Today's post is just a super quick update on my previous post PSA: Donating. The first thing I have to say is that the Red Cross seems to have taken a cue from Sweden, and are now letting donors know when their blood is used, which I think is pretty excellent. I feels like a much better way to motivate people to donate again than to call them every. single. day. When it comes to donating your body to science, this recent podcast from Stuff You Should Know provides a lot of information about just what that means and the different ways you can do it: How to Donate Your Body to Science. Lastly, even if you can't, or don't want to, donate blood, marrow, or organs, there's still another way to donate your body while you're still alive: let medical students (no matter whether they're future PAs, MDs, NPs, RNs, etc.) examine you or be present during your exams. I cannot express enough just how valuable it is for me to practice examining real patients or even simply observe as my preceptor examines them and explains their findings and the patient's conditions. For an example, Charcot-Marie-Tooth is no longer a vague concept in my head, but a disease whose symptoms and treatments I can easily remember because I can associate them with the kind woman who said yes when my preceptor asked if he could use her as a teaching tool. Yes, it can be awkward, yes, students will make mistakes, and yes, your appointment might go a bit longer, but the experience you give to future healthcare providers is invaluable. Really, in the long run you're helping yourself, and everyone else, by helping make tomorrow's clinicians the best they can be. There's an added benefit for you as well since things are less likely to be missed if two people are covering your history and exam, and there's also a decent chance that you'll understand your own condition better once you hear it explained to someone else. Consider it.
Primary care is an odd duck. It's certainly not the most glamorous part of medicine. Patients come in complaining of colds and acid reflux, not trauma wounds and surgical emergencies. It's not exactly the stuff of primetime medical TV shows. It can be tedious and monotonous, and it's no wonder that many primary care doctors become burned out over time. A large part of the burn out is the feeling of repeating yourself over and over without being heard. Much of primary care deals with treating chronic conditions and, more importantly, using preventive medicine to prevent these conditions in the first place. The focus on preventive medicine means that the same topics (e.g. exercise, healthy eating, safe sex, smoking cessation etc.) are covered with almost every patient, yet it can feel like an exercise in futility. It can seem like the patients who are doing well already know and follow the advice you're giving them, and the others have heard it all before and have ignored it. You can't help but ask why they would suddenly listen to you now.
A big part of the problem is that primary care battles against silent killers. The diabetic doesn't see the importance of keeping their blood sugars under tight control until they discover the foot ulcer they couldn't feel and suddenly face losing their toe. The patient with high blood pressure doesn't take their medications consistently until they have a hypertensive emergency. The alcoholic doesn't cut back on their drinking until they develop cirrhosis. The patient with high cholesterol doesn't change their diet until they have their first heart attack. The morbidly obese patient doesn't try to exercise until they realize it hurts too much too move. When you try to prevent problems rather than treat known issues, it's easy for patients underestimate their risks or think that they will be the exception. There are some tricks to get your message across, such explaining to the man with high cholesterol that his eating choices and smoking habit not only increase his risk of a heart attack but also decrease his ability to achieve and maintain an erection, yet all too often primary care can feel like an uphill battle, fraught with frustration.
This is not good.
PA-Cat Bob approves of PCPs
Here's the thing though: primary care might not seem like the most interesting or the most glamorous, but it is arguably the most important specialty in medicine. A primary care provider (PCP) might not be using their fingers to plug lacerated arteries and they might not be compressing a chest just to keep someone's blood pumping, but they are saving lives. They're helping to prevent patients from ever getting to that point of crisis. PCPs are the gatekeepers, responsible for recognizing the difference between when a patient has a common or manageable condition, and when they need to seek a specialist's help. They are the providers who are there for their patients at all stages of life, who get to see their patients in sickness and in health, and who have a truly awesome opportunity to get to see the whole picture of their patients rather than simply how a patient presents in a crisis. And who knows? PCPs might just make that once in a lifetime save after all. The man a PCP works up for iron deficiency anemia might turn out to have esophageal cancer causing an upper GI bleed (and thus the low iron levels). The young guy with pneumonia might have a carcinoid tumor that no one else caught before because they treated the immediate problem and didn't notice the suspicious recurrences of lung issues. The PCP who actually takes time to listen to his female patient and not be biased by the opinion of previous providers might recognize that her malnutrition and frequent bouts of vomiting are actually due to celiac sprue and not an eating disorder.* I don't know whether or not I'll end up in primary care, but I do know that after my rotation I appreciate it, and the potential impact it can have, more than I did before. With this in mind, I have some suggestions now for anyone who will ever be a primary care patient (aka everyone).
