Surgery

I am starting surgery at Cook County on Tuesday. Cook County is a huge hospital that mostly serves the inner city of Chicago. The TV show ER is based (very far from reality) on the Cook County Emergency department. 

In medical school the surgery rotation is often considered to be one of the hardest if no the hardest rotation of all. The hours are long and often the people you work with are not the most pleasant. There are all kinds of horror stories going around about different experiences that students have had while on surgery. Much of these experiences are location and person specific. If you work with a surgeon who is a jerk you are going to have more horrific stories than if you work with a surgeon who is human. 

You can bet that you will be yelled at and told that you are an idiot at some point during your rotation. The hours will be long and tiring and most people either love it or hate it. I am approaching this rotation with an open mind and I am very excited to see if this is a field I could see myself doing for the rest of my life. As I entered medical school I always thought that surgery may be one of my options and I still think that it may but I have never wanted to fully commit or reject the notion of being a surgeon until I had experienced a surgical rotation. This is why I have chosen to do my surgery rotation early in the year. If I love it then I can further pursue it as a career or choice and if I hate it I can erase it from my options. 

I am excited to learn and see all the different procedures. 

Study tomorrow is the Family Medicine Shelf Exam

Ok so today is supposed to be my day to get all caught up on my studies for the shelf exam I have tomorrow. The shelf exam is a national exam given to medical students after they complete a rotation. Tomorrow I take the family medicine shelf exam which is touted as being a very difficult exam especially if you face it early in your 3rd year prior to having completed many of your rotations. Why is it so difficult? Family medicine is a very broad specialty. You see internal medicine, pediatrics, and OB/GYN etc. This means that the exam can cover any of these areas. You have to be prepared to answer a wide variety of questions. 

I have been studying everyday for the past month by reading a couple of different clinical books about family medicine. I also have been doing practice questions from a variety of sources. The main problem is that after you finish a long 11 hour day of seeing patients the last thing you want to do is study. I probably have not put in the amount of hours studying that I should have, so I am hoping that is the case for everyone and that the national curve will reflect accordingly. 

Here is an easier example question:

A 50-year-old man has had progressive weakness and shortness of breath with exertion for 3 months. He appears malnourished; conjunctivae are pale and there are scattered petechiae. Labs:

Hemoglobin 6g/dl

Mean corpuscular Volume: 114 mm3

Leukocyte count 2500/mm3 with hypersegmented neutrophils

Reticulocyte count 0.5%

Platelet count 60,000/mm3

The most likely cause of his condition is a deficiency of which of the following?

a.) Folic Acid

b.) Iron

c.) Thiamine (Vit. B1)

d.) Vitamin B6

e.) Vitamin C

f.) Calcium

g.) Potassiun

h.) Copper

i.) All of the above

j.) none of the above

There are a couple of things that they a testing here. You need to understand that this patient has anemia by understanding his lab values. Just knowing that the patient has anemia will not get you the answer though. You also need to know that the patient has megaloblastic anemia. Then you need to understand that the 2 major causes of megaloblastic anemia are folic acid deficiency and vitamin B12 deficiency. In the answer choices they do not have Vitamin B12 listed, nor do they explain any neurological symptoms that are often caused by vitamin b12 deficiencies. So this leaves you with one answer that fits the scenario and that is choice a = folic acid deficiency. The questions are usually 2 - 3 step logic and it is easy to get turned around even if you understand the tested concepts fairly well. 

Family Medicine = Done

So yesterday was my last day of family medicine. There is some excitement as well as some sadness in this statement. Going into the family medicine rotation I did not expect to like it it too much. After completing a month of it, I can say that there were many aspects of it that I enjoyed. I do not think that I would choose family medicine as a career. Last night I was speaking with a someone on the phone and they asked me; "What did you like about family medicine and what did you dislike?" Although that is a difficult question I will attempt to break it down in today's post.

Here are the things I like about family medicine:

There was a lot of variety day to day. Essentially you could see a sports physical followed by congestive heart failure followed by HIV. Hopefully you did not see all of these in the same patients. Also family doctors have a wide range of things they can do in their practice. They can do cosmetic type procedures, Gi / colonoscopy, OB / deliver babies, wound management, urgent care, etc. Basically a family doctor could choose to focus on almost any area of medicine and make a practice around that area. Another thing I noticed about general family medicine is that it was fairly simple and not very stressful from a medical management aspect. There is a running joke with some doctors that says, family medicine doctors so not see sick patients. There is some truth to this which makes their day to day medical management stress not as intense as some other specialties. These are a few of the things I enjoyed about family medicine.

Now for the things I did not like. It seems that reimbursement has been lowered so much that it is difficult for family medicine doctors to make decent money. Especially in their own private practice. This financial stress, takes the joy out of the work. The average family physician needs to see between 30 - 40 patients / day to make a decent living. With this volume it is hard to practice quality medicine and everyone suffers. Then at the end of the day the doctor spends most of the evening charting and returning calls. This makes for long hours and a stressful life. Although family docs can pursue a wide variety of different practices within medicine they are often politically blocked from doing such things. For example, a properly trained family medicine doctor has no problem delivering babies, however in today's world most babies are delivered at hospitals. In order to deliver a baby at a hospital the doctor must have delivery privileges at the hospital. Often the OB/GYN doctors at the hospital will block family medicine doctors from getting privileges to deliver babies and without the privileges they obviously can't deliver any babies. 

These turf wars are common and the family practice doctor always loses as they are not considered the foremost specialty in OB, GI or other areas that they may want to focus on. Even if a hospital does give the family doctor privileges to do the different procedures they will always require that they have a back up doctor in the given specialty on staff at the hospital. It is difficult to find a doctor that you are competing with to want to take back up and liability for you as a family practice doctor. This prevents many family doctors from being able to practice in the many diverse areas of their training. 

