nanimov

PGY1 – Day 2

My first day in clinic. I started the day in pediatric cardiology clinic which felt like another full circle moment because this was the first place I shadowed during medical school. It felt good to be back in a clinical setting and seeing patients, and in cards especially seeing some interesting conditions, getting to look at echoes, and only having to focus on one condition. I impressed my attending because after we went back in together to see a patient, the patient who normally is not cooperative with any type of exam, motioned for me to listen to her heart again (probably just ’cause she’s just getting older, but still was gratifying).

Then in the afternoon I had my first continuity clinic patient, a newborn. It’s always fun to work with the wee babes and (usually) the families. I did have to learn and do all the stuff real doctors have to do though beyond writing the note; doing the med rec, doing the visit charge, etc.

It’ll be a pretty stark transition when I start in the MICU next week which I’m actually looking forward to, but for now I’m just going to enjoy the coming weekend for my brothers wedding.

Postgraduate Year 1 (PGY1) – Day 1

I couldn’t have asked for a better way to start my residency training. I was scheduled for community outreach all day which involved going to a local organization for “Questions for a Doctor” in the morning, and then in the afternoon we went to a local high school for an on-site “mobile” clinic to do sports physical for students. The opportunity to be out in the community and bring healthcare to people who may otherwise have limited access is a big reason why I wanted to be in this program. This morning I had some really great conversations with people in a setting that they feel comfortable and on their terms, answered some question, and got some advice on how to be a better doctor. This was my first time engaging with people and also doing clinical work as an MD, I even signed my first sports physical which was exactly as exciting as it sounds. While these kind of community-based activities are not going to be as frequent as I would like since I still need to become an expert at regular medicine, it was hugely motivating as I go into tomorrow to see my very first patients in clinic.

Residency Day 0

It’s been a while since last wrote anything on here despite this being probably the most eventful 3 months of my life. I matched into my first choice residency program, I finally went to Japan, I finally built a pizza oven with my dad, graduated medical school, and tomorrow is my first day official day as a resident loose in the world. Luckily for the world I’m on a weird +1 week this first week and in Med-Peds we can have a day of community engagement and so that is what I have tomorrow. It feels fitting though because involvement in the community is one of the big reasons I wanted to stay here at this program. And then Thursday I have my very first clinic patient. I am very excited to finally start after all this time since match day. Hopefully I can keep up this enthusiasm. But yes that is all for now.

Sub-Therapeutic

In medicine we sometimes talk about adequacy of treatment with medication in terms of whether or not the patient is receiving a therapeutic dosing of the medication. In some cases we check can check the blood to see if the level of the medication in the blood is high enough to be “therapeutic.” That doesn’t mean that the medication doesn’t work, it just means the patient isn’t quite getting enough to have the desired effect. We don’t stop the treatment, but rather we bolster it.

When it’s come to medications, it’s an easy thing to determine. We have objective* data telling us what a good blood concentration of a given medication should be. We are not as good at determining “therapeutic” levels when it comes to other types of interventions. While there are general guidelines for other types of intervention; how many fruits and veggies we should eat, how much exercise we should get. But these are more general guidelines, and what may work for one person may be sub-therapeutic for another. With psychotherapy, it’s seems the jury is still out as far as frequency and duration.

I also then think about social interventions. Having spent a good amount of time in the street medicine space and with people experiencing homelessness, I’ve also been exposed to countless initiatives and projects aimed at serving underserved and vulnerable communities. Not all programs are created equal, but there are definitely ones out there that seem to have a lot of promise, but they don’t have the resources to have the impact that the could. The funding isn’t there, or the staffing isn’t there, often because interventions of societal sickness don’t have any inherent profitability so society doesn’t care (just like managing chronic disease doesn’t immediately make a person feel better).

As an example, enhanced care management (ECM) has recently become a provision as part of some medical insurance in California. ECM is meant to provide comprehensive, focused care for individuals with complex medical and social needs through intensive case management. While the idea of this is amazing and would likely benefit many, many people, the need is large and the providers are few (and reimbursement I’m guess is small). Having had the chance to work with some ECM providers, they are stretched thin with their current empanelment as it is and have a lot of people who likely need services that they just are not able to get to.

If we are thinking of the injustices that exist in our community as society sickness, these interventions are sub-therapeutic. That doesn’t mean they are ineffective, it may just mean that the dose is just too low.

Don’t Recycle

Sometimes I feel like I should stop recycling. All it does is make me feel better about my consumption without any real meaningful recycling actually happening (since a good chunk/ most of it ends up in the landfill anyway, as far as I’ve been told). I realize this mindset is kinda throwing out the baby out with the bathwater since recycling done right probably is helpful, but I can’t help but think I would be more mindful of the materials use, and use less if I operated under the mindset that literally every single thing I use and throw out ends up as trash forever. Even that doesn’t feel like enough ’cause that trash all ends up out of sight and out of mind. It becomes someone else’s problem to deal with, and that’s my privilege. I’ve recently been annoyed seeing more and more people throwing trash out their car window and just littering in general, which I still think is bad, but am I really that much better by throwing things in the trash, especially if I am buying and using things blissfully detached from the amount of trash and pollution I’ve created throughout my life.

Now please excuse me while I throw away this plastic coffee cup.

