10/19/2008

Family & Friends-

I believe last time I got a letter written, I was on Family Medicine and thinking strongly that it was going to be my future career. I guess I must be fickle or something because that is not really the plan anymore. Sadly, I left family medicine with a bitter taste in my mouth that I think I’m going to have a hard time getting over – this was largely due to one of the professors that I really didn’t have good rapport with (more on this in a minute). My current thought is a lesser-known branch of medicine called Physical Medicine and Rehabilitation (PM&R). Obviously I’m going to need to take an elective in this before I commit myself, but it really seems to be a nice synthesis of the best parts of several other fields, including primary care, neurology, physical therapy and sports medicine. Because I know that at least my grandma’s will want to know more, and because I don’t want to take too much space writing about it, anyone who is interested in what PM&R doctors do can get an idea by taking a look at this website: http://www.aapmr.org/medstu.htm

Overall I really did like family medicine and I haven’t completely excluded it from my list of possible careers, but like I said, there was one doctor who I worked with who had the uncanny Hoover-like ability to suck all the joy of medicine out of each day I worked with her leaving me feeling like I had the intelligence of table salt and wondering if the day could get much worse. She was somebody who always seemed flabbergasted that a 3rd year student – someone with a total of a few weeks clinical experience – had failed to follow a particular line of obscure questioning or who had written a progress note in a format preferred by a doctor other than herself. Essentially she was one of those narcissistic Napoleon-esque doctors who thought everybody besides herself was wrong and who was totally intolerant of a student who was still in the steep part of the learning curve (but who deluded herself into believing she was absolutely open-minded and blessed with Job-like patience).
One particularly memorable day I was working with Dr. Hoover (not her real name), and we had a patient cancel, leaving us with about 30 minutes before our next patient arrived. My plan was to use the time to do some much-needed study about some of the conditions we had seen several times about which my fund of knowledge was lacking. Just as I was sitting down with my textbook, Dr. Hoover announced that we had an add-on patient. I stated I would be happy to visit this patient like normal and report back to her with what I found. However, Dr. Hoover said she would like to accompany me into this particular exam. I figured she must want to observe me doing the history and physical so that she could evaluate me and offer some constructive feed-back. Of course I was fine with this and so we set out down the hall toward the exam room.
When we arrived in the room I looked around perplexed because there was no patient in the room – just me and Dr. Hoover. She closed the door, sat down on the exam table and announced, “I’m your patient”. Fear stuck into my heart and I knew this was not going to end well for me. The story she gave me at that point was that I needed to do a fundoscopic exam (looking at the back of her eyes through the pupil using a tool called an opthalmoscope). She stated quite matter-of-factly that if I had the IQ of soup, I would find an abnormality with her retina. Let me pause here and take a small tangent that will help clarify why this was such a dastardly thing for her to do.
In medicine we use 2 major criteria, sensitivity and specificity, to determine if a test is useful. A perfect test would be both highly sensitive and highly specific. A test that has high sensitivity but poor specificity has its uses however, as do tests that are highly specific but poorly sensitive. A test that has both poor sensitivity and poor specificity is essentially worthless. The fundoscopic exam, as preformed in a primary care setting has low sensitivity and specificity, and thus it is not emphasized heavily in medical school training. Fundoscopic exams only become really useful when using the equipment in an ophthalmologist’s office. My training in fundoscopic exam was brief, as it most people’s. Almost all medical students and plenty of residents and doctors are not comfortable with this exam because it yields such poor results. If a person has vision problems or something suspicious about their eye they get referred to an opthomologist who can do a proper exam.
To do a fundoscopic exam, the examiner must get within a few inches of the patient’s face (essentially kissing distance) and shine a light into their eye while trying not to breathe directly into the patient’s nose or mouth. This wouldn’t be a hard thing to do…if your mouth were somehow situated on the back of your head – but as this is not the case, fundoscopic exams are invariably uncomfortable for both doctor and patient. In a perfect world, you are supposed to see a the optic nerve as it exits the back of the eyeball and spreads out into the retina as well as an assortment of vessels. The optic nerve (called the optic disc) is supposed to be a shade of yellow and have crisp defined edges. Part of the reason it is hard to perform this exam in the primary care setting is because you never dilate the patient’s pupil and so you are trying to see this anatomy through a tiny pin-hole pupil.
Okay, back to my story! There I was, my stomach somewhere down near my ankles cursing Dr. Hoover in my head for choosing the fundoscopic exam, of all the possible parts of the physical exam she could have chosen, to evaluate my prowess and progress as a student! For 20 minutes…let me say that again: for 20 minutes I was inches from this lady’s face (who has halitosis by the way) trying to see what was abnormal about her eye. It was so awkward and uncomfortable in that room that I was convinced that random objects were in danger of bursting into flames. To cut the pain short I started trying to ferret clues out of her, hoping I would stumble upon something that could help me identify her retinal abnormality, but to no avail. When she had tortured me long enough, Dr. Hoover demanded I tell her what I know and she would fill in the rest. I said that the optic nerve in her left eye had looked whiter than normal (more of a guess than a confident declaration, but a good guess I was to find out later). Then in a tone that let me know in no uncertain terms that my brain must operate via parcel post instead of express overnight mail, Dr. Hoover said that what I “should have seen” if I was not such a moron, was that the optic nerve in her left eye was whiter than normal and that the edges were less distinct – more fuzzy – than normal. All this put together should have let me know that she had an extremely rare anatomical variant where the optic nerve stayed mylenated after it exited into the eyeball (myelin is a coating that surrounds some nerves and which normally stops at the point the optic nerve exits into the eyeball). This is such a rare condition that I was forced to look through 5 books before I found a picture and description that I could read about. Overall it was not an experience that endeared me to Dr. Hoover, nor was it the only craziness she put me through. However, she was only one doctor and the other doctors were much more personable and so overall I enjoyed family medicine…though I’m not so sure I want it for my career anymore.

