Reading

I read very simple and straightforward advice on third year rotations. A short book called "Primary Care Otolaryngology" suggested that we read an hour a day. It doesn't sound like much, but apparently, but the end of the rotation, we'll have learned a lot. I have found this incredibly difficult to do. When I get home at night, I just don't feel like I have the time or energy. But I still think it is really good advice to prevent last minute cramming before the final or shelf exam. I'm about half way through the family medicine rotation, and I'm going to try to do at least an hour worth of work every day. It really shouldn't be that hard since it's pretty much an 8-5 rotation.

Spanglish

I heard painkillers translated as "mata-dolor." That amused me.

Jail or Pregnancy

An interesting issue came up with two patients I saw today. One was a G4P3 (fourth pregnancy) woman in her mid-20s who had biliary colic and is undergoing surgical removal of her gallbladder. I discovered that it's lucky she's pregnant because her insurance covers this procedure (cholecystectomy) for gravid patients but not for nonpregnant patients.

The second patient has a benign tumor of the heart (an atrial myxoma) which needs to be surgically removed. The cardiac surgeon requires her to have her dentition fixed first. The problem is she has no dental insurance. It was then brought up that the easiest way to get dental insurance is to go to jail (commit the most minor crime that will get you in jail) and have the government foot the bill.

Our society baffles me sometimes.

Direct to Consumer Marketing

Apparently they have started marketing PTCA (percutaneous transluminal coronary angioplasty), a highly invasive and highly lucrative procedure, directly to consumers. I feel this is entirely inappropriate and will contribute to the escalating costs of health care in America. Although it is important for patients to know their options, TV advertising is entirely the wrong forum to do so.

The Physical Exam

What is the utility of doing an annual physical exam on an otherwise healthy and asymptomatic person? Currently, it's standard practice; you listen to the heart and lungs, check the ears, eyes, and throat, etc. But is there evidence for or against routine physicals?

This is an interesting question, and I don't know a lot about it other than one paper we got on the subject. The program director here suggests that the efficacy of the physical exam should be compared to that of lab tests. What's the sensitivity and specificity of listening to the heart? What's the positive predictive value that an abnormal heart sound the average clinician finds turns out to be a cardiac defect?

He argues that most of the physical exam is useless. The average clinician isn't good enough at listening to heart sounds to warrant doing it. Both the sensitivity and specificity of catching a heart problem are low (perhaps <50%). The benefits of pursuing a workup of an abnormal cardiac exam on an otherwise healthy person don't necessarily outweigh the risks and costs. So he suggests that the cardiac exam is only good for building the patient-physician relationship; it is not a cost-effective tool to identify heart defects in a healthy person. Interesting.

On the other hand, pediatric cardiologists are extremely good at identifying heart sounds. Their sensitivity, specificity, and positive and negative predictive values are really high (>90% I think). They are good at differentiating between innocent benign murmurs and ones that need further workup. This suggests that listening to a newborn heart is worthwhile.

This was the first time I heard much on the utility of doing a physical exam on a healthy person, and I think it's very interesting and merits some more thought. Indeed, if some exam maneuvers have a high rate of false positives or false negatives, it might not be cost-effective to even do that maneuver. We think the same way for lab tests, why not apply it to the physical?

Poem: Trifecta

Trifecta

Why is the world so obsessed
with things that come in threes?
Primary colors, types of rock formation,
embryonic germ layers,
all triplets of convenience.
How many ships did Columbus sail?
How many ingredients in a BLT?
How many heads on Hagrid’s dog?
Even this poem seems parsed in threes.
When the French cry Liberty, Equality, Fraternity,
is one just a tool, adopted to keep the others company?
Was one of Macbeth’s witches a lonely sister
who had nothing better to do?

Even in medicine, triads have found a way
to persist through obscurity.
I imagine the condemned Hans Reiter
in a campaign to stay his name
deciding on arthritis, conjunctivitis, urethritis.
Who knows how long it took to decide on that third symptom
or which fourth to cut.
Tell me, can anyone really name the pentad of TTP?
But we remember the musketeers
of normal pressure hydrocephalus.

Three commands dogma, makes juries turn heads.
Just the other day, next to a poster about
the Father, Son, and Holy Ghost
I saw a flyer from the biology club
illustrating a trifecta of nucleotides
encoding the amino acid serine.

