Time is flying... I only have two weeks left here in Seattle. The more time I spend working in geriatrics the more I enjoy it. Once again my expectations about clinical year are completely wrong. I thought womens health was what I would find most inspiring, and although I enjoyed it, I am really loving geriatrics. I look forward to working through charts to determine what we can change, I enjoy chatting with patients and I enjoy the challenge patients provide simply because most have several chronic conditions that must also be considered in the event of an acute problem. On Wednesday, Dr. Addison and I had been working all day, it was 6:00 pm and we were trying to wrap up charting so we could sit in Seattle traffic to get home, but we had one more patient to see. He was a new admit and had several problems. I was trying to rapidly review his chart to determine what active problems he needed attention to, but his medical records were a mess, they weren't sequential and I was struggling a bit to move quickly. At that moment I looked up and saw two residents/patients that I truly enjoy because they are both always smiling and positive, they were eating dinner together in the common room where we were working, I could hear a woman down the hall hacking to get something out of her lungs over and over again, and I could hear someone speaking loudly (most likely because they can't hear) asking where all the chairs had gone ( I have no idea what this person was asking about). It hit me again, I am loving geriatrics and I couldn't help but giggle. I find some patients to be particularly grumpy when I ask them if I can sit and chat with them about their health, I take this as a challenge and hope that they will at least tolerate me for a bit, and they usually do. Patients with dementia can be challenging for several reasons, often times they dont even understand what I am trying to ask. For example I was asking a patient yesterday if he had diarrhea or constipation and his answer was "yea I pee and poop in there (point to the bathroom), you can go look at the toilet." This same patient wouldn't let me examine him because he had pain and didn't understand that I was trying to help him not hurt him. Although emotionally challenging, I have found counseling families about end of life issues to be rewarding.
"You know you're in love when you cant fall asleep because reality is finally better than your dreams."
-Dr. Seuss
Although I have no problems sleeping, my dreams are coming true and they are far better than I ever imagined.
Friday, May 31, 2013
Wednesday, May 22, 2013
Failure and Growth
One of the many things I learned during orientation to this PA program back in August 2011, was that I would fail, at something and that it was okay to fail. During the didactic portion of my education my classmates and I took well over 100 exams during the course of 18 months, somehow I passed all of these. Most, I even did well on. I hadn't failed anything except a few pop quizzes that I hadn't studied for prior to the pop, which didn't particularly affect my grade or my confidence because I knew I would know the information once I had time to sit with it and study it appropriately. Although I do not necessarily fear failure, I fear the consequences of failure. These are the things that keep me nauseated waiting for an exam grade. During didactic year these consequences meant having to stay during our much cherished breaks to retake an exam, during rotations this means returning to school to retake the exam. The stakes with retakes are higher, and we are required to receive a higher grade to pass.
Two weeks ago I failed an exam. I felt under prepared for both end of rotation exams (this was a common theme among all of my classmates) and I think it was because these were the first EORs we were taking. We didn't know what to expect but we did know there was A LOT of information on each one. In classic Kasaundra style, it took me a while to process. I was studying hard and it took a minor incident totally unrelated to the exam to push me over the edge. I finally broke. I felt vulnerable and scared and alone. I sent Tracey (clinical coordinator) an email because if I called I would cry harder, asking for guidance and encouragement. As I expected, she was amazing and said the words I needed to hear/read. Two hard weeks of long clinic hours, a lot of studying and a little sleep I had to retake this exam. I had to fly back to the bay for the exam monday, fly back monday night to be in clinic on Tuesday. The consequences of a second exam failure are high, I would fail the rotation and have to repeat it before I would receive my diploma in a year. After my exam I still felt very nervous.
