Friday, June 29, 2012

Family Medicine Shelf

Family Medicine (and THIRD YEAR) is finished - - - such a good feeling!

The shelf exam was alright. The questions are really broad and varied; I'm glad to have scheduled family medicine as my last clerkship of third year. Classically, it is the most failed shelf due to how broad the information is - the shelf would be pretty difficult if it was your very first clerkship of third year. But as it was my final clerkship, I felt quite prepared and confident in how I did. I ended up with an above-average score (and let's just leave it at that).

Family Medicine is incredibly broad and it is difficult to predict which questions will be asked on the shelf. I was at an advantage, taking this clerkship last, but I don't think it would have been horrible to have taken it earlier. I personally felt like IM was more a bit more difficult. To prepare for the exam, I:

  • Followed, managed, and learned from a variety of patients - including those with diseases such as Diabetes, Hypertension, Stroke Syndrome, Pregnancy, Well-Visits, Cellulitis, Musculoskeletal Injuries, Back Pain, Psych Disorders, Dementia, CHF, COPD, Surgical Clearance, etc etc etc etc etc
  • Used Uptodate to learn more about each of my patient's diseases and treatment plans.
  • We had lecture for a few hours during the course of the clerkship, which were somewhat (but not really) useful.
  • Read Family Medicine Case Files. It's a quick and easy read, honestly. And helpful to prepare for all of those "what is the next appropriate step" questions that are asked.
  • Read over the Ambulatory Medicine section in my Step Up to Medicine textbook.
  • Read bits and pieces of Step Up to Step 2 to review previous clerkship info (like surgery, ob-gyn, peds, psych, neuro).
  • Completed about 500 of UWorld's Step2 IM questions - which were really helpful to broaden my base of studies.
  • Completed all but 125 questions from USMLE Easy's Step2 Family Medicine's Question Bank.

My final takeaway on how to best prepare for the shelf exams during third year:
  • Have a quick review book (like Case Files) stuffed in your white coat pocket, and read over it whenever you have some down time.
    • No matter how busy you are (and you will be busy), always make time to read at least an hour each day.
  • Do questions every day. This is the part of studying which I dislike most, and I'm not nearly as faithful at completing the questions as I would like to be, but I did notice that once I started to use the QBanks more frequently, my shelf scores (and confidence) improved significantly.
  • Take on a variety of patients, even if it makes you uncomfortable. The single best way to learn is through experience.
  • Keep your Iphone or Ipad on you at all times, with a QBank open, UpToDate logged in, and the Epocrates app ready.

Thursday, June 21, 2012

Family Medicine: Day 16, 17, 18

I feel like I need to get this post in while I'm still officially a Third Year Medical Student - even though I really should just be studying for my shelf!

The past week has been crazy! On Monday, the clinic had over 50 patients. It was crazy. And every patient seemed to need a little extra time, with things like Depression, Pap Smears, Newly Diagnosed Diabetes, Nutrition Advice, etc etc etc. Things were insane. I finally got out of the office by 6:30 after all of my notes were complete (I had no time during the day to finish any notes, so it took me an extra 90 minutes just to finish notes). Also, we had a few patients that we saw in the hospital for a knee replacement and cellulitis. Then on Tuesday, the afternoon slowed down after we left clinic early to deliver a baby. That's always fun!!! I can't believe that I may never get to do that again... The attending even asked if I wanted to repair the episiotomy; I am going to miss procedures so so so much. Finally on Wednesday, I saw a variety of patients in the morning and the attending even let me finish early so I could go home to study. Today, of course, is a big time study day, because tomorrow I take the "most failed" shelf of third year!

I have had a great experience on Family Medicine. I was lucky to work with and learn from such a great family doctor; I know the score I will get on my shelf will be due, in large part, to her education and guidance. I really loved this rotation, and I'm definitely going to miss the freedom I was given while away from my medical school's hospital!

Thursday, June 14, 2012

Family Medicine: Day 11, 12, 13, 14, 15

Time to recap on all of the things that I've been doing on Family Medicine!

