For the Record

Every time Teslagrl gets a text message now, I have to ask if it's Sen. Obama. That right there is some pretty great politicking.

I think it would be cool if he takes the stage tomorrow in Springfield, and says "hang on a minute, I just have to send a quick text" before starting his speech.

SOS

I'll have more to say about it later, but I saw Mamma Mia, it was partly-to-mostly awful, and I can't wait to talk all about why. A few key points:

1) Watching people act as though they are having fun is not the same thing as having fun. (I have a similar opinion, this one more controversial, about The Blair Witch, as regards things that are frightening.) Watching people screech like 9-year-olds and stomp around like giant city-wrecking monsters on Ecstasy is not the same as being a witness to ecstasy.

2) Salon.com's Stephanie Zacharek is spot on: James Bond can't exactly sing, but as an actor he GOES FOR IT, and god bless 'im for it.

3) Speaking of effective expressions from the UK, to review this movie in five words or less I found I had to go beyond American English and use British English, which in general is far better for the occasional verbal sniper-shot. It's not that the film was poorly made (which it was), or that it was not fun (which it wasn't, really, and certainly not as much as it thought it was). It's that, all in all, this movie is just utterly pants.

From http://www.peevish.co.uk/slang/p.htm:

Pants(!) Noun/Adj. Nonsense, rubbish, bad. From the standard British English of pants, meaning underwear; also a variation on 'knickers'. E.g."The first half was pants but I stayed until the end and it was actually a great film." [1990s]
Exclam. An exclamation of annoyance or frustration. From the noun, (above).

Blogopenia

CC: "My blog sucks because I never update it."

HPI: 38yo WM with 3+yr hx of intermittent blog activity, ranging from thoughtful to snarky to extreme cheese-sandwichy. Last post about one month ago.

FHx: non-contributory.

SHx: ETOH 3-5/ wk, no cigarettes, no recreational drugs. Positive for PS2 with recent additions of Nintendo Wii (~2mos) and XBox 360 (~1wk). Works as scut-monkey scum, currently with urban Peds clinic, between 40-60h/wk.

PE: Lethargic subject in mildly poor physical condition, but in no acute distress. Personal hygiene WNL, but positive 1990s signs to some clothing. Cell phone, shoes, messenger bag, and PDA adequately cool.

A: Mild to moderate blog-malnourishment, secondary to lack of free time. Reduced motivation is a parallel problem worth noting.

P: Watchful waiting. Recommend shorter, more frequent posts. Hold off on initiation of Twitter or similar modalities until the situation is more critical. Short-range goal should be one post per week. Re-assess in six to eight weeks.

I diagnosed impetigo today...

I diagnosed the crap out of it!

What happens is, as the student I'm there to collect the info. I've been with an Internal Med doctor with a thriving practice and a ton of patients. Almost all of them have some kind of chronic issue going on, and even when that's not the reason for the visit, it's important to know how things are going. So I talk a lot about diabetes, and heart disease, and medications. I spend a lot of time writing down the ten different meds* the patient is on, the dose, what they've changed recently, and what they don't like to take.

I also do a review of systems, which is where I ask a ton of questions about all kinds of stuff that isn't what the patient came in for. The detail and length of this list increases proportionally with the length of time since the last visit, too. And since I don't want to take all day with this, it's a good thing that the actual physical exam portion of my standard history-and-physical can be made pretty snappy.

I do my writing, which has also become much faster, and then I go speak with the attending physician. We'll talk for a moment, maybe while walking, and then he'll open the door to the exam room, say hi to the patient, and do what I just did, except so much more quickly and efficiently it's kind of embarrassing.

Now, true, part of the reason he can do that is he already knows this patient well. In a lot of cases, they've been seeing this same doc for years. Another reason he can be speedy is that I just did the time-consuming stuff, and I've just distilled down the most important 30 seconds of the 20 minutes it took me to find it. But also, he's been doing this a long time and I just started.

