Christmas Break Adventures.

So i get a week and a half off for Christmas. I also got, thanks to my mom's connections, to have lunch with and also shadow a few different ER docs.

At lunch, I learned a bunch of things- things that I want to remember. So I've recorded this for me but take from it what you will. She talked to me about the cons of the ER and the politics of it. This is what I remember.

• if i want to be an attending (teacher) then I have to take a job in it right out of residency- its harder to go backwards than forwards 
• 90% of what she does to pts in the ER doesn't matter, they would be fine without any intervention. Its that 10% that she lives for, less than a patient a shift. You have to be fine with this to go into ER
• Be sure to remember there are multiple kinds of ER docs. private sector gets the $$, urgent care gets the time off, locum tenums gets the stories, and the academic get the insurance benefit and retirement plan. 
• I can specialize later in EMS administration, something an ER doc does on the side very basically free. But it means you're the head of the ambulance company and it might be something fun to do when you're retired (or if you are a part time mom part time doc :)
• Almost all ER doc contracts are for hours spent in the ER per year, not when or how. You can always work 3 months straight and have the next 6 months off-- the question is do you want to?
• Ask about who makes the schedules, how early the schedule comes out and how often you can request time off when you get your first job.
• Live in state where there is Tort reform, especially if you are paying your own malpractice. 
• Its hard to get over being sued, because your confidence decreases. there are no easy answers to getting over this other than avoid being sued as best you can from the start.
• Get a letter from a more established program because that carries more weight than a younger program. Two SLORs are recommended but a SLOR plus a letter from just 1 ER doc looks pretty good. 
• Getting a letter from a charge nurse, especially of ER, is probably the best its gunna get.

Shadowing was good. It was interesting to be at an ER without a residency program. The docs didn't know how to really handle a student and they weren't familiar with how to teach. In the end, I got the impression a few of the docs wanted me to admire their skills more than teach me something. But I did get to see a few good cases over the course of a few hours. One in particular was so good that I had to take pictures of it. It was a bouncer at a bar who tried to break up a fight. The guy got in a good punch and knocked him down and kicked his face. This is what it did to his eye.

And yes, he couldn't see out of his eye, you can see how large the pupil was (we call it a blown pupil since it doesn't respond to light).  We called the opthomologist who refused to get out of bed so eventually we called the plastic surgeons and they tried to repair it as best they could.  Seems like the guy kinda got a little screwed to me... but at least the plastic surgeon cared enough.

FM: sarcoidosis

I decided to follow a resident who I hadn't previously followed. He was somewhat younger and more inexperienced and as such I could speak more and explain things to patients. Got to see some cooler stuff.

Sarcoidosis

The female in the room was apparently afflicted with something. She was more than willing to talk about about it. And even more than that she allowed me to take pictures, which are below. She said that everything in her life is affected by it, but she is not on any medications. She doesn't have any long term problems as far as lung issues. It's just the skin that seems to be affected. She came for a simple check up, and she's in good health minus sarcoid.

Fam Med: I hate that I like it

I hate that I like family med. It's full of owning your own business and time restraints (must see patients for no more than 30 minutes) and horrible pay.  Despite all this, family med turns out to be what i think of when i think doctor. They do some procedures, some ob/gyn, some minor surgeries and get to follow up on their patients. They get to counsel the patients about their options and make diagnoses because despite the specialists the patients get referred to, most people pawn most of the patient care on the family doc. All specialists it seems state "follow up with your PCP in 2-3 weeks" after doing important tests and really leave it to the PCP(primary care physician) to discuss what the test results mean and how it changes the patient's life.

I hate to say that being a PCP would be frustrating and long hours and lots of paper work but it would be more fulfilling. You get to have a broader knowledge base and are expected to advise the patients about every step of their care.  And there is a huge range of different types of things that a PCP can do to 'specialize' so you can own your own practice, you can do OB/GYN, you can work in the ER, you can work as a hospitalist for your patients, you can work in urgent cares, you can work in planned parenthood, you can do a fellowship in minor surgery, you can do geriatrics, sports med, international medicine, academic medicine, you can do sooo many different things and once you have a few years of experience under your belt you can change every couple of years. Which sounds INCREDIBLY attractive-- no burn out and amazing flexibility.

