Oh, the possibilities...

Once again I am in the unfamiliar waters of not having a solid answer at my fingertips.  So much in medicine is evidence based - we know that if we give you antibiotics (the right ones) you will be cured of your pneumonia.  We know that if we sew your wound closed within 6 hours (newer studies are saying 24 hours for clean wounds), your chance of infection is only about 5%.  These are facts as far as we're concerned.  No more debating to be done.  As students, we learn myriads of these facts and are armed with solid answers for a multitude of medical complaints.  And then comes clinical year and we realize that so much of actual medicine is far less certain than we were initially taught.  Does this wound need a two layer closure, or will just one do?  How many sutures does it need?  Is this viral, or bacterial?  Will chronic tonsillitis cause a child to have paroxysmal nausea with vomiting?  Is this patient septic?  Does an elevated carboxyhemoglobin explain all of these symptoms, or just a few?  Should this patient be admitted, or not?  Many of the questions that we have can only be answered after a lab has had a chance to run certain tests, which often take a day or two.  Thus we make treatment decisions based on probability, or more plainly put uncertainty.  This is medicine, take it or leave it.

I have spent much effort getting comfortable with this.  As a clinical student, it is my job to learn to operate in this world of incomplete certainty - "Mrs. Smith - you most likely have a viral bronchitis and will not need antibiotics for this condition.  Use symptomatic treatments like cough syrup and throat losenges.  If you're not better in a week, come back and see me and we'll see if we need to do something different."  In this case, the most likely diagnosis is a viral illness, but it could be bacterial.  We can't be certain without expensive and, sometimes, inaccurate tests.  This case is a simple one but they can be much more complex and serious such that if we don't have a grasp of operating in uncertainty then we may end up contributing to a patient's demise.

In the ER it comes down to a relatively simple problem - what could this be that might kill the patient?  If we can rule all of those out, but still don't find an answer to exactly what's causing the symptoms, then so be it.  We'll have them follow up with their primary care provider later.  But when I was working in internal medicine, we were the primary care providers.  Here's an example: "I went to the emergency room over the weekend because I was having a lot of trouble with pain in my legs - so bad I couldn't walk.  What do you think it is?"  In this case, the ER has ruled out the "Big Bads" - things like PE, cancer (sometimes), fractures, and the nasty bacterial infections.  But they didn't give the patient an answer - they were only able to treat the symptoms (make the patient functional again, which is always a win in my book), made sure it wasn't anything "serious" and let him go on his merry way.  But then in internal medicine we were expected to come up with the answer - this is our job, so I'm not complaining.  Yet the patient sits in the examining room and we, without certainty, begin the workup again (usually we don't get the results of all of the tests done in the ER).  So from an uncertain footing we begin and we do all the same stuff as the ER docs/PAs/NPs perhaps with the exception of x-rays at first (though, of course, repeating an x-ray after a week can show occult fractures - something to keep in mind).  We repeat the physical exam, trying to be perhaps more thorough than the previous provider, and hope to come up with some more clues.  Sometimes we get the answer from a test or a physical exam maneuver, but sometimes not.  In that case, we have to say something along the lines of, "This is most likely [you fill in the blank].  We'll treat you much as they did in the ER, but we'll try something new that will cure it if it is what we think it is."  Talk about uncertainty...

This is generally not how we are taught to practice medicine.  In classrooms, we are taught the typical prodromes and clinical pictures of disease - a patient comes in with chest pain when taking a deep breath and his EKG shows a deep S wave in lead I, a pathologic Q wave and a flipped T wave in lead III - what is it?  This would be a "classic" presentation of pulmonary embolus (PE) but truth be told, it is nearly never that clear cut.  One preceptor notes that in all his years of practice, he has never looked for that classic "S in lead I, Q and flipped T in lead III" pattern for PE.  Thus classroom learning, though undoubtedly beneficial, does not reflect real world situations as well as we would like.  In my recent (though short) experiences, I would have to say that probably 1/5 or even 1/4 of the patients I have seen have not had "classic" symptoms of the conditions with which they end up being diagnosed.  Though this is not news to anyone, I think it highlights the value of clinical experience - both before PA school and our clinical year.  In some ways, I believe this year is my true medical education because I not only learn the facts of disease but I learn the uncertainty of medicine as well.

Perhaps if we designed a new curriculum to address uncertainty a bit better, we would all be better off.  Of course, whoever can figure out how to do that will be a millionaire and won't ever have to work again.  Where would be the fun in that?

