Tuesday, September 30, 2008

Always room for improvement!

This rotation is ending so quickly it is unreal! Already in my last full week of psychiatry and just about time to take my shelf exam and move on to OB/GYN. Things are still going well and feel very comfortable still with working in this department. I still feel like I could be really good at it but don't know if it is right for me. But that is what it is all about, right? Constantly learning, constantly learning about yourself and what you can improve.

Even today, I had to interview a patient for a suicide attempt by overdose. I've done my fair share of these in my rotation - so sure, no problem! It went smoothy and the case was presented back to the department heads. After the interview, I was immediately in the patient's defense. This was no suicide attempt nor was she drug seeking. Some thought from their many years of experience that they knew the diagnosis right off the bat. While I respect their long career and endless patient encounters, it really turned me off that barely through part of my presentation, it was - oh has she been in rehab? - she must have known what she was doing! - or even the rolling of the eyes from the nurse about her and the jokes made from the Internal Medicine doc of how she must have been so desperate to get high. It was an utter turn off. Is this what years in medicine do to people? Make them this cynical?? It was truly disappointing. Luckily, after my presentation it was time for round two - the doctor to do a bit of interviewing after me. Afterwards, they were convinced that she was a legit patient in a great deal of pain that was only taking medications because her previous pain management doc is not longer available and she has been out of her pain medications for months, left only to OTC medications she was left to desperate measures of going to buy something a bit stronger off the streets . While social work needed to help find her a new place for pain management, it was found that she indeed was not suicidal.

Room for improvement, no?

In that interview, all appropriate questions were asked for such a consult. Specifically, feelings of depression - denied. History of abuse - denied. But when the physician came in for the evaluation, confirmed and confirmed to both questions. UGH, I thought. You just told me 'no'! Why did she lie? Ok, ok... those were my first thoughts. After thinking about it, I realized that during the interview how much she was holding back, trying to be strong for her family as she was known as the strong one. Then I thought about what I did wrong and found that the way I asked those questions weren't as good as they could have been. At times certain questions in some interviews may appear unconnected or less important so they are asked quickly with the interview then continuing on.

Room for improvement again!

I now have a better understanding of how to at least attempt in opening up patients more, after looking to myself and what I could have done better and not blaming the patient for 'making me look bad'. Because of her I will be better and so will others if they let themselves truly think about how their countertransference plays such a huge part in professional and adequate treatment.

Finally, tonight my mother and I watched a program on Public TV about those with no health insurance. Alright, talk about room for improvement! It is so easy to look at the uninsured as immigrants, the voluntarily unemployed, etc. Just the toil that these families went through was unbelievable. Prospering families, stricken with a horrific illness or debilitating accident had left them with less than nothing. Even those with insurance, but not covering every single base left them without a basic necessity, for example a leg. This man lost his leg and was unaware his insurance didn't cover him, as the insurance company approved his visit to get the prosthesis. So here he is with his new ~$10k leg (by the way which was supposed to be only able to last 4 months) and all they can do now is hand him the bill. Finally now able to go back to work and a year and a half later still on the same old prosthesis waiting for benefits to kick in for his family of 5 - but of course with pre-existing conditions would probably not cover him anyway.

I could go on and on but just the constant need for everyone in medicine and for the system as a whole to improve is seemingly overwhelming but its water that we must tread. Drowning in this sea of uninsured, debt, MORE debt covering the uninsured (many with chronic illnesses because without some very basic health care, they were unable to get the medicine for which a simple pill probably would have cured them 5 years ago). Sigh. Definitely preventative medicine in this election is key, one which is the gateway to a less strained (already stretched) health care system. I just hope that our future, with all that has been going on as of late, gets stabilizes enough to instill a plan of action worth our time and hard earned money. I hope that the next president realizes that more than abroad - many domestic issues have gotten too ignored for too long and it is time to reel it in before insurmountable damage is caused... if not already so...

Monday, September 15, 2008

Will it be worth it?

Onto week 3 of Psychiatry and things are going just fine. I am learning a great deal and feel like I am getting a wide exposure thus far to the specialty. While I do enjoy pretty much each day to the fullest, I really don't know if it is a residency for me. I really think that it would bring me down after a while and unless I was doing psychotherapy (talk therapy) I don't know if I would feel like I am getting to do what I feel is my full potential for helping people the way I want. Three weeks from Friday is my shelf exam and then onto OB/GYN! Moves fast it seems but sometimes it also feels like it can be dragging in the long run of things.

