First one down

My family practice clerkship ended today, and I'm very glad to be moving on. I enjoyed an increased level of responsibility and patient interaction, and got some much-needed practice walking through the therapeutic paths for which patients present to their doctors. I didn't learn a whole lot that I didn't know; the practice was the real benefit to me.
The shelf exam yesterday went relatively well - I haven't gotten my scores back yet (obviously), but it was certainly easier than the step. There were of course some things I'd never heard of, and some things I simply hadn't thought to study, but overall, the difficulty of the questions seemed commensurate with my knowledge level at the end of 5th semester. It was held in Ross' building in South Miami, so Nicole and I had to drive all the way across town, and being back in the old neighborhood certainly brought back memories.
After the exam, we went over to Sports Authority to pick up some new running shoes for me. The cushioning in my old Nikes is as flat as cardboard, and running had just gotten to be painful (I guess I don't replace them soon enough). Then we headed out to Havanna Spice Cafe for the Cuban food Nicole's been craving since we returned to Miami, and sat down for a quick lunch of ropa vieja, arroz, maduras, y frijoles negros. Then it was off to the real goal of the shopping trip - Macy's tie sale. I found out a few weeks ago that all Macy's are nowhere near created equal, when, as Nicole was looking for shoes in the South Beach Macy's, I realized that I couldn't find single tie I liked. The Macy's at Dadeland Mall is supposed to be the largest in the state of Florida - their selection was, of course, fantastic. I picked up a few Tasso Elba ties that I simply couldn't part with, and we headed back to Miami Beach.
Nicole wanted to drive the long way home, so we could see all of Collins Avenue at night, but forgot that it's the middle of spring break, so we found ourselves snarled in some gnarly traffic as soon as we hit the causeway. Once in the heart of downtown, there was nothing to do but crawl along at a snail's pace, staring at all the drunken college kids and very expensive cars.
Something I ate at Havanna Spice must have really disagreed with me - I thought initially that I'd just eaten too fast and so felt uncomfortably full, but half-way through Gray's Anatomy, the food poisoning kicked in - and didn't let me rest until 6 in the morning. This isn't something that happens to me all the time, but there's nothing that sucks like night-long GI distress. It must have been the maduras (plantains), because Nicole didn't have any - that was the only obvious difference between our meals - and she was fine. The last time I remember feeling that bad, I was stuck on a fishing boat with my father and uncle out on Tampa Bay. This wasn't as bad as that; apparently, seasickness hits me just a tad harder. Anyway, I got an hour of sleep and just decided to suck it up and go see patients, finishing out the clerkship on a strong note, and sat around with the other med students discussing various types of preformed enterotoxins. Fortunately, today was relatively light.
If I'm feeling up to it, we'll head up to Sawgrass Mills Mall tomorrow - it's supposed to make the Simon outlet malls near my home look like a run-down flea market. And then there shall be reading on the beach. Life is good!

NKA: No Kids Allowed, or No Known Allergies?

I should have been reviewing for the family practice shelf the day after tomorrow, but (1) I have zero motivation, (2) it doesn't count for our grade, (3) we haven't really received any guidance on what to study, and (4) it's supposed to be the single most difficult clinical shelf exam. I've been reading all along, but we'll see - hopefully, The Essentials of Family Medicine has prepared me well (despite the negative reviews on Amazon. But what can I say? It was required).

I've made some realizations. Toddlers actually do fear the white coat - I tested this. One of the office ladies had her little one in at the end of the day, and I went to play with the kid. He saw me coming and immediately became incredibly shy, so I went back to our break-room and doffed the white coat. When I came back, the kid played with me like I was a different person. I first noticed this when, a few days ago, a patient's 18 month old daughter cried every time she looked at me. Her older sister(she was six) and I, however, got on smashingly - that must be my target age group (I got along well with another six year old yesterday).

I've realized that, even though I don't speak toddler, I'm apparently fluent in doctor. Last time we were in Miami, Nicole and I rotated with a GI doc who took us out for Cuban food, but that was just because he was a nice guy. At this clinic, there's one doc with whom I get along particularly well. Do I say that because he shares with us his Cuban coffee? No. Do I say it because he seems to prefer spending time observing my interviews with and examinations of the patients, or because he just seems to like me in general? No. Do I say it because he took me out for Subway at lunch today? Close, but no. I say it because he asked me to help him update his will.

