Family Medicine Shelf

I got my scores from my Family Medicine rotation. I didn't study nearly as intensely as I did for Step 1, but I did fairly well. Looking at how I did based upon my score as compared to the national average for U.S. medical students and the standard deviation, I did better than I did on the Step. This is motivation to study even harder for the OB/GYN shelf in six weeks!

Family Practice Clerkship: Finished

Today, we finished our clerkship in Family Medicine. Looking back over the last six weeks, I have seen hundreds of patients, written many, many patient notes (SOAP and full H&Ps), and I have written lots of prescriptions (which involves looking up the drugs and getting the physician to review and sign the prescription). I do not think that these last six weeks were the most academically enriching of my medical career; however, I feel like my clinical skills are much better and I got to practice being a doctor every day.

The last two weeks, I haven't really liked the clinic that I've been assigned to. I really liked the doctor, but the clinic definitely wasn't my favorite. That being said, I have had a few really interesting patients the last couple weeks and the doctor gave us a lot of autonomy, which puts a lot of responsibility on us and helps us learn.

Yesterday, we had to take the shelf exam for Family Medicine. It was very difficult! Family Medicine doctors treat patients from birth to death, including obstetrics. A family medicine doctors are considered generalists, which means they have got to know about everything. They might not need to know the information in as much detail as a specialists; however, they still have a heck of a lot that they need to know. Studying for this exam was difficult because family medicine doctors are generalists: everything was fair game. I thought that there would be lots of questions on diabetes, colds and hypertension, which there were; however, there were also lots of questions on birth control, endocrinology and cardiology. The moral of this story is that Family Medicine doctors are really unappreciated and respected. Everyone knows that there is a shortage of Family Medicine doctors and that they do not make anywhere near the amount of other doctors. There is also a push to have mid-level practitioners, such as Physician Assistants and Nurse Practitioners, take over much of the primary care in this country. I do not think this is a good idea. The mid-levels know a lot of information and provide invaluable services in our community, but Family Practice doctors have years more training and one cannot exchange a mid-level for a Family Practice doctor. They are NOT the same and should not be given the same rights and responsibilities.

I have the weekend off before starting my OB/GYN rotation on Monday. I am really excited to deliver a few babies, scrub in and assist in surgeries, and work in women's health. Last week, I had a patient who thought she might be pregnant (and didn't want to be). Farley said that he has never seen me so comfortable with a patient. I have always considered OB/GYN and I am excited because I feel comfortable in this specialty (and I guess I exude confidence and comfort in this specialty). I still think that Hematology and Oncology is my number one specialty (most likely pediatric oncology and hematology), but I am excited to explore OB/GYN more!

Ageism in the work place

I saw a pre-teen girl today in the clinic. She was very outgoing and asked me questions about the physical exam and labs. I liked her. Her dad left the room for a moment and this is the conversation that took place:

Pre-teen girl: "How old are you?"

Me: "I am 27-years old. Do you think that is really old?

Pre-teen girl: "No, I have cousins that are older than you. Are you married?"

Me: "No"

Pre-teen girl: "Oh, well then you are old."

Walk on the Boardwalk

Farley and I had another relaxing weekend. We watched Gonzaga play on Friday night! How exciting!! Then we had a pretty uneventful Saturday. I had my first workout since my surgery and it was extremely difficult for me. I've been really afraid to work out because I was afraid I would be in pain again and that I couldn't keep up. I was in pain, but it wasn't too bad; however, I have never gone three months without working out so I was having a hard time keeping up with the work out. After the work out, I went to Mass, which was peaceful and wonderful. Then, I decided that I wanted to have Greek inspired sandwiches for dinner. I made hummus from scratch (yes, I even used dried beans and everything), tzatziki (a Greek yogurt with garlic and cucumbers...creamy and yummy), and chicken with Greek Seasoning. I chopped up cucumbers and olives and made pita sandwiches. They looked a little sloppy, but they tasted like heaven! I also made baked pita chips to dip in the hummus and tzatziki and Farley decided to make cinnamon-sugar pita chips for desert (so yummy).

Sunday, obviously, I watched the Gonzaga game. It wasn't the best moment of the weekend. Then I studied and made lentil soup. Before dinner and the evening study block, Farley and I took a walk out on the boardwalk. It was really breezy, but here are a few pictures from the walk.

