Poem: The Sjogren

The Sjogren

My father says he has The Gout
and only now do I understand how
he made the disease his own

I have The Sjogren
dry eyes, dry mouth
defying all doctors
No drug coaxes a tear
no meal waters my tongue,
I’ve tried onion cutting, sour sucking,
the sappiest of films

Finally named it
when I found this to alleviate
the grainy film over my eyes
A photo, her face a hands-breadth from his
their eyes oblivious to the camera which has caught
them in motion, her arms extended
resting on his shoulders
She has removed her elbow-length gloves,
and they are folded in half,
dangling from her hands
locked behind his neck
Her teardrop earrings match the rose on his lapel
and the suggestion of a bowtie I can’t see

How irrational, this wrenching, this tearing
I don’t know why it happens
but I would not be surprised
if his boyfriend too
kept this photo in his wallet.

500

Picture taken by my friend Julia in Costa Rica, 2008.

Family and Community Medicine

As a whole, I had a remarkably great experience in family medicine. I didn't think I'd like it very much, but the rotation really grew on me, and I was sad to leave just when I had figured everything out and felt comfortable with the rotation. While Santa Rosa was not incredibly exciting, it was nice to get out of the city and be in a different place. The residency program there is fantastic with dedicated teachers and residents. I was pleasantly surprised by the quality of the didactics. The diversity of clinics was great, and I got a lot of hands-on independence for a first rotation. This site focused more on acute care rather than chronic disease management, but I actually preferred that.

Here is how I feel about different specialties:
1. Family Practice / Primary Care - I have a better impression of primary care, but it still probably isn't what I'm going to do. I thoroughly enjoy working with both adults and children, I like outpatient acute care, and the breadth of material is fascinating, from derm to infectious disease to orthopedics. However, common things are common, and it's not too intellectually challenging. The appeal of primary care is working with families rather than doing procedures or figuring out medical mysteries.
2. Emergency Medicine - I've become a little less interested in emergency medicine. I had a great time in the emergency department and enjoy a lot of the diagnosis, acuteness, and action. There's a certain thrill to having anything walk through the door and being called to figure it out. The procedures are fun. However, emergency medicine does a lot of triage and stabilization and doesn't always see patients through to the diagnosis and treatment. There's a lot of defensive medicine and resource inefficiency. I also think it has more trauma and orthopedics than I want.
3. Pediatrics - This has gone up on the list. I really had a good time working with kids. They're emotionally uplifting and fun to play with. Outpatient pediatrics has less diagnostic challenge, but the patients make up for it. I never had any problems with parents. I'd see myself in a subspecialty rather than general pediatrics though.
4. Family Planning / Gyn - This is certainly interesting as a medical student, but probably not what I want to do with the rest of my life.
5. Dermatology - I got a better impression of dermatology, but don't see it as a career. Derm requires a lot of visual pattern recognition and has a decent amount of diagnosis. It has fun procedures and a wide distribution of patients. However, I think I like medicine too much to focus just on skin.

M&M

On the last day of family medicine, I attended M&M grand rounds in the morning. M&M stands for morbidity and mortality and refers to a traditional conference discussing patients in whom complications or errors happened. These grand rounds function as peer reviews of difficult situations, a confidential forum to debrief, and a learning atmosphere to improve health outcomes. Though they may sound morbid to the public, they are an important part of quality regulation and improvement in hospitals.

I found M&M rounds to be a really great experience. The case presented was a life-threatening condition presenting with untypical symptoms. I found it to be enormously educational listening to the thought process of the team and identifying the lapses in judgment that lead to the poor outcome. I can't share any more specifics as M&M is really a confidential setting, but I think it's a fundamentally critical part of any hospital.

Our final exam was an easy short answer test dealing with common chronic conditions, not a shelf exam. Then afternoon clinic, and one rotation down, five more to go.

