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Family Medicine

Life got crazy for a bit there and I had no time to write! Alas, I’ve missed a few days, but the show must go on! Let’s begin with our day of chronic care. I’ll call my doctor for this rotation the Friar (not sure why I went with that… he’s definitely not a fan of religion… but the name seems to fit). So the Friar has a bit different approach to medicine than Dr. Leonidas and certainly a different environment medically. Where I have been seeing uninsured people for the most part in my family rotation, in chronic care I see extremely wealthy people that never really worry about the costs of medicine.   It’s a private setting and patient satisfaction surveys and the need to keep patients drive the doctors to overprescribe medications such as antibiotics and narcotics (I actually haven’t seen the Friar prescribe narcotics without good reason but just trying to make a general statement). He told me that the antibiotics that he prescribes are not needed 1/3 of the time but if he didn’t prescribe them the patients would simply go to an urgent care, get the meds, and would be lost to his practice. This really disappoints me. I know it is an extremely common theme in medicine to overprescribe so I’m not down on this doc at all but more on the whole medical system and the flippant mindset so many have towards antibiotics in particular. Doctors who prescribe like this are unfortunately increasing the rates of antibiotic resistant bugs and this trend towards hitting viruses with a Z pack is going to lead to billions of deaths in the long run. We study this stuff for 8 years and then go through more training with residency and fellowships oftentimes, yet we let our patients who have used google all of 2 hours tell us how much of and what medicine they need… yeah right. If a surgery isn’t necessary, don’t make the first cut. If it is possible to use steri strips rather than sutures, use the tape. A cardiologist was recently destroyed legally (I actually think he may be in jail) and barred from practicing medicine after it was found that he was doing unnecessary caths for financial gain. How is a doctor that is prescribing an unnecessary medicine in order to keep patients (and thus financial gain) not also barred? Again, not down on this particular doctor but the whole system that teaches doctors to do this. This is when those lectures we slept through on patient education are vital. I think about half of docs may really agree with what I wrote and half would be pretty pissed off (and listing three reasons why I’m wrong), but it’s how I feel and research shows that unnecessary meds increase mortality – Primum non nocere – First, do no harm.

To go on with patients and what this blog is meant to talk about, I saw a guy (in chronic care with the Friar) who had been in the hospital for an incredibly severe bout of pancreatitis and is now insulin dependent. He was a pretty solid guy who no one would ever have guessed was an alcoholic. Great family and job, exercises daily, doesn’t smoke, and just a flat out cool guy. He’s one of those you would want in your clinic but everyone has something, some struggle, some temptation that comes at them again and again and is too often hidden in the shadows. Unfortunately, this temptation almost cost him his life. He is now completely off of alcohol and is getting back into regular life again thankfully with a lot more help and honesty about where he is at. It’s incredible when someone gets hit with something like a month in the ICU and then changes their life. All the time that the nurses and docs worked on him was worth it. I’m hoping to follow him as a patient and see what happens and how he grows.   In the family med clinic, I sewed up a guy that chopped his foot with a machete. Practical takeaway point – don’t hit foot with machete. We told him it would cost extra to sew his shoe as well haha. It was nicely sutured and I felt proud of this one. I’ve been doing paps and pelvic exams lately like a master and feel like I’m really helping the whole office. We’re halfway through and hopefully I will improve as much as I have in the next three weeks as the first.

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Family Med

Doctor Leonidas is the man. He had to go to one of those fantastic computer training courses in the middle of the afternoon and just told me not to worry about coming back in because there would only be a couple of patients late. This meant I went out on the town and lived it up… Or found an incredible coffee shop for studying… Or both! What a day. My medical Spanish is coming along, now I only really have any difficulty talking with Cubans but I feel like I’m even starting to understand that. My little reggaeton radio station is doing its job. The most interesting, yet sad, case of the day was a 48 year old white woman who looked to be 80 years old. She had at least 60 pack years (2+ packs a day for 30 years) and noted a slowly enlarging mass in the right side of her throat 5 months ago. As it’s grown larger, she has had increased difficulty swallowing solids [very important to differentiate solid and/or liquid dysphagia. Thanks Dr. Goljan (actual name for once!)!], terrible hoarseness, and choking throughout the night. A lot of our patients wait until the disease is terrible before coming in and unfortunately I just don’t know what we’re going to be able to do for her.   Discussing this case with my attending was just so sad. If she would have come in 4 months ago, maybe we could have saved her and hopefully we still will, but the prognosis is most certainly very, very poor. On a brighter note, drug and company reps brought in slurpees today in honor of 7/11!