Entrance to the beach from the boardwalk at about 21st street.

There were three cruse ships going out to sea today and they were making the water very choppy. It was a bit overcast when I took the pictures. This is the best photograph of the cruse ships that I have. I will try to get another picture later. It is amazing to see how large these ships are and I don't think that this photograph really shows the size of the ships well (in part because it is hard to even see the ship).

This is one of the entrances to the beach at about 13th street near Lummus Park. Obviously, the entrances at different areas of the beach have their own unique look, as this is nothing like the picture posted above from about 21st street.
This is a picture of Ocean Drive from Lummus Park at about 12th street
Here is a panoramic picture of Ocean Drive from Lummus Park.

Miami Beach Apartment Pictures

Here are some pictures of my apartment in Miami Beach. The first one is a picture of the building, which Farley took. I just love that we are living in an Art Deco building! Miami Beach has the highest concentration of1920-1940s Art Deco Architecture (specifically resort architecture) in the world!

This is the living room. There is a big oak table on the side of the living room from which I am taking the picture that can sit six people. I did not take a picture of it because it is covered with books and study materials.
I LOVE this chandelier (or maybe it is just a light). It is in the middle of the living room.
Here is a picture of the tiny kitchen. The stove is brand new and despite being small, it is still pretty nice. There is a sideboard, which matches the oak table, that I can keep extra kitchen supplies in. Oh, and believe it or not, there is a closet with a washer and dryer in the kitchen (but it isn't in the photo).

Here is a picture of my bedroom. If you look closely, you can see the books on the dresser near the door.
Here is the other half of my bedroom.
Here is my bathroom, which is nice enough, but it is nothing compared to the resort like bathroom I had when we lived in South Miami. The South Miami apartment was newer and had some cool features, but this apartment has much better furniture, the location cannot be beat and the price is wonderful.
There is a second bathroom and bedroom, but they are Farley's domain, so I didn't photograph them. His bedroom has a door that leads down a path to the beach.

Let the Madness Begin...

I love March. It is the end of winter, the beginning of Spring and most importantly....it is time for March Madness. I LOVE college basketball!!!!!! I love it, love it, love it! If I could just take time off and watch the tourney non-stop, I'd do it. I love basketball. It is rather humorous because Farley could care less about sports, unless it is ultimate fighting. In fact, Farley and I couldn't be farther from each other on the love of basketball scale: I love it and he dislikes it (really dislikes it). This weekend is on e of the most magical time of the year: non-stop college basketball from Thursday until Sunday. But, alas, I will have to be in clinic and study so I won't be able to enjoy it as much as I'd like to.

In addition to all the basketball games, there are also great advertisements this time of year, which cash in on the madness.

Most importantly: GO GONZAGA, G-O-N-Z-A-G-A!!!!!!!

Blood Draw

It was a slow day in the clinic today, but I got to do my first blood draw. I am happy to report that I managed to get the vein and the blood on the first try. I was a little scared to try last week, but this week, I was ready to go. If I haven't done a procedure before, the doctor or I tell the patient that I am a student under Dr. Soandso's direction and ask if it is okay if I do the procedure or if they don't want me to do the procedure, can I watch Dr. Soandso. (FYI: Dr. Soandso is always watching carefully whenever a medical student do anything besides a basic

history and physical). Well, today I just blurted out, "I've never done one of these before. If it is okay with you, I'm going to try, If I don't get the blood on the first stick, then someone else will draw your blood." The patient had donated blood and plasma in the past and was completely fine with me trying to draw his blood. So, with two staff members close at hand, another medical student, and Farley, who worked as a phlebotomist, I was ready to start. I felt for the vein, I tied the tourniquet, I felt the vein again, I cleaned the skin, then I inserted the needle, and to my great excitement the needle filled with blood. Farley pulled the needle a tiny bit out to help the blood flow more quickly, but I did it! I was lucky to have a patient with really nice veins, but I was also lucky to have so much help around. It is always fun and exciting to learn something new and to be a useful and helpful member of the team!

