CMing

Going to take a quick break from studying physio to write a little bit about CMing at EHHOP today. It was my first experience being clinic manager, and I definitely felt unprepared for it when I got the phone on Thursday from Matt and Jeff. They explained to me all the things I had to do prior to the start of clinic on Saturday, and then what the day was generally going to be like. I called all the patients and got a little worried when I got in touch with less than half of them, but there wasn't much I could do about that. On Saturday morning, the two second-year CMs that were keeping an eye on me were really nice and did a great job of letting me run everything while making sure that I did all the things that I needed to do. There were a bunch of odd things that happened right off the bat (us having to use the Geri area instead of Medicine cause it was being painted, we couldn't find any of the files we needed because they were stored somewhere else, the websites were all down...) but we kind of went with the flow, and the teaching seniors were extremely helpful. I really enjoyed setting up the clinical teams and having them ask me questions about procedure or telling me about how they thought their cases were interesting. We had a little backup of patients around noon because we were waiting for Spanish-speaking seniors, but in the end I think it all worked out. Everyone got to see a patient, and most of the interviews went off without a hitch. I checked everyone out and closed up shop by 4:45, and was back by 5. It was also cool to spend some time with upperclassmen as they talked about second year, what sites to choose for third year, etc... It's good to get perspective from people outside of our first-year class once in a while. Now I have the EHHOP phone for the next two weeks because next weekend is the community health fair, but hopefully I won't run into any difficult cases. I think the next time I'm CMing I'll have a much better idea of how to direct people's questions (as opposed to having to confer with the teaching senior all the time to make sure I wasn't any wrong decisions).

Lack of Communication

In an effort to make this blog more intellectual (and less a recounting of everything I do during the day), I thought I'd start responding to articles and news that are medically pertinent. The first one I want to talk about is a actually a blog entry by a Dr. Brent Ridge, who happens to be a geriatrician at Sinai. Here is the link to the blog itself, but in case it gets taken down at some point, I am including the text here (it's not too long):

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Do you ever leave the doctor's office feeling a little unsatisfied with the visit? Are you ever frustrated by a conversation you've just had with the doctor? Do you ever think the doctor was outright rude? You're not alone. In this blog, I thought I'd try to convey the doctor's perspective. Being a caregiver for a sick relative or loved one is a difficult and often thankless and unrewarding job. More and more, physicians are feeling the same way.

To our discredit, doctors do have the habit of doing more talking than listening. Unfortunately, this has only become worse as managed care has strictly curtailed the amount of time each patient has with his/her doctor. While doctors do try to spend as much time with their patients, this time pressure constantly forces doctors to ignore the patient's own emotional health. Truthfully, if the doctor actually spends any amount of time at all addressing issues of the caregiver's sanity and emotional well-being, you should count yourself as very lucky.

However, I can't place the blame for the lack of communication solely on the doctor. Let's face it-- we are all human. Patients (and their caregivers) are not perfect, and also contribute to the lack of communication. In one survey doctors rated 15% of their patients as "difficult." Disagreements involve everything from expecting an instant cure to demanding prescriptions.

Patient and caregiver qualities described as "frustrating" by doctors:

• Do not trust or agree with the doctor. (You need to at least give your doctor the benefit of the doubt. After all, you are there for his/her advice.)
• Present too many problems for one visit. (I understand you are trying to make the most out of your visit; however, please remember, there are 15 more patients waiting right behind you.)
  
• Do not follow instructions (Again, you asking for your doctor's advice. What's the point if you don't follow his/her advice and instructions?)
  
• Are demanding or controlling. (Doctors are there to work with you to stay healthy--- not work for you.)
  
• Present themselves as overly helpless (You have to give your doctor some guidance in order for him/her to help you)
  
• Make a melodrama out of every symptom (Yes, it is important to let your doctor know every symptom. However, over dramatizing each one can be counterproductive. If you do so, your doctor will not be able to gauge which symptom is more relevant in determining your illness)

Despite the common saying that the "squeaky wheel gets the grease", that's not how it tends to work with the doctor. Studies have shown that patients or families who make too many demands on the physician's time ultimately get less attention.

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I thought this was an interesting point that Dr. Ridge makes. We often hear reports of how doctors don't listen to their patients, about how doctors don't make decisions with the patient in mind, and how in general a visit to a doctor is an unpleasant experience. Dr. Ridge remnds us that the visit is really a two-way conversation between two people, each who has his or her own thoughts, ideas, prejudices, and expectations. It's only by really opening this dialogue that you are able to really have an effective doctor's visit. This, unfortunately, often gets lost, especially when physicians are under pressure to see as many patients as possible.

