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.

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.

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...

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.

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.