Find a provider you like -I'm not saying you have to be picky and find the best clinician ever, but this is a potentially lifelong relationship you're starting, and there are certain characteristics you should look for. You should find a PCP who listens to you, addresses your concerns, and takes the time to make sure you understand any conditions you might have. Find a provider who is open and honest with you, and is willing to let you seek a second opinion if you're not sure about their advice. If a provider spends less than a minute with you, that's a bad sign. If they spend more time with drug reps than patients, that's a bad sign. If you feel like you're nothing but a nuisance to your PCP, that's a bad sign (unless you are being a nuisance; don't be that guy). You should know what your conditions are, what your medications treat, and why tests are ordered. Now, this last statement certainly requires you, as the patient, to actually pay attention when your PCP explains everything, but if you still have questions, you should feel safe asking them.
Get screened -A large part of preventive medicine is screening for certain conditions before they become a problem. While some PCPs may differ slightly in some of their screening techniques (e.g. getting blood work on all patients annually at any age vs. periodic checks after age 40), there are standard guidelines for many conditions which are continually reviewed and revised if necessary. For example, in general, sexually active women should be getting pap smears, women over 40 should be getting mammograms, and adults over 50 should get colonoscopies. The exact timing of these screenings might vary somewhat from person to person based on each individual's risk factors, but your PCP should know the guidelines and how to apply them to each patient. While I know that many people are afraid to be screened for medical conditions because some screening methods are uncomfortable and because sometimes it seems like ignorance is bliss, but the truth is that even if a screening test comes back with an unpleasant result, it's far better to detect conditions early when they're asymptomatic and there's hope of potential prevention or treatment, than later once they've become symptomatic and treatment is much more difficult or merely palliative.
Show up on time to your appointments, and call if you're not going to make it -This isn't some huge, life-shattering advice; it's just a courtesy that can be easy to forget. Both in my women's health and primary care rotations I experienced time after time of waiting at an office with all the MAs, nurses, and the PCP because a patient ran late or didn't call to say they wouldn't be coming. If there's limited time for lunch, or if it's at the end of a long day, you can bet most of the people in the office are pleased as punch to have patients who show up right on time (or even a little early), or who call to say when they're running late or can't come.
There's more that I can (and probably will at some point) say about primary care, but tomorrow starts my week in orthopedic surgery, which means I'm back to a 3:15 AM wake-up call rather than my leisurely 5 AM alarm for my weeks in the surgical offices, so it's time for me to go to bed. *These are all true examples, by the way. The first two come from a PA and an MD I know, and the third comes from the book How Doctors Thinkby Dr. Jerome Groopman.
When you start clinical rotations, you’re prepared (at least in
theory) for certain difficulties. You don’t know your schedule ahead of time,
though you know that it will change every five weeks, the emergency medicine
rotation will likely have odd hours, and you will probably have to wake up very
early for the surgery rotation. You’re told that you will likely feel like you
know nothing at first and that any time not actually spent at your rotation
site will probably be consumed by studying. You know that some rotations will be
better than others, but that even the worst ones will end. Then the first day
comes, you take a deep breath, and you step into a new realm of uncertainty. It’s
not just for the first rotation either; each rotation is different from the
last and while you may quiz your peers on what to expect, you still face each
first day of each rotation with a blank slate and lots of questions. What does
your preceptor expect from you? What are the typical hours? Are there typical
hours? Will I be quizzed constantly? What will the other students be like? Will
patients refuse to be seen by me? What if I completely botch a procedure? What
if I forget all the medications I ever learned? And on, and on, and on... The
truth is, the questions never really stop, they just change into new questions.
