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I was kinda all over the place today. Been a lot on my mind lately so I think that may be part of it, but my presentations felt very haphazard and I felt like I didn’t know how to talk. I kept getting lost in my train of thought and trailing off sentences without making a definitive or clinically relevant point.

Or maybe it has always been this way and I’m just becoming more aware of it. In any case, using the What, So What, Now What framework, that’s the “what” of my situation. The “so what” is that it’s kind of embarrassing and is a sign that I need to improve my presentation skills and also just my clinical knowledge. The “now what” is just more studying, being more proactive in seeking feedback, and to maybe be more intentional and organized with putting together my presentations. I did notice that last week I was writing out my presentation in kinda a bullet form for one of the attendings and that day I was feeling pretty good. I think I’ll do that again today.

I feel like a broken record at this point, but all the attendings here have been really awesome. They are also all so different personality-wise. Today I worked with 2 different doctors. One of them is an addiction medicine specialist. We had a patient who was now sober for I forget how long and doing a lot better and planning to be able to go to his daughters weddings now that he’s winning his battles. It was super heart warming and inspiring to see. The other doc is perhaps one of the most enthusiastic, charismatic docs I’ve worked with. All her patients seems so comfortable with her. They joke around together, throw jabs at each other, but they also appear to trust her completely.

These relationship and these stories are what attracted me to medicine in general and are just a part what I’ve loved about family medicine so far.

Today was a little bit slower. Most of the patients were Spanish-speaking and we didn’t have the staff for one of the MAs to come in with me to talk to the patient so I followed my attending (another new one) into those visits. I reeeeeally need to work on my Spanish more seriously.

When I did have English-speaking patients I had some really good conversations and I think my presentations were pretty good. I’ve gotten closer to a format I like and he accepted my assessments and plans without much changes. I even made a health maintenance suggestion where he went, “Oh yea that’s a good idea.” I’m learning a bit more everyday and it feels good (though I feel like I could have come in with a better baseline).

All this said, I have so many side projects that I need to work on, but when I get home I’m just so tired, and a shower and watching One Piece on the couch until bedtime sounds like such a nice comfort. I’ve also been feeling a bit more tired just in general. I’ll usually like to go to a cafe (or sometimes a brewery) right after work to combat this and at least be a little productive, but as soon as I get home I can’t do anything (though also a change in mindset there may help?). These are all projects that I want to do, I just need to find a way to maintain energy levels and motivation throughout my day. Part of that may be getting back to my morning routine and some exercise which has been falling off recently.

I thought my Ob/Gyn days were behind me. Today 40% of what I did was Ob. I did dopplers, I did fundal heights, I did a frickn’ Pap smear, pelvic exam, breast exam, AND I took a GBS sample which I literally never did the whole time on my Ob/Gyn rotation. It was good review and I am super appreciative to all the ladies who trusted me with their care, but just not necessarily what I was expecting when I came out here.

The afternoon was a little more varied and I was working with a new attending. The medical director of the clinic. Very nice guy, and a little more structured in terms of his expectations (understandably in part because he may have more at stake and in part because he probably had a little bit more lead time compared to the other preceptors). He picked out patients right from the get go, and also wanted a specific presentation format (honestly it was the pretty standard SOAP format, but none of the others harped on me for being all discombobulated probably as a courtesy), so I kinda had to pull my shit together. I only had 4 patients in the afternoon, an ob + one of her born sons, a diabetes follow-up, and a post-up follow-up. It was a nice spread and the fact that I knew who I was taking and what to expect gave me a chance to kinda review in between cases things I wanted to do and organizing my presentation. Overall though I think I did ok today. I sucked a little, but I’m still getting in the groove. Tomorrow I will suck less for sure (thanks Dr. Glaucomflecken).

New day, new preceptor. The experience today was a little more what I anticipate most of family medicine to look like. A lot of middle aged to older adult patients. A lot of chronic or age-related disease. That said all the patients I worked with today were lovely and today’s preceptor was also excellent. It was another half day at the clinic though and I had conference in the afternoon. Tomorrow will be my first full day in the clinic so it’ll be a good to see how I feel in this environment for 8 hours. Definitely gonna need to be nailing down management of hypertension and diabetes over the next few days.