Medical Spanish

I took Spanish in high school, the last time I regularly used my language skills. But since coming to Santa Rosa, I have found myself using Spanish regularly to communicate with patients. There is a significant Hispanic population that speaks little or no English. At first, I would pull in an MA (medical assistant) or use the translator phones to help, but over time, I have gotten more comfortable with my own language skills. Having an MA is the best option; I really dislike the translator phones set on speakerphone because I think it detracts from the patient-doctor relationship. It's always a little scary to communicate about something important and serious in a language I'm not completely confident in, but practice is also key to developing the skills. Now I feel good doing most of an interview for a straightforward chief complaint in Spanish. We have good patient handouts in Spanish for most common diseases; I often glance over that and refresh my memory on how to ask about certain symptoms. I always ask patients if they prefer a translator but I find that most don't want one and really appreciate my attempt at Spanish. I can always pull in an MA afterwards to discuss anything I don't think I can do.

Optometry and Neuro Clinics

In my last week at Santa Rosa, I got to work with an optometrist and a neurologist. The optometry clinic was really educational. I got to see the complete eye exam and all the fancy eye tools. While optometry can be a bit repetitive and routine with the "Which is better, 1 or 2?" and evaluation of visual acuity, it requires skill to use the slit lamp and evaluate the retina. There's little diagnosis; patients come in with known conditions: evaluation of diabetic retinopathy, change in visual acuity, red eye, and dry eye. The preceptor was fantastic; she helped me see hemorrhage in the eye, plaques, allergic changes, and the optic disc.

Neurology clinic was great. The preceptor was this brilliant respected Kaiser doctor who volunteers a lot of his time at community clinics and overseas. I got to see a good peripheral nerve palsy (brachial plexopathy post anesthesia), an interesting headache case (sounded like migraine with identifiable triggers, but turned out to be irritation of a cervical nerve giving retro-orbital pain), and a seizure case (likely due to side effects of morphine). The teaching was excellent and I realized how cerebral (pun not intended) neurology really is. It's diagnosis heavy, the symptoms are often not straightforward, and it relies on a good physical exam.

Poem: Lesson

This is an edit of a poem I wrote a while back. The earlier version is in the archives of this blog.

Lesson

The nurses here wear make-up
and all the doctors are available
Patients seize, swimming up from their beds
You wonder if they, too, have a crush on the intern

Learn medicine from your couch
Pay TIVO tuition, watching thrice married
surgeons save their ex-wife's ex-husband in time
for Southpark, another Great American Show, at 10

You can be a doctor too, you think
as the patient waits patiently on the screen
The only motion in the room: the buzzing of the lights
the sterile surfaces staring back

Santa Rosa

I just finished my rotation in Santa Rosa and realized I never wrote about the city itself, a slower-paced town. I actually enjoyed the 70 minute drive up, crossing the Golden Gate Bridge every weekend. I didn't really find time to explore the city too much, but I loved its open space and relaxed attitude. The weather was completely different than San Francisco, hot and dry.

The community clinic where I worked managed well with few resources. As students, we got to run the pregnancy tests, rapid strep throats, urinalysis. The medical assistants helped us so much. The preceptors were awesome, really taking time out of their jobs and lives to teach us and fix our mistakes. The administration at the program made life so much easier, working out organizational and scheduling problems that came up. Sutter Hospital actually has beautiful architecture and I got to know it pretty well. The hospital also payed for the students to stay at an extended stay hotel. While it wasn't home, I thought it was really generous for the hospital to do that.

I'm going to miss that daily commute from the hotel to the clinics, the grocery trips we made in our lunch hour, the joking around with the MAs. I actually wouldn't mind coming back to Santa Rosa, but the heat and the allergies make me wary.