By the time you finally start to feel comfortable at one rotation, time’s up
and it’s time to go some place new.
Before going into an appendectomy at 11 AM, and then later at
midnight, with at least 7 hours still left to my overnight shift.
The key to keeping sane
sometimes is to just be flexible. Some rotations will never give you a clearly
defined schedule and you just have to live day by day. For some rotations your
preceptor changes daily, so you’re constantly adjusting to new and different
personalities. For some rotations you realize that the experience of your peers
might vary vastly from yours, sometimes based on what seem like tiny details.
For example, I am currently on my surgical rotation, which includes an
overnight shift during the week of general surgery. The thing is, because I’m
in general surgery first, my “week” is actually one day longer than the other
weeks of this rotation, so there is a definite possibility that I may have to
do one more overnight shift tomorrow, even though I already did one last week.
I will admit right now that I am not thrilled about this prospect, particularly
since the “overnight” shift actually goes from pre-rounds (5 AM) of one day to
post-rounds (approx. 7:30 AM) of the next and sleeping rarely happens, but if
it has to happen, it has to happen. Rolling with the punches and adjusting expectations is just part of the clinical year. I’ll
probably do a post in the future about some of the other difficulties of the
clinical year that don’t often get discussed (What if your preceptor is a bad
teacher, or worse, a bad clinician? What if the preceptor for your next
rotation decides to reture? What about all the non-rotation related things that
can cause problems, like cars or living situations?), but right now I need to
grab some lunch, read up on laparoscopic cholecystectomies, and attempt to get
the electricity account transferred from one roommate to the next, so it's time for me to sign off. UPDATE: a kind medical student volunteered to take the overnight shift so I didn't have to do another one. It was only later that the chief resident informed us that a student wasn't necessary for every overnight shift anyway.
I started my June post remarking how surprising it felt that yet another month was over and that I was already in another rotation, and I could repeat those exact same thoughts now as July ends. Even though graduation next May still seems years away, the days have flown by ever since I started my clinical rotations. Since my last post I've completed my time in women's health, and I'm already done with two weeks in primary care. Leaving women's health was even more difficult than leaving my psych rotation, so before I move into full general medicine mode, I have some reflections from my time there.
This has nothing to do with WH, I'm just
proud of my first batch of cold brew
that I made with my coffee sock.
The first is that you learn to get over awkwardness in women's health. I'd say you get over it quickly, but that's not 100% true. There were still days toward the end of the rotation when it felt odd to ask a woman about her bathroom habits or if she had any discharge, not to mention all the times I said, "you're going to feel me touching you" or "do you have any irritation in the vagina?" Asking about a woman's sexual habits was pretty awkward at the beginning as well, especially if you started realizing those women were the same ages as some of your female relatives. That being said, my classmate and I needed to get over the awkwardness quickly. All these questions weren't asked just for kicks and giggles. They were necessary to get to the bottom of a diagnosis, determine if treatment was working, and figure out how a patient's issues were affecting their life. Plus, I quickly realized that the answers were not ones I could just guess or assume, especially when it came to sexual activity. A 50-year-old might look at me as if it was was crazy to imagine she might still be interested in sex, whereas a 79-year-old might answer "yes" so emphatically that it would seem crazy that I could think a woman might ever lose interest. There were a few women who asked why I needed to know, and at the beginning I might have wondered myself, but it was amazing how asking such simple questions could lead to important diagnostic information. I think of the women who'd given up sex because it had become painful or uncomfortable, but who had never mentioned it to a clinician because they were too embarrassed or because they thought nothing could be done, and then how elated they were when we could tell them that there was in fact a treatment for their interstitial cystitis, or vaginal atrophy, or pelvic organ prolapse, or whatever their particular problem was. It was pretty rewarding to be able to give someone back a part of their life.
