The Food Revolution - Michael Pollan

Michael Pollan is the Author of the Omnivores Dilemma. I have just listened to his talk from the 2015 Food Revolution Summit. My notes from this talk are pasted below.

He has recently submitted an opinion article to the Washington Post called "How a National Food Policy Save Millions of Lives" (http://www.washingtonpost.com/opinions/how-a-national-food-policy-could-save-millions-of-american-lives/2014/11/07/89c55e16-637f-11e4-836c-83bc4f26eb67_story.html) - this article has actually turned into an initiative/campaign to encourage the government to develop a national food policy. We don't have a national food policy. We have an agricultural policy. Other countries have a food policy. Food system in a country should keep people well fed and healthy. These objectives need to align with agricultural policies. Right now agricultural policies focus on production of large quantities of cheap, nutrient-poor, and quality-poor food.

The government has been subsidizing a fast food diet with their current policies. We are not regulating agricultural companies to handle the air pollution and waste they produce.

The government is underwriting type 2 diabetes by subsidizing current agricultural industries but at the same time spending an absurd amount of money trying to treat type 2 diabetes. Type 2 diabetes costs the government $245 billion a year to treat! That is equal to 1/4 of our nation's annual deficit. It takes 7yrs off life and markedly reduces quality of life.

Corn and coy being grown that has replaced local crops- these are the building blocks for the fast food diet- sweetener for HFCS, feeding for livestock. Soy makes up the oil our food is fried in. 10% of our calories are from soy oil which is not healthy and another percentage come from sweeteners.

Pollan thinks the ACA will pressure the government to change these food/ agricultural policies. Insurance companies are now stuck with treating the chronic diseases because they can't kick people off for pre-existing conditions.  They will start to realize that for every case you can prevent, that is a lot of money for insurance to save.  If they know what is good for them, they will align themselves with this agenda to make food more healthy.

Now regarding processed foods with added vitamins. These food companies are creating a nutritional facade around processed food products. It is fundamentally deceptive to put a health claim on a bottle of soda due to having some vitamins in it. We have to look at what we are telling consumers about our food.  The rules around health claims need to be re-examined. Fresh produce, there are no claims. He says to have a more healthy diet, don't buy foods that carry health claims.  Quietest food is the food you want to eat.  Vitamins have become a gimmick for selling processed food. They are terribly abused. See the history of the book Vitamania. Vitamins are now unfortunately being used to undermine our health.

They discussed consumer habits- now expenditure for eating out is roughly more or equal to that at home. The way to take back control of your diet is to bring it back home. Obesity epidemic is propagated by the collapse of eating at home. Family meal is conducive to all kinds of health phenomena. Lowers drug use, better relationship with parents, better performance in school. Answer is to get everyone in the kitchen and rediscover the pleasure of cooking food.

About the new dietary guidelines being issued this year- (http://www.health.gov/dietaryguidelines/dga2015/comments/Default2.aspx) lobbyists from meat industry are up in arms about efforts to reduce greenhouse gasses.  Pollan asks this question- How can you have a healthy diet on an unhealthy planet? Healthy environment and our personal health are linked. The new dietary guidelines send a clear message to reduce meat consumption and increase consumption of plants and whole grains. Pollan makes the point that there are ways to raise meat sustainably and we should not overlook this and assume its all conventionally being produced. Also the guidelines have said there should be no more than 10% of calories from added sugar, which is progress. However the guidelines have very little on the microbiome, the role of the microbes in the gut and what implications they have for healthy diet. Pollan believes that eating fermented foods may help our microbiome and mentions that sugar and saturated fats can compromise the integrity of epithelial layer of large intestine.

Pollan says: Eat food. Not too much. Mostly Plants. He says flexitarians are just as healthy as vegetarians. Of course if you ethically do not eat meat that is a reason not to.