In the increasing world of specialization the family doctors seem to be stuck in an overworked, underpaid and under appreciated capacity in our complicated medical world. I think the only way I would consider going into family medicine would be to work in a rural area or as a 2nd / combined specialty. There are some combined residencies that someone can pursue like emergency medicine / family practice or psychiatry / family medicine. The advantage of a combine residency is that you get trained in both specialties and end up being board certified in both specialties and overall you cut down on the training by 1 year. A psychiatry residency is 3 years and a family medicine residency is 3 years but if you do a combined psychiatry / family medicine it is only 5 years so you save a year.

Career in medicine = a privilege

Saturday we had a fairly busy day. Each morning as I drive into the office to see patients I have a great feeling of satisfaction. I have never had a job in my life before where I actual was excited to go in. This feeling of excitement was always experienced as I finished the day and was driving home. Even though family medicine is not my favorite kind of medicine I still get excited to go in and see patients. Each day there are a handful of difficult and frustrating situations the interaction with the patients makes it worth it. I am not naive enough to think that it will always be this way. I am sure as I move along in my career in medicine the newness and excitement may fade and the frustrations may become more common. Hopefully the satisfaction also continues. I just feel very lucky to be able practice medicine. It is a privilege.

During my previous careers my main goal was trying to figure out how to get out of work, trying to get more time off, waiting for the day to end. I longed for the weekend and could not wait to be away from work. It was more like work was a necessary evil to afford the things for my free / family time. My feelings for my free time have also changed. For example, in the past with previous jobs when things became busy it was often necessary to work nights or come in on the weekends and this caused feelings of  extreme dissatisfaction and ultimately job resentment. However so far in medicine, when a patient exam runs late or I am scheduled for Saturday I do not have the resentment (yet). It feels natural to me that if a patient needs to be seen in the evening or on the weekend, you just do it and I actually gain satisfaction from the process and the patients gratitude. Again I realize this may be a temporary utopia that fades over time as I become more and more jaded with the system. Right now I am going to enjoy it. One of my theories is  that because my day is spent helping / worrying about others I find it difficult to focus on my problems and this prevents me from feeling sorry for myself. The reduction in self pity makes everything seem better.

I still love my free time and family time. In fact on this rotation my only day off has been Sundays and I love these days. I feel like this is my time to recharge and spend time with the kids. It is needed time but as monday approaches instead of feelings of resentment or despair of having to go back to work I feel this excitement and look forward to the upcoming adventures. Hopefully this lasts for a little while. We shall see. A lot of the doctors that are my mentors and that I look up to still have this excitement. They obviously get bogged down by the frustrations of their career and they enjoy their time off but surprisingly they lack  much of the resentment that is typically seen in "work". I asked a surgeon mentor of mine how he can work some of the 24 hour shifts he occasionally has to do and his response was, "I do not even realize its 24 hours, in the middle of surgeries I am so caught up in the patient that the time flies by and before I know it I have finished my last surgery and I leave tired and ready for bed but extremely satisfied". I have worked with this surgeon several times and he is definitely sincere in his feelings. This is why I think that the ability to have a career in medicine can be a privilege rather than a burden. 

Another way of explaining it, is to compare it to video games. As a young boy I loved to play video games and I could play for hours on end. The limiting factor was usually my mom or dad forcing us to stop playing or having to go to school, church or other activities. I could play for hours because I loved the games and my brothers and friends who played with me. If someone said; you are going to have to play video games until midnight tonight I would have been thrilled and happily accepted the assignment. To a certain degree I feel like this way about medicine. On the other hand I would say my previous jobs / careers were more comparable to weeding. As a boy if I was told that I had to weed the rock pile, resentment would undoubtedly creep in, especially if it was on my brother's birthday. 

This is why I think that the opportunity to have a career in medicine can be a privilege rather than a burden.

Doctors and Money problems

One of the things I have noticed while working in family medicine is that many patients and the public in general have this idea that all physicians are rich / wealthy. Certainly many physicians make decent money. However the days where being a physician automatically meant being wealthy are over. I think that the specialties hit the hardest with decrease in reimbursement and pay are the primary care fields, particularly family medicine and pediatrics. 

As I have gotten to know and understand the 2 doctors I am working with right now in family medicine it has become very clear that they are struggling to make ends meet with their clinic / business. It is a common story that can be seen throughout the united states. A new physician just finishing their 7 years of training (not counting college) and they have an average of $150,000 + in student loans. As they interview and look for jobs they feel that the offers are too low so they decide to open their own practice. The usually lack the business skills and abilities to run a business and they struggle to get things going. Often they are required to borrow more money to get the capital to start their practice.

It will take them 2 - 4 years to get their practice up and running if they are fortunate enough to not go out of business. Finally when they have enough patients to make a living they realize that reimbursement has continued to drop and when all is said and done they never make the kind of money they thought that they were going to make. I tell people when asked about medicine as a business to not go into medicine if they are doing it for the money, because simply put the money is not there anymore especially if you are considering primary care.

Most of the rich doctors you hear about, make their money by running a good business and not from the practice of medicine alone or they are highly trained specialists. A doctor with superb business acumen can still carve out a niche business and do well but the days of "rich" doctors from what I am seeing are but a fading memory. The reasons for this decline in reimbursement are vast and could fill up an entire book on the subject. I still think that medicine is a great career but I knew going into it that I could make a lot more money doing business than I could practicing medicine and I still decided to leave business for the time being and pursue medicine. I am sure when I am done I will reunite with business and combine medicine with it. 

Subungual Hematoma

What is a subungual hematoma? This is an injury that causes bleeding to occur under a toenail or fingernail bed. It usually occurs from blunt force trauma. The current medical standard is that if the blood takes up more that 25% of the nail bed then it should be released. In order to perform the procedure the injury should be less that 48 hours. Once the blood coagulates treatment no longer provides a beneficial outcome. Basically a hole is made in the affected toe and the blood comes flowing out relieving the pressure.

