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.