The Beat Goes On

I closed out my peds rotation a few weeks ago and am two weeks into my family medicine rotation. Long story short, although nothing's been too mind blowing over the past four weeks, I've still enjoyed my time on the rotations.

Peds was a good rotation: good children's hospital, diverse pathology, fun med students, enthused residents, good faculty. I was/am in shock at how much I actually enjoyed everything. The best parts were well-child visits in clinic. Brief enough encounters that I don't get sick of the kid, but long enough that I get to play with them when they're healthy. Ironically enough, the worst part of the rotation was clinic. Outpatient just isn't as fun as inpatient stuff, especially when I'm seeing my fifth cold/flu/gastro of the morning. Up on the floors, my patients had things including: DiGeorge syndrome, osteosarcoma, CVID, and complex congenital heart disease.

By far the saddest patient on during my rotation was a two month old kid who came in with shaken baby syndrome. Yes, it's exactly what it sounds like. DCFS and the cops were close to making an arrest but couldn't tell us who, though we all suspected the dad. The kid had broken ribs, retinal hemorrhages, hypoxic ischemic encephalopathy, and ended up with both a tracheostomy and gastric feeding tube. At two months old. I hope the sick fucker rots in a cell.

Peds is actually a surprisingly diverse field, once you get outside of clinic and all its colds and stomach bugs. There's a pretty extensive set of pathologies that are peds specific and even common pathologies which present atypically in the peds population. Long story short: I liked the rotation and it's still on my radar.

Transitioning from one primary care field to another, I'm now two weeks into my family medicine rotation. As is becoming a common theme for my M3 year, I'm surprisngly into the rotation so far. As a student, I'm given a lot of autonomy: see the patient, workup an assessment/plan and present to the resident/attending I'm working with that day. Kinda makes me feel like a doctor :)

As a career, it's a diverse enough field for my liking, as pretty much anything of any age can walk through the door. Pathology-wise, I see whatever most people go to the doctor for, as family docs are most people's interaction with the health care system. Lots of colds, back pain, headaches, dizziness, belly pain, asthma, COPD, GERD, etc. Since a lot of this stuff is less acute and complicated, it's a lot more amenable to student level assessment and management. That right there might be why I like the rotation so much. This lower pathology complexity affords me more opportunities for patient education and counseling, which I actually enjoy. Since a lot of these conditions are also chronic, there's lots of continuity of care (which ER is lacking by nature). It's somewhat nice to see the same patients again, but also educational as a student to see how things progress, both for better and worse.

Some things I'm not a fan of are the lack of acute, diversified pathology (e.g. heart attacks, collapsed lungs, etc.), lack of inpatient experience (family med's by nature an outpatient practice), and patient noncompliance. All of the above things can be brought back to family being an outpatient specialty. If you're being seen in clinic, you aren't that terribly sick, which can secondarily lead to noncompliance. In the hospital, odds are you're reasonably sick and as such more amenable to treatment compliance. Compounding noncompliance is lying about it. I'm open to noncompliance if I'm told about it. Bonus points if it's reasonable: insurance, treatment timing, etc. But as long as I'm not lied to, then it's something we can work on.

The biggest thing I'm not a fan of is the compressed timeframe of family med visits. Sure, some things are bread and butter, like a slam dunk otitis. Grabbing the HPI (history of presenting illness), doing a quick exam, getting the azithro written, and giving followup instructions should take under ten minutes. Fifteen at a residency program where we present to attendings. But that's for a simple case of otitis.

If anyone ends up being a psychosocial visit (e.g. depression, bipolar, anxiety disorder), it's probably at least fifteen minutes just for the HPI. As a student, I haven't figured out how to diplomatically and also feel bad about cutting patients off. Especially if they're in for or bring up the aformentioned. And probably at least a third of my patients so far have had some flavor of psychosocial problem in their visit. As someone who wants to address everything that's brought up, I have a hard time condensing the visit into an appropriate timeframe. It's a bit frustrating and unfulfilling, since I don't want to diminish what's been brought up. Maybe it gets easier as I get more experience. But even as a resident, I then get slowed down by all the paperwork, presenting/discussing, and more paperwork.

