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.