The expansion of happiness.

"It is neither wealth nor splendor, but tranquillity and occupation, which give happiness." ~ Thomas Jefferson

Learn from yesterday...

...live for today, hope for tomorrow. The important thing is not to stop questioning. -Albert Einstein

Family Medicine in Greenbrae with flash gordon m.d.

The picture above, of Mount Tam, is essentially the view I had from the doctor's office for the last three weeks. I had the pleasure of rotating with flash gordon, md, yes- that is his name, and yes, he uses no capital letters :)

Dr. gordon is filled to the brim with knowledge and wisdom... he has so much of it that it just comes out at all times in the form of advice, quotes, old adages, and funny sayings. He was an emergency physician for many years and he also was the director of the haight-ashbury free clinic. In addition to being a physician, he is also a writer. I believe his experience with writing makes him the ideal teacher- he has spent years figuring out how to reach his audience and help them understand the way the body works in the easiest way possible. For someone new to the health profession, it can be very hard to keep it down to less than three syllable words when you are trying to explain processes of the body, medication uses and side effects, and treatment plans. After three weeks in Greenbrae with flash gordon, md, I am most certainly a better teacher, and do not use more than 2 syllable words most of the time ;)

For those of you interested in completing a FM rotation in beautiful Greenbrae, with an amazing preceptor and awesome, friendly office staff, you can request this for 3rd or 4th year electives. For more info about him visit: http://www.docflash.com/

Dr. gordon really made me feel like I contributed a great deal to his daily practice. He always introduced me by saying how happy he was that I was there, and that I have a wealth of knowledge about how the body works with my osteopathic training. He let me counsel patients on their posture and how to correct it. I found myself diagnosing upper crossed syndrome and lower crossed syndrome non-stop, and taught patients exercises to treat it. I also helped several people with TMJ, by inhibiting their pterygoid muscles with an intra-oral technique, releasing their SBS compressions and other related strains, and then teaching them conditioning exercises for their jaw muscles. Many of these people had only been offered extremely expensive mouth guards previously. Yesterday a woman in her late 80's came in with back pain and all it took was very gentile myofascial release of her bilaterally extended sacrum to fix it- she almost seemed like a new person when I was done!

I have not been able to practice my OMT skills this thoroughly on every rotation. For instance, on internal medicine, I stuck to a few techniques that were hospital-bed friendly and left it at that. My confidence and faith in my abilities is renewed whenever I am able to practice this much. I am thrilled about how helpful these techniques have been for patients and I really have my amazing professors at Touro-CA and my peers with whom I practiced during these three years to thank for it. Dr. gordon wants me to return after my audition rotations to hold an OMT clinic for his patients once per week or so. I am going to try to make this work!

As I embark on audition rotations in less than one month, my goal is to find the program into which I fit like a puzzle piece. I want to complete my residency where there is a supportive environment and encouragement for me to pursue the unique modalities of medicine that I am interested in. I hope to find a place that is supportive of my passion for preventive medicine, neuromusculoskeletal medicine, osteopathic manipulative medicine, and my desire to help patients improve their quality of life/functionality.

It is with the conclusion of this post that I announce my completion of third year! If you want to know what I have in store for this next year, the blog post before this one has a little summary at the bottom. Here's to having 3 weeks left in the bay area before I uproot myself for Summer and Fall.

I am officially a fourth year medical student and will be a physician in less than one year. Oh. My. Goodness!!!

Internal Medicine @ DMC, San Pablo

Internal medicine at DMC was such an incredible experience. The last 8 weeks were jam packed with journal clubs, lectures, EKG sessions, presentations, rounds, and tons of time to spend with patients. I definitely learned more on this rotation than I have on any of the others simply because of Dr. Afsari's mentorship. He has so much respect for his patients, and his bedside manner is flawless no matter what kind of patient he is working with. He has a special knack for calming people down and really focuses on reducing suffering and improving quality of life. There is a reason he has received a national teaching award, and I am blessed and honored to have had the chance to learn from him and his colleagues.