My emotions as usual are up and down. I truly believe that after my time here in Saginaw (finished June 5th, 2009) - things will be yet one more step better than things were before. I am just struck with all the guilt for leaving Tony home alone to take care of things and our dog, feeling so sad sometimes that I am STILL away after beginning this process September 2006 and feeling very much tension and anxiety awaiting for this stage to end and the next to begin.

I know that time is moving by fast and how lucky I am to be here but when you are in the thick of it - sometimes it feels like walkin' through mud. This is all I have ever known that I wanted to do with my life and I know I was meant for it, but this long, loooong road takes such a toll. Looking back I see how much I gave up, effort I put in and time I have dedicated to being where I am today and it really makes me feel better in the sense that I can see how far I have come. On the other hand, I think to myself sometimes - will it be worth it? I worry about the debt, if I will be able to start a family when I want to and even if I will be an effective enough doctor to make a difference - to get to the point in my career when I find that through my work with patients, it was indeed worth all the hassle, adrenaline and tears.

I am sure that it will all be fine but yet again I am hitting a tough patch lately. I think I should look back to my island days because for some reason it seems like I am hitting more of these times than I did there! Maybe it is because I am still in somewhat of a transition, even though I am 3 weeks away from finishing my second rotation. Just when I am getting into the swing of things, Step 2 is around the corner, CS (clinical skills) in particular. I have decided that I will be taking this in mid-April and signing up probably within the last week to take this. My CK (clinical knowledge) which is like Step 1 will take place probably in September, after my IM rotation and my wedding (yay!).

So many things on my mind now it is unreal. Then again, it has always been this way. I can't remember a time when it wasn't. Oh yeah I do - and it drove me crazy! Wierd huh? Seriously, now anything over a week or two and I get so stir crazy without tasks or goals. Is this even a good thing, lol? Sigh, well at least my rotation permits me to have my weekends free so each weekend I make my way back home to recover and put things back in perspective. I thank God for my home, family and friends. Sometimes I lose sight of how good I have it at home and being out living on my own is a great reminder of how badly I do want it back - days when I can sit in my own house and put those suitcases away for vacations rather than yet another move for my career. That day is coming, even if it doesn't feel so. I just need to be constantly reminded and hopefullyone day, when that day comes, I can look back and say not only that it was worth it but it was the one of the best decisions I have ever made.

Don't Quit
When things go wrong as they sometimes will,
When the road you're trudging seems all up hill.
When the funds are low and the debts are high,
And you want to smile, but you want to cry.
When care is pressing you down a bit,
Rest if you must but don't you quit.
Life is strange with its twists and turns,
As everyone of us sometimes learns.
And many a failure turns about,
When you might have won had you stuck it out.
Don't give up though the pace seems slow,
You may succees with another blow.
Success is failure turned inside out,
The silver tint of the clouds of doubt.
And you can never tell how close you are,
It may be near when it seems so far.
So stick to the fight when you're hardest hit -
It's when things seem worst that you must not quit.

Wednesday, September 03, 2008

Starting up in Psych...

My second rotation is underway and it is quite interesting for sure. I am still adjusting a bit to it and tomorrow I will complete week 1. Compared to Family Med, there is no where near the patient load (at least so far) that I am used to. I have been told that it has been a light week so maybe it will pickup next week but who knows. The consults however are much, much longer than FM. Today, I finally got to start the process of interviewing psych patients on my own and the interview lasted a good 45 mins or so. It was a case of depression which was a nice transition into the rotation, as this is the most common complaint to receive. Nothing really too difficult though. Prior to beginning this rotation, I have been doing my reading up on psych interviews, flow of questioning and laying out all of my handy mnemonics for psychotic disorders, mood disorders, PDs and more.

I do not think that this rotation will be overly difficult but I am very much enjoying it so far. I have not crossed out psychiatry as a specialty but already I can see how it would be a tough job, quite demanding of patience and energy. On the first day of the wards, I already got the pleasure of getting the "boot" out of the room. So many patients just hear "psychiatry" and feel the need to express how they are not "crazy" or "retarded". It is a shame that so many people feel that there is shame in talking to physicians in such a field. So far, there has been a couple suicide attempts, one in which I saw and plenty of BPD (Borderline Personality Disorder) to go around for all.

