Week One: In Review

This week has just flown by; I'll try to recap the highlights.

I've found that the first few weeks of any rotation is always a bit of a blur with trying to figure out all the new people, new clinic, new hospital, etc. It seems like by the time I get feeling comfortable, the rotation is half over. Maybe I'm getting better at making the transition through rotations or maybe I'm just where I'm supposed to be (doing WRITE, being in Libby, etc) because it's only been one week and I feel more on top of how things run, what my role is, and what the expectations are than I ever have after this short of time in my other rotations. That isn't to say that I have things completely figured out, but I just feel like the learning curve is a little less steep in terms of getting settled into this new rotation.

Most days start between 7:30 and 8:00 at the hospital. I follow patients who get admitted when I'm on call. Because my first call day wasn't until last night (Friday), I just picked up two of Dr. Gunther's patients on Monday since I was working with her for the first part of the week. I round on my patients (or as they say in Libby and Caldwell, I "make rounds"), which means that I look at their charts to see what happened in the last 24 hours and then I visit with the patients, check out any lab, radiology, or pathology results, see how they are feeling, and do a physical exam. Then I write a daily progress note with my assessment of how they are doing and plan for the day. I write orders (i.e. medication changes, labs that need to be ordered, IV fluids, diet, activity, etc) and then discuss my plans with the supervising physician. We talk about the things we agree about and inevitably, I miss something or get something wrong, so we discuss that and make any necessary changes (as a side note, our Medicine Clerkship director in Seattle told us that third year medical students are experts and getting things wrong, so I guess I'm right on track).

When we are done at the hospital (usually around 9:30) we walk over to the Libby Clinic to start seeing patients. I am assigned to one of the doctors each week and see patients with them. The schedule is flexible, though, and sometimes I see interesting cases, pediatric, or OB patients with any of the doctors who have those patients on that day. Generally, I will see a patient first by myself: interview them, see why they are there, discuss health maintenance, and do a physical exam. After that I grab the real doctor and we go back into the exam room where I present my findings to them and we have a discussion with the patient and make a plan together. After the patient leaves, the docs take a little time to teach me a few things, I write the note in the chart, and repeat!

Each doctor does things slightly differently and their schedules have some daily variations, so I have to stay flexible as I work with each of them. For example, Dr. Rice only uses the computer to write patient notes. He takes his laptop in the room so that he can have access to all their chart information. Dr. Gunther, on the other hand, doesn't really know how to use a computer. She is the only doctor I've met this year that still uses a hardcover PDR (Physician's Desk Reference: a reference for drug indications, dosing, side effects, contraindications, etc that looks a lot like Mom's Webster's Dictionary, only fatter!). There are a lot of electronic resources for this these days, which are available both online and in PDA versions that make looking up this information so fast and easy. As you might imagine, she doesn't use the computers to do electronic charting, so she orally dictates all the notes on the patients. This is fast for her, but very slow for me; I'm much more comfortable writing a patient note on the computer. She laughs about it says she knows she needs to learn and that she will try to learn enough so that she can find my notes on the computer to review them. Everyone in the office tells me, "good luck", with getting that to happen. We'll see.

The office takes a lunch break from 12:30 to 1:30. This is the first time all year I feel like the docs actually take a break on the lunch hour, which is great; I don't feel like I have to grab a Cliff bar between patient visits. I usually try to get home and let Annie out for a quick pee break, fix some hot tea, and eat real food before heading back to the office for the afternoon patients. It varies each day when we get done, but it's usually between 5:30 and 6:30. Most evenings I come home to take care of Annie, fix dinner, and do some reading/studying. I joined the Montana Activity Center (MAC) and am trying to go a few times a week. This week I only made it there on Wednesday for Pilate's and Thursday for my spinning class.


Here are my highlights of the week!

Monday/Tuesday:

I worked with Dr. Gunther these days. She is probably in her 50's and is certified in both Family Medicine and Internal Medicine. Her favorite patient population is geriatrics (just like me!). We see eye-to-eye on this and that is that they:
1) have great stories and are fun to talk to...we both want to record oral histories
2) are so cute
3) if they aren't cute, they are crotchety, obstinate, and VERY entertaining (that one isn't hers, but it's mine!)
Dr. Gunther is so happy and kind and always smiling. You can tell that her patients just love her and she loves them too. Tuesday morning we made rounds at the Libby Care Center (aka, nursing home) and met some very sweet ol' folks. One little old lady is blind and nearly deaf told Dr. Gunther, "you look so young and beautiful today! I'm so glad to see you, thank you for visiting," and then gave her the biggest hug ever. She also told me I looked young and that she was glad to meet me and gave me an equally big hug. She was just so happy and full of life and it really made my day. Another man told us that living there wasn't the best, but it was better than not because they gave him a button that when he pushes it calls a lovely nurse in; if he had that button at home, nobody would come. He was also very sweet and had a great sense of humor.


Wednesday:

I worked with Dr. Rice in the morning and Dr. Cuskelly in the afternoon. Dr. Cuskelly is also probably in his 50's. He was an Alaska WWAMI student and really believes in the WRITE program as a great way to train third year students. I worked with him the rest of the week and really enjoyed our time together. He is a great teacher, but pushes me to make decisions regarding patients. Dr. Cuskelly performed a circumcision in the office that afternoon. He walked me through all the steps and told me about the different techniques and the pros and cons of them and why he uses the technique he likes. He told me I can do the next one!


Thursday:

This day deserves it's own post....stay tuned.


Friday:

I was on call with Dr. Cuskelly on Friday. At first I was really bummed because I was spending all day at the hospital admitting patients and missing clinic. Then I realized that I was admitting patients! Not an attending, not an R3 (third year resident), not an intern. ME! An MS3 (3rd year medical student). The nurses would ask me things like, "Can we give Mr. X more percocet?", "When do you want us to start the IV antibiotics, and how fast do you want the IV fluids to run?", and "Would you like me to adjust the patient's oxygen up now or wait?" And then I would hesitantly answer with a question, "Sure?", "Umm...let's start them now and how about 100cc/hour?", "Uhh..adjust it up now?" They would run off and start doing it with hardly enough time for me to yell after them, "You should probably check with Dr. Mahoney first!!" It is the weirdest thing to feel like I know NOTHING and lack confidence about decisions that need to be made and then have people look to me first and then actually DO what I say. It's a little overwhelming, but also very cool. I finally feel like I'm doing something useful this year: I'm actually making decisions. Even the doctors ask me what I want to do with patients, and then say, "Okay."

My other triumph of the day: learning how to use the dicta-phone and seeing my dictated note magically appear in the patient's chart with the doctor's barely legible hand written note at the bottom: "Patient was seen and examined by myself and I agree with the above assessment and plan of Ms. Beck, MS3".

Wow! That was one long post. Is anyone even still reading? I don't expect that'll happen again...I'll lose my audience if I keep that up.