Tuesday, June 15, 2010

I'm going to be a dentist.

After completing my rotation in child psychiatry, I spent the next two weeks a the Free Clinic on a family medicine elective. For those of you not from Cleveland, the Free Clinic is one of the oldest free clinics in the country. Given the tremendous poverty in Cleveland, especially on the east side, this clinic is a huge asset to the community. The elective was recommended to me because it forces students to essentially get thrown into a room with a patient and manage them with minimal oversight. The autonomy was apparent from day 1.

I remember walking into the clinic, undergoing a quick 5 minute orientation, signing some papers, then being thrown into a room with a patient.

I walk in: "Hi, my name is Kavi and I've never done this before. Today I'm going to play doctor as I waltz around in my white coat pretending to know what I'm doing when I really don't. What brings you in today?"

Of course I didn't say that, but it's pretty much how I felt. After making my way through the history, doing a brief physical and coming up with an assessment/plan that the patient was cool with, I walked out back into the provider area and met with one of the attendings to discuss my patient. The preceptor was either a family medicine/internal medicine doc or a family med nurse practitioner depending on the day of the week. They would check over my notes, sign out the meds or any labs that I we agreed the patient needed. After taking care of labs and meds, we would both go into the room, chat with the patient for 2 mins. The preceptor would discuss the meds, hand over the actual pills, and wish the patient well. Regarding the meds, the free clinic has it's own pharmacy in house where patients can get meds. Pretty cool.

Basically, the preceptor was there to make sure you're not doing anything stupid. Otherwise, students were essentially in the driver's seat making most of the decisions. The first time seeing a patient and presenting was a tad nerve-wrecking, but the preceptors were very supportive. They asked questions (known as pimping), but they subscribed to the theory of gentle pimpology. Overtime I became pretty confident seeing patients and presenting. Most of the patients were chronic care patients. I'm going to break it down into a simple equation:

Primay Care = HTN + HPL + DM2 +/- MDD/BPD/Anxiety

There you have it. That's the majority of primary care in a nutshell. For those not medically inclined, HTN is hypertension aka high blood pressure. HPL is hyperlipedima aka high cholesterol (think of the dude in the lipitor commercials during the world cup). DM2 is diabetes type 2. Pretty much everyone in chronic care clinic had at least 2/3 of those diagnoses. There was quite a high prevalence of emotional issues as well including MDD (Major Depressive Disorder), BPD (Bipolar Disorder) and Generalized Anxiety Disorder. Once in a while a patient would present with some other condition top of the aforementioned trifecta of HTN + HPL + DM2. Some random conditions included arrythmias, thyroid problems, iron deficiency, plus others.

Needless to say, I became comfortable taking care of these patients. Some might find managing the same conditions boring, but it was pretty cool to flip through the notes and see that a patient with messed up blood pressure is doing quite well now. Or to see that someone's bad cholesterol has plummeted. Even better, someone struggling with smoking has quit. You don't know how many times I said, "quitting smoking is the most important thing you could do for your health." That's pretty much all I said for 2 weeks.

What was most amazing, though, was seeing patients make strides in their health given their socioeconomic status. Just eyeballing the demographic page each patient would fill out, I'd venture to say that the average household income of all the patients I treated was somewhere around 10-20k/year. Most were unemployed or underemployed and did not qualify for Medicaid or Medicare. Sometimes I felt bad telling a patient they need to try cutting salt from their diet, when pretty much all they can afford is salt.

However, there were times too where I really questioned the priorities of some people. For instance, there was the one 45 year old lady who told me she couldn't afford healthy foods and some of the meds we prescribed her that were unfortunately not available in our pharmacy (but cost 4 bucks at any drug store). Literally two minutes after she told me that, she interrupted me and whipped out her iphone to answer a call. I've gotten a lot better at not judging people, especially people I don't know well, but that just made me think to myself for a minute...hmm. The kicker, she can't afford her meds, but she smokes 2 packs a day. Frustrating. I'll give her the benefit of the doubt...it's tough though. I just have to put on my smile, keep on with the motivational interviewing and hope she is ready to one day turn the corner. Pretty much the best I can do.

