Last day of outpatient

Today was my last day of outpatient internal medicine. It’s hard to believe I am now 1/12 of the way through third year. There were several patients who were returning for cholesterol follow-up, and several other miscellaneous complaints. One of the most interesting was a 93 year old lady (still very sharp) who had multiple problems such as abdominal pain, constipation, osteoporosis, etc. Her son had been doing a lot of internet research and had convinced himself that she must have celiac disease, since many of the problems that she has are found in people with celiac disease. The doctor did not want to order a celiac disease test, because it is almost impossible that this lady has the disease, but he ordered it anyway to make the son happy. This brings up an issue that doctors often have to deal with—waste money and avoid offending patients, or refuse patients and save taxpayer money. Of course with the latter, there is always a remote possibility that the doctor could actually be making a mistake and then look like an idiot when another doctor orders the test and it turns out to be positive. Fortunately, I still have a couple years before I am responsible for those decisions.

Another interesting case was a man who started having diarrhea three weeks ago but without any other symptoms. He had no change in his diet, the only new medication was one which does not cause diarrhea, and he had no signs of infection. The doctor ordered several electrolyte tests, if they turn out to be normal he will have to get some more aggressive tests.

Tomorrow will be my first day of inpatient medicine at the VA. It should be interesting, I have no idea what to expect—I’m not even sure if it will be a full day, or just orientation to the hospital. Within the next couple days I will have to turn in my preference list for what surgical rotations I want to do next month. Everything’s going by very fast.

Hospital

Today the doctor I usually follow was on vacation so I followed one of his partners. He only had one patient scheduled in the morning at clinic, so I went with him to the (small community) hospital afterwards to round on his patients. Two were newborns who both seemed to be doing well, the only concern was that the parents of one of them had Hepatitis C, so it will be important to watch the infant's liver function. The family of the other infant only spoke Spanish, so we had to have an interpreter (who asked the nurse after we left the room if the doctor was married [yes with several children]. Yesterday one of the female medical students who is engaged was proposed to by an AIDS patient, leading to the question, does anyone bother to look at people's left hands anymore?).

There were three adult patients. One had heart failure, but is not improving as expected, the doctor thinks there is something else going on, so he brought in a cardiologist for a consult. Another patient had an exacerbation of emphysema, but is doing well and should be able to go home tomorrow. The last patient was admitted for a urinary tract infection that was thought to have moved up into the kidneys to cause pyelonephritis. However, she has been on antibiotics for several days, and still complains of pain. The doctor and all the nurses are 99% sure that she is faking, hopefully some tests that were ordered today will clear that up. After the doctor visited her and told her she might be able to be discharged today, she asked the nurses to get another doctor for her because she didn't think this doctor was "caring and compassionate" enough (rubbish), thereby convincing everyone that she is faking. This obviously is a complicated situation, because one doesn't like being taken advantage of by a patient, or knowing that thousands of dollars are being spent on her for nothing, but at the same time, there is a small possibility she might really be sick, in which case discharging her would not be good.

Syncope et al

Today I spent the morning in clinic, I saw quite a few interesting cases. One was the worst ear infection I have ever seen—not otitis media, or infection of the inner ear, but rather otitis externa which is infection of the ear canal. This infection had spread into the young man’s face, and one could actually see the swelling on one side of his face. Regular amoxicillin had not helped, so the doctor prescribed augmentin which is amoxicillin and a b-lactamase inhibitor which counters bacteria that are resistant to amoxicillin. Another interesting case was a man who had passed out for a few seconds while brushing his teeth yesterday—he had no signs that there was anything serious going on, so the doctor attributed it to being low on fluids combined with a vasovagal response (stimulation of the vagus nerve which slows heart rate) and sent him home. Twenty minutes later, the doctor got a call saying the man had passed out again, so the doctor had to have him come back in and get an EKG, lab work, and CT scan. I didn’t hear the results, but the doctor still thought it was most likely innocuous, and, worthless though my opinion is at the present time, I am inclined to agree. Very curious situation though. There were several other interesting cases, but I don’t have time to post all of them. As a side-note, I can say that my previously alluded to feeling of awkwardness interviewing patients my age is pretty much gone which is nice.

