Merck Manuals Student Stories Reblog: A Patient Patient

Originally posted on Merck Manuals Student Stories.

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“My parents abandoned me when I was five years old.” I listened intently, trying not to show the shock on my face, as the woman, about twice my age and sporting an edgy variation of a mohawk continued on. She had been drinking since her parents fed her beer in her baby bottle. She had smoked marijuana for decades. She had finally given up cocaine a month ago, “With a couple relapses,” and she was here today because of residual nose pain and bleeding from her years of drug abuse. With hours of lecture on seizure and anti-epileptic drugs to review looming over my head, this was not what I was expecting today.

For the past month, I’ve spent my Tuesday evenings shadowing a resident at the family medicine clinic, a couple blocks away from school. Before we saw the patient, the attending physician preceptor briefed us, informing us she had a complicated medical history and that her therapist had had to accompany and continually convince her, even just now in the parking lot, to come into the clinic today for her medical needs. Needing to run off to see another patient, the resident I was shadowing allowed me to gather and perform a full history and physical before she saw the patient herself. As a second year medical student, with little to no experience of working with, you know, actual real live patients, I freaked out, straightened up my short white coat, and knocked on the door.

I was nervous, but she was patient with me as I asked her questions and performed her cardiovascular, respiratory, abdominal, musculoskeletal, and neurological exams with pauses here and there as I gathered my thoughts. After finishing the history and physical, we chatted while we waited for the resident to join us. After telling me about her son, the main reason for her wanting to quit using drugs, and her trips hiking with her dog all over the state, a pastime we shared, she smiled and sighed, “You know, I was afraid of coming in here today. But you guys here are nice. You’re nice doctors.” I blushed at the compliment, not to mention her mistaking me for a full-fledged doctor.

Before coming in that evening, I was nervous about the time I would miss studying for my exam that Friday. However, all it took was a half hour with a patient who showed her appreciation for our time and a desire to better herself to help me see the bigger picture, one beyond books and test questions and one focusing on helping others.

Life seems to be almost calling to me from this strange new world above.

7. Cross Country Skiing at the Nordic Center at the Whiteface Club & Resort in Lake Placid

The summer before entering college and with my advisor’s encouragement, I e-mailed the cross country coach at Siena introducing myself and expressing an uncertain interest in running there in the fall mostly because my high school times were decent for scoring in a Howard County championship track, but nowhere near the level of a typical Division I program. The coach at the time responded with a blank e-mail with an attached Microsoft Excel spreadsheet and his answer in a single cell and in all caps (he was, uh, quirky): What size uniform? So I guess I was on the team.

Like the the creep that I was and, quite frankly, still am, I Googled all of the incoming freshmen and current team members on the roster to, you know, see what their deal was. Siena is a small liberal arts school located in an affluent suburb outside of Albany. If you head straight up Route 9 from the Soldiers and Sailors’ Monument in Washington Park in Albany to the school’s trademark gold dome on top of Siena Hall, you travel through Arbor Hill which is considered almost unanimously to not be a place to carelessly wander about at night. (I do admit I have run up Henry Johnson Boulevard in broad daylight during 20+ mile runs during marathon training, and with the busy traffic and ample police presence, I did not once feel unsafe). I couldn’t find the exact statistics, but from my experience students are generally from New York state and tend not to be from exotic locales such as California and Hawaii and even Maryland for that matter unless they are 1) in the Siena/Albany Med program, or 2) recruited athletes.

This was a really long way of saying it seemed a lot of my future teammates seemed to have run cross country and track like I did, but also competitively cross country skied and snowshoed in the winter, something that is nonexistent in Maryland simply because we just don’t have that kind of snow south of the Mason-Dixon line. Thus, I have always wanted to try both sports, and I finally had the opportunity to try cross country skiing this past weekend while in Lake Placid.

The hotel we were staying at for the conference had a special deal with the Nordic Center at the Whiteface Club & Resort about three miles away, and we only really had to pay for rentals. I was only out for an hour (I stopped by on my way home after the conference ended on Sunday morning and needed to get back to Albany), and I’m not sure if it was just the kindness of small businesses in small towns or if the kid working found my literally minute long awkward attempts at stepping into the skis pathetic or even endearing, but he ended up not charging me at all. So I got to ski for my favorite price: fo free!