Trivial Pursuit Round Two

We were given over 30 random questions to look up for Dr. SNL. One of these questions was "Which disease is associated with Chromosome 7?" Now, since I didn't know the answer to this questions I used my good friend Google and discovered to find the "Chromosome 7-Genetics Home Reference" which is a website maintained by the National Institute of Health. They listed about 20-30 diseases associated with Chromosome 7. When Dr. SNL asked me about the question, I was happy to report all of the diseases on the list. From that point on, I think Dr. SNL liked me. I was playing his game of Trivial Pursuit and for one round, I beat him at his own game.

While I was typing up this blog post, I found another site, "The Chromosome 7 Annotation Project" which is sponsored by The Hospital for Sick Children in Toronto. This website lists over 360 diseases associated with Chromosome 7. 360! Talk about Trivial Pursuit!

Trivial Pursuit

One of our proctors from this week is too interesting not to blog about. The first day I didn't know what he wanted and I felt so frustrated. After talking about him with Farley, we've decided that he is trying to be helpful and wants us to do well, but it just doesn't come across that way. He is like a comedic character from Saturday Night Live or Seinfield, so we will refer to him as Dr. SNL. Watching his interactions with students would be hilarious, if I were not one of the students!

Like many medical professors, Dr. SNL likes to quiz students. This is often referred to as "pimping" the student. Now, most professors like to pimp students on topics of importance either from the basic sciences or the clinical years (usually they focus on the clinical sciences since that is what will be covered on our next set of boards). The professors also like to focus their "pimping" on a patient and a disease that the student has been following. Not Dr. SNL. He likes to jump around all over the place. Dr. SNL is questioning a students on heart sounds and in the midst of the line of questions, he declares, "What is Kussmaul?" My brain doesn't work that fast, so I am sitting there trying to figure out what Kussmaul has to do with heart sounds when thankfully some other student asks, "Do you mean Kussmaul's breathing?" Then Dr. SNL confirms that is what he was talking about and obviously we do not know what Kussmaul's is so we must look it up (Kussmaul's breathing is hyperventilation and can be caused by many things, but is often seen in diabetic ketoacidosis). A student gives a dissertation on Kussmaul's breathing for Dr. SNL on the spot, but Dr. SNL says, "You had to think about it, and you cannot stop to think you must just know." A few hours later, Dr. SNL told us that we didn't think about things enough and that you cannot just burst out the answer without thinking. I am still confused about the whole thing. One hour he declares that we do not know the information if we have to stop and think for a second and later that same day, he declares that we don't think enough and we don't know the information well enough because we cannot think. I am telling you, it was like a game of medical Trivial Pursuit with the game's host being a character from an SNL skit.

I don't mind being questioned because it will point out my weak points (which is embarrassing) and make me a stronger student; however, his questions got a little absurd at some points. One question was "Think about the number 125. Tell me everything related to medicine that has to do with the number 125." I was flabbergasted. Usually, professors will ask questions like, "A patient presents with abdominal pain, give me the differential diagnosis." I have no idea what the purpose of asking about the number 125 was. He has a math degree and likes to think about numbers so he would just say things like, "I am thinking about the number 24. What does it mean." Then he glares at the students like we are idiots for not knowing what he was thinking about. It really would have been funny, if I were not the one getting glared out. He also asked us for the four types of cardiomyopathies, but we could only name three. He told us to look it up and find the fourth. There are only three cardiomyopathies--he just wanted to test us.

Anyway, we finally got to go see some patients. Dr. SNL wasn't very clear about what he expected other than that we go see the patient then report to him. My patient came in with a cold and after a line of questioning, I found that he had a psychiatric issue that I thought was very important. Every doctor wants things presented in a slightly different manner and Dr. SNL wanted things differently than the physicians that I had been reporting to the last few weeks. Some doctors are better than others about telling the students what they expect, and Dr. SNL was not very clear about his expectations. I tried to start presenting my case and I got stopped so many times I couldn't remember what I had told him and what I hadn't. Even thought my patient came in complaining of a cold, I thought he psychiatric issue was more important and tried to make that the main problem. Dr. SNL didn't like that and told me just to talk about the cold. I finally got through my case and in my assessment and plan, I wanted to send the patient for a psych consult. Dr. SNL was upset with me because I didn't talk to him about the psychiatry issue. I was so frustrated because I had tried to tell him and I finally just said, " I am so sorry I am not doing this as you want, but I don't know how you want me to present my case to you." He told me, "that is okay, I am here to teach you," and I got to present the case to him for the third time in less than 10 minutes!

