Saturday night and my excuse to stay in is that I'm being "responsible."

I haven't had any good blogging ideas for a while.  But since I've posted all of my rotation writings this year, I had been expecting to post my upcoming medicine paper.  Thing is I haven't made it yet- but its only supposed to be a page long (double spaced of course...), and sure enough keeping reflective writing that short will easily be the hardest part.  So I'm going to write one freely here- then edit for submission.

My assignment-

Reflective writing differs from other kinds of writing in that it allows the writer to express his or her thoughts and feelings about something (an experience, a text, a film, etc).  By the time I finish your paper, I should have a good idea of what your experience with one of your patients was like, how it impacted the care of the patient, and what it taught you about your future work as a physician.  Remember the goal of this writing is reflection and the subject is one specific, meaningful patient experience you had while on the Medicine Clerkship.  I want to know what you are thinking!

There are 3 parts to this paper:

1. Summary of the specific doctor-patient experience/encounter.  Tell the story.  Do not interpret here. 
2. Exploration/interpretation of the possible meanings of the event.  For example, how did this event contribute to your understanding of the patient?  What did you actually experience, feel or observe?
3. Description/prediction of how the knowledge you gained from this encounter can be used in the future for your profession.  For example, what implications are there from this experience that will impact your work as a physician in the future?  What did the experience teach you?  How will it make you a better physician?

 I believe the description of the assignment itself is about 2 pages double spaced.

It doesn't say in this description, but it is suggested in other course documents that this paper is supposed to reflect on a palliative experience, but not necessarily one from my palliative med week.  So as I try to recall patients I could potentially use, there are plenty that come to mind, most of them actually from my last couple weeks of the rotation.  It's hard to pick one, but I will probably pick the one I followed the longest...

The patients that I find the most interesting from a learning standpoint were those which were delirious, demented.  I had three that I would like to choose from... JW, PW, RG.

JW

61 woman who had a kidney transplant something like 15 years ago.  She came in because of confusion, or altered mental status, and kidney injury.  We did the full work up for all typical causes of delirium in a patient like this, but all work up was negative.  No infections, tumors, strokes. Discontinuing many of her meds did not do the trick to clear her up.  So in the hospital she stayed for 4 weeks, the exact 4 weeks I was at this hospital.  She waxed and waned in her confusion, a quality typical for delirium.  At her worst she was calling out, saying that she was trapped in her car and somewhere in Lexington.  In reality, she was dangling her legs off the side of the bed, tangling them in the bed rails, staring off into the air.  She was given antipsychotics for a week or so, but they seemed to only knock her out and not improve her confusion.  She did improve the most in the last week, but only to about the level she was at admission.  My attending decided in the end that it must be a psych issue that she has just kept masked well for a long period of time. 

We decided to consult palliative medicine at the beginning of the last week.  Largely because she was not eating or drinking hardly at all due to refusal, and she had made it clear in the past that she would never take a feeding tube.  Consulting palliative for a patient in her situation was very baffling for me.  You consult palliative usually when you know someone is dying.  We had no idea what was wrong with her, we just knew that she had already denied the types of care she needed to get better (feeding tube, dialysis for her worsening kidney function due to dehydration, blood transfusion for her worsening kidney-faulted anemia).  It was one of those end of life care situations that should make someone paranoid to make those life-prolonging-care decisions: a patient unable to make her own decisions during a hospital course that should be totally fixable, but previous refusals of care wishes prevent someone for bouncing back.  If she dies as a result of this condition, her cause of death will be something like renal failure due to dehydration secondary to altered mental status.

PW
88 year old woman.  My experience with this woman was brief, but I did learn some new things from her.  She was a patient of mine during my palliative week, and she was consulted due to "terminal agitation."  Agitation can kill you, huh?  That's not something we've ever learned for step 1 boards...  In more understandable terms for me, her diagnosis was "end stage dementia."  She was sleeping more, eating less, and had become combative in her confusion around others. During psychiatry, I heard for the first time that dementia is actually a terminal disease.  I hadn't known that previously, but those who get it usually die within 5 years or so.  I learned during this rotation that dementia has 3 types, two that are neurological, and the third is simple Alzheimer's.  And most people who have dementia don't just have dementia, they have Alzheimer's dementia.  The word is just cut short.  There is no such thing as plain dementia.

Everyone with delirium/dementia thinks the year is in the 1990s.  At least that was my experience.