Didactics

We get a lot of didactics. All family medicine rotations have a behavioral sciences component where we read papers and discuss race, bias, chronic disease, behavior change, etc. It feels very fuzzy to me, and I am inclined to say that we got enough in our first two years, but I guess the administrators want reinforcement. Thursday afternoons involve resident conferences on topics like dialysis and inflammatory bowel disease. They aren't geared towards medical students so a bit of it is out of my understanding. Medicine and Family Medicine grand rounds involve expert lecturers on topics of general interest. Monday mornings have didactics by the clerkship site director on relevant topics; we learned about outpatient antibiotics the other day. Friday morning didactics are by the program director, a brilliant and eccentric MD/JD/MPH who has fascinating ideas about primary care medicine. He's heavily evidence-based and has radical ideas about medicine which I will eventually write about. So there's a lot of learning in different forms.

Sports Medicine Reprise

I shadowed a family sports medicine doctor several days ago. It was cool to see sports medicine from that perspective. He sees fewer "surgical" patients (more chronic low back pain, patello-femoral syndrome, etc.) but a big role is deciding whether a patient needs to be referred to an orthopedic surgeon. It's also interesting that he has a heavy family medicine approach. One woman came in with a knee complaint and after examining the knee, he commented on a mole that looked like a basal cell carcinoma. He told her that they should monitor that over time, something I would never have heard from an orthopedic surgeon. Also, about half of the patients at his office aren't there for musculoskeletal issues; they have regular family medicine complaints like soft tissue infections.

The final thing is that this was private practice and it's entirely different. He schedules his patients 30 minutes because that's what he wants. The office has its own X-ray machine, and one of the receptionists doubles as an X-ray tech. He even had to have a conference with some of his neighbors because a new tenant was coming into the complex and needed to zone the parking lot differently. That was a weird conference; they kept on talking about contingencies and the city council and property value. I was pretty surprised.

Inpatient Family Medicine

I spent this morning with the inpatient team. Although family medicine as a whole is mostly outpatient, the resident training includes inpatient care similar to that of internal medicine. And since the only residency here is family medicine, they run all the usual hospital stuff. The day started early (or earlier than I am used to) with the usual morning rounds, discussing new admits. Then we had radiology rounds on brain imaging, which was really educational. I like didactics like that, and I think radiology is one that works so much better when you have things explained. This was followed by the usual morning "hour of power" (where residents get most of the work done). I tagged along with one of the residents to see our patients and write up a SOAP note. But one of our patients needed a tunneled catheter for hemodialysis access. The vascular surgeon came around and asked if the resident wanted to do it. So the resident and I got to scrub in (good thing I'd done that before) and place a tunneled internal jugular vein catheter! That was awesome! It was not an intense surgery, but a fun one because it involved ultrasound to place the cath and X-ray confirmation. I got to make the incision on the chest wall where the catheter was placed and then suture the catheter down.

The Problem with Outpatient Medicine

I think its incredibly difficult for medical students to jump in when the schedule is so packed. In many clinics, patients get 15 or 20 minutes a visit. That includes the note-writing or dictation too. We are, by our very nature, slow. We linger on the histories. We do everything for the physical. We hesitate before making the diagnosis. We stop and play with the kids in the room (or at least I do). You stick a medical student in a room, and you can plan on playing catch-up for the rest of the day. I don't know how real practitioners do it.

I've learned a good tip. Chart when you can. I'm one of those people who wants to take copious notes, then organize my thoughts, then write a well-calligraphied, precise note (after all, its a legal document). This kills. By the end of the day, I'm itching to go home, the patients are all jumbled in my head, the attending and staff are trying to bolt, and I'm still on chart 2 of 5. So now I chart when the attending is talking to the patient, chart instead of going to the bathroom, chart when I'm waiting for the nurse to get a urine dip.

Kaiser Family Practice

Today, I did a half-day with Kaiser family practice in Rohnert Park. I know I've really said this about everything in the past few posts, but I enjoyed it. The great thing about Kaiser's system is how smoothly everything runs. They have really figured out the electronic medical record and it's impressive. A few shortcuts and the SOAP note is populated with the patient's ongoing problem list, medications, lab values, and vitals. A couple clicks and the prescription is ready to be filled at the pharmacy. Emails from patients and colleagues are filtered and labeled in order of importance. The scheduling and rooming is all online. These seem like simple things, but after working in clinics where nurses have to write down the patient's room on a paper schedule to let the doctor know where to go next, this is welcome relief. Today, at Kaiser, I saw very bread-and-butter cases: a first diagnosis of hypertension and a routine adolescent checkup with complaint of acne. Simple, but good for the beginning of third year.

