Year 4! Block 1: Rheumatology/Neurology

To start off my 4th year, I had my medicine sub-specialty block, so I chose to do two two-week rotations in Rheumatology and Neurology. Both I felt to be very important aspects of family medicine and sports medicine.

My preceptor for Rheumatology was Dr. Gary Silverman, DO. He ran a pretty chill, low-key office in Scottsdale that made for a pretty good learning environment. I became very familiar w/ arthiritis, many auto-immune diseases such as lupus, and fibromyalgia. Most of the patients were long-term established patients who had diagnoses in place, so I was able to see how treatments were tweaked over time, and used this as an opportunity to learn more about musculoskeletal pharmacology. I had learned about a newer drug class called TNF-alpha inhibitors, and had become very popular over the last decade. It was interesting that Dr. Silverman remained very skeptical about them. He related that traditional DMARDS (disease modifying anti-rheumatic drugs are like a watering hose on the disease, and TNF-a are like fire hydrants; very effective, but very broad, leaving risk of serious side effects. And even though I will rarely use those drugs in my own practice, there were tons of other musculoskeletal joint meds that I learned a lot about. He was also very active in the medical community, and introduced me to an online medical community known as Sermo, who was recently in the news as they opposed Howard Dean and the proposed new health care legislation. Overall, this was a good rotation, and I am glad that I did it. But in 2 weeks I saw about everything I was going to, and wouldn't have gotten too much more out of an addition 2 weeks.

I moved on to Neurology next with Dr. Mark Winograd, who ran an office next to Banner Thunderbird. It was nice that it was so much closer to my house. This was a very different environment. Dr. Winograd was a lot more intense, as he reminded me a lot of Regis Philbin, as he would raise his voice at unexpected times, and often wouldn't make complete sense. He would also tell me the same thing over and over. He was a very good neurologist, though, and good to his patients. I learned a great deal about EMG's, and I appreciated that I had a lot of one on one face time with the patients. He had me see all new patients first,to evaluate them and present my assessment to him before he would come in. I saw some good things, like fibro, seizures, lots of dizziness, movement disorders, and a lot of chronic pain. I learned that neurology is the specialty that gets the patients that no one else knows what's wrong with them. As such, I became very familiar with the diagnosis of myofascial pain syndrome! This again was very good for hitting upon different areas of pharmacology, and found applications to primary care and sports medicine. And Dr. Winograd was good at trying to make connections to sports med, and related first line management at a primary care setting. It was a good rotation, but again, 2 weeks was perfect.

Meanwhile, on the homefront, Meghan was at the end of her 2nd trimester and feeling all the discomfort of pregnancy. She had a really bad bout of sciatic pain from the uterine growth causing secondary impingement on the nerve. I was able to provide temporary and partial relief with osteopathic treatments, but it was not long lasting at first. Finally, either treatments helped or her pain tolerance improved greatly, and she was able to do better with her normal activities. Braylei and Tayscen were both still in swimming classes, and I made it as often as I could, but I was at the will of my preceptors and the work schedules!

For updated pictures of the family and our adventures, check out my facebook page For all our photo albums!

Year 3 in review

Well I didn't do too well on keeping up with the blog. Needless to say, my 3rd year of medical school went by like a blur! Much faster than 2nd year at least! After surgery, I had a great family medicine rotation with Dr. Jack Hawks, who was an AZCOM grad himself. He ran a great office, and I was able to learn much about patient management with him. The downside was the same drawback from all civilian family medicine- there wasn't that much diversity. There was not much peds at all, no OB and very little GYN. There was some sports med, but it was small. Mostly it was adult ambulatory medicine. Lots of HTN, DM, and cholesterol, with flu/colds mixed in. I did learn a great deal about pharmacology, and different management strategies for common cases. There was also drug rep lunches every day, which is a huge perk for civilian medicine! Dr. Hawks was a great doc, and I did like his style of practice. He was very laid back and easily identified with the patient.

