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.
Saturday, October 21, 2006
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.
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