I must speak doctor, because another doc at the clinic today specifically requested me for a sensitive task. Apparently, he likes the way I work, because he sent me to interview and examine a 10 year old who'd been hit by a bus and suffered some severe left-sided trauma and neurological deficits. Recall that this clinic does a lot of insurance physicals and such - the mother needed documentation from his doctor in order to keep him in a certain program at school; the district was trying to throw him into regular classes, and there was clearly no way that was going to happen.

This is all refreshing - of course it's nice to reaffirm that I'm good with patients, but it's also nice to know that, since such a huge portion of our grade is subjective, I'm making friends in high places.

I have also realized that I'm going to have to do a lot of reading for OBGYN, which starts next week. I sat in while Nicole interviewed a patient, and it was like they were speaking Sanskrit. It wasn't just because Nicole's a great student, but it's because, being a woman, she'd been inundated with women's health all her life. I have not. It's foreign to me - a completely different culture. I know a few phrases like "last menstrual period", and "family history of breast cancer", but I don't really understand all of the connotations that go along with them. I'm just faking, essentially.

"Que?"

This little clinic at which I'm finishing out my family practice rotation does a lot of IMEs - independent medical examinations for insurance companies. They also do bus-driver physicals, and one gets sick of the rigmarole after a while - however the doc who's supervising gives a lot of leeway, which I like. Instead of being so pressed for time that he has to move at lightning pace through the patients, he allows us to sit and think about the best course of action, whether it be simply a lifestyle modification, adding a drug, changing a dose, or referring, and discuss it with him. With every patient I get more comfortable with the mental algorithm necessary to plot a favorable outcome, and with every physical exam, I hone my skills.

My Spanish has gotten a little better every time I've been back to Miami, though I dislike being forced to speak a different language in my own country. More than that, I dislike it when people can understand some English, and just say they can't; it's very frustrating. Roughly half of the patients in this clinic speak English - another quarter only speak Spanish, and another quarter only speak Creole (somehow, this close to little Haiti, we only have one medical assistant who is able to translate for us. She's kind of the boss). I can't imagine going to a foreign country and getting medical care without knowing how to communicate - especially if I was planning to live in that country. Forever. However, when two guys in short-sleeve shirts and ties come to my door on a Saturday morning with pamphlets and ask if I speak Spanish, I don't.

Down with the Sickness

I just finished the second of my three 2-week rotations for family practice. This clinic was a significantly different brand of medicine than the first two weeks - whereas the first placement was a wealthy retirement home, full of bed sores, dementia, and medication lists as long as my arm. We just finished at a clinic attached to homeless shelter. Only, it wasn't a homeless shelter per se; it was more of a rehab program - we saw people from all over the country, and from outside of the States. The illnesses were more of the flu-variety - Nicole and I both got sick on the very first day, and spent the rest of the two weeks recuperating (this was the first time that I was truly grateful for all of our required vaccines).

Fortunately, the clinic didn't have us working days that were as long as the last clinic. The information wasn't exactly mentally stimulating, but I loved it because of the autonomy. We went and saw the patients, did an H&P (history and physical), formulated a plan, and then came out and presented to the attending physician. The best part of it was the practice - constantly writing up SOAP (Subjective, Objective, Assessment, Plan) notes,tying in pertinent positives and negatives, getting a pointed physical exam, and figuring out how to connect the dots of their physical presentation were perhaps the best parts of it. Also, the reading and researching became much more streamlined - instead of going over dementia and COPD, I got to review things that were a little more common in family practice - differentials for cough, diabetes, hypertension, and the differences between viral and bacterial upper and lower respiratory infections. This was all covered on Step 1, but the clinical aspect helped to cement things. It's one thing to know theoretically that you give antibiotics for bacteria, but it's another thing entirely to have a patient who presents with a two-day history of cough hack up some sputum, so you can see if the color warrants a Z-pack or just water and bed rest.

Also very positively, this clinic was run by one of the docs who taught us during our 5th semester. This gentleman is so personable, he's gotten other docs to come volunteer at this clinic, and is responsible for setting up some of the rotations we did in 5th semester, as well as, possibly, some of the clerkships we may or not soon be getting in Miami.