  • Yesterday, I delivered my first baby. The doctor I am working with allowed me a lot of freedom in the delivery, so I did most of it on my own (under her very close supervision). She did the episiotomy and repair, and I delivered the baby and placenta. It was amazing. Witnessing the miracle of life never ceases to amaze me. What beautiful moments!
  • I attempted to pull an object out of a child's ear (sadly felt like I had foreshadowed this occurrence by telling a previous patient that day about The Things We Find in Our Patients' Ears!).
  • I spoke with a patient - at lengths - about the basic principles of good nutrition. For example, I advised that instead of eating a double-bacon-half-pound-cheeseburger with large fries and a giant-sized Coke twice a week, try to make it more of a once-every-other-week treat. 
  • I made *almost* every kid I saw in the past week smile and laugh. (Yes, this is coming from the girl who has openly admitted her significant disinterest in pediatrics)
  • I am getting to be quite proficient in pap smears, and could probably now diagnose BV based on the whiff test alone...!
  • I continue to be surprised by how people will openly tell me the most personal details of their life without hesitation. Some questions which I routinely rattle off and patients honestly respond to:
    • Any new sexual contacts?
    • Any possibility of a new STD?
    • Number of sexual partners you have had?
    • What type of sexual protection do you routinely use?
    • Have you had any recent constipation or diarrhea?
    • Has urination been painful recently?
    • How many times do you get up in the middle of the night to urinate?
    • Are you breast-feeding your child?
    • Are your nipples sore or cracked?
Family Medicine is so much fun. I can really see the appeal of the lifestyle, the short residency, the close relationships with patients... I actually find it interesting to see a few kids interspersed between adult visits for hypertension, COPD, Diabetes, etc... if only there could be an Oncology Fellowship at the end of its residency, then it would look quite tempting!!!

Thursday, June 7, 2012

Get Your Rear In Gear! My First 5K

This past Saturday, I completed my very first 5K race.

My sister and me:

The race was to benefit the colorectal cancer society where I live, so that we can increase education and patient access to appropriate colon cancer screening and preventative care. There were over 500 people who showed up to support the cause, along with several local news stations, and it felt so good to be surrounded by so many people who care so much about colon cancer.

Running In Honor of My Cousin, Greg:

The start was the best part - 300 of us, jam packed together at the starting line. The starting gun went off and we were moving shortly thereafter, having to filter our way past the slower participants that started in front of us. Even with the slow start as we made our way past other runners, my first mile was completed in 7:30 (which is fast for me!). Just as I crossed the 1 mile mark, my right knee started giving me problems - stabbing pain lateral to my patella - Iliotibial Band Syndrome (ITBS), which comes from increasing mileage too quickly, slowed me down for the remainder of the race - but I still finished in 25:16. I didn't reach my goal of under 25, but my sister did (24:55)! Still, 25:16 isn't bad for a first timer! I finished 76th out of 300+ runners. Next race, I will be under 25!

After the run:


For an update on my life:

Wedding: We officially have the church and reception venue booked, as well as our photographer and florist. We're currently in the process of hiring a DJ, transportation, and booking a block of rooms at a nearby hotel. We're also trying to compile the type of photos we'd like for our engagements - I would love to do a set of photos with a certain theme, which would capture some of our favorite things...but I'll leave that for a surprise! 

Work: Mike's teams have just finished their spring soccer seasons, and he's currently working on putting together a few soccer camps for the summer. He'll also be coaching a few new teams this summer (he's in pretty high demand!) in addition to studying for his medical school entrance examinations. He's one busy guy lately. And I must admit, I'm impressed by the amount of studying he is able to do each day on top of all of his other commitments (volunteering, coaching, fitness, etc)

Future Plans: After meeting with the priest who will be presiding over our wedding, we began to talk a little bit more definitively about what we anticipate our future to look like. For the moment, we're keeping an open mind about the future, and it seems as though Mike and I will be applying for med school and residency (respectively) in both the US and UK so as not to limit ourselves or our options. This means twice the work in applications and examinations, but this might be our best shot at being able to continue to pursue our dreams while being on the same continent as one another. 