"Lost to follow-up"

This phrase is one that is often used in scientific literature to describe members of a longitudinal experiment who cannot be contacted after a certain period of time following the initiation of the research project.  They have been lost as far as the researchers are concerned.

I have titled this post as such because this phrase keeps running through my mind as I consider some of the patients I have seen and treated in the ER.  A vast majority have been treated and discharged, some have been treated and admitted only to be discharged a day or two later by their hospitalists.  I don't consider these patients "lost to follow-up" because there is, essentially, no follow-up required.  We have provided definitive care either in our ER or within our hospital system and these patients leave my care in stable condition.  However, I carry the cases of a select few patients who did not receive definitive care while I was rotating through the ER.  Over my month-long clerkship, there were just a few patients who were so ill as to warrant admission, but who did not receive a cure while within our system.  These few are lost to follow-up for me, and it occurs to me that I am somewhat saddened by the fact that I couldn't have a hand in "fixing" them - making them free of their illness as I was able to with so many others.

This is part of being a student - involved in a certain population for a while, then off to the next rotation and everyone you had previously cared for is lost to follow-up.  

The worst day

Putting this one into words may be a little bit difficult.  My aim is to convey a couple of ideas and I need to do it while preserving plenty of anonymity.  On top of this restriction, it's a bit of an emotional issue - so please bear with me as I stumble through this topic.

A number of days ago, we had a remarkably sick patient come through the ER.  Not knowing how sick this person was, I was initially a little unimpressed by the presenting illness - nothing seemed too amiss.  As I presented to my Attending and proposed a workup and treatment plan, I was educated in just how to treat someone with these co-occurring symptoms.  Through this process I realized how ill our patient was (or had the potential to become) and thereafter kept a keener eye on how things progressed.  I was humbled by the experience of having initially assumed our patient was not sick when in fact the opposite was true. 

This brings to mind another point: we have had drilled into us the idea that we need to be able to differentiate sick from not-sick.  Sometimes this is referred to as a doorway assessment or a ten-foot assessment.  One of our instructors would show us pictures of patients and quiz us: "Sick or not-sick?" he would say...  Sometimes it was obvious, others not so much.  Admittedly it was difficult to tell especially for a new student.  I still have a ways to go, naturally.  But it's an important skill and this case illustrates that well.

At any rate, this patient was definitely sick and my doorway assessment was inaccurate.  Our patient became a bit more ill in our department so we got an admission to the hospital set up.  The patient got worse and ended up in the ICU (intensive care unit).

This is where the main point of this post comes in.  One aspect of emergency medicine that is incredibly rewarding is the fact that we often take care of people on their worst day.  Something has brought them to see us that is worse than any other illness or event in their life - something like a heart attack, brain attack, or major accident.  We have the opportunity to make a horrendous event just a little less miserable, sometimes make it resolve altogether.  What a great thing to be able to do.

On this particular day, our patient's worst day, I had the opportunity participate in the care that made it a little bit better.  We helped a family cope with difficult times and cared for a patient who, without good treatment, faced a terrible prognosis.  This is a part of the honor of practicing medicine.

Condensed down into a pithy saying: a patient's worst day brings the opportunity for us to have our best day.  I just hope that, with time and more training, I will be able to fulfill my end of the deal.

There'll be days like this....

As we all set about our medical careers we understand that there are going to be certain days that stick in our memories for a lifetime.  There will be days when the events that unfold make an impression upon us - days from which we learn volumes yet feel as if we have fallen flat on our faces.  These days are difficult to bear, but strike so well at our weaknesses that they are essential to becoming proficient medical providers.  Today was such a day for me.

Without going into too much detail, we had a number of pretty sick folks come through the ER today.  As a student, I was unfortunately a bit hamstrung in what I could do to help in these cases - the bustle of activity surrounding me included skills that I do not possess and skills that are not easily acquired in just a month of emergency medicine.  This experience was intensely frustrating in some ways and incredibly valuable in others - frustrating because the skills are ones that I need to know to practice medicine well, yet valuable in that essentially I was allowed to be a fly on the wall observing some talented providers work together to provide good medical care.  In my case, the frustration overshadows the value a bit.

But to make good use of the time I spent in the ER today, it is my job to see to it that the value is evident in the end.  Our clinical experiences will be what we make them to be, not more and not less.  With this in mind, I can let the memories of the events that unfolded today sink in and stay with me so that when I am in practice and begin taking care of patients as sick as those that I saw today, I will at least understand the sequence of the things that need to occur.