Yesterday I had a great day in clinic. I was at a facility for the second time, it was nice to be in a semi-familiar place. The patients as always were great to talk with, I was able to follow up with two patients I saw last week, and they both seemed to be doing better. In the afternoon I was reading a chart of a patient that was at the SNF (skilled nursing facility, we say "sniff" for short) because he was hospitalized for bowel impaction/constipation and he needed to figure out his bowel routine before returning home for his wife to care for him. He was on a medication called GoLytely, used for bowel prep/cleansing or in the case of severe constipation to induce a softer bowel movement and possibly diarrhea. If this med was given to anyone without constipation it would cause severe diarrhea. I was giggling a little as I was reading, I dont know why but the name of this medication made me very happy. Just then, I heard a woman in the hall (who I cannot see) yelling "JUST LET ME SIT DOWN," the physical therapist calmly says "you have 10 more steps until you are at the chair to sit down." Again "WHY WONT YOU LET ME SIT DOWN." And I lost it, I realized in that moment that I am falling in love with geriatrics. I was giggling loud enough that Dr. Addison stopped what he was doing to see why I was so amused, I explained and we had a nice heart warming giggle together. My day was great and a distraction for the wait until my exam grade was posted.
I PASSED! I have proven competency in pediatrics and obgyn and never want to be in that boat again. I feel this failure has allowed me to understand how grateful I should be for all the times that I have done well on an exam. I have learned how much I need to be studying in addition to clinic hours. I have learned that I have a rally of cheerleaders standing behind me, and just how grateful I am for their support. And I have learned that it is okay to fail but I dont want to do this again. I have gotten back up, wiped off my scrapped knees, put my ego in check and these wounds will heal with time and some care.
I was looking for a quote to end this post and there were a lot that spoke to me, but this one gave me a wide smile because in one year I will be graduating, I am looking forward to that success!
"Failure is the condiment that gives success its flavor."
-Truman Capote
Two weeks ago I failed an exam. I felt under prepared for both end of rotation exams (this was a common theme among all of my classmates) and I think it was because these were the first EORs we were taking. We didn't know what to expect but we did know there was A LOT of information on each one. In classic Kasaundra style, it took me a while to process. I was studying hard and it took a minor incident totally unrelated to the exam to push me over the edge. I finally broke. I felt vulnerable and scared and alone. I sent Tracey (clinical coordinator) an email because if I called I would cry harder, asking for guidance and encouragement. As I expected, she was amazing and said the words I needed to hear/read. Two hard weeks of long clinic hours, a lot of studying and a little sleep I had to retake this exam. I had to fly back to the bay for the exam monday, fly back monday night to be in clinic on Tuesday. The consequences of a second exam failure are high, I would fail the rotation and have to repeat it before I would receive my diploma in a year. After my exam I still felt very nervous.
Yesterday I had a great day in clinic. I was at a facility for the second time, it was nice to be in a semi-familiar place. The patients as always were great to talk with, I was able to follow up with two patients I saw last week, and they both seemed to be doing better. In the afternoon I was reading a chart of a patient that was at the SNF (skilled nursing facility, we say "sniff" for short) because he was hospitalized for bowel impaction/constipation and he needed to figure out his bowel routine before returning home for his wife to care for him. He was on a medication called GoLytely, used for bowel prep/cleansing or in the case of severe constipation to induce a softer bowel movement and possibly diarrhea. If this med was given to anyone without constipation it would cause severe diarrhea. I was giggling a little as I was reading, I dont know why but the name of this medication made me very happy. Just then, I heard a woman in the hall (who I cannot see) yelling "JUST LET ME SIT DOWN," the physical therapist calmly says "you have 10 more steps until you are at the chair to sit down." Again "WHY WONT YOU LET ME SIT DOWN." And I lost it, I realized in that moment that I am falling in love with geriatrics. I was giggling loud enough that Dr. Addison stopped what he was doing to see why I was so amused, I explained and we had a nice heart warming giggle together. My day was great and a distraction for the wait until my exam grade was posted.
I PASSED! I have proven competency in pediatrics and obgyn and never want to be in that boat again. I feel this failure has allowed me to understand how grateful I should be for all the times that I have done well on an exam. I have learned how much I need to be studying in addition to clinic hours. I have learned that I have a rally of cheerleaders standing behind me, and just how grateful I am for their support. And I have learned that it is okay to fail but I dont want to do this again. I have gotten back up, wiped off my scrapped knees, put my ego in check and these wounds will heal with time and some care.
I was looking for a quote to end this post and there were a lot that spoke to me, but this one gave me a wide smile because in one year I will be graduating, I am looking forward to that success!
"Failure is the condiment that gives success its flavor."