Overall, family's been pretty good: great residents/attendings, decent autonomy, reasonable hours (including no call or weekends), and that "being a doctor" feeling. Downers include lack of time crunches, lack of acuity, and noncompliance. Thus far in my mind, the pros outweigh the cons though.

Pediatrics

I'm four weeks into my six week peds rotation. At my site (Hope Children's Hospital), I spend three weeks on a general floor, one week in the nursery, one week in outpatient clinic, and one week in a subspecialty (just finished up my peds GI week).

Taking a further step back, this half of my M3 year is more medically oriented (vs. surgical - e.g. ob/gyn, surgery). As such, I have had dust off my thinking cap and throw it on in the morning. And there was quite a bit of dust on my hat.

At this stage in our careers, I'm realizing it's not all about nailing the correct diagnosis. Yes, it's nice when your residents and attendings agree with your assessment But it's all about thinking about what something could be and what else it could be.

Take appendicitis for example. Classically, it will present in 10-15 year olds beginning with diffuse abdominal pain and cramping that localizes a few hours later to the right lower quadrant, 2/3 the distance from the navel to a hip landmark. Pain should precede any vomiting or anorexia (vice versa in gastroenteritis). On exam, the patient'll probably be febrile, hopefully without any peritoneal signs, and hopefully positive one of a few classic signs: psoas, obturator, Rovsing. It's said that 80%+ of diagnosis is based on history and physical and they guide appropriate workup. A story convincing for an appy will buy you a CBC to confirm infection and probably imaging to confirm that you've actually got an appy.

The story I just gave is pretty straightforward for an appendicitis. In thinking of right lower quadrant pain, one's also gotta consider adnexal cysts/torsion, ectopic pregnancy, PID, mittelschmerz, mesenteric lymphadenitis, Crohn's, volvulus, intussusception, pyelonephritis, urolithiasis, Yersinia enterocolitica. In entertaining thoughts of appendicitis-mimics, the vice versa also has to be considered - appendicitis mimicking other conditions. That is, appendicitis presenting in an atypical fashion.

Long story short, it's interesting having to actually think through a patient's story. And I'm pretty sure I like the process. Even though I'm realizing how much I don't know at this point. At the same time, I still have an itch to do procedures. Sooo, I still haven't made any progress in the surgical vs. medical debate.

That said, I'm actually enjoying my peds rotation a lot more than I thought I would. The floor patients are pretty interesting - if a kiddo's in the hospital, there's got more going on than the stereotypical sore throat or ear infection. Patients I've had include: congenital heart defects (mostly tetralogy of Fallot), foreign bodies, ovarian cysts, nephrolithiasis, pill ingestions, hydrocephalus, diabetic ketoacidosis, Crohn's, supraventricular tachycardia, common variable immunodeficiency, and seizures. More typical peds admissions include RSV bronchiolitis (shittons) and appendicitis.

On a sadder note, some kids ended up having with serious shit. I.e. hepatocellular carcinoma, leukemia (ALL), and osteosarcoma. The osteosarcoma was particularly sad - a 17 y/o girl whose presentation was a lumbar vertebral fracture leading to paraplegia. It was on her workup that a femoral osteosarcoma was found with metastases to her abdomen and spine.

Those sad stories aside, probably the only interesting case to nonmedical folk would be an incidental finding of pinworm in a girl getting scoped for Crohn's. Note: the upcoming in parentheses might be a bit disgusting.

(Classically, its presenting symptom is perianal itching. If having worms in your colon isn't offensive enough, the reason for the itching is because they come out of your GI tract at night and lay eggs perianally - it's these guys that cause the itching. The traditional diagnostic test is the scotch tape test. Double side some tape around that area before bed, let them do their thing, have a look at the tape in the morning.)

Now that I've gotten sad and disgusting stories aside, there's not much to write home about. I'm shocked at how much I'm enjoying the rotation. I can appreciate the diversity in pathology, patient age, and the fact that kids' problems aren't self induced (alcoholic cirrhosis, noncompliance, etc). In all honesty, it's playing with the little ones that's the best part of my day. Especially the 3-15 month olds in clinic - good age group and if they're in clinic they're reasonably healthy and amenable to playing. This week I'm in the nursery and the NICU. Not gonna lie, the kiddos are pretty cute.