Playing Doctor

had an AWESOME holiday weekend at my parents' log cabin on the river. beautiful, winter-ish, relaxing and loooooots of good eats. my aunts and grandmas are some mean cooks & bakers, so it's easy to be indulgent. i am bloated and disgusting, but hella happy. i think over the course of the weekend, after many courses over many meals, i still made room for roughly 70 Christmas cookies. oh yes, 'tis the season. i have the greatest family ever. i really do. yours might be nice and all, and i don't mean to be rude, but mine win.

anyway. i started rounding at the hospital with my preceptor today and will do so in the mornings daily before going into the clinic. it's great. it's a sneak peak into internal medicine. she's good at what she does and it's wonderful to be in the hospital. i find energy in hospitals. i love the pace, the feel of it. even the sights and sounds (maybe less so the smells). it's just so comfortable for me there. i think your comfort zone depends on your background- mine was in an in-patient setting, and that's where i feel the most at home.

at clinic today it dawned on me once again what a fake experience this is. i'm seeing real patients, and even occasionally saying something helpful to them, but mostly i'm just practicing my skills for my sake. it's just part of being a student, and i certainly need all the practice and guidance i can get, while i have the opportunity. but it seems so totally ridiculous for me to look in a patient's ears and then have the real doctor come behind me and do the same thing. i'm like a little kid with her fisher price doctor bag using the fake foamy stethoscope on mommy to make her feel better (or using that giant 10 gauge plastic needle to stab her little brother in the name of medicine). it just seems goofy to me. the patients are all very kind about it and don't seem to think it redundant or lame. and it is a good education- the only way to do it, i suppose. when i find signs or acquire history from patients, i'm then able to put together a picture of what might be happening and come up w/ treatment plans and discuss these with the MD's, and that is very beneficial. i just feel bad for the patients.

so please, if you're ever in a teaching setting- don't let the student practitioners go nuts on you or your family, but do be patient and kind to them.

Why Do I Hate America?

Funny facts about Thanksgiving....

1. Turkey breeding has caused turkeys' breasts to grow so large that the turkeys fall over. Wild turkeys can fly for short distances up to 55 miles per hour but commercially raised turkeys cannot fly (primarily because they are too top-heavy).


2. Americans feast on approximately 600 million pounds of turkey on Thanksgiving (about 45 million birds)

3. The symptoms of Salmonella are: bloody diarrhea, fever,
abdominal pain, nausea, headache, and muscle pain

4. Each year, the president pardons 2 turkeys, named "Liberty" and
"Freedom," saving their little turkey lives
(I am NOT kidding). go to:

5. The chemical in turkey that makes you feel sleepy is called Tryptophan.
Go and impress your loved ones with that bit of knowledge. As an
interesting aside, it appears to effect men more than women, since
somehow the women are still cleaning the kitchen after eating the turkey
and the men are comatose on the couch. Perhaps this disparity in men
and women's physiological response would make for an excellent
undergraduate research project.

Bells Ringing, Holly Growing, Pumpkins All Dried Up

well, we're closing in on the holidays and i can't believe how fast this month has gone. there's Christmas music 24 hrs/day on one of the local stations and i'm starting to see lights out and about. if we're true to form to how we've been in the past, it will be december 20th before they go up, but to make up for our procrastination, we'll leave them up until at least early june. i love this time of year- it puts me in a great mood. even the novelty of holiday mall shopping hasn't warn off yet. it won't be long.

this week was better at the clinic- i stopped feeling guilty for not knowing everything and decided to just soak it in and get as much out of it as i could. i love the patient interviewing and exam part of things, and i'm picking up more on what diagnostics to order and am at least sometimes in the ballpark on treatment plans now. that's still rough.

what's amazing to me is how subjective everything is. if i happened to notice something while doing my exam, a) it may look/seem totally different to another practitioner and b) the significance of it as a finding can be dependent on how it is assessed (or whether it was found at all in the first place). was that just a normal looking shadow on the xray, or was that a lung tumor? did i really feel a lump in her breast, or did i convince myself i had because the patient said someone else had felt one there before? was that a tumor or an ovary on pelvic exam? is that an enlarged thyroid, or does the patient just have a huge fat neck? (referred to, in PC medical speak, as "increased body habitus"). was that a click or pathological S3 or just a normal split S2 heart sound that i heard? as a student, i take a guess at what i think it is/is not and run it by someone much more experienced. but in just a matter of months, i can't turn to my peers to look over my shoulder at everything and i'll be making these judgment calls on my own. i know that many new practitioners tend to order testing up the wazoo to help reassure them that their findings are accurate. i definitely understand why.