Chronic care generally lasted from 10-6pm each day. Some days I got out early, other days I stayed a bit later. Once each week there was an acute-care clinic from 5-8pm. Basically acute-care in this setting=STD. Here's a great story-slightly disturbing, so skip this part if you want. What follows is pretty much what took place, verbatim.

Me: "what brings you in today?"

[Imagine a 5 foot 9 African American Male, looks and sounds just like Ludacris. Picture provided for reference.]


Patient: "Man, I tell you 'bout these girls dude. Damn. I'm here for that STD check if you know what I mean."

Me: "Could you tell me more about what happened?"

Patient: "It's like this. I was at the bus station on the corner of St. Clair and 105th wearing this huge fur coat. This girl walks up and looks at me. I'm like, dayumn! So next thing you know she steps inside my fur coat and I stick my finger in her and lick it. Then we got on the bus and I haven't seen her since. My throat kind of hurts now. I need to be checked out pronto dude."

Me: "I see your concern..."

That's pretty much what STD clinic was like. And by the way, the last I checked, the guy didn't have an STD. I counseled him to think before he does something like that again. Otherwise we had a great conversation about Cleveland sports and he told me some jokes (really dirty jokes)-he's an aspiring comedian--an impulsive one apparently. And to my female readership, please for the love of god, AVOID THE RTA.

The last aspect of the rotation included Fridays. Yes, Fridays. The day of female well visit exams. Shoot me now. I never want to do pelvic exams ever again. I can tell you right now, I've crossed out OB-GYN as a possible career path. It's just not happening. I mean, nothing bad happened on the two Fridays during my rotation, other than seeing some gross stuff where the sun don't shine. Not just females. I've done a fair share of rectals during the rotation too. Maybe urology needs to be crossed out too. No thanks. Not for me.

Well, my free clinic rotation is over now and I have moved on to the VA where I am currently on a 2 week cardiology rotation. This elective will be my last before I transition over to my core rotations starting with Internal Medicine at University Hospitals. I've only been on the service for 2 days and I can tell you already that it's quite a shock to the system especially after being on child psychiatry and family medicine which was pretty much all outpatient with very nice warm fuzzy attendings who care about your well-being and future. It's not that the cardiology staff are mean (they're not at all), they're just not radiating as much enthusiasm as some of the attendings/fellows/residents in the outpatient setting. There is a lot more cynicism, back-handed comments and grumpiness that goes on. Pretty much par for the course in any hospital, or at least what I would suspect. Of course this seems to vary depending on the individual.

The rotation is kind of weird in that it tailored to the interests of each student. I told the cardiology chief to help me a plan a rotation that would give me a taste of what cardiology is like...like a broad overview. My schedule has me rotating through different areas such as echo, cath lab, electrophysiology, cardiac critical care, stress lab and outpatient clinic. So far, I've learned a great amount of stuff. I spent Monday with fellows and attendings learning how to read echocardiograms. It's amazing to see how proficient they are at picking out insufficient valves on the fly. I was supposed to spend Monday morning in the outpatient clinic, and I did for about 45 minutes. As soon as I walked in, the fellow staffing the clinic that day told me, "dude, I got nothing to teach you today. Clinic sucks balls. It's just med management like primary care. Go bother the fellow in echo. It's so much cooler and he'll teach you stuff." And he was right, I did learn stuff. It's just too bad some docs don't like talking to their patients at all. It turns out this guy is going on to an interventional fellowship, so he has a different mindset/interests-fair enough I suppose.

Overall, cardiology seems kind of cool. I can see why it's so popular among med students and internal med residents. It's a field with lots of toys, lots of procedures and outcomes that can be good. The procedures/treatments make sense since everything can be traced back to basic cardiovascular physiology principles, there are new advancements all the time especially regarding diagnostics, the field is in high demand, and the pay is good (though is due for 30% reductions in diagnostic procedures with the new healthcare bill).