For the most part subungual hematomas are benign, however the larger they are the more likely a complication can occur. What are the complications, you ask? Well, due to the tremendous pressure as the new nail forms it will be deformed and its growth may be stunted or not occur at all. Also there is a greater chance or infection with the larger hematomas. 

I have had a few opportunities to treat patients with this type of injury. A couple of times in the ER and today in the office. an 8 y/o female, african american patient presented complaining of a subungual hematoma in her right had in the thumb. The hematoma was the result of getting her thumb shut in a car door the evening before. It was determined to involve approximately 60% of the nail bed. The pain was stated to be 8/10 and the patient had not slept at all the previous night due to the pulsatile pain. The patient failed over the counter analgesics administered by her mother. After close examination it was determined that the best course of treatment would be to make a hole in the nail bed to release the blood and relieve the pressure. I used an electric cautery device to burn a hole in the nail bed. The initial sting from this procedure is very painful but once the blood is released the patients pain from the pressure is relieved and they usually say that the pain from the procedure was well worth it as the pain relief from the release of the blood is amazing. 

1 thing that I like about this procedure is that as soon as you burn through the nail the blood bursts out like lava from a volcano. There is so much pressure that the blood explodes out. In fact blood splattered all over my white coat today as I performed the procedure. The patient was very brave but let out a horrendous cry as I made the hole in her nail. About 10 minutes post procedure all of her pain was relieved and I have a good feeling that she is going to sleep just fine tonight. Her mom was very happy especially when we told her that her daughter has a much better chance now of a normal nail re-growing. 

Lottery Results

It was great to go to the lottery last night. The entire class was there, I got to see friends that I have not seen in a while. Everyone was exchanging stories from there rotations. It sounds like everyone is happy and satisfied to finally be acting like doctors. 

At the lottery I was able to talk to a few classmates who are currently in the internal medicine and I found out that the North Chicago VA hospital is great for internal medicine. I decided to go for that rotation, but there was only 1 spot available and another student from my track really wanted it. So I went with Lutheran General as I had originally planned, but I have emailed the director asking if it is possible to add another spot at the VA. I will have to wait and see what she says. 

I did not have to use any points, which was nice. I still have all 20 of my points. I only have 1 week left of family medicine and then I start surgery at Cook County. 

Upcoming Internal Medicine Rotation

Later today (8/20) after my afternoon of family medicine lectures I have to go into the city for the lottery for my Internal Medicine rotation. At the beginning of my 3rd year my classmates and I all started with 20 points. These points are to be used over the course of the year at several different lottery sessions to pick rotations. 

The first lottery was set up to choose a specific track. There are 16 different tracks which dictate the order of your rotations. Everyone had different theories as to which order was best. I did not really care what my order was so I did not use any of my points to win a specific track. The 2nd lottery was set up to pick locations for my first 2 rotations, ER/family medicine and surgery. I did not have to use any of my points for these rotations. This 3rd lottery tomorrow evening is to set up the location for my 3rd rotation which in my case is internal medicine.

There are several locations available for the internal medicine rotation. I am going to go for Lutheran General, which is an excellent teaching hospital. I will use some of my points if there are more students than spots available at Lutheran General. I have heard that this rotation is excellent and that there are a of learning opportunities. The call schedule is not too harsh either. The location for me is great as well. There is a good chance I could end up doing my residency at this hospital so this could be a good opportunity to build some good relationships with attending physicians. I will probably not do a residency in internal medicine but because internal medicine interacts with nearly every department that as a student on the internal medicine service I will get to meet physicians from emergency medicine, surgery and the other departments. These physicians could be influential in choosing residents. Hopefully I can make a good impression and forge some good relationships with these physicians.

I will not begin the internal medicine rotation until after my 8 week surgery rotation.

Public Aid

I was raised in such a way that I was not really allowed to borrow things from people. A pen or a pencil was fine but anything of significant value was off limits. I remember one time we borrowed a weed whacker from a neighbor and it did not work properly. Even though it never did work in our possession we were required to replace it. My mom told me that if you are going to borrow something then you have to be prepared to replace it and that it was generally less expensive emotionally and financially to either rent or buy the needed item. 

I have also never been comfortable in receiving something that I did not pay for or earn. I would just rather pay for the item. In certain circumstances I have had acquaintances offer services or goods free of charge and I am not sure if it is pride or a sense of proper ownership but I have never been able to accept these kinds of things. It is fine to receive a gift within reason and I have no problem trading goods or services with friends. 

I think that the aforementioned feelings about freeloading makes it hard for me to deal with the patients who use public aid and or WIC. I do believe that there is a population of patients who need these services, in Chicago we have projects filled with families who truly have no other way to get any healthcare. I think originally these programs were set up for these individuals who are truly below the poverty line and indeed would perish or suffer severe consequences without healthcare offered through public aid. However there are also a large number of people who look at public aid like free samples at Sam's club and figure out a way to get public aid and make the system work for them. 

Some of these people feel that they are entitled to this free service and that they deserve it. They bring this attitude into the office as well, and in their own way demand the "free" medical services. I am sure that they do not know that the doctors who take public aid do so at an incredible loss. Public aid here in Illinois has horrible reimbursement rates for doctors and a large percentage of the time they do not pay and when they do pay, it is after 9 + months and several man hours dedicated to getting them to pay. 

I know a handful of groups who will see public aid patients as a service. It is their way of feeling like they are giving back. I do not know any who see public aid as a revenue source, inevitably it is a business loss given the low reimbursement and the labor / supply costs associated with seeing the patient. Almost every group I have come into contact with refuses to see public aid at all. However, the group I am working with now does see public aid newborns and will follow them as children. 

It is frustrating when some of these patients come in with demanding attitudes and sense of entitlement. The interesting thing is that many of these patients have their kids decked out in the latest fashions and expensive clothes yet somehow expect free healthcare. They do not realize that their "free" healthcare comes with a cost and it is paid for by the tax payers and further paid for by the doctors who do agree to see them. Also these patients are the most likely to sue according to some recent studies. 