The second reflection is a bit of a long one. It began with how we joked frequently during my rotation that being a woman sucks. Sometimes it was the playful joking of saying that women go through the awfulness of periods just so we can go through the agonizing pain of childbirth, or that once you hit menopause everything starts falling out (at least one kind of prolapse was found in 14-34% of women in the WHI study, and some studies think this is closer to 50%). At times though it was a rather dark sort of joking, especially when you looked at statistics. For example, 1 in 8 U.S. women will develop breast cancer in their lifetime. That sucks. Cancer of reproductive organs in general has the potential to be more deadly for women than for men because the reproductive organs of men are more easily examined, whereas the reproductive organs of females are primarily hidden inside the body. To often this means that symptoms of a cancer are not detected until the cancer has progressed and spread, a primary reason why ovarian cancer is the fifth leading cause of cancer death in women, even though only 1-3% of women will ever get ovarian cancer. Looking at younger females, 1 in 15 sexually active young women (ages 14-19) will have chlamydia at some point. This is can be quite tragic since chlamydia is most commonly asymptomatic in females (possibly as few as 5% have symptoms) so it's not treated, but left untreated chlamydia can lead to pelvic inflammatory disease (PID) in at least 10-15% of women. PID in turn can have drastic effects on a women's fertility: 1 in 8 women with a history of PID will have a hard time becoming pregnant, and the rates of infertility increase dramatically with each incidence of PID. For any woman who does become pregnant, she then faces the possible heartbreak of a miscarriage. Depending on which study you look at, miscarriages happen in 31% to 70% of pregnancies, though most of these occur early in a pregnancy, often before the woman even knows she's pregnant. Still, 15-20% of confirmed pregnancies end in a miscarriage, a rate much higher than many people realize, which can lead many women who miscarry to believe that the miscarriage was their fault or that they must suffer alone because they think no one else knows their pain.
The hardest statistics to look at are the ones where a woman's suffering is not related to purely medical causes, but to what other people do to her. For example, there's the disturbing statistic that the rate of abuse of women INCREASES during pregnancy. In the UK it's estimated that 30% of domestic abuses begins when a woman becomes pregnant, and in the US almost 1 in 6 pregnant women have been abused by their partner. The fact is that I need to be more concerned about screening pregnant patients for abuse than for preeclampsia or gestational diabetes because the rate of abuse for pregnant women is higher than the rate of both those conditions combined. That's absurd. Even if a woman is not abused during pregnancy, chances are she has already been abused in her life because studies show that 1 in 4 women in the US were sexually abused as children. While I may not have statistics for it, there also seems to be an alarming number of women being sterilized against their will. I saw 3 such patients over the course of 4 weeks. Three! That's a lot in such a short time frame. These weren't old women either; all three had been sterilized by force or without their knowledge within the last 5-20 years, so this is a current problem. While all 3 were from countries other than the U.S., this is not solely a foreign problem. California didn't pass a ban on forced sterilization of prisoners until last September, and that only after an investigation had revealed over 140 females patients were coercively sterilized between 2006 and 2010, at least 39 of those without legal consent. This doesn't just suck; it's horrifying.
Shout-out to the woman who first introduced me to the
beauty and strength of being a woman: my mom
I could leave this post right here. I could end with the conclusion that women have horrible lives due to their own anatomy and the injustices of society. I could do that, but I won't, mostly because I disagree with that as a universal statement, and also because that's just not the conclusion I got from my rotation in women's health. Over and over again I was presented with the sheer strength of women. Sometimes it was the forceful strength of the woman in labor, pushing with all her might. Sometimes it was the quiet strength of the woman who'd suffered in silence, simply plugging away with her life despite lasting discomfort. Sometimes it was the plucky strength of the older woman who'd wink while reminding me and my classmate that "it's a terrible thing to grow old." Sometimes it was the resilient strength of the woman who'd faced injustice after injustice and hadn't let it break her. I've never really used the term "girl power" (at least not seriously), but there was something about working with women every day that grew in you the feeling of sisterhood and camaraderie. Yes, sometimes my patients convinced me that women were completely crazy (especially during my first week), but they also convinced me that I could work in women's health and really enjoy it, even the parts that aren't all pregnancy and babies (though there is something simply magical about locating a fetal heartbeat on your own for the first time... and every time after). Is women's health where I'll end up? I don't know yet, but I'm so very grateful that I was able to spend 5 weeks there. And now as I close, some last few bullet point thoughts*:
KEGELS! No matter your age, women, you should be doing these. They might not be the most effective treatment once a problem like prolapse develops, but starting them early might help prevent some problems from developing in the first place.
