Most physicians who go into family medicine prefer it to internal medicine because you really get to know your patients better, and you get to see what's going on with them long term and how things progress for them. It seems to me it's kind of the opposite in med school on rotations.
In my family practice rotations, I would meet patients once because I'm only there for a month, and I only saw a few of them a second time (usually the unfortunate ones). On my IM rotation, I see the same patients every day until they leave the hospital. With the post-op patients, that means I see them like 3-5 times. With the acute patients I see them at least twice. So I get to know people and see how their health issues get resolved.
That's my two cents for the day.

NPO after midnight or you'll turn into a gremlin!

I'm so not a morning person, however, I've gotten use to waking up super early (4ish, which is ungodly early for me). I've gotten use to having to answer questions for attendings at 6 a.m. Going to bed at 9 p.m. is fine now. But I still feel bad every time I walk into a hospital room at 5 a.m. and wake somebody up to ask them questions like "have you passed gas yet?" Maybe it will encourage people to get well quicker so they don't have to deal with med students asking questions about their bodily functions the minute they're jolted into reality.

A Lazy Yet Productive Weekend aka A Type B Weekend

Tasks completed:
-Scholarship applications
-5 Mahalo pages
-Case presentation
-Cleaned my whole house
-Sold 7 items on eBay
-Wrote a blog entry
-Wrote all my notes from 3 months of rotations into my IM book

Yet:
-slept in until noon every day
-watched 2 seasons of The Office
-caught up on Heroes
-managed to spend 9 hours in a row in front of the computer

I am most proud of the last accomplishment :)

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A Very Medstudent Thanksgiving

Or

“How am I ever going to decide if I can’t get past the first question?”

Oy, this month has got me leaning to the left.

Its funny the little rules we make in our head, or the things we keep telling ourselves and not really challenge.

I’ve been putting writing off for 2 reasons. One…I’ve been too busy, to state it plainly. Well, at least by the rules in my head. I figure if I have a case presentation and scholarship forms to do, I am too busy to write. I am also too busy to call anybody or to clean. But not too busy to watch TV. Funny how that works. Two…I don’t want to be one of those people who only write when they want to whine about something. I’ve had plenty of occasion this month to do so,
but not much to balance it out. I mean, there has been wonderful stuff, just in small doses compared to the econo-sized crankfest thats been going on this month.

Well, I overturned that rule in the last few days, starting with the cleaning. The place isn’t sparkling but hell, I vacuumed. That was like the 2nd time since we moved in. Today I’m writing b/c well, I need to. Its therapeutic for me, in that once I get out all those thoughts that
have just been rolling around in my head over and over again, it allows some new thoughts to finally break through. Many good thoughts, smart ones, with some wit and silliness, perhaps involving Johnny Depp or Heather Graham. Mmmm. Wait, what was I saying? Oh ya, too busy to call too. Ya, I’m going to try that this weekend, so if I owe you a call, be looking out for me. After I finish scholarships. Baby steps.

You know what’s also funny? How it is humor nature to only dwell on the negative. So, bleh, I am really tired of worrying in general. The 2 hour drive to the rotation site I took every morning and the drive home every night gave me ample quiet time to dwell on things. Things like getting kicked out of my rotation housing and the subsequent ass-raping of my integrity in the eyes of the dean. Things like how I am going to be fucked when it comes to the Internal Med test b/c I spend 4 hrs of valuable studying time in the car every day. And I especially dwell on the fact that the dwindling of my bank account by Dec is not likely to match up with the replenishment of loans in January.

Ok, bad things out of the way. Now, how to build up this month in my memory as something other than the month of ass-raping? Though that does have a ring to it, don’t you think? In the spirit of Thanksgiving, maybe I should focus on what I am thankful for this month:



1) Jesse came to visit me!

-She was here for a whole weekend and we rocked Boulder, I must say. We cruised the Pearl Street Mall, enjoying the local “color” (aka marveling at hippies & street performers), supporting the arts (aka buying hand-made greeting cards), and partaking of local fare (aka eating an orgasm roll at the BEST sushi place ever.) We finished outthe weekend rocking out to Guitar Hero III, laughing at the whitey white people dancing at the local bar, and buying Jesse a new wardrobe at Old Navy. Wow that weekend did my heart good. I am so lonely here, so the company was great, but talking to her was also an essential reminder that I am not crazy normally.

