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 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 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...

Mile 2896: Experience the Difference

Above: Nope, I'm not driving in Britain. The Florida Turnpike (right) and I-95 (left) run side-by-side for many miles in South Florida.

CAN YOU WRITE
A LITTLE BIT BIGGER, PLEASE?
My preceptor at my Family Medicine Rotation

(Relax: It might be April 1st, but no pranks here. But this might help.)

I'll admit to you that I was thrown into culture shock as I got settled down in my apartment here in Miami. My apartment isn't exactly in the best of areas (although the accommodations are pretty nice and I'm staying with a friend from high school), and some of the neighborhoods where I'll be driving through were quite sketchy (I wouldn't walk outside here at night). At a point, I started feeling like I wasn't admitting things to myself. I had to finally admit to myself:

I'm a suburban kid who might be afraid of the "big city" concept other than in my hometown of Chicago.

I was scared because of the rumors that I've heard about the horrible drivers, the high crime rates, and the not exactly country-friendly people in Miami. And my doubts about Miami were further hastened when I was assigned for my first two weeks to a private clinic in an area that didn't exactly get "smiles" when I mentioned the place to anybody local. I did a test drive to find my site there, and the environment was different from anything I was used to: numerous black bars were on the windows, people talked through plexiglass at the surrounding gas stations, police cars were patrolling the area left and right, and sketchy-looking trailer homes with poorly-maintained landscaping were prominent. And the kicker: I was the only one assigned there for the first two weeks. On the first night, I took some time that night to remove the CD's, bags, and anything valuable out of the interior of my car.

However, as discouraging as all that sounds, I'll say the first week turned out to be the best mind-opening experience I had to date. What made the difference?

First, time. With each day, I found myself getting used to the area. I found out that driving in Miami takes patience, predicting, and communication. I also found appreciation in the lack of big stores along my route (I could probably call it the Pawn Shop Parade) in creating a community-driven economy. And not to mention, now experiencing an area first-hand that originally I would only want to see through pictures in magazines or newspapers is now something I am truly enjoying.

Second, the clinic & the patients. The clinic I'm working at isn't exactly the most modern up-to-date clinic on earth, but the nurses and the staff treat me well. For instance, as I was leaving today, one of them shouted out the window as they were backing out of the space, Have a good one! It made me smile as this friendly gesture went against my original assumptions of people here in the area. It also surprised me that I've seen my interesting share of cases in a primary care clinic. Folks, the material that's present in textbooks really happens. Last, but not least, the patients I have worked so far with have been extremely cooperative with me, and I'm thankful for them contributing to my learning.

Third, the experience. For the first two-weeks, my assignment was one-on-one to a doctor instead of a larger group of 3-5 students, as in my last rotation. What this provides is some awesome personal attention. As for my attending, she's awesome. She really trusts me, and is patient as I'm still trying to master the art of history taking and diagnosis making. I am able to make the clinic an effective learning environment as she is always accommodating my questions.

As one of the travel program hosts on PBS always suggests (I think its Rick Steves), travel with an open mind. It's true. It's that open mind that helped turn what I thought was going to be disaster into pure pleasure.

BTW - There's a fourth reason: The weather. But that's kinda expected in Florida, so for me, that doesn't count.

Mile 2740: Roadgeek Alert

Above: I am appalled to see so many signs about Dix on the road.
(SB I-57, Illinois Mile Marker 103)

I LIKE YOUR SUNGLASSES...
BECAUSE OF THE GREEN TINT.
Attendant at an Effingham, IL Gas Station

Even with long shifts, eating crappy fast-food, not looking debonair, sleeping on beds that aren't mine, and seeing my eyes dyed a crimson red at the end of the day, I still feel like I'm enjoying where my life has taken me. No, I'm not describing what residency is like: It's how to experience Americana through a road trip.

Whew. 1438 miles done and set.

I've actually made it to my Family Medicine core rotation, which takes place at the Miami Jewish Home & Hospitals in Miami, FL. With only a weekend from the end of my last pediatrics rotation and my family medicine rotation, I've been on a rush to make it from one part of the country to another. However, its good the route is actually not foreign territory, so 2 days went by no sweat.

Our family has visited the state multiple times and are yearly visitors to the legendary Disney World. My mom and dad have accompanied me on these trips, and even when as I was just 6 years old, I was the navigator of the trip, looking through road maps to keep us en route. In 2003, just after getting my drivers license, I added onto my duties, taking over my dad at the helm of our van for my first trip. To me, that drive to Daytona Beach in 18 hours from Chicago was one of my rites of passage.

I ended up loving road trips, and not only for the sights at my destination. I discovered a few years ago that the best way to describe my love for the road is with the term "roadgeek." I'm not alone either. There's many other people who are amused when an expressway comes to a stoplight, a 5-level stack carries cars in multiple directions, or trying to explain how poor designs of interchanges leads to traffic jams. I'm also the type of person when, if I have the time, would stop at every hole-in-the-wall restaurant, and little point-of-interest along the way. And finally, but not least, I love road trips because of the people I meet. On the way down to Miami, I chatted with one of the cashiers at a Wendy's in Georgia, a clerk at a gas station in the middle of Illinois, and another clerk at a Winn-Dixie here in Miami. Learning about how other people communicate and their respective culture can be done most of the time with a simple hello. Just keep the attitude that being on the road isn't just a long car ride. With an open mind, you find out its an awesome experience.

Anyway, tomorrow at 8:30 AM, I begin my next six weeks of the journey... Provided nobody blasts through a red light here and hits me, I should make it to May.