I’ve been downhill skiing a couple of times, but the speed always freaked me out and kept me from really enjoying the experience. Cross-country skiing eliminated that fear and was such a great workout I didn’t feel as bad about skipping my Sunday long run as I should have. There was also just something really relaxing and calming about being out on the snow covered golf course by myself and making the first tracks on the freshly fallen snow that I really loved. The conditions, though, highlighted my not so graceful stumbles especially on anything remotely resembling a descent, but the constant moving kept me so warm I hardly noticed.

I feel like I missed out on a lot of these outdoor activities, especially these winter ones, as a kid, and I’m thankful to have the opportunities now to give them a shot. I still need to try snowshoeing, but cross-country skiing was definitely a winner and I would for sure do it again, even at places in the Albany area.

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Cross Country Skiing at the Nordic Center at Whiteface Club & Resort in Lake Placid

When and Where: Wintertime; 373 Whiteface Inn Lane in Lake Placid

Highlights: Great workout, beautiful weather, fo free

Loses points for: Trails could have been marked better, but I also am severely directionally challenged, so that might just be me…

Cost: $12 for full day trail access and $17 for full day rentals ($8/$15 for kids); check to see if your hotel has any deals like mine did, but if you’re lucky like me you might be able to do it without even pulling out your wallet

Good for: Active people, families, people looking for a good time in Lake Placid

Would I go again?: Absolutely!

Smoother than a fresh jar of Skippy.

6. Dog Sledding on Mirror Lake

I can recall at least three different occasions my elementary school teachers must have thrown in the towel for the day and slipped in a VHS destined to inspire any kindergartener to fifth grader with a soul: Balto. I remember the story as the heroic tale of an adorable dog who led his team to win the Iditarod Race despite the frigid Alaskan conditions; Wikipedia (and every other source, for that matter) disagrees. Apparently the story was about the 1925 “Great Race of Mercy” in which a dog sled team, led by an adorable dog named Balto (this part I remembered) transported diptheria antitoxin 674 miles across our country’s geographically largest state to prevent a diptheria epidemic in the city of Nome.

I admit that this version is much more appealing to me as a young lady on the long, windy, and in my case very circuitous road to becoming a doctor (mais ća, c’est une autre histoire). Corynebacterium diptheriae is a gram positive bacillus or rod-shaped bacteria that is non-spore forming and non-motile and causes a “bulls neck” sore throat, fever, and pseudomembranes of the tonsils, pharynx, and nasal cavity (aka diptheria) and is spread via aerosol droplets. It is prevented with the DTaP (Diptheria, Tetanus, and Pertussis) vaccine at a young age and bolstered with the Tdap booster shot during adolescence and young adulthood. It is diagnosed clinically and via throat culture and is treated with antibiotics such as metronidazole, erythromycin, and penicillin G. And yes, that was mostly off the top of my head, so don’t you go telling me I ain’t learned nothing in school…!

At any rate, Balto clearly had an impact on me during my most formative of years at Clemens Crossing Elementary School. Which is why when given the opportunity to go dog sledding this weekend while in Lake Placid for the New York State Academy of Family Physicians Winter Weekend conference, I, well, did just that.

The dogs, like Balto, were adorable. If you know me at all, you know I love my dog Jonas, a socially retarded (as my brother puts it) six pound maltese with a severe Napoleon complex and the good fortune of being absurdly cute which he manipulatingly uses to his advantage in any and every situation, especially those involving bodily fluids. The funny (or sad, depending on how you look at it) thing is that the ten or so dogs (I’m no dog expert, but I have some legitimate doubts that they were not all huskies) pulling my sleigh were not much bigger than my pup at home in Maryland. And while I felt sorry that they had to pull me ( + all of the candy I ate on my three hour drive north that I so nutritiously substituted for dinner the night before), they just seemed so happy and excited to be doing their job of dragging overweight Americans around for a mile-ish at a time. It was obvious the owners sincerely cared for the dogs, affectionately calling them by name when one got out of line (heh heh, see what I just did there?), boasting about their unique personalities, and switching them out when one got particularly tired.

Was it a fun time? Yes. Was it the most exciting thing I did all weekend? No. Were they really cute so much that it was worth it? Perhaps.