2) I was able to spend Thanksgiving with new friends.
-Just when Josh & I were wondering what we were going to do on the holiday, and how we could afford all the fixings we wanted, my 4th year mentor sent us an email inviting all stragglers to a Thanksgiving dinner at her place. When we got there, they had chicken instead of
turkey (we hate turkey!), homemade croissant rolls (that is our holiday tradition!), and real pumpkin pie with fresh-made whip cream (ohmigod, our fave dessert ever!)…it was amazing! How did they know?? Plus I was ecstatic to be talking to someone my own age, let alone fellow medical chica. I hope we can do something together again soon

3) Being poor brings out our creativity & makes us more thankful for what we have.

-Y’know, I talk alot of smack about how poor we are, but really, things could be so much worse, and in fact are worse for tons of people. We at least have a roof over our head, and no matter what, don’t ever have to worry about going hungry. Things are tight, but when they are, it makes a focus in on what we really need vs want. We get creative in how to stretch the most use out of something, and how to make a little extra money on the side. Most of all, it reminds me how close Josh & I are. We are both fiercely independent, and probably our biggest crime
is not really keeping eachother “in the loop” of what’s going on. We don’t plan dinner, we don’t call if we’re late, and we don’t go to bed at the same time. However, when things get stressful and money gets tight, we don’t argue or blame eachother. Rather, we band together and become a great team to figure out a way to survive and make our way out of it.



4) It was a great rotation!

-Almost worth the daily drive. I learned tons about medicine and its given me a new perspective on how to run a practice. Y’see, my doc was like an older version of the boss Michael Scott on the Office. He would waste 20min of a session just bullshitting with the patient, and make really corny and often times inappropriate jokes. His favorite was to diagnose an 80 year old woman’s problems as her being pregnant. His other one was to demand more complaints from the patient b/c he needed to make more money or else 1) he couldn’t afford the brothel he visits 3 times per week OR 2) he’d go home, beat his wife, and he can’t afford the alimony. But I did like him, and his patients LOVED him. Life Lesson #1, People like the abuse. They also were willing to wait an hour for him b/c they knew he gave them his undivided attention without any consideration of time. I also loved the staff. They said I was the first med student to treat them with any respect, so they helped me out and taught me things they flat out refused to do with other students. On the last day, they took my information and let me know that if I ever move back to the area, I’d have a whole office staff waiting for my practice. It was really sweet.



5) Friends, family, health, puppies, doing what I love…and all that other mushy stuff!

-I have the best friends I’ve ever had in my life, a family who loves me enough to visit me in Denver & nag me to tell them about whats going on in my life, a loving husband, 2 puppies I couldn’t imagine loving anything more until I have kids, Josh and I are both in careers we love, and we all have our health. I really don’t have the right to complain as much as I do!

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Medical Divorce

Went to my first tumor board today. It was pretty cool, nice to finally see some real pathology from actual patients. One patient had Burkitt's Lymphoma with the classic starry sky appearance, that one was particularly interesting. They had her on some sort of a port through her head to give her intrathecal chemo, I need to look that one up and see why intrathecal rather than systemic. It was nice seeing actual doctors review cases together and ask each other questions about why they handled certain cases the way they had. Also need to look up EGFR.

There was one patient who had had 4 stereotypic screening biopsies in two regions of her left breast, and one from each region showed pretty severe calcifications. It was documented that all physicians involved independently recommended a mastectomy, and the patient refused. A girl from my class spoke up and said she'd seen her in primary care, and she was a very difficult patient. She's a smoker with emphysema and uncontrolled diabetes, and she also has temporal arteritis but refuses to get a biopsy done. Between that and the diabetes, it's only a (probably short) amount of time until she goes blind. My classmate said her rationale for refusing the mastectomy is that she saw a program on TV where a lady had a total mastectomy and then ended up being cancer free. She firmly believed that when the biopsies were done, the cancer was now gone and she was cured.

