nANIMOv

Mitote is a concept I was introduced to in Miguel Ruiz’s The Four Agreements. It’s been a while since I read the book, but from what I remember he describes it almost like a haze that clouds the mind, or like an unintelligible chattering of voices. I’ve been feeling a lot of that recently. I think it has something to do with this change in scenery. I have less distractions out here, which seems like a good thing if I can take advantage of it. That also means there are fewer mindless activities to default to when I get bored (I haven’t set up my desktop, so no video games), and so I think my mind doesn’t know what to do with itself. I find myself picking up my phone more often, just to glimpse and then put it down, or reopening YouTube or Facebook on my laptop just minutes after I just closed the tabs.

At the same time, I feel like I’m being pulled in a bunch of different directions by all the things that I need to do, or want to do, or feel like I should do. This is held in contrast to my weekdays when I have a very clear direction in my clinical encounters. It feels clear to me that I don’t actually have an issue focusing when I have a clear and specific objective, so in the absence of that I need to take advantage of my environment, some self-awareness, and maybe some creativity to help clear the mitote.

There are certain devices that exist that I feel like have been severely limited by their original design. They were invented at a time when technology dictated what was and wasn’t possible in terms of form and function.

Nowadays, the technology exists to do a lot of really cool stuff that once was impossible, and I can’t help but think that of lot of things we use in our daily lives only exist in their current form because either to change them would require changing all the other devices built around them or they are so universally used that to change them would be a huge disruption to society.

I realize this is all kinda vague and eye-glazing, but take dishwashing machines for example. I have never liked using dishwashing machines and in the times that I have used them, I have never been completely satisfied by the result. There’s gotta be a better way to automatized washing dishes that’s more effective than shooting hot swirly water at them. Or like are quadrilaterals really the best shape for screens and phones?

On the other end of the spectrum, we have all the As Seen on TV stuff, a lot of which is genius in theory, but the world is just not ready/ not set-up for them to be successful.

Ok so I still haven’t been able to see a patient completely on my own here. I was so close. I told my attending the plan; on the next obi (obstetrics – initial visit) I would get the patient’s history and stuff and record it exactly in the way that he does in the electronic note, but on paper so we can easily transfer it. Turns out the obi didn’t want a medical student. Ok no biggie, we’ll switch; instead I’ll just get a brief history on the other new patient who was checked it. Wait, she’s Spanish speaking only. So it was a lot of that in the morning and we kinda just gave up. It was unfortunate because everything that could’ve stood in my way, as far as seeing patients by myself, did. We’ll try again next week.

This weekend my attending is on call, so I told him if he gets a call, if he could let me know so I can try to be there for the delivery. He made some jokes about me saying that I would try to be there, but hopefully he will actually let me know.

I also did my first real bimanual today. I feel like this is a specialty where it’s especially sensitive when it comes to being ok with medical student doing certain parts of the exam. Like, they totally don’t have to say its ok, and yet in most cases they are ok with it (I hope they don’t feel pressured at all). So shoutout to all the patients who have contributed to my learning experience out here.

At lunch time today I got a chance to talk a bit more with the MAs at the clinic. I was just having leftovers from last night. I asked them for recommendations for food, nightlife etc. They have me mostly food recs, which is the more important one and so I have a running list of places to try for food out here. I also got to hear some of the gossip around my attending and also about some of the other students who have come through. It sounded like they liked me and thought I was doing a good job relative to others which felt good (but also it doesn’t quite feel like I’m ahead of any curve whatsoever). Hopefully, they weren’t just trying to be nice.

For dinner my roommate and I went to this Mexican restaurant downtown that was pretty good. It was one of those kinds of places that when the food comes out you feel like you’re getting your money’s worth. We then went out to a couple different bars. The last one we ended at had major locals’ vibes, and by the time we left it seemed like the Visalia nightlife we just starting. An adventure for another time.

I probably won’t write again this weekend, but tomorrow I’m supposed to meet up with some other students who just moved out here earlier this week. Looking forward to it.

