Mile 13624: Final Push

Above: Team "Kentucky Fried" takes one final shot. December 2010.

PUUSSHHH!!!!

Being on call has become a routine for me. Every fifth day during my rotation, my partner and I end up staying 24 hours at the hospital "on call" in the Labor & Delivery Ward. We're responsible for admitting patients in labor, writing their history & physicals and to observe / assist with deliveries. Sounds hectic, but yet over the 6 1/2 calls I have had over the last 6 weeks, there was none more busy than my final day. However, that doesn't mean that the night was tiring beyond measure, as I found the pace of this call exhilarating. I found myself in synchronization with three other nurses saying "push!" to get a mom to finish her delivery and even was treated to a "fourthmeal" along with the nursing staff underneath our attending doctor's tab.

I'll be honest, a quarter pound burger along with a frozen non-alcoholic lemonade sits pretty well when being on call.

However, even after not having busy calls, that night was our "test" to see how much we learned through the deliveries that we had over the calls in the past weeks. And that's something both my partner and I both noticed: we learned a lot simply by observation (and much more than we give our eyes credit for). With the help of our attendings and our past memory, we were able to position the baby's head on its exit from the vaginal canal, deliver placentas, and even coach the mom through her contractions.

I'll admit that it is really invigorating and exciting to do the coaching. I've always seen it on telemagazines and on TV shows, but when actually doing it, it feels quite different. Coaching seems to be one of the most important parts of delivery, as I see how good coaching can result in much more efficient pushing and quick delivery of the baby.

Okay... 10 seconds... Let's go!.... Come on back into it, take a deep breath, give me 10 more seconds... you can do it!

I really loved the OB portion of my rotation. There's always some type of joy associated with delivery, and it brings a type of doctoring where instead of dealing with something that holds back our own lives (the loss of health), OB most of the time brings happiness and its not just to the mother but to the baby's family. This was best seen midday, when one of the nurses yanked my partner and I out of the nursing station simply to do "rounds" consisting of delivering a muffin-top birthday cake and 2 glasses of "fake champagne" (aka sparkling grape juice) to each mom with a newborn that day and singing "Happy Birthday" to each new baby boy and girl. We did 9 newborns that day, and it felt very rewarding.

Even in a world where malpractice could be scary, I can definitely see the light that OBGYN doctors see that motivates them to do their work everyday.

---

Forgive me for not writing for the last month. I'll admit the hectic schedule of OB has held back my ability to stop and think and write. However, I was able to see a side of my OBGYN rotation that is more applicable to anyone in every field, and I'm thankful to have an attending that was inspirational as the one I had to show me it. More on that in the next entry.

Mile 12056: First On-Call

Above: Almost a perfect shot on my "adopted sister's" final night in town. Replace that lightbulb, Chicago! November 2010.

SOMETIMES THE UNEXPECTED
JUST HAPPENS.

This week, I began my OBGYN rotation at St. Anthony Hospital in Chicago, IL. There's a group of 10 students working what has been nomered as a q5 schedule. A typical stretch of days include clinic, surgery, more clinic, call, and post-call. Call and Post-Call add up together for a 24 hour time shift from 6:30 AM - 6:30 AM the next day.

And that's exactly what I just went through.

I'll admit that call does have its pros and cons. Let's start with the cons first, because I personally think they won't outweigh the pros. There's less sleep (and odd patterns of it) and an acquired horrible diet (100% fresh pure high-fructose corn syrup in my Crush Orange Soda to start off my day and a nurse offered me chili cheese fries for the night).

Then there's the pros that make call kinda cool: A nifty on-call room (with a comfy bed and a small flat-screen TV). My crush soda (along with the rest of my on-call meals) were taken care of with meal cards. Hanging out with a cool nursing, midwife, and medical staff when there was a long period of downtime. An awesome resident who took the downtime to teach us.

However, the big win of the night occurred early in the morning almost 24 hours after my first call, when my partner shot me a call on my cell phone that woke me out of my trance of sleep in the on-call room. "The doc's here, just wanted to let you know so you won't miss the delivery." So within 10 minutes I was upstairs. I had taken the patient's H&P earlier that night (looked like labor was going to move on smoothly), and hit the sack rather worried about not getting to see a birth that night.

And here I was scrubbed up with the doctor, and the whole experience just went by so quickly. For me as a new medical student, the novelty was definitely there and made every single moment from scrubbing up to catching the baby to waiting for the placenta to come out post-partum exciting. I was glad I had an attending who was willing to trust me to guide me throughout the process. It felt really awesome to participate in the joy with the family & parents that were there.

So here I am, typing up this entry after just ending my shift (a little of editing at home led to a later release). In a discussion I had with my partner in the elevator post-call, we came to an agreement saying that although call is so tiring, a call experience is very rewarding and very cool (although doing too many calls I think makes the novelty wear off). Both my partner and I delivered for the first time today. It totally takes technique and practice, but with the joy brought of making a new boy or girl make it into the world, to me, there can be nothing more motivating to perfect my delivery skills & knowledge as much as I can in the next 6 weeks.

Mile 11942: Exploration - A Prelude to Part III

Above: Michigan Avenue in Chicago has to be one of my favorite streets of all time. September 2010.

IN JANUARY 2011,
WE'RE TRULY HITTING THE ROAD.

Is this something I'm truly excited about? Yes.

With me finishing up psychiatry (roundup ahead), I have two big cores left, OB/GYN and Surgery. Both are at St. Anthony Hospital in Chicago and I begin the OB half this upcoming Monday.

Now that all the bugs have been smoothed out (they were kinked for a little bit), I can tell you that I'm going on an amazing road trip. In May of this year, I went on a road trip that was independent of medicine, just to explore life without limits, and not to be a medical student for a little while. However, beginning in January, I'll be going on the road to do several rotations away from home. It's my time to explore where I might do residencies, different places to work, and even experience what it is to live in a city that's not my own.

(Please don't get me wrong, I love my hometown, the Windy City, to death. I'm just an explorer at heart.)

My current remaining schedule looks like this:
November 2010 - Obstetrics & Gynecology Core at St. Anthony Hospital, Chicago, IL
January 2011 - Family Practice Sub-Internship at Decatur Memorial Hospital, Decatur, IL.
February 2011 - Internal Medicine Sub-Internship at Wilson Medical Center, Johnson City, NY.
March 2011 - Intensive Care Unit at Grant Medical Center, Columbus, OH.
1 week break to take the ever-so-important Step 2 CS on April 1, 2011.
April 2011 - Surgery Core at St. Anthony Hospital, Chicago, IL
Planning 4 week break to take the also very-important Step 2 CK in July 2011.

After then, we're back to an abyss as to what to expect after then. I have about 16 weeks of electives remaining to schedule, as to what they are, we'll see as I have a series of sites I'm looking into and will be putting in my reservations for them soon...

