Family & Friends-
I find that when it has been this long since I last wrote, the best thing to do is choose the best 1 or 2 nuggets, write about those and ignore trying to "catch up" on 5 or 6 months worth of events….the only trouble now is remembering what those 1 or 2 nuggets might be!
I'm just now drawing to the end of my out-patient/ambulatory internal medicine month. Because medical school has its own lingo and the phrase "out-patient/ambulatory internal medicine" is pretty esoteric, let me rephrase by saying I'm finishing a month in a clinic much like you might think of when you say "I've got a doctor's appointment today". Out-patient means it is not in the hospital, rather it is in a clinic. Ambulatory means that the patients walk in and walk out in the same day (they "ambulate"). Internal medicine means it is simply primary care for adults -- they are the generalists who do not specialize in one organ system, rather they are trained to handle problems from almost any organ system. This month I have spent approximately 80% of my time working with patients who have common chronic problems such as high blood pressure, diabetes, high cholesterol, back pain and coronary artery disease, etc. The remaining 20% or so was spent on more acute things like gout attacks, asthma exacerbations, etc. For some reason (probably because most medical students are cowboys who like that adrenaline rush), Internal Medicine and chronic care in general gets a bad reputation. I heard over and over that I'd be board out of my mind this month, but I guess I'm just made of different stuff because I've really enjoyed things! Admittedly, it is frustrating to have to see a new patient every 15 minutes (I'm sorry, 15 minutes is simply not enough time to do anything, even in the best of circumstances!) but aside from the problems of managed care, I like the clinic life. Next month is an in-patient Internal Medicine month (meaning I'll be working with much sicker patients who have been admitted to the hospital). Traditionally this is one of the hardest rotations in medical school, so I'm trying to mentally prepare myself for the gauntlet ahead!
Well, really only a few stories are coming to my mind that might be even slightly entertaining to write about (and I'm not sure they are even all that great…we'll see I guess!) However, before I dive in, let me preface this as I have in the past: I will be using "medical words" (meaning I'll be talking about certain anatomy) and if this is likely to offend, feel free to stop now. Also, because I don't want any of the HIPAA Gestapo to come breaking down my door tonight, I will be changing certain details in order to absolutely protect the identities of individuals. Having said that though, I am not changing the major details of what actually happened, nor my thoughts & feelings (or lack thereof).
One thing that you find out as you work with different medical educators is that each person has a different level of commitment to your learning experience. On one end of the spectrum you have the doctors who really don't want you around and who only keep you there because it is part of their contract. When working with one of these doctors (let's call them the "Apathetics") you learn very little, but the ride is usually pretty smooth -- you be as inconspicuous as possible and they won't fail you out of medical school. On the other end of the spectrum you have what might be called "The Dedicated". These doctors (bless their hearts) do ANYTHING and EVERYTHING to ensure you learn something. While this is certainly the better end of the spectrum to be on, it can get a little excessive, as I learned to my dismay a week or two ago:
I was in the clinic with a doctor -- let's call him Dr A (I'd classify him as a "dedicated" but not excessively so) and our next patient happened to be another doctor who works as a specialist at one of the local hospitals -- let's call her Dr B (it is always kind of weird to be a doctor for a doctor…but anyway, that is beside the point). Dr B was in the clinic for a routine yearly physical exam. Dr A asked all the appropriate questions, did a brief yet adequate physical exam and was writing his note, when Dr B (someone I would classify as light years beyond the "dedicated" mark) turned to me and asked if I was going to be practicing my physical exam skills on her. Dr A tried to explain that when the patient was another doctor whom the student (me) may have to work with sometime in the future, he usually didn't have them do any physical exam in order to avoid any awkwardness. Dr B would have none of it! Ignoring completely the explanation of Dr A she began to grill me about how to do a proper cardiac auscultation exam…
At this point let me take a tangent and explain the full cardiac auscultation exam (auscultation means "to listen" usually with a stethoscope). Because the heart is divided into chambers and because there are multiple valves within the heart and because something may go wrong at any of these sites, a full cardiac auscultation exam involves listening to the heart at different places on the chest -- at each spot a different part of the heart can be heard better. This does not mean that at spot #1 you only hear the aortic valve, it just means that the aortic valve can be heard best at spot #1. At spot #2, the pulmonary valve is heard best, and so on.
