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

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