As it turns out, I don't think I have a choice about whether or not the events that transpired will stick with me - some things we don't tend to forget. 

SCUT Monkey

Many books have been written on this topic and every medical provider has had to perform this role at some point in his or her career.  The role of the "Scut Monkey" is one that some do not desire for, to be honest, it can be an undesireable job.  But this work has to be done.  I have learned to fulfill this role mainly in the form of taking care of our "frequent fliers."  It has been challenging, but interesting, and up to this point I don't mind the job too much.

The situation is usually the same - the doctor (my preceptor) will say, "I think you should go see Mrs. Smith," usually with a sly glint in his eye.  The PA working in the department will say, "Ooooh, yeah!  Mrs. Smith will be a good patient for you to see," with a wicked grin.  Of course the PA really means, "This is going to be a challenging and potentially annoying case that will probably end with the patient making inane requests or having a laundry list of complaints a mile long that we have already worked up literally twenty times without any new results... so let's see if you can get all the right answers."  I try to dutifully march off to see the patient, but often I say to myself, "Not another one!"

It is here that I must take pause and mention something that my preceptor and the PAs in the department have already taught me - even frequent fliers get sick sometimes.  The same things that can afflict John Doe can effect Mrs. Smith, and it is in this type of patient that we will most likely miss a major medical problem, because we've heard it all before.  We have heard the complaints of abdominal pain, or back pain, or headaches a hundred times (sometimes literally) and there is never anything to point to an actual cause of the symptoms, so we think, "Why should this time be any different?"  Isn't the definition of insanity something along the lines of repeating the same exact activity a number of times and expecting a different result?  Admittedly, it takes a bit of a naive mind to subject oneself to the difficulties of getting an H&P on this type of patient, but that is exactly what I am - a naive mind.  I need to fill it with something, right?  Who better for a naive mind to see than someone who has a number of complaints without corresponding physical findings?  It is this patient who will challenge my diagnostic abilities the most - and one that I have the luxury of time to examine.  Will I be allowed to assess a patient in flash pulmonary edema?  Not likely - this patient's respiratory compromise warrants more urgency than a PA student in his second week of emergency medicine can provide, especially since this particular PA student has only seen one or two of these types of patients in his entire life.  But the frequent flier...  This is a patient that the doctor already knows and someone that will allow the PA student the time to perform a solid H&P and the appropriate tests in the hope that this naive mind might give them whatever it is that they seek.  And this is why it is a good experience for me to see our frequent fliers.

Interestingly, in one book on the topic of "Scut Monkeys" the charge was given to think of SCUT as an acronym for Some Clinically Useful Training.  My charge to those that come after me is to adopt a constructive view of scut work for we will all have to perform these tasks - but they are what you will make of them.

Thrill ride

I have been having some trouble coming up with an update about where I am and what I'm doing.  I think this is mostly because I've been having too much fun doing it. 

Thus the update of the day is that I am currently doing an ER rotation at the largest regional medical center in our area.  It is so enjoyable that I hardly feel I am at school.  My preceptor has an amazing amount of knowledge to share and has been pretty willing to have me experience new things first hand - like suturing.  On my first day a patient came in needing a number of stitches... my preceptor said, essentially, "Go for it," and with the appropriate supervision (he looked over my shoulder the whole time) I closed the patient's wound with no trouble.  It was a good experience.  I have had many others already, and I've only worked 2.5 shifts (30 hours) so far. 

One dilemma I have faced so far - and one that hit a little too close to home - was that of how far we as providers should go for patients in a permanent vegetative state.  This came up in my last rotation as my preceptor and I listened to a radio news broadcast on the subject.  We discussed this and the question that arises is this: should we do absolutely everything for everyone?  Of course, if we say that we should not provide life support for people in permanent vegetative states then at what point will we draw the line?  Will we begin to draw it further and further down the line?  Will we start withholding medical care from the frail elderly or those who are simply so ill that they have no change of a meaningful recovery?  Truth be told, this decision does not lie with us (the medical providers) but often times families ask us what we think - what we would do.  It is their decision, but they seek affirmation of their choice and support for whatever they elect to do.  The weight of the situation is such that it warrants a great deal of forethought. 