-Truman Capote
Thursday, May 16, 2013
Death and Dying
This week, for the first time, I spoke with a patient about dying. She has metastatic colon cancer and has fought the disease for a long time but was put on hospice care a month ago. After reviewing her chart, I went to speak with her. Last week she was doing okay, this week she is "ready to go" she tells me. She asks me "how long until I can meet Jesus?" We continue to discuss her family and friends and she tells me she is too exhausted to see them anymore but they keep showing up. We chatted for some time, every few minutes she would ask me to feed her some ice for her dry mouth. As our conversation would pause I realized how at peace she was with this decision she had made, the decision to stop living, the decision to die. In her presence I was surprisingly at peace with her decision as well.
In my life I have had limited exposure to death. In school, when we discussed it I usually became anxious, I would think "this is going to be so difficult and stressful." To my surprise I was completely at peace with this conversation, I was grateful I could be there for this patient to support her through this decision. Speaking to Dr. Addison after I finished my history and physical before he went in to see her, I asked him how he answers the question "how much longer can I expect to hold on?" When she asked me this question I was very truthful, I lack experience and have no idea how to estimate the amount of time a patient will continue to live. He says he decides how much longer he thinks and adds a few weeks.
Throughout my clinical experience I have found many things that are not the way I had expected them to be. In OB/GYN I expected miscarriage to be really challenging for me emotionally, however it was quite the opposite. The times I was most emotional was when parents heard the fetal heart tones for the first time or saw their baby on ultrasound. Their joy filled the room and me, several times to the point of holding back tears. That was unexpected. In pediatrics I spoke extensively with a 12 year old female who was depressed and considering self harm and suicide. She had great family support, but she was unhappy socially. We talked for a long time about friends and by the end of the conversation she was crying and I was fighting hard to keep my tears in check. I know life is never how I expect it, this is what keeps it exciting. I am sure my emotions as a provider will continue to surprise me, and I am okay with this.
In my life I have had limited exposure to death. In school, when we discussed it I usually became anxious, I would think "this is going to be so difficult and stressful." To my surprise I was completely at peace with this conversation, I was grateful I could be there for this patient to support her through this decision. Speaking to Dr. Addison after I finished my history and physical before he went in to see her, I asked him how he answers the question "how much longer can I expect to hold on?" When she asked me this question I was very truthful, I lack experience and have no idea how to estimate the amount of time a patient will continue to live. He says he decides how much longer he thinks and adds a few weeks.
Throughout my clinical experience I have found many things that are not the way I had expected them to be. In OB/GYN I expected miscarriage to be really challenging for me emotionally, however it was quite the opposite. The times I was most emotional was when parents heard the fetal heart tones for the first time or saw their baby on ultrasound. Their joy filled the room and me, several times to the point of holding back tears. That was unexpected. In pediatrics I spoke extensively with a 12 year old female who was depressed and considering self harm and suicide. She had great family support, but she was unhappy socially. We talked for a long time about friends and by the end of the conversation she was crying and I was fighting hard to keep my tears in check. I know life is never how I expect it, this is what keeps it exciting. I am sure my emotions as a provider will continue to surprise me, and I am okay with this.
Tuesday, May 14, 2013
Support
I am so grateful for all the support I receive from my family and friends. I have also met some pretty amazing people in the past three months while on rotations. People I may never see again, but for whom I am very grateful to have met. These people who have opened their homes, practices and lives to me will forever be apart of my journey to becoming a practitioner, for this I have so much gratitude and appreciation. I am currently living with my classmates parents, who are amazing! I have only lived with Simon and Kimmy for a week and they have been stellar hosts. They have accepted me into their home as though I am their family. We have been to yoga together, cooked meals together and played rummikub. I am feeling full of love and happiness!
Monday, May 13, 2013
DIY
Today I completed a Do It Yourself project. A few weeks ago the shifter button (the button you press to change gears in an automatic) in my car broke into several pieces. I was slightly annoyed, but continued changing my gears by pushing in the pieces, which were still functioning. I had an appointment already scheduled at Honda to have my brake pads replaced, so I asked for a price quote... $165.00. I decided to do a little research of my own, found the part on Amazon for $15 and a youtube video to demonstrate. The day after I arrived in Seattle I was at a grocery store ready to head home when the shattered pieces that were still functioning fell apart. I couldn't figure out how to get my car out of park. I used my nail clippers to fish out the broken pieces of plastic and was able to manipulate the inside of my shifter nob to drive home. For the past week it has taken two hands to put my car in gear! Humorous? Yes, but I received the part in the mail a few days ago, the replacement took me less than 15 minutes and IT WORKS! The sense of joy I felt once completed was great, I wanted to call Honda and laugh about the $165 quote. Instead I had a little extra pep in my step and went back to studying.
