I really am a nerd

I just finished writing up a history, physical, assessment, and plan for my preceptor on one of my patients. The really sad thing is that I enjoyed it. I can't think of another time I've written a research paper at the last minute, used ten references, stayed up past my bedtime, and still enjoyed myself. Wow. I thank G-d for putting me in this place.

It's the only way a nerd like me can survive, thrive, and even be thought of as halfway normal by the populace at large. That still might be too much to hope for in my case though...

Every step of the journey, is the journey

Today, while working with a new attending (I'll call him the Zen Master) in general medicine clinic I had more autonomy than ever before. With three of the patients I saw, I came back to the Zen Master's room, presented my findings, told him what I wanted to do, and he said "ok" signed the note, wrote the orders, and told me to send the patient on their way. Granted, there are uncomplicated complaints, but it still is fun to reach that stage of proficiency and trust.

The Zen Master is also a great teacher. When a patient was late, we sat down and discussed some articles from the New England Journal, he quizzed me on algorithms for the work-up of various complaints, and he expressed his own philosophy of medicine. I think the letters "M.D." after a person's name predispose them to philosophizing and solving the world's problems on the back of an envelope. Although I'm probably already there without the letters. Maybe that kind of person just goes into medicine.

Dr. Woodley also had some great comments when I ran into him today. He said "People read these [scientific] papers like they're gospel. They're so far from gospel I can't even begin to tell you." And then later he pronounced: "Medicine is not for the brilliant. In fact, anytime you find a brilliant doctor, make sure his nurse practioner is real compulsive and attentive to detail. Brilliant people are liable to be absent minded and hurt people." Priceless.

It's not always about pills

Today I was reminded that medicine is not entirely about pills, and not entirely about sickness. I was in the cardiology clinic, wrapping up a patient encounter with my attending. It hadn't been a difficult one, the guy is pretty healthy, and was only in the clinic because of a scare over an abnormal EKG, which he had only gotten because he was participating in a study. He works in one of the clinics downstairs, and this was his follow-up appointment. Asymptomatic sinus arrhythmia, not going to bother him. He had managed to stop drinking alcohol, which had been recommended the last time he was in and his only request was to get the nicotine patch. But Dr. Woodley did something quite interesting. Their conversation went as follows:

"I think you can stop smoking on your own. But what is really important is that you leave here and improve yourself. Go out an get an education. The military will pay for it, go get a degree"

"I know, I'm trying, but night classes are hard"

"Yes, thank you for reminding me that life is hard. Go get an education, and don't come back here unless it is to brag to me. I'd love to see you for that purpose"

Later that day, Dr. Woodley was telling me how to take a history (a favorite subject for attendings talking to med students) and he mentioned that the most important part of the history was the social history. This surprised me. More important than knowing about chest pain, dyspnea on exertion, past medical history, surgical history or anything, is knowing whether a patient is married, whether they have kids, whether they smoke, drink, have any hobbies, go to church, etc. Amazing.

This evening I was telling a friend how interconnected the cardiac system is. How the heart is affected by the kidneys, by the liver, by the lungs, by the brain. Cardiology then, (like most of medicine but perhaps more so) requires a knowledge of every part of the body and how they affect the system of primary concern. And the holistic approach evinced by Dr. Woodley's advice shows that far reaching concern.

Finally, Dr. Woodley said something which sounds at first like a compliment, but is more a statement of philosophy. He said "What's the best thing to happen to medicine? You are. Never forget that."

Maybe it's silly, but...

I showed up to my walk-in clinic today, and got a fun surprise thrill. I have my own office, with my name on the door. I feel more like a professional all the time.

More patients

So I finally got back into the clinic today, and though I got off to a rocky start, it went well. Since this is rheumatology, my patients were fairly typical. I saw a woman complaining of pain in her joints to start the day, and with some careful questioning, elicited a diagnosis of Sjögren's syndrome. The next patient was having similar symptoms, but mostly arthritic, with no obvious keratoconjunctivitis sicca, so we settled on just saying she has rheumatoid arthritis with some concerning blood work. She'll need regular follow-up, but for now she gets Tylenol and eye-drops.

The last patient was a procedure. He's got a Baker's cyst, a swelling at the back of his knee which causes some pain with walking. So the treatment is to enter the knee from the front with a large needle (after anesthetic, of course), drain out what you can, and re-fill the space with lidocaine and steriods. (The lidocaine numbs the area acutely, and then the steroids reduce the inflammation in the long term. It works beautifully.) After Dr. Sears numbed up the area, I got to do the rest of the procedure. It can't be a pleasant one under any circumstances, but I mangaged to pull if off without causing unnecessary discomfort, and my attending was pretty complimentary. About the entire day, actually. He said I did a great job getting the histories and physical exams, and (in a fairly typical attending move) tried to convince me that rheumatology was the way to go for a specialty. All in all a great start.

Rheumatology might actually be a lot of fun. It is a solely clinic/lab specialty, so you can't get called to the ER late at night because Mrs. Jone's has had a flare of her arthritis. And so the hours are great, and, according to Dr. Sears, this is great for a family. I don't presently have that concern, so maybe I'm not as wise as I might be, but the siren song of cardiology still calls to me.

Next up, walk-in clinic, pretty much where you go if you don't need the ER, but can't wait a week. No idea what I'll see, but the attending doesn't know either, so I'm not at too much disadvantage there.

But yes, the rocky start I referred to above. You know how sometimes the word, phrase, or question you need is just at the tip of your tongue? Now extend that to an entire conversation. I clean forgot what questions to ask, how to write down my findings, everything. I was writing a SOAP note like an H&P. Horrors. Of course, this is medicine, and it is easier to get away with that, but I was having flashbacks to Surgery, and heard Dr. Harb's voice saying "Stop using complete sentences, Nathan. I don't want complete sentences." I survived though, thanks to an understanding patient, and some appropriately timed thoughtful pauses.

And so it begins

First day of Internal medicine today. Mostly orientation, getting new schedules and the like. The first six weeks will be in outpatient medicine, with different clinics and preceptor meetings. Just keeping all the requirements for my presence straight will be a challenge.

I am quite excited that I will be working in Cardiology one morning a week, and that my attending for that won the "best teacher" award from the class which graduated last summer. It will be quite difficult, I imagine, but ultimately rewarding. Tomorrow I start off with Rheumatology, and it looks like I'll be working up a patient who may have lupus, followed by an older man with knee pain. According to Dr. Sears, that may net us a procedure, which should be fun.

So overall, I've got one morning of cardiology clinic, one morning of rheumatology clinic, one morning of walk-ins, one morning of general medicine, one full day at a satellite clinic, two afternoons with a preceptor discussing papers I'll write, and two free afternoons. Not a bad schedule.

So far I am concluding that internal medicine guys are far, far nicer than their surgical collegues. Dr. Sears called me in, showed me the schedule for tomorrow, told me what to read, and offered to meet half an hour before clinic starts to give me a run-down on what to expect in my first patient. The focus is on learning and teaching, and they are excited to help the process along.

Into the Flourescent Tomb

I borrowed part of the first season of Scrubs from a friend today. It's the first time I've seen it, and yes, I am way behind the times in that. An amusing show, not always great, but giving a pretty good picture of life in the hospital.

Rotation 5 starts tomorrow.