---

And now approaching 12,000 miles, I have ended psych. The doctor I round with in the morning and I have seen many things we never have expected to see, everything from people saying that they were "poisoned" to people who have ended up with more money in their pocket after dying. I even met someone from Bedrock (ever Meet the Flinstones?). And as crazy as these stories may seem to some people, doing a psych rotation really has put new perspective on how to look at these patients. To me, with each interview, I was getting onto a roll of taking each interview as a conversation I'd have with someone over breakfast or a cup of coffee. Each patient (from the elderly with dementia to the teenager with schizophrenia) presented with a new challenge, which was something I always welcomed. That's the way I learn: through my challenges.

Although my career interests currently don't involve psychiatry, I value now being able to see how the skills that psychiatric interviewers use to talk to their patients can be used in any setting, and it certainly helps in making any doctor's job easier. Thanks psych for a wonderful six weeks, I loved every moment of it.

So now I'm now a Fourth-Year student (by numbers of weeks of rotations)... If this past year came that fast, well... the next year is going to fly.

Mile 10121: Now You See It

Above: Jack Narz was the host of the 1970s edition of the great game show "Now You See It."

SOMETIMES YOU JUST HAVE TO
SEE THINGS FOR YOURSELF.

As Dr. Psychobabble said, "Psychology is the bestest." Even though, yes, it is a biased opinion (she said so!), this week on the wards, I started seeing how it was the "bestest", exactly as I told you in my last entry. So far, my schedule on the wards has been pretty consistent. Each of my days are faced with an interesting juxtaposition: earlier in my day, I round with a Psychiatrist who is a consultant on the medicine floors, while later in my day I round with a Family Physician who is a consultant on the psychiatric floors. It provides two different perspectives on how to look at a psych patient.

However, to date five things have stood out about psychiatry that have made my first two weeks on the floors enjoyable:

1. Au contraire: psychiatry doesn't just deal with the extremes.
In my last entry, I described some of the more severe cases where my friends were physically "harmed" by a psych patient. However, although there's a chunk of patients that do present with danger, a majority of patients are not like that. Many of the medicine floor patients talk just like their non-psychiatric consult counterparts on the floor. The patients on the psychiatric floor have very cool personalities and backgrounds. Many of them are quite easy to talk to, which leads me to point two.

2. A psych patient is still a person.
During lecture last week, I heard in lecture that the best way to interact with a psychiatric patient is by starting a conversation just like any other in one's non-medical life. I totally enjoy getting away from the standard "conversation conformed to standard history taking" format, and being able to use the interview in another dimension to assess mental function is pretty cool. It was a concept I finally got a hang of this week and am trying to tweak.

3. Sometimes your imagination itself just has to fly.
A few days ago, I heard a patient down the hallway start to sing. Mind you, it wasn't emmy quality, but the few simple notes that the patient was singing were pretty catchy. I ended up looking out the room and saw the patient dancing a semi-two step to the same song. I was very tempted to go out there and dance with him, but I was still getting used to the psych ward. However, that moment really brought a smile to my face.

4. Psychiatry offers some really unique situations.
If I went to a cocktail party, I could actually ask the question, "How many med students does it take to cut a person's ring off?" and answer truthfully six. Our group spent 2 hours switching between each other with a manual ring cutter to cut this patient's ring off. It was grueling, but it was good to see our team pull together with each twist and grip of the ring cutter.

Although this situation could be seen in some other fields (ER for instance), I'll be honest, it was fun to hear our patient sing "Free at Last" when the ring finally came off.

5. A psych rotation offers skills to both future psychiatrists and non-psychiatrists combined.
Every doctor is going to run into psychiatric patients of different sorts throughout their career. Getting an opportunity to see how to interview these patients has been, so far, a great learning experience. To recognize different psychiatric conditions and how to handle them can help aid with not only treatments of the mental conditions but improved understanding of the patient and increased compliance with treatments for their own medical conditions.

I love having an open mind... it makes me enjoy more of what life has to offer. That's what has made me get through 10,000 miles... Here's to 10,000 more!

Mile 9714: Get Psyched!

Above: Meadowbrook Park in Urbana, IL gives visitors a glimpse of the original praries that covered Illinois.

NEVER EVER ASSOCIATE PSYCH WARDS
WITH STRAITJACKETS.

This week, I've started a new round and a new rotation at Jackson Park Hospital in Chicago for Psychiatry. My friends love to tell me stories about things that have happened on the wards when they did their psych rotations. Their stories weren't exactly the most amusing... one got coffee thrown in her face while another put up pictures on Facebook of arm bruises from of a friendly tap from a patient that was all but well... friendly.

Oddly enough, using psych terminology, I think I have a psych ward phobia to get over.

I'm personally determined to use systemic desensitization to getting over it. My first day on the rotation was on Monday, and I'll admit that the adventure was filled with just about every anxiety-producing moment I wanted to just avoid. I kept my eye on the doorway while interviewing patients, I made sure that the door was locked behind me to the nursing station, and I even watched my back to make sure that nobody tried to make a move on me. However, the only way I'll learn and the only way that I face what might happen head on.

After taking on weekend call today, I'm starting to see how Psychiatry, like Peds, takes the concept of medicine and adds its own interesting twist. There's an increased reliance on other people's histories (police, family, nurses), some treatments involve a huge amount of trust in psychology, and blood tests and lab values don't carry as much importance as they do in medicine in pulling a diagnosis (but still can be helpful). And it is for this, just like my previous adventures, I am looking forward to my adventure in psychiatry. There's a reason why psychiatrists enjoy what they do, and I've read about them. However, the only way I'll completely learn and understand is if I see these reasons for myself.

And, that's exactly why I'm keeping my eyes open.

Mile 9363: Countrified 4 - Growing Culture

Above: Nothing beats a tall set of golden arches to greet you on the road. Gilman McDonald's, Exit 283, on Interstate 57 in Illinois.

"I ROAMED THE COUNTRY
SEARCHING FOR ANSWERS TO THINGS
I DID NOT UNDERSTAND."
- Leonardo da Vinci

4:40 PM, Sunday - My friend Don and I were driving back on good old Illinois Interstate 72, after visiting an elective site I'll be attending this upcoming January. I-72 is a four-lane corridor originally designed to connect the mid-sized cities of Springfield, Decatur, and Champaign, Illinois. We got to talking about places that seemed so "perfect," that they were "too good to be true." And for some odd reason, that got me on a mantra to talk about what I liked about Champaign, a city I spent a good 4 years of my life in. To me, it was an example of perfection, but there seemed to be no strings attached to that experience.

----

The debate is still hot. Even though it has been just over a year since I've written anything on this topic, it's still something I do think about. I'm still attracted to the sense of urban sophistication that's given in the larger cities like Chicago, but something also pulls me towards the growth and potential in smaller cities found away from metropolitan areas.

I drove down to Champaign this past weekend to spend some time with my good friends Neal & Christine, who I've always wanted to spend time with (more than the 13 hour stop I made last time I was in town in May). On a cold Saturday morning, I whipped down I-57 and made it from the Chicago Area in a very efficient 2.5 hours (without speeding, and with a McDonald's stop for coffee placed in there). When I got into town, seeing a good chunk of people outside at 8:30 AM doing their morning jog on streets made me smile. It was good to see at a metropolitan area of about 100,000+ people (without the students at the University of Illinois) still had that sense of freedom that comes with safety. I soon found myself in the outer rim of the city, entering the "suburb" of Savoy where Neal & Christine live. I smiled when I noticed that when I looked to my left, I saw houses, but on my right, I saw the beauty of endless fields of corn blowing in the wind.

