosurgeon and relocating here since neither one could speak the other's native tongue!
Then I typically spend one day a week with NPs on meds management; one with psychologists on therapy; one at a homeless shelter we're contracted to provide for; and one shadowing our liaison to visit clients at inpatient hospitals after they've been picked up for going off Meds or onto street drugs.
Peds is the most interesting and tragic part I've seen. One young man had a high fever requiring resuscitation that led to seizures at 10 and psychosis later. A family understandibly had the mom in counseling after three of her four kids acquired mental health issues and the father is an uninvolved soldier recently returned from Iraq. Being near Ft. Lewis, we get many less extreme cases related to the war in Iraq. Besides PTSD, soldiers' families frequently have major depression, ADHD and other mental health issues.
Next week I hope to get more directly involved. I'm supposed to spend a day working on wound managment for medicaid clients which will mostly consist of I&Ds on drug injection abscesses. Then I'm going to use my laptop to write my own client notes and scripts since everything here is computerized. Monday I should get to see some really interesting clients committed at Western State just a few miles away. That place is fascinating and scary. It's an old Civil War era Army base the size of some towns converted into one of the country's largest mental hospitals. The hospital has 983 beds! It has a jail for the criminally insane. It even has a farm that inmates used to raise crops on. It also includes a lake and park for the public to use.
The fact that the boys and I have to enjoy the sunny weather, greenery and 75 degree temperature doesn't hurt either :-). Becky is back in Phoenix working and understandably jealous.
This is going to be a great year, regardlesss of the Board scores I get this week. I just love learning with realy patients. Textbooks do not teach the craft of healing.
Recovery and Orientation
Recovery
I really only had three days to recover before orientation for rotations. While I should have been finishing the Gamma Knife research paper I was writing for a classmate, I couldn't do much of anything medical related.
Playing with my kids and dogs was refreshing. I even read a pleasure book over the weekend and got in some swimming. It just felt so good to never have to worry about Monday and Friday morning finals again. The table in the student lounge that I had lived at for the last few months was now free for the next victim. It had been my favorite study spot for most of the previous two years. And for the last couple of months, most nights I left my garbage and a half dozen books or so on it not so much to claim ownership as to save myself multiple trips to my car.
I also cleaned out the books in my car, three milk crates worth of Boards prep material!
Orientation
Our Clinical Education department is not world class (just trying to be polite). And while the staff works hard for us, orentiation was disorganized and not very beneficial. I skipped several lectures to read Boards & Wards and scope books for rotations. I purchased many from Ebay at steep discounts, but wanted to plan ahead and not end wasting money on bad decisions.
Some lectures on didactics and rotation preparation were pretty good. Especially the ones run by our new Surgery and OB/Gyn dept heads. The ones run by Profs in IM, FM and Peds were generally poor. You'd think that after they've been on the job for 8+ years and had the recent examples set by the newest dept heads they would at least try meet the bar. But no, they seem almost clueless to what students need for rotations.
Moreover, the ClinEd dept has put a bunch of new requirements on us like logging ICD-9 codes of all the patients we see. They don't provide any tools or lists, just a huge new hassle. Ugh!
At least our class gets along very well so we will share rotation objectives, tips, best practices, etc. I've learned far more from classmates and upper classmen than from the oldtime docs in ClinEd.
Finally, it was time to say goodbye to classmates and pack for the drive to first rotation at my mother-in-laws: psychiatry in Lakewood, WA. Becky and I switched driving while the kids slept through the night. We arrived Satuday morning after 24 hours of driving. The Seattle area is so beautiful in the summer!
It's wierd to think that our class won't be back together as a whole until our MSIII finals and MSIV orientation next summer.
I really only had three days to recover before orientation for rotations. While I should have been finishing the Gamma Knife research paper I was writing for a classmate, I couldn't do much of anything medical related.
Playing with my kids and dogs was refreshing. I even read a pleasure book over the weekend and got in some swimming. It just felt so good to never have to worry about Monday and Friday morning finals again. The table in the student lounge that I had lived at for the last few months was now free for the next victim. It had been my favorite study spot for most of the previous two years. And for the last couple of months, most nights I left my garbage and a half dozen books or so on it not so much to claim ownership as to save myself multiple trips to my car.
I also cleaned out the books in my car, three milk crates worth of Boards prep material!
Orientation
Our Clinical Education department is not world class (just trying to be polite). And while the staff works hard for us, orentiation was disorganized and not very beneficial. I skipped several lectures to read Boards & Wards and scope books for rotations. I purchased many from Ebay at steep discounts, but wanted to plan ahead and not end wasting money on bad decisions.
Some lectures on didactics and rotation preparation were pretty good. Especially the ones run by our new Surgery and OB/Gyn dept heads. The ones run by Profs in IM, FM and Peds were generally poor. You'd think that after they've been on the job for 8+ years and had the recent examples set by the newest dept heads they would at least try meet the bar. But no, they seem almost clueless to what students need for rotations.