Peds Clinic

I have discovered I really enjoy pediatrics clinic. Kids are really fun. Most of them are generally healthy or come in with manageable concerns. I haven't had any issues with parents so far. I don't like the indirect interview - getting all the information from the parents - so I generally try to engage the child even if he or she is only 3. Although I had imagined kids would be afraid of the doctor, the patients I've seen have been a real treat to work with. Infants will reach for my stethoscope or name tag or necktie while I fuss over them. Adolescents actually listen to me and my judgment. The cases are good learning material involving common complaints. Kids are cute.

Poem: Faded Genes

I wrote this poem 4 years ago for a biology class sophomore year (biocore). There was a poetry and protein contest to come up with a poem that used only letters that were 1-letter symbols for amino acids. With twenty amino acids, the letters we could not use were BJOUXZ (O was the rate-limiting factor). The TAs even put this into software to calculate the amount of alpha-helix and other peptide parameters. Rereading this poem now, I don't think it's very good at all, but it amuses me.

Faded Genes

It all starts with a TATA,
Even if tata in English means farewell.
Here, in the letters that direct cells,
We start at the signal indicating Met.
I met a triplet yesterday –
He was a CCC, that cipher waving at
The tRNA with the weird acid –
Cyclic, yet where is the amine end?
I sigh with relief, finally, as I see
A calm street – GCC, GGA,
Glycine, alanine, spiraling in
Alpha helices,
A strange Van der Waals dance
‘Til the sterics in Trp mess the helices–
What Thanksgiving feast makes this peptide fat?
Here, I see a place waving at a splicing
Peptide and its assistant snRNPs,
Snerps, I like calling them.
Again, I see a cysteine,
With linkages with its pair,
Making a tertiary crinkle.
Where shall this peptide travel?
Wrinkling a pea, perhaps,
In a geneticist’s garden?
Instead, a plasmid in a flask
With reverse transcriptase and cDNA?
Perhaps in the dinner, as a split pea entrée,
Entering the digestive tract in a pretty girl
Named Maria
With gastric acid that will add an H in aspartic acid
And attack with trypsin,
Tearing my lysine apart.
And the reader might ask
The identity in this verse,
A speaker packed with facts and data –
I can’t see and predict everything, can I?
I am merely an rRNA segment
23S, in fact,
With my five-prime cap
And my walking stick,
Wandering and translating,
Wearing faded genes.

HIV Clinic

In Santa Rosa, most patients who are HIV positive receive care from a family medicine doctor. This is very different from the way HIV is taught to medical students. As a medical student, I think of HIV as end-stage AIDS: pneumocystis pneumonia, candida infection, CNS lymphoma, Kaposi's. But really, HIV is a chronic illness. People live for decades managing this disease, and the care falls to the family physician. I got to spend some time in the HIV clinic at Santa Rosa and I had a thoroughly good experience. Although the patients were HIV positive, they were seeing a family doc and came with complaints as diverse as arthritis to disability forms to routine check-up. The doctor did address HIV related issues such as immunizations and lipids (side effect of protease inhibitors), but much of the visit focused on health concerns entirely unrelated. So it made me think a bit about the benefits and consequences of having an HIV clinic addressing primary care needs. It also helped me put HIV into the context of primary care.

Family Medicine

I am currently on a 6-week rotation in family medicine in Santa Rosa, about 60 miles north of San Francisco. Family medicine is our dedicated outpatient rotation (we have a longitudinal outpatient experience and some clinics on Ob and Peds too) which is interesting since most of real-world medicine practiced today is outpatient. In Santa Rosa, we really get the gamut of family medicine; there are clinics in general family medicine, pediatrics, dermatology, HIV clinic, neurology, endocrinology, Indian health, and emergency room (the only thing missing is Ob). The cornerstone of family medicine here is a general medical clinic run by medical students. Guided by an attending, we see patients, come up with a differential, present, chart, and write up prescriptions. We try to make follow-up appointments on days we'll be at the clinic so that we get continuity of care. The schedule is medical student friendly; patients are allotted more time, and we typically see around 4 patients in a morning. We have general medical clinic 2-3 half-days a week. For the rest of the week, we have 2-3 half-days of didactics and about 5 half-days of the other clinics mentioned above. The schedule is amazingly flexible; every week, all my classmates and I (there are 4 of us) sit down and fill the calendar to meet our interests.