Today I got a taste of what internal medicine might be like. I got a chance to sit in on the cardiac critical care unit rounds and follow the attending, fellow and 4 medicine residents around several floors as they check up on patients. Today I was supposed to pick up a new admission and follow that patient and be ready to present on rounds tomorrow. The resident who was on call today sent me home after 3 pm because no new admissions showed up by then. He gave me an old patient to present. So now I have to get to the hospital by 7 AM tomorrow, do a quick pre-round session then be ready present by 8. No big deal really, just a tad bit annoyed that no new patients showed up! It seems like my day was a waste, but the resident was one of the nicest people I've met in the hospital thus far. For one, he was kind enough to actually introduce himself and the rest of the team to me (I've grown accustomed, after yesterday especially, to go out of my way to introduce myself). He was very interested in teaching and we went over management of acute coronary syndrome and atrial fibrillation. He did give me some advice though. He told me to go into radiology or dermatology if I can. I was kind of surprised to hear him say that because he actually looked like he enjoyed what he was doing. He himself is planning on going into cardiology, but he said it's a really long road and the lifestyle sucks. I got the same advice from the two fellows planning on doing interventional cards. I kind of wonder why they are doing interventional if they're worried about lifestyle...

One final note, I'm tired of everyone asking me what my "interests" are or what I plan on "doing" after med school. It's not that it's a bad question, but I'm not going to lie to you all. I am at times ashamed to tell people my true interests. I know it's just a fact that everyone in the medical field pisses on their colleagues in other fields. Surgeons hate internists, primary care docs hate specialists etc. I get such a negative reaction when I tell people psychiatry (and by people I mean attending physicians, residents, fellows, patients, hell even other friends in medical school). I get responses ranging from "only crazy people do psychiatry, and you're not crazy..." to "you're to smart for that" to "it's not real medicine," to "ah, interesting..." Among certain physicians it's no problem. I have no shame telling a psychiatrist (obviously), neurologist or primary care physician that I'm interested in psychiatry. In the hospital though, it's a different beast. I was about to just tell the cardio fellow Monday morning "I think I'm interested in psychiatry," until he started cussing to himself about this bipolar patient we had and how it's such a pain dealing with psych issues in clinic. I even remember telling an attending once on a clinical immersion I'm interested in, and after I said psych he was reluctant to show me some aspects of his practice because "oh it's stuff you'll never do as a psychiatrist, don't worry about it." So I've started hedging the question saying, "undecided at this point." Or saying "I'll see what third year throws at me." Or, "we'll see." Or even, "I'm going to be a dentist." I think I'm going to stick with that.

Monday, May 17, 2010

Mood Disorder NOS

It's 3PM, May 13 2010. I'm in a medical examination room inside an outpatient pediatric office located on the East Side Suburbs of Cleveland sitting across from my attending psychiatrist, Dr. Mike, thinking about a couple of things. First, I'm hungry. I'm always hungry. Second, this is so much cooler than studying. Third, in a two incredibly short years, I'll have similar responsibilities as the guy on the other side of the table. As I begin to daydream Dr. Mike asks me, "what's your differential?" Without even thinking I respond, "ADHD combined type and Mood Disorder NOS."

Two very short years of pre-clinical training brought me here to my first ever clinical rotation. The last time I posted an entry was December of 2008. At that time, I was a first year medical student. Everything was new to me. 18 months has transpired since that time and I still feel like everything is new to me. Only this time, I'm not so concerned about anatomy, IQ groups or taking tests. Now, I actually get to deal with real patients, their families, physicians, and other health professionals. It's pretty cool.