Day 1 – Family Med

Never would have guessed I’d like my first day so much. My preceptor’s a solid young doc fresh out of residency that has a great perspective on patients and medicine and just seems to want to help people. I’ll call him Dr. Leonidas throughout this rotation (not his actual name of course). Who would’ve thought on the first day of my first rotation I’d be doing pelvic exams and the like? Already have multiple interesting patient interactions but the one that stood out was a white 50 year old lady that came in with fibromyalgia AND rheumatoid arthritis AND multiple car accidents resulting in neck pain AND a heart murmur AND mental slowness AND excruciating right lower abdomen pain for one month… Needless to say, she had a high pain tolerance and rated the pain as a 7 on a ten point scale while in no apparent discomfort (nor any sweating, elevated HR/breathing). I love patients like this, you realize that it’s all just a mental thing but it’s still real to them (I should point out that the heart murmur was very real and she gets a nice visit to cardio) and so you’ve got to figure out how to treat them without giving drugs with abuse potential. What’s really irritating though is when they use these “pains” to collect disability and then sit at home smoking multiple packs a day and watching TV… haha and then get mad at you for running late despite offering free (or almost free) services. So besides that we had a young black male with a full set of gold grillz coming in with orchitis (swollen testicle) and discharge after multiple unprotected sexual encounters with multiple partners… not in multiple weeks. What really “stood out” about him was, well, let’s just say we later had a laugh as we asked the nurse what was going on before we got in the room if you catch my drift. Well, hopefully my stories were entertaining for you today. To sum it all up, my first day of my third year of med school taught me a valuable lesson: a glass of red wine, walk on the beach, and romantic dinner with extra virgin olive oil and French vanilla candles in a dimly lit room do more than a pill ever could.

So tomorrow will be the first day of “rotations”, where medical students work with physicians in various fields of medicine. At my school in Texas, students were split between various campuses in order to maximize the amount of time that we get to spend one on one with our doctors and patients. Third year, though not as difficult in terms of studying as the second year of med school, is the year with the least amount of time. Many doctors have told me that they wished they would have written down their thoughts and memories throughout their clerkships (rotations). Things move so fast that we stop being able to remember the process and beauty in the development of medicine from a science to an art. I’m writing this simply because I don’t want to forget. I want to be able to look back one day and be proud of where I’ve come from and how much I have progressed. I want to remember the first times I deliver a baby, sew up a brutal cut, hold someone’s hand as they pass on to the next chapter, diagnose emphysema correctly, get pimped (when a doctor asks a med student something the student has no chance of knowing) and surprise my professor with the right answer, hear that I saved someone’s life, and see some of those rare diseases that we focused on so much throughout the science years of med school (and thought we’d never see!). Maybe that sounds strange to you, but, for me, these memories are everything. Each day, I’m planning on writing just a brief story, worry or idea that I have. Obviously, any patient name and information I use will be completely made up (violating HIPAA before I even start as a “real” doc would be very unfortunate), but the story behind that will be truth. The things I’ve already seen have, at least in my mind, been shocking at times – from holding a tiny four year old girl with measles to comforting the parents of a baby born with Pompe’s Disease (a rare lysosomal storage disorder that is a death sentence) to reevaluating all of my political views as I watched families being torn apart when the government decided to send illegal immigrants home. Doctoring is more than medicine and basic science. Maybe in one of those situations I made a slight difference… of course, that’s what being a doctor is all about.

The question, O me! so sad, recurring – What good amid these, O me, O life?

The Answer:

That you are here – that life exists and identity,

That the powerful play goes on, and you may contribute a verse.