the worker's comp and disability stuff is tricky, too. i know there are people out there abusing the system, but in turn the system is virtually impenetrable for people who really need it. there are a few manual laborers at this clinic with these acute on chronic back problems who have zero income right now and can hardly sit or stand, much less resume lugging their big cans of paint or boxes of whatever they lug for work. and it's really on the practitioner and their documentation to prove that this person is legitimately wounded and warrants some benefits while they heal, or for the rest of their days. that's a lot of responsibility. and a hell of a lot of paperwork. these docs are cool, though. i see them calling insurance companies, pharmacies, etc on their cell phones in the exam rooms with the patients trying to sort things out before the patient even leaves the office. so at least they're trying to be proactive. but then you as the practitioner always have to have in the back of your head- what if this person is out for pain meds? what if they're shopping around town for someone who will agree w/ their claims, but they're actually ok and i'm just reinforcing the problems with the system?

so it's good to watch old pro's handle these probs. i'm learning a lot. and this stuff may not be as exciting as surgery or delivering babies, but it effects people's lives every bit as much.

Week 2 Family Med, Soapbox

better yesterday. i still stammer and grope for simple words and phrases, but my physical exam skills occasionally come up with something good. i caught 2 hernias yesterday (not the "oh, my" kind, but just umbilical ones) and a heart murmur that you could practically hear from outside the room... but i got a nod from the MD for catching it (and grading it correctly- woohoo!) anyway.

that one was funny because the little old lady i heard it on was a wee bit demented (but really charming) and said she had no idea anything was the matter with/different with her heart and if i just asked the doctor, she was sure he'd give me a clean bill of health. well, i did ask the doctor about it, and it was very much a known problem that had hospitalized her previously and one that they had discussed surgery to fix. we all 3 discussed it when the MD came in and she said, "well, i guess that's just something the doctor has been keeping to himself." i think things like valve stenosis get easily forgotten by patients if they're rarely symptomatic or don't require any meds to manage. it's not like they're listening to their own hearts. but, if she had gone to a clinic/ER that didn't know her hx and she'd told them she had never had a problem w/ a murmur, they would have thought it was new and done a complete workup, maybe focused on it and missed other things, etc.

this is why i strongly encourage all patients w/ a significant medical hx to keep a little list in their wallets of all their allergies, meds (up to date!!), MD names, known conditions, and past treatments/ surgeries with dates. i know this tirade is boring, and i apologize, my dear bloggies. but it's difficult and dangerous when a patient show up at a random ER or clinic where the practitioners don't know him from Adam and he doesn't have any of his health hx on him. that's all i'll say about that. maybe i'll write my congressman. :) or make a PSA about it. perhaps i can get one of the cast members from "grey's anatomy" or maybe hugh laurie from "house" would do it.... he could say something like "Figuring out a diagnosis is enough of a puzzle, it sure helps the doctors to have all the pieces. Carry a current health info card on your person at all times. it could save your life." ooh-i like that. he could really take home the last line by pointing his cane at the camera. hmmm....now i just have to figure out how to break into his house and convince him to agree to do it. hey, now...."kidnap" is such a strong word....

One Thing I Know For Sure

I am Not Smrt, I am Quite Dum.

i think i may have a leak in my brain. seriously. i get asked simple questions about bugs and drugs that i should know, or treatment plans that should be pretty obvious and i basically drool all over myself. all of medicine. 12 months of education plus all that stuff i never learned but should have, is all fair game to be presented with in this out-patient clinical rotation. and i'm so far something like 2 for 300. i have no earthly idea if all other students at my level are equally lacking or if i am the worst ever. i suspect that i am, in fact, the worst ever. i shall pout about it for a while, i think.

i just want to know it all and be comfortable and confident and not doubt my ability to practice as a PA. or to spell my name correctly. grrrr.

cute kids today, though. one 5 y/o little girl got her vaccines and was all tearful, but what REALLY set her off was when she was put outside the room with me and she heard her twin brother screaming from in the room when he was getting his done. she reached over to me and said, "go in there and make them stop. tell them to stop!!" it was really adorable. and kind of sad. we need to figure out how to give vaccines by dissolving them under the tongue or something.

so i'm obviously in a self-bashing mood, so my husband decided to make this weekend a mini vacation for us. so we went to a movie tonight (see side bar) and then to a brand new tapas bar for drinks (delicious chianti) and snacks (snobby cheese tray). now i'm feeling much more cheerful (drunker) than i was earlier, so that's good.

