Saturday, June 25, 2011

Fixing children

I want to share a brief experience I had the other day that left me feeling essentially elated over the fact that I will soon be able to practice medicine. 

The case was almost as straightforward a case as it gets - I won't include any details at all so it will be quite a vague recollection.  At any rate, a kid comes into the clinic not feeling well.  I took a thorough history, did a thorough exam, and everything was pretty unremarkable.  I selected a medicine that would treat the symptoms well and allow the child to recover essentially without intervention aside from some short term diet changes.  The kiddo had a very good response to the medicine, I monitored to make sure there were no side effects and that the medicine was indeed having the desired effect, and the child's persona changed on the spot.  It went from looking and feeling sick to looking like a normal little one and almost bouncing down the hall on the way out the door.  The turnaround was drastic, and gratifying. 

Family medicine definitely has its perks, and fixing children is a BIG one. 

Tuesday, June 21, 2011


This post is as much a request for feedback from experienced professionals as it is a warning to those who will be PA, NP, or medical students reading these words later on. 

In several of my rotations I have noticed that some of the more seasoned providers have become rather presumptive about some of our patients.  Granted, they know our patients better than I do and I am still the student so I have to learn to approach difficult patients with caution.  But the providers I have worked with that I am talking about herein are providers who have made assumptions about our patients like, "He just wants pain meds," or, "She's just looking to get high."  It appears from my perspective that these providers are becoming jaded with their experiences, as if they've been burned by drug seekers too many times to be able to remain objective and avoid jumping to conclusions.  I say this because I, in my naivety, have approached them with a blank mind (quite literally sometimes) and have found some pretty profound pathology - a patient who I suspect of having an ACL tear, or a patient who has significant osteoarthritis, and several others. 

To the experienced providers I ask this: is there a method by which you have avoided this pitfall so as to maintain functional ability with difficult patients?  It is my short experience that if we can maintain a sensitive approach to even our most difficult patients, then we will be able to treat them more effectively.  Am I wrong? 

To those students who are coming after me, I offer you this from my experiences (stop me if you've heard this story): many months ago I was working in the ER when a patient bounced back from earlier that day.  This was a young girl who had been complaining of back pain but now she was coming in with severe abdominal pain.  In passing a nurse commented about her prior visit to the ER and the likelihood that she had, "Just not gotten what she wanted."  I bought into that thinking about her right away and it was reinforced as I watched her roll by on the stretcher writhing in pain.  As I went in to examine her I was unimpressed by her pain given that she reacted excessively to every test that I did - minor pressure on her belly elicited near screams.  She had no other symptoms that I could find.  I presented the case to my preceptor who taught me a valuable lesson that day - he said, "Yeah, it could be a bounce-back because she didn't get the meds she wanted... Or she could have something wrong in her belly, so let's look."  He ordered an ultrasound and found a GIANT ovarian cyst, reaching nearly up to the patient's ribs.  As soon as I heard that I hung my head in shame... I had made a bad assumption based on very little evidence, and I was dead wrong.  I would have been infinitely better as a provider if I had not assumed as much as I did, and I hope that I never forget the shame I felt that day - it was a good teacher.

Sunday, June 12, 2011

Family Practice

Seven weeks ago I started my last clinical rotation - Family Practice.  The first thing that struck me was that I was very excited to be starting my last clinical rotation.  It's a little bittersweet, but mostly sweet so I like that very much. 

Family practice is a different animal than any other specialty that I've worked in (for the most part).  Here I have to be a Jack-of-all-trades, master of none.  I have to understand and treat the major Ears/Nose/Throat (ENT) issues for infants, children, adults but I have to know when to refer to the ENT specialists when the patient keeps getting sick or when my treatments are not successful.  The same goes for cardiology, pulmonology, gastroenterology, urology, neurology, dermatology, orthopedics, rheumatology, hematology/oncology, endocrinology - you name the specialty and we dabble in it.  It is a MASSIVE amount of information to understand and have a handle on.  Putting it into words is even more intimidating than just thinking about it - seeing that list is nearly frightening.  Yet somehow, day in and day out, I go to work and know what I'm talking about for the most part.  

In addition to all that stuff, we also run a sort of minor care/emergency clinic through our family practice.  This is for those things that just can't wait but aren't necessarily bad enough to go to the ER.  Interestingly (very), since we are out in the boonies, we actually get a LOT of patients through our "quick care" that actually would be good candidates for the ER - women with severe lower abdominal pain and positive pregnancy tests, old men with crushing substernal chest pain, children who come in slightly confused with a fruity odor to their breath and blood sugars in the upper 500s.  We get it all here and we have to know how to quickly and efficiently get the answers that we need to make nearly critical decisions.  This part I love, very truly, but this is quite possibly the scariest thing I have done yet.  The other day I had an older woman with diabetes tell me that it felt as if someone was sitting on her chest, but she just thought it was a bad reaction to her medicine and she wasn't even going to come in that day, but the clinic was conveniently located so she did.  The problem: we are 40 minutes away from definitive care if the patient goes by ambulance - it would take the ambulance 20 minutes to get to us and 20 minutes to get the patient to the hospital.  If something goes very wrong, we are essentially on our own. 

So the last seven weeks have been yet another lesson in being appropriately uncomfortable which I am all the time.  I have to work remarkably hard to know my limitations and stop myself from going over them.  I am at the point now where I can see a patient in 20 minutes and have a good plan that will get to the root of the diagnosis, but I still consciously think, "Ok, what else could this be that might kill the patient if I don't look at it?"  I do a few more tests than the experienced providers, but so far it's all been reasonable so I feel confident that even though I don't know and I'm uncomfortable I will still get the diagnosis that I need.  And so far, I have.  The pinnacle: I made a diagnosis of malignant melanoma on a patient who had a previously benign lesion re-occur.  So, you never can tell what will come of a test or what might walk through your door - and that makes me uncomfortable, but I am slowly becoming ok with that.