Uteruses are overrated. They're good for growing babies but after that they're more of a nuisance.
If you are menopausal or postmenopausal, a local estrogen (either a ring or a cream) is something you might want to talk to your gynecologist about.
Coconut oil has a surprising number of uses.
If you're being abused, or you think someone you know might be, do not keep quiet. There are always ways out and always ways to help. Obviously this post was focused on women, but this point applies to anyone, male or female. Oh, and while we're at it, instead of just helping someone who is being abused, let's work on creating the kind of society where abuse is neither tolerated nor encouraged.
Don't rule out a male gynecologist. My preceptor was a man and he was one of the best doctors I've ever seen. My classmate and I both talked about how we want to be clinicians like him one day, and you could tell his patients loved him. Sure, some women admitted being nervous about seeing a male gynecologist, but it was well worth it for such excellent care.
On a similar note to the last point: Ladies, be nice to the male students. It's always going to be awkward to have a student in the room for these kind of examinations (and a few patients did turn away me and my female classmate), and it can seem even worse if the student is some young, attractive fellow, but if your clinician asks if you mind having a student in the room, please consider saying yes. The practical experience is invaluable and many of my male classmates have left their women's health rotations frustrated because no patients would let them see them. Just think about it.
Turtles know the proper way to enjoy sunshine.
If you've made it all the way to the end of the post, congrats! It was a bit longer than my usual posts, and somewhat lacking in photos or catchy songs (I was unable to find a song that adequately conveyed the idea of "if you're a girl there's a good chance you'll face societal injustice, multiple forms of abuse, the pain of your own body working against you, and when you' go through menopause everything will go to pot and/or fall out, but it's ok because girls are awe-inspiring and amazing," so if anyone knows of one, let me know), but I had a lot to say after this rotation. Who knows what I'll have to say after my time in primary care. For now though, it's back to the books to review all the intricacies of diabetes, coronary artery disease, hypothyroidism, and basically everything else in medicine. Hopefully I'll emerge from my study cave to get at least a little vitamin D this weekend. :)
*I'm not a licensed or certified PA yet, so any medical advice is simply a suggestion. Talk to your own healthcare provider further if you have questions.
Two summers ago I did a short PSA on drowning because many people don't know how to recognize the signs, which are often subtle (not the thrashing and yelling that Hollywood teaches us to expect). Today I present another PSA on a topic that has the potential to save even more lives: CPR.
First, I have some quick background info. CPR is used to treat cardiac arrest (also called sudden cardiac arrest or SCA). While a heart attack can lead to SCA, the two are not the same. In a heart attack, a blockage in the heart's blood vessels deprives areas of the heart of oxygen, which causes the affected cells to die, resulting in pain. The heart will usually continue to beat though. In a SCA it's the electricity of the heart that is affected. The normal electrical systems of the heart that control heart rate and rhythm stop working, and thus the heart stops beating completely, often without warning. There are many possible causes of SCA, everything from coronary artery disease to inherited heart defects (e.g. hypertrophic cardiomyopathy, valve diseases, Brugada syndrome) to stress to drowning to simply being hit in the chest by a baseball at the exact moment that the heart's electrical system is vulnerable (i.e. commotio cordis). If a heart attack is left untreated, it can also lead to a SCA once enough cells die or enough scar tissue forms. Because it is the electrical system of the heart that is failing, victims of SCAs require immediate defibrillation to "jump start" (so to speak) the heart and get it to beat properly again. If the heart is not beating, oxygen is not being delivered to the rest of the body, including the brain, and permanent brain damage can occur within 4 minutes, and death typically follows by 8 or 10 minutes. This is especially concerning because, as their name implies, SCAs often happen without any warning (the first sign is typically when a victim loses consciousness) and 88% occur while a victim is at home, away from the immediate help of emergency services.