In February, I was on OBGYN at Maricopa Medical Center. I am so glad that I did my OB training here, as it was very hands on and lots of opportunities. A huge majority of the patients were from Mexico, and most did not have great OB prenatal care. I was able to do 2 weeks of the "mole shift," or night float. My day started at 6pm and I was on all night and got off at 8am. Then I got to make the 40 minute drive home, and sleep for about 5 hours before going back in. Over those 2 weeks I slept in our closet because it was dark and quiet, especially when Meghan ran her preschool twice a week. But the service was good, and like I said, I was afforded great hands-on training. I got along well with the chief resident and most of the residents. However, I noticed that the morale wasn't all that great there. Maybe it was just the residency, or maybe it's OBGYN in general, but there was a little backbiting too. I also spent a week in clinic, doing mostly prenatal care, with some colposcopy mixed in. And I spent a week on GYN surgery, where I was seeing a lot of hysterectomy and D&C cases. I loved what I did there, and I gained a great appreciation and fondness of the field, particularly the obstetric side. There's something magical about the birthing process, and I was able to share in the joy of the family, and create more enthusiasm in them by sharing my own experiences as a parent! However, I don't think that I could exclusively do OBGYN. It's easy to burn out on, with all the call and long hours. Plus, I do enjoy diversity in my day-to-day schedule.

March was a fun month, as I did my outpatient pediatrics rotation in the greatest place on the planet, Cedar City, Utah! I figured Utah would be a great place to do peds, as there are so many kids per capita! I was at Color Country Pediatrics w/ Dr. Burrows. I was amazed at how much I saw there, for a smaller community. I also came while it was still flu/strep/croup season, so I became quite familiar with a upper respiratory infections. I also saw some more rare conditions, such as histiocytosis, fragile X syndrome, and a cephalohematoma. Megs and the kids came up for 2 weeks. We crammed into the small 1 bedroom apartment that was given to us by the rural health education center who coordinated the rotation. The funniest part about the apartment was that the hallway from the living room to the bedroom doubled as the kitchen. On one side was the sink and dishwasher and on the other was the fridge and microwave. Classic. But it was fun for the kids because it snowed quite a few times while we were there. So they had fun playing in the snow quite a bit. They also really like discovery park!We also got to see some old friends. We really missed seeing Cordelle and Wendy, and Emily and Chris. It was awesome to see Scott Bauman and the women's gymnastics team, too! It was a great month. Especially because during this time, Meghan found out that she was pregnant once more with child number 3! We were so excited!

Then we returned back to AZ for April and I had my ward based Pediatrics rotation at Phoenix Children's Hospital. Let me just saw that that is one of the coolest hospitals ever! All the staff seem to be much happier there than in other hosiptals! The walls are all colorful, there are massive toy trains that go around open gardens. Best of all, the food was awesome, and as a student, I got a card with $1000 limit for the month!! But inpatient peds was a very different experience than outpatient peds. These kids were really sick, very seriously so in some instances. I saw everything from a little one year old with E. coli meningitis, to a 16 year old elite soccer player with extrapulmonary coccidiomycosis. There were obscure things like rat bite fever, to complications of more common cases like mastoiditits. Plus, I got to really work well with the residents, which I really enjoyed. I learned a great deal over this month and it made a huge impression on me. Peds is one of my favorite disciplines of medicine, and I frequently tell people that if I wasn't in the military and I wasn't exposed to the vast diversity that military family medicine had to offer, I would likely go into civilian pediatrics. I was very rewarding, but at times, very sad.

Then I moved on to my final rotation of the year- Internal Medicine at the VA hospital. Despite mixed reviews from some of my classmates, I had a great experience. It was challenging for me, but I got a lot out of it. It was a stark contrast to PCH, as all the walls were white, the hospital was bland, and the staff was not nearly as enthusiastic! That being said, the residents were very helpful, and I was able to see a good bit of pathology. I did see a lot of COPD, along with diverticulitis/osis. Of course, there were trips to the ER for chest pain cases, and many more people had complications regarding their coronary artery disease. I did see a cool Ace inhibitor induced angioedema. My favorite patient was a 61 yo male presenting with cocaine intoxication. After a huge drug binge, he realized her needed help (probably ran out and had no more money), so drove down to check himself into the hospital. He managed to make it to the hospital, but her ended up crashing his car into the flagpole outside the ER! We took care of him, got him cleaned up and after a few days, he was doing well. He said he wanted to check into a program and return to family up north to get away from influences and start fresh. He came back in the next day with repeat overdose. Found out he sold everything he had to get that extra fix. How sad it was.