Although not a DIY project, today I completed my first injection on a patient. And it was easy. I am so grateful my first injection was not on a child who would have been screaming in pain, it was instead on a woman with dementia who sat still and quiet. It was as if I hadn't touched her. I also saw a patient today who attended Kansas State University, I know this because he had a purple mug sitting on his shelf. My Nana and Grandpa live in Manhattan and we had quite a conversation about the school and his accomplishments while there. My favorite part about geriatrics thus far is spending time with patients. Ultimately most of them just want to feel they have a voice and are being heard by someone. Interestingly, my greatest struggle in geriatrics thus far is being heard by patients. Many of my patients are greater than 85 years old and about half are 90+, therefore many of them are hard of hearing. When I speak louder my voice tends to increase in pitch as well (this is a common mistake most people make when speaking to people with senile loss). Presbycusis/senile hearing loss is associated with high frequency loss, therefore even when I speak very loudly, many of my patients still struggle to hear me.
" One of the most valuable things we can do to heal one another is to listen to each other's stories."
- Rebecca Falls
Although not a DIY project, today I completed my first injection on a patient. And it was easy. I am so grateful my first injection was not on a child who would have been screaming in pain, it was instead on a woman with dementia who sat still and quiet. It was as if I hadn't touched her. I also saw a patient today who attended Kansas State University, I know this because he had a purple mug sitting on his shelf. My Nana and Grandpa live in Manhattan and we had quite a conversation about the school and his accomplishments while there. My favorite part about geriatrics thus far is spending time with patients. Ultimately most of them just want to feel they have a voice and are being heard by someone. Interestingly, my greatest struggle in geriatrics thus far is being heard by patients. Many of my patients are greater than 85 years old and about half are 90+, therefore many of them are hard of hearing. When I speak louder my voice tends to increase in pitch as well (this is a common mistake most people make when speaking to people with senile loss). Presbycusis/senile hearing loss is associated with high frequency loss, therefore even when I speak very loudly, many of my patients still struggle to hear me.
" One of the most valuable things we can do to heal one another is to listen to each other's stories."
- Rebecca Falls
Sunday, May 12, 2013
The First Day
After a crazy week of traveling back to Vallejo to be on campus for two days, the long drive to Seattle, and two clinic days with my new preceptor I am starting to feel settled again.
I was researching quotes about first days (because during this year I will have eight first days, thursday was my third) to end the blog with and a found several with this concept. Each day is a once in a lifetime event. I can't say I have really ever thought about life in this way, however clinical rotations has made this very apparent. I am constantly learning new things about medicine and becoming a better practitioner. I am making mistakes and receiving gentle guidance from my patients and my preceptors on how to improve myself, and I LOVE IT! I am so grateful for all the time and energy my preceptors are willing to put into my education. I can't think of another time I have ever received one on one training that was this in-depth. I have spent two full days with Dr. Addison, he picks me up from the office around 8:30 and we are off in his car for the day. When we are done for the day he still has to return me to my car, thus leaving us a lot of time for discussion. We have discussed different diagnoses in detail, politics of medicine and running a successful practice, office politics, and the list goes on. I am excited to see what the next five weeks has to be discovered.