About right now you might be asking how all this affects you. If you're not a healthcare professional, you might never be trained in how to use a defibrillator, which is what a person suffering from an SCA most needs. However, anyone can be trained to perform cardiopulmonary resuscitation (CPR). While CPR typically does not cure an SCA, it buys valuable time. By keeping the heart pumping, CPR ensures that oxygen is still delivered to the rest of the body and thus staves off the death of other cells until defibrillation can be performed and the heart can resume pumping on its own. According to the American Heart Association (AHA), CPR can double or triple a victim's chance of survival, but in the US it is performed in only 32% of cases. So what can you do?
The simplest answer is to take a CPR class. The AHA and Red Cross regularly offer classes in Basic Life Support (BLS), which includes training in the performance of CPR and the use of a defibrillator, and often includes training in the Heimlich maneuver as well. Classes do not cost much, last a couple hours, and are offered in different versions for laypersons and healthcare professionals. If you don't have the time or money for that, at least learn the basic steps. They've been simplified over the years to encourage more people to learn them and they're rather easy now. As depicted in the graphic to the right, the first step is check a person for responsiveness. You can yell at them or rub their sternum with your knuckles, and then check for breathing. If they don't respond at all and/or they're not breathing, move to the next step. If you're by yourself, call 9-1-1. If someone else is with you have them make the call and send them to find an automatic external defibrillator (AED) as well. Next, begin CPR. The AHA currently recommends that laypeople do what they call "compressions only" CPR, which means that you don't have to stop to give the victim breaths. You simply need to "push hard, push fast" in the center of the victim's chest. Ideally you're pushing at a rate of 100 bpm, and you're allowing for full recoil of the chest, but the fact of the matter is that poorly performed CPR is still going to be better than no CPR at all. Even if you are incredibly nervous (and that's normal), it's far better to start compressions than to sit around wringing your hands waiting for EMS to arrive. If you're scared of hurting the victim the fact is that they are already dead (at least in a cardiopulmonary sense), and your attempts to provide CPR can only help. The bottom line: just try. Still nervous? Here's a 90-second video explaining how to perform CPR, complete with cheesiness and the Bee Gees.
Lastly, I'll conclude this PSA with some encouraging news about CPR from Sweden. Almost one third of Sweden's population of 9.6 million is trained in CPR. That fact in and of itself is pretty amazing and worth celebrating, but the Swedes continue to go above and beyond to find ways to help their citizens survive a cardiac arrest. In The New England Journal of Medicine published June 11, 2015 Swedish researchers published two articles back-to-back that explored the effects of early CPR (before EMS services arrived) and on how to dispatch laypersons to the scene of an out-of-hospital cardiac arrest. The first study showed that when CPR was initiated before EMS services arrived, a victim's chances of surviving increased from 4.0% to 10.5%, a significant increase. The second study looked at the use of a new app for people trained in CPR. When a call is made that someone has just suffered a cardiac arrest, the app will notify any users within 500 m of the incident and dispatch them to perform CPR until EMS arrives. This study found that the app resulted in bystander-initiated CPR in 62% of the incidents, as opposed to 46% in the control group (still better than the US average of 32%) when the app was not used. Already some cities and counties across the US are trying to create their own similar apps. Who knows? In a few years or a decade, maybe bystander-initiated CPR will occur in 75% or 80% of cardiac arrest cases, and maybe we can bring the survival rate higher than the dismal 4% or 10.5%.