More on greenhouse gasses: Nitrous oxide from fertilizer used to feed meats produces lots of greenhouse gasses. Studies show that reducing meat consumption will lower carbon footprint significantly. Conventional fruits and veggies grown with nitrogen fertilizer and till often which produces carbon emissions. If fertilizer is used, that decreases the carbon. 1/3 of carbon in atmosphere right now was produced by tilling and we should be able to put much of it back. He feels like modern agriculture started global warming. especially when you remove trees for agriculture. We were apparently much more healthy as hunter gatherers and our statures were better and healthier then. Pollan says that we may see organic agriculture can out produce conventional agriculture. We may see an increase in food production with a shift to organic production.

Regarding genetically modified food- the question is not good over evil. The question is- is it safe? is it a good idea? We have a scientific, environmental and economic arguments. Diversifying and localizing agriculture is a better solution than modifying our plant seeds. The company has bought up a very large stake in the world's food supply. They argue on the basis of food safety. Critics of GM are now trying to fear monger back. We should be fighting on the ground of transparency and who controls our food supply. People should be demanding to know whether they are eating GM food or not.

Moving in the right direction: Now nearly 9,000 farmers markets exist nationwide. Schools have been dominated by "big food" but now school districts are having farm to school programs. There are some positive developments. Food industry experts are nervous about consumers who are moving away from what has been largely allowed to happen over the last few years. Added by myself- Pressure on large food companies like Chipotle, to become GMO free: http://organicconnectmag.com/project/chipotle-commits-going-non-gmo/ And panera's move to remove artifical ingredients from its foods- http://www.usatoday.com/story/money/2015/05/04/panera-panera-bread-fast-food-restaurants-dining-artificial-additives/26696823/. These are small steps in the right direction.

http://www.nongmoshoppingguide.com/

Uncapping the pen...

It's May 9th, 2015. Three years gave passed since my last post in this blog. I wish I could say that I have been writing elsewhere, chronicling my residency experiences and writing about lessons learned during residency.  Unfortunately, on most days I have been so exhausted from the demands of residency that my blog has shifted down to my last priority.

Moving through the years of post-graduate medical education, I have noticed I always work the same amount of hours. During intern year, my hours were long and scheduled as shifts. My job was to advocate for patients, learn the ropes of the local hospital/clinic and learn how to navigate the medical community (and lets not forget the scut work- someone has to do it!). Second year, my job was to get better at the things I did intern year and supervise the interns closely. My scheduled hours were slightly better and I finally had a chance to start engaging in my neuromusculoskeletal (NMM) specialization and read more on my own time. Third year hours dramatically improved, but my clinic patient load increased. I have been seeing 12 patients in a half-day, and have found that I can keep up with associated calls, forms, messages, but closing the charts on time has been a challenge. I have taken on quite a few leadership roles now that I know the ropes and am familiar with the inner workings of various professional organizations.  I have also dedicated my time to becoming the next chief of my NMM residency. So while my shift-hours in residency will be significantly better this upcoming year, I will be as busy as ever- tending to my leadership roles and helping to promote positive ripples in my residency, the greater orlando community and the osteopathic profession. I am sure this last year in residency will yield memories and lessons just as the last three years have, and I'll try to make it a goal to post more, even if just a couple of lines every once and a while.

Speaking of the osteopathic profession, it is an interesting time for us. The profession has changed quite a bit since my last post.

The ACGME and AOA boards have merged, and this occurred for many reasons. Many fear that DO's will lose their identity in this process, but that does not have to happen. The primary tenets* of osteopathic medicine should be propagated in each profession. Why would we not want everyone in the health profession to observe tenets that so greatly benefit our own patients? We now need to fully open the osteopathic profession and leadership to MD physicians and leaders. Our questions going forward will be: Throughout the board integration process, how do we maintain the separate distinction between DO's and MD's? Throughout the history of our profession, we have struggled with the feeling of inferiority. It is a natural human reaction to doubt something that is not a common practice. When you exist in such smaller proportion than MDs and you are a relatively new profession, you're going to have to work hard at gaining equal recognition. Now we are truly equal, with boards merging. How do we maintain our separate identity in the years to come?  The DO profession should be engaging our medical students, residents and physician members alike in this discussion.