The icing on the cake was when Dr. SNL asked student #1 to think of the hardest question he could think of and ask student #2. Student #1 asked a question about diabetics and blood pressure (the goal is to keep diabetics blood pressure even lower than the normal population because they are at risk for heart diseases). Student #2 didn't know the difference in the blood pressure scales, but that wasn't enough for Dr. SNL. Dr. SNL asked student #1 how difficult he would rate the question on a scale from 1-10. The student said a 4 or 5, but it is extremely important. Dr. SNL then said, I didn't ask you for an important question, I asked you for a hard one!

I think the main problem is that English is Dr. SNL's second language and I don't think he is 100% comfortable with it. I think that we, as students with English as a primary language, speak too quickly and he can't process everything we are saying because of the language barrier (He wasn't happy with any student's case presentation to him and he missed things that other students said too). After thinking about the day, I think that Dr. SNL really wanted to help us and teach us rather than being picky just for the sake of being picky. However, I think if there was a camera in the room, it would have looked like the Medical School edition of Candid Camera. The best part of the day was when he looked at the us, five medical students who looked like we no longer knew up from down, and told us we could go home then he declared, "Okay. Good, good. I love you all."

The Gift

It was so unnecessary for the patient at the free clinic to give me a gift: A Cold. This is a gift that keeps on giving. I know, I know, by going to medical school I signed up to be exposed to colds and other yucky things. I've heard after you finish your first year of residency you've been exposed to so many things and have built immunity so you don't get sick too often. Right now, I am building immunity and I have my wonderful patients to thank. But really, they don't need to bring such kind gifts to me. I'm happy to see them without gifts that keep on giving.

Unique and Unconventional Tools for Pain Management: Shaking Beds and Water Massages

The hospital inspections are still going on, so they have been having a harder time finding things for us to do as the physicians need to be available for the inspections as much as humanly possible when they are not with a patient. Thus, it was round three in the pain center. Today, three of us got to try out the shaking bed. It looks like a normal hospital bed, except that there are these boots that you strap into and the bed then stakes, mimicking a baby being rocked by his mother. It was very strange. It was relaxing and I could feel the tension in my shoulders (where my stress ends up) dissolving; however, it was kind of weird to be shaking in a bed. Then we went over to the physical therapy area where we tried out "the human car wash." I am sure that it has a real and scientific name; however, it looked like one of those touch-less car washes. First we had to take off our shoes, and then we lied on the mattress. Next, a domed, plastic top with a water-proof tarp came over us and warm water started shooting from the dome onto the water-proof tarp. It was like a water massage. It started out with weak water pressure then moved into a stronger pressure. I am so ticklish that in the beginning the water was making me laugh, but as the water pressure increased, my tickling decreased. Between the shaking bed and the water massage, all of the tension in my back was gone; however, I thought I was getting a little lower back pain towards the end of the water massage.

One hour later, I was in horrible pain. It was like I time traveled back to my post-surgical days and pain. I think there was just way too much stimulation for me and it made my internal organs, which were operated on, start to spasm (just like after surgery). I had some non-steroidal anti-inflammatory medicine with me so I took it immediately. Then I returned to the clinic, to wait for my afternoon assignment. Yet again, I was very lucky. We were dismissed early because the inspectors were still hanging around and they needed all available physicians for the afternoon. Usually, I'd be disappointed because it was a missed opportunity to learn; however, my spasms and pain were dramatically increasing. By the time Farley and I were driving back to Miami Beach, I was in tears and death gripping his hand. I took some more pain medications, iced my suture line, and took a nap. I was so lucky that I didn't have that pain come on when I was in with a patient or with one of my proctors.

I didn't think that it might bother me to try out the shaking bed and water massage because pain patients use these every day. However, post-surgical pain is a very different beast than chronic pain. I thought that I was almost 100% better, other than getting fatigued easier than normal. I learned my lesson today: I am not 100% yet!

My afternoon reiterated how horrible it is to be in pain and how helpless one can feel. As a medical student, it is always good to be reminded of how vulnerable patients feel and how with one bad turn it could be me in the hospital bed rather than a stranger. Being sick is such a humbling experience. I've always considered myself a compassionate person; but after my surgery and recovery, I think I've come to a new more personal understanding of pain and illness, which I hope will help me become a better physician. I can't even imagine what it is like for a physician who has had a grave illness, such as cancer. I expect it completely and utterly changes their view of medicine.