After the last day, Nicole and I drove up to drop off our patient logs, site reviews, and the paper we had to do, and turned in the paperwork for our next clerkship: OBGYN. After that, since we took a little drive up to Costco. The goal of the trip was to get to Sports Authority, so I could get an E-Z curl bar and some weight plates - I'd been trying to work out with some resistance bands I'd gotten at Target, but they snapped. Anyway, there was a Costco close by, and Nicole loves her Costco. So we walked around, lite-shopping with a friend, and were caught in a torrential downpour. The clouds were black and ominous when we left the clinic, but by the time we finished shopping at Costco, it was the Biblical flood all over again. I should have listened to the girls; they were telling me to keep the cart along the sides of the parking lot, next to the cars, but deep down inside, I'm still a little boy - giving the cart a big shove, I figured I might be able to just ride it through the rapidly accumulating lake. Much to my chagrin, the car stopped right in the middle of the ankle-deep rainwater. Fortunately, it was more hilarious than frustrating. After draining our shoes, we made our way to the sports store, and then I drove barefoot all the way home.

Yesterday, a friend came down and we all walked down the Boardwalk to Starbucks, making the most of the day. I can’t help but be pleased that I’m not up north, despite how I’d thought things would be - I prefer Ocean Avenue to snow any day. After she left, I took Nicole out to eat at Catina 27. I had an interesting salmon-farfalle, and then we went for a walk. Nicole had really wanted to go to theVan Dyke Cafe, so we went ahead and stopped in. Apparently, it's incredibly difficult to get in to listen to the live music, but we didn't have any trouble. Tony Succar and "El Grupo Mixtura Latin" threw down their singular brand of Afro-Caribbean jazz, and we made our way back down Lincoln Road to home.

Promised Pictures

Here are the pictures I promised - it's the pathway from the street, into our building, through my room, to the sea. It's really rough living down here....I know....

Can't get away.

I know....it's been ages since my last post. Pictures from the rodeo and shots of the beach are both forthcoming, however I'll wait for a more stable internet connection before I post them. I got through a pleasant bouquet of books – enough to hold me for a while (Barbara Kingsolver’s The Poisonwood Bible, Denni Lehanes’ Shutter Island, Diane setterfield’s The Thirteenth Tale, Stepehen Erikson’s Gardens of the Moon, and Randy Alcorn’s Safely Home). Now, I’m easing my way through Gene Wolf’s Litany of the Long Sun, and am as happy as a kid in a candy store.

Well. For the third time in my life, I have - without really expecting it or wanting it - been sucked back to Miami. The first time was for MERP - Ross' medical education review program. That time didn't particularly bother me; I was just thrilled to be starting on my medical education. I knew that my journey would take me to “a land behind God’s face”, as my mother would say – the nowehere-island of Dominica. After 16 months there, I’d applied to remain on the island for my 5^th semester. The word on the street was that 5^th semester on the island afforded much more time to study for step 1. Much to my chagrin, I was repatriated (I blogged about that vexation). However, it all turned out for the best; 5^th was fun, and the Kaplan course I took helped me to rock Step 1.

Now – Ross has most of its clinical spots in New York. They’re scattered around NYC, and so this is where I thought I’d be for my clerkships. I looked into making sure I was applying for programs that would be accredited in Texas, and began to look into housing. Once my scores came in, I submitted them along with the myriad bits of facts and desiderata composing required paperwork. I don’t know if it was the Christmas and New Year’s holidays, but both my and Nicole’s submissions were lost to some abysmal inbox in Ross’ central offices, such that a little too much time passed, and we called in to make sure they’d received everything. When I finally spoke to the administration, I was told that, if I still wanted to go to NYC, I wouldn’t be able to start until March 29^th. This was back in early January, and I was severly nonplussed; not only did I just not want to wait that long, there was a time-limit to the length of my vacation, after which I’d incur the relentless wrath of Sallie Mae – my student lender. I essentially had no choice, and would have to start again. There were two options – the family practice residency in my hometown, and Miami.

I’d have loved to have stayed in Harlingen – I’d worked for the family practice residency program during the summer after my freshman year of undergrad. They needed someone to update their patient information databases, and once that was done, I was fortunate enough to be allowed to shadow the docs and residents a few hours a week, as well as participating in Summer Medical Institute – their program for medical students who came down and helped the residents and attendings run their door-to-door medical clinics, as well as free medical clinics in Mexico. I had a blast doing that, and apparently made quite an impression – even though they don’t allow FMGs to do clerkships, they’d make an exception for me – just not for Nicole.