Thoughts

I have been thinking lately about what specialty I want to go into. Fortunately, I still have about a year to decide. I am pretty sure I want to go into some type of surgery; I always assumed that I would want to specialize in some area. Two things have kind of surprised me on this outpatient medicine rotation. First, I have enjoyed being in the general internal medicine outpatient clinic a lot more than I thought I would. I like the fact that the doctors there have regular patients whom they get to know. I also like the fact that they see a wide variety of cases, in one day they can see anything from a toenail infection to congestive heart failure. The only thing that I would worry about is that after years I might get frustrated with only being able to do a certain amount before I would have to refer certain patients to specialists. This brings me to the second thing that has surprised me, I really have not particularly enjoyed the couple days I’ve spent in a specialist’s (nephrologist’s) clinic. (Note: everything I write here is based on three weeks of experience—no doubt many of these opinions will fluctuate over the next couple years, and I will probably look back on this someday and be amused at how naïve I was). One morning I wrote up almost the exact same note for five patients, two or three of them needed to have the same medication adjusted. I would be very concerned that I would get bored out of my skull if I had to see the same types of problems every day (again, this is based on three weeks of experience). But, there are possibly confounding factors here: for instance, the general internal medicine clinic is a very nice clinic, with very nice doctors, and I don’t have to deal with the computer system. The nephrology clinic was at the VA (not the nicest atmosphere), the doctors were nice but not gushing with warmth, and I had to deal with trying to figure out a complicated computer system as I was talking to the patients. It will be interesting to see if my opinion of surgery changes in September when I start that rotation.

Lectures and clinic

Today I again got up early (for me) to make it to the EKG lecture by 7:00. After an hour of EKG (I can now calculate heart rate, tell if there is a sinus rhythm, and figure out if there is left or right axis deviation [in clinic this afternoon the doctor asked me what I made of an EKG, I saw that it had a left axis deviation, then he told me that no one ever looks at that, I should just know it for boards]). Then, I went to grand rounds, which were basically presentations of interesting cases by residents to students, residents, and attendings. Then, I went to a lecture on geriatrics, had two hours to study, then drove to the clinic. Patients I saw included an asthma patient; a man with several lipomas (fatty tumors that are completely benign), one of which started hurting three weeks ago; a little girl with a possible eye infection; and a young lady with oral thrush (fungal infection of the mouth). One interesting moment was when one of the patients who had commented on how young I look when I spoke to her alone asked if the doctor and I were brothers when we went in together. While obviously a compliment for the doctor (haha), I am not sure what it was for me as I am considerably younger than him.

VA

Yesterday I had clinic in the morning, and four hours of lecture in the afternoon. I saw a few interesting patients, two of them were patients I had seen last week. Lecture was unremarkable.

This morning I went to nephrology clinic at the VA and saw five people with renal failure. It is a little strange there because one has to type up the progress note as one talks to the patient. And, since none of the patients have any idea what medical problems they have, why and when they had procedures done, and what medications they are on, one has to spend fifteen minutes searching through the chart on the computer. I think after a while I would get used to it, but it is rather frustrating right now. I asked one patient if he had high blood pressure, and he said no, it’s always good. I looked at his chart and saw that he was on three blood pressure medications. After asking several patients when they had certain (often very invasive) procedures done, and getting a blank look in return, I have learned to just look it up in the chart. It should be interesting when I have to do inpatient there next month.

I saw one patient who had one of his legs and half of his other foot amputated due to his uncontrolled diabetes. Now, his kidneys are going, and he is starting to lose his vision, but he still seems perfectly content to let his blood sugar go to three times normal. I can’t comprehend that.

Punctured foot, broken toe

This morning I went to clinic. The doctor I usually am with was out of town, so I followed one of his partners. Patients seen included: young man who had stepped on a nail and had warts on his hands (antibiotic for foot, liquid nitrogen for warts), a man with a plugged up ear from swimming (doctor irrigated ear, watched disgusting clumps of wax come out), a lady who had fallen and hit her head on concrete (CT scan), a sore throat (probably viral, but culture just to be sure), and a man who dropped something on his foot a few weeks ago whose nail was now popping off (the doctor burned through the nail with a cautery tool to release any pus or blood that might be underneath. He gave me the cautery tool to take home since it can only be used once on a patient. It can light a candle faster than a match:).

