Friday, September 2, 2016

My Life Since May

So I haven't set aside much time lately to write about what has happened since May.  Olive was sick with a stomach flu today so I took the day off to watch her. She is now napping so I decided to take a therapeutic time out and reflect on the past few months. I will summarize it as fast as I can.

In May I got out of school and began studying for my USMLE Step 1 and Comlex Level 1. I kicked Hailey and Olive out of the house and told them to go to Utah for about 5 weeks so I could focus on studying, not really, but they did go to Utah so I could study. It payed off as I was able to dedicate about 12-15 hours a day just to board studying. I took my Comlex, which is the DO board exam, first on June 13. Then I took the USMLE, the MD exam, on June 22. 
After taking the exams Hailey, Olive and I took off for Lincoln City, OR to spend some relaxing time on the Oregon coast. We stopped off in Tilamook and saw the cheese factory, then drove down the coastal highway. It was an amazing trip full of exploration of new places, a few risky hikes, and a lot of good food and shopping(see Facebook for pics). After about six weeks I got my scores back and scored really really really well on my Comlex and I did just really well on my USMLE. I was way happy with the scores and so grateful for Hailey and her family for giving me the time to be able to study for that.

I started my first rotation on July 11th. I started out in Family Medicine. I was in a privately owned family medicine clinic for six weeks in Richland, WA.  The experience was amazing.  The practice was partly a concierge medical practice, meaning that many of the patients payed a yearly "membership fee" to receive same day appointments, 24 hour access to their doctor, 30 minute appointments, free yearly labs, and 90 minute comprehensive physicals. It was an interesting business model that has formed recently because of how messed up our health care system is right now. Insurance companies are really pushing the quantity over quality bit. I think the hardest thing about medicine right now for me is understanding that I am not really in full control of what I can and cannot do with the health of my patients. Insurance governs so much of what we can do for patients. For example, if I want to give my patient the best treatment for rheumatoid arthritis, then I must first start out giving patients the cheaper medicine first that has been proven to have horrible side effects. The patient must then have documented side effects for the insurance to justify switching to the more expensive and effective RA drugs. I understand the reason behind insurance, but I still feel a good fair amount of people are getting ripped off by such a complex system. Anyways, I think a decent amount of doctors are switching to concierge medicine because it's easier on the doctor and the patients. On days where we did not have concierge medical patients we were seeing 4 patients an hour. Now that doesn't seem like much as far as a patient load, but that means each patient only gets 15 minutes from start to finish once they enter the doctors office.  The doctors office has to address the chief complaint of the patient, take vitals, review medications, review recent consults from specialists, obtain a thorough history from the patient, update any changes to the medical record, and then the doctor comes in and has about 5 or less minutes to complete a physical, answer questions(which usually bring up even more medical issues), and educate the patient on often very complicated issues.  When I was assigned certain patients to examine, I really struggled and was frustrated when I realized how short my time with patients is. I still struggle with it because I feel patients deserve more; however, I cannot  and will not be able to give them more time without losing my ability to pay for my student loans and provide a living for myself. The reimbursement from insurance just stinks.

Here are my pros and cons of family medicine: 
Pros: Flexible hours, see a wide variety of patients from babies to kids to adults, I can have some family time, own my business, ability to take on PAs and possibly earn more money, lower stress(relatively speaking), develop wide variety of skills, change the lives of many patients(because we have to see so many), front line of prevention, influential in the community
Cons: Not enough time with patients, deal with lots of chronic illness that patients often times never change(diabetes, HTN, Hyperlipidemia), lower paying(compared to other specialties), always feeling like the middle man(takes a lot of time to get paper work/results from specialists and the communication network with medical records sucks!)

So I just started my Internal Medicine in-patient hospital rotation. In a nutshell, I am with doctors, called hospitalists, who admit patients to the hospital from the ER or post surgery and take care of their medical needs and decide when they are to be discharged.  This is my second week and I love it.  Probably just as much as I love family medicine. We get to see hundreds of interesting illnesses and complicated patients. Our patient load now consists of a patient with pulmonary hypertension, a morbidly obese patient with COPD, a patient with recent fall and brain bleed, a patient with an infected cardiac pacemaker, and a patient with dementia and a possible herpes infection in the brain. So the variety of the illnesses of the patients is crazy, and I have realized how little I actually know. When my attending(boss) physician asks me, "what is your plan with this patient?" I usually just say, "I don't know." Then just look at him like a deer caught in the headlights.  Don't get me wrong on some patients I know what to do, but its hard to know how to do it, who to call, what to order, what to dose, which medication is safest, where to discharge the patient, and the list of things to do goes on and on. The main goal of my education in my 3rd year of medicine is to really discover why the patient is sick, develop physical exam skills, and to come up with basic diagnosis skills and plans. My 4th year and my residency are more focused on developing the specific care plans for my patients which tends to be the hardest part because that involves the most critical thinking and depends on experience gained through seeing hundreds to thousands of patients.  

Pros and Cons of Internal Medicine
Pros: Work in hopsital(depends), payed a salary, high demand, payed insurance, payed retirement, variety of patients, time with family, can be in a private practice outside hospital, develop a wide variety of diagnostic skills
Cons: Work in hospital(depends), long hours(usually 12 hours shifts or longer), work mainly with adults and no pediatrics, more difficult to own a practice as PAs aren't used as much in internal medicine, not as hands on as family medicine(depending)

Anyways thanks for reading about my journey.

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