We had a public aid day and I spent the day trying not to get caught in the pettiness but I certainly left at the end of the day with less love for patients who use public aid and WIC while they pay for their house / cars and other bills yet refuse to pay anything for healthcare and then come in with a demanding sense of entitlement. 

As a doctor I think I would rather offer up 1 - 2 weeks a year and provide free medical care in the projects or under served communities and  serve medical missions than to offer to accept public aid. This way I could assure that my service goes to those who are truly in need. 

Communication Breakdown

Led Zepplin has a song called Communication Breakdown:

communication breakdown

its always the same,

I'm having a nervous breakdown

Drive me insane

I think that all areas of life are filled with miscommunication and it is no different in the physician - patient relationship. Often I am able to be an observer of the attending physician treating / talking with the patient. In this role I get a unique perspective where I can listen and see the doctor and patient communicate. It is very easy in this role to see where communication breaks down and a misunderstanding occurs. 

Often a patent presents a symptom or tells how they feel and the physician may or may not understand exactly what the patient is thinking. The physician does his / her best to interpret the information and then go down a particular  path to help the patient. Unfortunately many people (including physicians) are horrible listeners, so they do not get the whole story which potentially leads them down the wrong path. Often the patient does not want to interrupt or question the physician so the chosen path may not be corrected.

Today we were seeing a 25 y/o female who had presented earlier this week with lumps in both breasts and a small amount of discharge. She was worried about breast cancer. After examining her the doctor and I both thought it was fibrocystic change / fibroadenoma which is a benign fibrous growth. In young women this is very common and most often it is the diagnosis when a young women complains of finding a lump in her breast. However, to cover everything we did a full blood work up and ordered an ultrasound. This patient was coming back to discuss the results.

We looked at the results before she arrived and as we thought everything was completely normal / benign. The ultrasound showed that most likely these lumps were fibrocystic change (benign). Basically she was completely normal. The only way to 100% confirm fibrocystic change is to perform a needle biopsy of the lump but it is not usually done unless the patient is overly worried or there is a strong history of breast cancer in the family. 

When the patient arrived we met in the exam room and I just watched and listened as the doctor presented the good news  to the patient. I could tell that the girl was very nervous about receiving the info. As the doctor explained the findings I could tell that she did not understand exactly what he was saying. She was really looking for reassurance and the doctor was trying explain the ultrasound and the results. I was just observing. I could see that there was a breakdown in the communication and that the patient was still very concerned. She tried to clarify with a couple of questions bit the doctor misinterpreted the questions and failed to really provide the comfort that the patient needed and in fact deserved.

Doctor: Hi, so how do you feel?

Patient: Fine

Doctor: Well we have the results of your blood work and your ultrasound. (long pause as he re-reads the ultrasound report)

Patient: Ok (more pause)

Doctor: Your blood looks good.

Patient: it looks good?

Doctor: You have a disease, (pause) It is called fibrocystic breast disease. (pause) 

Patient: Ok

Doctor: So we can never be sure and the only way we can confirm it for sure would be a biopsy of the breast. 

Patient: oh...... Do I need to do the biopsy today.

Doctor: If you want to go down this road, we can set up a biopsy. Do you want a biopsy?

Patient: Well, what is it for? Do I have to....

Doctor: No, no I suggest you come see me in 2 months and we examine you again. If you notice any changes or I notice changes the we can go from there. 

Patient: Ok 

Doctor: Great, have a good day and I will see you in 2 months.

Doctor leaves the room feeling great. I stay in the room with the patient who is on the edge of crying and not quite sure if she just heard good news or bad news. She looked scared and confused. So I asked "do you have any questions" she did not say anything and so I began to explain what exactly these things meant. I reassured her that this was good news and that she wanted to continue to follow up with exams (next one in 2 months) and to continue her self exams. I explained that fibrocystic change is fairly common in younger women and that she should not panic. I could see the anxiety melt from her entire countenance. I asked her if she had other questions and told to ask everything she wanted to ask and that nothing was a stupid or bad question. She had several more questions that I addressed.

I think that it was easy for me being the observer to sense the miscommunication. So this experienced reinforced a couple of things for me. I need to make sure that I listen and watch for the patient's non-verbal cues. Also, as a patient I need to not worry about asking all the questions I need to ask. Just interrupt and ask the questions. You can worry about annoying the doctor for 2 - 3 minutes or you can leave worried with a lack of understanding and maybe even on the wrong therapeutic path. I would annoy the doctor 2 - 3 minutes. 

How many patients can you see.

The family medicine group I am with have 2 locations and most days 1 doctor is at each location but on Thursdays they both work together at their busier location. Today I had double the patients and double the fun. From the minute I entered the office in the morning  until late into the evening it was nonstop exams. I saw 40+ patients today. The whole day seems like a blur. 

It is unfortunate that primary care doctors are often forced to see large numbers of patients to keep their doors open. Given falling reimbursement, payment defaulting, and increasing costs it has become difficult for primary care physicians to make enough money to sustain the costs of running their practice. Today's medical students are coming out of medical school with more school debt than any other generation. It is well know amongst students that primary care dose not pay well, so as you can imagine, it is becoming harder and harder for to recruit / convince medical students to choose primary care as a profession. Unfortunately there are not any real remedies to this is the foreseeable future. 

I have been speaking with some of the other students on the family medicine rotation and they are all having to see tons of patients and only allowed to spend limited amounts of time with each patient. This scenario creates angry patients and frustrated doctors and sets up an environment for less than optimal care. I think most doctors are able to deliver sufficient care with these packed schedules but they could certainly deliver a much better standard of care with more time allowed for each patient. 

Even though there are many things I find appealing about family medicine, I do not think I am up for the torture that these doctors are forced to deal with as primary care physicians. Way too many hours of work for way too little income (often a negative balance sheet), for too much liability. 