Tomorrow I have the morning off (I love outpatient medicine), and one hour of lecture in the afternoon. But, since I really need to study more, I’m sure I will stay busy.

Early to rise

Today I had to get up at 5:15 in order to make it to EKG lecture at 7:00. It was a very basic introduction, we didn’t actually look at any EKGs. At 8:00, those of us on outpatient stayed for chairman’s rounds, which is where the chairman of the department of medicine sits with us for an hour and talks with us about what field of medicine we want to go into, and how we should go about it. Very nice of him to take the time to do that. Breakfast was even provided (I always think it’s ironic that these free breakfasts for doctors and medical students always have several plates of donuts and pastries. There were other options, though, and only one student out of about 20 ended up having a donut which is a good sign since we spend so much time trying to convince patients not to eat junk food). He said several interesting things, one was that he believes that the city the school is in is “still in the ‘80s” as far as the medical lifestyle goes. Apparently, many students are scared away from going into surgery and OB/GYN based on the doctors’ not having a life outside of the hospital. According to him, in most other cities, doctors have more balanced lives. Encouraging, but I’m taking that with a grain of salt.

After chairman’s rounds, I drove out to the clinic. The doctor was pressed for time, so I basically just observed. Several interesting cases, though. I saw a man a couple days ago who hadn’t been taking his diabetes or cholesterol medications for two months, but came into the office because he had hurt his knee. Also, he noticed his vision was getting blurry. He said that he had lost 20 lbs, felt great, and that his glucometer had said his blood sugar was 18 for the last month, but had been about 300 the month before (normal is 70-100). Since this was clearly impossible, I assumed (but did not tell him) that his blood sugar wasn’t 18, it was just so high that the glucometer couldn’t read it and was going haywire. The doctor got him to the lab. Today he came back to hear the results. Turns out his blood sugar had been well over 300, his triglycerides were almost 700 (normal I believe is less than 150), and his HbA1c (shows how well the diabetes has been controlled, healthy people have about 5.5, well-controlled diabetics have about 6.5-7) was 14.1. I think this scared him badly enough that he is going to be serious about taking his medications, so it is probably a good thing this happened.

I saw a couple today who were both in their nineties. The doctor had me listen to their hearts, and I was able to correctly identify their murmurs (the man had aortic stenosis, the woman had aortic stenosis and mitral stenosis), so I have learned something these last two years. Funny thing, the man was examined for the army during WWII, and a heart specialist told him he had six months to live. Well, he was only about 60 years off!

I got a chapter of the textbook to review a couple days ago, and I started reading it last night. I was afraid that I wouldn’t have anything to contribute, but after reading the first paragraph that is no longer a problem. I am guessing the author’s native language is not English, or else he just isn’t used to writing text-book style. The information is all really good, but is very choppily written.

Today, I got a chance to have my notes evaluated. The doctor told me they are too wordy, I can definitely see his point. Apparently it is better to write not quite complete sentences so people can quickly scan the note and not get bogged down. For example, he said that instead of “The patient states that he began to feel nauseated three days ago. He has not had a fever, cough, or abdominal pain. He took two ibuprofen two days ago which helped a little.” It should be: “Nauseated for three days. Denies fever, cough, and abdominal pain. Ibuprofen somewhat effective.” I think it is going to be a little hard for me to get used to that, I’m very glad he told me now before I developed bad writing habits that would be hard to break down the road.

First VA experience

Yesterday I spent another morning at the main clinic I go to. I saw several patients, including a couple asthma patients, a fractured little toe, and a toenail fungus (almost impossible to get rid of by the way, unless you want to take drugs with very bad side effects, usually not worth it). I saw a girl who was getting over the stomach flu, her mother brought her in because she thought it was unhealthy for the girl to be sleeping all day. Apparently she has been getting the girl out of bed to eat, and trying to keep her busy during the day. ???. I would be awfully ticked off if I were getting over the flu and someone wouldn’t let me sleep. The doctor very nicely told the mother that it was all right for the daughter to rest as much as needed, and to call if she weren’t back to normal in a couple weeks. I had two patients request that I not be in the room for the first time, although I am surprised that this is not more common. I was fine with it though, if I had hemorrhoids or the other patient’s problem which I will not disclose here I wouldn’t want anyone other than the doctor in the room either.