So I did end up asking today, which in retrospect was not really a scary thing to do ’cause I can’t imagine how he would have a negative reaction to my asking (actually I can imagine, in which he would laugh and say something to the effect of, Haha ya right you’re not ready). He was all for it, but then he said he didn’t know how it would work out with the charting. I mentioned that I could write notes with my log-in and then he would co-sign, but he seemed to think that wouldn’t work so I didn’t want to push it. He has a system down and is particular about how his notes are written, so I’m formulating a way to make it as easily transferrable as possible, at least for certain encounter types (like initial ob visits).

At one point in the day some administrators came to the office. There was a big fuss about them coming and the MAs even made my attending hide or throw out his can of iced coffee because I guess it wasn’t a good look. Just as they were walking in he chugged the rest of it and tossed it in the trash under his desk. But he recognized the MD and they started having a pretty banterful conversation. Turns out he isn’t only savage when it comes to patients and med students. If anything he was even more ruthless when it came to his admin.

I did get to talk to her briefly. Turns out she’s the director of medical education at the hospital. While we were talking, I was shockingly given props by my attending. He said that he was impressed because I was his first student in maybe five rotations that asked to see patients on my own. I thought it would be the expectation, but I guess that historically is not the case here. Still felt good though.

He is slowing having me do more though. At this point it’s the expectation that I will be the one to place the speculum if we are doing a physical exam that requires it. At one point, he even had me give the ER protocols spiel.

“<insert name of patient> four things should worry you. First, the baby should be moving at all times. If you feel the baby is moving less, you count. If the baby moves less than ten times in two hours go to the hospital. (2) Bleeding, (3) leaking, (4) cramping, you go to the hospital. Anything unusual, just go to the hospital.”

Tomorrow, I think he is scheduled for some surgeries so hopefully I’ll get a chance to see something cool.

For lunch I went to A&W, like the root beer place, and got some chicken sliders. I keep forgetting to prepare lunch before I go/ the night before. I’ll be prepared tomorrow though with the leftovers from dinner tonight. I used the veggies, which I’m almost through with, and stir fried them with some jalapeno-pepper jack sausages. It was pretty good, but there are some ingredients you can’t go wrong with. That and I feel like I have a pretty low bar for the things I will tolerate in terms of items that are consumed for sustenance.

Much love to anyone who actually reads these ❤

Little by little I’m becoming more and more confident in being able to handle the more routine OB appointments. Tomorrow I’m going to come in with a plan for all the patients and then ask if I could start handling some on my own. We’ll see if I can muster up the courage come tomorrow. But something happened today that kinda motivated me more towards this.

We had an encounter in which the subject was pretty delicate and tragic. While we were talking to the patient, I couldn’t help but think about how I would approach the conversation if I were to do it by myself. How would I have let the patient know that I hear her and that I care? What would I do? Where would I sit? What would I say? My attending tried to normalize the situation and was very direct about ways we can address what she was experiencing, but I couldn’t help but think that this approach, while perhaps valid, was a little cold and maybe not what the patient was quite looking for in that moment. I am still just a medical student, but I came into medicine partially because I want to be with patients in these vulnerable moments and support them through those moments at their own pace, and I am a strong believer that part of the art of medicine is know when to be a problem-solving scientist and when to be just a regular human being.

I don’t blame my attending for this and obviously he knows more about clinical medicine than I probably can even conceive of right now. But he seems also somewhat burnt-out, and I’m not surprised why. The way the health system here is set-up is not super friendly for Ob’s. He works super hard for ungodly long hours, with what seems like little respite. I can tell he cares and that at the end of the day he finds joy in what he does; in working with patients, with the staff, and with students, which it what makes me sympathize with him more and also makes me concerned for my own future.

Anyways, my opportunity came. My attending left the room to find the MA and it was just me and the patient. I was trying to find some words of comfort after what seemed to me a reductive encounter for a sensitive situation. However also I was also thinking that I didn’t want to overstep my bounds, or worse, say something that would somehow cause more distress. I ended up standing there awkwardly for a little longer, then (not-so) stealthily slunked out of the room when an MA came in with some paperwork. I still keep going over it in my head and tell myself that if I started that encounter on my own, I definitely would have had no problems addressing the situation as I normally would, which is partially why I feel so bad. Why couldn’t I say anything? Should I have said something even while my attending was in the room? I didn’t want to interrupt him or say things that contradicted what he said or that invalidated his approach, but I also felt like I should have tried to open an opportunity for the patient to speak freely and express her thoughts without feeling like she was being rushed or like we were just trying to treat her and send her on her way.