ER

We spend some time in the emergency department here at Sutter Hospital, a different setting than I'm used to. While this is not a trauma center, we do get an interesting splatter of acute cases. The pacing is very different. I look on the triage board, find a case I think I can manage, and do a rapid H&P. I've seen a kid who stuck a finger in a fan, non-responsive alcoholics, renal colic, shortness of breath, shoulder dislocation, and otitis media (did not belong in the ER). It's fun to be the first person (besides the triage nurse) evaluating a patient and under the pressure of time, coming up with an assessment and differential diagnosis. I then go find an ER doc to present the case and make a plan.

The interesting thing about the ER is the low threshold for ordering labs and tests. Almost all women of a certain age get a pregnancy test even if the chief complaint is completely unrelated. Most patients get a smattering of CBC, electrolytes, and drugs of abuse. There are a number of reasons. The ER is in the business of ruling out life-threatening diseases. There is no margin of error for missing meningitis, appendicitis, hemorrhage into the brain. We also don't know the patients. There's no therapeutic relationship to begin with and we don't know how much alcohol they drank or what drugs they're on. Finally, there's always the threat of lawsuit which looms over every ER visit.

It personally bothers me to order so many lab tests because I don't think it's practicing efficient medicine. However, I do understand why it's done and I think it's justified. Unfortunately, that means I'm less inclined to be an ER doc. I love the acuity. But I hate that everyone gets a CT scan just in case. The ER is also prone to misdiagnosis. It's unfortunate, but I've seen patients in followup clinic and upon further investigation find that they didn't have what the emergency department thought. On some level, I understand. They made sure the person was not dying and didn't need to be admitted to the hospital. But once those criteria were satisfied, their attention went to more acute patients.

I did have one interesting ER visit. A 16 year old girl presented with an hour of vertigo, imbalance, headache, and nausea. But she looked toxic to me. Her mother says there was an altered mental status and she was poorly responsive. Although oriented, she did not want to answer questions and was pretty much curled into a ball. It looked serious; I thought she would be hospitalized. This feeling actually prompted me to be extra careful in my history and exam. I was motivated to work extra hard to identify how serious this was and what the cause might be. It may sound bad, but I actually liked that feeling of acuity, that something really was at stake here, and that I needed to act to prevent this toxic-looking girl from deteriorating. The truth was, the episode resolved without any heroic intervention and she was diagnosed with migraine-associated vertigo. But I realized that I am at my best with complicated and serious cases.

Palliative Care

I shadowed a pain/palliative care doctor today. Trained in family medicine, he had an early interest in death and dying and worked for the first hospice in Sonoma County. He is now the medical director for a palliative care unit and also does private care pain management. It was interesting to see the differences in this practice. He takes very good care of his patients; the first patient was in a wheelchair and I noticed that he was particularly gentle in wheeling him through the narrow corridors. This doctor does all his histories in his office, an executive-looking room with mahogany (or some other fancy wood) furniture, oil paintings, and comfortable chairs. He only uses the stuffy exam room if he has to do a physical. His patients are all fairly complicated, with chronic pain and cancer pain, and he takes a long time with them. I'm not sure I could deal with that kind of chronicity and difficult management as a career, but it is definitely an important aspect of medicine.

Teen Pregnancy

One surprising thing I found in my time here doing family medicine is the number of teen pregnancies. I've seen many teen mothers, the youngest being 16. It is often hard to reserve judgment but I really try. Some are absolutely in over their heads. Others are doing well, supported by family, still in school, motivated. In all cases, I have found the father to be fairly disinterested, which is unfortunate.

But today, I discovered something different. I saw a 20 year old woman who has been trying to get pregnant for over a year and a half but has been unsuccessful so far. This really made me think again about my preconceived (pun not intended) ideas of what's right or wrong in teen pregnancy.

What Matters II

What really matters? Why are we doing what we do? What are the ultimate goals of medicine? Are we in the business of saving a guy from a heart attack just for him to get a stroke a few months later? Are we striving to make people immortal? How much are we willing to pay to make people healthy? Does anyone deserve more or better health care than anyone else?