In the afternoon I had three hours of lecture, two hours of down time, and then a two hour OSCE in which I had to interview three actors pretending to be patients and perform a physical exam on each. These interviews were videotaped, so I then had to watch myself examine one of the patients. I got out in just enough time to make it to Bible study, although I missed dinner. I left the school at 8:00 pm, and met one of my friends leaving the hospital. He’d been there 16 hours! This is what I have to look forward to in a couple months.

This morning I had to go to the VA nephrology clinic. The calendar the school gave me said to be there at 9:00, so I showed up 15 minutes early. One of the clerks led me to a work room and told me to wait there for the doctor. I waited until 9:20, then went out in the hallway and asked someone if the doctor was in yet. Turns out he was in an exam room with another third year student, who was supposed to be with a different doctor who told her to meet him at the VA but then went to the school’s main hospital. So, at 9:45, the doctor left the exam room and I had to chase him down the hallway and tell him that I was supposed to be with him today. He then informed me that clinic starts at 8:00. Argh…Fortunately he is pretty nice, so it was fine, and even if he wasn’t it wasn’t my fault, so whatever. I was prepared before I came for a mix-up based on several stories I have heard. A girl I spoke to yesterday said some clerks told her to wait in a waiting room, so she sat there for twenty minutes before finding out that she was in the wrong place, and the doctor she was supposed to be with had the same last name of the doctor in whose waiting room she sat. Anyway, I saw two patients, both with nephrolithiasis (kidney stones). The VA’s system is entirely computer-based, so I had to type up an H&P note as I was interviewing/examining the patients which was kind of weird.

Spanish speaking clinic

Yesterday I spent the morning at clinic, and the afternoon visiting a hospice patient. I saw several patients at clinic. Two little girls came in with their mother for a well child visit, so the doctor had me watch the whole visit including when the nurse was talking to them (for those of you wondering my I am seeing children on my medicine rotation it is because the doctor I am with is board certified in both internal medicine and pediatrics). Both of them were pretty healthy, the mother’s main concern was that the older girl kept developing what she thought were nervous habits, but the girl’s school was really worried about it. Turns out the mother was right, and the doctor recommended just ignoring it. The younger of the girls brought along her toy cell phone that she had gotten for her birthday. It records little bits of sound, so she had me talk into it for a second. I spent the next five minutes hearing my voice saying “how’s it going?” time after time in rapid succession.

Other patients included knee pain secondary to slipping and hitting her knee, abdominal pain, and regular check-ups. That afternoon I went and toured a hospice, which was very nicely set up, and interviewed one of the patients. We were given a list of topics to cover, including things such as the patient’s understanding of his health, religion/spirituality, support system, goals, etc. The man I interviewed was very nice but spoke very very very quietly and I couldn’t tell most of what he was saying. He had congestive heart failure, does have family in the area who visit him, and is Catholic. He is not particularly happy about having to live out of his home, and apparently has given the staff some trouble about it, but I think he is starting to realize that there is no way he could live on his own, or even with a caregiver in his home. Most of his answers were pretty short, but since I had no intention of probing into more personal matters (if I were his doctor or even part of his care team, then yes I would have asked more detailed questions, but as a visiting medical student it didn’t seem appropriate) I spent the rest of the time asking about his family, and what he had done before he retired. He wanted to know about where I was from, and what my siblings are going to do, etc., so I told him about that. Of course, in a doctor-patient relationship, technically it is considered poor form for the doctor to give personal information to the patient, but I don’t think that applied in this case. I felt bad when I had to leave since he seemed pretty lonely. I was fine interviewing him, but it was really weird when I left and realized that he will probably not be alive in another month.