*Tenets of Osteopathic Medicine as approved by the American Osteopathic Association House of Delegates:
The body is a unit; the person is a unit of body, mind, and spirit.
The body is capable of self-regulation, self-healing, and health maintenance.
Structure and function are reciprocally interrelated.
Rational treatment is based upon an understanding of the basic principles of body unity, self-regulation, and the interrelationship of structure and function.

But, now I will tell you a secret--a mystery. Those who suffer need you to be something more than a doctor; they need you to be a healer. And, to become a healer, you must do something even more difficult than putting your white coat on. You must take your white coat off. You must recover, embrace, and treasure the memory of your shared, frail humanity--of the dignity in each and every soul. When you take off that white coat in the sacred presence of those for whom you will care--in the sacred presence of people just like you--when you take off that white coat, and, tower not over them, but join those you serve, you become a healer in a world of fear and fragmentation, an "aching" world, as your chaplain put it this morning, that has never needed healing more.  -Donald Berwick

Donald Berwick, recent Administrator of the Centers for Medicare and Medicaid Services in the Obama Administration and a founder of the Institute for Healthcare Improvement, gave this speech at his daughter's graduation from Yale Medical School on May 24, 2010.

HEART Elective

http://www.sacredmirrors.org/flash/sm_full.html Artwork by Alex Grey

The physician who knows only medicine, knows not even medicine. -Mark Twain

I have finished with the Humanistic Elective in Activism and Reflective Transformation (HEART). What an incredible way to bring my medical school career around to full circle. I decided to do the rotation after hearing great things about it from dear colleagues of mine every year.

HEART is an intentional community, and each year students find a way to magnify their impact on the world through positive intention and collective consciousness. HEART was probably the BEST rotation I did during medical school. I feel physically, mentally, and spiritually transformed. During medical school, our passions and life purpose can sometimes get away from us- this is a great rotation in which to renew that.

Check out this trailer video that was made during my month at HEART!

The dates for HEART next year will be March 24 - April 20, 2013. HEART Website

Just a few of the important tools I'm taking to residency:

 Tips for going into residency:
1. Learn to accept change, for it is the only constant in life.
2. Learn to be flexible
3. Learn to accept the question marks in life and don't try to erase them. That is why we never allow pencil!
4. Nuture relationships
5. Strive for balance
6. Find meaning in medicine
7. Find mentors
8. Have gratitude and forgiveness for others and yourself daily.

The three most important things we can give our patients:
1. Presence- self-care and self-love is important! If we nurture ourselves, we can be more present with our patients, empowering them to do the same.
2. Intention- Be compassionate and loving, non judgmental, and know that there is a complete story behind everything. Be honest, open, and transparent.
3. Appropriate modality- recognizing what situations are best approached with western medicine, integrative medicine, or a metaphysical/psychological/spiritual model.

5-minute Compassion Meditation:
"May you be happy,
 May you be peaceful,
May you be free
From pain and suffering."

Say this to Yourself,
A loved one,
A stranger, and
To someone with whom you have been having conflict.

A Summary of this Year & New Adventures Ahead!

http://paulbates.com/florida-beach-scenic-sunrise-pictures-photos/

I matched into my #1 choice for residency, the Florida Hospital East Orlando (FHEO) Integrated Family Practice/ Neuromusculoskeletal Medicine (FP/NMM) program!!! I hope I can continue to represent my school, my cohort, and my profession in the greatest way possible while I am a resident at FHEO. I am absolutely honored to join the other hard-working, dedicated, and compassionate FHEO residents! Many people want to know what my program entails- it is a four year residency after which I will have obtained my separate family medicine and neuromusculoskeletal medicine board certifications. I know this will be stellar training in medicine, and I'll have the opportunity to really become an expert at osteopathic principles and practice.

