Primary Endpoints

Apparently one week is the time limit before I start getting sarcastic feedback on a pause in blog-posting, so to appease the likes of CW (and to kill some time on a Friday night before going to bed), I'll try to make up for lost time and provide a quick overview of the last week.

In reverse order:

FRIDAY

Today marked the end of my 6-week Primary Care Clerkship which consisted of 6 weeks of working in different clinical settings. In theory, I was supposed to be learning the foundations of family medicine, but in reality things turned out a little different. My most valuable experiences turned out to be in emergent/urgent care settings and an ENT's office. Unfortunately, the time once a week that I spent in the residents' internal medicine clinic at the Mothership turned out to be a complete bust x 6 weeks. During those afternoons, I worked diligently perfecting the art of being polite and interested-looking while sitting in a corner of the exam room as the resident interviewed patients. Fortunately, I had other experiences to fill the learning-void. One of the most valuable was working in the urgent care clinic of The Center. Some highlights:

• Diagnosing a woman with superior vena cava syndrome. A very, very, very sad case, but interesting from an academic point of view.
• Working up a man with the chief complaint of "I want to go left". This guy had a very strange sensation of wanting to go left. He could walk straight if he focused, but if he was in autopilot mode, as most of us are a lot of the time walking from one place to another, he found himself frequently making non-sensical left turns, e.g. down the wrong hall, into doorways, etc. He was completely neurologically intact, although his wife had noticed what sounded to be like complex partial seizures or periods of profound inattention (more so than most wives get from their husbands). When I asked him to write a sentence for me as part of a mental status test, he wrote "I am scarid[sic]". Right frontal brain tumor. Nice guy with a wife and 3 kids.
• Bowel obstruction, bowel obstruction, and bowel obstruction.
• Trying to find a cause for a woman's hyperkalemia. CT scan -> adrenal met. Possibly adrenal insufficiency? Interesting to think about...
• Realizing that I've learned a thing or two during my third year of medical school and rediscovering the enjoyment of treating patients.

The other useful clinical experience was working in an ENT's office on Thursday afternoon. I think ENT is my #1 backup if Rad Onc doesn't work out. A couple of pearls I learned:

1. Childhood screening audiograms are not as low-yield as some people may argue. I saw one patient with profound sensorineural hearing loss who was a brilliant, articulate man (although with a speech impediment secondary to being almost completely deaf without hearing aids) who is now working as an executive for a non-profit, but was thought to be mentally retarded until the age of 8. When his home town ENT discovered the hearing deficit that was missed my teams of Johns Hopkins physicians, he promptly took the boy's medical record documenting his "retardation" and physically tore it in half in front of him.
2. An acute otitis media in an adult is NOT normal. Requires further workup to rule out the presence of a predisposing anatomical or functional defect.
   
3. It is possible for a nasty, white plaque on the larynx of a smoker to come back benign.
4. A very smart and talented ENT refuses to use nasal decongestants. Saline sprays only for rhinosinusitis.
5. Acute, persistent hearing loss is an emergency as it may represent a condition that may be alleviated or limited in some way by corticosteroids.

Anyway, getting back to today: took my primary care exam, met with my advisor, talked with Dr. K about a letter of recommendation (she asked me if I was an "outstanding" student, referring to the "code words" used in Deans Letters; wasn't quite sure how to respond to that one), and had a very productive meeting with the statistician I'm working with on the liver IGRT project--a very bright, thoughtful, and professional fellow. Sitting in his office talking about endpoints and probabilities and teaching each other stuff captured what I think is great about academics: mutual teaching and understanding. Like I said, a very edifying and productive discussion. Afterwards, I had to work on dosimetry data for this patient whose treatment planning data existed on an old tape drive that was was buried in one of the medical physicists offices. Fortunately for us, we got the data off. The tape that was put in after was devoured in a most savage manner by this relic of information storage. After spending two hours piddling around on an agonizingly sluggish Unix machine, it was off to SB's for a celebratory dinner in honor of CW leaving her job for a much better-paying one. Unfortunately, a windowed office had been replaced with a cubicle. The Hawaiian chicken was superb.