Thursday was my first day of Rotation 3, here in Seattle I will be working in geriatrics. Each day of the week I will be at a different skilled nursing home, assisted living facility or making house calls with Dr. Addison. Thursday we spent the entire day in a skilled nursing facility covering for one of his partners who is on a sabbatical. This was a great introduction to geriatrics because all of these patients were new to Dr. Addison so we did A LOT of chart review. I found this to be particularly helpful because in pediatrics and obgyn the charts are not as extensive as in geriatrics. I saw two patients on my own thursday. One was a new admit, she recently fell and broke her femur and will be in this facility until she is able to bear weight and be independent again. I spent about 45 minutes with her doing an extensive intake and physical exam. Right before I went to go see her Dr. Addison gave me her most recent labs and told me to "figure it out." What he wanted me to figure out was why her ESR (erythrocyte sedimentation rate) was greater than 140. ESR is generally a marker for inflammation, but is rarely >20. (To read more about ESR, click here). After I saw her I returned with Dr. Addison, he did a much shorter physical exam then asked me what I thought. I was still puzzled by this ESR. He had made a diagnosis, then as we discussed the ESR and her symptoms, everything changed. His demenour regarding her diagnosis changed. Instead of a furuculosis (a bacterial infection) being the cause of her rash we were suddenly discussing vasculitis. Her hematoma was no longer just a hematoma but possibly another symptom of vasculitis. He walked me through his thought process and asked how I would treat her, this I knew... Prednisone!
Friday we spent the day making home visits all day. I see why as a geriatrician it would be easy to be overweight as many of our patients had treats for us. My favorite was homemade pear pie and it was delicious!
The weather has been absolutely beautiful since I arrived, in the upper 70's to 80's and sunny. Today is my first day of Seattle rain and it is supposed to rain all week. I had a beautiful welcome to Washington and now I get to experience what the weather is really like here!
"Each new day is a blank page in the dairy of your life. The secret of success is in turning that diary into the best story you possibly can."
- Douglas Pagels
I was researching quotes about first days (because during this year I will have eight first days, thursday was my third) to end the blog with and a found several with this concept. Each day is a once in a lifetime event. I can't say I have really ever thought about life in this way, however clinical rotations has made this very apparent. I am constantly learning new things about medicine and becoming a better practitioner. I am making mistakes and receiving gentle guidance from my patients and my preceptors on how to improve myself, and I LOVE IT! I am so grateful for all the time and energy my preceptors are willing to put into my education. I can't think of another time I have ever received one on one training that was this in-depth. I have spent two full days with Dr. Addison, he picks me up from the office around 8:30 and we are off in his car for the day. When we are done for the day he still has to return me to my car, thus leaving us a lot of time for discussion. We have discussed different diagnoses in detail, politics of medicine and running a successful practice, office politics, and the list goes on. I am excited to see what the next five weeks has to be discovered.
Thursday was my first day of Rotation 3, here in Seattle I will be working in geriatrics. Each day of the week I will be at a different skilled nursing home, assisted living facility or making house calls with Dr. Addison. Thursday we spent the entire day in a skilled nursing facility covering for one of his partners who is on a sabbatical. This was a great introduction to geriatrics because all of these patients were new to Dr. Addison so we did A LOT of chart review. I found this to be particularly helpful because in pediatrics and obgyn the charts are not as extensive as in geriatrics. I saw two patients on my own thursday. One was a new admit, she recently fell and broke her femur and will be in this facility until she is able to bear weight and be independent again. I spent about 45 minutes with her doing an extensive intake and physical exam. Right before I went to go see her Dr. Addison gave me her most recent labs and told me to "figure it out." What he wanted me to figure out was why her ESR (erythrocyte sedimentation rate) was greater than 140. ESR is generally a marker for inflammation, but is rarely >20. (To read more about ESR, click here). After I saw her I returned with Dr. Addison, he did a much shorter physical exam then asked me what I thought. I was still puzzled by this ESR. He had made a diagnosis, then as we discussed the ESR and her symptoms, everything changed. His demenour regarding her diagnosis changed. Instead of a furuculosis (a bacterial infection) being the cause of her rash we were suddenly discussing vasculitis. Her hematoma was no longer just a hematoma but possibly another symptom of vasculitis. He walked me through his thought process and asked how I would treat her, this I knew... Prednisone!
Friday we spent the day making home visits all day. I see why as a geriatrician it would be easy to be overweight as many of our patients had treats for us. My favorite was homemade pear pie and it was delicious!
The weather has been absolutely beautiful since I arrived, in the upper 70's to 80's and sunny. Today is my first day of Seattle rain and it is supposed to rain all week. I had a beautiful welcome to Washington and now I get to experience what the weather is really like here!
"Each new day is a blank page in the dairy of your life. The secret of success is in turning that diary into the best story you possibly can."
- Douglas Pagels
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