With a lot of smaller cities, especially those home to colleges, there is an investment into downtown areas, to infuse culture, improve the quality of life and to show that these cities have identity. The Champaign-Urbana area has exactly been doing that, and every time I come back, there's something new or something improved about the area. When I first visited the U of I in 2002, I saw the potential in the area, as this was when the improvements were beginning in the cities. And 8 years later, I can see there's something for everyone, with everything from a Weekend Farmer's Market in Urbana to fancy eating in the downtown area of Champaign to summer festivals that complement any social outing quite well.

No, this isn't a post to simply limit my future to be here in Illinois (although I would love to be), but an example of a place I would love to live. I look at other large college towns, like those in Bloomington, IN, Madison, WI, and somehow that "oasis" of urban-ness within miles of rural terrain pulls me to places like those too. From a professional standpoint, the mix of people coming from a city-life and from the rural areas to receive health services makes this an attractive patient base to work with in my future. For me, there's always something about a city that is with vibrant growth that will entice me to live there.

So, although I got some R&R by hanging out with my friends in Champaign, I also got to learn a little more about what I wanted too. And that's what made this past weekend quite awesome.

Mile 8895: Keep on Moving

Above: I do miss the 6 AM rush hour.

ALTHOUGH I MISS INTERNAL MEDICINE,
THE ADVENTURE MUST CONTINUE.

And just like that... it's over. One of the odd ways I've thought about the last 16 weeks is, I've been at the hospital 4 weeks longer than the current interns.

My last 16 weeks at Westlake Hospital were absolutely amazing.

Some of the biggest lessons that I learned during my time in Infectious Disease weren't even in infection (although, with the amount of cellulitis cases that we got called for, I would almost consider myself an expert in cellulitis now). When comparing my 12 weeks on the floors, where we took care of just about every single aspect of our patients, my 4 weeks on infectious disease were simply focused on that. I still remember the first day when I was on "floor mode" - as I liked to term it - and wrote just about every single assessment and plan on the patient I could in my note. I quickly learned that was quite inefficient considering I was on a consulting service. But this is one reason that I couldn't see myself - at this moment - going into a subspecialty; I feel odd treating only one aspect of a patient.

One thing that I really enjoyed was that my Infectious Disease rotation came right after my Internal Medicine rotation and at exactly the same hospital. I knew how the teams worked along with who worked the teams, which not only made the transition easy, but I appreciated how the tables turned. On the floors, my intern would let me know what consults I need to pull, but now the interns were coming to my doctor and me with new consults. I'm going to miss the rhythm I started putting together with the interns, seniors, and students, but I must keep moving...

It was with this program that I appreciated some of the aspects of smaller community programs, getting to know everyone's face, seeing common cases repetitively (i.e. like the cellulitis above), working with tight knit teams, and sometimes seeing patients over and over again. I've been a big fan of the "make a big world a small one" concept, and community-type residency programs attract me in that manner.

For the next 3 weeks, I have them off, but starting in late September begins my Psychiatry rotation at Jackson Park Hospital. But I tell you, I surely am going to miss running up and down those floors.

A huge thank you goes out to the attendings, residents, and students at Westlake.

Mile 8652: (Cue Marching Band)

Above: Rush University Medical Center's new Advanced Center for Emergency Response. From Rush News.

I FELT LIKE I WAS IN AN
AIRPORT TERMINAL...

I learned this week a situation where clear, accurate documentation is critical for monitoring a situation. Let's just say this, figuring out whether or not someone has a "critically morbid chronic condition" from hearsay isn't the best way to handle it. With medicine, a certain line of things need to be done to confirm or rule-out whether someone has a condition. If those tests aren't done in order, it breaks the chain, and a degree of uncertainty (which is never good) hinders the line of treatment for the patient. Nobody wins if things are not documented and tracked appropriately.

----

A few weeks ago, the Infectious Disease team that I am a part of goes to the Infectious Disease grand rounds that go on at Rush University near the heart of Chicago. My attending picked me up from the hospital and we soon walked into a series of tall buildings, a facade of steel and glass. We soon were walking down a hallway with large directional signs and a walkway that could support a flow of a huge crowd (making me feel like I was about to catch my 9 AM flight). After going up to the fourth floor of the building we were in in the middle of a slightly crowded conference room that holds about 50-75 people, I watched several presentations from residents of some fairly interesting cases that they ran into. As the attendings, fellows, residents, and students chatted amongst themselves (and myself with my attending) to discuss each case, I felt that the openness to discusssion I observed to encourage each other's understanding of the concept was amazing. When I look back to my several hours there, I honestly saw myself as a kid in awe at a candy store.

And that's what is really attracting me about university programs when I'll match (next year). The variety of cases that you get to see there, their reputation for being at the forefront of medicine and research, the resources that are available, and not to mention the aura of academia (which I enjoyed after my 1.5 years in a Masters program at the University of Illinois) are just astounding. I really feel that a university program would easily satisfy me academically and open me up to even more new opportunities in medicine. However, aspects of community programs also reach out to me, and I'll tell you more about what attracts me to them in the next post.

Mile 8246: To Tell the Truth

Above: A depiction of the electronic medical records system from Upstream.

WHO CAN I TRUST MORE:
THE PATIENT OR THE CHART?

Infectious Diseases has been a great rotation thus far. Although I'm still at the same hospital as my previous rotation, the days feel a lot different as a consultant than as someone who's working the floors. Maybe its that the subject matter is much more specialized, or its probably also not having to deal with as many folks left and right when managing patients (on the floors for the last twelve weeks, everything from nurses to consultants and even writing notes would slow down a day's efficiency dramatically). However, I'll be honest that after 12 weeks of intensely working the floors, 4 weeks of consulting is a breath of fresh air.

Don't get me wrong, I've learned a lot about management of infectious disease simply from my first week on the post. I've at least had some slight refining with my knowledge of antibiotic spectra, common sense on when to appropriately check for blood cultures, and even evaluating if a "fever" is truly a fever. For some odd reason the "card-playing" game with empiric and more targeted antibiotics is something that intrigued me. I'm looking forward to learning more about that in the near future.

1:30 PM Friday. My attending and I are in the room of a patient along with their family. However, when my attending was further questioning a part of the patient's family history, we basically got a irate response of, "Go look in the chart!" from the family (I'm guessing that getting asked the same questions multiple times by multiple people finally go to them). My attending handled the situation calmly and well and explained to them that it is better to get the information from the patient rather than from the chart, because the chart has the higher chance for errors. Only when the patient couldn't recall the information would my attending refer to the chart. My attending further mentioned that the patient was someone that could be trusted more. With that, the patient, along with the family, had smiles of confidence and breaths of relief.