Greenlawn Cemetery, a great place to relax if I get home early
Yet another month has come and gone, and with it has come the end of my psych rotation. Going into the psych rotation I hadn't expected that I'd be sad to leave it, but I was. I had a great preceptor who taught me so much and who helped me grow as a practitioner, and I was surrounded by so many other healthcare practitioners who were just as friendly, encouraging and helpful. It was also such a great thing to see actual differences in the lives of the patients. The best part might have been finally seeing an improvement in one of my patients who was in the ward for my entire rotation, and who didn't respond to treatment for quite some time. When the patient finally said that they were starting to feel better (something we'd been seeing, but the patient hadn't previously admitted), and when the patient's family members mentioned that they thought that my time with the patient had made a difference, my heart felt full to bursting. It's one of the sad things about leaving the rotation that I cannot know how things ended for that patient, but I hope and pray that they continued to improve and were discharged soon after I left. Now that I'm done with my psych rotation, as well as my first End Of Rotation Exam (EORE) and PACKRAT (Physician Assistant Clinical Knowledge Rating and Assessment Tool), I've moved on to rotation #2: Women's Health. Although country is one of my least favorite genres of music, I have to admit that I did love some Shania Twain when I was younger and thinking about describing my new rotation kept making me think of her song "Man! I Feel Like a Woman" (plus it seemed a bit more appropriate than "Lovely Ladies"from Les Miserables) so for anyone who wants a bit of mood music while they read this post, here you go:
Women's Health has been quite fun so far. As an introvert, it can be a bit difficult for me to adjust to meeting new people every five weeks, and it can take about a week before I really start feeling comfortable, but for this rotation I'm paired with another girl from my class, so it's nice to have a friendly and familiar face with me. Our preceptor for this rotation also likes to pimp us with questions more than my preceptor in the psych rotation, so it's been good to be able to brainstorm with someone else, and somehow not knowing the answer to a question feels less horrible when the other person is just as clueless. Not that we're okay with being clueless. Oh no. My fellow student and I try to spend our time between patients and at home look up any questions, and often try to look at the patient list a day ahead of time so we can study up on pertinent issues ahead of time. We still get stumped frequently, and getting asked questions still makes me nervous, but at least we've started to answer questions correctly, sometimes to our preceptor's surprise. Plus, we've also realized that, as nerve wracking as it can be to not know the answers, our preceptor often cares more that we are thinking through the questions, pushing ourselves to learn more, and to answer with confidence than that we actually know the answers right away.
This isn't quite related to my rotation, but I found this girl at the beach to be adorable.
I think there might have been some people in my program who questioned the necessity of a required rotation in Women's Health, but I am so thankful for it. I'm also not simply thankful because I am a woman and thus the things I'm learning seem particularly relevant to me. The truth is that it has become apparent to me that there is widespread ignorance of women's health issues, even among women. For one example, it seems like most post-menopausal women I've seen thus far have some form of urinary incontinence or prolapse or both, yet these are not issues commonly talked about. Both in this rotation and in my life in general, I've also found that many women, young and old, are fairly ignorant of their own anatomy. I'm not sure if this is simply because male genitalia are talked about more in public, but whatever the reason it does women a disservice as they know neither how to describe their problems, what causes them, or how to prevent or treat them. Even trying to explain how to perform Kegel exercises resulted in at least one woman becoming uncomfortable and deciding to simply have surgery instead, despite the fact that Kegel exercises are simple, non-invasive, and decently effective for her condition. Though I'm a woman who's trained as a healthcare professional and covered women's health in school, I'm still struck by how much I've already learned on this rotation and yet how much I feel I still need to learn. Whether in the office or the operating room, there's something new every day. I'm excited to keep learning for the remaining three weeks I have here, and to be able to share this knowledge. In fact, I wish I could write more about this rotation and some of the things I've already learned and done, but I'm tired and I have to fit in some studying for tomorrow's patients before bed, so I'll have to save those things for my next post.
I don't often have time to go exploring, but Salem really is quite lovely, even on cloudy days.