Cardiac auscultation is fairly easy on a male because they lack certain chest anatomy that is present in female counterparts. Where things can get difficult is when listening to a couple of the spots on the female patient because breast tissue often needs to be held out of the way. Also, part of the exam involves finding the PMI (Point of Maximal Impulse). The location of the PMI gives an indication of how large the heart is (an enlarged heart can be a sign of impending heart failure). Again, finding the PMI on a male is not too hard…but in a female, it requires a lot of maneuvering of breast tissue.
Because of these complications, in a potentially sensitive situation such as examining a teacher or colegue, the cardiac exam is often superficial and unless there are symptoms or risk factors to suggest something is wrong with the heart, a superficial exam is all that is needed (Note: this may not be what the textbook tells you to do, but we live in the real world and in the real world, sometimes the cardiac exam is sacrificed in order to preserve dignity)
…okay, back to the story! There I was, getting grilled about the cardiac exam when Dr B said "show me the proper exam technique!" (and since she was the only patient in the room, it could clearly be surmised that she meant to have me perform the cardiac exam on her). I shot Dr A a quick glance as if to say "is that okay?" and Dr A gave me a look back that said "sorry pal, technically she is right and should get a full cardiac exam today…better luck next time!" With all the enthusiasm of a man walking to the gallows, I went through the motions of a cardiac exam, trying to be as quick and non-invasive as possible. Approximately 4 seconds later I had listened to all of the necessary spots, pretended I'd found the PMI and had backed up halfway across the room to give Dr B plenty of personal space. Now, because Dr B has a level-10 black belt in medical education, she knew what I was up to and was not going to have any of it! She made me repeat the full exam 3 or 4 times until she was convinced that I had learned something about how to do a proper exam. I'll not be more detailed in my explanation than that, but I don't think a world-class imagination is needed to paint a mental picture!
Let me emphasize that while this was an uncomfortable situation for me (funny in retrospect, yes, but still uncomfortable) there was no reason to think that Dr B had any motive in mind other than the proper education of a student. She works day in and day out in a field where she sees students who are not properly trained in physical exam technique because no one is willing to let the proper exam be done on them. "Dedicated" doctors have been known to go to greater extremes than that in times past to teach a student and by comparison I got off easy! (Also, Dr A was present in the room at all times, and besides she was probably twice my age or more!)
***
So this next story is probably not quite as memorable for the reader of this letter as the last story, but for me it was a real red-letter day!
There have been plenty of times in the past where I feel like I have no idea what is going on…I do take comfort in the fact that all 3rd year medical students often feel this way, but none-the-less I sometimes sit there trying to think of some distant piece of information I learned and all that comes to my brain is that the patient probably needs a tetnus shot (not that tetnus shots cure any of the patient’s problems…but sometimes that is all that comes to mind). Fortunately, things are coming together more and more every day, but regardless there have been a few times that if you could read a transcript of my thoughts, this is what it would look like:
"This patient has sarcoidosis of the lungs, how should we treat him?"
"Tetnus shot?"
"This patient has pseudomembranous colitis, what should we do next?"
"I know, give him a tetnus shot!"
"This patient has a bunion on his foot"
"Tetnus shot is just what he needs!"
"This patient has excessive earwax"
"Tetnus shot! (then a CT scan of his head!)"
But, a few weeks ago I finally, let me repeat, I finally heard something before my attending did! In listening to a patient's heart I heard a murmur, and it wasn't until I insisted that I heard something abnormal that my attending listened closer and agreed with me! We sent the patient for an echocardiogram and it turns out he had aortic stenosis (not a real good thing). While I feel bad for the patient, a part of me can't help but be excited that I finally caught something that no one else caught!
Anyway, that’s about it, so I’ll finish here.
Love you all!