The point makes much sense though. If you've ever seen people try to spread news from one person to another, it never comes out straight after being handed down several people. The chart is like that, especially exaggerated when trying to interpret someone else's words when someone is not there to clarify or answer any of the doctor's questions. The bottom line from this lesson is that the purpose of the chart is to document what was done, but not to be used to substitute for a proper history taking or physical examination.

A simple, but very useful lesson.

Mile 8052: Teaching an old dog new tricks

Above: Jon, John, and Khoi and myself enjoying a night out at an Ethiopian restaurant after our final day.

ON MY LAST DAY
I BROKE A SWEAT.

7:40 PM Friday. I never really had Ethiopian food before. I'm very glad that one of our colleagues Jonathan had brought up the idea. You basically go in, and all the stuff that's ordered comes out on this huge platter. If you've been to Maggiano's or some other "family style" Italian eatery, you know how family style works. But I learned that Ethiopian family style is much more adventurous... it involves eating with your hands. I never imagined that eating with my hands could be so enjoyable... and so tasty!

Who knew that at the end of a medical rotation, I'd still have the brain capacity to learn something new.

-----

It's the end of my twelve weeks here for Internal Medicine. Before I keep going, I apologize for not writing more during those twelve: it was that intensive. I admit that its tough for me to study at home even more now, because I guess I've conditioned myself to take home as a place of rest. Even with coffee, I sometimes struggle with trying to make it through the latest literature or even just high yield Step 2 studying.

Am I glad its over? In ways yes, and in other ways, no. Yes, I'm tired. Yes, I need a vacation (even though I had an awesome one a few months ago). But I loved my group (we all had a rhythm and enjoyed each other's contributions to the team), and also what I had learned in the last few weeks. One of the attendings had said to us that learning medicine was the essence of repetition, and I'll admit that seeing dozens of many cases made me get into a rhythm of what to look for while taking a history and the direction to take when managing a patient. I loved running the floors, writing notes, and working with nurses, attendings, and case managers. I really had the feeling of what residency would be like in internal medicine.

What's next for me? Well, same place, but second verse. It's time for a little adventure into the world of Infectious Disease (ID) for four weeks. Think of it as an extension of Internal Medicine. So during the next few weeks, I'll try to replay some of my experiences during IM, and also try to expand on what exactly ID brings for me.

Mile 7166: Teaching the Ropes

Above: A well deserved 7000 mile car wash.

I LOVE IT WHEN
THE TABLES ARE TURNED.

At points in the last four weeks, I've felt like I've become the intern at times.

Traditionally, every four weeks during our twelve-week rotation, we switch interns and teams to give us an idea of how rotating in a residency program feels. However, for the first switch after my first four weeks, we didn't switch teams. If we had, it might have been a mortal mistake.

Why? The caveat was that the timing of the switch matched to the time my hospital injected new interns into the 4-week rotation last month. When I say new, I mean "Just-Out-of-Match-2010" new.

Many of the interns at the hospital I am at had just simply survived a week of orientation at the hospital, and were all of a sudden thrown into the "real world." I have heard many of my friends who have gone through residency talk about the adjustment into residency and how hard it is, but here I was, along with six other medical students to see it first hand. I haven't seen as many blood shot and baggy eyes at any other point in my life than these four weeks! Some of them started to even question what they got themselves into (that was part of what I termed the post on-call syndrome.)

In some ways we knew more than the new interns.

Working four weeks at the hospital was actually four weeks more than some of the interns. Over the first four weeks, our rhythm on the wards was finally taking shape, we knew how the different rounds were scheduled, we knew where to grab the empty forms when needed, and we even knew the secret places in the hospital to get coffee. However, the most important thing that I saw during the intern switch up was how well we knew the patients on our teams; had we done the traditional team switch, that continuity of information may have been lost.

But over the last few weeks, it was odd to be teaching interns the "ropes" of the hospital. I mean, the interns knew a lot more about medicine (they finished school!), but I guess the working mindset is what we needed to teach them. The hospital world is now theirs, but now it it is time for them to make it their own. Each one of us medical students made sure that we gave the interns a framework to build on to make sure that their time at the hospital was successful. It was an odd way of learning for us students, as the last few weeks was a great lesson in learning how to teach.

Well, four weeks have passed. My intern has not only survived, but has changed since the first few days at the program; he's more comfortable with the ropes and is starting to get his rhythm with working the floors. But it's time for a new intern, and because not all the new interns for the residency IM program here have been on the floors, it's time to teach again for a second time around. It felt awesome to have been a part of my interns first four weeks in residency, and it felt awesome to be an intrinsic part of a medical team.

And here begins my last four weeks of internal medicine. I'll admit, its getting rather bittersweet.

Mile 6650: Aha! That could be it!

Above: The weirdest sign I saw on my May 2010 roadtrip. Talk about a one-stop tourist trap. Kissimmee, FL along Route 192.

It's been busy. There's no time to sit back and relax. Things aren't stopping. And for me, stopping could be dangerous.

BUT I LOVE THE BURN.

Week 6 here at my internal medicine rotation. I finally got the layout of my hospital down, know when and where to get coffee on my commute, what entrees at the cafeteria I should have/avoid, and even where the "secret rooms" are to do my work.

The importance of the IM rotation for anyone comes not in just getting to work in a hospitalist format, but also learning the art of medical thinking... something that I am still in awe of and want to master.

ONE CAN NEVER SAY A DIAGNOSIS IS CLEAR CUT.

It never is (unlike many medical dramas on TV put it). Its a common fallacy I run into. To me, Step 1 thinking is all about the "clear-cut" ness and classical cases, but coming into Step 2 and Step 3, things are completely different. If Step 1 thinking is taken into clinical medicine, fairly significant diagnoses can be missed, and one can head down the wrong road of management. Medicine kinda breaks the rules; it is unsafe to always think that X + Y + Z = A always. After a set of what we call "differential diagnoses" are given out (these are the lists of possible things that are going on), it is up to the clinician to rule out specific ones (especially ones with the most deadly prognoses along with the most common). A good set of differentials actually leads to better diagnostics and therefore, management.

Our tools to solving the patient's issues include the history we take on the patient, the physical exam, and laboratory tests. Each one of the tools has an advantage / disadvantage, usually measured in terms of cost (dollars and cents), usefulness of the info returned by the test, and time-to-benefit ratio (waiting 3 days for confirming something that might kill you in an hour isn't exactly a good thing). Some of the best clinicians I've seen at the hospital will perfectly balance all three by picking the right questions, exam procedures, and tests to confirm and rule out diagnoses (somehow they make the puzzle pieces fit). I'll admit, to use all these options efficiently is an art, and my mentors (attendings, seniors, and even the new interns) are always able to think of something I can't.

It's amazing that a lot of them say that the history is usually the best place to find out the diagnosis. However, even for the best clinicians, there are times where cases where the diagnosis is so unclear or takes an unexpected turn that a "Hail Mary" throw of tests needs to be done. But they're so good that this is usually last resort only.

The art of being a clinician is easy to put into words, but mastering it in practice is going to take more than 6 weeks to accomplish.