But perhaps the most valuable lesson from this rotation is something that I realized on my own, and it pertains to what my role is as a medical student. Right now, I have the time to sit down with my patients and explain what is going on until they fully understand it. I have the time to research resources in the local community and make sure they obtain the connections they need to maintain their progress. I have the time, as a 3rd and soon, 4th year medical student. I may be exhausted, but I have the time. Being the patient advocate has always been a goal of mine, but during the first part of third year, I really had to focus more on how to get by in the various hospitals and clinics in which I rotated. Now I finally feel like I am used to all of the change and perpetual process of starting each month anew. I can really focus more on each individual patient on my service, and I am very happy to give all my patients the attention they need and deserve.

And thank goodness for getting used to change, because in a couple of months I will really need to get my butt into gear. Right now it looks like I will be doing the following (all subject to dramatic changes): After my last third year rotation at the Touro Clinic, I'll have my anesthesiology rotation, take my boards step2, and go to the SOMA leadership conference in Chicago. Then audition rotations start and I jump around like this: Washington -> Michigan -> California -> Florida ->Pennsylvania -> New York ->Everywhere for interviews (hopefully all in November... yeah, right, like that will work out!) I think that as crazy as this schedule is, it will be worth it. My ultimate goal is to find the perfect program for me and if I have to search the country for it, then so be it!

All of the major traveling takes place between July-December. That means I'll have 6 months until my wedding when I return to the bay area to finish up my rotations. So in addition to traveling for all of this, I need to apply for residency, and I need to find time to plan my wedding and maintain my other commitments while doing all of that. One-day-at-a-time. Luckily I have the love and support from Walter, my family, and friends. Just banking on the ability to have Walter join me during my travels whenever possible. I am going to be sure to breathe a humongous sigh of relief this December when I'm finished running around. Until then, wish me luck!

Brookside Family Medicine

After finishing the first 4 weeks of my Family Medicine rotations for 3rd year, I have taken home an extremely important lesson. Your patients will reflect to you the respect and responsibility you give them. I had the pleasure of shadowing Dr. Mahoney all day Friday, and I could see that his patients were extremely respectful to the MA's and to him. They were happy to be there, they brought their medications, their blood sugar charts, and had honest life-style changes to report to him. Every time Dr. Mahoney entered the room, he immediately sat down to see eye-to-eye with the patients, asked about their personal lives, checked in about their families, etc. He also took time to teach them and explain his thought process regarding their health and care. He ran 10-15 min late with every patient so he had to catch up during lunch, but people were understanding and never angry at him for this. Most of his patients are doing very well and making such amazing progress.

I'll contrast this to another physician at Brookside, who spends more time at his desk than with the patient, and as a result never runs late, but also has patients that don't seem to care about their health, have an attitude of entitlement and get angry very quickly if they don't get what they want. After working with this physician, I went home and literally cried. I felt like my whole world had been turned upside-down- I was supposed to love Family Medicine but I felt like completely eliminating it from my list after spending time on that side of the clinic. Yet after a couple of days with Dr. Mahoney, and after talking to him about this phenomenon, I realize that patient behavior is largely physician-dependent. No matter what field I decide to enter, this rule will apply.

Brookside is a community clinic next to Doctor's Medical Center, San Pablo. The patients are mainly insured by Contra Costa County/ Medi-Cal, although the clinic does have protocol for seeing uninsured patients and immigrants. This week they began the extremely difficult task of switching from paper records to electronic medical records, which will be necessary for almost all clinics in the future. My last day was Friday and they had not yet started using the EMR in the rooms with patients, but I am sure they are in for a bit of a rocky transition. There was a lot of stress and frustration regarding the training sessions from the MA's and Physicians. For this reason, I don't think it would be very helpful for me to talk about what my daily schedule was like for any 2nd year or 1st year readers- it will most definitely be different by the time you rotate through.

One thing that will remain the same is the primarily Spanish-speaking population, so if you have a good grasp on your Spanish skills, you'll thrive! If you are still working on it, like me, people are happy to help you learn. I have been working through Rosetta Stone, but its helping only a fraction as much as actually spending time with Spanish-speaking patients. I really hope I have time to do a traveling rotation at the end of my 4th year so I can immerse myself in a new culture and be forced to use my Spanish 24/7.