So. I've filled in half the page or more, with my block-printing marching a couple dozen rows down. Then he'll scrawl "IMP" (for "clinical impression," which is like diagnosis except that it doesn't necessarily have to be something that is truly, technically a diagnosis), and then put in a word or two the answer to the question I started asking back at the beginning of my interview: "what is it that we can help you with today?" The MD then scrawls "PLAN" and lists the tests, the meds, the treatments that will be needed to get the patient to the next step, so we can start all over in a week or a month, or whenever the next visit should happen.

I like it this way. My own "IMP" and "PLAN" are part of the conversation we have outside, of course. I'm not just a note-taker or an inquisitor -- although the key to a good diagnosis is asking the right questions (and hopefully not too many that turn out to be dead ends). You've seen "House." You know the score. But my impression doesn't go in the chart, because that's not the way we do it here. And that's cool with me.

Except when I'm really, really sure. There have been a few things that I've felt so confident that I would have been just shocked if I was wrong about them. I sent a woman to the ER because right in the middle of telling me about the vertigo with a horrible headache that comprised the attacks she'd started having, she had one... and there was a little bit of a seizure too. The doc agreed that she needed to get down there, so we whisked her away. We admitted her, and it turns out she had a nasty infection in the bones of her skull.

Today was a case that kind of jumped right out of the mental version of my dermatology notes. So I wrote "IMP: Impetigo" before I went to fetch the doctor. He looked at the patient, said, "yep, I agree," and did the rest of his scribbling.

Maybe it's a Stockholm Syndrome kind of thing, with the hours and the intensity, but it's really nice to get props of this nature.



* seriously, sometimes it's 12 or more. Rarely it's only one or two, and I'm like, "huh." And then there are the patients younger than 45 or so who take no meds at all -- they're the minority, and I don't tend to see them twice within my six-week term, ya know?

Milestones

Sorry I've been so quiet. A lot has happened since the last post, but I've been so wiped out as a result of the activity that I've been less able to write about it.
Here's something that crossed my mind recently...

My 35th birthday, I seem to recall, was spent either packing, or driving out east to start my post-bacc program. My girlfriend (now wife) made the trip with me, but I dropped her at the Albany, NY airport for the first of what would be several times, before I continued on the last little bit to Bennington, Vermont.

On my 36th, I had finished up that one intense year of pre-req courses, having had a few successes, a few painful encounters with my own limitations, and a whole lot of educating on what my life would be like for the next phase of my adventure. I had come out there with a goal, and come back with a plan. In the interim, I had learned a lot, including the difference between the two. Also, I read Diablo's book, I listened to Jonny's record, and I started to see how I could be good at medicine, for real real.

My 37th was spent driving back home. All my stuff fit in my 4-door car. Well, except for the futon and furniture I'd stashed in my dad's shed, and the books and whatnot I'd left behind in the woman's basement.

I just had another birthday this week. The day started with me arriving to the clinic a little ahead of my supervising MD, so I took the first patient on the list, with the MD following up a little later on. He agreed with my diagnosis, too.

Weird, how fast it all seems to go by. Next year I'll be within days of graduation, and I may even have an idea of where I'll work when school is done.

My Nuptuals are Impending...

...and it feels wonderful.

Many of you I'll see this weekend, for the wedding. Others I'll see later on, after we're back from a week in Vegas, baby!

One anticipated highlight: finding a cinema near the Strip, so we can see the new Indiana Jones.

See ya post-matrimony, everybody.

gsnlzzxhwgh!

Hey marathoners and people who run, like, 10K's,

Do the last few yards make you feel like you want to finish because you're happy and proud to have made it this far? Or is it more that you want to finish because if the aggravation kills you dead on the spot, while that would be a blessed relief it would also mean you won't have the pleasure of saying "I'm never doing THAT again"?

Oh, there's good news too. I had my white-coat ceremony, so my own classmates were looking like the stylized figures in the header image. We got to take a practice version of the national boards exam I'll do a little more than a year from now, after I've graduated. I passed. I was actually a touch above the class average. In theory, then, the real boards should be just fine.

But who wants to concentrate on the positive stuff? I'm tired, finals are next week, and sitting in a chair looking at PowerPoint presentations for a year has helped me gain 10 to 15 pounds. I'd rather be ONLY concentrating on the wedding (yayy!).

Anyway, that's my deal. Big fun coming up.