Saying goodbye

I'm sitting at DT-UT having a cappuccino, taking it easy and enjoying the end of Histo. Stacey's in Uganda this week working on an AIDS orphan project, and I don't really have a lot of work to do for tomorrow, so this is the perfect chance for me to get out of the Mt. Sinai area and do something different (and yes, going down to 2nd Ave and 84th St IS doing something different, since it seems that whenever exam time comes, I don't ever leave the 3 block radius around Sinai). I would probably be up to doing something even more exciting tonight, except that I'm recovering from a cold that I've had for the last few days, and fifteen blocks is about as much as I can muster right now.

Tonight we had a closure ceremony of sorts for our Anatomy class... even though Anatomy ended three months ago, this was the first time that was available for us to reflect on the experience we had in Anatomy and say goodbye to the cadavers we worked on all last semester. About half the class showed up for it, and it was a very solemn experience, with a number of people having some very sincere words to say about what the experience meant to them. Some people read poems or read things they had written about the experience, and others just spoke about what came to them. I hadn't planned on speaking, but when we were asked if anyone had anything to say, I decided to make a few comments about what I thought Anatomy had meant to me. I spoke about a conversation that I had had with Eric towards the end of the Anatomy class, where he had said that throughout his life, he had always been alright with being ignorant about the things that were inside the human body. After Anatomy, though, I think we all have a different appreciation for what makes up the human body, and may never see a person in the same way again, which in itself is pretty significant. After everyone who wanted to speak had spoken, we went into the Anatomy Lab and lit some candles while Patrick played a piece on his clarinet. It was a rather emotional moment, and a number of people were crying, or at least trying to hold back tears. I thought it was a very fitting end to a course that was a very significant part of the medical school experience. Truth be told, I think I might not have thought enough about the whole cadaveric donation process and what it all meant to the people who donated their bodies and their families, but in the end I am very glad that we learned Anatomy in the way we did. Anything less "hands-on" would have taken away from the full experience.

Tomorrow is the last day at our first set of ASM clinical sites, which have been been a really enlightening experience. I think the things that we are attempting to learn in ASM are only truly learned through the experience of interacting with patients, and so I've really appreciated the time that we're spent with Dr. Serlin. I know that we'll have plenty of time to do all of this ad nauseum in future years, but I think it's really important to get a sense of why we are all going through this process, even at this point.

I am also meeting with Dr. Zier tomorrow, the person in charge of medical student research projects. I'm trying to work something out with a professor who is doing health disparity work in the ER, but she hasn't gotten back to me yet, and I am hoping that Dr. Zier can help me out with setting something up. At this point, I'm starting to feel like I don't want to deal with the stress of setting up some grandiose summer project; instead, I'd just like it all to be figured out already. There have been too many extraneous things to think about so far this semester.

Tomorrow night I'm having a conference call for the AMSA program with Stephen Lewis, the UN envoy on HIV/AIDS. He worked at the Earth Institute while I was there, and I saw him speak a number of times. He's an absolutely phenomenal speaker, and I'm excited about getting the chance to speak with him. The topic is on women's health and HIV, and I think he'll have a lot of interesting things to say.

Alright, I think it's time for me to be heading home. I've got some Belize emails to send, and I want to get ready for my meeting with Dr. Zier tomorrow.

What renal physiology, the global TB epidemic, and esophageal varices have in common

Stumped? Well, I won't keep you in suspense any longer: renal physiology, the global TB epidemic, and esophageal varices are all related in that I spent a very long day yesterday dealing with them. I started off with two hours of Dr. Hanss' physio lectures, and then rushed over to Columbia for the TB Alliance Reversing the Tide of Tuberculosis symposium. The symposium was held in Low Library, which was kind of exciting since I had never actually been inside the building while I was studying at Columbia. Jeff Sachs opened the conference, and then a host of familiar faces were either involved in the presentations (i.e. Josh Ruxin, one of my readers for my Master's Thesis, was a moderator) or as audience members. There were talks from drug and diagnostic development companies, the Vice-Minister of Health for Mexico, as well as many others. On the whole the presentations were interesting, though the symposium was running late so they constantly had to cut people short, and there wasn't as much discussion and I would have liked. Still, the TB Alliance is a group I am interested in working with, so this was a good look at what the group does. I had wanted to stick around after the symposium to try and talk to some of the people who work there, but I had to run off to the train so I could get across town to Elmhurst.