Mile 5998: Fritos & Coffee

Above: Roadside stands like these are available all thoughout Georgia. I get my load of honey-roasted pecans each time I pass here.

EVEN WHEN ITS ONLY FIFTY-DEGREES OUTSIDE,
MY WINDOWS ARE DOWN.

Every minute seems to blur into another, as the weeks pass by faster and faster. We're already in our third week (about to start our fourth), and it was only yesterday that I remember we were getting into the realm of things. The one thing I like about the internal medicine (IM) rotation I currently am at is that it satisfies the standards that I had set at Mile Zero on my journey very well. Doing this rotation actually makes me rather excited about IM. Our work on the floors has the quality of intensity, something I have been desiring for some time.

The following is a normal itinerary for me on a weekday.

6:00 AM - I leave home early. In Chicago, traffic accumulates with every minute lost in the morning, so this is the absolute goal for departure. Although I don't have to be at the hospital until 7:30, I'd rather do some reading in the resident's lounge than waste more time stuck in traffic. I usually get to the hospital about 6:30 AM, and when I get there, I'm loading up patient data from the computers and visiting the patients I'm following before my intern arrives.

7:30 AM - My intern arrives. The first thing he does is make coffee at the maker in the resident's lounge. On the table in front of the maker is an aluminum tray with a few juice cups and bags of snacks that the hospital delivers for the on-call team for the night. He usually isn't able to grab breakfast in the morning, so he grabs a bag of chips and opens it up for breakfast. Not leaving my resident alone with the morning ritual (even though I already had my Frosted Wheat Puffs and Ovaltine earlier this morning), I usually pull up a bag of Fritos (or Cheetos, as a viable alternate) and get a cup of coffee.

This is a superb example of a resident-recommended diet.

8:00 AM - I round with my intern, releasing the data from the labs I pull in the morning and the data I pulled on the history of the patients I'm following. These rounds are walking-intensive (involving going up and down several floors and down several wings) and can slow down whenever patient demands in the ICU or on the floor come up. I usually find myself walking around in "shadow mode" sometimes, leading myself to walk exactly in the footsteps of my intern (which could have me backing up into walls or other health care staff).

10:00 AM or thereabout - On some days, we have what they call "teaching rounds," with a senior attending physician along with our group of interns and students (about 8 in total), which involves a component of lectures, bedside patient presentations, and resident/student presentations. This is one of the lecture components provided. I believe that lectures are good to recap what's going on in the hospital. Getting lost in the demands that the rotation/residency provides is easy; we can't forget we have to learn every step of the way.

12:00 PM - We have another didactic lecture over lunch, on a hot health topic. This usually takes place in the lecture hall and makes our day more efficient, by giving us a good time to combine eating while our learning. Time management and efficiency is critical to operating and being successful in residency.

1:00 PM - I sit down and write progress notes on patients I'm following. The afternoon is usually left to admitting new patients, taking their histories/doing physical examinations, running actions/plans past my intern, and reading up on their cases. Medical education is very reliant on real cases, and that's a good thing. It's not the same reading about a topic in a book. Each medical case encompasses critical thinking skills and problem solving. Memorization won't get a physician anywhere.

5:00 PM - By this time I'm ready to leave the hospital if I did everything right. Sometimes there are exceptions, either late (or multiple) admissions, falling behind on notes, and the occasional assisting the intern, so he can get stuff done earlier. But in the end, I don't see the way I work with my intern as senior-junior, but in many ways it ends up as a team. I think that's just really cool, because that team combo has enhanced my learning experiences in medicine.

6:00 PM - After some time in traffic, I stop by one of the nearby Caribou Coffees or Starbucks and pick up a good iced coffee that powers me for the rest of the day. That night, I read up on primary literature for my cases and lectures, and I finally get to bed by about 11:00 PM.

And with that (and some occasional changes day-by-day), it's simply rinse and repeat for the next day at work. Weekends are a tad shorter (ending by 3:30 PM), but the same routine above follows. I'll be shooting out more specifics on what goes on during my internal medicine rotation, so stay tuned.

Mile 5855: Shortie: Whoa!

Above: Jurassic Park truly exists, Folks. Along I-65 in Kentucky.

THIS EXPERIENCE MAKES ME GO
WHOA!

I was talking to my friend Nik about not writing for 3 weeks, and I said to myself, "Wow, I went about 500 miles without letting you know where I went. That's kinda like going to Nashville and leaving you behind in Chicago."

Sorry. Let's get you caught up.

The last three weeks have been some of the busiest med schooling I've gotten so far. At a teaching hospital in Chicago, I'm currently doing Internal Medicine. The program set up is a shadowing of an intern both on the wards and in the ICU (depending on what patients are assigned to him). And I've done a lot of walking, writing, and paging (the last one's my favorite... I get to proclaim myself as a "medical student" on the phone!). I've seen some awesome cases at the hospital left and right, presented in front of interns and staff, and felt an intensity that I've been wanting to have in medicine for a while. Sometimes I get home with a load of primary literature I need to dig through!

But I'll tell you this, an intense rotation can be quite exhilarating, but it can also be more tiring too. All in all, the work here makes me love medicine so much more. My homework: get you some concrete examples of my experience this weekend. I won't leave you behind on the trip for much longer.

Mile 5318: Exploration - Part 2

Above: Capturing the Louisville, KY truss bridge on Northbound I-65.

A PICTURE TELLS
A THOUSAND WORDS.

Yup, that's an overused cliche phrase, but I'm going to throw some pictures here because its much easier to tell some of my highlights of my week-long adventure with a few pictures. Enjoy.

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Stuck on the Beach
After being sucked into driving on the beach (and seeing other sedans doing it too), I decide to go and drive on the beach in Volusia County. Unfortunately, "traction control" doesn't do the trick in sand... so after parking in a spot on the beach, I found my front, 1/8 a tire deep in sand. With the help of the Volusia County Beach Patrol and two random civilians, we got the car dug & pushed right out. However, you're gonna have to ask me how my car got stuck two times more after it was dug out the first time.

11 Countries, 2 Hours
At Epcot at Walt Disney World, my favorite theme park of all time, I decided to take the "Around the World at Epcot" tour, where I was trained to ride these nifty two-wheel devices called Segways (takes a little adjustment). Then a guided tour on the Segways was provided by the Guest Relations staff around the World Showcase of 11 nations (while it was closed to mainstream guests). I totally enjoyed slaloming through the pillars at the Italy Pavilion.

Up Close & Personal with Atlantis
Knowing that the Space Shuttle Mission was coming to an end, I decided to take an upgraded tour at the Kennedy Space Center to visit the space shuttle the closest most civilians could visit it (about one mile away). Apparently, being that close to the shuttle during launch would lead to my death (the vibrations and sound would kill me).

Seafood Galore
One thing about Florida was the abundance of fresh seafood. After eating at the Boston Lobster Feast in Orlando, FL (I ate a lobster, pictured above, that would have killed me first) and D.J.'s Deck in Port Orange, FL (under the Dunlawton Bridge), I got a serving of seafood that I would have not enjoyed as much at home. On a side note about food, it was awesome to stop at places like Shoney's and Western Sizzlin' to get my steak urge satisfied... but also to experience dining in a Southern cultured environment too.