In starting this rotation, it’s been easy to forget that I do bring to the table quite of bit of experience working with patients and working with people. I have my own style and my own approach to working with patients, and I want to be able to showcase that. Obviously learning the basic of the rotation is requisite to getting that chance, but I think I’m ready.

In other new, I did my first couple Pap smears today and was involved in a colposcopy and cervical biopsy. It’s sad that it’s taken me doing this rotation to truly appreciate all the discomfort and pain that is involved in routine care of individuals with female reproductive organs.

I brought leftover fish and veggies for lunch and after we finished up with our last patient, I went to nearby Sonic to get a corndog. Came home to change, went to the library to finish up some work, worked out in a nearby park, returned home, made a burrito with some of the leftover and then finished the rest with some rice. I also made some more progress in the pineapple I have sitting in the fridge. Then I finished off the night with a peppermint tea.

Today I was scheduled for another cryptic shift.

“LC Shift w/ Crystal”

I had no idea what LC stood for, and Google was of no help even when in combination with words that might be relevant to what I thought I might be doing. There was some indication of where to go and luckily my visit to the labor and delivery floor yesterday helped get me oriented with the hospital a bit.

After a bit of wandering and asking around I finally found the mysterious Crystal who turned out to be a lactation specialist, and LC stood for “lactation consult.” My attending texted me about a C-section that he had scheduled in the morning, that I might’ve been able to go to before the LC shift. Unfortunately, it got pushed back, but I figured I’ll get plenty of opportunities to see one before the rotation ends.

Back to lactation (backtation if you will), as soon as I met up with Crystal, we hit the ground running and started on the next scheduled consults. The day was pretty much in and out of rooms of postpartum mothers, and she would assist them with latching and provide tips and education for the whole process. I learned a lot. Breastfeeding is one of those things I guess I took for granted. Like you have the baby and then you just automatically know what to do, whether it be from TV or movies or sheer maternal instinct. I’m sure most moms would figure it out, but having someone with specialized experience definitely seems like it would be of great benefit to the baby and to mom (especially given the amount of anxiety we encountered in some of the rooms regarding breastfeeding).

I did feel a little confused about what my role was supposed to be there, besides observing and learning. Just entering the rooms, I often could feel the eyes of mom, and especially dad if present, narrow when I entered the room, so I figured no one would be comfortable with me attempting to assist. I only got asked to leave twice though.

Unlike in the clinic when I could actually somewhat know what I’m doing, in this case I was really out of my training realm. After observing several, I probably could get through a consult if I was forced, but also something about being a person who will likely never lactate giving tips on breastfeeding doesn’t feel right.

But yea that was my day. Overall, it was a great learning experience and the consultant I worked with was a pleasure to learn from and just kinda hang out with for the day. And this was also my first full day in the hospital.

For lunch I finally went to this burger place that has been on my radar since I saw it that first fateful night when I was locked out of the apartment. It’s called Wimpy’s, like the guy from Popeye, which is why I wanted to go bad. Turns out it’s close to the hospital so I went during my lunch break. I was actually quite impressed. To me it had some of the neatly tucked quality of a Habit burger, with the messy hominess of the Five Guys burger. The fries were also good, and there was something about their cheese that just hit different (and plenty of cheese paper a la Carl’s Jr commercial circa 2001).

Then for dinner I finally started using some of the chopped veggies I’ve had sitting the fridge. Cooked them up with some tilapia in like an adobo/ paksiw style sauce that I thought turned out pretty good.

I took part in my first delivery today.

The first 3 hours of my day was business as usual at the clinic. Mostly prenatal care with a few other gynecological encounters sprinkled in.

I went out to lunch and got a sandwich at this small diner close by, came back to a bit more of the same. My attending gets a call that a patient’s water broke when she got to the hospital and was pretty close to delivery. We finish up with the patient we were with and – safely – rush over to the hospital. My attending seems pretty pressed. We gown up and my attending examines the patient. False alarm. He says delivery is still a ways away.

We make the drive back to the clinic and he tells me his thought on The Power of the Dog. I was a bit disappointed, not about his cinematic review, I was just really looking forward to witnessing my first live delivery. It was good practice though. I got a chance to practice putting on boots, my gown, gloves, knowing kinda where to stand.