At the afternoon conference I met some more attending and residents, most of whom (I didn’t meet them all) seemed like wonderful people. I really like the casual vibes they gave off. I also really appreciated the deadpan humor of the attendings, but maybe that’s just me.

Family medicine is probably the core rotation that I am most curious about. I’m curious about how I will feel working in it for a relatively extended period of time and I’m curious if what I’ve envisioned working in primary care could look like is the reality (I keep rereading that sentence to see if it makes sense). Primary care is kinda the whole reason I decided to go into medicine. I loved the idea of having loooong-term relationships with my patients, to really get to know them, to be the person they trust above all other doctors. I want to be the doctor that my patients come up to while I am with my family in Costco just to say hi. I want to be able to prevent my patient from getting disease, not just treat it when it happens. I want to be able to teach them about their bodies, and work with them depending on their individual situations, life experiences, world view, to figure out a plan that aligns with their goals and values. Today, I got a glimpse, and I’m excited to see more.

The morning was all just orientation. Getting my badge, doing paperwork, learning how to sign-in to the EMR, etc. Apparently I get free lunch at the primary medical center which I took advantage of after orientation especially since I won’t be going there often. I got a bit of a tummy ache with the pasta, but the lunch ladies were all so nice maybe I’ll go back just to say hi.

After lunch I had a little extra time and got some studying done at Starbucks and then made my way over the clinic to meet my preceptor for the day at 1 PM. When I go there I really had no idea what the plan was so I just checked in at the front desk and was told they would notify the administrator and they would come get me soon. I waited about 15 mins, at which point I went back to see what was up, concerned that the doc was expecting me. The MA at the desk said, “Oh they are in a provider meeting, someone will come out when they are done.” In my head, I was just like “??? you couldn’t have told me that earlier so I’d have some idea of a timelines.” I just went back to studying in the waiting room. Couple minutes later someone came out, one of the administration assistants and I guess the head EMR guy there, he said he would give me a tour of the facilities while the provider meeting was going on. The medical plaza was impressive for what it was. There was relatively high capacity for primary care (at least it seemed that way) as well as on-site availability for labs, specialty care, and some imaging.

We finished up the tour and I was introduced to my preceptor who apparently was only finding out in that literal moment that I would be working with her that afternoon (she was having difficulty moving due to some apparently extensive sun burns down her legs which was a repeat source of some [sympathetic] comic relief throughout the day). She was very nice and welcoming, and I was told during the tour she was one of the family med docs who also specializes in high risk OB which I thought was interesting. Turns out she’s a whole ass badass (a WABA^TM if you will). I mostly followed her through the afternoon, but in that short time we basically did everything. Pediatric well-child checks, hypertension follow-up, OB superimposed on a neuroendocrine disease, severe eating disorder, low back pain with narcotic addiction, she was even consulted by the other doc there for management of some lactational mastitis. I was a whirlwind and she handily dealt with it all, jumping from patient to patient, knowing their stories and their situations. For one of the well-child checks she gave birth to this patient and watched him grow up and works with both the parents. She still takes call to do deliveries and even performs C-sections.

Oh and did I mention half the patients were Spanish-speaking and to my untrained ear she sounds basically like a native speaker (which I don’t think she is but I could be wrong).

It was really impressive to watch her work and to work with her (she also really reminded me of my aunt who is also in family medicine and has a similar way with patients and is multilingual). I don’t think I’ve ever been this impressed with a provider. All the one’s I’ve worked with in the past have been good and knowledgeable, but just the sheer breadth of what she is able to do and manage with the competence was really remarkable. No only does she have to know a lot of medicine, but she has to actually apply all of it on a daily basis. What I saw today was why I came into medicine and why I envisioned myself in primary care. I came out of the clinic more motivated than ever. I guess we’ll see how it holds up over the next 5 weeks and working with a few different physicians.

There’s been a culture shift in medicine in which individuals and systems have been making self-care and self-compassion more of a priority. Whether or not the interventions to that end have been effective is another story, but given the levels of burnout, depression and suicide among healthcare workers I think we are at least moving in a good direction.

Since starting college, I thought I was pretty good about being compassionate towards myself. For a variety of reasons, I stopped placing all my self-worth in my grades and academic performance. I was forgiving of myself for my shortcomings, and I was good about taking time for myself when school was getting overwhelming. From then to starting medical school, I continued to focus more and more on myself; getting to know myself, being more reflective, and really understanding my personal values.