Exceptionally Hot

There was an annual inspection at our clerkship site today; thus, this afternoon many of the doctors cancelled their non-emergent patients to be available for the inspection. We were given the option of going to the rehabilitation center to see some of the physical therapists and occupational therapists work with patients or we could go back to the pain center. We asked to go back to the pain center. Once we got back to the pain center, they let us choose what we wanted to do and we asked to be with the acupuncturist. I am very interested in complementary and alternative medicine and what these traditional remedies can achieve for patients. I really liked this Doctor of Chinese Medicine and had a great time learning a little bit about what he can do for patients. One thing that I can take back to my practice, is how closely he listened and how much he observed. He asked me if I had a lung problem because I am so pale. I was shocked that he could figure that out by just looking at me (I have asthma but was not having any problems breathing). He talked to us about pressure points and some of the herbal remedies (Most are very safe, but some can have extremely serious side effects, including death. Everyone who is taking any herbs needs to let their doctor know because some medications can interact with these herbal treatments. Also, herbal treatments need to be taken seriously and taken at the recommended doses not at extremely high levels.)

The Doctor asked us if we tend to generally feel hot or cold. The other girl medical student and I said that we tend to be cold and Farley said that he tends to be hot. Then, the Doctor even preformed acupuncture on us! I was nervous when he was getting ready to put the needle into my arm, but to my shock it didn't hurt at all. I've seen the needles before--they are amazingly thin, but I've never had acupuncture done before. It was astonishing how deep the needle went into my arm and how flexible the needles are. It was so painless that I completely forgot it was in my arm! When the doctor started to remove the needles, he said that in some people you want to remove the needle without covering the spot,from where you removed the needle, to let the energy out and in others you want to cover the spot to keep the energy in. The example that the doctor used was to help Farley cool down, he would remove the needle and not cover the spot, since Farley is exceptionally hot. I didn't think anything of it at the time because it made sense with what he was saying. However, after thinking about this, I realized that Farley was diagnosed as being exceptionally hot today and I am afraid it is going to go to his head!

All in all, I'd be happy to send one of my patients to an acupuncturist for treatment. If I do in fact go into oncology, I'd be especially interested since acupuncture has helped patients with nausea, vomiting and pain issues. It is not as easy to perform studies on the efficacy of acupuncture with modern medical studies, but it is an area of research that is growing. The National Institute of Health even has a division dedicated to this arena of research, which is known as the National Center for Complementary and Alternative Medicine. They have a great website and have links to studies that are open and enrolling patients if you are interested.

They maybe old, but they are not dead!

At the end of last week, I was examining a patient with a cardiologist. I was suppose to take the patent's blood pressure and listen to his heart. I introduced myself and started to take his blood pressure. My lovely patient, lets call him Mr. MemoryProblem, said to the cardiologist, "if my blood pressure is up, it is this girl's fault." Then Mr. MemoryProblem asked my name several times and declared that he probably won't remember my name but he will always remember my face.

On Monday, Farley and I went to see another demented patient, who we will call Mr. Dementia. Mr. Dementia was feisty and tried to teach us life lesions, but I think he just liked lecturing us. Anyway, I thought Mr. Dementia didn't want us doing a history and physical because he was extremely agitated; however, he kept telling us that he did want us there and that we shouldn't leave. Just based upon observation, I thought that he had a serious visual impairment or was even blind, but he kept saying things like "move so I can see you" so I thought maybe he could see. Farley was asking questions for a while, then Mr. Dementia loudly asked, "Where is the pretty girl?" I presumed that he was talking about me and I replied that I am still here. Then it was my turn to ask questions and he said he was happy to answer, "The pretty girl's questions". During the physical exam, Farley was looking into Mr. Dementia's eyes (to see the retina, vessels, etc)., and Mr. Dementia informed us that he is blind. Then he told us that he knew I was a pretty girl because of my voice. Farley said something like, "she is a good person" to which Mr. Dementia declared, "How do you know? She isn't your wife! Besides, she is interested in me not you, young man." It was all I could do to keep from laughing. I only wish I had a picture of the look on Farley's face.