The Short White Coat

I've had a couple of very nice e-mails, in response to the last post. People want to know when I'll be in town, or what I'm doing when, or generally the whole dealio with the clinical year thing. So here's the two scoops, my raisin brahs:

As of the end of May, after the wedding and once we've returned from Las Vegas, I start up the second year of my two-year program. Basically, now that I've sat in a classroom for a full year, learning a little about everything and a lot about a few things, I now get to run around all day and try to apply it all. This would be the clerkship year.

It's a series of six-week stints in various specialty areas. Because we students (we PA kids are interchangeable with the med students at this point) move from place to place as the year wears on, each of these is called a 'rotation.' As I mentioned earlier, I'll begin by being the student in an Internal Medicine practice not far from where I live. And that means I'll be seeing people with hypertension, diabetes, and everything else that can go awry in the adult human body; the MD will be right behind me.

I'll move on to different practice situations at different locations, in my case covering private offices and hospital departments, in three states. I'll spend time working in Women's Health, Pediatrics, Family Medicine, General Surgery, Emergency Medicine, and then I get to set up an elective rotation. I head back to school periodically, to sit and take a test on the subjects I should have mastered. The year ends with a super-sized eight-week preceptorship, which depending on how you look at it is a chance for a wild fling or a marriage. You can use the time to do something cool and exotic you may not feel like doing for a job the rest of your life, or create a chance to impress some practice group enough that they offer you a job when school is over.

So. I'll be back home just after New Year's 2009, and I still have to figure out what to do with that eight-weeker. For the elective rotation I have lined up something pretty cool... but that's another post.

Here's a crazy thought...

I'm getting married, in less than 40 days.

I have about 35 days of school left, and that means I'll be halfway done with the official part of my training. It also means I'll be ENTIRELY done with the "sitting in a classroom, taking notes" part of my schooling.

Mostly, this scares the crap out of me. Now and then, however, I get a little glimmer of how things are going to work in the next year. Small, sometimes reassuring flashes of the kind of problem-solving and connection-making I will get to practice, and occasionally be really good at.

I also got my letter: when it's time to do my six-week Emergency Med rotation, guess which site they're sending me to?

Here's a hint: I already know where they keep all the supplies, and I can work the computers.

Finally, the new REM is amazing. It's a good week for old guys.

Yup. New Template.

Hey, it's getting toward the end of my classroom phase -- and that means it's that much plus a few days until my wedding. Seems like as good a time as any to tinker with the settings. And that old customized teal-and-orange stripe was looking old n' busted.

Um, yes, I am also studying for a test. Why do you ask?

I'm Going In...

Wish me luck. The last of the standardized patient training deals is coming up for me.

You'll recall that just a month or so ago, I learned the correct way to perform a breast exam. The right kind and amount of pressure; the right technique to make sure you don't leave anything out, so I'd feel a suspicious lump, but I wouldn't take forever either.

Then I learned how to work the male exam; the outer and inner survey of the twig n' berries, the dreaded hernia check. I'd had these in yearly checks, but this was from the examiner's side. And then I got schooled in the prostate, a skill that I know will eventually become not just un-special, but actually boring.

Consider that, right? A day is coming, and it's not too far, when I'll not only be the guy responsible for giving the one-fingered salute to people, I'll grow to hate it not because eww, it's my finger in somebody's pooper, but because gawd those are so boring.

Well, another one of those things we do a lot of in the ol' clinic or Emergency Department is the friendly neighborhood pelvic exam. Guess what I'm doing this week?

I definitely feel like I'm turning into a clinician, so that's good. But, man... I am getting SO TIRED of looking at either male or female genitals. And how messed up is that?

It may look like a walnut...

There is a notorious phenomenon that occurs in people who are in medical training; as you learn more and more about the various things that can go haywire with the human body, you gradually come to believe that an implausible number of them are happening to you. I believe that some of the reason my school's student-health clinic is staffed with semi-retired old docs is that they've seen and done everything, and most of the reason is that none of us are ever actually sick.

