Life is Open Book: Family Medicine (28/30)

I do miss having this as a view on my commute to work.

These two are alright.

     I've mentioned in previous posts that an important part of clinical rotations is learning to be flexible. This was certainly true regarding my rotation for Medicine 2*. I had originally been scheduled to return to my Primary Care site for a second rotation there, but plans don't always go the way they're supposed to, and, before my initial Primary Care rotation was even over, I found myself working together with my clinical coordinators to find a new site for Medicine 2. As luck would have it, my Medicine 2 rotation was scheduled for the first block after Christmas break, and my coordinators were completely willing to let me pursue a rotation back in Oregon, which meant that I could come back for the holidays and stay for 2 months. It took about 6 months to get all the pieces in place, with multiple people on both sides of the country working tirelessly to make the rotation a reality, and I technically didn't receive the final stamp of approval until just 4 days before my rotation was scheduled to start, but it all went through in the end, which is how I found myself doing Family Medicine in Oregon this January. 

I do not get to see my cousin, or her
kiddos, nearly enough.

     Having almost two full months in Oregon was wonderful. This meant that, even before I started my rotation, I had my own form of "family medicine." I was able to not only live at home with my parents and sister (and kitty!), but also see all my grandparents (even getting to celebrate one grandma's 88th birthday), and much of my extended family. The last time I'd seen my cousin's boys was last Christmas, which was much too long ago (especially given how fast kids grow), but being home for my rotation meant I got to play around with them on two separate visits! I not only had quality time with family, but I was able to catch up with friends, some of whom I hadn't seen in years. Having two months in which to see everyone was so much nicer than trying to cram all the visits into 7-10 short days like I usually have to do. I certainly had less time to hang out once my rotation started, but it was alright because family medicine was quite enjoyable, and chock-full of important lessons, some of which were new, and some which I simply needed to re-learn.

MAs are also super helpful
with doing procedures like
orthostatic vital signs.

     One important lesson I was reminded of was to learn from everyone around you. As students we know (or at least we should know) that we have much to learn from our patients and our preceptors, be they PAs or physicians. Sometimes, however, we forget that there are many more people who can teach us, and, as an introvert, it can be difficult for me to reach outside my comfort zone to talk to yet another unfamiliar person. It's worth it though. Especially when you're a student or new provider, the wisdom that can be gleaned from the MAs, nurses, floor managers, etc. is invaluable. During my first two weeks in family medicine I often worked with an MA who gave me her spiel on each patient before I went to see them. She'd been an MA long enough that she was often quite good at guessing common diagnoses and she usually added a couple tidbits about the patient's personality or attitude. Even if I didn't always agree with her proposed diagnosis or interpretation of the patient's character, I still found her insights helpful, I loved that she prepared patients to be seen by me, and it was always nice to be forewarned when a patient was hostile. 

Picture taken with patient's permission.
I took that hook out, and the next
day removed another foreign
body from an ear.

     Another thing I needed to be reminded of was that sometimes Nike is right; sometimes you need to just do it. In the case of family medicine, this meant being willing to do new procedures and see unusual or difficult patients. Both the PAs I worked with during family medicine performed procedures and provided cross-coverage care  for their practices. This kept the days interesting, as the regular routine of patient visits was broken up by small procedures like skin biopsies or joint injections, and even the regular patient visits were often surprises since many were same day appointments or walk-ins. I'd done plenty of joint injections during my orthopedic rotation, but family medicine was the first time I'd done trigger point, bursa, or tendon sheath injections, and I certainly hadn't done any skin biopsies or fishing hook removals on my previous rotations. It's always a bit nerve-wracking to try something new, and often the desire to learn a new skill is dampened by the fear of failure or disappointing your preceptor. The fact is though, you'll never learn if you never try, and sometimes you have to just be bold and do it. Now, obviously, this doesn't mean that any time a preceptor offers to let you do a procedure you just waltz right in without preparation or supervision. For the trigger point and bursa injections, I followed the "see one, do one" pattern. For my punch biopsy though, my preceptor talked me through the steps before I entered the room, and then watched me do it, providing additional coaching as needed. I'm glad I didn't demand to see one first as that was the only punch biopsy we did, and it's really something you can only learn by doing. Sometimes I was nervous, but both my preceptors were great coaches and pushed me when I was hesitant, usually proving that I was more competent than I'd realized. I say usually because no learning process is ever mistake free. My first shave biopsy was excellent, and I think I definitely got the hang of toenail removals, but the first time I froze a wart on someone other than myself I managed to give them a blister because I had not yet mastered the staccato pattern of administering the freezing spray, which is so necessary to keeping the affected area small. I felt awful when the patient returned with their blistered foot the next day. I still feel awful, and I was definitely reluctant to try freezing the next wart that came through. But I did. You have to. You cannot be paralyzed by fear of failing when learning; you simply have to make sure that you are learning new skills in a safe manner, under guidance, and that you minimize the risk of damages as much as possible. When you do mess up (and you will), apologize and learn.