Here's a run down of everything that has transpired since my last post:
  • Completed Block 3: biochemistry and GI (I thought it was fun)
  • Completed Block 4: cardiovascular, pulmonary, renal systems and general pharmacology (I thought this was fun too)
  • Completed Block 5: microbiology and other stuff (total hell)
  • Completed Block 6: neurology and psychiatry (most fun I've had in med school)
  • Officially graduated with my Masters in Public Health in January 2010
  • Spent 5 weeks studying like mad
  • Ditched studying for 3 days to hang out with my friends in Houston
  • Took a 7 hour test in a little booth under closed circuit surveilance.
  • Reaped the rewards of 5 weeks of studying like mad
  • Flew to Cambridge University in England to present a poster
  • Drove to Philadelphia to present another poster
  • Walked across the street from the med school to present another poster, and won $100 for the poster.
  • First author of a paper pertaining to off-label uses of psychotropic medications (I know, no one cares)
  • Mourned the deaths of two good people
  • Celebrated a few births (in the extended family)
  • Flew to India to visit my relatives after a 6 year hiatus
  • Switched from a Blackberry to iPhone
  • Played 30 rounds of golf at about 25 different courses in 4 different states (Ohio, Alabama, California and Florida)
  • Witnessed another Cleveland sports disappointment
  • Began my first clinical rotation

After finishing up Block 6 in March, I took 5 weeks to study for Step 1 of the USMLE. For those who don't know what that is, it's a big bad exam that all med students freak out about. Most go into hiding for a certain time period, then re-emerge once the exam is over. Most usually pass and life goes on. High scores generally help when it comes time to applying to residencies. I achieved a score that was higher than what I was expecting, so no complaints here. Glad that it is over. To celebrate completion of boards, I spent 3 days golfing in Alabama with one of my friends. Upon returning from my golf trip I did absolutely nothing the next 10 days. And by nothing, I organized my room, cleaned my car, went hiking with my dogs until they were sick of me, worked out 3 hours a day, played more golf, caught up on research work, read more journal articles, yelled at the TV as the Cavaliers showed no effort or desire, and finally booked my trips to New Orleans (this weekend for American Psychiatric Association Annual Meeting) and Las Vegas (no fancy conference here, just hanging out with some good friends from Rice).

At Case SOM, third year consists of three core rotations (called Core 1, Core 2, and Core 3) and a 4 month research block, affectionately known as vacation-unless you take your research seriously. I placed out of the research block since I spent a substantial time during my first two years finishing up my MPH, which included a scholarly project that took more time than the allotted 4 months for the med school research block. After boards, I'm scheduled to be on 2 months of my research block, followed by core 1, followed by the remaining 2 months of research, followed by Core 3 in January, and Core 2 in March. Since research block does not exist for me, I can theoretically do whatever I want during this time. Having Obsessive Compulsive Personality Disorder, I'm on top of my game. I have decided to use this time to take clinical electives that can be used towards med school graduation credits. This way, I can either defer my four months of vacation to the end of fourth year, or I can decide to use that time later for research since I like research and will probably engage in some other scholarly activity before I graduate (next year's APA conference is in Hawaii...).

So I am officially starting off third year with three 2 week rotations: child psychiatry, family medicine at the free clinic and cardiology consults at the VA. My idea is to pick fields that I find interesting and to work my way towards a more intense inpatient experience that will get me ready to hit the ground running for Core 1 in July, which consists of internal medicine and surgery.

I chose child psychiatry because of all the psychiatry didactics we had in Block 6, I found the child stuff to be the most fascinating. Furthermore, the faculty were really supportive. It also helps to have a father who is a child and adolsecent psychiatrist. So far, I think I made a great choice. Some might think I'm interested in psychiatry because my dad is a psychiatrist. My dad's a smart guy, but not the best test taker in the world. The only reason he's a psychaitrist is because it was the only field he could into. Good for him because he absolutely loves what he does. Part of me wants to see what the hype is about, but honestly I'm interested in psychiatry because I am fascinated by behavior. Child psychiatry makes sense to me because it is a perfect opportunity to intervene early on when psychopathology begins to manifest in individuals predisposed to mental illness. It kind of fits with the public health side of me in that sense. Furthermore, psychiatry as a whole interests me because not much is known about it. Epidemiology is key to research into phenomenology and treatment. While not a whole lot is known about psych compared to other fields of medicine, child psychiatry is basically in its infancy. There are a ton of questions out there waiting to be answered. This kind of fits with the research side of me. Definitely not a bad way to start third year.