Pulmonary Medicine – The Whole Tamale

Overall it was a pretty tame rotation which is why I am lumping it together all in one post, and also because I kinda just saw it as a continuation of my ICU rotation as a Pulm/Crit super rotation (and not because I forgot/ got lazy). It was definitely slower paced on the ICU, but it allowed for a lot of time for learning and education and stuff, while still allowing me to get home before rush hour. I really enjoyed learning more about pulmonary physiology and tying it back to our basic physics. It reignited one of my many life goals of creating a science museum on exploratory body science. Anyways it seems like between the two services of ICU and pulmonary consult/ clinic, life as a PCCM attending seemed more chill than I expected, but that is also coming from a limited medical student lens. But the key phrase is “than I expected.” I still imagine it’s pretty demanding to get there in terms of the fellowship training, and the high likelihood of having to have call for the rest of my professional life. What I do like about Pulm/Crit is that you have the ability to specialize in a certain area while also still being more or less a generalist when on the ICU in terms of still needing to have a pretty robust knowledge of all of medicine. Then the next part of concern is if this is a career that would be compatible with my med-peds training and my family/ life goals. Lots to think about and looking forward to figuring thing out (or getting more confused during residency).

Change Happens

I switched things up this morning and decided to listen to Seth Godin’s Akimbo podcast on the way to work instead of the radio. He was talking about being “supple” and resilient in the face of change. One thing he said stood out to me this morning as a good reminder to keep in mind. He said:

“The world does change more slowly when you fight against it.”

Being at a place where there are a lot of change in my personal life coming in the next year, and there are a lot of technologies that are (or will) rapidly changing how we work, it’s important to think of how I can adapt and change with the change that is happening around me. Even though the extrinsic change that happens around us day to day feels inevitable, growing and changing myself is not as simple as waiting around for something to happen. It requires effort and work.

Medical ICU – Skipped Days and the Rest

I’ve been pretty bad about staying up to date with this, and in general using my time after getting out of the hospital to do any kind of meaningful reflection which I feel like has taken a toll on me in various ways that are hard to quantify.

The rest of my MICU rotation was pretty good though. I actually liked the overall operation of the ICU. I liked the complexity of patients that came through and management of drips and vents, while still having to pay attention to the standard internal medicine things like blood sugars and electrolytes. I expected to be more dissatisfied with the aspect of not getting to see patients to discharge, but in most cases there was a sense of completion. Either the patient was stabilized enough to transfer to the lower acuity floors or to another hospital, or even in some cases be discharged directly from the ICU (in some cases they were basically stable enough to go home from the ICU after being super sick but stayed a few more days on the floor for monitoring or other reasons, or in the other unfortunate case they would pass while in the ICU. It is a lot of training though, but it does seem like something I could be interested in in the future.

This experience also makes me curious about the pediatric ICU, the things I’ll see and the types of conversations I’ll have.

Medical ICU – Day 10

The them today was goals of care. I’ve talked about this a bit before on my internal medicine rotations and the Palliative Care attending that I had and the tips that he shared. Compared to IM though, these conversations are happening on a weekly if not daily basis in the ICU. It definitely makes me think a lot about how I would approach having these conversations with patients and families.

My attending this week offered an approach that I thought was pretty compelling. It was a pretty simple one in that in many of these cases we have done everything we can to help patients recover, and so her approach was to let patients know that, which I know seems basic and common, but she also stress the importance of explaining what improvement looks like to us from a medical perspective and what deterioration looks which I think is helpful in setting expectations with patients and their families. Being objective in these conversations does necessary have to mean being cold, and the objective aspects of a patients health or lack there of can be delivered with compassion and ultimately should help guide patients and their families to being at peace with whatever decisions they decide to make.

MICU – Day 9

I was able to actively participate during a code today for the first time today (I know it only took all of Med School). It was pretty different from all the Mock and Sim codes I’ve done or the BLS/ ACLS training I’ve done, but understandable so. I was recruited to do chest compressions, though I wasn’t the first one so I didn’t experience the rib cracking. It was a bit more tiring than the Mock codes I’ve done and definitely a lot scarier with an actual life on the line. The defibrillator/ heart monitor wasn’t hooked up correctly at first or didn’t have good contact or something based on the signal, so it kept saying “push harder” which definitely added to the stress. It hard to maintain a steady pace without actively thinking about my rate. And at the same time I was trying to listen to everything else going on so I could learn. It was only 3 minutes but it felt like a long time and a short time at the same time. After my round of compressions we checked a rhythm and got a pulse (or as we say return of spontaneous circulation or ROSC). Was it my excellent compressions or was it the meds he was getting who’s to say??? Let’s just say it’s good we were in a room full of seasoned professionals.

At the end I wasn’t sure how I felt, or how I thought I was supposed to feel. I feel like there were maybe less emotions than I was expecting given this was my first real code. The only prominent emotion was excitement which feels wrong. Of course I felt bad for the patient and it is terrible that this happened, but at the same with him being sedated through the whole thing there was no emotional feedback to go off of, and everyone around me was super professional and if not stoic or in some cases kidding around with each other. So that was the emotional energy that I was feeding off of I guess. Still feels a bit weird, but only because I feel like it should. A man almost died in front of my eyes. If anything the person who was at the forefront of my mind was the patient’s mother who had constantly been at bedside and was in the room when they decided to intubate which eventually led to a code (she was out of the room when they lost the pulse thankfully). I was constantly trying to think of the right words to say to her if I were the one to tell her what was going on, what happened, or what might’ve happened if it came to that. I kept drawing blanks beside the basics and cliches, so definitely something I need to work on, and then be able to do it in Spanish.

Otherwise it was a pretty standard day, besides me coming back in from the weekend and us starting with a new attending who seems pretty badass.