The family doctors in more rural areas are able to do a little better because often these smaller towns will subsidize the pay in order to get a doctor to their town. The down side of the rural medicine is that often you are the only doctor which means you are never off, you are on call 24/7. The other problem is having to raise a family in the middle of nowhere could also have some unique challenges. 

Family medicine, and medical missions.

Today we had a lecture series all day at Lutheran General Hospital. One of our family medicine faculty is the great doctor who is married to an OB/GYN oncologist. They took their young family (2 kids) and moved to Nigeria for 7 years to work there as medical missionaries. He had also done several medical missions in South America as well. This guy is so interesting and has so many stories and experiences that are amazing. 

Basically he ran a hospital as one of the few doctors and as family medicine doctor did nearly everything from GI to neurology to dermatology. His wife did lots of surgery and pioneered a technique for treating / curing VVF (vagino-vessicular fistulas) and RVF (recto-vaginal fistula). VVF and RVF are conditions where there is a hole that allows communication or passage  connection of the bladder and the vagina (VVF) or a hole between the rectum and vagina (RVF). As you could imagine, this type of condition causes many different health complications. How does one get this condition? In the USA this is fairly uncommon but in Africa some have said that it is an epidemic. A common cause in Africa is young women have babies when their body is still very small and not completely developed. Often at 10 - 12 years of age they will be married and become pregnant. They will go into the brush to go into labor and have the baby. If the baby is too large for their small body it will get stuck and they may be in labor for several days. The baby will often die in the birth canal and eventually pass. However when this occurs the vaginal wall will slough off leaving a hole (fistula) between the vagina and bladder or the vagina and rectum. Another cause of these conditions is a complication related to female circumcision. 

Culturally in Nigeria, the females have their clitoris removed. This procedure is done with a scalpel by a faith healer. Due to the lack of a sterile field and the sloppy manner of which this is done, commonly a VVF will occur. 

If left untreated these young women can die from infection and complications. The wife of doctor who taught us today, essentially developed a treatment / repair for these conditions and then trained other healthcare providers how to do it. She has made a huge impact in treating this problem and decreased the related mortality throughout the country. 

The lectures were very interesting and I found my mind fantasizing about medical missions and all the adventures I could have with my family as we traveled around the world trying to provide healthcare to undeserved populations. I do want to do at least one medical mission and maybe several. I think that one of the exciting things about medicine and being a doctor is the ability to help regarding healthcare in undeserved areas. This can be done almost anywhere. Rural areas, inner city populations, many other areas within the United States are in need of medical services. Outside of the United States the amount of locations that need this assistance is overwhelming and never ending. 

Family medicine is a great specialty for the medical mission type doctor. Any specialty and all specialties are needed in these areas but because the family practice doctors have such a broad training and many skills in nearly all areas of medicine they can provide a great number of services. Since the need is so great as a medical mission doctor your ability to practice / perform procedures is only limited by what you are willing to do. These situations also create doctors who become adept at many different procedures that they would never learn or perform in the USA given their training. However in these under served areas, as the only doctor in the area, if you do not do / master these procedures they will not be done and patients will suffer from the lack of care.

This concept of being a medical mission doctor is very intriguing to me. There are so many areas in medicine that I find interesting, yet ultimately I have to choose an area / field of medicine and train accordingly. I think it could be exciting to have the opportunity to practice a wide variety of medicine and at the same time have the opportunity to provide a much needed service that will have great impact on the individuals who need the treatments. 

Who knows where / what I will do as a physician but I am going to try and keep an open mind throughout all of my rotations so that I can try to determine the field that I want to go into by giving all of them a trial run. If the past is an indicator of the future, then the only thing I can predict about my future is that, whatever path I ultimately choose it will a circuitous route filled with circus like excitement. Bring on the bearded ladies and the goat boy.

A cool case.

Today a patient came in complaining of  lower back pain. After a detailed exam I was able to isolate a muscle spasm in the lower back and rule out more serious conditions. During the exam I noticed that the patient had a lipoma on his cheek near his ear lobe. A lipoma is a benign tumor consisting of adipose tissue (fat). They are very common. I asked the patient about the lipoma and he said it showed up 3 to 4 years ago and continued to grow. Now it was to the size that had become embarrassing to him and his granddaughter asked him what it was and why he had it. I told him he should have told his granddaughter that it was a parasitic twin. I offered to remove it and he was more than happy to bid farewell to his ugly companion. I told him he would no longer be required to buy 2 airplane tickets when he flies. He started laughing to the point of tears, so at least I had him in a good mood. 

The exciting part came in the procedure. I used lidocaine to anesthetize it and then lanced it. Following the incision I had to nurse the fat out and make sure to remove all of it. It is like seeing a dead animal on the side of the road, you do not want to look but you find it impossible to stop looking. It is interestingly disgusting. It was unbelievable how much cottage cheese-like material I was able to get out. It looked liked cream coming out of a maple bar or long john donut. The best part was how thankful the patient was with the result. He was glad to have it removed and no longer following him wherever he went. I used steri-strips to close the wound and made sure to use plenty of antibiotic ointment to reduce the chance of any infection. 

It was a good day!

The nice thing about family medicine

Today was great for several reasons. Family medicine is pretty straight forward and for lack of a better explanation; easy. As a medical student who is looking to be in the trenches and getting as many procedures as possible, it is easy to have no interest in family medicine. You may even call it boring. However as person who will have a job and provided for his family, you can start to see the appeal of family medicine. It is easy and has much less liability than other fields, you do get see a broad spectrum of conditions, there is a lot of area to grow, expand and even change your business. I am sure as the novelty of being a doctor wears off and you realize it is a job these benefits of family medicine would be good things to have. 