Codes

Each hospital has its own set of "codes" and while some are somewhat standard (Code Red for fire, Code Pink for infant/child abduction), most are just a mess. There's no standardization between hospitals as evidenced by the Wikipedia article. I almost feel like they came up with one which worked well and then some administrator went entirely overboard making more up.

Etymology

I wrote once before on medical terminology and nomenclature. I'm not a huge fan of it but I learned something interesting. I don't think this is a hard and fast rule, but Latin words may be favored for anatomy while Greek words are favored for pathology. For example, Latin for bladder is vesic for vesicouterine pouch, but Greek for bladder is cyst for cystitis and cystocele. Latin for breast is mammo for mammogram; Greek is mast for mastitis. Eyelid is palpebr in Latin (palpebral fissure) and blephar in Greek (blepharospasm). Fingers are digit (Latin) or dactyl (Greek); lungs are pulmon (Latin) or pneumo (Greek). It explains why you have an umbilical cord but a developmental defect is an omphalocele. Or why there is a lingual tonsil but glossitis. Or why uterine pathology is assessed with a hysteroscope. This is why the peroneus (Greek) muscles should instead be called the fibularis (Latin) muscles.

All information here was taken from Wikipedia.

Poem: Open Heart

Open Heart

We are not unlike pigs, if only they
stood proudly on two legs, wrote limericks,
ran races by day, businesses by night.

Holding my breath, I stare into the steel
reflection of the scalpel, stainlessly
negotiating the bloody terrain
of this man’s wish-broken car-trampled heart.
While the surgeon works deftly carving this
new home for a porcine graft, I wonder
how my hands would be: apologetic,
curt. For what would you say if, coming home,
you saw a pile of straw, a starving wolf,
a huff, a puff, a piggy dream cut out?

Orthopedic Surgery III

I'm not sure this really counts since it was only two weeks, but I just finished my first rotation! It was fun. I feel like I got a decent sense of sports medicine and a flavor of orthopedics. The faculty was really enthusiastic to teach us, the residents were great, and I loved the patients. I finally learned how to do a proper knee exam and am doing a little better with the shoulder. I worked on general clinical skills like reading imaging studies and doing H&Ps. I did a presentation on Achilles tendon rupture which went well. I had a few days in the OR which I really enjoyed. I'm pretty sure I'm not headed into sports medicine, but I really have a newfound appreciation for it. I've realized I can't rule out doing a surgical field in the future.

Orthopedic Surgery II

One thing I've noticed about orthopedic surgeries is that the set-up time for surgeries is significant. For example, ACL surgeries require the leg to be secured at the thigh but mobile at the knee. The other leg needs to be out of the way, and a surprising amount of effort and equipment goes into effecting that. The rotator cuff arthroscope I saw required the patient to be sitting up, which doesn't sound very remarkable. But we spent a lot of time making sure the airway would not be compromised, especially since the sterile draping would go over the patient's head, preventing us from being able to see the head and neck.

At the end of surgeries, I get to suture close the surgical incisions. For residents and attendings, it's a chore; it's a mindless task after the main show. But I really enjoy it. The residents are really good about guiding me about how big the bite should be, how tight the knot. Even in these three days in the OR, I find that my manual facility has really improved. And it's a fun thing to allocate to the medical student.