Beautiful Florida Manatees

I can't believe it has been so long since I last updated this blog- I decided to leave it alone during interview season due to sheer lack of time to update it. During interview season, I traveled to Yakima, WA, Grand Rapids, MI, Orlando, FL, Southampton, NY, Los Angeles, CA and back to the Bay Area. I had such an amazing adventure, from experiencing two new states- Michigan and Washington, to finding out that Walter and I are capable of finding happiness no matter where we are on the globe.

My journey, summed up in 5 bullet points:

1. Washington is such a gorgeous state. I landed in SEA/TAC on a beautiful partly cloudy day and had an absolutely picturesque view of Mt. Rainier- hues of pink, purple, blue, and silver- it looked like the lost city of Atlantis. There are so many places to hike, and over 600 wineries in central Washington alone. Quite an incredible state, with nice people. I am convinced after spending 10 weeks in Humboldt and 4 weeks in Washington that I personally vibrate on the frequency of the pacific northwest. If you have never set foot on that part of the country, I strongly suggest that you plan to do it at some point in your life :)

2. Grand Rapids, MI is a cool city. I was there during August, and saw some of the most beautiful sunsets and sunrises walking in and out of the hospital. August is THE month to be in Grand Rapids. The only bout of bad weather I experienced was a lightning storm. I woke up that night flying out of the bed because a bolt had literally struck right outside my window. Oh, and the rumor is true- it does smell like ozone when a bolt strikes next to you. Yikes!

3. On top of its super fun theme parks, Orlando, FL has some amazing BBQ and southern food. The city is only 45 min away from the Atlantic and landing/launch site for NASA space shuttles. Also, I actually loved the humidity- I could breathe a lot better than I ever could back at home, interesting, huh? The rumors are true, FL has some beautiful beaches and it also has bugs the size of my face. Love everything.... except the bugs, haha :)

4. The Hamptons is a beautiful place, even in the winter time. I felt like I was the only person living in Hampton Bays while I was there, but the solitude and quiet was almost therapeutic for me while I faced an internal struggle of what specialty I would choose for residency. That area vibrates circa 1650, around the time the English settlers erected the town of Southampton. I kept feeling like I would run into some revolutionary war soldiers on my morning walks... ha ;) And yes, The Hamptons is a gorgeous place. I did not go all the way down to Babylon, which I regret. One thing I loved about this leg of my journey was seeing many of my 1st and 2nd cousins, and my aunt Debie & Uncle Fred. I absolutely love my family and am so thankful that they hosted me for holidays and quick visits!

5. When it rains in California, people FREAK OUT. It does not matter if they are northern our southern Californians, they forget how to drive, what to wear, what to do.... everything. I say this because for the first time in my life, I was rear-ended during a freak 15 minute lightning storm near LAX, literally a few minutes after I had picked up a rental car. Don't worry, I am fine, and the man who hit me took care of the repairs with the rental car company. I still need to get myself to an OMM specialist to make sure nothing was thrown off... I was in LA for interviews and to complete a PM&R rotation at Casa Colina, which is a famous rehabilitation hospital in the San Gabriel Valley. I have never liked the San Gabriel Valley because the smog in LA likes to accumulate in that area, but after a 4 week rotation, I grew to like it much, much more. Perhaps it is because Pasadena is pretty close to that area- still too far from the ocean for my taste (says the girl who is moving to Orlando for 4 years!).

So now that I know where I have matched for residency, I'm coasting downhill from here. That by no means is going to be an easy ride, but it will be a fun one.

I still have my emergency medicine rotation next month. Then after that, I join some of my 4th year medical student colleagues at a 4-week HEART Rotation in Ben Lomond, CA. After that, we've got some time to tie up loose ends in the Bay Area.