Moreover, the ClinEd dept has put a bunch of new requirements on us like logging ICD-9 codes of all the patients we see. They don't provide any tools or lists, just a huge new hassle. Ugh!
At least our class gets along very well so we will share rotation objectives, tips, best practices, etc. I've learned far more from classmates and upper classmen than from the oldtime docs in ClinEd.
Finally, it was time to say goodbye to classmates and pack for the drive to first rotation at my mother-in-laws: psychiatry in Lakewood, WA. Becky and I switched driving while the kids slept through the night. We arrived Satuday morning after 24 hours of driving. The Seattle area is so beautiful in the summer!
It's wierd to think that our class won't be back together as a whole until our MSIII finals and MSIV orientation next summer.
Boards
USMLE Step 1
Surprisingly my stress level for the actual USMLE Step 1 on June 12th was pretty low. At that point, I knew I had done the best I could to prepare over the month since classes ended. Sure I could have put in a few more hours or studied more effectively if I had to do it again. But I really lost my motivation. Burnout had overcome my demoralizing schedule.
The test was not what I expected. In fact, along with many classmates, I'm shocked that this is the primary tool used to rank future physicians. It felt like the test was for a PhD in Biochem. The actual medical knowledge tested was incredibly minor. Out of 350 questions (7 blocks of 50 questions) I had less than 25 Pharm questions, a similar number of Micro questions and 25% or so Path questions (vs. the predicted 40%).
My recollection may be biased towards the more difficult questions, but I got tired of the questions that basically included the following stub; "A researcher testing a new drug uses three knockout mice lines to test its efficacy..." Then you had to interpret test results that had nothing to do with knowledge learned in medical school. Luckily I had exercised the day before so I got plenty of rest and a good night's sleep. I can only hope that the test goes like the MCAT where I end up doing better than expected. <Please!>
Afterwards I vegged out on Studentdoctor.net. The match results for RadOnc were very depressing based on the 40+ folks who listed how they matched. I definitely need a good fallback even if I got a decent score.
COMLEX Step 1
I had two days to study for COMLEX after USMLE. However, my motivation was pretty low. I got nowhere near the 12 to 16 hours of studying in I had hoped. I got maybe 10 hours each day consisting of 6 hours of repetitive COMLEX practice questions on Kaplan's Qbank and 4 hours of Pharm and Micro review (which rumor had it were heavily emphasized).
I'm glad I hit those areas, but in the state I was in I don't think that I retained much information. I also didn't prepare as well. I was too burned out to exercise, so I slept horribly the night before. The test started an hour and a half earlier so I didn't get in my two hour "last minute" cram session of buzzwords and formulas. I started with the feeling that I just wanted to get it over.
The test itself was 400 questions in eight hours. I had heard the questions were MUCH more straight forward than USMLE so I expected to finish earlier even with the extra 50 questions. I did have less time pressure than on the USMLE (I actually had time review check-marked questions) but it wasn't as easy as many students reported. I hope that I just had harder questions instead of my being frazzled and/or less prepared. I figure about 50% of the questions were easy whereas friends who took the test earlier put the number closer to 75%. I could very well have scored higher on USMLE than on COMLEX. I'm ok with this as long a) I pass both and b) the USMLE score is over the 85% so the door isn't closed on some specialties.
Scores come out this week. I'm numb and emotionless about it. I know this could be a great week, or a very depressing one. Either way, I can't express how glad I am that those two years are over. I think I'm still in recovery from the stress. It's very de-humanizing and no one gets into medicine to put through it.
Surprisingly my stress level for the actual USMLE Step 1 on June 12th was pretty low. At that point, I knew I had done the best I could to prepare over the month since classes ended. Sure I could have put in a few more hours or studied more effectively if I had to do it again. But I really lost my motivation. Burnout had overcome my demoralizing schedule.
The test was not what I expected. In fact, along with many classmates, I'm shocked that this is the primary tool used to rank future physicians. It felt like the test was for a PhD in Biochem. The actual medical knowledge tested was incredibly minor. Out of 350 questions (7 blocks of 50 questions) I had less than 25 Pharm questions, a similar number of Micro questions and 25% or so Path questions (vs. the predicted 40%).
My recollection may be biased towards the more difficult questions, but I got tired of the questions that basically included the following stub; "A researcher testing a new drug uses three knockout mice lines to test its efficacy..." Then you had to interpret test results that had nothing to do with knowledge learned in medical school. Luckily I had exercised the day before so I got plenty of rest and a good night's sleep. I can only hope that the test goes like the MCAT where I end up doing better than expected. <Please!>
Afterwards I vegged out on Studentdoctor.net. The match results for RadOnc were very depressing based on the 40+ folks who listed how they matched. I definitely need a good fallback even if I got a decent score.
COMLEX Step 1
I had two days to study for COMLEX after USMLE. However, my motivation was pretty low. I got nowhere near the 12 to 16 hours of studying in I had hoped. I got maybe 10 hours each day consisting of 6 hours of repetitive COMLEX practice questions on Kaplan's Qbank and 4 hours of Pharm and Micro review (which rumor had it were heavily emphasized).