In other news, I am still on the fence about Family Medicine v. PM&R, although in recent weeks I have leaned more in the direction of Family Medicine. On the personality assessments, PM&R keeps coming up for me ahead of Family Medicine, but not by much. When I take time to deliberate over the pros and cons, I usually end up thinking I should do Family Medicine. I think its hard for me to decide because I could probably end up loving what I do no matter which path I take. There are a few things I know for sure:

1) I love OMT, and must be able to use it in residency and subsequently in my practice.
2) Similar to #1, I have a special interest in Neuro and Musculoskeletal systems. This interest is apparent to my preceptors and I notice that they tend to call me in with them to evaluate complaints related to these systems.
3) I want to be the kind of physician who can give my patients the time they need, and I also want to eventually have time to be a good wife, mom, relative, friend, and to take care of myself. To me this is the definition of living a meaningful life.

I picked TUCOM-CA for medical school because it was a direct and solid fit for me, and I am sincerely hoping I can find a way to do that for residency. There is so much anxiety for me about this right now because I am in the middle of trying to schedule my audition rotations. Hopefully the remaining ones will be scheduled with ease and at the right programs for me.

In other news, my parents are coming to visit this weekend! And I don't think I posted about this yet, but we found a wedding venue we like! Unfortunately we pass the # of guests we can afford with just family alone, so I don't know how we're going to handle the guest list. Lets just think about that one later, shall we? haha.

Psychiatry at the Mental Health Services of San Joaquin County, Stockton

Today was the last day of my psychiatry rotation at the Mental Health Services of San Joaquin County, and I am genuinely going to miss this rotation. The staff and psychiatrists on site were so kind to me, the patients were extremely interesting, and the days were very short-getting home by about 3pm on average! Really the only downside to this rotation was the commute- from Benicia to Stockton its a good 1 hour and 30 min. Interestingly, driving 3 hours per day really started to wear on my bones and joints. I have a whole new appreciation for what truck drivers have to endure on a daily basis.

My preceptor was Dr. Silver, who has spent years treating patients at this psychiatric health facility (PHF). Dr. Silver was actually there even before all of the state hospitals closed in 1982. Rotating at the PHF, I was able to see how integral this kind of facility is for ensuring the health and safety of many individuals. What is upsetting is that in order for the county to be adequately paid for providing these services, they need to convert one of their units to a 23 hour facility. I can't think of many patients I saw in the PHF whom would have been ok to go home in less than 24 hours. It often takes a few days to get the meds right and to even get the entire story regarding the patients psychiatric health history. Even patients who are not psychotic but simply depressed should technically be in the facility for long enough to make sure the anti-depressants they are placed on are working. The general trend right now is that psychiatry is becoming a mainly out-patient-based field, mostly due to insurance reimbursement issues and lack of state/federal funding. We're experiencing what is called a "revolving-door phenomenon," where patients are sent on their way with meds, can't continue to take them for a variety of reasons sometimes specific to their disorder and sometimes just specific to having a disability, so they decompensate and wind up back in the facility, if they are lucky enough to be brought to a PHF. Some of the patients decompensate so badly that they wind up in prison. 20% of the 2 million Americans who are currently incarcerated have mental health issues. Think closing the state hospitals was a good idea now? I could go on and on about this, but I am stepping off my soap box...

At the PHF, patients come in with an extensive history of psychiatric problems, and Dr. Silver is always so open to re-examining the differential diagnosis. The list is always extremely long and its very hard to tell what specific disorder a patient has- many times because there are several things going on at once. We saw the term "Psychotic disorder NOS" (not otherwise specified) and "personality disorder NOS" were some of the more common diagnoses entered into Axis I and II respectively by crisis workers. About 70% of the patients at PHF fall into the psychotic category- people with schizophrenia, schizoaffective disorder, bipolar, bipolar with psychotic symptoms. 10% were depressed/suicidality/danger to others, and the other 10% were composed of patients with various diagnoses- some of them were just very hard to pinpoint. We had one patient who had been diagnosed with postpartum psychosis and two patients who claimed they had dissociative identity disorder (formerly known as multiple personality disorder) although I honestly think neither of them had it.

Another truly interesting experience was listening to the patients. I loved hearing them talk, looking for thought disorders, faulty logic, appropriate responsiveness to cues, etc. We had quite a few patients with flight of ideas, word salad, some who made up words, some who spoke in rhymes, and some that repeated what we said only.