-Eric
I find that when it has been this long since I last wrote, the best thing to do is choose the best 1 or 2 nuggets, write about those and ignore trying to "catch up" on 5 or 6 months worth of events….the only trouble now is remembering what those 1 or 2 nuggets might be!
I'm just now drawing to the end of my out-patient/ambulatory internal medicine month. Because medical school has its own lingo and the phrase "out-patient/ambulatory internal medicine" is pretty esoteric, let me rephrase by saying I'm finishing a month in a clinic much like you might think of when you say "I've got a doctor's appointment today". Out-patient means it is not in the hospital, rather it is in a clinic. Ambulatory means that the patients walk in and walk out in the same day (they "ambulate"). Internal medicine means it is simply primary care for adults -- they are the generalists who do not specialize in one organ system, rather they are trained to handle problems from almost any organ system. This month I have spent approximately 80% of my time working with patients who have common chronic problems such as high blood pressure, diabetes, high cholesterol, back pain and coronary artery disease, etc. The remaining 20% or so was spent on more acute things like gout attacks, asthma exacerbations, etc. For some reason (probably because most medical students are cowboys who like that adrenaline rush), Internal Medicine and chronic care in general gets a bad reputation. I heard over and over that I'd be board out of my mind this month, but I guess I'm just made of different stuff because I've really enjoyed things! Admittedly, it is frustrating to have to see a new patient every 15 minutes (I'm sorry, 15 minutes is simply not enough time to do anything, even in the best of circumstances!) but aside from the problems of managed care, I like the clinic life. Next month is an in-patient Internal Medicine month (meaning I'll be working with much sicker patients who have been admitted to the hospital). Traditionally this is one of the hardest rotations in medical school, so I'm trying to mentally prepare myself for the gauntlet ahead!
Well, really only a few stories are coming to my mind that might be even slightly entertaining to write about (and I'm not sure they are even all that great…we'll see I guess!) However, before I dive in, let me preface this as I have in the past: I will be using "medical words" (meaning I'll be talking about certain anatomy) and if this is likely to offend, feel free to stop now. Also, because I don't want any of the HIPAA Gestapo to come breaking down my door tonight, I will be changing certain details in order to absolutely protect the identities of individuals. Having said that though, I am not changing the major details of what actually happened, nor my thoughts & feelings (or lack thereof).
One thing that you find out as you work with different medical educators is that each person has a different level of commitment to your learning experience. On one end of the spectrum you have the doctors who really don't want you around and who only keep you there because it is part of their contract. When working with one of these doctors (let's call them the "Apathetics") you learn very little, but the ride is usually pretty smooth -- you be as inconspicuous as possible and they won't fail you out of medical school. On the other end of the spectrum you have what might be called "The Dedicated". These doctors (bless their hearts) do ANYTHING and EVERYTHING to ensure you learn something. While this is certainly the better end of the spectrum to be on, it can get a little excessive, as I learned to my dismay a week or two ago:
I was in the clinic with a doctor -- let's call him Dr A (I'd classify him as a "dedicated" but not excessively so) and our next patient happened to be another doctor who works as a specialist at one of the local hospitals -- let's call her Dr B (it is always kind of weird to be a doctor for a doctor…but anyway, that is beside the point). Dr B was in the clinic for a routine yearly physical exam. Dr A asked all the appropriate questions, did a brief yet adequate physical exam and was writing his note, when Dr B (someone I would classify as light years beyond the "dedicated" mark) turned to me and asked if I was going to be practicing my physical exam skills on her. Dr A tried to explain that when the patient was another doctor whom the student (me) may have to work with sometime in the future, he usually didn't have them do any physical exam in order to avoid any awkwardness. Dr B would have none of it! Ignoring completely the explanation of Dr A she began to grill me about how to do a proper cardiac auscultation exam…
At this point let me take a tangent and explain the full cardiac auscultation exam (auscultation means "to listen" usually with a stethoscope). Because the heart is divided into chambers and because there are multiple valves within the heart and because something may go wrong at any of these sites, a full cardiac auscultation exam involves listening to the heart at different places on the chest -- at each spot a different part of the heart can be heard better. This does not mean that at spot #1 you only hear the aortic valve, it just means that the aortic valve can be heard best at spot #1. At spot #2, the pulmonary valve is heard best, and so on.