After the rotation, we had a week of classes, simulated patient cases, and a comprehensive exam. Then I flew out to Philly to take my level 2 performance exam, which tests clinical skills. Each examinee has 12 simulate encounters. We had 12 minutes in with the patient then had 9 minutes to write a soap note. They were very anal in the testing center, and I was rebuked multiple times for showing too much enthusiasm or smiling, or some other means that could be construed as communicating. It went pretty well, though, and it was fun because there were 5 other students from my school that took the test at the same time.

Then it was back to AZ, where I had a few weeks to study for my level 2 written board exams. I studied quite a bit and felt pretty comfortable with what was going on. I walked out of the exam feeling relatively well. However, when I got my results, it was not what I had hoped. In fact, it was lower than my level 1 score. Sure, I passed, but it was not what would be considered a strong score. I was pretty down for a couple days. But Meghan really came through and picked me up. She is always such a great support for me, and she lit a fire inside of me, and convinced me that I will go out into my audition rotations and show them the kind of doctor that I will be, and that I will not let a number define who I become. I'm so lucky to have her in my life.

Also during this time, we had the kids in swimming lessons, so I enjoyed taking them to swimming nearly every day while I was off. Braylei was also involved in many things such as her city gymnastics class and dance class. Meghan also finished her preschool classes in May, and she decided not to teach again for the fall, as she is due at the end of October. And so we got Braylei in another in home preschool. Meghan will still be teaching piano, however. And little Tayscen is just a hoot! He is so full of energy and he can entertain himself for hours if he needed too! I love that little guy!

Rotation Block 5: General Surgery

During late November through Mid December, I had my general surgery rotation at Banner Del Webb Hospital with Dr. Marco Canulla and Dr. Kathleen Koerner. The best thing about this rotation—it was right by my house!!! The past few months I had been traveling to Scottsdale and Wickenburg every day! The hospital was less than 10 minutes from my house!

This was a pretty sweet rotation. I realized that I really liked surgery and enjoyed the OR more than I expected. What I did not like as much is the sometimes crazy hours they worked and the ridiculous turn-around time from one case to the next. There were a few days were we got there at 5:30 or 6 am and were there until 10 or 11pm! It was nuts! I am very happy that I decided to do a preceptor/department based surgery rotation as opposed to a ward based rotation. Ward based rotations (at teaching facilities with residencies) are important for students looking into surgery residencies. It is great exposure, you typically see some pretty cool cases, and any ward based rotation is good to get more comfortable with the residency environment. The downside, though, is that it is with residents who are training and therefore get to do most of the work, leaving the student to watch or do very minimal participation in the case. On my rotation, I was able to scrub in to most of the cases, and many times was the 1st assist on the case! I had a ton of opportunities to run the laparoscope, make incisions, use the electrocauterizer, use laparoscopic tools, and do closures! And as I am a hands-on learner, this was very helpful to me!

Another student, Stephenie Sterrenberg, was on the rotation with me, and we usually both scrubbed in on the surgeries or took turns. We also rounded on all the surgical patients each morning and wrote notes, so we still got a lot of hospital experience. And the learning was good too. Dr. Canulla is a laid back, hip-hop lovin’, get-er-done kinda guy who would perform 25 minute lap cholecystectomies. He seemed absolutely fearless! There wasn’t a case he would turn down, and he did general and vascular surgery. So in addition to the GI surgeries, I was able to assist on a lot of AV fistula grafts and revisions, which got extremely bloody sometimes! He took a genuine interest in our learning, quizzing us on things like fluid maintenance in addition to surgical knowledge. He was always looking for ways to improve the rotation as well from our perspectives. He was a great model of a preceptor. Dr. Koerner was an AZCOM grad and was fresh out of her surgical residency. It was awesome to get her perspective on things, and she was really patient and easy going in the OR. She remembers what it was like to be a student, so she made sure that we had a lot of opportunities for hands-on involvement. I was also able glean some osteopathic surgical philosophies from her. Nothing crazy or anything, but just thoughtful methods that perhaps took an extra few minutes, but showed that they improved healing time and patient comfort, as well as enhanced post-surgical performance. This mostly involved different types of irrigation, different methods of closures and so forth. True, being fresh out of residency translated to some longer cases, but she always seemed happy that we were there! It was a really strong rotation, but I was very grateful that we had a 2 week winter break afterwards! And then there was the shelf exam. That did not go as well for me. True, I passed, but it just took me longer to get through the questions. And as we only have 2 hours 10 minutes for 100 questions that are all clinical vignettes. Needless to say, I had to bubble the last 15 questions in with “C.” So thankfully I still passed!