From Alice's Adventures in Wonderland by Lewis Carroll
This month I finally began my very first clinical rotation! As you might be able to guess from the quote I chose for this post, I started off in psychiatry of all places. I'll admit that I was a bit nervous when I looked at my rotation results after the Spin and saw that. After all, in school we tried to cover everything we could possibly see in practice, but rather than having a section in clinical medicine that covered psychiatric conditions, we covered everything in primary care psychiatry during our first year, and then hit upon conditions again as they related to our systems or topics (delirium and dementia in neurology, autism spectrum in pediatrics, treatments of anxiety and depression in therapeutics, etc.). It made sense to do things that way since the majority of the cases we'll see in practice will be medical and not psychiatric, but it does mean that I spent the last month of classes reviewing my notes from previous psych lectures and feeling woefully unprepared as my first day loomed closer and closer. And then it was here. I lucked out with my first day of rotation because the morning and afternoon were primarily filled with orientations on different subjects and so I was sort of eased into everything. I didn't know that would be the case ahead of time though, so I'll admit that I was pretty nervous as rotations came closer. I actually texted my boss the night before I started and asked if she'd be willing to "mother" me a bit and give me a hug in the morning if I stopped by to get coffee on my way. She did even better than that and not only gave me a hug and coffee, but she sent me inspirational clips from the Rocky movies and an encouraging message. It was exactly what I needed, and, after another message of "good luck" from a dear friend, I was ready to tackle this first rotation with gusto. Because of concerns about HIPAA, I cannot say specifics about my rotation, though after three weeks in psychiatry, there are certainly stories I'd enjoy telling. Instead, I'll just include a few of the lessons I've learned so far.
It is so important to get input from multiple disciplines in order to treat a patient. In part, this is something I already knew. I actually chose to be a PA partly because I love that one of the major emphases of the profession has always been to recognize that PAs work as part of a team to provide care. It's one thing to know this in theory though, and another thing to see this in practice. In psychiatry, it's not just the PAs, NPs, MDs, and RNs working together, but there are also the occupational therapists, mental health counselors, and social workers. It's been so helpful to see how many people can work together to provide care for a patient, whether it's a social worker who helps the patient plan for discharge or a nurse who is the first to notice a change in mental status or an OT who can provide insight into a patient's participation in groups. Family members are also key players because they know the patient best and can provide clues that you would have noticed on your own. It's tricky to get the whole picture without everyone contributing their pieces, but when people work together, it's a beautiful thing.
Sometimes you cannot "fix" the problem. Sometimes the problem is a condition that progressively worsens over time and you might be able to return a patient to their baseline, but not to "normalcy." Sometimes the problem is not a medical one, but a personal or social one, and all you can do is provide the patient with the tools they need to make changes, but those choices remain their own. Sometimes you do everything right, you use treat the patient with the standard of care, and it doesn't help, or it works, but so, so slowly. This last case might be the hardest and most frustrating, both for clinicians and patients, but it doesn't mean we give up or stop looking for other options.
I've come to recognize the joy of "normalcy." It's the joy of realizing that the problems being discussed at a family meeting are no longer a patient's psychotic delusions, but rather issues that could be seen at any family counseling meeting. It's the difference between asking a patient, for example*, why they think their parents are spies for the KGB, and asking the patient to explain to their parents why they would like a little more privacy and responsibility when they return home, and to be treated like the young adult that they are, and not like a child. It's the joy of realizing that your patient has improved to a point that you can now identify with their problems.
Sometimes you just have to jump right in. I hate talking to people on the phone, but when your preceptor tells you to call another doctor for a consult, or a patient's family member to get more information, you have to do it. You have to swallow your fears and your nerves, pick up the phone, and announce your name and title with pride.
When passing through locked doors, always make sure no one is following you through who shouldn't be. Just trust me on this one.
We are ridiculous, but great.
I still have two more weeks left in this rotation, and I can only imagine what more I'll learn in that time. It seems like everyday is filled with lessons about conditions, medications, treatments, what questions to ask, and how to solve tricky diagnoses. I actually might just miss psychiatry when I move on to my next rotation, which is not something I expected I'd ever say. I still don't know if I'd go into psychiatry once I begin practicing, but I will admit that this time has been challenging, but fun. There's never a dull day. Of course, I must admit, there's a very good chance that I enjoy it so much because I'm not that "normal" myself (after all, how many people spend part of their last day at home convincing their parents to join them in dressing up like hobbits?), but I'm okay with that, just as I'm okay with keeping my options open for all the rotations to come so that I can enjoy and learn from each of them in turn. It's an adventure, and I'm enjoying it all.