I felt more safe on this rotation than I have on many other rotations, simply because there were always support staff around us during rounds and keeping watch in the wards. Brad and I went to the San Joaquin County Jail today to tour the facility and we felt very safe there as well. I felt much less safe on ortho surg with Dr. Welborn when we went to the 7th floor of DMC to see the prisoners- we would have them take off the cuffs in order to examine them at times- scary when you think about how unpredictable they can be. Bottom line is never to find yourself in a room alone with a patient when you have ANY reservations about the situation. One other thought related to the prisons- just remind me to commit a crime the next time I break a bone so that I can go to jail and get the fabulous, free health care that prisoners get- paid for by all of you lovely tax payers. We criminals appreciate all you do for us ;)

Next week I start my family medicine rotation at Brookside, which is right across from DMC in San Pablo. I am stoked to finally participate in my FM and internal medicine rotations. Kind of backwards if you ask me- I would have benefited greatly from having all of the nitty gritty medicine stuff first. Guess its also nice to have it right before I take step 2. If you are reading this as a 1st or 2nd year from Touro and you are trying to decide whether to have a psychation or a real psych rotation, I will just say this- you can't escape psych! Especially if you are considering primary care, I would not skimp on your psych rotation one bit. Thanks for reading!

Student D.O. of the Year!

Tonight I received an E-mail from the TUCOM President that made my jaw drop and hit the floor. I am the 2011 TUCOM Student D.O. of the Year! It is still sinking in... wow!

I just want to thank friends and family for your warm messages! I am so humbled by this honor, and as I have said to a few of you already, I feel like Student D.O. of the Year is really more of a reflection of the Touro - CA Community. I have been able to acquire knowledge and wisdom from the best- and you all have helped me learn more than I ever thought I would in just 2.5 years of med school thus far! What an incredible journey it has been and I am so excited for what lies ahead!

The SDOY application consisted a CV/ list of achievements, and an essay response. My response to last year's question can be found in the blog under Feb 2010, I think. For those who are curious, I have pasted my response to this year's prompt below (word limit was much shorter than last year):

"Recent analysis from the Centers for Disease Control and Prevention reveals that if current trends continue, as many as 1 in 3 adults in the United States could have Type II Diabetes by the year 20501. What measures will you take to help prevent this outcome among your patients?

Source:
1. Centers for Disease Control and Prevention. (2010, October 22). Number of Americans with diabetes expected to double or triple by 2050 [press release]. Retrieved from http://www.cdc.gov/media/pressrel/2010/r101022.html."

In 2010, it was estimated that 285 million people had diabetes, and predictions by the International Diabetes Association indicate that this number will increase to 438 million by 2030. Decreasing the incidence and prevalence of diabetes will take a major effort to remove the barriers to prevention, which are largely cultural, social, economic, psychological, and educational. As a future physician, I should play a major role in this effort by developing competency in diabetes prevention and management, and influencing the removal of barriers to behavioral change.

According to the National Institute of Health, those at high risk of developing diabetes who can implement dietary changes, develop healthy coping skills, participate in support groups, set goals like losing 5-7% of their body weight, and get at least 150 minutes of moderate physical activity per week will decrease diabetes risk by 58%. In my practice, I will encourage patients to take responsibility for their health and motivate them to implement these habits and goals. Studies by Prochaska & DiClemente (1986) have shown that a technique called motivational interviewing can help physicians identify the level of intervention appropriate for patients’ levels willingness to make changes in their lives. According to this research, by focusing on my patients’ level of readiness to make lifestyle changes, I can create individualized diabetes prevention and management recommendations for my patients. Believing in my patients’ ability to become healthy, I can open the door for them to carry out a self-motivated program of lifestyle changes that can reduce their risk for diabetes and even reduce diabetes-related complications in those who already have the disease. Once patients start to implement their diabetes prevention lifestyle changes, I will encourage them to become health mentors for their families. A community effort would help make leading a healthy lifestyle part of the norm, which would alleviate some of the societal psychological barriers to healthy living.

