nANIMOv

It was a long day today. There was a change in my schedule ’cause the doc I was supposed to work with actually didn’t have patients scheduled today, so I was reassigned. We ran pretty behind this afternoon, in large part because a lot of the patients just needed more time than the 15-30 mins (what’s new), but I think in some cases we got a little carried away with some of the conversations. They were mostly productive conversations, but also at times we had patients wait for almost an hour past their scheduled appointment for relatively simple follow-ups.

Idk, just something to be mindful of. No ones, fault necessarily, ultimately a systemic issues, but at the same time that is the reality we live in so we need to try our best to work within those parameters while fighting for change.

I’m actually a little surprised that I haven’t encountered more difficult patient encounters. Nearly all the patients have been pleasant, or at the very least neutral. Today I did have one encounter where the patient seemed to be kind of at their wit’s end for reason unbeknownst to me, but even so they was overall nice (perhaps a little passive aggressive).

I don’t expect this to necessarily be an indicator for the reality of primary care though (even if it generally is), but I kinda want some more experience working with difficult patients. I also want more practice with motivational interviewing. Opportunities have been there, but I just get caught up in going through motions and I forget. Also part of it is being cognizant of time, or lack thereof.

Then again, I have enough to worry about with trying to nail the simple more routine patient encounters.

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.