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.