An interesting aspect of family med is that the residents are trained more about billing codes and what insurance companies cover and what they don't than any other residents i've seen. They seem to be more in tune with what meds cost what and what their patients are ready for and what they're not.  PCP's are also very aware that they get paid based on how many patients you see that day.  And are required to see a patient every 30 minutes. In 30 minutes, you can really only address at most 2-3 complaints per patient.  That is the rule actually, any more than 3 complaints and the residents get yelled at.  However, lots of patients don't show up, which means you get caught up on your paper work. But it drives me a little crazy.

Still this rotation I got hooked up with a resident this week that got so behind and didn't really want to be bothered teaching me, so he had me go see his patients first, and i hopped from patient to patient and then updated him and told him what i thought and what suggestions for patient we should do. I felt like a resident, which is sorta cool. There were several patients he didn't even go see because he was so behind and it was just a contraception consultation or just a med refill.   He trusted me and even listened to my suggested plans. It was pretty freakin awesome!

 I managed a diabetic patient on my own, which means I got to recommend types of insulins, give the flu and pneumonia vaccines, prescribe baby aspirin, explain why an annual eye and foot exam is necessary, counsel smoking cessation, order a fasting lipid panel, start an ACE inhibitor, and tell the patient exactly what having diabetes means.  This is a standard new or uncontrolled diabetic appointment. I've probably seen it maybe 30 times. Thank goodness I remembered it all.

I also got people who come in with cough and I argued against the residents and attendings who wanted to give antibiotics for an obvious viral illness.  We got well child visits (like 1 and 2 and 3 year olds who need their shots).  I got a 19 year old girl who wanted to discuss types of contraception.   I got a few other teens who were concerned about STDs.  (funny its mostly girls).  We also get tons of people who have chronic limb pain (shoulder, knee, back, hip, you name it i've seen it.). These patients are hard because you want to help them but you cannot prescribe narcotics too easily.  The best we can do is give tramadol (ultram) and refer to a pain clinic. I got an older woman who had CHF and several people who wanted to follow up after their ER visits.

That said this rotation is what you make of it, several other students essentially just shadow the residents. Nobody really cares about students. If i said i wasn't supposed to be there except M,W,F  they would say "okay" and even the residents don't take things all that seriously because they arrive  30 minutes late most of the time.  And nobody pays attention in didactics. I had to force the residents to let me talk and present and stay late to help with paperwork etc.  (cuz its not like i have anything else to do). But I think they know that I want to learn even if I may not be the smartest student they had.

And the truth is despite its reputation, i could be a PCP and be happy enough. I state this now, because I want to remember feeling competent at something. In Jan I start surgery and I know its gunna be a whole new ball game.

FM: G clinic & denial

So I'm pleased to report that the G clinic is so much better than the N clinic. I got hooked up with a few residents (more like I figured out) who would let me talk to the patients on my own or at least conduct the interview while they were typing. This electronic medical records system is really slowing them down alot.

I feel like even the seniors are a feeling a little behind with their patients.  These residents are funny because they have such a different perspective.  They always compare how many patients they have that day and 8 per half a day is "a lot." The way it works here is everyone gets a hour and half lunch break.  Usually you spend the first half an hour finishing up your patient or your paperwork and then you get an hour lunch. I always feel a little bit of a loser going out to lunch downtown surrounded by people in suits, eating alone with a white coat and stethoscope on.  Hahah.

