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. 

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