These are somewhat fundamental questions to the practice of medicine but ones that are rarely addressed. I get the sense that most of my peers believe in universal health care; they believe with respect to health, we all deserve the same attention and treatment. But what does this mean on a population scale?

With limited resources, how do we distribute health care? If, for example, I give someone a treatment that costs society $30,000 for him to live a year longer, is that worth it? What about $100,000? Or a million dollars? At some point, we should abandon these costly interventions and focus on more cost-effective treatments for our patients. Dialysis may cost $30,000 to extend someone's life expectancy a year. But what about counseling a person on diet and exercise? How much does that cost? And how strong are its benefits?

A Mediterranean diet and 30 minutes of exercise each day exert a huge health benefit. But I guarantee that if doctors suddenly became nutritionists and coaches, we'd become a much less palatable field. Yet shouldn't our focus be here? If we want people not only to live longer, but enjoy better quality lives, shouldn't we spend the bulk of primary care visits counseling about fruits and vegetables and swimming and smoking cessation? If successful, this beats all the colonoscopies and stents and antibiotics in the world.

But this still is thinking on too small a scale. To really get people to live longer and better lives, we need large scale system wide changes. We need to ban smoking. Get rid of trans-fats in food. Increase the educational level of the general population. Get people to exercise.

For a long time, I thought I would end up in critical care or anesthesia. It now disappoints me a little that these fields really aren't the ones that will make hugely influential changes in lives of the general public. Probably no traditional medical fields will. We focus on individual people and specific diseases not large populations. What matters? Helping out one person or helping many? Doing expensive cool technically challenging things or mundane obvious and obstinately difficult things?

Poem: Tessera

This is a new poem which still needs a lot of work.

Tessera

Where does the accent go in the word tessera?
Does it hop onto the first e it sees
making a less dynamic cousin of Tesla
or does it ride the second syllable, suave and Spanish?
I can almost see the accent running late, hand holding hat
from flying in the air as it leaps onto the train
and chugs behind on the last a, a caboosing rhyme with hurrah.
Even though they seem to be all the rage these days,
I really never understood cabooses,
if such things can come in the plural.
Back in my day (a fortdecade ago),
I had no train freewheeling figure eights
around a Christmas tree, no model tracks
to click together for the praise of engineering parents.
I had simply a teddy bear who now has cataracts,
his eyes glazed from rambunctious trips into space
or the Wild West or some other childhood haunt
that escapes my aging imagination,
where the foliage of the trees has overgrown the forest.

Oprah

I attended Stanford's Commencement ceremonies today as a few of my friends were graduating. The speaker this year was Oprah Winfrey and though her speech wasn't too remarkable, her delivery was fantastic. For some reason, I enjoy taking part in this sort of pomp and circumstance. I come out re-inspired to do something meaningful in this world.

Image from Stanford News Service, taken by L.A. Cicero.

What Matters I

Family medicine is the lightest third year rotation with no call and little work outside the outpatient clinics. I was advised to leave this for the middle or end of my third year when burn out is a large factor. But because I'm not tired or burned out, I've been doing a lot of thinking. Much of this is stimulated by talks given by the residency director Dr. Kopes-Kerr.

What matters? Why are we doing what we do? These two questions are really changing my paradigm of medicine. For example, why do we listen for bowel sounds in anyone except post-surgical patients? To say there are no bowel sounds, you have to listen for a significant period of time. Let's say I don't hear bowel sounds in an asymptomatic patient. How does that change my management? It really doesn't. Even if someone came in with constipation and I heard no bowel sounds, I don't think it would change what I did at all. As far as I know, it's not sensitive or specific enough of any symptom to really change my thinking. It's just a variable. Who cares?

Another thing taught to us is that a patient with stable angina (substernal chest pain radiating to left arm exacerbated by exercise, relieved by rest) should get a stress EKG. But why? The history is strong enough (high enough predictive value) that you would treat this as stable angina regardless of what the stress test results show. Thus, the test is just a waste of money. Really, if something doesn't change management, then is it worth doing?