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Dog Sledding on Mirror Lake 

When and Where: Wintertime; Mirror Lake in Lake Placid just off Main Street

Highlights: Adorable pups, stroll down memory lane thinking of Balto, awesome time and place to be outside

Loses points for: Being $10 for no more than a five minute ride (there was a student discount for $5, but the people running the gig denied it even when I pulled up the website on my phone…)

Cost: $10/person

Good for: Families, young children, not morbidly obese people if you catch my drift

Would I go again?: I’m not sure I would ride again, but I would go just to see the dogs and watch other people. That sounds creepy, but seriously. It would be fun.

And out of all these things I’ve done, I will love you better now.

This weekend I had the pleasure of attending my first professional conference, the Family Medicine Education Consortium, which took place in Arlington, Virginia. In its 20th year, the FMEC meets once every fall to “inspire medical students to seek a career in Family Medicine, create and sustain regional teams that support cost-effective, quality improvement initiatives, support and stimulate innovative approaches to primary care service delivery, strengthen academic Family Medicine by providing faculty development mentoring and leadership experiences, and support residents as they transition in their careers.”

I am fairly certain my future is in primary care, but my positive experiences working with the family med department at school through service projects, community events, and my undergraduate program have definitely and unknowingly pushed me towards the field of family medicine.

I’m going to be honest: I’m not the greatest student in the world. I go to class, I study, and I pass my classes, but I also love to spend my time running, biking, writing, reading, spending time with friends, baking, and…almost anything you can think of that does not have a tendency to involve me sitting in the fluorescent lights of the library.

That being said, however, there is one class in which I really do shine. It’s called Clinical Skills.

Essentially, the class’s objective is to prepare us to, you know, actually become doctors. In the first year, this meant learning how to take a patient’s history of present illness, review of systems, past medical history, family history, social history, and sexual history, in addition to how to do a head to toe physical exam on a standardized patient (an actor who pretends to be a patient with a medical problem). This year, we’re learning to do more focused histories and physicals in addition to developing differential diagnoses for the patients’ chief complaints.

In our last “patient encounter” at the Clinical Competency Center (it’s made up of maybe twenty or so fake exam rooms to really mimic a doctor’s office), I was told that I “dominated” it, which, in the midst of the confusion of the lymph/heme systems was incredibly encouraging to me as a student. (Fourth year students in their “Learning to Teach, Teaching to Learn” block watch live video of us from a side room and then meet with us to give us feedback…it’s a bit insane).

It was, perhaps, my first realization that, yes, I can be good at something in med school!

Some of my classmates find Clinical Skills to be difficult and nerve-wracking, but frankly, I have a difficult time believing that. I mean, I do suppose the physical exam requires more than a bit of coordination (something I need to work on…closing one eye when trying to finagle an opthalmoscope is harder than it looks!), but for everything but the actual physical you’re just talking to people. And I think I’ve finally pinpointed why I’ve found success in this class: I love talking to people. Which is also a big reason why I want to go into primary care. I love meeting new people, getting to know them, and building relationships with them. I love the idea of longitudinal care and being able to care for patients and their entire families for years and years. A girl in my Evidence Based Healthcare class last year bluntly stated she would never go into primary care because “all my primary care doctor ever did for me was write me a prescription.” But I see so much more value in treating the patient’s personal illness rather than their direct from the textbook, scientific disease. After all, healing encompasses much more than just helping someone with his or her physical well-being. Family medicine seeks to treat the whole person, not just their fever or diabetes.

So this is the attitude with which I went into the conference, which, I think, solidified that primary care is the field for me. I won’t go into the gory details (mostly because I need to sleep; neuro final on Friday!), but it was awesome to hear so many speakers on a wide variety of topics (I particularly enjoyed hearing Dr. Thomas Wilkinson speak about his work overseeing the medical care of the volunteers for the US Peace Corps and Dr. Erika Bliss speak about her experience as president and CEO of Qliance, a direct primary care company), participate in workshops, and talk to so many people including students, residents, and attending physicians who are passionate for family medicine. (And lemme tell you, I met some of the coolest, nicest people just sitting down at a random table for dinner).