Revisiting Undergrad
Visits to my alma mater of the University of Illinois at Urbana-Champaign & a big ten university where I spent some time to do research (Indiana University - Bloomington) reminded me of the times I enjoyed during undergrad. It was good to see good friends, my former supervisors & research advisers (I actually saw one of them in Miami!), and places where I worked. The landscape have changed (e.g. like the skyscraper apartments pictured above on Green Street in Champaign), but the culture at both institutions still is something that has not changed.

Road Time
I love the road. There were points in my trip I found myself in the middle of nowhere, like in the picture above of Indiana State Route 46 between Terre Haute & Bloomington, IN. Driving through the country with the windows down is something I always wanted to do. My adventures included those to small towns such as Adel, GA and Manchester, TN. I even passed through a recovering Nashville, TN (from recent flooding).

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So folks, those were the best parts of my week off, but not even those highlights encompassed all that I did and the excitement I had during each of my excursions. However, I can't really put it in words yet, but I feel that I learned more about myself somehow through the explorations on the road. I hope that I can share my stories with patients with my next rotation and the future: the one, the only, the big one (at 12 weeks in length): Internal Medicine.

The adventure continues tomorrow.

Mile 5318: Exploration - Part 1

Above: One of the best highlights on the road was the "All Jacked Up" truck on Northbound I-65 in Indiana.

MYSTERY CREATES WONDER, AND WONDER IS THE BASIS
OF MAN'S DESIRE TO UNDERSTAND.
Neil Armstrong, Apollo 11.

At the Kennedy Space Center (KSC), I met Bob Springer, an astronaut that participated on a couple of Space Shuttle missions with NASA. At the KSC, guests are able to interact with real astronauts and ask them questions. With my curious (and sometimes over-curious) personality, I decided to pull a question on him and immediately raised my hand when the floor was open for questions.

A man with a microphone walks over, and puts the black device in front of my face. Looking up at him on the stage from my seat, I then asked, What types of medical monitoring are done on astronauts in space?

As the man pulls away the microphone, Mr. Springer on stage starts to talk about the types of research astronauts have performed in space. Although he probably misinterpreted my question (I was asking about measuring heart rates, respiratory rates, etc.), he produced a very intriguing answer as he started talking about how astronauts have studied the effects of bone density in space, the concept of "space motion sickness," and effects of gamma radiation on astronauts in space. I couldn't tell you how much that stuff started to spark my medical neural pathways.

I got to meet Mr. Springer firsthand at a photo session afterward. After he told me that I asked a great question, I told Mr. Springer that I would definitely look some of this research up when I got home. The task is still on my list.

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After leaving Miami last Friday, I had a week off between rotations. I decided to take it to explore places, do things, and basically not be a medical student for 1858.7 miles on my journey. (If you were wondering why I didn't blog for a week, that's why.) I did everything from learning to ride on a Segway, getting my car stuck in the sand on the beach, seeing the space shuttle on its pad ready for launch, seeing how airlines train their pilots & staffers, and even meeting a cashier at Wendy's named Zzyzx. I took a week to do stuff I would never get to do in the hospital.

But my journey wasn't just about what I saw or experienced, it was also about the people I got to meet along the way. I visited people I haven't seen in a while, friends and former supervisors/advisers that really made my experience on the trip. I thought that a hearty visit would be more than appropriate to thank them all for all that I have done so far. But for me, when getting involved in loading my brain with medical info, I have found it easy to forget myself. Seeing all of them was a good refresher, as many of them reminded me of who I am as a person and what personal qualities helped me get to where I am today.

At first it might seem rather superfluous to include my vacation miles on my journey, but for me, time to explore more about myself (and be myself too) is a huge part of my development as a doctor. I'm not just a doctor or a provider. I'm also me. So, tomorrow, I'll tell you more about some of the specifics of my journey, but for now, my Ford Focus and I are going to get some sleep. There's a lot to process from my week retreat.

Mile 3452: Answers on the Asphalt

Above: I-95 Northbound near Brickell. An overhead shot of this strip was used in the TV series Miami Medical.

FOLLOW-UP PATIENTS
ARE MY FAVORITE.

A patient that I saw a few days ago comes in for a follow-up. He/she looked excited to see me, and that brought a smile to my face. A firm, solid handshake confirmed the camaraderie. A few weeks ago, I saw this patient in a much different state, rather sick with severe pulmonary & cardiac symptoms. Earlier in the rotation, I said to myself that I hated the idea of moving on, and well here was another case of it. The last time i saw him/her, the patient had smoked for more than 20 years and didn't want to quit. Now, he/she was just starting to quit, and I was so proud of the initiative, I had to shake his/her hand. Gosh, I was about to build a good patient-doctor relationship here, and now I have to leave. I started to get to know the patient's family, culture and more, and I would have loved to see the progress that he/she was having to reclaiming his/her own life from smoking...

I'll admit that interaction today was a good ending to a wonderful rotation in Miami. My last two weeks were spent at a more conventional medical center in the Miami area. However, our attending taught us a lot of practicality in medicine while we went through it (why we avoid certain medications, the business aspects of medicine, and just to be more confident in what we do). Now, I know how it feels to start to "want to do everything." I got hooked to treating adults too. I'll admit, that its still early in the game for me, but I hope that a week on the road can give me some answers. Driving has always been my way to think deeply about all that goes around me... There are times I think so much that I just let the dashed white lines in the road come to a blur.

Road? Yup, I'm about to start on a mini-vacation, to be myself for a week (not a medical student), think on the road, and get ready for 12 weeks of Internal Medicine which will take place at Westlake Community Hospital near Chicago. Throughout my trip, I'll be seeing some time at campus I've been at (the University of Illinois and Indiana University), meeting a few folks that helped me to get where I am today, and exploring the world in ways that I haven't been before. It's going to be exciting. However, as much as I love to travel, I miss Chicago. It's my town, Chicago is.

Thank you Miami for a wonderful experience. May the travels begin.

Mile 3374: As If "Yes" Wasn't Enough

Above: I-95's southernmost exit that leads Key Biscayne. After this exit, I-95 ends and merges onto the busy U.S. 1, Dixie Hwy.

If there's one lesson that I'm going to have to walk away from Miami with, it would be,

A RECIPROCATED QUESTION IS A GOOD THING.
(MOST OF THE TIME)

And how exactly did I come up with this conclusion? I thought of it as I was observing several of my preceptor's teaching styles.

Case 1: One of my doctors at my previous mini-rotation looked me in the eye after I asked him, "Is the diagnostic glucose level for Diabetes at >125 mg/dL?" He then said, "Is it?" I nervously replied (with more confidence put into the last word than the first), "I think it is." He nodded and then said, "You are right." I sighed a breath of relief.