Rotation Block 4: Psychiatry

In Block 4, I had my psychiatry rotation, which was with Dr. Karp, DO, at Rosewood Ranch in Wickenburg, AZ. Rosewood Ranch is an inpatient based center for eating disorders. They see patients from across the nation for anorexia nervosa, bulimia nervosa, binge eating disorder, and mixed disorders. They also have both male and female patients. The structure of the program was very interesting to me. The rehab features both a very custom nutrition program along with group and individual cognitive based therapies. The idea is that when someone is so nutritionally imbalanced, they are cognitively affected as well. There is also three levels to the rehab. The first is the inpatient facility, after which they can transition to a residential setting, where they converted a motel to apartments for the residents. There, they have more freedoms and choices, but still have the program structure and support they need. A typical treatment period is variable from patient to patient, but was usually 30 days inpatient, with an additional 30 days in the residential. Many also choose to do an outpatient program, where the patients work or go to school, then have evening classes and programs as they continue to transition back into life. Another neat aspect they have is called Family Week, where the patient’s family comes to Wickenburg and has day classes with the patients. With eating disorders, it doesn’t just affect the patient, but the entire family. They learn in detail the psychological and medical aspects of eating disorders, and have a lot of family based healing therapy. Many times, the eating disorder will tear the family to shreds.

I learned so much on this rotation! This was recommended to me by an upper classman as a great way to immerse yourself in patient interaction and delving deep into the patients’ psyche. The first few days I mainly sat in on the group therapy sessions so I could gain a good grasp of the concept of the program. Then I sat in on new patient interviews and the daily and weekly interviews with Dr. Carp. The next week I spent going back and forth between the inpatient and residential facilities. The third week I spent at family week, where I was able to witness both the damage that an eating disorder can cause, as well as the healing that can take place with therapy, commitment, and work. The final week I spent conducting the new patient evaluations, along with daily and weekly interviews. I even was able to dictate my initial evals! It was a really great experience for me, and I grew a lot as both a person and future physician.

The whole time I tried to put myself in another’s shoes. Whether it be the patient, thinking about how easy a mental disorder can take control of my life, and the tailspin of detriment that can result, or the perspective of a brother, father, or significant other, who is watching this happen to my loved one. There were many times at Family Week that I cried as I witnessed the hurt and anguish that has come from this underestimated disease.

On the positive side, I bonded with many of the patients, trying to connect with them and showing them that I really cared. It was really rewarding to me to see the progression of some of these patients, and it is awesome that I am still in contact with many of them today.

While this may not have been the most academically challenging rotation, and true, I didn’t see a ton of pathology like I may have in an acute psych ward. But I gained so much more than that. I got so deep into the minds of those around me, and this was emotionally challenging for me. I feel that it prepared me to be able to handle other mental disorders as well, as I worked in acute, and chronic settings, and also worked with the family aspect. This helped me to see how I can apply this to the Army physician setting in working with PTSD or other acute stress disorders. One thing is for certain—I will always be grateful for the lessons I learned from Dr. Karp, but even more importantly, the wonderful, courageous patients at Rosewood Ranch!

Oh, this rotation was actually my first NBME Shelf exam, which are nationally standardized tests for all the core medical rotations. You basically get 2 hours and 10 minutes to answer 100 clinical vignette based questions. It really is not enough time to get through everything, especially as I am a slower test taker. I felt the Psych exam was fairly straightforward, but it asked a lot of questions about the type of therapy that would be best in different cases that I wasn’t prepared for, especially since it is so subjective and different psychiatrists use different methods. I also did get to the last 8 or so questions, so I had to bubble in “C” for the last handful. Luckily, I still did okay despite that fact!

Absent

I have been way too negligent of my blog over the past few months. I am trying to get them up now. Things have been insanely busy and I haven't had the necessary time to dedicate to updating the blog. I will post my medical school rotation reviews first, then I'll go back and write about my family happenings, including Thanksgiving, Christmas, New Years, and Valentine's Day. So hang in there, if anyone still checks in!