I, being older and presumably wiser than many of my classmates, have avoided too much trouble with this. I had a hacking, body-shaking cough for about 8 or 9 weeks, but I knew that was just a virus, combined with the dry air, combined with my train commute and incarceration in the same windowless classroom every day. Even when Teslagrl told me to go get a damn chest x-ray, I knew it wouldn't show anything. And anyway, we covered chests & lungs in the Physical Exam class, and nobody could hear anything wrong.

But then, a couple weeks ago, we got around to the male genito-urinary exam. Yeah... so I'm 37. You see where this is headed?

Before learning the correct way to inspect, cradle, squoosh, and prod another man's junk, and then go around back and knock on the back door, we learned the right way to talk about the exam. What it is, what it isn't, and why it's important. At my school we use 'professional patients,' people who are trained in much the same way we are, with all the attendant anatomy, physiology, and pathology... but from the other side. They learn how the exam is supposed to feel, when done correctly, so they can tell us stuff like "okay, you can press a lot harder than that," or "yep, you're right over it now; you should be able to feel it."

Yes, it's weird, and even though we'd already done the breast exams, the five dozen or so in my program were all quietly freaking out on "Nuts & Butts" day. We went into rooms in groups of four, which somehow made it worse. But once the guy did his intro speech, dropped the Caesar Ocatvius sheet he had added to his patient gown, and the first volunteer got to business, it was all very technical and interesting, and somehow we were all professional and more or less relaxed.

So, speaking now as a future professional, it's not a big deal. And the thing is, it's really super-imporant. A decent exam takes three minutes out of your life, it doesn't hurt, and it involves no needles and no radiation, unlike so many other tests. And the risks of being a big wuss about it and doing nothing are fairly dire. Ask Lance Armstrong about that.

Which brings me back to my own experience. Having honed my little speech, I had to consider my own very mild symptoms, from the past year or so. Nothing major, really, but some research pointed me toward an issue with the tissue, in the palace of the pants. Gradually I had to admit that if I were hearing from a friend what I was thinking, I'd tell that friend to go in and get checked. So I had to go see the stately, joke-cracking, HMO-hating doc over at the clinic.

This is a guy who graduated the very same medical school, more than 40 years ago. He's kind of a role model for me. He works pretty much because he loves medicine, and he'd be bored out of his mind puttering around at home with, I don't know, bonsai trees or model trains or some shit. He'd much rather be gloving up and getting to know me better than either of us anticipated.

He needed to leave for a minute to go find the tube of lube. I told him to TAKE ALL THE TIME YOU NEED, man. Search high and low.

And it turned out fine. My prostate is, apparently, awesome. I have no blood anywhere it's not supposed to be. Best of all, that info is documented, bitches! I'm not saying the exam doesn't suck just a little, but it's no worse a sensation than, say, the feeling of having crud stuck under your contact lens. It's less painful than irritating. You go ow ow ow ow shit ow, and you take out the lens to wash it. Then you're fine. And I'd rather have a rectal than some of that bullshit that dentists do to your gums with metal hooks.

The preliminary diagnosis? It would be nice if I didn't have to sit motionless for ten hours a day. So basically, my man-bits are suffering from IRONY. But yes, I absolutely did the right thing by going in.

The moral of the story for all my friends who are, or who love, guys: a dude should check his sack, once a month. And don't fear the finger.

Dang, I forgot Albania

This was harder than I thought. Admittedly, it's also something of a spelling (and typing) test.

62

But hey, naming a new country once every five seconds for five minutes solid isn't so bad, right? Give it a shot; how many did you come up with?

Such Conflict!

Here's pretty much the central dilemma for any health-sciences student who has a blog, and tries to tell interesting stories: how much can you say, without messing up the educational experience for yourself, your classmates, or your patients?

Anyway, wait for a respectable period of time to pass -- I'll think of ways to change around the identifying details, and then I'll be able to talk about my first breast exam.

(Note: not my breasts. I'm not a skinny guy, like I was in high school, but aside from that thirty-something softness in the belly, I'm not hefty either.)

Vacation is Almost Over

So soon, I'll be back to the grind. I passed a course that I might not have, and made some rather huge changes to my habits... my outlook... my inner world, really. More on that later, when I'm not so Oscar-drunk.

I'm reading some excellent books; I'm studying some interesting stuff; I have weird hours this term. I hope to be here more often.