But at some point, I think I overshot. I started justifying unhealthy habits by writing them off as “self-care.” Self-care and self-compassion doesn’t mean taking a nap, playing video games, catching up on your backlog of unconsumed media or “treating yo self” every time you meet resistance in your work or feel tired, which has been becoming a pattern for me over the past year.

When thinking about compassion in general I like the Dalai Lama’s description in The Book of Joy and how he differentiates in from empathy. He says that empathy is liking finding someone stuck under a giant boulder and then chillin’ under the boulder with them, whereas in compassion you get under the boulder with them, but then actively work with them to remove it.

In the case of self-compassion, both the person under the boulder and the bystander are you, and the boulder is suffering. Using the word suffering sounds so dramatic, but suffering can take a lot of forms, but the way different people experience suffering is often similar or can at least feel similar (does that make them equal?). Subjecting myself to tedious work or “boring” work can feel like a form of personal suffering and watching a video about how Mantis Shrimp strikes create generate enough force to boil water at the bottom of the ocean relieves that suffering.

However, the guilt of not reaching my potential and of not doing work that will help me one day better serve others is also a form of suffering. The question I need to ask myself is which of these is this rock really made of.

It’s not about protecting life. It never has been.

It’s not about protecting the Constitution (which in itself is an idiotic reason).

It is and always has been about control and about power.

It’s about a system of government that disproportionately caters to populations who already hold most of the power and who have used that power to keep it that way.

It’s about politicians who desperately need to maintain their seats in Congress in order to stroke their fragile egos, so they pander to those populations despite what they personally believe and despite what the majority of their constituents may believe.

It’s ok for people to have fundamental differences in what they believe, and it’s ok to fight for what you believe to be right in your own life, but that should not come at the expense of other people’s ability to make decisions for their own lives. For what it’s worth I’m confident many of the politicians who are gleeful about the Supreme Court’s decision don’t give a shit about m0rality, they are interested in what’s going to keep them funded and in office next year.

It’s really curious to me that most lectures start out with providing the learning objectives. I think it kinda represents the backwards way in which we approach education.

If I am trying to teach something, the objective should be self-evident. It’s ok to have learning objectives, but to say them explicitly upfront is cheating.

By the end of a “lesson” we should be able to ask participants what they learned or what they think they were supposed to learn and those things should track with the learning objectives.

And if people aren’t walking away able to identify the undisclosed learning objectives intended by the educator, then it should be on the educator, not the students (or at the very least equally on both), to rethink how they deliver the material. That said educators who take their craft seriously should also want to make changes that benefit their students and not be afraid to critically evaluate their teaching for their students’ sake.

I don’t want this to come off as an indictment or a generalization on educators because they do some of the hardest and most important work, and in general teachers are overworked and underpaid. I will say that all my favorite teachers have been one who have challenged traditional styles and went out their way to create meaningful experiences for us as students to better understand the material. And as someone who plans to take on an educator role in the future, this is something I aspire towards.

Today was my last day of the rotation. It was a little bittersweet. Honestly I wouldn’t mind coming in for a little while longer. Maybe that a cringey thing to say, but it’s true, at least at this moment in time. Though part of it is probably the fact that I’m under no obligation to stay there the whole day, I don’t have any actual responsibility there, and the residents are all so cool and fun to work with. Maybe also because I really don’t want to take my Shelf exam. Another part is when I learn in the hospital or in the clinic it feels like my learning is actually connected to something that matters, not just a red X or a green checkmark.

Anyways it’s over whether I like it or not and I’ll just have to appreciate it for what it was. Overall it was a very positive experience and I’m definitely now leaning more towards working in peds in some capacity.

We had a new attending today, and he brought with him a first year medical student (who I’m pretty sure lives on my floor) and an undergraduate student. They came on rounds with us and so we did a little extra teaching with each patient. When we got to my patients I felt a little more nervous than usual and I wonder if the youngers could tell I had no idea what I was talking about (ok I had some idea). That said, and I think I mentioned this before, I do enjoy teaching and I could see it as a part of my future, but first I need to gain more mastery of all the material. Seeing them though, and thinking about how I was once in both their shoes was motivating.

I think it’s really time for me to really dial in on a Plus Ultra attitude.