**Next Day**

Okay, I got distracted yesterday and will try and finish the letter today.
After family medicine I spent 2 weeks on Neurology. I really hadn’t expected to like Neuro because I hadn’t liked our neuroscience class, but I was pleasantly surprised to really enjoy clinical neurology. We spent our time working with stroke patients, brain trauma patients, or patients with neuro-degenerative diseases such as multiple sclerosis, ALS (Lou Gehrig’s disease), Parkinson’s disease, Huntington’s disease, Alzheimer’s disease, etc.
Last Thursday I started my Psychiatry rotation. I was placed at PCS (Psychiatric Crisis Service) – basically the Emergency Room for psychiatric patients. Most of our patients are brought in by the police because they are suicidal, homicidal, or in the midst of a psychotic or perhaps manic episode. In the 3 days I’ve worked there so far I have seen the craziest of the crazy (Scott, I’m sure you know what I’m talking about). One guy came in because he was picked up while running down the street naked. Another guy set his couch on fire in some ceremony because the voices had told him to do it. Most of our patients are depressed and dangerous to themselves or dealing with drug addiction problems. One lady was antisocial to the point she had to be subdued by several branches of the armed forces. Again, I didn’t think I would like psych because it was never a class I enjoyed attending lecture for, but I find myself excited to go to work everyday. Admittedly, we see a lot of the bleakest society has to offer and in order to cope we maintain a dark humor but even then it is fulfilling to be able to intervene in a person’s life when they are at their lowest. Yes, many of these people will deal with relapses for the rest of their lives. Yes, many of these people are addicted to substances with little hope of recovery, but already there have been several people who probably wouldn’t have survived themselves for more than a few more hours if we hadn’t seen them on the service. Suffice to say, I’m really looking forward to the next 4 weeks!

On a different note, my roommate got married on Saturday. He was one of the 3 or 4 guys who really took me under their wing when I first moved out here and has helped make my time here in Milwaukee such a good experience. He has been dating this girl for the last year or so and I’m really excited for him and his new wife! They are both fantastic people and I will enjoy keeping in touch as time progresses. Without a doubt, the sealing ceremony on Saturday was 15 of the most amazing minutes I’ve ever experienced. I’ve been to many sealings at this point and they are all incredible, but the teaching and council this particular sealer spent his time on really hit home with me. I curse my feeble memory and wish I had perfect recall because I couldn’t absorb all of the doctrines covered as fast as they were coming. I only hope I can remember and apply some of what I learned in my life now and in the future whenever I find that certain someone.

I find it interesting to be living in a “swing state” during a presidential election. For all the elections since I reached voting age, I have either been in Utah (not exactly a swing state!) or I’ve been overseas and thus separated from the political Gettysburg that I had only heard rumors of. I will leave my own thoughts on politics and the candidates out of my letter but I will say it has been eye-opening to witness first-hand the political WWF Monday Night Raw that exists out here.

Well, I’d best call it a night! Love you all!
-Eric