Orthopedic Surgery I

I had three days in the operating room which was good exposure to surgeries for orthopedics. The first surgery I saw was a humeral prosthesis. It was a long open surgery and the most eye-opening part was when they pulled out fragments of bone from a broken humeral head due to trauma. I also got to feel the glenoid cavity of the arm from the inside, which is a pretty unique experience. Last Friday, we did two arthroscopic ACL reconstructions using cadaver graft. I really appreciated doing two of the same surgery on the same day; it not only reinforced my learning by getting a better understanding of all the steps in the procedure, but it also helped me see the variability that could happen in the surgery (the first patient bled a lot preventing easy visualization; the second patient had a huge PCL). Arthroscopic procedures are really impressive; they're technically difficult, requiring a good knowledge of surface anatomy, manipulation of the joint, and manual dexterity to orient the camera and tools. It also requires a ton of patience. On Monday, we did an Achilles tendon rupture repair which is an open surgery. It was really cool to see a careful dissection: exposing the ruptured tendon ("frayed paint-brush ends"), isolating the sural nerve, finding the plantaris muscle (it's tiny). The suture-work to re-appose the ends of the ruptured tendon is also quite impressive. Lastly, I saw an arthroscopic rotator cuff repair, a long arduous procedure that requires an amazing technical ability to throw sutures within the joint using tools from the outside. It's difficult to describe, but very, very cool to see. It can be incredibly frustrating too when you worry about tangling sutures, unexpected knots, and difficulty manipulating the tools.

Image from aclsolutions.com

Scrubbing

It wasn't until now that I learned to scrub into surgeries. It's an intense experience. The first surgery I scrubbed into was a shoulder prosthesis and part of the protocol requires wearing these crazy helmets with a venting system. So not only am I sterile gowned, double gloved, and in ortho booties (serious shoe covers that go up to the knees), but I also get a face shield and a helmet hooked up to a battery for the fan. I kind of like the whole ritual, but the first few times, it's certainly a bit overwhelming.

Why We Do It

One of the other things I do during sports clinic is conduct pre-operative histories and physicals. I go over the pertinent medications, allergies, past medical history, etc. and do a quick heart and lung exam.

Over the last few days in the OR (probably tomorrow's post), I have been pleasantly surprised when I go see patients before their surgeries and they recognize me. I go in fully expecting to reintroduce myself, and instead, they turn to their family or spouses and say, "Oh, this is Craig, he was the medical student at my appointment earlier this week."

I don't know why I don't expect patients to remember me. But I always think of my role as insignificant; I don't do much that really counts, and everything I do is double checked by someone else. I'm here for learning; I'm only on the service for two weeks. Yet patients remember me. It really does feel nice to have some continuity of care.

Poem: Memories

I'm still working on this poem, it's fairly new.

Memories

Home: a stranger that welcomes me back
with a kettle on the stove,
a plate of peanut butter cookies, the tops
crisscrossed by the tines of a fork.
Growing up, the tea was bitter, scalding,
but now the memory soothes my throat.
I broke my arm, I’m told, and I find evidence
in photographs, orange time-stamps: ’88, ’89,
but no matter how hard I try, I cannot recall
which arm or whether I wore a bag while showering.
It’s the same if you asked me the Bill of Rights
or whether my childhood dog was short furred
and long tongued or the other way around.

What does it mean for these things to be lost
to the convalescence of a burdened mind?
Drinking a brew of Old English,
looking out this new city now,
its violent hills racing down to the bay.
I imagine a marathon of memories gamboling
down those side streets, through the park, waving banners.
Take me, keep me, they cry – a first kiss
at Rodin’s Gates of Hell, the presidents of the United States,
Yeats’ poem (what was it?) about Helen of Troy.
Her face never drew my pen across the page,
but it seized Yeats with purpose.
Such strangers vying for attention,
knowing I cannot take them all back,
afraid of being resigned to the place I’ve already tossed
this week’s grocery list, the lecture on Beck’s triad.
Outside my window, I see an x-ray from class today stop
to pick up a young boy in rollerblades
who has just fallen and fractured his arm.

Sports Medicine

I just finished the first week of a short two-week rotation in orthopedic surgery. I work with a sports medicine physician who is also the team doctor for national soccer and taekwondo teams which is very cool. Although the hours of sports clinic aren't bad (8:30-5), the schedule is packed; patients are allotted only 15 minutes each, which includes not only the history and physical but also dictation. This is typical of a regular clinic, but certainly isn't what I'm used to. Sports clinic is also nice because most of the patients are otherwise young and healthy athletes. I've seen a lot of knee and shoulder injuries, especially ACL tears and rotator cuff injuries. I've been learning a lot about those joints and how to do a good physical exam, feeling a positive Lachman and pivot shift. We also have didactics in the morning (conference from 6:45-8).

Stupidity

Stupid things happen to everyone. The right thing to do is to calm oneself, think about the patient and make sure he or she is safe, then follow protocol.

Excitement

Congratulations to one of my dear classmates who just gave birth to a happy baby boy! Hooray!

Picture taken by a friend of a friend.