Last week, I saw a patient who was extraordinarily reluctant to accept treatment for her diseases. She didn't want to take any medications (even OTC medications), she didn't want to try physical therapy, and she didn't want psychiatric counseling, yoga, relaxation, or anything. Really, she just wanted a miracle to cure her (and we'd give it if we had it). So even though we diagnosed her with deQuervain's tenosynovitis, it made no difference. It just put a name to a problem she refused to treat. We could have diagnosed anything and the outcome would be the same.

This is frustrating to me. I completely understand the patient's reservations in avoiding medical treatment. That's fine. But then what can we do for her? Really, not much.

Derm Clinic

I spent two half-days with Kaiser Dermatology seeing all sorts of skin problems. Skin is woefully taught in our traditional curriculum which focuses heavily on internal medicine. Then again, derm is a subject best learned through experience rather than reading a textbook. I got to see a host of common and unusual diseases. From dermatitis to psoriasis to skin cancers to plantar warts, there was both the important and the disgusting. Derm does have that association with "yucky" looking stuff and it takes some getting used to. I think the most important skin thing to learn is differentiating something suspicious for cancer and something benign. I'm beginning to learn how to describe how a lesion looks which is actually fairly complicated. In the derm clinic, I got to see full body skin cancer screens, a number of punch biopsies, a fast office procedure for obtaining tissue, and an excision of a nevus sebaceous (shown above) on the scalp. I'm learning a lot.

Image from www.dermis.net.

Family Planning Clinic

Today I spent an afternoon in a family planning clinic. It turned out to be a gyn heavy day with several Pap smears. It has been a long time since I've done or thought about a pelvic exam so that was a little nerve wracking. But with some review, I felt generally okay. Most were just well woman check ups with a clinical breast exam and a pelvic. We focused very heavily on primary prevention - smoking cessation, nutrition, exercise. Nothing too remarkable, but a new experience.

In my morning clinic at Kaiser, I got to cryo my first actinic keratosis today. It involves using a liquid nitrogen spray to freeze off precancerous skin lesions. Really easy (just point and spray) but quite fun. I also got to see a knee aspiration.

Healthcare Pun

This image was sent to me by a friend.

Poem: Switchback

Switchback

We play those hairpin turns in this game of chicken,
weave from side to side, the isolated road
racing away from the vineyards. The next switchback
around a manzanita, its fiery bark giving us pause.
We drift across the double stripes and a bump in the road
rattles the cases of charts in the trunk.
What did this mean, this forbidding evergreen
guarding the dropoffs down to Sonoma Lake?
How could we have known we had the wrong tools,
that instead of beta-blockers and diuretics
we needed scalpels and retractors
an army corps of engineers and a small miracle
to dissect out the Kashia tribe from the Western pannus
of canned foods, wide-screened TVs, diabetes.
Somewhere along those dirt roads, in that one-room school,
there is a hint of song, of dance, a tradition dormant
and unknown to the surrounding viticulture and spirit.

Indian Health Service

I got the opportunity to make house calls with a doctor working with the Indian Health Service (IHS). We went to the reservation of the Kashia tribe, about an hour and a half away from Santa Rosa in the secluded mountains. Doctors visit the tribe about twice a month to check up on patients (especially the older ones) who cannot make it down to the nearest city to see the clinic. In the morning, we loaded up the van with five huge crates of charts (since we could potentially see anyone on the reservation) and two large boxes of medications. We set off for Healdsburg, a really cute town to get some breakfast, and then off to the mountains. It was fun touring the area, passing by several vineyards, Sonoma Lake camping grounds, and the winding deserted mountain roads.

