Pathology:Day 1, 2, 3

At the medical school I attend, we are limited to the number of weeks we can spend in each discipline of medicine during our fourth year electives. That magic number is 12 weeks...so, since I have spent 2 weeks in oncology, 4 weeks on internal, and I will spend another 4 weeks in oncology, I've been limited on what I can do. This is such a shame, because internal medicine covers a huge variety of subspecialties which I wanted to become more familiar with prior to residency - like MICU service, cardiology, nephrology, pulm, rheumatology, and oncology. But instead, I will get to see more areas of medicine before my life becomes solely internal medicine - which is nice, in a way, to give more of a well-rounded education. It's not so nice to have to find something that will spark your interest enough to make the time and effort worthwhile.

This brings me to how I ended up on a pathology rotation. Bearing in mind my ultimate desire lies in medical oncology, I decided to do an elective on a rotation which will be helpful in my future career. Pathology is definitely a specialty which I will use! So, what the heck, I signed up and here I am.

First day was spent completing an autopsy. I almost forgot how much I hated dead bodies, being that my time with my cadaver, "Hans", was three years ago. It's just so...morbid. Not my thing. And then to cut and search for a cause of death - not exactly my idea of fun. The smell, the flies and gnats flying about, the bone saw, the knives - it is just so not for me. I did get to cut through the bronchioles and breadloaf-slice a lung, so that was actually kind of cool. As for a cause of death? Still pending...

Second day began by investigating brain specimen (dissecting brains at 8am, what a way to start the day). The rest of the morning was spent in the Immunology Lab. It was really cool to see how the tests are run and what different things look like under the microscope (so that's what speckled ANA looks like!). It's also nice to see such knowledgeable staff and lab technicians who are seriously passionate about their job. It takes a team to care for a patient, that's for sure. Then I looked at a bunch of slides of uterus and cervix and ovary as well as a few skin biopsies and GI biopsies. Its very rewarding to see the diagnosis on a cellular level and to correlate it with the patient's clinical history. In the future, I think I will be more inclined to visit with the pathologists regarding particular cases when I have questions or think its an interesting case.

Today, I attended a few lectures, watched the phlebotomists draw blood from a bunch of patients (I volunteered to take a few, but was pretty quickly denied - disappointing, because I enjoy doing it and I'd like to continue to improve my technique and experience). Then I peered under the microscope for a few hours, looking at some skin biopsies and GI histology among others.

I'm enjoying this experience, but I do hope that the number of autopsies are kept to a minimum! yuck.

AI in IM: Days 10-20

I finished with my AI in Internal Medicine today. I am now completely confident in my decision to pursue a residency in internal medicine. I have had the best time I have ever had on the wards in these past four weeks. There was a lot of teaching, there was a great amount of teamwork, it was a low stress environment, I had really great residents and attendings, I saw a variety of diseases, and best of all I was actually making a real difference in patient care.

My residency application is finally submitted. It's almost an unbelievable amount of work, time, and effort that is put into this thing. From compiling the documents, signing papers, asking for and receiving letters of recommendation, putting together a confident yet humble and honest personal statement, and then determining which programs to send the application to...it is a lot of work. And, not surprisingly, actually a lot of money. Each application you send costs money, plus to release your score reports and pay for the national match program...it adds up fast. There goes another $500+ on education-related fees. And I haven't even purchased a flight or paid for a hotel yet. Geesh!

Mike took his GAMSAT today (GAMSAT = UK's version of the USA's MCAT - medical college admissions test). Fingers crossed for a good score - although we probably won't find out for several weeks (typically sometime in November). I'm praying that I'll actually have my Step2CK score before that time (yes, it has been more than 6 weeks since I took the exam...). Oh and also the GAMSAT is only given once per year, and only distributed in the UK - so Mike hopped on a flight to England on Monday and won't be back for a few weeks. Despite the fact that he's away, I am still ridiculously busy with the rest of my medical school responsibilities. I am still loving what I do - I am so incredibly lucky to be able to live my dream. I am reminded of this every day that I spend with my patients; this is truly a humbling and rewarding profession. 

AI in IM: Days 6,7,8,9

Just a quick one to keep things current...