And so I prepared to return to Miami. This really frustrated me – after leaving the last time, I’d decided that I don’t like this city. Despite the fact that I have a significant support system down here, with family on both Mom and Dad’s side spread out over Dade County, I didn’t like the city. I didn’t like the self-important, superficial, arrogant attitudes that seemed to be everywhere. I didn’t like how people drove as if right-of-way was determined by the price of one’s car. I didn’t like being forced to speak another language in my own country because the people I was speaking with gave me dirty looks if I spoke to them in English (oddly enough, though most folks in Harlingen are bilingual, the attitude is entirely different – I guess we’re just more polite). So I wasn’t happy to be sent back, but deep down I knew that it wasn’t so terrible – I’d gotten family practice, OBGYN, internal medicine, and psychiatry scheduled back-to- back right from the get-go, which, based on the feedback I’m getting from my classmates, seems to be a blessing; a lot of people have huge gaps in their schedules. Also, Nicole and I were scheduled for the same rotations, so that made the whole transition much easier. She was thrilled that things went so smoothly, and I grudgingly joined her in the planning. The only snag in getting here is that my bags took a later flight out of Charlotte (it seems to happen whenever I fly in to meet Nicole somewhere; when I went to visit her in Spokane after we first started dating, my bags decided to stay somewhere in Milwaukee. I stepped off the plane without my winter clothes into Washington’s first serious blizzard of the year. Fortunately for me, her father loaned me a coat until my luggage and I were reunited.)

Seems like I just can’t get away from this place, but it more and more reasons why I should be grateful manifest daily. This isn’t a particularly gentle winter for the northeast, and after hearing how many hundreds of flights have been cancelled and how many feet of snow have burdened the roads, I think I can admit that I’m in a good place. I don’t believe in strings of coincidences – of course they’re possible, but I think it’s simpler than chance. Inopportune events befall everyone from time to time, but if I get wrapped up in a string of unpleasant calamities, it’s always my fault – generally I was too lazy and didn’t plan well enough (Hopefully I’ve gotten that out of my system). However, when a string of blessings encircle me, I can’t help but know that it’s the Hand of God preserving me and ushering me away from some other calamity. I guess this is the case with my seemingly inextricable linkage with this city; I can’t get away, but it’s been for nothing but good.

This time, I’m living on South Beach. No, seriously - I’m talking Miami Ink, Ocean Avenue, art-deco South Beach – and I love it. The feel is entirely different from down-town Miami; the pace of life seems to be a bit more even, and on this little island at least, though we’re bogged down with constructions as they prepare improvements for tourist season, the drivers are downright polite (such is not the case back on the mainland. The nerve of some people). There seems to be a bit more money down here, but it’s a bit more low-key, folks don’t flaunt it and aren’t arrogant like they are across the bridge. It’s surprising that we found a place at the price that we did, but I think it’s because (1) the building is a bit older and, (2) I think the owner’s paid off the apartment. Shockingly, this is the cheapest I’ve ever paid for rent in Miami – and I’m on the beach! I jog along the boardwalk, my route taking me between the ocean and Ocean Avenue, what with her posh bistros and exotic cars. Know that “punchdub” game, where, if the advertising campaigns are to be believed, you’re supposed to punch someone in the arm if you see a Volkswagen of some type? Nicole and I only play that with Bentleys.

Anyway, 2 weeks ago, I began my family practice rotation at the Miami Jewish Home and Hospital, under the program run by the Center for Haitian studies, in conjunction with Jackson’s residency programs. The family practice clerkship is 6 weeks, and ours is broken up into three sections – the first two weeks of which are at MJHH. It’s a “home and hospital for the aged”, and, initially I was thrilled to be starting with the geriatric part of family – that way I could get it over with. It’s been a few months since I studied hardcore, but it wasn’t that difficult to get back into the swing of things – the required text is atrocious, but we’ve got online access to Harrison’s, so I can’t complain too much. Anyway, this was a nice rotation to begin with – we showed up to the clinic every day at around 9, and then either sat in with a cardiologist, neurologist, ENT doc, pulmonologist, dermatologist, endocrinologist, or wound clinic. We worked with several docs throughout the two weeks who had us examining, writing-up progress notes for, and following up on various patients. The experience was so varied, because these docs weren’t run-of-the-mill family practitioners; they were experts in their respective fields. The previous medical director (who’d just stepped down, claiming that he was getting too old to get dragged out of bed in the middle of the night) had been a 35 year arm-doc who’d published over 200 papers. We saw a lot of dementia, but I guess that should be expected; the median age was somewhere around 85. It wasn’t until the end of the first week that I felt comfortable in my own skin again, with the stethoscope around my neck and short, white coat draped over my shoulders – and by then, I’d come, much to my surprise, to be genuinely enjoying myself.