Today I went to the spanish-speaking asthma clinic, and saw one patient. He understood a little English, but not much. Fortunately, the resident I was with is from Peru, so the language barrier was not a problem. I knew enough Spanish to keep up with the flow of conversation, but not enough that I would feel comfortable gathering medical information by myself. He is a very responsible patient, knows how to take his medications, and keeps good records of his peak flow meter. Unfortunately, though he is taking the maximum doses of his asthma medications, he still has symptoms everyday and cannot do more physical activity than walking for 15 minutes. Even so, his lung function has improved considerably in the three months he has been coming to the clinic. Today, a sinus infection was making him worse, so the doctor started him on augmentin (an antibiotic + a chemical that inhibits bacteria’s ability to resist the antibiotic) and is going to have him started on omalizumab for which he is an excellent candidate due to his many allergies.

I have the afternoon off to run errands, study, and relax. I am going to have an incredibly rude awakening next month on inpatient when I will get one day off a week and be at the hospital from 7:00am to 11:00pm every fourth day.

(PS: man the titles of my posts are inane--I'm going to have to go back to the Latin titles. They're still inane, but nobody knows.)

More clinic

Today I had a very full day of clinic, going from 8:30 to 5:30. I saw about ten patients, for the most part I would go into the room and talk to them, then present to the doctor, and then we would go in together. I will describe some of the more interesting ones:

1) The doctor sent me into one room to talk to an elderly man on 4L O2. His wife and daughter were in the room with him. After I asked him what kind of lung problems he had, his daughter told me, “You don’t want to go there”. She and her father then proceeded to get into a five minute long argument over whether or not he had had lung cancer. It was kind of like watching a tennis match. She (and her mother to a much quieter degree) were trying to convince him that he had had cancer and that was why he got radiation, and that the doctors would not have given him radiation if he did not have cancer. He was arguing that the doctors didn’t know it was cancer, but rather gave him radiation because that is what doctors do when they don’t know what’s going on and want to cover their rears. I tried to steer the conversation a couple times by asking about specific bits of information they mentioned (eg. The man mentioned that he didn’t have to be on oxygen before the radiation, so I asked “Oh, so when was that?”) which worked for about ten seconds before they got back into it. Eventually I just waited for a millisecond break and quickly said that I had all the information I needed and that I would bring the doctor back. I left the room and found the doctor cracking up at the work station. Apparently he had been able to hear bits and pieces through the door. They were fun.

2) This patient wouldn’t have warranted a spot on my blog when I first saw her, but when her lab results came back that changed. She had a boatload of liver and kidney problems due to alcohol abuse, but had successfully quit alcohol and her lab results had shown improvement over the last few months. Her symptoms had improved considerably as well, making the doctor very satisfied with her progress. Then her labs came back and showed she had a hemoglobin level of 4.8. That is really, really, bad. At first the doctor didn’t believe it, so he had the lab run it again, but the same results came back. So he had to spend a large amount of time getting a blood transfusion arranged for her.

3) This patient was unusual in that he was a guy my age. I have never in my two years of shadowing physicians, and 2+ years work in the hospital seen a male patient my age. Since his chief complaint was bloody stool and he was young, the doctor decided it would be too awkward for the patient to have to talk to me alone, so we just went in together. Turns out we needn’t have worried, but I was a bit relieved all the same. I have no problem at all asking embarrassing and personal questions to people outside of my age range, but for some reason I feel very awkward when the patient is in my age range. Especially since this patient was also similar to me in education level as he will be starting grad school soon. There were several other similarities, but they would be considered identifying information so I won’t post them here. I would guess that most people would think it would be easier to talk to patients who are similar to oneself, but for me it is the total opposite. I think it is just confusing for me to figure out the proper relationship. For example, if I had met this person anywhere outside of the doctor’s office, he would be someone who would quite easily fit into my social circles, possibly even become one of my friends, so it is hard for me to be comfortable maintaing a professional relationship in which I am by definition in some degree “superior” (that doesn’t sound right, maybe "authoritative" is a better word). On the other hand, someone who is older than me, or even a female closer to my age, would not normally fit into my social circles, and therefore I have a much easier time being professional and somewhat “aloof” (again, not quite the word I’m looking for, but hopefully this makes some sense). He turned out to have hemorrhoids, which wasn’t a big surprise.