So far the elective has been great. It's mostly observational, but I do get a few minutes during each patient interaction to ask the patient (the kid) and his/her parents questions. The attendings are very supportive and go out of their way during the patient interview to highlight key areas in the patient presentation/history that they feel are good learning points. The patients I've come across are amazing. Kids in my opinion are so much more fun to work with than adults. The challenge though are the parents. Not always, but sometimes. The apple doesn't fall too far away from the tree, as they say. Sometimes it's tough to fix the kid when it is the parent with the serious psychopathology. It's so interesting seeing the type of personality disorders the parents have. I never thought I would see so many cluster B personalities (people with relationship problems generally). Lots of narciscism, lots of borderline behavior.

A common misconception in child and adolescent psychiatry is that a given practice consists of all ADHD, and all psychiatrist do is just push pills. ADHD does consist of a decent proportion of the patient population, but you'd be surprised to see how much substance abuse and mood disorders are present. Lots of kids have bipolar. Since not much is known about pediatric bipolar, and since psychiatrists don't like to give kids labels, especially so young in life, pretty much every patient is slapped with the disorder "Mood Disorder NOS." The NOS stands for Not Otherwise Specified. A tip for those of you ever rotating in child psych: if you want to score points on your differential, just blurt out Mood Disorder NOS. And about the pill pushing: in a 30 minute follow-up evaluation, 5 minutes is spent managing the medication while the other 25 is generally spent counseling the patient and his/her parents.

What's amazing is seeing the improvements that kids make. Having spent time in the past working in adult outpatient and adult inpatient psychiatry, I've kind of grown accustomed to taking solace in small victories. Unlike adults, many kids go from manifesting serious problems to doing well at school, and meeting developmental milestones. Early intervention can literally change the course of a kid's life. There is nothing better than seeing a kid who was failing school and getting into all sorts of trouble come back to the office with a huge smile on his face reporting that school is going well, they are making friends and things at home are going well. It's not glamorous like surgery, and it doesn't provide an adrenaline rush like dealing with trauma in the ER, but if that isn't saving a life, then I don't know what is.

The job does come with its challenges. First, you have to be willing to deal with uncertainty. Psychiatry is vague, ambiguous and is not rooted in strict biomedical science (not yet that is). It really is more of an art than a precise science. Psychiatrists have done a great job in the past of observing behavior and categorizing those behaviors that are perhaps problematic into sets of "disorders." In order to help treat psychopathology there are two main tools available: drugs and talking. The arsenal drugs at a child and adolsescent psychiatrist's disposal include anti-depressants, anti-psychotics, mood-stabilizing agents and stimulants. Equally as important is talk therapy (psychotherapy, CBT etc.). No one knows why these things work, but they do. Everyday new research is coming out to fill in the blanks. The biggest explosion of medical knowledge over the next 50 years will be in the neurosciences and in particular, mental health. If you don't like the fact that ADHD can't be explained as simply as lobar pneumonia can, then this isn't your field. Second, you have to have patience...a lot. Parents can be demanding, and often rightfully so because they have to put up with their children all the time whereas you the physician deal with them for fifteen minutes. You have to be calm, and reassuring. Third, your job does not start and end with medical science. There are times where I wish I can just order a lab test, or look at an image. And yes, it is frustrating at times. In the end though, you treat the whole patient. This includes talking with teachers, counselors and parents to see how the patient is functioning in all aspects of their lives. Medical school doesn't teach you this. Life does. Being a good caring person goes a long way.

The other day, a 8 year old girl came into the office with her mom. Poor thing was suffering from some bad OCD. She came into the office and told me everything that was wrong with her in the past. She wasn't able to touch doors, shake hands, or even open her school desk. Kids at school were making fun of her, she had no friends. Life sucked. Six months of SSRI treatment and counseling 3x week resulted in dramatic improvements. She loves school, she has friends, things are good. Before she left, she gave me a gift:







I still have a long ways to go before I decide on a field, let alone a subspecialty. I'm going to wait until I experience everything third year throws at me before I make up my mind, but I can say that child and adolescent psychiatry is something I can definitely see myself doing in the future. I can see why dad loves his job.