The biggest adjustment I think that I am making is getting used to different styles. For my first two weeks I will be in the hospitals then rotating a bit around with other physicians. While in the hospitals, students could be with one of three people - all with different styles of teaching, interviewing and treatment. In FM, it was better because I had one great model to follow and it made it easier to develop my own style quicker that would fit the liking of my preceptor. Now, doing interiews one way, isn't necessarily liked by all. So far, I am in no way getting any heat from how I do my interviews or presentations, but I assume getting to know my teachers (albiet - quickly, as I rotate from person to person on nearly a daily basis) will aid in my ability to blend better with them. I find that I have a pretty good flow with my interviews and alternately, many just do "bulleted questioning", sometimes not allowing the patients to really speak much. Of course, some patients have that gift of going on and on - but to me there are more creative and less abrupt ways of directing the interview to where you would like to go for investigation.

Also, I am finding that some of my teachers go above and beyond what we were initially called down to do. For instance, an initial depression consult (which was stable and basically a recheck) turning into a mild (very mild) dementia - ordering brain imaging, fixing metabolic disturbances noted in the electronic chart, etc. At first, I was turned off. Why were we doing this? It just seemed out of the realm of what we were called down for. It seemed like just doing it to... well, do it. I know that in consults you have to do what you can for the patient and CTA (cover your... hiney!) but I didn't know if it was thoroughness or overkill. Furthermore, the patient was even happy with her medication for her depression and felt that it was doing a good job as now with her recent illness, she is now facing the difficult adjustment of being more limited in her life activities. After discussing increasing her dose of her MAOI, she was not interested and already didn't feel completely comfortable taking any mediation for it - yet the executive decision was made to increase her dose anyway, of which was known to all but the patient, as this decision was made post-interview while charting. Even now, I feel it bad to cast any judgement on my preceptors (like my one week has any bearing at all on their lifetime experience) but it just really opened my eyes keeping an open mind to look at the bigger picture at times than just focusing in on the one thing that you were initially investigating.

Sigh, it has been an interesting few days though and I know it will be a really great experience in the weeks to come. The psych department here is really into teaching the students and getting us some wonderful exposure to a vast array of clinical senarios and ethical issues. Now, onto finish week one - I wonder what tomorrow will bring? :)

Monday, September 01, 2008

Back in Saginaw...

So, the journey continues. I am finally feeling quite settled in now and only awaiting the cable to be hooked up this week, which I am getting along fine without. It is so much different than the last time I was here. Last time, I was in a hotel two doors down from a friend to hang with and now I am in a pretty big apartment - alone. It is so quiet and it feels too big of a space for one person to have. Just have that lonely feeling creeping up on me again which I cannot stand. Sigh... On the up-side though, I had a wonderful Labor Day weekend at home with Tony and Maggie and miss them already. I even got to buy my wedding dress! YAYY! It is so beautiful and I just fell in love with it so long ago (found it while I was still on the island, haha). So now 3 things are down: church, reception hall and a dress! But alas after the weekend, it was time to head back. Maggie watched me pull out of the driveway again (getting used to the routine that mommy has to go away again) and ran after my car and jumped up to the window to give me kisses. Next time I see her she will be already fixed and probably in some pain which makes me sad I won't be there to take her in but at least I will be there by the time she checks out of the vet.

My apartment here though is very nice and fully furnished with towels, sheets - even silverware, pots and pans. Very easy transition, which is nice considering each time I do this "moving" business I grow bitter and am finding myself exhausted emotionally. All I keep hoping is that this will all be worth it. It's funny how on the island it seemed that it was flying by. I mean, it still does but now it is beginning a whole new chapter to medical school and I can't help but feel like it may never come to an end and I will never be permanently home. I'm exaggerating as I know I will be soon (hopefully only having to do my 3rd year away) but this process just feels so much longer than I anticipated. I can't imagine doing this schooling only if it was because my parents wanted me to go into medicine or only because my relatives were docs before me - without that passion, I know I would probably have stopped a long time ago. I just feel in the thick of it now and I guess that is better than starting from scratch. Soon enough I will be leaving the deep end and coming back to shallower waters where I can finally find my footing again - hopefully enough to walk those things on home, haha.

Anyway, so last week was our orientation to Synergy Medical Eduation Alliance, which I had already done in 5th. No real big deal at all but now since the long weekend is over, it is time to do my clerkship orientation - psychiatry. They said to dress for clinic so I am not sure if it means that we will be starting immediately or what but I have been trying to do some reading to get refreshed in psych. Nothing else much to do here anyway. Soooo, I guess that is my major news for now and I will let you all know how my 1st day of my second rotation goes! Just a hunch but I do think I will enjoy psychiatry alot - let's hope that is true!