Back at the clinic we were a little backed up since some of the patients who were scheduled had to be put on hold or be seen by the NP who likely had her own full schedule. The rest of the day was haunted by the threat of a phone call that never came. We ended up finishing about an hour after the last scheduled appointment time and then went straight to the hospital.

We got there and things seemed like they were a little further a long, but it still wasn’t time yet. So my attending and I just stood behind the nursing desk twiddling our thumbs for a bit.

“You hungry?”

“A lil.”

“Let’s get something to eat.”

We head down to the physician lounge and look inside one of those fridges with the clear door like in a supermarket.

“Grab whatever you want.”

I browse the tantalizing selection of veggie hummus sandwiches and turkey hummus wraps and opt for the turkey.

There we are sitting at the table eating in silence and taking turns sifting through the headlines of the newspaper like an old married couple. I eavesdrop a bit on the drama of the other physicians and then settle in with the crossword. I’ve got 7 across; the missus, informally, on the tip of my tongue when he’s says it’s time to go back.

We head up do a bit more standing and then a swarm of nurse come to our side of the unit, and I’m not exactly clear on what’s going on, but it felt kind of bizarre. Shift change is my best guess. My attending’s phone rings. It’s time. He answers the phone, and I follow him 20 feet into the delivery room.

It all happened very fast, and I had zero idea how involved I was expected to be in this whole thing. I’m struggling to put on all my PPE, and next thing I know my attending me is urgently waving me over to the splash zone. He guides my hands onto this thing that looks like a hairy turnip, which apparently was the head. It starts to come out slowly and I am able to confirm that it is indeed a human baby head. With his hands over mine we continue to coerce the being into the world, and in half the time it took for us to get the head out, the rest of the baby makes its debut. The feeling of that moment is hard to describe. A bit of panic mixed with excitement. A part of me just wanted to burst out in like a maniacal laughter, while another part of me wanted to start crying. I probably would have given into one of those urges if I wasn’t tethered to lucidity by instructions from the doctor. We moved the baby up onto mom’s lap and I was instructed to select amongst the various clamp-looking tools on the cart, the one that looked most like a clamp. I made my selection, and we clamped the cord, I had to make a couple other tool selections, including the scissors to hand to dad to cut the cord.

With the cord cut we took a blood sample and it was time to deliver the placenta. I was ready to get pimped on the 3 signs of placental separation/ delivery. Uterine contraction, cord lengthening, gush of blood. I was ready to get a question right.

He never asked (for obvious reasons). He placed my hands on mom’s belly and showed me how to use the uterine massage to help facilitate delivery of the placenta. It came out. That’s all I care to say about tfhat.

We did some checks on the placenta and on mom to make sure everything was ok, and then it was time to clean up. After leaving the delivery room we had a small debrief and then he sent me home.

Good night.

Today was a good reminder of how much more I like being in the clinic than sitting in the classroom. This morning of didactics was pretty tortuous, but the more I think about it, the more I think about how it doesn’t have to be that way. The culture that has been created around didactic learning/ teaching and the expectations that said culture sets-up in the minds of the students and teachers is what makes it so utterly unbearable. I feel for teachers, because even when done well, getting students to engage with enthusiasm is like pulling teeth. Students are afraid to get the wrong answer or just tell themselves that class should be boring and lame, so they refuse to participate. Teachers know that despite their best efforts, students aren’t going to be excited about whatever it is they are teaching so why even try.

End mini rant.

There were a lot less ob encounters when I was in clinic this afternoon. I don’t think I did a single doppler. It was mostly different health concerns, that may even come up in a regular primary care visit. I did get to help out in the removal of a Nexplanon, but that was also a very simple task I was given.

Sometimes, I’m not sure how involved I can be in the encounters. Sometimes when we are talking to the patient, I want to ask the patient questions about their condition that my attending doesn’t ask. Moreso out of curiosity, but also sometimes to illicit more of their perspective and feelings towards whatever they are experiencing. But I don’t want to impede the doc in his flow or be out of line.

My attending did have to induce a labor in the evening, so I was hoping to get called for the delivery, but I never heard anything.