Marshall Creek, at The Quaker Center in Ben Lomond

Over the next four months, here is my to-do list:
1. Vacation in Hawaii
2. Ship our belongings across the country and move into an apartment in Orlando, FL
3. My Graduation from medical school My Zadie, Alan Kantor D.O. at his medical school graduation circa 1959 :)
4. Get married!
5. Take a little under two weeks to drive across the country to our final destination!
Map of our trip to Orlando, leaving the Bay Area on June 11, 2012:
Benicia-> Los Angeles-> Las Vegas-> Sedona-> Albuquerque-> Dallas-> New Orleans-> Pensacola-> Orlando! We'll be spending a few nights in Vegas, Sedona, New Orleans, and Pensacola.

What a way to end an amazing chapter of our lives... and with absolutely no break in between, we'll head right into a new one! (That's Robyn-Style, as Walter likes so say)

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!

Ending thoughts, new beginnings!

Yesterday was my last day at ARMC OB/Gyn, and I have to say that the minute I walked out of clinic, I breathed a huge sigh of relief. The rotation was very hands on and I learned by collision, but there were many barriers to getting work done.

The morale of the nurse assistant staff is very low right now and as a result, the wait times for patients double. We had to run around looking for our assistants, sometimes met with an eye roll when we asked forthem to chaperone (which is required), and sometimes straight out shot down and told to find someone else. Not all of the assistants are like this, but I would say this was the only thing that made this rotation difficult for me, other than the lack of orientation. I am sure its frustrating for the staff to constantly have to deal with new med students who don't know what they are doing because of the lack of orientation. I certainly hope that they can get to the bottom of what is going on in clinic before patient care is affected.

I am happy that I had a chance to rotate at Arrowhead, and I learned tons about women's health on this rotation. I am glad I had to bust my butt in that hospital because my future patients deserve to have a doctor who put forth this effort to learn. I am just surprised at how various health care professionals can treat each other when the common goal is supposed to be quality patient care, individual health, and community healing. I will continue to approach healthcare with the perspective that we need to work cohesively as a team to increase the number of successful outcomes. If you choose to go into medicine, no matter what your specialty or position, you are making a commitment to help others and that service should bring you joy. Working in this field, you make many personal sacrifices- among the most important of things, your time and energy. It is good, honest work and those of us who choose to do it should be happy that we have the chance to work together in such a positive effort.

And stepping off of my soap box, I am so happy to head back to the Bay Area tomorrow to continue my life in Benicia with Walter! It has been 16 weeks since I slept in my own bed, woke up to the sun shining through the blinds, the birds chirping outside our bedroom window... man it will be good to be back!

I start Orthopedic Surgery at DMC on Monday, which is a 4-week rotation. After that I am doing a 2 week elective rotation at East Bay Cardiology, and a 2 week elective in PM&R near CPMC in the mission, SF City. So excited and happy to commute from my home in Benicia :) Until next time...

OB/Gyn at ARMC in Colton

Its a sunny day in Riverside- the high will be 78 degrees which is the norm in the beginning of November around here. We have veteran's day off, but I have not left the house yet because the Santa Ana wind is blowing at 20-30mph out there! Over all it has been interesting. Driving through the parking lot freeways on the morning has really been affirming the way I generally feel about this area. Think of the Weeds theme song- "Little boxes on the hillside..." There is a lack of variety compared to the bay area, and the people and generally a little nicer up there.

ARMC in Colton is a federally funded community hospital- Obama-care if you will. For the most part, it is a well-oiled machine. Some departments are functioning a little more smoothly than others. As it is a teaching hospital, you find that the lower you are on the totem pole, the more scut work you do, but you learn tons doing it!