One discussion point that I think helps me the most is this: perhaps we should draw the line between prolonging death and preserving quality of life.  If a patient is in end stage lung cancer with multiple metastatic lesions to their bones and in excruciating pain all day, every day then perhaps we should not seek to blast them with all sorts of chemotherapy and make them endure their pain longer by only slowing the progression of their disease without hope of a cure (aside from a miracle direct from the hand of God).  Perhaps in this situation we should simply help them be comfortable - not hastening or prolonging death, but providing comfort and care for the ill in their final days.  And I think that most reasonable medical providers can see the logic and compassion in this situation. 

But how does it change in a pediatric patient?  Perhaps there is more hope for a cure and long years of a high quality of life, or perhaps a child is so ill that he cannot be saved.  This is a huge dilemma for all of us, and the answers are not so clear cut.  I have struggled with this recently and will no doubt revisit it.  But my preliminary thought is that if, for example, a child has an injury that has left them without higher brain function such that they have a steady heartbeat and steady respiration we should do nothing to prolong their entrapment in that tomb made of flesh and bone.  We should not hasten death, but I have to ask a question: what good does it do a person to be trapped without hope of recovery inside a body that itches, that hurts, that will become ill over the years?  In this situation there is no expressive faculty left for the patient and no ability to move - in my opinion this would be more like torture than life. 

So where should we come down on this issue as medical providers?  Well, I have my opinion, and others will have their own.  And, to be honest, it is unlikely that all of us will ever agree.  But we should all give it a great deal of thought and we should all do it early in our careers so as to be ready for these situation because, as I have seen, they come up often. 

PA school interviews

Taking part in an interview for PA school is quite an adventure in and of itself - I should know: I did it twice.  The day begins as any other with an alarm clock blaring.  The first difference is that the candidate is most likely already awake and just waiting for the alarm clock to go off.  The morning routine progresses with more intensity, more enthusiasm, more attention to detail, and often more quickly than usual.  The trip to the interview site goes more quickly than ever before, too.  It is filled with thoughts about how to answer the questions, about what the future might hold, and often about how much the interview itself means to the candidate.  One question that comes up often is, "Why do I want to be a PA, anyway?"  Everyone's answer is different, but this is the central question that interviewers want to get at.  The interviewers want an answer and then they have to judge whether a person's motives are adequate.  This is the tricky part. 

It is this last part that I want to comment on today.  I have now had the experience of interviewing the next round of candidates to come through my school's PA program.  It was my task to assess whether or not the candidate's motives are right, whether they are at the right depth and maturity, and whether or not the candidate really knows what lies ahead - what a PA is and does, what it means to be in PA school, and what taking sips from a firehose is all about.  In the end, it comes down to one decision: accept or reject.  This was the hardest part for me.  Having been in their shoes so recently, I could see the future they were hoping for and that this interview was their first step.  I could still see it from their perspective very freshly.  Thus it was difficult to weed out those who just didn't have it - I wanted them all to succeed because they all brought some sort of promising characteristics to the table.  Some not as much, and these were the ones that I could not decide upon.  But weighing these things - desire, motivation, knowledge, maturity, motives - was done well and a good class is coming up for next year. 

I was honored to help select them and humbled by those that I did not select.  Afterall, I did not get selected once and I remember how it feels.  My hope is that all those who didn't make it will show their true character by keeping their chins up, setting goals to improve themselves over the coming year, meeting those goals and re-applying next year.  If they do these things, they will shine brighter among a group of bright young people next year and will, in the end, make a fine PA someday. 

Sirens awail

This is what I do in my spare time.  I am a volunteer EMT with the local fire department's ambulance company. 

Let me just say that the folks I work with in the company are an inspiration to me and have been a very strong influence on why I want to practice medicine.  They work hard and are available 24/7 to help those who are in need of medical assistance.  The kicker: nobody gets paid a dime.  Their sacrifice embodies the Christian principle of, "My life for yours," and reminds me every time I run a call with them why the calling of medicine is so great.  For another perspective, go here and click on the video at the bottom labeled, "Moscow."

More transitions

This week I began a stint with the government.  I'm working in general internal medicine, which has been quite the culture shock.  I see patients with no fewer than five concurrent medical problems, and during the visits I generally manage to elicit at least two additional medical complaints from side pain to, "Oh yah... I've got this thing on my toe..."  This rotation is intimidating beyond what I had initially anticipated, but the biggest challenge for me has been the adjustment from the fast paced and well delineated world of general surgery to the much more relaxed paced (yet still incredibly busy) and nebulous world of internal medicine. 