The oncologist in the room said that it was important for all docs involved not only to chart that she'd refused the mastectomy, but also have her sign a paper saying the same. He said that he'd divorced her. A ripple went through the crowd that each doc involved had done the same, and her primary care was getting ready to.

Such an interesting term to use for basically kicking a patient out, divorced. I've much more commonly heard it referred to as firing a patient, but that one doesn't make a whole hell of a lot of sense either. Where does the responsibility of the doctor end and the responsibility of the patient begin? And how is it helping the whole situation if the doctors involved switch from being primarily concerned about the patient's well-being to being concerned about not getting sued? I guess it makes them more aware that the patient understand exactly what she's turning down, but I feel like the system is forcing us to compromise our ethics at times. I mean, I know the responsibility of the doc can only go so far, but it seems wrong that good doctors need to "divorce" a patient when they realize that the patient is an idiot and their risk of getting sued is too high. I wonder if the older docs, or I guess the middle aged ones who've dealt with this longer even realize how fucked up it is anymore. I hope they do.

Addendum:

EGFR is "epidermal growth factor receptor (EGFR; ErbB-1; HER1 in humans) is the cell-surface receptor for members of the epidermal growth factor family (EGF-family) of extracellular protein ligands." Yeah Wikipedia. I thought it was some sort of growth factor.

And here it talks about why to use intrathecal chemo in Burkitt's, there's a high chance of meningeal involvement.

And bam I was right that the Burkitt's translocation is t(8;14).

Question

Me:
"What's a technical way to say that she feels pain whenever her buttcheek jiggles?"

The Attending (stifles laugh):
"I think you just said it."

What I Remember

I remember the look on her face, the pain, the fear she wouldn't be able to breast feed after the surgery.

The teenage mother with no car who walked her baby's stroller to the office for every checkup. How she would never become the inadequate mother that her mother or sister were. Knowing she meant it.

The cries of new babies. How deliciously unfair it felt to be able to sit in the nursery and rock them while their mothers didn't even know. The realization that they might not all be perfect.

My hand on her chest, holding the retractor. Making it through the first sight of blood, the pus and infection, but starting to pass out when I thought about her breathing beneath my hands.

The morning I first became a doctor. Being in the room with them when she came in the day before, "dizzy," in the middle of a stroke. Watching silently, taking it all in, then going to get her son from the waiting room. That next morning in the hospital. Not even in med school yet, no clue what to say. She thanked me for taking such good care of her the day before, for being such a good doctor, and being there when she needed it. The amazement of this woman, so much older and wiser than me, looking up to me as her caretaker.

The rush, the intoxication of the first time in an OR. Playing the passive student, but internal monologue racing, telling the surgeon why she had lost her bearings on the camera. Confidence I forgot was mine, confidence that used to define who I was. Flashing back to correcting the teacher who was incorrectly teaching the other students how to read. Knowing I could have, would have been able to do the operation better. The thrill of rediscovering what it felt like to be me.

The fear of the first cut. The fear I wouldn't be able to handle it, that I would pass out or be sick. And once it started, never wanting it to end.

The Amish baby boy's steadfast, determined grip on my finger during his circumcision. His strong resilient personality showing itself only two weeks after birth.

When the pain stopped and osteopathy started.

The girl who said nothing. The teenager, impregnated by her uncle, hoping to deliver before the beginning of her freshman year of high school. The anger that she wasn't ever allowed to make the choice, regardless of what it would have been.

How he saw tonight. He saw right through me, grabbed the thought, and realized he was right. The split second look across the table, when everyone else disappeared, and seeing that he knew. Looking in through a window, seeing decisions I didn't know I had made. His excited smile of realization, I had already began to fall for it. Feeling that fraction of a second, shared only between us, being etched into my life.

Constant, nagging thoughts that I will never be good enough. Always trying to suppress it. The inequality of test scores and real life interactions. Knowing that not only am I equal to them, I am better. The hope that someday someone else will also see that.