Other patients included a headache; neck pain; brain tumor; swimmer’s ear (I did the history and physical by myself); tinea cruris (aka jock itch--the poor kid had to show the rash to the doctor and me in front of his mother, sister, and brother); probable GERD (gastroesophageal reflux disease or heartburn) but with a possibly suspicious EKG; bronchitis; and a possible UTI, but since it was a youngish man (only 8/10,000 men get UTIs per year as opposed to 30% females over their life times) STD testing was necessary which consisted of a urethral swab which is exactly what it sounds like.

Asthma Clinic

Yesterday was my first day of clinic! It was very laid back, and I didn’t get to do as much as I wanted to, but that should change as the month goes on. There weren’t any particularly interesting patients, mostly just follow-up for chronic problems. Most of the patients I would just watch in the room while the doctor talked to them, but a couple he had me go in and talk to first. I would like to be doing the initial history and physical by myself by next week, but I know it’s hard to do in an outpatient clinic that needs to stay on schedule. That is one of the things I dislike about outpatient, I feel like I am an inconvenience to the patients and doctor. At least in the hospital the patients don’t have anywhere else to be so students can spend more time with them. There was one little girl who had a rash, so I went and spoke to her and her mom and looked at the rash. I am considering that to be an H&P, albeit a focussed one. That afternoon I had to drive the half-hour to school, then go to two hours of lecture, one on abdominal pain which was quite good, and one on COPD (chronic obstructive pulmonary disease) which wasn’t as interesting, but was quite timely as I had asthma clinic this afternoon.

This morning I had to go to the VA hospital to get my password and training for their computer system, since all their patient charts and records are computerized. (Interesting tidbit I learned yesterday: apparently employees walking off with hospital scrubs is a huge problem, costly enough that my school’s main hospital is going to invest >$100K to buy a scrub dispensing machine that won’t give a person new scrubs until he returns the ones he checked out before. At the VA walking off campus in hospital scrubs is considered to be a federal offense, which presumably cuts down on scrubs’ disappearing.) Then I went to my school’s main hospital (wow is there a difference in even the appearance of private vs government-operated hospitals) for asthma clinic which I greatly enjoyed. Students are responsible for doing all of the patient interviewing and educating, and the physical exam, then they report to the incredibly energetic doctor and she goes to see the patient. Since they are going from paper charts to a new and apparently very frustrating computer system they only saw half the patients they normally do. I saw an asthmatic with very poorly controlled asthma despite her being on three or four medications, and I managed to classify her asthma correctly and come up with a fairly accurate assessment (she needed more drugs). The next time I go to asthma clinic, it will be a spanish speaking clinic.

They respiratory therapist did spirometry on all the students and the intern (the "kids" as the attending put it) to show us what it was like. Basically, you blow into a tube and then inhale, and a computer measures how much air you blow, and how quickly you blow it out. My FVC and FEV1 were 120% of their predicted values, which means that I have excellent lungs.

We scheduled our first Bible study (going through Daniel) for next week; the school then informed me that I have an OSCE (interviewing an actor pretending to be a patient) at the same time. I am very miffed. I did take advantage though of an opportunity presented by the course director to be a student reviewer for an internal medicine textbook. Normally I probably wouldn’t take the time to do that, but we’ve been promised to have our names published in the book’s next edition if we help review it. I, being a sucker for padding my curriculum vitae, could not pass that up. Oh, and helping improve the education of future students will be nice too.

One more day of orientation

Yesterday was my orientation to internal medicine. My first month will be in outpatient, which has a bit more jumbled schedule than inpatient, but requires less time during the week. It is going to take a while to figure out what is required, and what things are due when, etc. For the most part, my time will be divided among three clinics, and several half-days of lecture. The clinic at which I’ll be spending most of my time is around a half hour away from school which is not going to be fun the days I have lecture in the afternoon at school and clinic in the morning (or vice versa). I will also spend a couple days at a nephrologist’s office, and a couple days at an asthma clinic. The asthma clinic should be interesting, especially since students are responsible for almost all patient care, including educating the patients as to how to use the various types of inhalers and spacers, most of which I had never even seen before yesterday. Two of those days will be at a spanish-speaking clinic.