I feel there’s a tendency for students to sort of blow off primary care, looking down on its reputation as a low-paying, high-demand, high-burnout career path. But being amongst the people at the FMEC showed me that family medicine is the complete opposite of that. And now, armed with this rejuvenated spirit and dreams for my future, back to studying I go!

So lay your hands on the left behind.

It’s not quite running around in the heat at wellness camp, but for my second and final week in Shiprock, I’ll be hanging out in the hospital shadowing in the family med department and the health education center.

I’ve shadowed doctors before, but it’s definitely been a more interesting experience now that I have some actual medically related knowledge and some clinical skills (in addition to some actual context of the medications I helped fill while working as a pharmacy tech for several summers in college) under my belt. Now, how much of that I actually remember is questionable, but I have become a pro at recognizing things that sound somewhat vaguely familiar so far this week!

When people ask me what I want kind of medicine I want to go into or what I want to specialize in (the generic follow-up question you will undoubtedly get once you tell someone you’re training to become a doctor), I’ve sort of come up with a thirty second elevator speech I can recite half asleep:

“I’m pretty sure I want to go into primary care, probably into family medicine or a dual internal medicine/pediatrics residency. I’m also interested in sports medicine, but I would probably want to split my time between, like, 25% sports med, 75% primary care, although, at this stage of my education, who knows!”

Although a clearly rehearsed speech, all of what I say is true. However, if there’s anything I’ve taken away from this week about family medicine is that even within the broad field of family medicine, you can tailor your day to day tasks and job to work with the patient population and to do the type of work that you dig the most.

Between yesterday and today, I’ve worked with three different family med physicians whose respective practices could not be more different than night and day, even though they were trained in the same field and are separated by only a single wall. For example today, I worked with a family med doc who came to Shiprock 17 years ago as a part of a federal loan repayment program, a common route for many newly trained physicians at Shiprock, apparently, and has stayed ever since. She works in the hospital only a couple days a week at most, spending most of her time visiting patients in nursing homes in her hometown of Durango and the nearby city of Farmington with her mostly elderly, geriatric patient population. Yesterday afternoon, I worked with another physician who was sort of the quintessential picture of a family practice doctor in a rural area I think of; incredibly knowledgeable of all of her patients and details about their families, she waits to work on paperwork after patients leave the office, wanting to spend more time talking with patients face to face rather than talking with patients for five minutes and typing information into the electronic medical record for the next 25 minutes. Her compassion to and utmost respect of her patients’ unique situations and struggles that made making health one of their top priorities difficult was inspiring and something I hope I can share with my future patients. (We must have talked to an elderly patient trying to lose weight so she could qualify for inguinal hernia surgery about the pros and cons of certain yogurts for a good 15 minutes). In addition, yesterday morning I worked with yet another family medicine physician who worked with several patients who had a lot of complicated, chronic conditions in addition to family, social, financial, and legal issues that made matters even more complex.

I would consider each a good doctor anyone would want to go to, but at the same time, each physician had a distinctly different way of showing compassion and concern to and providing the best care she could to her patients. I suppose different patients respond positively or negatively to different personalities and styles of care. Another way their varying styles were demonstrated was in the use of translators, whether they be official translators or family members; many of the elderly Navajo only speak Navajo, and could not communicate with the English only speaking physicians: some spoke in second person, directly to the patient; others spoke to the family members or translators about the patient sitting right next to them in the room.

The diversity of doctoring styles and lifestyles each doctor built for herself was one notable thing I’ve noticed, but this patient population’s unique issues are another. Obviously, type 2 diabetes is a huge issue in the Navajo (I mean, I just went to a camp run by the hospital to teach kids how to prevent the disease!), but other things like obesity, osteoarthritis, alcohol abuse (although interestingly, not smoking), and, (from what I can tell), certain sexually transmitted diseases, and others are huge.  Likely genetic risk factors, but also probably cultural and social influences, play a role in the prevalence of these diseases and must constantly be on physicians’ radar when examining and diagnosing patients.

Tomorrow I will be shadowing a dermatologist who works in the same “Piñon”/”Sage” primary care department I’ve been in the past couple days and Thursday, I’ll be spending the whole day back in the Diabetes Education Center for a day-long class, I think, for patients newly diagnosed with type 2 diabetes before leaving Shiprock on Friday.