nANIMOv

Slowly I’m becoming more doctorly. I’ve been trying to be more consistent with providing my assessments and my plans more confidently, even if they are potentially wrong. Trying to avoid qualifiers. No “I’m not sure but…” or “This might not be right…” or “Not sure what you think but…” Just going for it. So far my preceptors have been very gracious in hearing me out, endorsing the good things I say, and suggesting adjustment or alternatives when necessary.

More and more I feel like I’m asking the right questions and I’m a little more focused in my histories and physicals. I’ve also been doing a little more reading of primary literature this week for various reasons, and while not all of it has been super relevant the present clinical practice, I’ve enjoyed reading the papers and it always feels good to learn new stuff (or at least feel like you are).

I can definitely see how easy it is to burn out in family medicine. Don’t get me wrong, I’m still enjoying it, but in the absence of good wellness practices it can definitely be a ticking time-bomb. More so today than any other so far, I saw the effects of the the short appointment slots. A lot of the patients we see can be complex and/or have a lot of problems to address, and the 15 mins that are scheduled simply are not enough. At the same time, we can’t just increase their scheduled time because other patients need to be seen. From the patient perspective it can appear like doctors are being dismissive of their problems or of their time which can hurt the relationship. From the doctor’s perspective, they would like to do more and to have all the time in the world, but it simply not possible, and there can be feelings of being under-appreciated. These feelings can lead to physicians be short or inpatient. Together these things can feed off each other, especially in the absence of empathy from either party (and actually likely applies to many healthcare professions).

To simply say doctors should develop better wellness practices though would be short-sighted. I think it’s an important part of the puzzle, but I think we need to also work towards systemic changes to improve patient care and physician wellbeing. Alright, give me some ideas…

Today went pretty well I think. Not perfect, but better than yesterday. I didn’t really end up writing things down, but I felt like my mind was a bit less foggy. There were a couple Spanish speaking patients that I saw today. It’s always hard to develop the same rapport that you can have with a patient with whom you share a common language. I try my best though. I look at the patient when speaking and not at the translator. I think I have a tendency to use less sympathizing or colorful or encouraging phrases when speaking through a translator, but I try. But also I think the translator feels a little awkward when they have to translate me saying things like, “I’m really happy to hear you are feeling better,” and will even sometimes paraphrase or just smile. That’s what I’m missing, and what I hope to gain by learning Spanish; being able to develop those connections without having to go through a filter. I can get by on certain parts of the interview and physical without a translator, but for a lot of the technical or more complicated stuff, I still need them.

Today we had a lecture related to end of life care. It was mostly centered around what to do when a patient request to continue palliative chemotherapy when it is determined that doing so would do more harm than good. The lecturer made a point that I thought was very important (well he made several, but to met this was the most impactful). When someone is in end-of-life care and the doctors have run out of curative treatments, we commonly hear in film, TV, other media, the phrase, “I’m so sorry, there’s nothing more we can do.” However, that is not true. There is always something we can do. It may not always be in the form of a pill or procedure, and it may not always extend a person’s life, but our role as physicians and healers should always to be to help our patients live their best lives based on their own values, regardless of the time they may have left. Sometimes that involves the stroke of a scalpel, other times words of reassurance or providing information. Sometimes it’s being present, other’s it’s giving space and being silent. There is always something we can do.

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.