Family Practice Clerkship: Week Two

The Family Practice Clerkship is six weeks long. At the location I am doing my clerkship, we are sent to different clinics every two weeks. The idea behind this is to expose us to different aspects of Family Medicine. The first two weeks, I was working with geriatrics patients. I believe the average age of the patients at this geriatrics site was 85 years old! There were many, many patients in their 90s and 100s and some of them still had excellent memories. I really liked working with these patients, especially those with the excellent memories because they have seen so many changes in their lives and it was fun to hear their stories.

For the next two weeks, I will be working at a homeless shelter's free medical clinic. I am really excited to be able to help out people who would otherwise have no medical care. Farley and I stopped by the free clinic yesterday after we finished at the geriatrics locations. They told us that they give medical students a lot of autonomy. We will be given a patient, do a history and physical, come up with a diagnosis and treatment plan then present to an attending physician, who will see the patient and either agree or disagree with our diagnosis and plan. We will even be given the chance to help with procedures, such as draining abscesses, under the supervision of the attending physician. I am really excited and scared to be able to do more hands on work. One of my personal doctors once told me, that they never let students do anything they are not ready for but at some point you have got to learn. I guess I am ready!

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.

Third Year Clerkships

I received my schedule for the rest of my third year of medical school. As I already knew, I will be in Miami completing my core clerkships in Family Medicine, Obstetrics and Gynecology, and Internal Medicine before moving to New York City to do my Psychology rotation. Today, I found out that I am going to be able to stay in New York City to do my Surgery rotation and my Pediatrics rotation. To top it all off, all of my rotations are separated by only a weekend, which means that I started this grand adventure in my third year clerkships on February 15, 2010 and I will finish my third year clerkships on January 14, 2011 (assuming everything goes according to plan). I am really lucky that I got everything back to back; however, that means I only have a weekend to move to New York and I really don't get a break between the rotations. Oh, and since I will be in the middle of my Pediatrics rotation next December, I will not be able to come home for Christmas next year. I knew at some point in my medical education I'd miss Christmas with my family, but I didn't know for sure when. On an exciting note, on January 15, 2011, I will be a 4th year medical student!! It is amazing to think that in less than two years, I will have finished my medical doctorate!

Miami Beach vs. South Miami

Since moving to Miami Beach, I am rather amazed at how many people are out and about. There are people taking strolls and jogs early in the morning and into the early evening (on the streets and the beach), there are people running errands on foot rather than driving. I've only lived here for about a week, but I haven't left my building once without people walking on the streets. This is totally different than when I lived in South Miami. You'd see people out walking but primarily everyone was in their expensive cars and that area of Miami did not cater well to pedestrians. Life down here in Miami Beach is completely different than in South Miami. The drivers are no where near as rude to one another, they stop for pedestrians, people say hello when passing each other on the sidewalk and there is a rich mix of races, ethnicities, religions and socioeconomic classes. When living in South Miami just about every other car was a BMW, Mercedes, or an Audi with Bentleys and other more exotic cars mixed in. In Miami Beach there are still all of those fancy cars but there are also lots of Hondas, Toyotas, Fords and Chevrolets. As a generalization, Miami Beach thus far has been a happier, more polite version of Miami. The city of Miami Beach seems to pride themselves on their artists and cultural events. There is a ballet, museums, and concerts on a regular basis; I hope that Farley and I have time to attend a few of these events. There are tons of restaurants specializing in foods from all over the world and I am excited to try a few of them (some are way to expensive to try, but others are really reasonable). I know that I have complained about Miami a bit in the past and in moving to a different area of Miami I am not encountering the things that irritated me before. I did not intend on moving back to Miami for my medical clerkships; however, I am glad that I did. I am getting to know a different side of Miami and it is amazing.

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!

Miami Beach

I've moved into my little apartment half a block from the boardwalk and the sands of Miami Beach. It is a cute little place in an old Art Deco building. It is great because I am just blocks from the action: I can go visit the action if I want but I can still sleep at night because I am a few blocks from the most exciting part of Miami Beach. Unfortunately, it has been cold in Miami--highs in the 50s and 60s as well as lows in the mid 40s. I know up north that doesn't sound so bad, but this is Miami and it should be hot, hot, hot. I guess I cannot complain too much because the weather here is much better than if I would have been placed in New York City this time of year, as I expected.

Here are a few pictures from our Valentines Day walk on the beach:

Above: The beach entrance just a half block from my door.

Below: Farley and I on the Miami Beach boardwalk
Below: The sunset above the hotels of Miami Beach

Baby Steps

I still don't feel 100%, but I am getting stronger every day. I am sure by 15th that I'll be ready to start my family medicine clerkship. Every day I have been trying to go out and run errands, walk and just get up and about. I am not allowed to work out for a few more weeks, but I am able to go walking around the mall, a large store, and even going to the hospital to visit old friends for several hours, which I couldn't do a week and a half ago. It is a little scary to start moving again after surgery because there is a fear of pain and weakness after being so helpless, but at some point you just have to start trying and I've been surprising myself on occasion.

I am getting both excited and incredibly nervous to head back to school. I've been looking forward to my clerkships since I started medical school. In fact during the first two years of medical school when things got tough, I would remind myself to keep my eye on the prize: being in the hospital learning practical medicine rather than just book medicine. Now that I am ready to start the part I've been looking for, I am nervous. I hope that I am competent, knowledgeable, compassionate and tough enough to get through the next phase of my training. I have had higher grades every semester of medical school (as every semester is more clinical and practical than the last) so anticipate that I will do great in this next phase of my training. But, I am still a bit nervous...of course anything new in life and worth doing is often daunting.