All of the rotations I have had so far, I have been extremely blessed to follow an attending basically on my own. I even had 3 to myself during pediatrics in Humboldt. In this hospital, I interact with the attendings very little in comparison. The downside is that I don't get to see the way they interact with patients (very few still see clinic patients in person), the upside is that I get to interact with patients and learn what style works best for me. I research my patients' charts, take my own history and perform my own physical exams, write up my own SOAP notes, update the problem lists, and then formulate a plan going forward complete with which labs, imaging, and education is necessary. At this point in my third week, I have learned the basics and read enough that most of the time the attending checks my work and signs off on it. The only time I get to spend with the attending in the room is when I need him/her to check out something that deviates from normal in the physical exam, or when I need to do a quick abdominal or vaginal ultrasound.

This clinic is an especially important experience for me because I am helping high-risk OB patients, which unfortunately there will be more of as time progresses and society's habbits are too slow to change. Weight management, diabetes (both gestational and chronic), and twins are all sent to our clinic for the high-risk days. So we have these complicated cases, and we're expected to get through 45 patients in the morning and 35 in the afternoon on most days! Add to this a small amount of clinic space, too few computers, illegible handwriting in charts, nurses that are impossible to find sometimes or clearly do not feel like helping (although some are much nicer and more willing to help than others), and you get the ultimate high stress environment. Its no wonder the attendings mostly never leave the physician break room- its a war zone out there :)

I think what also makes clinic so difficult is the paperwork- there's a huge learning curve in the beginning getting used to it all. They expect you to only spend 30 min with returning patients and 45 min with new ones, but on the first day you're not even familiar with the charts, paperwork, EMR, or even where things are in the hospital yet (if you're completely new to the area like me). By the end of the second week I was golden in terms of all of that, but at the beginning of the second week we had new students from Western come, and training them was like the blind leading the blind. There is no real official orientation, so med students help each other as much as we can, while also trying to get our own work done.

The labor and delivery floor works much differently than clinic. Our duty as med students is to help out the flow of the prep room, which is like emergency triage for pregnant women. We see the patients, find out what they're there for, present to the residents, and help see to it that they are admitted, watched, or discharged smoothly. On the floor, we chase residents around making sure that we help them with efficiency, scrub in on bilateral tubal ligations, cesarean sections, dilation and curettage procedures, and vaginal deliveries. We can follow the uncomplicated patients and personally help with placenta and baby delivery. We can also shadow attendings in the gynecological surgery OR and scrub in on procedures like total hysterectomy and total salpingo-oophorectomy (removal of uterus and ovaries). Overall, if you are ambitious and determined, you get to see tons.

So overall, this has been an incredible learning experience. I practically feel like a resident with the responsibility I have and the skills I have acquired. This rotation alone has actually gotten me more excited about residency because I feel like its less of a mystery to me now, and I know that I can do a good job when the time comes. Although its not easy, it is also not thankless- the patients are very gracious and nice here and you get the feeling that you're really helping make their lives a little better one visit at a time.

This windy day off is a perfect day to catch up on quizzes and reading, so I am signing out and heading down to Denny's ;) I'll check in again at the end of the rotation. Next up is orthopedic surgery back at DMC in San Pablo.

Pediatrics in Humboldt

Much to my dismay, I am close to the end of my pediatrics rotation in beautiful Humboldt County. My preceptor is Dr. Ted Humphry from the Open Door Clinic, and I would often shadow Dr. Wirthlin and Dr. Heise when Dr. Humphry was out of the clinic. Having all three of them to myself was amazing- no other students or residents with whom I needed to compete for their attention. It was nice to see their individual methods of blending intuition with medical knowledge. I would go to the clinic every day for outpatient experience, and in the mornings I would make inpatient rounds. I was also called in at all times of the day to watch and eventually participate in C-sections and make rounds on inpatients.

My favorite part of this rotation was when I got to see patients on my own. I would take a brief H&P, report with my assessment to the attending, and then we would go in together to close up the visit. I also wrote SOAP notes after some of them- totaling about 2-3 per day. The only downfall of this rotation was not having Internet access. I had to wait until I got home to work on quizzes. I am going to miss the people of Open Door Pediatrics in McKinleyville and the physicians with whom I rotated. Not only were people courteous and welcoming, but they helped advocate for my ability to learn and participate in patient care.