Last night I went to a barbecue with my Bible study group from school. To illustrate the variation of third year experiences, here is a list of our orientation day experiences:

Me: 4 hours of lecture-style orientation, two hour-long pre-test, start clinic on Wednesday
Guy #1: Couple hours of orientation, start clinic next Monday(!?)
Guy #2: Couple hours of orientation, scrub into surgical case, stay at hospital until 6:15 pm, be back Wednesday (other guy on his team there today, one stayed all last night)
Guy #3: Similar to above, but stayed at hospital until 7:00 pm
Girl #1: Could not come to the barbecue as she was on call at the hospital for trauma surgery all last night
Girl #2: Same as me, minus two hours of orientation
Girl #3: Same as guys #’s 2 and 3, but stayed until 8:00 pm (orientation started at 7:00 am, she had to page her resident as soon as it was over), back today

Since I am on outpatient this month, I will have weekends and evenings off, but next month in the VA, the course director made it clear that we get one day off a week, and it must be a Saturday or Sunday. If we end up with the whole weekend off, we work it the next week. Should be a very interesting experience.

Free Clinic and a Lot of Books

Today I gave up sleeping in to volunteer at the free clinic run by the students at my school. I saw three patients. One had a swollen leg, one had severe abdominal pain secondary to a hernia operation from a year ago, and one just needed prescription refills. The doctor wanted an ultrasound done on the patient with the swollen leg to rule out a deep venous thrombosis, and put me in charge of getting it set up with the hospital. Unfortunately, the US techs don’t work on Saturdays, and only come in for emergencies, so my call was bounced back and forth among several departments. After being told they would call me back, and waiting over an hour for the call, the doctor finally just bypassed to usual routes and called someone higher up directly, with the result being that the patient was able to have the US done this afternoon. Thankfully the patient was one of the most patient people I have met, and was very nice about having to sit around for several hours. Of course it’s not as if it was our fault, or even the hospital’s that it took so long, but it is amazing how many people don’t understand that sometimes things take time.

The patient needing medication refills was a type II diabetic who has done a remarkable job of controlling her diabetes just by diet. Unfortunately, her blood pressure medications have not been sufficient to adequately control her hypertension, so the doctor had to up the dose of her diuretic. But, since diuretics of this type can cause an increase in renal excretion of potassium, she will have to have bloodwork in a couple weeks to make sure that she is not hypokalemic (low blood potassium). Sadly this means she will have to go through the several-hour-long line all over again since student-run first-come-first-serve free clinics are not the fastest moving clinics on the planet.

Working at the free clinic is always a good experience, particularly the first two years, since it allows one to put into practice concepts taught in lecture, as well as practice skills such as writing notes. It also at times teaches one to work with people of different personalities, such as the first-year student who started drilling me as to why I asked the patient certain questions, and arguing with the way I wrote up notes. It kind of took me by surprise, since when I was a first year I looked up with awe at upperclassmen and would never have actually argued with them about something that presumably they were better at than me, but now that I look back on this morning, I think the first year was honestly just trying to learn, but just doesn’t know how to ask questions in a non-antagonistic way. Thankfully, I tend to be more amused than irritated at people with different personalities, so I was very polite and nice about it.

After clinic, I visited a used book store that I have heard about, but never gone to. 18 books and $73 dollars later, I came home. I got quite an assortment of books, including Sayers, Marsh (I cleaned out the entire Marsh section), Stout, Schmitz, Tolstoy, and a book on the Tudors. The book on the Tudors was randomly chosen to accommodate my desire to read more non-medical non-fiction. It could happen. I am currently reading Ann Coulter's "Godless", but that is another post.

As I was leaving one section of the book store, a man, assuming that I worked there, asked me if the scifi section was separate from the regular fiction, and if so, where it was. Fortunately, minutes before I had found the scifi section hidden in the corner (it is a large book store, and while each section is well organized, figuring out where the sections are is difficult), so I was able to point it out to him. The question is, was it my scholarly, obviously intelligent face that caused him to think I must work in a book store, or was it the (then 17) books I was balancing in one arm while browsing with the other?

(Despite the fact that combined with rotations I am not going to get through these books for months, I just got a Barnes and Noble gift card for my birthday, and I assure you I have every intention of using it. Today.)