Lots of these residents are foreign. And i got assigned to a guy who is Arabic. One of our patients, DL, is a small Arabic woman who doesn't speak much English, comes in.  She has been diagnosed with breast cancer that is 80% curable. However, she is in such denial that she doesn't believe she has cancer. It doesn't hurt and despite the 4 biopsies she insisted on that turned out positive for cancer, she won't be convinced.  It took doctors 4 years to talk to her into chemo where she complained that she felt worse after the first treatment and since the lump did not shrink it must not be cancer.  She also was offered a surgical option and she talks in horror about losing her breast for no reason and despite reconstruction refuses.  Doctors including her primary care physician (PCP) and oncologist and surgeon all of whom speak arabic have spend over 60 minute appointments in the last 5 years trying to talk her into getting treatment since her cancer hasn't metastasized yet.  It was the one of the most frustrating patients i've seen yet. I am ashamed to say I just wrote her off after about 15 minutes into the discussion. We can't make her do it, all we can do is explain it and offer options.

There was another case I saw that same day that I again wrote off in the first probably 10 minutes. She was a 19y.o. female but she just kept changing her story. She came in for vaginal pain, but every time we asked her questions about her symptoms or history she changed her story.  Her first time having sex was last year then at 14 then at 16. She said she only had 2 partners then 4 then over 20.  She then didn't have discharge then did then didn't but it was a smell.  Basically, we ended up not even knowing how to present the patient to the attending doc. And we did a full panel for all STDs, UTIs, and yeast panel. We also did a pregnancy test, which was negative.  But these cases are very hard-- and i am only a third year.  And I already wrote her off within 10 minutes.  I feel a little ashamed, but I don't really know what else to do about it.

Family Medicine: Intro

So family medicine. Its set up a bit different for students than for residents. So to start we have to talk legestics. There are two clinics that take 4 PGY-1s (first year residents aka interns), N clinic and G clinic.  So I spent thanksgiving week at the N clinic, it was extremely uneventful. I got thanksgiving off since the office is closed and I took my USMLE so I worked 2 days and one was full of didactic lectures. I saw maybe 4 patients total. It sucked. Apparently, FM has a big problem with getting patients to actually show up for their appointments.

I can say I had a pretty shitty intern who did not let me participate in patient care. He just had me follow him around and it sucked. I pretty much watched him blow off patients. Not to mention the clinic just switched from  paper charts to electronic records so the interns, most of whom are foreigners are struggling.

Actual situation:  68y.o. white male with Diabetes, in apparent distress.

pt: "My wife died last week and she was always the one who handled my blood sugars. I don't even know what number is a good number."

shitty intern: "Uh-huh. When you have last colonoscopy?"

pt: "Oh. I don't know, maybe last year or the year before. My wife, she kept track of that. Can you tell me what number is a good number for my blood sugar?"

shitty intern: "Uh-huh. We talk about that later. You have flu shot recently?"

And the situation went on as such. And we never addressed his diabetes, never explained what it was or what number was good. Although he did send him to a diabetic nutritionist who the patient can't afford. Handy right?

My second week was on inpatient FM.  We are there to take care of the 2 clinics' patients in the hospital. In the morning we are supposed to round on the patients and then we round with the doctors and then we sit in this room til 5 and wait for the ER to call with new admissions.

The first day I showed up at 7 as instructed and no residents showed up until 930. needless to say I was panicking. But apparently we did not have a single patient in the ER. That happened the second day too. I was getting pretty tired of it. Luckily toward the end of the week had a couple ER admits and 4 patients. So i got to see something, finally. But it wasn't anything of note.

All I can really explain is when we got to go to the ER, I was so relieved. I was like the ER!! Thank you GOD!  And after my shift ended I just chilled out in the ER and followed a resident I knew and saw a bunch of patients. I was like kidney stones, AWESOME!  Drug seekers, I MISSED you! it was so much better than FM. I saw twice the patients I saw in FM that day! Granted I only stayed for like 2 hours because I was tired (i mean i did work/sit around all day). I thought about staying until 10. Maybe I should have. I dunno. I got to meet several of the attendings tho and hopefully they will remember me later. I do feel dumb as a rock when I go in there tho. I don't know what tests to order next or what drug to prescribe and that is basically what you do in ER.

I just ended the inpatient week knowing that although its fun to get to know the residents, I'd rather be in the ER.