A week ago I was doing rounds on a number of patients each with a clearly defined medical history and all of the necessary diagnostic testing at our fingertips.  We would be sent a patient complaining of right upper quadrant pain, for example, and they would have blood chemistries and blood cell counts already done or available within the hour.  They would have CT scans already performed and the scan would be accessible to us within two minutes. 

But this week I am working in a governmental systems with more "i's" to dot and "t's" to cross than I can keep straight.  When the patient comes in with a complaint, we are the ones trying to coordinate the labs and imaging which we won't see for at least a week.  We have records dating back YEARS that we must pore through to get to the bottom of the issue.  The conversation often goes, "I was seen by a doctor... whatshisname... over there at that one clinic?  Yeah, that guy.  Anyway, he saw me and ordered all sorts of tests.  He called my condition "somerandomname" and gave me these pills.  Itinilol or something like that.  Can't you just look at the records on your computer?"  Of course we do our due diligence and track down all of the records, complete and incomplete alike, and piece together the progress of the problem at hand.  It takes an experienced provider at least 20 minutes to get it all together, and it takes me easily three times as long.  It is frustrating, but rewarding.  I put together the pieces of the puzzle and get to the bottom of the problem, find a solution, and get the patient sent on his merry way.  My biggest challenge now has become determining which pieces play a large part in making the diagnosis and which ones are less important.  For example, a patient with unexplained weight loss, restlessness, insomnia, and excessively active reflexes doesn't necessarily have a thyroid condition as one would suspect based upon the textbooks. 

I think the issue that has come up is that as a student I don't have enough snapshots of what hyperthyroidism, renal artery stenosis, autonomic orthostatic hypotension, etc. look like.  I have pre-conceived notions of how these things might present, but these don't match with reality well because of my lack of experience.  My hope is that this will come to me quickly and that each time I see something new I will take a good mental "snapshot" of that condition and store it away for benefit to my patients in the future.  In the meantime, I need to be wary of trying to shoe-horn symptoms into a pre-conceived mold of what condition a person with mild peripheral nerve problems and large red blood cells has. 

What an exciting time!

Interesting experiences...

So today marks the first day that I have been lied to by a patient.  Short version: there was a car accident.  The patient denied using any "substances" prior to the incident.  Toxicology disagreed. 

I was notably chagrined to find out that I had not done my best to get an honest and complete history from the patient.  But I learned that there are situations that are not acceptable - having a patient's family in the room will not work.  I understand that in situations like today, it is not good medicine to have family in the room. 

And I have taken another step on the path to good judgment.  As they say, good judgment comes from experience, and experiences are gained by having bad judgment.  I deemed the patient a reliable source, and my poor judgment on that gave me some more good experience.  Experience I hope I won't soon forget. 

All good things

As I come to the end of my surgical rotation I note that all good things must come to an end.  This has been a fantastic rotation for me.  I have learned quite a lot about the practice of medicine both from the medical knowledge standpoint and from the practical application standpoint.  One of the biggest take home points is that my academic knowledge translates well into real world scenarios, but not always the way that I had expected.  For example - a patient with intractable nausea and vomiting whose CT scan shows gallstones doesn't necessarily have cholecystitis and should not necessarily be taken to surgery right away. 

That said, I leave this rotation feeling as if there is so much that I don't know that it is frightening.  I recognize and fully admit that I don't know everything about medicine, but at the moment I am feeling the weight of precisely how much I don't know.  From what I've been told, this is a natural feeling.  It's still uncomfortable, and I am even more aware that by the end of the clinical year I will still not know all there is to know.  My prayer is that I will know enough, and more importantly that I will recognize when I don't know what I need to know.  I think that the latter is the most important thing and I hope that I get a chance to develop that skill in the coming week. 

Surgical self-reflection

As I muddle my way through the surgical clerkship I am reminded that continuous self reflection and precise revision of ideas, thought processes, and methods for carrying out tasks are skills that are developed alongside clinical acumen that comes with experience. 

As we worked through the didactic year, we all had to develop our own studying styles and methods for parsing out the critical information from all of the LOADS of information we were presented.  We had to continually monitor the way we learned to get to the key features of what we needed to learn.  After each exam we needed to evaluate how we had studied to determine if it was the right way to do it - did we get the result that we'd wanted? 