My colleagues and I can also help decrease the incidence of diabetes by leading the effort in designing and implementing community programs directed at increasing physical activity, healthy eating, and health literacy. According to studies by Thompson (1995) and Pate (2003), more than fifty percent of all US adults do not get the recommended amount of exercise needed per week to reduce diabetes risk, and two-thirds of all adults in the US have BMI’s of over twenty-five, which means that most people are overweight. This statistic points to the need for programs aimed at reducing diabetes in the overweight and obese population, focusing on diet and exercise. The National Diabetes Prevention Program, which launched in April 2010, is helping communities plan and execute workshops and educational events directed at diabetes prevention through life-style changes in this population. Another program, called Passport to health, works with families on managing their weight and preventing obesity-related health problems. Physicians should advocate to have these programs and other national health awareness tools shared with their communities.

One of the best ways to get the community together in a collective effort towards health and prevention is to promote the development and use of community centers. These facilities provide space for workshops, support groups, mobile health clinics, communal kitchens, and local gardening space. My colleagues and I should advocate for the creation of supportive facilities that successfully promote preventive health practices within our patient population. We should recruit students and professionals from the health care field to volunteer at these facilities by running workshops and free health clinics. The goal in this effort should be to teach clients about health maintenance and connect them with local resources.

If we focus on the effort to overcome barriers to diabetes prevention within our communities and ourselves, we can successfully reduce the prevalence of diabetes in the US population. I believe I can help decrease the incidence of diabetes by helping patients realize their unique role in the greater health of the community, and I can reinforce their health through education and preventative action. Most importantly, I must live a healthy life style and lead by example, encouraging patients to personify the words of Mahatma Gandhi, to “Be the change you wish to see in the world.”

Physical Medicine and Rehabilitation in SF City

Yesterday I finished my two-week elective rotation in physical medicine and rehabilitation. Physicians who are board certified in PM&R have completed a four year residency. Post-Grad Year 1 (PGY1) is a traditional rotating/FP intern/IM intern year, and then PGY2-4 is PM&R. Most of these docs go on to complete a fellowship in their area of interest- sports med, pain med, spinal cord injury, brain injury, neuromuscular medicine, etc. In this field it is easy to become inspired by motivated patients who work hard to overcome or adapt to their disabilities. According to an attending who responded to a post of mine on SDN, doing this kind of work, "requires practicality, rationality, resourcefulness, creativity, motivation, and inspiration."

I shadowed Dr. Lewis at St. Luke's in SF City these last two weeks. He focuses on outpatient pain management, medico-legal consults and QME's for worker's comp, EMG's, and rehabilitation following orthopedic surgery (he is in the same office as Dr. Akin, the orthopedic surgeon whom many kids from Touro and UCSF rotate with as a part of our surgery requirement).

Dr. Lewis seemed to be swimming in the legal paperwork, but despite the stress from that he would make his patients feel like he had all the time in the world for them. While in the exam room with Dr. Lewis and his PA Jim Buck, I assisted with corticosteroid injections (decreasing joint inflammation), hyaluronic acid injections (lubrication for the integrity of collagen and elastin), and Electromyography and Nerve Conduction Tests. For a little over half of his patients, I would go in and start the appointment- taking H&P's and really solidifying my ortho exam skills. I usually managed to slip in a little osteopathic manipulative treatment (OMT) accidentally ;)

After the appointments, I would get on the electronic medical records and do the charting/dictation. Its amazing how much time this takes, even with the use of templates. Dr. Lewis told me that one of his colleages has a free day each week, but she uses it to go to the office just to finish the notes for her patients and complete unfinished paperwork. There has to be a more efficient way of charting than that- it may mean staying in the office until 6-7pm at night, though. As an example, I completed the dictation for a woman whom we wanted to receive a motor scooter from medicare and it came back the next day with a list of 19 things we needed to put into the dictation in order for her to qualify. Apparently people were receiving free scooters from medicare and selling them, so medicare made the qualifications more stringent. The total amount of time I spent on that note was about 1.5 hours inserting all of the requirements, when these notes should normally take 15 minutes. Really an interesting sneak preview of one of the downsides to medicine these days- jumping through hoops and getting over the red tape dealing with loads of paperwork. Not even a specialty like Ortho Surg is free of this burden, but from what I hear, family practice (FP) has the largest burden in this regard.