Let's just look at the variability and growth of family medicine compared to ER. If you are a family medicine doctor you can really pursue many different areas of medicine; OB (deliver babies), GI (colonoscopy), Pediatrics (vaccinations, well baby exams), Sports Medicine, Cosmetic procedures, etc. These are all things that can be done by family practice doctors and if you want to focus on one area you can do that as well. In emergency medicine you are set in what you do, there are not really many options to expand out into other areas of interest. You can't really open a private practice as an ER doctor or grow a business plan to make money in other clinical businesses. You are tied to the hospital for the most part. As a family practice doctor you can open your own business and grow it in many different ways without a huge barrier to getting started. If you want to do something like this in ER it is much more difficult and the barriers to entrance are large. You would have to form a large group and sell it to hospitals. Most major hospitals are currently serviced by a handful of large groups with long histories. So if you want to make more money in ER you option is to take on more shifts and eventually you will hit a ceiling. Where in family medicine and other fields the earning potential is unlimited depending on your abilities in business. However if you want to just look at national averages the ER physician makes quite a bit more than the family practice doctor. I have never been just average so why would I start now.

In family medicine you are basically seeing patients who are not very ill. You do have some sick patients in the hospital but many of your office patients are healthy with minor complaints. This makes the practice much easier with little liability. These are some of the things that I have to take into consideration. 

No vaccinations!

This week we had a new baby that was referred to us by an ob/gyn doctor. We went over to the hospital to see the new patient and meet the mother. The ob doctor gave a vague warning, by saying the mother is a little strange. At the mother's bedside we entered into her twisted, obsessed and confused world. We began to talk to her about vaccinations and you would have thought that we said we were going to give arsenic to her baby. She began spewing out info that the media had fed her about autism and the dangers of vaccinations and how they should be illegal etc. 

By the tone and pressure of her speech we realized it would not be of any value to try and explain to her the reality of vaccination and the millions of lives that have been spared by there use. We could not explain to her that the autism claims were based on pure conjecture without any real studies. On the other hand there were 100's of studies documenting the danger of not using vaccines. She was too far gone and had shut down. So we asked about using antibiotics in the infants eyes to prevent any bacterial infection. The most common cause of blindness in the world is bacterial infection in the infants' eyes. This is no longer an issue in the USA since we began treating infants with antibacterial drops at birth. We have nearly erased this kind of blindness in the USA, in fact the only cases that occur in the USA are cases where the parent refused treatment for their child or had a home birth without treatment. The mother refused this treatment as well and began to rant about the evils of medicine. 

I was wondering how the doctor I was working with was going to handle this situation. She politely addressed the patient and explained that she could not accept her baby as a new patient. She explained to the mother that not being able to treat the baby with appropriate treatments would be against her philosophy as a doctor. We tried to answer any questions but our effort was futile. It was like trying to convince the leader of a cult that his/her views were slightly askew. The mother would not hear any of it and we were afraid that she would ask us to partake in her kool-aid. 

The interesting thing about the media, is that they run articles and news stories that do not have to be based on actual facts or scientific data. By doing this they create a legion of zealous followers who rally together and continue to keep the movement which is often based on false concepts, going. A perfect example is in the early 90's a movement came about when many news media sources ran articles about silicon breast implants. Their mantra were stories of how these silicone implants were causing a myriad of illnesses, from cancer to connective tissue diseases.  At the time that these stories were published there were no studies backing up their claims. Most of their claims were based on anecdotal stories told by questionable patients. These stories gathered momentum and converts were many. Eventually the momentum was enough to put many doctors out of business due to law suits they received for putting in silicone breast implants. The final death blow came as the media continued to push the issue that still had no factual studies or evidence behind them, until the manufacturer went out of business and lost millions of dollar to lawsuits. 1000's of employees lost their jobs. Many doctors started making money by removing the silicone implants and replacing them with saline. The patients thought nothing about a second surgery as they felt that it was necessary to remove the evil silicone. 

Researchers started questioning the claims of the few isolated patients and the media and began multiple studies to determine if the silicone was the evil that the media had claimed. After many years and several double blinded studies it was determined that silicone was completely safe and caused no diseases as had been claimed. Eventually the data was so overwhelming that the media sheepishly bowed out and we have not heard anymore of their false claims. The problem with this is that in the mean time we have many jobs lost, several doctors driven out of practice and 1000's of patients who underwent needless surgeries of which a small number suffered serious complications and even death all as a result of media hype.  

The vaccine issue shares many similarities to the silicone debacle. Unfortunately the media is powerful and is not held under the same scrutiny that researchers are held to, when it comes to making claims. The media can sway a nation and change the face of medicine with their claims but often these claims are not based on true scientific data.

Goals of Family Medicine

Family practice doctors pride themselves in prevention. In an ideal world they would want all of their patients to come in for annual well check up exams / physicals. At these physicals they would examine the patient and run a variety of tests depending on the patients age and risk factors. Then they would treat the patients accordingly. The idea is prevention. If a person with a family history of HTN (hypertension) comes in and starts to have a slightly elevated blood pressure, the family doctor will begin aggressive treatment to prevent complications down the road. 

Despite these lofty goals, many patients are too busy or lack the insurance to come in every year for these type of exams. So what actually happens is that when a patient gets sick and shows up at the doctor's office, the doctor will treat the acute illness but at the same time try to do a more thorough exam to determine the patient's baseline with other risk factors. 

This past week we I have been studying and learning about preventative healthcare. This is easier in children. It starts at birth when they are given their first vaccinations and then at 2 months more vaccinations and there are regular follow ups and more vaccinations at each visit until the child is almost 2 years old. Most of this is preventative medicine. Then on the opposite side the elderly are often sick and thus are consistently in the office or hospital. Much of the preventative medicine in this age group is too little to late but there are still many things that can still be done.

24/7 No rest, always working

One problem with many areas in medicine is "call". This is when the doctor is on call for patients. There  are many laws and regulations regarding call. You have to round on a patient with in 24 hours after hospitalization for non-emergent issues. There are time limits on how quickly you must respond to a call. There are mileage restriction during call. I am realizing that call takes a considerable toll the physician, especially for individual doctors. If they do not have a partner then they are on call every night. The disadvantage of having partners is that when it is your turn to take call, it will be a much busier call due to the volume of patients. 