After each surgery and each patient encounter, I have been evaluating the way that things have gone.  Did I ask all the right questions?  Did I anticipate the surgeon's movements well enough?  The most interesting aspect of this has been that the surgeon I've been working with does this, too.  After every case he goes through the steps of the case no matter how routine to make sure that it went as well as it possibly could.  If something wasn't right, he has to figure out why.  This is a skill we could all benefit from developing and one that I know we as students have to work through.  But the challenge and the charge is to continue to self-reflect and develop new ways (better ways) of practicing medicine. 

It's not that I think this is news to anyone - rather it is probably mundane by the end of your didactic year.  But it should not be mundane or taken for granted.  We should all work to analyze each suture, each H&P, each patient encounter - and make the most of our experiences so our patients will benefit in the end. 

Social ettiquette

I have to write about this as a bit of a pointer to those who will come along behind me.  In a way it's kind of humorous because most who know me in a professional setting probably understand that I am fairly particular about rules of social behavior.  I like my personal bubble and I try to respect other peoples' personal space.  "Please," and, "thank you," are common words in my vocabulary (though not common enough to some).

But the world of surgery is different, and I am having some trouble adjusting to it.  The other day I asked for, "Scissors, please."  When I received them, I said, "Thank you."  The surgeon stopped what he was doing and stared at me.  His words were, "you need to stop that right now.  Stop being so polite."  He was half joking, of course, but he had a point.  That is that we must be as polite as is feasible but as direct as is required to get our job done.  Extra words are, in a pinch, unnecessary.  And today I was having some difficulty visualizing the surgical field because of where I was standing - to the right of the patient across from the surgeon.  The surgeon was working deep in the abdomen and I could not see what she was working on in order to keep the field clear.  But I couldn't see because I was trying to keep my head a reasonable distance from hers (personal bubble).  It was frustrating for her that I couldn't do my job, and unacceptable in my opinion.  The tech explained that the sense of personal space is modified in the OR and the surgeon explained later on that I have to do whatever is necessary to see the field in order to help her do her job.  This might include being nearly ear-to-ear so that I can see what I need to.

So another lesson from the surgical ward: get over being polite... sort of.

Know your patient.

Most books that provide advice to medical students are unified on this aspect: know your patient.  Know them as well as a neighbor or a friend.  Know them better than their doctor's, your preceptors, know them.  Know their kids' names, parents' names, and whether or not they have any pets.  Maybe even find out what their favorite color is.  Ok, favorite color was my own addition, but you get the idea.  The fact is that our instructors last year gave us the same advice.  Know your patient.  

I have continued to think about this charge that we have been given.  I have been working to know my patients as well as I can, and I have made many inroads in this direction.  But I keep coming to this idea that knowing our patients is extremely important to the practice of medicine.  We must know their complaint, and the history of the illness.  We must know their entire past medical history and no detail is too small, really (unless it's a multivitamin, perhaps, but even then that can be important).  Their medications, their allergies (even hay fever), their history of surgeries, their habits...  We must know it all.  We must know it all so that we can practice accurate medicine - provide the right medications, the right operations, and the right recommendations and counsel. 

But what really strikes me about this is how willing my patients are to discuss any aspect of all of this with me.  I realize that the patients simply want to get better and this desire drives much of this.  I don't know what accounts for the rest, but I hypothesize that it's the white coat, or perhaps the stethoscope I carry.  Maybe it's the nametag, or simply the idea that anyone who introduces themself as a student and begins asking the right questions should receive this kind of deference - the voluntary submission of information.  Whatever the source, it amazes me that my patients are so forthcoming and that these relationships - knowing our patients as well as we need - is relatively easy to do. 

Compassion

The course of this week has been much different than the last.  This week I have been challenged on a different scale.  I have enjoyed the rigors of the surgical service as much if not more, and we have had some very interesting cases.  But this week has presented me with an interesting opportunity - an opportunity to take a step back and try to remain objective about the practice of medicine.

I have noticed that it's easy to get caught up in the practice of medicine under a preceptor (or, more appropriately, learning to practice medicine).  In the process of simply learning the art of medicine, it is easy to become influenced in many ways - and often it is important to let oneself become influenced - by our preceptors.  But this week I have had the opportunity to evaluate the attitude that both my preceptor and I take into the patients' rooms.  I have noticed that my attitude is different, notably more naive, but at the core is this desire to have compassion no matter what the patient's condition or complaint.  My preceptor has a more realistic view, a more seasoned view, one that includes compassion for hard plights but a more comprehensive understanding of the human element that plays into how we practice medicine.  My preceptor is efficient and cuts through the fluff surrounding a patient's history.  I can understand how this might come off as indifference to the patient's problems, but this week I have had the opportunity to see an excellent surgeon take on some difficult cases and difficult patients and their families.  There is a difference between what is perceived and what must really occur behind the scenes from the provider's point of view.  This week has been an exercise for me in not taking the surgeon's reactions on face value but rather I have had to try and understand the experience that has gone into my preceptor's approach.  At times it is difficult to avoid disagreeing with that approach, but I am the student.  I am the young one - the inexperienced one.  I have much to learn and this is an experience I can use to gain insight into the practice of medicine in the real world.