I'm glad I hit those areas, but in the state I was in I don't think that I retained much information. I also didn't prepare as well. I was too burned out to exercise, so I slept horribly the night before. The test started an hour and a half earlier so I didn't get in my two hour "last minute" cram session of buzzwords and formulas. I started with the feeling that I just wanted to get it over.
The test itself was 400 questions in eight hours. I had heard the questions were MUCH more straight forward than USMLE so I expected to finish earlier even with the extra 50 questions. I did have less time pressure than on the USMLE (I actually had time review check-marked questions) but it wasn't as easy as many students reported. I hope that I just had harder questions instead of my being frazzled and/or less prepared. I figure about 50% of the questions were easy whereas friends who took the test earlier put the number closer to 75%. I could very well have scored higher on USMLE than on COMLEX. I'm ok with this as long a) I pass both and b) the USMLE score is over the 85% so the door isn't closed on some specialties.
Scores come out this week. I'm numb and emotionless about it. I know this could be a great week, or a very depressing one. Either way, I can't express how glad I am that those two years are over. I think I'm still in recovery from the stress. It's very de-humanizing and no one gets into medicine to put through it.
Didatics are over!!
Well it's been a long time since I last posted. I even forgot my account information and had to spend a while this weekend looking it up. So let me begin by summing up the last six months of MSII. Then, either in this message or following ones, I can cover Boards and my first rotation.
January and February were Hell. Tests constantly and stress levels that are simply unhealthy put most of the class in depression. I pretty didn't care about grades, family or health anymore. I did ok, my lowest quarterly score overall, but only by a couple tenths of a percent. My impressoin of AZCOM and medical school in general hit a new trough.
The forty or so of us who paid to take the Northwest Medical Review course beginning the day after finals had no idea how burned out we'd be. Saturday through Wednesday we sat in class for eight hours a day covering a ton of material. I don't think I was the only one in a stupor.
I begin Spring quarter with a poor attitude towards school, but determined to do my best on Boards. I skipped a lot more class to study on my own and proceeded to work through most of Kaplan's Webprep course. Not having Micro was a relief but it was replaced by a stupid class called OCM that crammed 4 credits into 8 hours a week of lecture for the first half of the quarter. Everyone expected that we'd have a lot more time to study for Boards the last half. We were mistaken.
In the end I got through all of Webprep except the most important subject, Path. I also started onto Goljan's lectures for a second time. By not caring as much, I even got my best grades of the year. However, I had no idea how truly spent I was at the after finals.
I tried to power through Webprep Path and then dive into FirstAid, Step-up and Goljan's high yield notes while doing 100 practice questions per night (and reviews answers) plus 350 over each weekend. I burned out. I took a three day break and didn't finish Kaplan's 2100 question Qbank, let alone questions from NW Medical, Buzzwords, Rapid Review books or the freebies from NBME. The highest yield for me was Goljan's notes, Qbank and the last week of going through FirstAid and StepUp a second time. I wrote a ton of additional notes into StepUp and many of my own notes. Path, Micro and a lot of Biochem really came together over that period.
An then USMLE Step 1 on June 12th...
January and February were Hell. Tests constantly and stress levels that are simply unhealthy put most of the class in depression. I pretty didn't care about grades, family or health anymore. I did ok, my lowest quarterly score overall, but only by a couple tenths of a percent. My impressoin of AZCOM and medical school in general hit a new trough.
The forty or so of us who paid to take the Northwest Medical Review course beginning the day after finals had no idea how burned out we'd be. Saturday through Wednesday we sat in class for eight hours a day covering a ton of material. I don't think I was the only one in a stupor.
I begin Spring quarter with a poor attitude towards school, but determined to do my best on Boards. I skipped a lot more class to study on my own and proceeded to work through most of Kaplan's Webprep course. Not having Micro was a relief but it was replaced by a stupid class called OCM that crammed 4 credits into 8 hours a week of lecture for the first half of the quarter. Everyone expected that we'd have a lot more time to study for Boards the last half. We were mistaken.
In the end I got through all of Webprep except the most important subject, Path. I also started onto Goljan's lectures for a second time. By not caring as much, I even got my best grades of the year. However, I had no idea how truly spent I was at the after finals.
I tried to power through Webprep Path and then dive into FirstAid, Step-up and Goljan's high yield notes while doing 100 practice questions per night (and reviews answers) plus 350 over each weekend. I burned out. I took a three day break and didn't finish Kaplan's 2100 question Qbank, let alone questions from NW Medical, Buzzwords, Rapid Review books or the freebies from NBME. The highest yield for me was Goljan's notes, Qbank and the last week of going through FirstAid and StepUp a second time. I wrote a ton of additional notes into StepUp and many of my own notes. Path, Micro and a lot of Biochem really came together over that period.
An then USMLE Step 1 on June 12th...
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