Face time with med/psych residents

Last week, the chief resident took me and a few other med/psych residents out for my first recruitment dinner of the interview season. It's a great opportunity to get to know the people who I may be working with closely over the next five years. Do I like them? Would they be easy to work with? No doubt they are asking those same questions about me. This dinner was all the more important, for all of us. Because I have mostly been working with dually-trained attendings and psychiatry interns, I haven't had the opportunity to get to know my potential future colleagues.

Recruitment dinners in general have an interesting dynamic. On the one hand, it's a social event, and everyone should be having fun. I don't want to come across as boring or rigid or anything else negative, but I also don't want to have too much fun. I've heard many stories from current interns about applicants who drink too much alcohol during these recruitment dinners and end up making asses of themselves. Why anyone would do such a thing with so much in the balance is beyond me. Regardless, I did genuinely enjoy dinner and chatting with the med/psych residents.

Then, this weekend, I took a day trip to San Francisco with one of the med/psych interns and a couple of her friends. The whole day was very relaxed and a ton of fun, a showcase of what my days off could be like if I end up at UC Davis.

Answering personal questions from patients

I was interviewing a depressed patient with my attending in the room, watching. I asked my patient if she had any thoughts of death or dying, and she said yes. "Well what of it? Haven't you had those thoughts?" This direct personal question took me aback. I faltered, then I answered her question. I knew right away that she was trying to rationalize her own morbid thoughts by normalizing them. See, you think about death, too, so my thoughts of death are normal.

Then she turned to my attending and asked him the same question, but he handled it completely differently. He sat back relaxed in his chair, looked down at the floor briefly then right back up at the patient meeting her eyes, he smirked slightly, then he said, "You know, I think it's really interesting you asked me that." His voice was saturated with sincere curiosity. "Why is it do you think you asked me that?"

I was in awe. How deftly he had flipped her question right back to her and incorporated the very fact that she had asked that question into an exploration of her depressive symptoms! The patient went right along with the flow of the conversation. My attending never did end up answering her question.

I talked with my attending about it afterward. "You're going to be asked a lot of personal questions throughout your career: Are you single? Do you have children? How much money do you make? There's always something behind the question, and it's your job to figure out what it is." He went on to say that a very real power differential exists in the clinical interview. It's not unfair; that's just the way it is. If I ever feel like a patient is interviewing me, that should give me reason to pause and wonder, Why? From there, I should let my own curiosity guide my response.

This lesson made quite an impression on me, and it gave me an important tool to use in future clinical interviews.

UC Davis: Summary of the first week

My first week on medicine/psychiatry was a good one.

I am spending most of my time at the Sacramento County Primary Care Center (PCC), which mostly caters to an indigent patient population. There is a separate Integrated Behavioral Health clinic with a set of three dually trained physicians who supervise me and another fourth year student. She attends UC Davis and is applying for internal medicine residency. I am also spending a few mornings per week at a pain clinic staffed by the Medicine/Psychiatry program director.

Everyone with whom I have interacted is very nice and welcoming... and just as important, they all seem happy.

But so far, I haven't met any Medicine/Psychiatry residents. The one resident at PCC is a psychiatry intern and so is not a good person to talk with about dual training. The Medicine/Psychiatry chief resident, though, has been in close contact with me to make sure that I am having a good experience. I am looking forward to interacting more with the Medicine/Psychiatry residents. Beyond just asking them questions, I want to get a better feel for how happy they are in the program, with their training experience.


Regarding what I have discovered about the actual practice of combined medicine and psychiatry, I was surprised that the vast majority of patients who I saw at PCC were there only for management of chronic psychiatric conditions without addressing any of their medical problems. My attending says that this is mostly due to insurance reasons, because neither Medi-Cal nor Medicaid reimburse fully for office visits that address both psychiatric and medical problems. That is concerning to me but not altogether unexpected given some of the criticisms I have heard from various people about combined training programs.

I have been exposed to a lot more of mixed medicine and psychiatry in the pain clinic, where patients' chronic pain issues often stem from both physical and mental causes.

There is still so much to experience during this externship. Next week I will also see patients on the psychosomatic medicine inpatient unit.

Studying for Step 2: A thank-you to my parents

I want to say a special thank you to Mom and Dad.

Before driving up to UC Davis for my externship, I spent a couple weeks studying for the USMLE Step 2 at their house. I'm pretty sure that I wasn't the most pleasant person to be around during those two weeks, but they put up with me anyways, and they did so much to help me get through all the studying.

They set aside a designated study area and respected my need for a quiet study environment. My dad found an empty room at his office that served as an alternate place to study when I got tired of studying at home. My mom was home most of the time, and we chatted or played a quick game of Parcheesi in between question sets or when I needed a short break. We went to the movies together and played pool together in the evenings when it was time to relax. Plus, my mom fed me! Except for all the studying, I had a wonderful time visiting with my parents.

