Family Medicine: The nucleus

During April I rotated through my mandatory family medicine ‘elective.’ About a year prior, I began my first rotation ever, and, of course, I had formed many opinions of rotations and specialties before I even had them scheduled. Rotating through M3, you hear the stories of other students and their trials and tribulations, misfortunes and misgivings. Everyone’s a pariah. Somewhere along the line, I had formed the opinion that FM was among the more banal rotations, and, naturally, this was supported by mountains of anecdotal evidence.

However, regardless of my preformed inclinations, I always try go into a rotation with an open mind and an eager spirit because there are great teachers everywhere, and prejudgment leads more often to disappointment than substance. I was taken aback by the versatility and welcome of the program I rotated through. It was ideal for a student, and the residents were excited and genuinely caring and kind. The attending physicians were surprisingly well-attuned to listening, and were receptive to our presentations. The structure of the rotation was also well-designed; two weeks of clinic, one week of inpatient nights, and one week of inpatient days.

The population served had abundant pathology and disease, and I was thrown into the thick of it during my first overnight shift when a patient coded and I performed compressions. That memory will stay with me for some time – the code itself was successful, but, I had asked myself that night, at what cost? After the fact, I learned that the patient was on her way to hospice care and her daughter had wavered that day on a Do Not Resuscitate (DNR) order. The code was grisly. Throughout the whole ordeal there was brown seemingly feculent material streaming out of the patient’s mouth. I performed compressions as the resident valiantly attempted intubation, intermittently suctioning. The large laparotomy wound on her abdomen that was leaking serosanguinous fluid was held together tenuously by staples; these began to tease apart during only the second round of compressions – by the fourth or fifth the thing had come undone. The anesthesiologist intubated, and I was rotated out of the compressions, and that pause let me absorb the scene. Somehow we attained return of spontaneous circulation (ROSC), though the patient was unresponsive.

Other memorable events included management of post-surgical hemorrhagic shock overnight, textbook rheumatoid arthritis, and of course, clinic. The abundant clinic time gave me comfort in that setting and I was able to see the wide swathe of patients that FM encompasses; from routine pediatric visits and obstetric patients to idiopathic pulmonary hypertension and sepsis, FM is the first line for many encounters. I remember suturing supervised with a resident’s and attending’s guidance in one clinic encounter – never during surgery had that ever happened.

In short, I had a great time on FM. I learned much, was actually able to get up close and involved with some of the management aspects of ward medicine, and worked with extremely kind and caring physicians in a clinical setting.

The order

I am forced to render some order to the events of my life, to say it began here, and then because of this, that happened, and this is how the end connects to the beginning, and so here I am.


Surgery: A sense of duty

Last week I finished my surgery rotation; two months of general surgery followed by a specialty elective. I, of course, have my thoughts.

“Love is a better teacher than a sense of duty.”

– A. Einstein

Surgery is, in many ways, the quintessential human realm. At its most basic level, it is straightforward: there are problems that can be dealt with surgically, and there are those with the surgical acumen to help. This sentiment is lost in the reality of the upkeep of a surgical service. The truth is that surgery is the intersection of many interests, with divergent and convergent goals. There is the attending, the resident, the student, the scrub tech, the circulator, the anesthesia team, the company representative, and, of course, the patient.

From this blog, there is the vantage point of the student: my perspective. The surgery clerkship is, in the words of one resident I worked with, “a rite of passage” for all budding doctors. That being said, many who graduate with an MD after four years of studies do not pursue further surgical training. While I will not seek a career in surgery, I can appreciate the rigors of what such a path would entail. Being a student on the service gave me insight into the daily schedules and demands of life as a surgery resident, from PGY1 to 5. Life seemed to drain out of some of the residents. Many were abrasive. The gentility I had encountered during my medicine clerkship was largely absent. Stern looks and long silences were not uncommon.

The operating room, however, was its own beast. I was introduced to the O.R. in my Ob/Gyn rotation, and the romanticized ideas I had of it were quickly dissuaded and replaced with an understanding of my role in the surgical hierarchy and my total lack of surgical skills. My initial reticence waned as the months passed, and by my fourth month of surgery on orthopedics (after urogynecology, general surgery team 1, and general surgery team 2) I was competent with a needle driver and suturing. Moreover, I was not afraid to ask to be more involved with cases even if I would likely be turned down.

There is a certain thrill one receives in the O.R. when properly executing a technique under guidance from a mentor that is almost unparalleled. For me, that thrill alone is not enough to push me to pursue a lifetime of surgery. One wise surgeon I spoke with described surgery in two ways; one as an addiction and one as a duty. He said to truly embrace being a surgeon “you have to be addicted to it – you have to want to be there at all times.” The other side of the coin (and this is where that quote at the beginning of this post comes in) is that surgery (for the surgeon) should feel like (and is) an obligation. Per that surgeon, there should be a strong sense of duty involved in surgical training and practice – “it’s like the military, really,” with its structure and commitments. I think that duty, while a strong motivator by any means, is far surpassed by love; by that I mean that passion should be the prime motivator for action. For some, it may be enough, and I’ll leave the operative interventions to them.

I think when I came into surgery, I had grandiose notions of what I would encounter. There a sense of authority that comes with surgery; it is the final measure in the eyes of many, and the acuity of surgical problems is keener. That said, I would be remiss if I did not mention the sense of pride you carry when you say you were “in a case for __ hours” and were able to help or perform part of the operation, albeit minor.

A few good people is often all it takes, and I can say there were a few residents and attending surgeons I was lucky to work with that were very accommodating and eager to teach. There were a few days I was able to be first assistant to the attending surgeon while on general surgery, and these experiences were particularly fun.

By far the most experience I got with actual surgical tasks was during my month of orthopedic surgery; it was a pleasure to rotate on that service (despite the NBME surgery shelf exam looming over my head). The residents were very enjoyable company and generous teachers, patiently walking me through the fundamentals of some techniques and giving good feedback. Oh, also – the residents’ knowledge of orthopedic surgery really seemed inexhaustible. That month the variety of cases I saw was excellent. I’m sure if I had been there for another month some of the cases would have seemed repetitive, but some of the bigger cases like hip and knee arthroplasty were so involved and fascinating that I enjoyed the multiple exposures.

That’s my surgery experience in a nutshell. On to the next one.