Graduation: Will be here in ONE YEAR. That's crazy. Which means that when I'm not working in the Family Medicine Clinic, you may find me:
  • Studying for my Family Medicine Shelf (LAST SHELF EVER!)
  • Polishing my CV and applications for residency
  • Researching potential residency positions in various hospitals
  • Studying for my Step2CK
  • Doing loads of questions on UWorld and USMLEasy
  • Trying to make sure I'm choosing the right specialty
Summer Season: Which means - Running Outside, Long Walks with the Dog, Peaches&Bananas, Sunglasses, Strawberry Shortcake, Open Windows, Gorgeous Sunlight, Campfires, Swimming, and wanting to move the clinic outside. I will actually be able to enjoy an entire WEEK with my family at the lake this year (for the first time in 5 years) - and I can't WAIT!!!!!!! :)

Wednesday, June 6, 2012

Family Medicine: Day 9, 10

The doctor with whom I am working asked me to see a patient who came in to talk about diabetes management. This patient, she had told me, was considerably non-compliant with our interventions and the importance of monitoring her blood glucose regularly. The patient was young, but had significant morbidity associated with poorly controlled Diabetes; she had some peripheral neuropathy, poor vision, and recurrent yeast infections. After looking through some items I planned to speak with her about,  I went into the patient’s room, and I introduced myself. The patient quickly asked me, “you have to follow them HIPPA rules, right?”, to which I hesitently responded,  “Yes, whatever you tell me will be held in complete confidentiality, aside from 2 exceptions: if you are planning to harm yourself or someone else, I must contact proper authorities to maintain the safety of yourself and others”. She then quickly began to tell me about her anxiety and depression, which has been causing her significant distress over the past several months. This patient has a child with developmental disabilities, who can be exceedingly challenging to care for at times. She also was suffering from many other stressors, including loss of employment, feelings of failure, mental abuse from her husband, and the lack of a good emotional support or friend. I listened to her empathetically, and I managed to slide in questions about the diagnostic criteria for depression (SIGECAPS), and I found that she met criteria for clinical diagnosis of depression, without thoughts of suicide or homicide. I felt really overwhelmed by the difficult situation this patient was in; I have completed my psychiatric clerkship, but the interaction felt a lot different in a family medicine office visit than in the psychiatrist's office, especially since this interaction was completely unexpected. The main concern that this patient had was the fact that she utilized an illegal substance in order to deal with the stress of caring for her developmentally disabled child, and she wanted to quit with help from us. We were able to prescribe to her an antidepressant and an anxiolytic for acute attacks, as well as referring her to our psychologist for further assistance, and we will follow up with her again in a week.

The whole interaction was so quick. The scheduled office visit was for 10 minutes, but we spent much longer than that with her. As it happened, I wish I would have spent more time with her, and directed the conversation a little bit more (I had allowed her to talk freely with empathetic statements to encourage her to speak freely - its what we do on psych, but not very time efficient for family medicine!). It’s never easy to ask about suicidal or homicidal ideation, and I hope I didn’t make her feel uncomfortable with my questions. I look forward to seeing her in the clinic for a follow up visit, knowing that I will have had some time to prepare for the encounter.  I do feel like I handled this situation fairly well, but it emphasizes the fact that you never know what to expect when you walk into a patient’s room, and it is best to remain open minded. I’m glad that I didn’t have this experience when I first started third year rotations, because I would have felt completely off-guard; it’s reassuring to know that I was able to handle this interaction without too much of my own anxiety!

Tuesday, June 5, 2012

Family Medicine: Day 5, 6, 7, 8

Last week, I had a few interesting patients:

1. A multiparous woman at 41 weeks gestation required emergency Cesarean section due to non-reassuring fetal heart tones/fetal distress...we quickly went from calm and collected to running down the hallway to the OR. Baby came out with APGARs of 8 and 9 (healthy), so it was a happy ending to a stressful situation.

2. I watched about 20 pap smears in one day. That is one long day.

3. I saw a kid with a complaint of hurting her ankle and I was able to diagnose cellulitis (somewhat rare to find in kids, so when I suggested cellulitis as my diagnosis to the attending before she went in to talk with the patient, my attending thought I was crazy - but I was correct!).

4. I walked into a patient's room, anticipating a conversation regarding diabetes management, when I was bombarded with someone who was suffering from massive anxiety and depression (more on that story later!). 

I see some crazy thing each day. I'm constantly surprised by the number of "oh, by the way" symptoms that patients bring up just as we are leaving the room. And you honestly never know what to expect behind each patient's door!