I will also miss Humboldt County- such a beautiful place with fresh air, a slower feel, and might I say, tons of great food. I will be back, especially since I have much more north coast left to explore!!!

Next stop, SOMA Fall Convention, then OB/Gyn at Arrowhead Regional Medical Center in Colton. So far I have been away from the Bay area for 9 weeks and it won't be another 7 until I can finally call it home base again. I have missed Walter terribly, but thank goodness for g-chat with cameras and the fact that this place is only 5 hours away. We saw each other every weekend of my NMM rotation, and every other weekend during my pediatrics rotation. I thank him for being endlessly patient with me. Thanks for reading- don't hesitate to message me if you have any questions on how to rotate in Humboldt, leave a comment below if you don't have my contact info.

Neuromusculoskeletal Medicine in Humboldt

In case there are any 2nd years who are still actively reading my blog, I wanted to share about my NMM/OMM rotation with Dr. McCaffrey in Humboldt.

She practices OMM at her clinic, called Redwood Osteopathy. She takes PPO/HMO/Medicare patients, and she has the MediCal patients come to the Student Clinic, where you take a history/physical, create an assessment and plan (including treatment), present to Dr. Kate, and then treat. I found it to be exactly like suitcase clinic, but you take care of the visits on your own (unless someone is rotating with you, in which case you could see the pt together if you wanted) If you are uncomfortable doing this on your own right off the bat, you can let her know and she will be happy to have you observe for a couple of visits before you jump into it.

You also help her with the intake and follow-up visits for non-MediCal patients- you take notes onto the computer for her and help her treat, sometimes you go in with the patient and start taking the history/physical and present to her. You'll see 5-8 patients per day,sometimes more! It's good, solid work and I not only learned new
treatment techniques; I experienced continuity of care. Its nice to see how patients do after you treat them! I also feel like my hands have turned on again, if that makes sense- I had not practiced much OMT between May- Aug before the rotation.

Dr. McCaffrey also teaches you about billing/charting/EMR, and how to run your own business. As far as hours are concerned, Tues, Weds, Thurs you are there for about 9 hours each day with a long lunch break, then on Friday its a half day (3 day weekends!). There is a compassionate pain management group that she has students join during their time at the clinic to get an idea of how facilitated groups
work. This is a beautiful group and you might be surprised at how much you learn about yourself and others during the short meeting. The office staff and medical massage therapists who she supervises are very nice and like to share knowledge during in-services. You can also trade OMT/ medical massage with them ;)

I'm still in Humboldt- now rotating with Dr. Humphry, Dr. Wirthlin, and Dr. Heise for inpatient/outpatient peds. I literally have all 3 of them to myself! If you are interested in rural medicine or peds and you want to know more about this rotation just let me know. Dr.Humphry is the director of the Open Door Clinic and loves to teach medical students. It is a very loving, educational environment.

Humboldt is very much in need of people from our generation to come up there to practice since many of the current physicians will be retiring within the next 5-10 years. This is why they really want us to come up there and they make sure we get the special treatment- a good education and friendly interactions.

General Surgery - a short conclusion, after 4 weeks.

As amazing as surgery is, I probably won't become a surgeon. I want to know medicine inside and out, perform the occasional procedure, possibly know how to do a cesarean....but I just don't see myself being a surgeon day in and day out. That said, I want to absorb all the information I can while I am on these rotations so that I can be extremely knowledgeable about when it is appropriate to refer. It is also important to have a good grasp of what my colleagues do, and what my patients will go through when they have surgeries so I can care for them properly before and afterward.

Even if I do not picture myself in particular fields in which I am required to rotate, I'll have fun with it, learn as much as I can, and I'll always be humbled by how much I still don't know. So excited to follow the life-long pursuit of acquiring knowledge-- next up, ten weeks in Eureka (4 OMM, 6 Pediatrics). Will update soon!