I don't defend mindlessly adopting the attitudes of anyone who instructs us.  But in this situation the options are to accept, reject, or make the most of what could be perceived as a cynical attitude toward certain situations.  I think that this week has taught me to take a step back from being enmeshed in dealing with patients to evaluate as objectively as possible the attitude with which I do it.  Will I have blind compassion for the patient and pour out my utmost for each and every one?  Will I approach each individual with the idea that they are simply gaming the system?  Or will I figure out now in some small way the difference between those who truly need compassion and those who should not be taken at face value?  Experience builds this ability the most, but my hope (and the opportunity that this week has presented) is that I will take from this rotation at least a step toward knowing the difference.

Good Medicine

A couple of days ago I was tasked with doing a consult in the Emergency Room to determine what the patient's status was, confirm the suspected diagnosis, and determine what admitting orders were needed for the patient.  I found the patient easily and had a brief conversation with the provider (a PA, by the way).  To make a long story short (and HIPAA compliant) the patient's illness worsened and we ended up having to do surgery.  I was able to assist, and the operation went off without a hitch.  It was an unparalleled experience for me and one I hope I won't soon forget.  Taking care of another person on this level is what I have always wanted to do and I suppose this was my first chance to do so.  I guess all I can say about it is that I feel blessed. 

The impact that this case had on me was indescribable.  This is the first patient that I have seen from the beginning of the hospital course, through the surgical course, and I will see this patient again next week to follow the case hopefully through discharge.  As I left the hospital I was filled with so many emotions that I could barely contain myself.  I felt compassion for the patient's plight, but pride and accomplishment that the surgeon with whom I work was able to make huge strides toward fixing the problems.  And then there was joy - I was overjoyed that my first week had ended so amazingly. 

As I write this I feel a bit cheesy.  I'm not one to talk about emotion much, but this week has just been so very filled with emotions of all types that I feel it's an important part of the process of getting through a clerkship.  Recognize and understand your own emotions and don't be surprised or dismayed by them.  At least, I think that's the way to go. 

Surgery - the early days

Today I completed the second day of my surgical clerkship.  I have observed/assisted/evaluated 24 patients including 3 surgical cases in which I was allowed to scrub in and perform what I believe are the duties of the first assistant in surgery.  I use the phrase, "I believe" because I have been allowed to perform the duties that my books describe as "first assistant" duties, however I haven't done anything beside suction, retraction, suture following, and a few other things.  Whatever my official capacity has been, though, I have thoroughly enjoyed the experience.  Having a patient open in front of me is, in a word, awesome. 

But the greatest asset to this clerkship so far has been how much of a humbling experience it has been.  Over the didactic year, I became good at getting the academic answers correct.  I got good grades and generally felt that I had a handle on the information despite my mad-dash late-night cram sessions before finals.  I always felt that I had done well.  The surgical clerkship has been a different animal altogether.  My feeling is one of uncertainty most of the time (unless I'm transcribing a pre-op exam note which is pretty straightforward).  For example: musculoskeletal anatomy has always been something I have had extensive use for as an Athletic Trainer.  I have utilized knowledge of the origin, insertion, and action of muscles of the leg, thigh, trunk, shoulders, etc. many many times and I felt that I had a good handle on this information.  But yesterday as we worked on a patient's thigh, my preceptor quizzed me on which muscle bundle he was holding in his fingers.  I looked at it, at it's orientation with the surrounding tissue, at the blood in the field, the smoke from the electrocautery unit, and I stated without certainty the muscle that I thought it was (because it looked like that's what it should be).   As it turned out, I was lost in the anatomy of the thigh and didn't know what I was looking at.  That feeling of being lost is unfamiliar and uncomfortable, but I believe this may be the most valuable thing that I learn in the coming month: how to challenge my personal comfort boundaries while at the same time remaining somewhat confident. 