I ate lunch at home since I had the didactic session, just leftover sinigang. And then I ate that for dinner as well.

I’m looking forward to being off on the weekend, though there are some responsibilities I do need to take care of, but otherwise I’ll try to do more exploration of the town and see what cool spots I can find.

I lost my streak today. I was dopplering the wrong side to find the fetal heart rate. Though now that I think about it, maybe I wasn’t really doing it right before. I just learned today how to distinguish between listening to the cord and listening to the heart itself, and there were definitely times before when I was just listening to the cord and thought that was enough, which in a way it is for the purpose of just getting an FHR reading, but it’s not as satisfying. At one point when I got the heart itself right away my attending said, “I’m so proud of you.” Which may have had a tinge of sarcasm to it (if you met if you’d get what I’m sayin), but it still felt good.

I also did my first real bimanual exam today. That’s all I have to say about that.

What I keep getting tested on though, and keep failing is being able to say what kind of follow-up/ next step is needed for different Pap smear results. I think I’ve gotten close to covering them all (by getting them all wrong) though so, we’ll see how I do tomorrow.

Honestly though I know it’s only day 4, and really only day 3 of actually seeing patients, but I’m still able to stay pretty motivated throughout the day. When patients don’t want a medical student to come in on the visit, the MA will put a little sticky not on the door that says, “NO STUDENT :'(” and while I understand it also makes me a bit sad and I go sulk at my computer pretending to be productive. I hope by next week I maybe can start to be a bit more independent and maybe see some patients on my own. At least for the simple, uncomplicated prenatal visits I pretty much have his script down pat. We’ll see though, I still have a lot to learn.

I had breakfast this morning, which is unusual for me, but it was because I was meeting an old DWW friend who is from the area before heading to clinic. It was nice being able to catch up and get the low-down on Visalia and Tulare County in general. I had the eggs benedict and a coffee. It was good.

I skipped lunch cause of breakfast but did go to another coffeeshop close to the clinic. For dinner I made sinigang after I got home.

Tomorrow we are back to didactics with the school in the morning; back to COVID Zoom school yaaay.

Today was my first full day in clinic. This clinic was a little further out, but the routine and flow was pretty much the same. Same patient population as well, at least from what I’ve been able to observe so far. We had more further along pregnancies this time, so I was able to get practice feeling which side of the belly to listen to the fetal heart rate on (in younger gestations I was told mostly to be searching along the midline). I think I’m batting 100 with it so far, not that it’s super difficult.

Today I learned what a pessary is, I did a breast exam on an actual patient, and otherwise mostly did the same ol’ measuring fundal heights and listening to fetal heart rates. I am getting a good feel for the different recommendation at given gestational ages, and I think I probably could probably see a patient and select the right orders and do the proper patient education. As long as it’s a relatively uncomplicated case.

I do need to work on my Spanish more. It definitely has improved, and when a Spanish-speaking patient comes to clinic I can for the most part follow the conversation (though it also helps that I have a pretty good idea of what my attending would be saying if he was speaking in English). I know the phrases that I could say for my little parts of the visit, but I always get scared and chicken out. Gotta get over that.

For lunch I went to this little local cafe/ diner place and had a club sandwich. Had a chance to video call Mom and also eavesdrop (they were basically yelling) on these guys at different tables talk about their experiences at a “gentleman’s” club and their favorite performers.

I went back to clinic we finished a bit early, so I came back to the apartment and went across the street to a nearby park for a workout. The suburbs here are quiet and mellow. Parents and their kids playing in the playground. A little league team practicing on the field. High schoolers with baggy pants and long curly hair riding around on these weird tiny gas-powered motorcycles, while the ones in tank tops but the same hair held up by bandanas were playing basketball.

I got back home ate some leftovers and made some smashed potatoes (more unused items from the barbeque) while knocking off some to-do list stuff intermittently.

I’m starting to get a sense of how hard it may be in the future to devote time to keeping up with other hobbies and activities while working as a physician, and I my schedule right now is still pretty chill. I don’t have any charting to do at home. I’m not on call. I don’t have any dependents. All I wanna do when I get home is sleep, but there are also things that I want to do but have a much higher activation energy. I guess in the coming weeks we’ll see if my post-work endurance increases, or if I will succumb to the muted siren of my bed.