But the fun isn't just for me. One of the little ladies got a HUGE smile on her face when Farley did a cardiac exam on her and even winked at the doctor for assigning Farley to do her exam! She was watching Farley every chance she got, but unlike the older gentleman, she didn't ignore the doctor to check Farley out.

I guess the bottom line is, these geriatrics patients maybe old, but they aren't dead!

Made My Week

Last Friday, one of our attending physicians assigned us to patients that we are suppose to follow for a week and report back to her about how the patient is doing and about his/her pulmonary disease (this doctor is a pulmonologist--lung doctor). Another student and I were lucky enough to be assigned to an older gentleman who used to be a band leader and I think was relatively famous locally here in Miami. He, unlike many of the other residents in this elder care facility, does not have dementia. My partner for this assignment and I had a great time working on his history and physical last week. I went by his room today and visited with him for about 20-25 minutes. I think it was the highlight of my week. He has so many great stories to tell, as I suspect anyone who lives to be 97 years old and has the mental facilities to remember his life would. He was listening to classical music when I came into the room and I told him about my musical background (playing the piano and having a scholarship in college for it). Towards the end of my visit, he asked me a couple questions that I didn't know the answer to. I told him that I would research it tonight and let him know the answer (to the best of my ability as I am only a third year medical student). He stopped me and said, "You, my dear, are going to be a great doctor. I have seen a lot of doctors and tons of medical students and I know you are going to be great." I think that might be one of the nicest things anyone has ever said to me, especially since he has only met me twice.

Family Practice Clerkship: Week One

During this first week of my core rotation in Family Practice, I was assigned to an elder care facility. Now this is no normal nursing home. This place is 20 acres with an assisted living facility, advanced nursing care facility, outpatient and inpatient rehabilitation programs, another building of general medicine at a hospital level of care (not ICU or surgery types of stuff, but illness that would require hospitalization), an outpatient health clinic and to top it all off one of the best comprehensive pain centers in the country. I am thrilled to have the opportunity to learn from the excellent staff and in such an amazing environment. So far this week, I've worked under an Ear, Nose and Throat (ENT) specialist, cardiologist, pulmonologist, endocrinologists , internal medicine physician with a fellowship in geriatrics, physical and occupational therapists, and obviously family practice physicians. I almost forgot to mention that Farley and I got to spend a few hours with a couple nurses who manage the wound care clinic . We were the only medical students who stayed late and we got to help clean and change the bandages, use a Doppler ultrasound to find difficult pulses (clogged arteries) and probably most importantly we were able to comfort some very scared and sometimes extremely demented patients to help them through the wound cleaning, which can be very painful. Comforting the patients wasn't the most exciting thing we did all week;but honestly, I think it was the most important and helpful task of the week. There is so much more to being an excellent health care provider than just memorizing facts and having book knowledge; to be an excellent health care provider one must be compassionate, competent and caring.

I have been getting along with the patients so well that Farley has nicknamed me "The Granny Whisper". I think the key to my success is that I try to treat all of them as if they are still competent adults, even when they are demented and may not understand what I am saying. I try to speak slowly and loudly, bend down so that I am at eye level (they are often in wheel chairs), introduce myself and state my level of training, then I tell them what I need to do and ask if it is okay. I have had a few patients that are so demented that they cannot respond to me, but I cannot prove that they cannot understand so I still explain what I am going to do (such as listen to their heart with a stethoscope) and ask if it is okay. I had one patient who cannot speak at all. I spoke to her nurse about her a bit and he was shocked that she let me do almost a full physical exam. Apparently, she hits caregivers that she doesn't know. Not only did she not hit me, she was as compliant as one would expect for an immobile patient who can not speak. She even smiled at me throughout the exam. I find it interesting to see other medical students interact with the patients. None of them have been rude or done anything inappropriate; however, many of them don't really have a bedside manner. It amazing how much more compliant Farley's and my patients have been just based upon the way that we treat them.

On another note, life on the beach has been great. The weather in Miami this week hasn't been ideal. The lows has been in the 40s and the highs have been in the 60s. Today we decided to take a walk north on the boardwalk. Here are a few pictures from our walk today:

Considering Miami Beach is basically my back yard, I think I have the best back yard in the world!