Impromptu lessons on alveoli and pulmonary
vasculature in different disease states.

     The last lesson I learned was one I really should have known already. In fact, before I started clinical rotations, PA students from the year ahead of me met with my class and even told us about it. The lesson? Admit when you don't know an answer. Now, I've known for a long time how important it is to know what you don't know, and I've certainly made it a point to look up anything I didn't know right away, but admitting when you have no clue is easier said than done. In school you cannot simply leave a question blank on a test or say "I don't know" in the middle of a practical exam, so when stumped you get into a habit of throwing out answers and demonstrating your train of thought, hoping to get partial credit, and it's hard to fight the training of always needing an answer. One of the doctors I worked with during my first two weeks figured this out about me very quickly. He then made a point of asking me questions to which he knew that I did not know the answer, just to see how long it would take me to say, "I don't know." 

A walk-in patient we promptly sent to the ED. The right
picture was taken first, and shows a pneumothorax in
his right lung. 

     In the instance I remember best, he'd asked me to see a patient who had been scratched by a monkey on a visit to a southeast Asian country, and then asked me what we should do with her. I was at a loss. In my head, I was planning to look up the shot she'd been given shortly after the incident to determine what it was and whether she needed more, followed by further investigation into what foreign illnesses were endemic to that area, but the truth is that I could not give any definitive answer as to the plan until I knew more information. Rather than simply saying that I didn't know and needed to get more information, I rattled off what I did know: the incident happened 3 weeks ago, the wound was well healed without any sign of infection, and the patient seemed completely healthy and without any systemic symptoms. The doctor was in the middle of asking me if, based on that, I really thought she could just be sent home, when his phone rang. It was the Infectious Disease consult he'd requested while I was in seeing the patient. The point of his lesson was immediately clear: even physicians who have been practicing for years need to ask for help, or, as he put it, "life is open book. Use your resources." I'll admit that there were still times during the rest of the rotation when I struggled to provide an answer rather than asking for a minute to do some quick research first but I did learn. In an interesting twist, I even discovered that you sort of can answer "I don't know" on an exam in PA school. When I did my OSCE,* I forgot to ask my "patient" one part of her history. It didn't actually affect her diagnosis or treatment, but when my proctor asked me a question that related to this information, I had to answer with, "I don't know, but I can ask the patient." My proctor smiled, thanked me for not making up the information, and passed me. In medicine, as well as the rest of life, honesty (and humility) really is the best policy. Acting the "cowboy" might save you some embarrassment, briefly, but sooner or later, it will hurt your patients.
     There are far more lessons I learned, and far more stories I could tell, but time grows short and this post grows long, so instead I'll simply leave you with this bit of advice from my beloved Dutch Bros Coffee: 

*All PA students are required to have two rotations in general medicine, one of which should be inpatient, usually internal medicine. The second is more flexible and can be in anything from primary care to family medicine to women's health to rehab to geriatrics, as long as it's not overly specialized. 
*Objective Structured Clinical Examination -basically a practical skills exam that all medical and PA students have to perform and pass in order to graduate. Part of it includes performing aspects of the physical exam as instructed, and another part is taking the patient's history, asking for the physical exam and lab findings (without actually performing the exam), and presenting your assessment and plan to both the proctor and the patient in medical and then layman's terminology.