Case 2: This week, a patient with rheumatoid arthritis walks in, and I noticed the patient had a neck injury in the past that caused lower body paralysis. In a rather naive tone, I ask the doctor, "Is that caused by atlantoataxial subluxation?" As he was entering patient data into the computer, he asks me, "What do you think?" I just ended up throwing a Hail mary by shooting out a "Yes" from my lips. He nodded with me as I began to feel the sweat near my forehead and said jokingly, "That's right... Why do you ask questions to which you already know the answer?" This was a rather deep point that simply brought a smile to my face. At that point in time, I just didn't know why.

I'll admit that getting a reciprocated question always makes me second guess, but I found that my preceptors are trying to see how confident I am in my answering. However, a reciprocated question has other uses than to say "you're correct." I've seen myself and other students get reciprocated questions, and the question is designed to develop the student's case for diagnosis & management of the patient. I've been through times where I'll explain my case completely, and the doctor will then tell me otherwise, with the consolation of acknowledging my train of thought made sense, but probably wasn't practical.

Making a strong case is of the valuable qualities of being a doctor I'm still trying to work on, as it is important to defend what I think is best for my patients. I'm glad Miami got me started to work on it.

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After writing underneath my pen nickname "TENergy" for the last year, I've decided to put my real name down just so my adventure can have a real face to it. Thanks for reading!

Mile 3288: Shortie - Nature & Nurture

Above: Jason Alexander as 2nd most popular motivational speaker in the USA, from the short-lived ABC series Bob Patterson in 2001.

"MOST OF US ARE
FAR FROM OUR POTENTIAL."
Dr. Angela Duckworth at the University of Pennsylvania

Folks, its been a busy week at the new clinic I'm at. So here's a quick shortie, and you'll get a full update on what's going on very soon.

The sacrifices that we make to go to medical school are large (both for U.S. and Caribbean students). For many of us, the sacrifices include a long time in school and being piled in debt that is miles high. For others, the sacrifices are greater, either from the demands of moving from place to place, and even trying to support a family during the demanding time schedule of school. Some of us have been more successful at balancing the plates than others.

One thing I've always wondered in such a demanding & competitive environment is whether or not there really is an advantage of background when going through medical school? Is the person who comes from a lineage of doctors going to be more successful from the student who comes from a farm-based community in Iowa who wanted to become a doctor to exit the world of agriculture? I know of many successful doctors who have come from families where mom, dad, or more relatives came from the medical field.

What truly determines our success, the drive or where we come from? One of my Facebook friends, Frank, posted a link to a New York Times article saying that motivation actually outweighs nature and nurture (background) in the long run. It's been a debate that has been going on for centuries. Some scientists are saying that genetics are not related to how well someone does in their own field. Others say that challenging environments make people better at their field by generating motivation. And finally, we still have people out there saying that families of people good in a field will foster future generations also good in that field.

After going through my Leadership Certificate training at the Illinois Leadership Center at the University of Illinois, I still believe it is truly up to the person to make themselves the "cream of the crop." And it is for this I want to somehow become involved in teaching, because I have always wanted to empower others to reach their potential; many people at the U of I have motivated me to make it this far, even as I'm not from a family of doctors. From my experiences, I think its a good combination of the right environment and self-motivation that can make someone the best that they can be. Talent isn't necessarily inherited.

I encourage you to read the cited article below to learn more.

Source: The New York Times

Mile 3187: Stand Up

Above: April 2010. Our wonderful crew & one of our attendings for the last two weeks.

GET UP... STAND UP...
STAND UP FOR YOUR RIGHT.
Bob Marley

I have something to admit. I'm a frequent second guesser. I know. It's a bad habit. I gotta quit... I'm working on it.

I'm coming up on the last day of these past two weeks. From my last entry you've seen I've had many firsts at the clinic we're working at. Our past Wednesday was one of the busiest we've seen, and at the end of the day we found ourselves sitting on those big fluffy couches, simply tired. Our attending (different from last time), comes in, pulls up a roller chair and starts to talk to us.

His words were quite simple, but they were encouraging. He said to us that our team (the one pictured above) pulled in quite a huge amount of patients for such a short time period, much more than previous teams he had worked with. We had worked efficiently and hard to accomplish a lot. Then he told us some good advice, advising us to start defending our decisions. I forgot his exact words, but from what I remember, it made lots of sense: the only way that us students will learn is if we take our own positions and defend them as well as we possibly can.

It comes down to a concept that I've been trying to work on all along: making medicine my own. There's a lot of data, opinions, and options out there in the medical field. But in order to learn, I need to interpret and make sure I can be competent in taking whatever is best and applying it to the decisions I make for my patients. Each patient that I'm put in charge of is my responsibility... if someone tells me or tries to do something that stands in the way of my approach to the patient, I need to be secure about my decisions. Otherwise, something might go wrong, just when the ability to control the situation slips out of my own hands.

So I need to stop second guessing. The physician's assistant (PA) that was working with us told me that she saw no reason for me to overthink, and to pick up that confidence to make solid decisions. With 2 more weeks in the rotation to go, I'll give that my best shot, with some motivation from her encouragement.

So, to Eric, Faith, Vanessa, Melissa, Veronica, and Shannon, thanks for being a great team. To our attendings at the clinic, Dr. S., Dr. G., and Dr. M., thanks for all your support to us. Finally, to the people at the shelter we serve, thanks for all your trust.

Mile 3166: Firsts

Above: May 2009. First time I ever popped an umbrella with Mary Poppins. I hope there'll be a second time.

THERE'S ALWAYS A FIRST
FOR EVERYTHING.

Last week was filled with a bunch of firsts. Here's five.

1. FIRST BLOOD DRAW.
Blood drawing can be intimidating for all the parties involved. On the patient end, seeing needles and blood is not exactly a pleasant sight. On the doctor end, it can be scary to not find a vein or take a wrong approach to inserting the needle, as both may cause discomfort to the patient. Adding both can lead to a stressful situation, but with the help of the patients in the chair, it made my experience much more inviting.

"If I can be the guinea pig and can handle being drawn blood from all of these sites, you can do it," one of the patients told me. I came out clean and was honest about telling the patient this was my first time. Tourniquet on. Search for vein. Spotted. Alcohol swab. Swished it around. Insert needle. Tube in. A flash of crimson blood entered the tube and it began to fill. I thank the patient in the chair for making my first try successful. I guess the first time isn't so bad with the right support.

2. FIRST FETAL OCCULT BLOOD TEST.
Okay, I'll skip the details, but we had to analyze for blood in a patient's stool to eliminate the possibility of any GI conditions. When our attending requested someone to do it, the hand that always gets me in trouble went up in the air. I soon was in to get the sample. This first showed to me that after the first time, its easy to get into the rhythm of things. Sometimes, exposure to the extreme is just what one needs to cross barriers.

3. FIRST PAP SMEAR ASSISTING.
I wanted to say "actual pap smear," but this was simply an assist. Getting a pap smear is intimidating for a male-doctor-in-training, for obvious reasons. But with the help of four other female doctors & nurses in the room, I was able to get through it. A complex process if done by self, but hopefully I'll be able to be in the hot seat with my awesome support team finally this week to try one.