Cardiac auscultation is fairly easy on a male because they lack certain chest anatomy that is present in female counterparts. Where things can get difficult is when listening to a couple of the spots on the female patient because breast tissue often needs to be held out of the way. Also, part of the exam involves finding the PMI (Point of Maximal Impulse). The location of the PMI gives an indication of how large the heart is (an enlarged heart can be a sign of impending heart failure). Again, finding the PMI on a male is not too hard…but in a female, it requires a lot of maneuvering of breast tissue.
Because of these complications, in a potentially sensitive situation such as examining a teacher or colegue, the cardiac exam is often superficial and unless there are symptoms or risk factors to suggest something is wrong with the heart, a superficial exam is all that is needed (Note: this may not be what the textbook tells you to do, but we live in the real world and in the real world, sometimes the cardiac exam is sacrificed in order to preserve dignity)
…okay, back to the story! There I was, getting grilled about the cardiac exam when Dr B said "show me the proper exam technique!" (and since she was the only patient in the room, it could clearly be surmised that she meant to have me perform the cardiac exam on her). I shot Dr A a quick glance as if to say "is that okay?" and Dr A gave me a look back that said "sorry pal, technically she is right and should get a full cardiac exam today…better luck next time!" With all the enthusiasm of a man walking to the gallows, I went through the motions of a cardiac exam, trying to be as quick and non-invasive as possible. Approximately 4 seconds later I had listened to all of the necessary spots, pretended I'd found the PMI and had backed up halfway across the room to give Dr B plenty of personal space. Now, because Dr B has a level-10 black belt in medical education, she knew what I was up to and was not going to have any of it! She made me repeat the full exam 3 or 4 times until she was convinced that I had learned something about how to do a proper exam. I'll not be more detailed in my explanation than that, but I don't think a world-class imagination is needed to paint a mental picture!
Let me emphasize that while this was an uncomfortable situation for me (funny in retrospect, yes, but still uncomfortable) there was no reason to think that Dr B had any motive in mind other than the proper education of a student. She works day in and day out in a field where she sees students who are not properly trained in physical exam technique because no one is willing to let the proper exam be done on them. "Dedicated" doctors have been known to go to greater extremes than that in times past to teach a student and by comparison I got off easy! (Also, Dr A was present in the room at all times, and besides she was probably twice my age or more!)
***
So this next story is probably not quite as memorable for the reader of this letter as the last story, but for me it was a real red-letter day!
There have been plenty of times in the past where I feel like I have no idea what is going on…I do take comfort in the fact that all 3rd year medical students often feel this way, but none-the-less I sometimes sit there trying to think of some distant piece of information I learned and all that comes to my brain is that the patient probably needs a tetnus shot (not that tetnus shots cure any of the patient’s problems…but sometimes that is all that comes to mind). Fortunately, things are coming together more and more every day, but regardless there have been a few times that if you could read a transcript of my thoughts, this is what it would look like:
"This patient has sarcoidosis of the lungs, how should we treat him?"
"Tetnus shot?"
"This patient has pseudomembranous colitis, what should we do next?"
"I know, give him a tetnus shot!"
"This patient has a bunion on his foot"
"Tetnus shot is just what he needs!"
"This patient has excessive earwax"
"Tetnus shot! (then a CT scan of his head!)"
But, a few weeks ago I finally, let me repeat, I finally heard something before my attending did! In listening to a patient's heart I heard a murmur, and it wasn't until I insisted that I heard something abnormal that my attending listened closer and agreed with me! We sent the patient for an echocardiogram and it turns out he had aortic stenosis (not a real good thing). While I feel bad for the patient, a part of me can't help but be excited that I finally caught something that no one else caught!
Anyway, that’s about it, so I’ll finish here.
Love you all!
-Eric