Often the doctor never feels like he/she never really gets anytime off. Also there is so much going on during the day that many times charting and other things have to be done after seeing patients. The doctors I am working with now seem to have to work 65 hours+ when you consider all of the after hours responsibilities. Generally this is typical of many specialties. 

ER doctors are protected from this in many ways. They do not have to take call because they do not have any patients. They see the patients during their shift and then are not required to follow the patients. All of the charting is done during the shift. Many times they will stay an hour or so after a shift to complete some of their charting, but because they are paid hourly they do get paid for these extra hours. When you are off the clock, you are truly off the clock. You can actually take vacations. This is a major draw for many people to pursue emergency medicine. There are not many other areas in clinical medicine that allow for this freedom. 

Line up to have you lips plump!

This morning when I got to the clinic our first cosmetic patient was getting her lips plumped up with Restylane. It turned out that it was a nurse from the ICU who I had met while I was rotating at the ER. She had just finished her shift and was in need of fuller lips! I help the doctor with the procedure and half way through she said "Hey, Dr. J how do you think you are going to learn how to do this if you do not start practicing?" So she said I could do the lower lip. Fortunately I have seen this procedure done several times back in the clinic days. I grabbed the syringe and penetrated the vermilion border of the lower lip and filled it with the restylane collagen like substance. Then I massaged it to smooth it out. 

The patient was very nice to allow me to practice on her and she was happy with the outcome. I could see doing some of this for $$. The patients are so thankful and can't get their credit cards out fast enough. The interesting thing is that later today we had 2 patients (non-cosmetic) who were being managed for chronic conditions, 1 was diabetes that this doctor diagnosed and is now treating and the other was life saving diagnosis and now treatment for hypertension, who came in complaining about bills and refused to pay. They were convinced that they did not have to pay and they were angry and offended that the doctor had continued to bill them and that their insurance had not paid for the entire amount of the charges. It came down to the fact that their insurance paid 80% of the discounted fee and the patients were responsible for the remaining 20% of the discounted fee. Neither of them wanted to pay and ultimately may refuse to ever pay. 

I just find it interesting that when a doctor makes a diagnosis for a patient and then provides life saving treatment, the patients sometimes refuse to pay and bitch and moan about how they have been ripped off. On the opposite end of the spectrum, the doctor plumps up a patients lips and she is overwhelmingly happy and pays right away, often prior to the procedure and follows up with thank you letters and christmas cards etc. The medical patients are mad at the doctor and may even change doctors believing that they got a raw deal while the cosmetic patient tells all her family and friends how great the doctor is and names one of her children after the doctor. What the hell is wrong with society? No wonder so many doctors are moving to a more cosmetic practice.

Family Practice and cosmetic procedures?

Tomorrow is the cosmetic day in the office. You may be asking yourselves why would family practice doctors have a cosmetic day? They are not plastic surgeons. The short answer = money. Family doctors are finding it harder and harder to pay the bills as reimbursement continues to go down. To stay in business many have branched in to the cash business of cosmetic medicine. This includes; laser rejuvenation or photo facials, laser hair removal, Botox, Restylan injections and microdermabrasion. These are all entry level type of cosmetic procedures that can generate extra income if done properly. Many of these primary care physicians can get themselves in trouble if they are not careful. They can buy a bunch of expensive lasers and other equipment only to find out that they do not have enough cosmetic patients to pay for the equipment. They underestimate the marketing and business skills required to run a successful cosmetic business. I will have to see how the day goes tomorrow. The good news is that when I had my clinic we also did the cosmetic procedures so I have some experience and may even be able to help out a little. 

Family Medicine 1st couple of days

2 days down and many more to go. This is not the Emergency Medicine. It is obviously a totally different feel. I do not want to say boring, but I find the pace quite slow. We basically see 2 patients / hour. The patient's illnesses are much more benign than the ER as well. 

Here is my schedule:

Monday: 8:00am - 7:00pm

Tuesday: 8:00am - 7:00pm

Wednesday: 12:00 - 7:00pm

Thursday: 8:00am - 7:00pm

Friday: 8:00am - 7:00pm

Saturday: 9:00am - 2:00pm

Sunday: off 

What kind of patients does a family practice doctor see? The group I am working with will see mostly kids on Mondays. These will be school physicals, well baby check ups, vaccinations, sick kids. The sick kids mostly have mild things that the parents are worried about, so far I have seen a handful of allergic reactions presenting with urticaria (hives), pink eye, sinusitis, pneumonia, pharyngitis, pulled muscles, constipation, diarrhea, asthma, headache, menstrual cramps. When I was growing up these were all things that you did not even bring up as "illness" so it is interesting to see these things from the doctors point of view. On one hand the doctors do not want to discourage this, because this is what pays their mortgage but on the other hand they almost feel guilty because in 80% of the cases all they are really doing is reassuring the parent and explaining that most likely the illness is due to a virus. However many of the parents will not shut up until they get an antibiotic and even the ones who don't beg for antibiotics do not feel like the doctor did anything unless they get some kind of medicine. Unfortunately, there is a lot of inappropriate antibiotics being thrown around. The doctor I was working with today told me that when she does not give an antibiotic she can plan on a ton of calls over the next few days and often the parent will come back in claiming the child is sick but when she gives an antibiotic she will not get the worried phone calls at all hours of the night and the parents are very grateful and refer their friends. They feel their child was healed by the doctor even though 9 out of 10 times the illness was viral in nature and had to run its course. It is a tricky juggling act. 