It was unexpected – I’d walk through the halls and see patients I’d examined; I recalled notes from their charts and specifics about their disease processes like you’d remember something about your friend when you bumped into them unexpectedly. I saw things change – people healed, and people got worse. Patients remembered my name, and their faces lit up when they saw me. I got to know the nurses (I’ve always gotten along well with nurses), and perhaps because of this, I think I got a little special treatment. One thing I had a whole lot of fun doing was the wound-clinic – many of these geriatric patients are quite literally losing their mind and are bed-bound. Overworked nurses are just treading water trying to take care of everyone and turn them every two hours, and so bed sores happen – they’re unavoidable; if old hearts and lungs fail, old skin fails too. Add to that the significant diabetic population, and wound-clinic was never slow-moving. While it was great examining and interviewing patients, and reporting to the attending physicians or just following them around listening, I much preferred working with my hands. Within a few minutes of watching my first wound cleaning and dressing, I was assisting, and by the end of that first session, I was doing it myself and the nurses were assisting me. It was gratifying, because people came in with a problem, and I improved it. I’m not going to treat wounds for the rest of my life, but this reaffirms for me my conviction that I’m going to have to do something with my hands.

Towards the end of our two weeks, JCAHO descended upon MJHH, and, like magic, the docs were no longer available. This slowed some of our plans, because I was unable to go and follow-up with some patients I’d wanted to see, but it all worked out. I had a great time, and felt that all of the docs (some of whom also teach at UM) were fantastic. On Friday, after dropping off some required paperwork, Nicole and I drove out to our next station – a free clinic for homeless and low-income folks. It was hell to find (thanks sprint GPS….), but once we got there, I was pleased to hear from the staff that the medical students were pretty much given free reign; we interview the patients, examine them, and formulate a plan, which we then present to the attending physician. This autonomous, hands-on approach feels to be just what I need – I’m not yet 100% confident in some physical exam things, having done the lion’s share of my practicing on healthy medical students – and this is where the rubber meets the road. This is grass-roots medicine, without fancy diagnostics and expensive equipment; this is a sick, person, myself, and my understanding of the disease process. I’m looking forward to this because, unlike the wealthy MJHH, the people I will see starting on Monday have no other options, and I will do what I can to make them well.

My OBGYN rotation is next – it’ll be fun, but it will also be a significantly different philosophy of medicine than I’m accustomed to…being a man. There’ll be a lot to learn, but what I’m really looking forward to is doing my internal medicine rotation at Mount Sinai – 3 months of nose-to-the-grindstone medicine. At some point, every doc I’ve ever met in my life has asked me what type of medicine I want to go into. I guess some folks just know where they belong. Since Dad’s an interventional cardiologist, that’s the type of medicine I’m most familiar with, and it would be tempting to just hang my hat on that, however, there’s so much out there; medicine develops and changes every day. Thus, when people ask me what I want to do, I tell them about my background, but also that since I’m perched on the beginning edge of my clinical education, I haven’t had enough experience to close the door on anything (I do, however, refrain from relating that I don’t think either family medicine or psych are for me). Nevertheless, in my admittedly limited experience, I’ve come to believe that doctors who have either completed an internal medicine residency or a pathology residency have the greatest fund of knowledge with which to understand the disease process – and so, I’m excited that I’m going to do my internal medicine rotation as such a well-known, well-established institution. It’s also a bit of coming-full-circle; you see, all those years ago in medical school, my father also completed his internal medicine rotation at the very same Mount Sinai Medical Center.

I’m definitely keeping my options open. I may fall in love with surgery. I guess we’ll just have to see.

Now I can read the signs.

I went and got my glasses today - mom and Grandmom helped me pick them out before mom's hair appointment. I must have tried on 30 or so pairs - I don't think it was that many, but I wasn't planning on wearing them all the time. So, I decided on the pair above after deep-sixing a pair with very interesting frames, but too-loose arms. After that, I left the boys and Grandmom in the food court, and headed off to Starbucks to read and await the completion of my corrective lenses. While thumbing through Emotions Revealed, this guy who worked there came up to me, and asked what I was reading. We got to chatting, and it turned out he'd moved down to Harlingen with his wife and 4 month old daughter from Houston, where he worked at this really hippie-sounding cofee shop, and was eager to get the same sorta thing started here. After that, I went back and picked up my frames - and was shocked at the difference. I stole the picture from pfsk.com, to illustrate my myopia. That's honestly what it's like, but it's not something I really noticed; I knew that my far vision was going, but not until I was presented with the alternative (switching back and forth between my new lenses and the naked eye while looking across the mall) was the difference so clear. I won't wear them all the time, but I'm certainly going to take advantage of my upgraded vision.