Completing my PM&R rotation and reading about the specialty has really turned my world upside-down. I applied to medical school with the intention of going into primary care, FP to be exact. I think the reason I am attracted to PM&R is because it is very much like family medicine in the continuity of care aspect (in outpatient settings), but it also emphasizes musculoskeletal/neuro. I can see myself being able to perform OMT and manage patients on a long term basis in both specialties. During the last week or so I have been making sure that I get my audition rotation applications out to our clinical education department for the FP/OMT residencies, while simultaneously weighing the differences between FP/OMT, Integrated FP/NMM, and PM&R. Here is what I have come up with:

A) It is clear that I like the neuromusculoskeletal aspect of these specialties and I want OMT to be a regular part of my daily practice. I would be able to do this with both.

B) It appears that PM&R is potentially a longer residency, but with better hours, much less call, and better pay. As a PM&R doc, there would also be no call. This is because by definition, patients ready for rehab in the hospital are no longer acute.

C) The work in PM&R may not be quite as diverse as FP, where you would maybe treat a 75 year old man with an acute gouty flare up/ diabetes neuropathy/ congestive heart failure, a pregnant woman with back pain, and a newborn with a cold all in the same day. That is part of what makes PM&R appealing to some, though, because many do want to become an expert in their chosen field and have that be what they deal with every day. I can picture myself working with chronic pain patients- treating them with OMT, complemetary alternative therapies, and other necessary medical interventions- but then again, the chronic pain population means dealing with more drug-seeking behavior, and possibly dealing with the fact that many of your patients don't seem to get better (you get them after most preventive methods would have helped).

D) I do not want to eliminate the possibility of treating newborn babies, and the only exposure to children I would get in PM&R are children who have already been diagnosed with cerebral palsy, muscular dystrophy, etc- very sad cases. They would also benefit from some forms of OMT, but I think for my own sanity and the feeling of having patients who actually get better, FP may be the way to go. Or, do I want to go into PM&R and potentially do some efficacy research regarding these patients and OMT?

E) There is extreme need for primary care docs, and with Obama care we're hopefully headed in the direction of more emphasis on prevention. Although who knows- if he isn't re-elected in 2012, everything may be turned upside-down again. Bottom line is that reimbursement is not going to be even in my top 10 list of priorities when I am deciding between these specialties.

So as you can see, I flip-flop on these thoughts quite a bit, and unfortunately it is quite distracting. Since this is about the time I should be narrowing it down, its scary to be considering these things almost equally.

In other news, though, I start my psychiatry rotation on Monday! Four weeks commuting to Stockton, although I have heard the drive isn't bad because its against traffic and he lets students out around noon on some days, so I would actually be home much before I would if I were rotating anywhere else. After these next four weeks, I start FP at brookside (finally!) It is amazing that I have considered FP for so long and have not even completed my core rotation in it! Anyway, sorry for the longer blog, but hopefully it has helped some of you who are also considering these specialties.

Cardiology Elective @ DMC - 2 weeks

On Friday I finished my 2 week cardiology elective at Doctor's San Pablo. I had such an incredible time rotating with Dr. Weiland- he is probably one of the best in this field. To give you an idea of how cool it was, the very last thing we did in my 2 weeks rotating there was watch Dr. Weiland do a thrombectomy and angioplasty on a man who just had a STEMI at the gym 40 minutes prior. STEMI= ST Elevated myocardial infarction (heart attack). I glanced at the ECG in the emergency room, which showed the most classical anterior MI with ST elevations in leads V1-V6 and AVL, with reciprocal ST depression in the inferior leads. On the cath monitor we could see that the LAD (left anterior descending artery) was 100% occluded when he started, with mild disease in other coronary arteries. When Dr. Weiland was done, we could see on the monitor that the blood flow had been restored completely. After the procedure, Dr. Weiland asked the patient, "Do you have chest pain?" and the patient responded, "What chest pain?" I would say that is a job well done :)

On this rotation, I did get to actively assist with patient care. One of the coolest opportunities I had was to shock a patient back into sinus rhythm. The staff makes sure the patient is sufficiently sedated and you set the biphasic system to the amount of joules you want, clear the area, charge the defibrillator, and press shock- pretty simple. The patient is jolted awake and sinus rhythm is the desired result.