• This service is definitely keeping me busy.
• I'm having a hard time finding the time to complete my residency application, which is due on September 15. I feel like I don't know what I'm doing and I'm scared I'll mess up one of the documents or something. It's hard to finish something that you know to be so extremely important...
• I am pretty nervous about officially selecting my specialty...particularly due to the fact that I really don't enjoy what general internists or hospitalists do. Is this the right choice for me? Am I making a mistake? Will I be stuck in IM or will I be able to snag a fellowship after residency? Will I survive 3 years of generalist training and still enjoy my life? This choice is so important, I can't afford to change my mind after September 15th.
• I'm still waiting for my results from my Step2CK. Honestly, I took this exam early in the year so that I would have a better idea of how competitive my application is - I can't determine this if I don't get my score back before applications are sent out on the 15th. I'm more than slightly annoyed...
• Mike's big exam is in two weeks, so he's actually stressing out (I have never seen him stress out before). I have a new found love for him because he's been able to put up with my three years of sporadic freak outs. It's not easy!!!
• I still need to set up a few clerkships in the UK for January/February. I seriously need to get this done...after my residency application is completed.

I'm going to go ahead and stop typing before I freak out about the millions of things I have to do and instead I'm going to go ahead and start to complete a few things!

aaaaaaaaaaaaaaaaaaaaahhh I thought fourth year was meant to be fun!?

Internal Medicine - Acting Internship: Days 1,2,3,4,5

On Monday, I began my Acting Internship in General Internal Medicine. It's going pretty much as I expected - a lot of hours, a lot of reading, a lot of learning, a lot of patient problems. So far, my most interesting cases include:

A 62y/o male with a history of IVDA and Alcoholism presents to the ED with RUQ abdominal pain and distension for the past several weeks. On physical examination, he was found to have scleral icterus, tenderness to palpation in the right upper quadrant, abdominal distension, and bilateral 2+ pitting edema in the lower extremities. After some laboratory work up, it was discovered that the patient was slightly anemic, with thrombocytopenia, elevated LFTs, and prolonged PT/INR. A CT of the abdomen with contrast was completed, which revealed a mass in the liver. Evaluation of the mass is currently pending, as are some important labs related to these findings (namely alpha-fetoprotein). So, what are we anticipating this mass to be? There are a few possibilities: benign etiologies may include hemangioma, cysts, hepatic adenoma, focal nodular hyperplasia, and abscess; malignant etiologies may include metastases (typically they appear in several focal areas with nodular margins) and hepatocellular carcinoma. Given the history of alcohol abuse, I am leaning towards the dx of HCC, but we will need a biopsy to confirm such findings before one can say for sure.

A 42y/o male with recurrent clostridium difficile presents to the ED with complaints of bouts of diarrhea occurring every 15-20minutes. C.diff is a bacteria which may reside in a spore form in the intestines; if normal, healthy gut flora are wiped out after the use of antibiotics. Other risk factors which can predispose you to overgrowth of C.Diff include: recent use of antibiotics (especially clindamycin, fluoroquinolones, penicillins, and cephalosporins), hospitalization, age over 65, severe illness, immunosuppression (steroid use, chemotherapeutics), inflammatory bowel disease (like Crohn's or Ulcerative Colitis), use of proton-pump inhibitors, gastric surgery, gastric bypass, recent major surgery. So, how do we treat C.Diff? This seems like a straight-forward answer any medical student can answer when the attending pimps them. We learn Metronidazole, if it persists give another round of Metronidazole, if it still persists give PO Vancomycin. But sometimes C.Diff persists even after this extensive treatment (especially as antibiotic-resistance increases). What do we do then? Well, we can give other antibiotics, such as Fidamoxicin or Rifaximin (there are many other options available to try if it persists after those treatments). So if we've exhausted our medical therapy without finding that the infection subsides, we have the option of fecal transplant. In order for this therapy to be effective, it is best to obtain stool from a relative or spouse, screen the stool for certain bacteria/viruses/parasites (like shigella, salmonella, campylobacter, etc), then emulsify the stool into a more liquid form, and to deliver it into the patient's GI tract via enema or via an NG tube into the duodenum. Kind of disgusting, but I would imagine a person would be desperate for a definitive treatment after months of constant, profuse, watery diarrhea.

Busy week! And I'm enjoying my time on the wards!