Then on tuesdays the doctors see adults. These are travel vaccinations, annual physicals, blood draws to check labs for management of chronic conditions like hyperlipidemia, diabetes, hypothyroidism. Today I saw adults suffering from, diabetes, diarrhea, constipation, hyperlipidemia, genital warts, annual paps, breast exams, asthma management, depression / anxiety, congestive heart failure. In the afternoon we went to a nearby nursing home to see 12+ nursing home patients of the doctors. This was an assisted living center so most of the patients were ambulatory and fairly healthy. We followed up on previous medications, renewed prescriptions, check labs and adjusted meds accordingly, and did some basic check ups. 

At the nursing home we had this couple; she was 93 and he was 95. She was plagued with many of the illnesses we see in the elderly like diabetes, congestive heart failure, neuropathy, arthritis etc. She was on about 12 different medications to keep her alive. He was a hilarious old man with nothing wrong. He said "doctor can you tell my wife that she needs to quit acting all sick and broken and just toughen up like me!" Then he explained that he has never been on any medication and has never really been sick except for one case on pneumonia that he caught while in the doctors office for a physical. I asked him what his secret was and he said in all seriousness that since the age of 10 he has been drinking a glass of red wine at 4:00 in the afternoon and a drink of brandy with vermouth at 7:00 pm. He said that is all the medicine he needs. Now he calls his 72 year old son and his 70 year old son everyday at 4:00 and 7:00 and they all drink their "medicine" together over the phone. I told him that it was obviously working and to keep up the good work. His wife rolled her eyes at her husband and said to him "don't you think you can over do it sometimes?" and he laughed and said he was too old to change, she smiled and said "you have been saying that for 75 damn years!". It was a great exchange. I hope I am that healthy at 95!

Family Medicine vs General Practice (GP)

What is family medicine? There is a large misconception about family medicine and general practice. To legally practice medicine in the USA one must finish 4 years of medical school and pass all the board exams and the complete at least 1 year of residency, which is called the intern year. Many moons ago some doctors would stop their training after their intern year and open up shop. The physicians were called general practice doctors. (GP's) However in today's world some insurance companies will not pay services provided by GP's. Also most patients want their doctor to have more training. 

So in the 1960's based on the idea of general medicine but with better training the family medicine specialty was born. The residency is 3 years of training after medical school. These doctors see patients from cradle to grave. They see it all and generally have a broad spectrum of medicine that they practice. In some rural areas the family medicine doctor is all they have and he/she will deliver babies, do pediatrics, adult medicine, geriatric medicine, etc. So the family medicine doctor is the new form of general practice doctor.

These doctor see the most amount of patients in the USA. They make up a large portion of the primary care market. They are trained in pediatrics and OB to a certain degree. In your average suburb these doctors will see entire families and take care of most of their medical needs. THey will refer out to specialists when an illness needs specialty care. For example, a family practice doctor may diagnose a patient with diabetes and start therapy and continue to manage their therapy for the majority of the patient's life. If the diabetes develops to end stage disease when certain therapies may be necessary the family doctor would then refer the patient to a specialist like an endocrinologist or a nephrologist depending on the therapy needed. 

Also family medicine doctors can continue their training after their 3 years and sub specialize in a few different areas like, sports medicine, or women's health, etc. 

This weekend I have been studying and preparing for my family medicine rotation. I have to read over a broad spectrum of cases because as a family practice doctor you can pretty much see anything in a given day. So I have been brushing up on all the basics. I will see diabetes, well baby check ups, vaccinations, school physicals, some dermatology, UTI's, pneumonia, GERD and other GI issues, headaches, hyperlipidemia and basically all other ailments. This should be an interesting rotation. 

ER Final

Today I got the highest score on the exam! That is cool. In order to get an A on the final exam you need to score 0.25 standard deviations above the mean. There were 100 questions on the exam and I answered 84 correct. The mean was 75 with a standard deviation of 6. Which means if you scored a 76.5 or higher you would qualify for an A. 

The way these rotations are graded is there are 6 categories that your clinical skills are graded. These include: 1.) knowledge 2.) Patient care 3.) Professionalism 4.) Life long learning 5.) Up to date clinical practice skills 6.) Communication. The physicians you work with basically rate you on these 6 core skills. The ratings are Outstanding, Good, Adequate, Inadequate. The other grade components = assignments and projects and the final exam. In order to get an A in a rotation you have a couple of different ways to do it. Firstly, if you get 0.25 standard deviation above the national mean for the exam (all 3rd year medical students take these exams) and 3 of the 6 core skills are outstanding and only 1 core skill adequate then you get an A for the rotation. The other way to get an A is to score the mean on the national exam and get 4 of the 6 clinical skills marked as outstanding and only 1 core skill can be adequate, then you will also qualify for the A. It is set up this way to help people who are better at exams and help those who are better at clinical skills. 

Why are these grades so important? Well in order to get into competitive residencies and competitive fields of medicine you have to compete against all the US medical students. Residencies look at many aspects of the applicants. The major factors include: 1st and 2nd year grades in the basic science courses, 3rd year clinical grades, the 1st and 2nd USMLE scores (board exams), and your 4th year elective rotation grades, letters of recommendation, research publications, Dean's letter and other letters of recommendation. There are other things as well and there are several theories about which of these things are considered most important for being a competitive applicant. The current thinking by many is that the 1st USMLE board exam score, and your 3rd year clinical rotation grades are the most important but I am sure it varies at each program. 

It seems like since the day you decide you want to go to medical school until the day you get your first job as a doctor you have tests and different requirements looming in the near future. There is an underlying stress throughout the entire process. It all starts with doing well in college and then doing exceptionally well on the MCAT. 

At my medical school there were about 10,000 applicants for roughly 150 spots. They offer about 500 acceptances to fill the 150 spots. This is about the same at all the other US medical schools. I feel lucky to even have the opportunity to study medicine. I got lucky and blessed to even get in. Many who are more qualified do not get accepted and have to do something else, go to a DO school (slightly less competitive than the MD schools) or go to a school in a different country (Caribbean medical schools). 

Then once you are accepted the exams and keep coming and never seem to stop. It is constant and unrelenting. At least I find it fun and exciting which makes it well worth it.