THE REST OF THE WEEK I'm getting tired of writing and you (and I) have better things to do, so again in outline form:

Thursday Slept in. (Whoops! Was I supposed to be in the Ob/Gyn clinic? I prefer to spend my mornings doing something where I'm not actively ignored. Sleep works, too.) ENT office. Studied.

Wednesday Urgent Care at The Center. Dr. Bos was very complimentary as I left, which always helps with the ol' confidence levels.

Tuesday
Please don't laugh: Today I shared a poem as part of my geriatrics assignment. We were supposed to come up with a "creative response" to a geriatrics home visit, and I took this challenge personally, as Dr. D had joked that if you were a math nerd, you could just read a poem someone else wrote. Here it is for your enjoyment (or potential blackmail material):

Chocolate cake
At ninety-eight
Seems to provide its share of grace
When eaten every day
After your morning tea.

Who would have thought
A bejeweled pill box
With who-knows-what pills inside
Serves instead to remind
Of a daily dose of Ghirardelli’s
Open next-to at your bedside.

Perhaps that’s what quickens the mind.
A 30/30 mini-mental status exam finds:
Penny, Pink, Apple—
“Why that’s what they used to call me!” you say.
Apple.
And your blouse is an apple-green.

“Where is the school
To learn such careful script” I think
As you write out a sentence
Quote
This is an interesting test
Unquote.
A vanishing line of
Of poise and propriety
And conscientious serifs
On the numbers of your clockface.

Sitting on the couch
Eyes bright and broken ears
Earnest to grab a piece of the conversation
And add some genteel wit.

Will you go back to bed when we leave?
To lie on your side
Like the child we saw
When we walked in the room?
Waiting for nothing, watching.
Or maybe just thinking about the next party.

Well, it’s time to go.
And I agree:
It will be fun to make it to one-hundred.

Tuesday night - This month's best spending of money that I don't have: a Counting Crows concert at the Town Hall. It was a great performance of the August and Everything After Album along with several songs from the upcoming Saturday Nights and Sunday Mornings album. I was struck by the uncanny resemblance of the lead singer, Adam Duritz, and a certain drollish groundskeeper:

I'm set for a new personal best of concert-attending this year after The Police and Guster.

Monday - I'm sure I did something. Oh yes. I volunteered at the Cornell Free Community Clinic and had a patient syncopize during the physical exam. Anxious guy + really deep breaths on the lung exam + possible seizure history + "I feel sick--something's happening" = don't leave a 2nd year medical student alone in the room while you run to get something for the patient to throw up in.

Sunday - Church, etc. Saw Brother R leaving the meeting before us. It reminded me of the time I met him in the 66th and Columbus building while I was working there. Without recognizing him initially, I asked him and his wife to help as volunteers. They of course said Yes and only had to be prompted a few times.

Saturday - My last Roosevelt Island multi-stake social. In fact quite possibly my last church dance-type activity. I've come to the conclusion that such events are actually probably very low-yield for "meeting that special someone" and that I prefer visiting with friends and getting to know people under other circumstances. This opinion probably has some relation to my Level Zero dancing skills and everyone's high distractibility factor when the theme is to "see and be seen". Plusses of the activity:
1. Getting to visit with some folks I hadn't seen in a while, including DH, a fellow Ram now living in Philly.
2. Running along the East River back to the tram to catch up to the UES folks on their way to grab a bite to eat. Despite my prior hunger pains (the food at the dance was gone upon our arrival), I felt like Flash Gordon: the speed, cool night air, and the city skyline at night shifting with my changing perspective as I ran were great relief. Maybe we should have stake running activities.
3. Finally getting some food at a diner on 63rd.

Well, that's all for now folks.