I got to the ER at Elmhurst around 6pm, and things were relatively slow. There was a patient dying of COPD with a DNR in the trauma room, and the whole family was around and emotional. The wife actually was making suicidal comments, and wouldn't let go of a bottle of morphine that she threatened to drink, so psych had to be called down to evaluate her state. The husband was sent off to hospice care upstairs so he could be more comfortable. Dr. Okuda was extremely helpful and willing to talk through some of the cases, and offer a perspective of what life is like in the ER. I really enjoyed the time we had to just talk about how things are run down there. I also got a chance to spend some time with Dr. Clint Masterson, who is an ER resident that is coming on the Belize trip to OrangeWalk. He was also extremely nice, and let me hang around while he was taking care of some patients. When the ER finally got busy around 7:30pm, we saw a woman with a GI bleed (probably from esophageal varices), a 98 year old man who fell down 15 steps (he was called in as a red trauma, but ultimately he ended up being perfectly fine, not a single bone broken), another man who was drunk and fell down a flight of stairs (and was massively bleeding from his scalp-- I had to apply pressure to try to stop the bleeding), a 27 year old man who dislocated his shoulder playing soccer, a elderly woman with COPD who got excited when her son was in an argument with his neighbor, and stopped breathing, and a 80 year old man who was suspected of having a stroke. Dr. Okuda said that there wasn't any case that was tremendously spectacular, but I thought on the whole there was a lot of excitement. Truthfully, when I left at 11pm, it had felt more like 15 minutes had gone by, not 5 hours.

So today is the 8th of March, which means that we are leaving for Belize in less than a month. This is really starting to stress me out, because I really don't think we are where we need to be in the planning stages of the trip-- at least I don't feel comfortable with all the information I have from Peacework to feel that the trip would run smoothly at this point. And there is so much that still needs to happen in the next four weeks that I'm sure is going to go by in a blur: I have to finish preparing for Belize, we have to take 3 exams (two finals and a midterm), I have to take my trip to Chicago for the AMSA Convention, I'm going to have a number of phone calls for the Global Scholars Program, I have to be clinic manager at EHHOP, we are starting two new courses, and I have to pretty much figure out my plans for the summer, since the funding deadline is while I'm going to be away. All of this is quite depressing, actually, because I know I'm not ready for any of it. I guess it has to happen though.

Also, not sure how long it'll be on the web, but the AMSA Global Health Scholars website for this year is up. There is something satisfying to having your life summarized in approximately 200 words.

'Cause in my head there's a Greyhound station

So I spent most of the day reorganizing my life by finding a place to put most of the clutter that was taking over my room (and thereby my life), listening to Death Cab for Cutie, mourning Duke's loss to UNC last night, and hiding from old man Wheater's Histology. By the looks of it, i's a nice day outside, and I'd like to get out into the sunshine at least for part of it. I'd also like to make it to the gym downstairs as well, but that's contingent on me finishing the Physio quix before dinnertime. Even so, it feels good to be about to walk around my room again (and not trip on cardboard boxes, shoes strewn around the floor, and other equally random objects) and be able to actually find things when I'm looking for them.

I've got a bit of a rough week coming up, since it's the week before the Histo exam (which I absolutely can't get excited about, even though it means that we'll actually be finished with the worst "real" class in med school so far). Tuesday is a wash in terms of studying because I'm going to be running around the city, first for lecture here and then the TB symposium at Columbia (Jeff Sachs is doing the keynote), and afterwards I'm heading to Elmhurst to shadow Dr. Okuda in the ER until 11pm. It should be a very long, but hopefully good day.

All I have to do now is get excited about renal phys.

Children = evil.

It seems that I do the bulk of my posting after days at EHHOP. Today I was working there as a Junior Clinician, and I was able to see one Mexican patient who came in for a routine physical exam. She was a nice lady-- 23 years old with two children, ages 3 and 5. Her mother is 38 years old, which means that by the age of 33 she was already a grandmother, which I think is pretty crazy. Anyway, she needed a PPD and a tetanus shot, so the Senior gave her all that-- all the while her two children were absolutely reaking havoc on the examination room: throwing latex gloves in the air, opening every drawer and playing with the otoscopes, etc. They just could not sit still for a minute, which made it incredibly difficult to try to translate a history and do a physical exam. In just the hour or so that we were with the patient, I got absolutely exhausted by having to constantly tell the kids not to run around the room. I can't even imagine trying to treat children on a daily basis. It would be a nightmare.

Since immunology/allergy is a field that deals mainly with infants and children, it's starting to fall a few rungs in my list. To be honest, the only thing I could really see myself doing right now is EM, and possibly Med/ID. Possibly. I'm not thrilled with the idea that ID's main job is consults from other physicians, though. All I do know though is that children are evil, and I can't imagine taking care of them.