They have already done so much to support me in medical school, and I want them (and everyone else, apparently) to know how much I appreciate everything they do to help me.

In short, my parents are wonderful. Thanks, Mom and Dad!

Externship at Davis

I have neglected to mention on this blog a major development in my medical education. During fourth year, it is common for students to do clinical rotations at different medical schools. These away rotations are called externships; they serve as a sort of month-long interview for residency, allowing both the student and the program to check each other out before or during the interview season.

I applied for an externship at the University of California Davis in their combined medicine/psychiatry department, and that's where I am right now. In fact, today was my first day! I am looking forward to this coming month to gain first-hand experience in this combined field.

How are medicine and psychiatry combined in practice? What do my attendings' careers look like? What sorts of careers do the medicine/psychiatry residents hope to forge for themselves? Do I want to spend the extra time and money for this dual training, or can I achieve my career goals through another training route?

This coming month promises to be very informative.

Escape

After taking the MCAT, I escaped to China. After taking the USMLE Step 1, I escaped to the Utah National Parks. Now that I just finished taking the USMLE Step 2, both Clinical Knowledge and Clinical Skills, I am escaping up the California coast. I love California!

Half-mast

I'm on campus today studying for Step 2, the first time I've been on campus since the Aurora shooting 10 days ago. It was a bit of a shock to me seeing the heightened security and having to show my ID badge to get into the building in which I took all my classes during the first two years of medical school.

I set up shop in a corner room on the second floor, quiet with lots of natural light. It also has a view of the main flagpole standing over the main entrance to campus. The flag was still at half-mast when I arrived this morning, but sometime during my first or second problem sets, the flag was raised back to the top. A sign of this community trying to move on.

Oral presentation without notes

Today I had to present a new patient from memory. The team split up in the morning, half going to clinic and the other half rounding quickly on patients. I only had two patients to present, one of which was a new patient I had seen yesterday with an intern and still needed to be staffed with the attending. I realized after it was too late that my intern had taken the History & Physical with her to clinic.

Given my previous struggles with oral presentations, I was a little worried about how this presenting-without-notes thing would play out. To my surprise, though, I not only pulled it off but gave a thorough, concise, and conversational presentation (in my humble opinion). What's more is that the senior attending from another team happened to be at the patient's room and stayed specifically to listen to my presentation, so I had an audience.

It felt good to get it right.

Numerous attendings have told me that the best way to improve my oral presentation is to present without notes. That seemed like an impossible task a few years ago but within reach now that I have some more clinical experience under my belt. I'm going to take their advice now and try to present patients with as little help from notes as possible.

Zebra hunter

Working on a consult service is very different than taking care of my own patients. The primary care team calls up neurology when they think that a patient of theirs has neurological problems. The neurology team evaluates the patient, gives the primary team a set of recommendations, and follows the patient until the neurological issues are resolved.

Over the past two weeks, I have seen what a "good" consult looks like and what a "bad" consult looks like. A "good" consult has a true neurological problem with a clear question for the neurology team.

We had a "bad" consult the other day that was essentially, "I think my patient has corticobasilar degeneration," a neurodegenerative disorder similar to Parkinson's disease but much more rare. The resident who ordered the neurology consult anchored onto a very rare neurologic diagnosis and basically wanted the neurology team to confirm his diagnosis.

On exam the patient did indeed have some parkinsonian signs and symptoms, but he was also taking some medications that could potentially cause those symptoms.

My neurology resident got frustrated when he was pressed on corticobasilar degeneration. He finally told the primary care resident (in a very professional manner) that the neurology recommendations would be the same regardless of whether the true diagnosis ends up being corticobasilar degeneration, Parkinson's disease, or drug-induced parkinsonism: Discontinue all medications that could cause parkinsonian symptoms and re-evaluate the patient in two days.

This could have been a "good" consult if it was worded differently: "I have a patient with intention tremor, small handwriting, and cogwheel rigidity who is also taking psychotropic medications. Our team wants you to evaluate the patient to rule out Parkinson's disease or parkinsonian variants."

Aside from learning what good and bad consults sound like, I also learned that one quickly develops a reputation based on behavior like this. When my resident staffed this patient with the neurology attending, the attending interrupted to ask, "Is this the zebra hunter resident who ordered this consult?" His reputation had preceded him.

Immature

My neurology attending is a big kid dressed up in a suit and tie and a white coat. Don't let the gray hair fool you.

There's a line of tape on the ground in clinic, to help evaluate gait in patients. Today he jumped on the line, arms spread wide, walking it like a tightrope with an exaggerated wobble. Then he banked hard to the left around a corner, made an engine revving sound, and yelled "Airplane turn!"

He turned around and flashed a grin. "You're never too old to be immature!"

I can't wait until I'm established enough to get away with letting out my inner kid like that.