Monday, October 11, 2010

Family Medicine!

Next up was Family Medicine! I was excited to start this rotation, but I didn't know just how much I would like it. It was all outpatient clinics (meaning not in the hospital) and I would see a patient, listen to what was going on and do a physical exam, and then present my findings and plan to a faculty physician or resident. I realized that I love education and disease prevention, which is a big part of Family Medicine. I learned about Community Medicine which is sort of a branch of Family that is involved in community health, advocacy, social programs, and improving patient care among many other things. I got to see patients of all ages, from newborn babies to 98 year old ladies and that was really fun. I liked not having any patient population excluded. I got pretty excited about it so Family has definitely made the list of fields I may pursue! There are a variety of settings you can work in, and the training is really broad which excites me. I met doctors who chose their own hours and had a great family life which is really important to me. The more I learn about it, the more I get excited about it, so we will see if that's where I end up! Here is my essay from Family Medicine...

"In the first few months of my clinical training, I have spent most of my time learning about how to recognize signs and symptoms of diseases and how to treat them. I have also learned a lot during my Family Medicine rotation about disease prevention, patient education, and health maintenance. I get excited about figuring out a diagnosis, deciding what steps to take next, and counseling patients. It is exactly what I’ve been waiting for, the chance to practice medicine. However, over the past few weeks of Family Medicine, I’ve recognized that not everything is quite so black and white. Often there are financial, social, spiritual, and educational barriers to healthcare that require flexibility and sensitivity on the part of the physician. It is just as important to find out about those issues as any other part of the encounter. If a healthcare professional does not take the time to ask about different aspects of a patient’s background, then the rest of their plan of care may not matter because a patient may not follow it. Or, they may cause unnecessary emotional strife by being insensitive to a patient’s beliefs or level of understanding.

Many patients I saw this month had financial difficulties that prevented them from receiving the textbook treatments for their disease. It was often necessary to look at the Walmart $4 prescription list to choose medications that would be feasible for a patient to purchase. The five minutes it took to figure out which medications would fit a patient’s financial needs made treatment possible. Sometimes though, patients had multiple comorbidities, so even the $4 medications would add up and a patient was left deciding which medication was the “least important.” Before I jumped to labeling a patient as noncompliant, it was necessary to figure out WHY they hadn’t been taking their medication. After hearing that paying for prescriptions took a huge percentage of a patient’s monthly income, I suddenly became much more understanding and less judgmental of their “noncompliance.” Furthermore, some patients had difficulty finding transportation to their appointments or figuring out how to get childcare. It is easy to tell a patient to come back to do fasting labs or to follow up in two weeks without recognizing how big of a request that may be. Socioeconomic status also affects a patient’s ability to follow certain diets, especially when they have to provide for the needs of children. It is imperative to be aware of these issues and to be ready to counsel patients on less expensive ways of achieving their goals.

Education level also affects the way a patient responds to their disease or treatment plan. It is easy to take for granted that a patient would understand what kind of diet they should follow as a diabetic, when a patient may think they only need to avoid candy or coke. Also, certain conditions carry stigmas in different cultures, so the way information is presented to a patient with those beliefs is so important. I’ve learned that cultural competence, socioeconomic awareness, and being educated on social issues are going to always be a big part of my career. I need to work hard to learn as much as I can about the community I practice in and the resources available around me."

Surgery Part 2

So much for keeping up with writing things down this year. I had all the best intentions, but free time has come at a premium these days.

Surgery ended about 6 weeks ago now, and I'll be the first to admit that I was very happy to see it go. I learned some valuable things, but I am definitely not going to be a surgeon. On Trauma, we saw patients on the wards from about 5-6ish, and then went to the Trauma Hall in Parkland and waited for patients to come rolling in. We carried a pager with us and it would go off whenever someone was on their way and give us a few key pieces of info to be prepared for. To this day, the sound of that pager gives me chills. I also do not love the whole trauma scene, it is pretty horrific to me but I'm thankful for the people who want to take care of those patients. On my first day of trauma, the first patient that came in ended up dying and it was pretty hard to watch. We have to write short essays at the end of every rotation, and I reflected on that experience...

"On my first day of Trauma call, within the first few hours of the morning, we received a page for a Level 1 trauma. The patient had fallen 20 feet on the job and landed on the concrete below. The paramedics were already performing CPR as the patient rolled in, and the nurses and doctors resumed CPR as they moved him to a trauma bed. The room was packed, it seemed like there were 20 people there and they were rushing around, yet it was surprisingly quiet so everyone could hear instructions. I watched as they performed the ACLS protocol and waited anxiously for some sign of life from the patient. After the protocol had been followed through, one of the doctors in the room said, “What time is it?” My heart sank. She called the time of death at 11:17 am and you could see the energy in the room drop and people started taking off their masks and gowns and walking away. The whole thing must not have lasted more than 10 minutes, but it is an experience that I will not soon forget.

It was strange to me how everyone just sort of dispersed afterward. They didn’t seem to be overly affected by the event. They resumed conversations, talked logistics, even smiled. It was sort of shocking to see people just move on. I couldn’t help but wonder how they could just walk off and leave the man lying there. One of the nurses said that we needed to still do a full evaluation of the patient to document the injuries, so I went with the resident over to the patient. It was so strange to see his face and know that he woke up that morning thinking he was heading to work just like any other day. He probably had a cup of coffee, said goodbye to his wife, and may have told her he’d be home by 5. Then I thought about his family. They were about to find out information that would completely change their lives. There was no warning for them, the patient suffered an accident in an instant that claimed his life. And yet, the rest of the team was back in the hallway talking about discharging the guy in the next room. How could it be that easy for them?

Then I started to realize that they were doing what needed to be done to be a good health care team. If everyone were completely crushed for the rest of the day, then other patients and their own personal lives would suffer. Death is a reality on the Trauma Hall, and the doctors and nurses need to be able to pick up and move on from it. Over the course of the next week, I watched other patients come in and became aware of many others in the SICU who had sustained major injuries and may never recover. I think for me, I need to find a line between processing what is happening around me when it comes to disease, injury, and death, and not dwelling or thinking too deeply into it to where I can’t move forward. I want to always respect life, to not take it lightly or to treat death flippantly, but I see now that all patients are not going to have good outcomes and I am going to have to learn how to deal with that in a healthy way. I don’t think I need to stop feeling sad when people are hurting or when they die, but I recognize that in order to be a good doctor, I’m going to have to do my best to treat the things I am able to and accept the things I can’t change. It will be through a combination of prayer, processing things with others, and talking about it at home that I will continue to learn how to cope."

After Trauma was Emergency General Surgery which was probably the roughest part of Surgery for me. We had to be there at 4am most days and were pretty busy all the time. We drove the camera for the laparoscopic procedures which is not a super easy task in my opinion. Maybe its because I never played video games, but it was tough to navigate those cameras when the surgeons were moving their instruments all over the place. I also learned about working with people who are very difficult to work with which was not fun at the time, but I know it was an important lesson. All in all, I think I took a lot away from the surgery rotation, but I couldn't have been happier when it was over!