Sunday, July 21, 2013

Family Practice Rotation

On Friday I finished my family practice rotation. On Monday I'll begin my surgery rotation. It's interesting that those two are paired together this block. In the clinic this past month I have found myself most excited about the procedures of the day rather than discussing sugar and cholesterol levels, side effects of new medications, how well a new dose is tolerated, etc. Not that those items were intolerable, they were just a little bit monotonous. Perhaps it would be different if I were actually able to participate in the mental exercises that led up to the decision to try something else...or not. On the other hand, perhaps I enjoyed the procedures because there were relatively few of them compared to "talking only" visits. Most days were 8-5 and once a week the clinic had extended hours 7-7 so the overall time commitment was reasonable. I liked the outpatient clinic for its versatility and income potential, but quite a bit of time is spent on stuff that is not reimbursable like answering patient emails, phone calls, coordinating specialists, tracking down patient records, medication refill requests, and paperwork verifying health status of high school athletes, commercial truck drivers, medical marijuana applicants, worker's comp, and everyone else who needs a doctor's note.

I really enjoyed my time during family practice, but I think that's mostly because I enjoyed the people I was working with rather than something truly enjoyable to me intrinsically specific to family practice. For the most part the patient population here were white middle class with a few Hispanics here and there. I liked that I never knew what the next patient was going to bring. Patients came in with issues of skin, memory, fatigue, lungs, bowels, bladder, heart, and psyche. Variety helped keep the monotony at bay, but after a while I found out that most times nobody knew for sure what was going on with most of the patients.

For example, a 45 year-old obese white female came in with difficulty breathing. She described being unable to comfortably take a deep breath due to epigastric discomfort. It had been bothersome for the last three months and she decided to get checked out. She did not admit to pain, cough, fatigue, nausea, vomiting, fevers, congestion, or black or bloody stools. She had tried GasX with no relief. She had a history of gall bladder removal 5 years ago, but no other surgeries. On physical exam she had a BMI of 38, temperature of 98.6, blood pressure of 126/82, and heart rate of 75 bpm. She was obese, had clear lung sounds, normal bowel sounds, with some reproducible epigastric 'discomfort' on palpation just under the ribs and sternum seven inches on either side of  midline.

The first time she came in we took her blood and waited for labs. Labs came back normal for amylase, lipase, ALT, AST, WBC, RBC, Hct, Hgb, and AlkPhos and abdominal xray and CT scan were normal. She came back in 3 days later with worsening symptoms and we finally decided to send her for an endoscopy. I left before I could hear the results. The doctors were all as stumped as I was which was a fairly common occurrence and the default in those cases was generally take some blood and watchful waiting.

On the other hand, there were infrequent experiences when things went as smoothly as a board question. A 30 year old white male with a recently acquired sedentary job presents with unilateral calf swelling and 10/10 pain just inferior to the popliteal fossa. It has never happened before but his father has had multiple episodes of 'blood clots in his legs.'

We sent him off for an ultrasound to check for clots and tested for Factor V Leyden mutation both of which came back positive.

In the end, I'll give family practice a good score:
+ variety
- procedures
- 'talking only' visits
+/- compliant, happy, good, not-too-high-maintenance patients
+ time commitment
+ family friendly
+/- financial stability

Sunday, July 7, 2013


I started third-year clinical rotations this month. First thing I noticed was that it is so much more fun that sitting in a classroom or studying all day.

I started off in a family practice clinic of 4 doctors and I wasn't quite sure what to expect my first day. For close to two years I have heard of institutionalized hazing - abuse built into the system for those trying to learn how to be a doctor. The first day I feared getting yelled out, told to stay out of the way, criticized for how little I knew, and getting my clothes sneered at for being under-starched. Those are the stories that people tell. What they don't tell is how wonderful the doctors and nurses are, how funny and respectful the patients are, how nice the staff members are, and how helpful everyone is.

I rotate between three doctors and when one of them discovered that I wouldn't be with him that first day he looked a little disappointed - just enough to make me feel like it was important to him that I was there. From where I stand, I decrease the productivity of these busy people to whom time is money and a third-year student takes time away from seeing patients by having to explain what is going on, or giving the student time to examine the patient, and formulate a diagnosis and plan. I don't know if or how much the school might reimburse the doctors I am working with for lost productivity, but the ones I am working with currently have been wonderful to work with.