As a side note - I know academically that challenging my comfort zone is key to increasing knowledge and understanding, but actually doing it is quite a bit different.   And it seems that understanding the difference between academia and the "real world" is yet another key component of the clinical year.   My there is so much to learn!

Preparation

Word has finally come down from higher up that I am confirmed to be doing my surgical clerkship first, beginning on Monday the 20th.  To say that I am excited is an understatement.  But it is also an understatement to say that I am a little intimidated. 

The surgical clerkship, I am told, can be gruelling.  Not only is surgery among the more rigorous medical specialties, but for a person without much operating room (OR) experience, this is much akin to diving into the deepest end of the pool possible.  Thankfully I have done well in the past by diving in head long and God has been good to always help me come to the top again. 

A few words on preparing for a surgical clerkship:

I have heard that having a thorough understanding of the anatomy involved, the indications for, and the procedures associated with laparoscopic appendectomy, cholecystectomy, and hernia repair is a good way to begin.  I will see many of these over the coming four weeks. 

I have also worked at tying good surgical knots.  I have spent hours on this task alone, and have plenty yet to learn.  But I am told this will come with time. 

Having a basic resource for understanding how to write the myriad pre-operative, post-operative, admit, and nightly progress notes has been helpful.  For most of this I have turned to the infamous "Scut Monkey" which I have already found to be a good resource. 

But here is my favorite way of preparing for a surgical rotation:

(In case you're wondering, that's me practicing suturing nasty gashes in a pig's leg)

I will do my best to pass along any tips/tricks I can think of to surviving a surgical clerkship. 

Transition Week

As you might guess from the title, this week we are working on our transition from the didactic year to our clinical year.  The week in and of itself is an interesting concept because it seems as if it's the week to teach us stuff that doesn't readily fit into other areas of our education.  But perhaps it is just a week to help us realize how far we have come and what we have learned over the past year such that in six short days, when we first set foot upon the wards, we will approach our patients with at least a little bit of confidence in our fledgling knowledge and skills.

During the didactic year we had such courses as Basic Clinical Skills, Pathophysiology, Adult Medicine, Emergency Medicine, Maternal & Child Health, the ever important Behavioral Medicine to name just a few.  Transition week is the week when we take an overview of some topics that we either covered too briefly, didn't cover at all, or that are incredibly important to being at least a little bit functional as students on the wards.  Yesterday we took another overview of laboratory medicine and reviewed the multitude of labs that might be ordered to aid in diagnosis or treatment of our patients.  Today we reviewed Medicare's requirements for billing and coding of visits.  There are many other topics to come including one last practice session so we can once again review our physical exams.

At the same time as we are doing all of these little tasks, we are realizing that we can look at a sheet listing all of the possible laboratory tests that might be ordered and have an idea of what each test is for, what the normal values for a result should be, and what abnormal values reflect.  Our lecturers are reinforcing that we have come a long way, that we have learned much, and that next week when we begin to learn from preceptors (instead of textbooks and lecture notes) we will be able to communicate intelligibly about the patients we will see and understand the things that we will be taught.


It's still intimidating beyond what I initially expected.  But along with nervousness and a little trepidation is a fount of excitement about next Monday.  I really can't wait.

Introduction

By way of introduction, I am a PA student just beginning my clinical year.  I have survived the dreaded didactic year, but now the time has come for my real education.  I will spend the next year going from site to site learning the intricacies of clinical medicine.  I will typically spend four weeks at each site with the exceptions being a two week selective rotation and a four month long stint working in a family practice office.  I have many plans for where these will be, but very little is set in stone at this point.  I am striving for flexibility and patience, as are my wife and the rest of my family that have supported us this far.  And I speak for all of us when I say that we are ready to get on with this year - mostly so that I will be done with school and can resume at least a semblance of a real life. 

A word on the title: Primum Non Nocere is a Latin phrase meaning, "First, do no harm."  It is, in a very big way, the foundation of medical practice.  I found it fitting for a student going into the clinical years (where I will actually be working with and on patients) to make this the headline of the notes that I will be passing along to friends, family, and all others who come along to read these posts.  It is a major concern, of course, that in learning to provide medical care I will make a mistake along the way and cause harm to one of my patients.  In fact, if I were NOT concerned about the potential for harming someone, I would need to have my head examined.  So may it be a reminder to me as I write and a declaration to all that my head is in the right place and I am suitably sensitive to the weight of the tasks I will be undertaking.

That said, I think this year will be a lot of fun.