The reservation itself is a really moving experience. It is composed of 20-25 homes and a school for grades 1-8. The nearest town is an hour away. Few teenagers are willing to do the daily commute to go to high school. A lot of the teenagers work at nearby cities or wineries. Much of the food is surplus commodities given to the reservation. The roads are dirt roads. The resources are scant. Unfortunately, the Native American culture has been diluted down by various factors; divides within the tribe due to different religions, arguments over the importance of tradition. Most of the homes were in various degrees of disarray. I was really affected by everything. This is what it means to be in a low socioeconomic underserved population.

We made house calls and all the patients we saw were obese, hypertensive, and diabetic. I really see how difficult it is to change diet, motivate exercise, manage medications. The patients were 200 or 300 lbs struggling to get by the day to day, not even thinking about complications of their diseases down the line. It's easy in an office to expect patients to manage their diseases by changing lifestyles and taking drugs. This made me realize how awfully difficult reality is. The patients, though, were really glad to have me and the doctor come into their homes and talk to them about their lives and functional status.

The sad truth is the Indian Health Service is a well run federal health care provider. The clinic at Santa Rosa is fairly impressive. They send up medications to the tribe every other week. There's health care access despite the poverty. And yet, these chronic diseases exert their toll. How we can change this, I don't know.

The Problem with Screening

The problem with screening for colon cancer with colonoscopy, breast cancer with mammography, cervical cancer with Pap smears, etc. is that the positive predictive value of such tests is highly dependent on prevalence of diseases. Most of abnormal findings on mammography are false positives; the screen detected something that turned out not to be cancer. Obviously, the predictive value of a test increases if the prevalence of the disease increases. The problem is the highest prevalence of these cancers are seen in those with low socioeconomic status. Yet patients with low socioeconomic status are not the ones getting screened. The problem with our health insurance system now is that it systematically excludes from screening those who would benefit the most from it.

Rat Poison

In the early 1920s, a bunch of cattle started bleeding to death from eating moldy sweet clover. Karl Link and Harold Campbell, chemists at University of Wisconsin, identified the anticoagulant substance in that clover as a coumarin derivative. Link then worked on making coumarin derivatives for rat poison, finally coming up with the commonly known drug warfarin. So where did the name come from? It stems from WARF, the Wisconsin Alumni Research Foundation + -arin from coumarin.

Source: Wikipedia.

Out of Practice

In Medicine Grand Rounds, three case presentations of unusual diseases were given. I should have gotten the diagnosis for two of them (the third was cryptogenic stroke) and I was so close; it's that moment you have when you know the answer but you just can't articulate it. Anyway, I shouldn't beat myself up over it; a bunch of the old-timer attendings were racking their brains too. But it was still a frustrating feeling knowing that I knew the diagnosis but not knowing the diagnosis.

Asclepius

This is a statue of Asclepius from the Glypotek, Copenhagen. Photo credit goes to Nina Aldin Thune, shown under GNU Free Documentation License, taken from Wikipedia.

Monday Morning

People aren't the only ones who get sick. My computer caught a (hopefully) self-limited virus this weekend. Oddly enough, I started thinking of the sensitivity and specificity of anti-viral programs. I usually run a few to increase the sensitivity I catch something. You would think the specificity would be 100%, but some anti-viral programs actually search for code sequences and signatures that have a similar pattern to real viral code; this increases sensitivity at the cost of specificity.

But I have a joke for you from my friend Kate.

What did the hippocampus say during its retirement speech?

"Thanks for all the memories!"

Poem: Heroic Couplet

This is one of my more obnoxious attempts at form poetry.

Heroic Couplet

The two hold hands and cross the muddy grass
They reach some muck she wonders how to pass.
With grace, he sheds his cloak and leads her ‘cross
The shallow puddle o’er the field lacrosse.
The coat a bridge, the boy a hero true
The young girl’s cheeks develop pinkish hue
What lovely smiles indeed do grace their faces.
The charming teenage couplet then embraces.