Monday, June 22, 2009

Coming Full Circle

First day status post-first rural weekend. Catfish/collards at the local dive. Lazy afternoon shindig with a host of new characters, comparing pharyngoplasties. Casual solo 50 mile bike ride into the great beyond (find me on Facebook to see these RIDICULOUS photos...). You know, just another day in the life.

First day full-time at the clinic, really. Most of it was anti-climactic. The trouble with being supported by a grant to work on ONE project that comprises perhaps 8% of the attention of anyone with relevant input/output is that it's pretty hard to make much headway, since all of such people are out actually doing their jobs and contributing to life in a meaningful way. I was marginally useful, and selectively carved out a few experiences that I wanted. I observed a neat neuro workup of adult ADHD, and then taught myself a ton of useful things about ADHD drugs. I learned how to remove skin tags by freezing with liquid nitrogen (which is easier than scalpel/cauterizing but not as cool, and not as effective). I saw "stock" symbols of primary care -- infected fingers, irritating eczema, that sort of thing. I liked them; they made sense. But apart from those moments, I started to feel like I was in the way. I wasn't. My presence isn't actually important enough to BE in the way. I just had hoped to be more useful by now.

I suppose I was marginally useful. I got a ton of people to agree on a very complicated document that I am debuting tomorrow, doing patient interviews and medication reviews to help streamline the clinic's protocol for staying on top of current and accurate med lists, and to developing an understanding for obstacles to consistency between the treatment plan as the provider understands it and reality. The best part, really, is that I found a way to sneak in a measurement of a variable that *I* think is important -- that is, a patient's understanding of the what, why, and hows of their medications. My hypothesis is that I'm going to show a relationship between patients' LACK of understanding of certain key variables and the number of inconsistencies with a given treatment plan. It's such a small, subtle measurement folded under a larger project -- but it's the part I really care about. I don't need to be right all the time -- but this is one of the central underpinnings for my entire drive to care for patients. If I'm wrong, I'd be disappointed.

Just as I was feeling kinda lame and disappointed about the anticlimacticness of my day, my preceptor mentions that he has to take off for "the free clinic." The what? Turns out, he volunteers at a free clinic for the uninsured on a monthly basis in town 20 minutes away locally appreciated for its dreary hopelessness. I looked at him with hopeful eyes. "Wanna come?"


Just then, the PA who has taken me under her maternal and professional wing pokes her head in and says that she has to drain an icky infected ear. This development about accompanying my hero to a new world of significance empowered me to take action to actively create more opportunities. "Can I come?"


So, I learned how to irrigate ears to flush out cerumen (how did I make it through 25 years of life without knowing that earwax had a technical name?) obstruction. It was AWESOME. This giant plug of awfulness that had been plaguing this poor man's existence... just OUT, floating around in a cup. The patient started to leave the exam room -- and then, all of a sudden, the PA told him to sit back down so that I could examine his eyes.

He didn't need an eye exam. The PA remembered that I had told her over the weekend, on a random drive through the hills of my new life, that I had three important summer 'life goals':
1) I will ride my bike every day, except for when I needed recovery (like today).
2) I will take blood pressure every day.
3) I will perform an eye exam every day.

She not only remembered but went out of her way to contribute to MY life goals. "Ask and ye shall receive," I suppose. I never think to ask. I'm too concerned about being in the way. I was so touched.

I wasn't successful but it meant so much to me that another human being was committing to my commitments. I returned to my preceptor's office and told him how awesome the PA had just been -- and, in so doing, told HIM about my 'life goals.'

I hadn't told either of them of my 4th goal because it seems kind-of entitled. I really want to present a patient's case every day -- I'm so uncomfortable presenting. I've only presented a case twice in my life -- once as a 19-year old TFP intern (and I got interrupted by Former Boss' informative yet nonetheless tangential soliloquoy), the second on my first night at the clinic (and I did a terrible job). Table that.

My preceptor takes me in to see a "character" he thinks I'll like. I recognize him instantly from my first night at the clinic. The "gruff" guy that I blogged about appreciating how talented my preceptor was at playing cool, and how I wanted to make it a point to get better at adopting various characters to cope with given situational demands. I forgot about that, and obviously haven't been doing an ideal job of it. But today I was better. I rolled with his heckling and sarcasm, and was totally cool. It felt weird and un-me, but very awesome.

We head out to the free clinic. It was fascinating to observe my preceptor in a different element -- it was intriguing to tease out what qualities/behaviors were specific to a particular context, vs. specific to him. I admired him all the more.

All of a sudden -- BAM, I'm given a chart and told to go take a history and present. I did. I felt totally comfortable. I presented the case to my preceptor and was totally calm. I accomplished goal #4, without even having requested the opportunity. BAM, second patient, do it again. Another ear-flushing! Patient's at check-out -- my preceptor says, "Go back in and take his blood pressure."

He remembered! Again, so touched.

I take his pressure and screw it up. 170/80. Obviously not. My preceptor shows up in the doorway. I tell him what I found, acknowledging that I know I did something wrong. He repeats it; we're used to this drill. Except he found 170/84. I didn't screw up, and we now had the opportunity to counsel him about the dangers of his undiagnosed hypertension.

Next character. I take blood pressure again and again screw it up. 210/120. No way. I suck. The nurse had recorded the pressure as 160/80-ish. I looked at my preceptor in despair, trying to laugh it off - but obviously very distressed. He took the pressure himself again. 210/118. "I agree with you, Dr. Marotta," he said.

He takes the patient's pulse, listens to his heart.
"What's the #1 cause of cardiac arrhythmia?"

I had almost like a 'Slum Dog Millionnaire' moment. We're in his pickup truck on my first night at the clinic in early March, en route to my first house call. He asks me that question. I don't know it, because I don't know anything at that point. He tells me it's hypertension. I write it down. I later transcribe it into an Excel spreadsheet. I vow to never forget that one friggin' fact, ever in my life. It was the first time I felt like a major idiot but immediately appreciated my capacity to learn something.

I feel my eyes gloss over. I smile with a confidence I've really never felt in his presence before.


He hands me the fundoscope. He remembered.

This time, I saw something alright. A bleeding retina. Retinal hemorrhage secondary to RIDICULOUS hypertension. My understanding is that it's a huge rarity to see such a thing as a medical student.

I still didn't see an optic disc, since it was obstructed by all this commotion. But for the first time, I believed that I would -- that I could. And I believed that remarkable things really do happen if you actively carve out your own opportunities -- that it's ok to ask for what you want, that as long as you're really excited about learning something, people really do want to teach you. That if you get over worrying about feeling like an idiot and just open yourself up to being and learning and experiencing, all things really are possible.


rideon said...

I think it is great that you had such an experience. I remember my clinicals and I was terrified to even touch a patient much less interact with the patient and the doctor. Now I am right at home, keep moving forward and making your own path.

Melissa Marotta said...

Thank you so much for sharing that! It's encouraging to know that feeling so intimidated 99.9% of the time is a common phenomenon ;-)