4. FIRST TIME IN COUNSELING MODE.
I won't get too much into the story here, partially because of HIPAA and second because most of the situation occurred in Spanish (a lot more than Señor Fixity-Fix-It below). But I learned today that there are times that it is okay to step across the professional barrier, and not call someone by last name and to be honest about what's going on.

A lot did go over my head during the patient interaction, with some translated by an accompanying PA in the room. However, with even the little I knew, I went ahead, was honest, and told the patient, "No hablo mucho español, pero cree que eres un hombre/mujer fuerte. Puedes hacer todo,"* the reply of "Gracias" and a smile made me know that I connected with the patient when I needed to. I'm a sucker for emotional moments, but they're one of the most beautiful things about life.

*Translation: "I can't speak much Spanish, but I think that you are a strong man/woman. You can do everything."

5. FIRST BERRY & OREO ICE CREAM COMBO AT COLDSTONE CREAMERY.
One word: simply amazing. Okay, that's two, but that's how good it was... especially after enjoying the new movie release Kick-Ass.

And with all these firsts, I hope there will be seconds.

Mile 3106: Pimped

Above: With a careful eye, this overexposed picture outside my apartment shows a traditional occurrence in Florida weather, the sunny rainstorm.

I'LL TAKE THE
PHYSICAL CHALLENGE.
The best way to play the 1980s Nickelodeon game show, Double Dare.

MONDAY, 9:03 AM. Six medical students, and one physician assistant in training are all wearing white coats and sitting on huge beige pillowy leather sofas right outside of the doctors office. Some are waiting patiently, with their legs crossed and eyes toward the wall, while others seemingly less patient, get into the rhythm of tapping, some with their pens and others with their feet. Being this the first day, we do engage in some small talk as we wait patiently to begin our day.

A creak at the door awakens all the students out of their trances.

A doctor comes into the room, sits down on a sleekly designed roller chair and rolls around to each of us to welcome us to the clinic. After he finishes his round, he gasps, and rolls over to one of the students sitting two seats to my left, leans over and asks him:

What do YOU think you're strongest on?

OH SNAP. Usually the following concept is great: Say something you're strong at when someone asks you for your weakness. However, the opposite would be bad... Especially here, since the doctor then started popping questions out of his head one by one by one. He soon came up to me and asked me the question. It was my turn to engage in "the game." The word that involuntarily came out of my mouth was "Endocrinology." And soon I felt I was playing one of those shooting games as he was firing the questions out at me like a mad man.

Hit. Miss. Hit. Hit. Miss.

The final question he asked me had to be what he thought was the toughest one, because as he leaned over in his rolling chair to ask me it, his right eyebrow upturned, and he started to massage his chin with his right hand. He stared at me like he was focused on his target and soon started to ask me about what nuclei produce the hormones released in the posterior pituitary.

It took quite an amount of effort for me to say the words "Supraoptic" and "Paraventricular," partially because this is Step 1 information that I have not looked at since my exam. I thought I'd follow the general piece of advice to go with my "gut." The words came out of my mouth one sy-lla-ble at a ti-me.

A half-smile grew soon on my face rather nervously after I said those words. A moment of silence began.

"You are an expert," he suddenly said, as he extended his hand, smiled with a gentle chuckle, and shook my hand. My simple reply was a rather nervous, "I guess I am." (To this day, I still think, "I guess I got the question right.") After seeing some patients that day, I walked out the door feeling like I had been just slapped with the stamp on my forehead that said:

"PIMPED."

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I believe in challenges. Provided that the one giving them does them for the right reason, not being able to meet all of them shouldn't be discouraging: Mistakes give me motivation to become better. And this is the first time I've undergone the medical school teaching concept called pimping. From my understanding, pimping is getting asked a series of challenging questions on the spot revolving around a concept when in groups during clinical rotations.

I like it, it forces me to think on my toes, and because someone actually wants me to be responsible for the information, I get myself to learn it. Getting feedback and evaluation on what you know and don't know is very useful in medical education. This philosophy continues on in residency and when I become a real doctor, because it isn't the teacher who will drive me to learn; my patients are going to expect me to be responsible to have the right information so I can treat them correctly.

For more on the effectiveness of medical school pimping, check out this New York Times article from 2006.

(And just to make sure it's on the record, this week was filled with firsts, including my first Digital Rectal Examination and my first blood draw on real patients. More on this later.)

Mile 3079: Back to Basics

Above: "Hole in the walls" are some of the best places to eat. May I recommend the Oasis Cafe if you're ever on Key Biscayne, with its sophisticated year-round Christmas lights. But their Tilapia Filet & Rice is absolutely amazing.

ARE YOU THIRTY? - One of my patients.
Me: Ha, not yet!

I remember having a talk with one of my professors in Dominica about why med schools do two years of basic sciences. At that point in time, I thought that basic sciences education wasn't really worth my time. My naive self then was thinking, "How is the pathway of glycolysis going to really be used in a clinical setting? I'm not going to tell my patients about it."

Now looking back at things, without basic sciences, to me, learning the clinical sciences would be like learning things blind.

Basic science education has its hits and misses. It kinda sucks that with basic sciences information, practicality in real situations doesn't really come by until put together with clinical experiences. After Step 1, I probably could tell you a lot about what tests to run with a patient who comes in with concerns about breast cancer, but knowing that the the genes BRCA-1 and BRCA-2 are linked to that cancer won't tell me when to start yearly mammograms, what questions to ask from my patient to assess the situation, and how to reassure them.

Practicality can come in the form of algorithms (flowcharts which guide clinical thought). These are great when trying to organize one's thoughts take a proper, succinct history. Although for common conditions, they work well, but what if someone doesn't have a "textbook" case or condition? Here I see the benefits of basic science education, as the foundations of medicine can help clinicians to adapt to "new-found" cases. Because the processes within the human body are linked together, there has to be a way to explain non-textbook cases through the mechanisms learned in the basic sciences.

But that's not the only benefit... the human mind is one to learn more by links & context (I think I might have blogged about this before). So by knowing the mechanism as to how drugs work, how diseases appear, and the molecular background behind the human body can one make the puzzle pieces of medicine fit together a lot better. Integrating the basic & clinical sciences can contribute to better skills in diagnosis & treatment for our patients.

Although I still think of it as frustrating, taking time to memorize the glycolytic pathway in first semester is now something I am more appreciative of.

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Today ended my 2 weeks at my current site in my family medicine rotation. On my last day, one family came in, displaced from another clinic that was closing down. One of the kids in the family was afraid of shots, so I offered some of my "insider tips" for surviving them, which made the patient smile. I could tell by the kid's expression that he/she was ready for immunizations when I left the room. When the family left, they all said, "We'll see you next time." And I said to myself, Damn, I won't be here next week. Here, I was about to start a strong foundation for a good relationship with this family. On the outside, I laughed, saying "I won't be here next week, but you'll see another student just like me." But on the inside, I had one of my first feelings of settling down; I started to feel how much I valued relationship bonding in medicine. I didn't want to move on.

Starting next week, I'll be moving on to a clinic run by a local homeless support group here in Miami. Four more weeks, and then the adventure will take me to what I think is the most critical rotation in my education...