Getting Broken In

things are going pretty well. i love the hours- i work 9-5 (well, i've been there to closer to 6 both days so far and haven't really taken much of a lunch, but still beats getting up at 5am like my past 2 rotations). i will be working one day/week in the urgent care clinic, hours being 1pm-9pm...may get to do some suturing and stuff. we'll see. everyone's really friendly. i have now seen a few peds patients....a 2 y/o w/ an earache who i promptly made cry. have also seen a few cases of MRSA (it's really out there in the community, people- wash your hands!!)what else? lots of hypertensives, diabetic, and high cholesterol routine visits. some viral infections, knee probs, lots of back pain, post car accident pains, etc.

we students don't get access to the computer-based charting system (all the MD's, PA's and MA's carry around laptops and just put in everything as they talk to the patients...they even print prescriptions to the front desk for the patients, make referrals, receive emails from the MA's w/ vital signs, etc), so when we go in to see a pt before the MD does, all we get is their billing sheet on the door that gives a few word description of why the patient is visiting. it often says things like "6 week follow up" and you have no idea what they're following up for. or it will say "ill" and you have to find out what kind of ill. so far i haven't been caught too off guard and patients don't seem to hate telling a clueless student the contents of the chart that i could easily have with me but don't....but i'm sure someone really "ill" at some point will snap at my lack of background on their case. it's kind of nice for the docs for us to see the pt first, because then we present to them about why the pt is there and some background that we gathered and the doc can go in and cut to the chase and not have to hear the whole 15 minute discourse that we sat through on why they have been taking their antihypertensions every other day instead of daily as ordered because they have to share them with their cat...things like that.

i don't know any of my meds....it's embarrassing. as is my ekg reading skills. the MD's are pretty good teachers, though...so i think i'll pick up a lot while i'm there. it's a very different atmosphere than the hospital. i'm still adjusting, but it's early yet. i have 6 wks to get in the groove.

Family Medicine

...started today. i have a headache, so i won't write much now, but i will say that so far so good. (and that i think the headache is from lack of coffee, not from my first day at the rotation). it's a nice sized practice w/ a few docs and PA's and an urgent care clinic at night. there are 2 other PA students w/ me, but there's mostly enough patients to go around. i got to see a 6 yr old and a 79 yr old and everything in between. i helped diagnose diabetes on a patient (classic symptoms- frequent urination- polyurea, frequent night urination- nocturia, and lots of thirst-polydipsia). it was fun for me, hella shitty for him to find out he has NIDDM now and will be stuck on meds for the rest of his days.

more later.

Well, Sports fans, I'm All Done and Moving On (again)

(you really need to watch thursday night tv to get most of my references. calling people "sports fans" is from last week's "scrubs" episode. i am a devoted fan, even though i realize the show has long since run its course and should have wrapped up a few years ago...not unlike roseanne when it runneth over and we as a country collectively sighed in exasperation when the conners won the lottery and dan had a heart attack and all went into surreal crazy tv land...but dutifully continued to watch anyway because we knew at the heart of the show there was good(!) and we had been loyal all those years...)

so anyway...obgyn ended today. i'm feeling kind of sad. just as soon as i get settled in a rotation and feel like i know enough to do some good and to really get into the nuts and bolts of it, i'm moving on. and i'm petrified of family med. so far, with surgery and obgyn i've seen such narrow scopes of medicine. with family med, anyone any age with any problem can come in and i have to know how to find it and fix it. intimidating. so far i've been able to be the amazing ekg-less PA student and have been able to mumble my way through questions on drugs. not so for family med. but i'm hopeful i will get to do more women's health while i'm there.

my reviews were good from the obgyn rotation. i was told by a resident that i was better than 95% of the medical students who come through there (that SOUNDS flattering, but i have to tell you, that compliment has rather limited range) and by one of the attendings that i'm beyond most 1st year residents. that was nice. i guess if i pay attention, am helpful and friendly to the patients, and don't say too many stupid things (out loud), i get by. so far.