For those of you considering doing cardiology at DMC with Dr. Weiland (which I highly recommend), read on. On the cardiology service at DMC you see on inpatients during the morning, write SOAP notes, and then gather for rounds with Dr. Weiland around 8:30am. During the course of the day you see inpatients on all floors, in all departments. He is constantly getting phone calls and needing to be in 3 places at once, but he balances all of this very well and stays very grounded- its a great example for people who may want to go into a specialty where their services will be in high demand. You also visit the clinic to see outpatients in the afternoon sometimes. Weekends are free, but plan on being in the hospital until 6:30pm or so each night, wear comfortable shoes, and bring snacks because you go long periods without being able to have a meal. You will see lots of great pathology at DMC and you will be able to learn about cardiovascular disease prevention, management, and rehabilitation.

Bottom line, 2 weeks is just NOT ENOUGH TIME for a cardiology rotation. I don't even think 4 weeks is enough. I'll just have to try to get much more exposure to cardiovascular disease management during my FP and IM rotations this year. During 3rd year we don't have much time for electives. I used my vacation to study for boards, did a 4 week OMM elective, so the only choice I had was to split up with month into 2 electives. On Tuesday I start PM&R with Dr. Lewis in San Francisco. I heard he mostly does outpatient care with an emphasis on musculoskeletal rehabilitation. Should be very interesting! Stay tuned for a report on that in a couple of weeks ;)

Orthopedic Surgery @ DMC

As a famous orthopedic surgeon once said, "If you can't pin it or cast it- then screw it." Just finished ortho surg, and I have to say that I had a tremendous amount of fun. If you are assigned to Dr. Welborn, you not only get to see him in action, but the other surgeons at DMC also reach out to you, teach you surgery, knots, and have you first assist on cases. During the course of this rotation I experienced several awesome things, a few of which I'll mention here:

1. First assisting Dr. Lyon during an ORIF of the femur in a space suit X2. Really a sterilization technique that is expensive and more for protection of the surgeon than the patient, but fun to do. On those cases, Dr. Lyon had me create the spaces for the screws and screw in the plate. He taught me the two-handed knot and I am finally good enough at it to help the surgeon close up without taking too much time.

2. First assisting Dr. Barry with a rodding of the femur in a diabetic patient. This was extremely nerve wracking for me, but mostly for Dr. Barry and the OR staff. Luckily their competence and care for the patient always prevails. I think I was exposed to more than a minute of X-rays during that surgery unfortunately but I was wearing a lead suit so I hope that helped.

3. Working with the lovely OR staff @ DMC! So hilarious, laid back, but of course strict about sterilization procedures, etc. What a fun-loving environment. Only one thing though- if you have seen this in my facebook status I'm sorry to repeat it here, but if I had to listen to "Like a G6" one more time while I was trying to concentrate on assisting, I would have had to personally go out and steal one for the anesthesiologist so he would stop playing the song. And I am not even sure if having one would make him stop playing that song. Geez.

Overall, I learned tons from the orthopods I shadowed, I enjoyed spending time with patients at clinic, and I'm super happy that I get to experience several other rotations at DMC. It feels great to have such a short commute and to be able to rotate in an environment that is so conducive to learning.

And of course, I didn't want to leave out my favorite jokes about orthopedic surgeons (and no one loves these jokes more than the surgeons themselves):

What do you call 2 orthopedic doctors reading an EKG?
A double blind study!

Patient: Doctor, Doctor, I broke my arm in two places!
Doctor: Stay out of those places!

Q. What is the difference between God and an orthopedic surgeon
A. God doesn’t think he is an orthopedic surgeon.

I know, how lame! I guess when you're mentally and physically exhausted, and slightly delirious, these jokes can make you crack up for minutes. Or maybe that's just me? :)

Actually I am no where near as exhausted as was when I had my peds and OB/Gyn rotations, but every rotation has been different, fun, and incredibly rewarding thus far. Tomorrow I start my 2wk cardiology rotation @ DMC and I'll finish up January with a PM&R rotation in SF City.

This year is going to be exciting and challenging. I have a number of personal goals regarding my health and fitness that I have been working on and hope to make more progress in the coming months. I also have Step 2 of my boards, audition rotations, residency applications, interviews, and a wedding to plan! Here's to a healthy, smooth, and productive 2011!