My first day I expected to be thrown into the lion's mouth and expected to do everything all on my own. Instead my preceptor told me to "stay close, and try to get a feel of the pace around here. I bet you are so overwhelmed right now that you can't even function, so let's go slow, get you comfortable, and you can start seeing patients when you are ready." Before the end of the first day I was ready.

On the second day the doctor was with wanted to move a bit faster and said, "I want you to go see our next patient. I'm not going to tell you anything about her, but I want to know what you think."

I go it and my extensive two year training did not even begin to prepare me for what followed.

"So, what brings you in today?"

"I am here for an excision biopsy to remove some basal cell carcinoma."


I was never told that some patients might actually know what is going on. Everything I'd ever done indicated that the patient is in the dark, has one complaint and my job is to find out what that one thing is. Additionally, the situations we were trained on either wound up needing antibiotics or reassurance. I had absolutely no idea where to go from there or what my preceptor wanted me to learn so I turned to my extensive knowledge of basal cell carcinoma gleaned from having just barely finished 12 hour study-days in preparation for Step 1 of the boards just a week before.

"Have you ever been exposed to arsenic?"

"Not that I know of."

"Do you get sunburned often?"

"I did when I was younger, but I try to avoid the sun now."

At that point, a histopathology picture showed up uninvited in my mind and that's when things started to get awkward. Peripheral pallisading, myxoid stroma, artefactual clefting. None of that would be useful to talk to the patient about. She had probably never seen a histopathology picture. After a few quiet seconds I excused myself and went back to my preceptor. All she had to say was, "Good! I'm glad that you learned it's a basal cell carcinoma. Let's go take it out."

Cranial Week

Cranial week was an exercise in patience. An overview of the week goes something like this:

Eight to five every day for one week we were either in lecture learning about the anatomy, embryology, axis of motion, and dysfunctions of the various cranial bones and sacrum or we were in the lab with our hands on the heads of our partners trying to feel 'cranial motion.' Inherent cranial motion is the intrinsic motion of the brain, the involuntary rocking of the sacrum, and the waxing and waning of the cranium.

The sense of fullness or the widening of the distance between your hands is termed flexion or external rotation of the cranial bones. It's opposite is extension or internal rotation and both are related to a specific positioning of the sacrum. Bert and Ernie are often used to illustrate the difference between a flexed head and an extended head.

You may wonder why you have never heard of this type of motion. An arm has an shoulder, elbow, wrist, and digits full of joints that muscles act on to achieve a desired position. You have probably never heard of this type of motion because only a subset of a subset of medical professionals practice this type of medicine. Most DOs have some training in it, but a relatively small number actually work these techniques into their practice.

The week that we dedicated to 'cranial' would have gone much better if the teachers and proctors had been more credible human beings. Cranial motion is supposed to be just above the resolution of neural sensitivity in our hands, but tuning into the minuscule motions for the first time is difficult. Throughout the week when I responded that I couldn't feel my partner's head moving I got responses like:

-"If you were hallucinating, what would you be feeling?"

-"Pretend you are making it up. After a while you will believe you feel it so that you can feel it."

-"You have a very yellow aura about you. That means you need to stop concentrating so hard, back off, and tune into your right brain."

-"Those eddies of cerebrospinal fluid that you are sending across the brain to heal that suture are weak."

-"How's your shoulder feeling? I'm sending waves of positive energy to it."

Working under the assumption that the cranial bones move lead to some interesting anecdotes where practitioners were able to cure formerly incurable headaches, some types of blindness or deafness, fussy infants, and various types of back pain. I asked what I thought was a legitimate question in response to these anecdotes:

"If you are able to cure blindness, shouldn't inexpert students be able to cause blindness if they apply to much pressure or place a finger wrong in a certain area?"

The response was no, but I was never told why. Somehow, cranial is resistant to anything bad happening and the worst that can happen is you are no better off at the end of a treatment than you are at the beginning.