RG

92 year old woman.  It may not be easily assumed, but dementia and delirium is all over the hospital.  Hold for Peds I've probably had dozens of patients in these states.  You get used to them though.  Every morning you see them, you go ahead and assess whether they are still confused, then you tell them you are going to take a listen to them and move on.  So when we visited RG on Wednesday, it didn't feel overly imposing that the fellow, my classmate, and I all did focused physical exams on this woman.  She was awake and responsive to stimuli, moving slowly and deliberately, but was not following commands, acknowledging our presence, or speaking.  When I first walked into the room during the fellows exam, he was working to have her release a tight grip on his index finger, before moving on to look at her feet.  My classmate and I both did exams on her because we needed a patient to demonstrate a physical exam on so the fellow could fill out eval forms for us.  We could not do very good ones without her cooperation, but we went through the motions anyway. 

The next day a code was called on her during our morning rounds, and I was the one that went to the unit to see if it was her.  As she was the day before, she appeared to have no visitors, but instead the typical 15 or so response staff surrounding her, attempting to intubate, doing compressions, on her plank-like, exposed and bony frame.  We were a consult team for her, so I am not certain of her complete course, but my attending said she was likely septic all along.  I feel bad about doing the physical exam.  But maybe I feel worse that she was not DNR.

I know I didn't address all three criteria for reflection in each of the patient stories... but I probably could once I pick which one I decide to use... obviously RG or JW, probably JW.  I'll take thoughts if anyone wants to give.  I'm supposed to submit by March 19 I think.

Career Exploration – Gynecologic Oncology

Another reflective piece I needed to write for school below.  It's talking about my week elective I did in gyn onc back in early November.  It was fun.  But not for me I think.  I'm taking picking my specialty more serious all of the time.  I spent a day of break focusing on looking into specialties.  Right now my tops are Urology and ENT.  And if I decide against those (#1 negatives- Urology- working with all those darn genitals. and I was thinking I'd like to avoid the pelvis period, ENT- bitches too competitive! :( ), you can bet I'll just do general.  But surgery, I'm coming for you, baby!

            The nature of gynecologic oncology consists of working with women who are either diagnosed with female cancer or suspected of a diagnosis.  One of the most important things I learned with this broad description is that the Gyn Onc surgeons are truly primary caretakers of their cancer patients.  Aside from radiation oncology, gynecological oncology surgeons are not just surgeons.  They are diagnosticians, surgeons, and chemotherapy caretakers.

gyn surgery = watching a boob tube for a few hours.  that's an ovary getting bovied off a ligament...

             The training involves the Ob/Gyn 4-year residency plus a two-plus year fellowship focusing on oncology.  I only spent a week in the exploration, but a typical academic gyn onc surgeon would operate 2-3 days a week, have 2 days a week for clinic, and an administrative day.  Hours seemed very comparable to typical general surgeons, with early mornings starting at 5 for residents and days ending with the ending of procedures, which could vary from 5pm to 8pm on any particular day of procedures.  Many of the surgeons seemed to like having marathon surgery days, consisting of 3 or more surgeries one after the next.  None of this was overwhelming after just having completed my surgery rotation.   In fact I enjoyed the similarity.

            I mentioned that understanding the composition of gyn onc work was one of the most important things I learned in my week of exploration.  I did not know that gyn onc spent so much time in clinic following up with long term patients and making major treatment plans beyond surgery.  I had spent a 3-4 weeks before this exploration following surgical oncologists, and had always enjoyed their clinic.  In Surg onc, clinic usually consisted of new patients looking for a positive or negative diagnosis, patients ready to undergo surgical treatment decisions, patients coming to hear their pathology results, and beyond that, long term follow-up of already “cured” surgical patients.  In gyn onc clinic, I was distressed at the amount of bad news and difficult decision-making advice I watched the surgeons give.  These solemn encounters were oddly out of proportion to what I had considered routine in cancer surgery work.  I couldn’t help but get the impression from this that it meant that gyn onc’s had to deal with some of the worst and most incurable cancer seen in medicine.  But I knew that this assumption couldn’t be correct.  

Da Vinci! concept kind of cool.  but laparascopy in general can't ever seriously be fun unless your behind the electronic arms :)  Not to mention pretty much 80% of the surgeries I saw were hysterectomies.  shoo.

            It didn’t take me long to realize that the lack of comparison to surg onc was due to the fact that surgical oncologists have the convenience of turning away cases that are inoperable, and thus are able to turn away situations doomed for bad outcomes.

            I have long thought to myself that I like sick patients.  But I have also thought that I like sick patients that can and are going to get better with a physician.  The typical excuse some people use when they go into surgery comes to my mind: a desire to cure patients in a expeditious fashion [with surgery]. 

            I know I want to work with cancer.  This may sound counterintuitive in the opinion of the typical person, but those who go into cancer work dooming themselves to the struggle of dealing with failure and death (and likely desensitizing themselves to death in the meantime)…. are the medical oncologists.  I want to go into a field of oncology that has been shown to be capable of truly curing cancer patients.  Surgeons may not cure all, but the rate of disappointment is statistically much better than those who have to depend on chemotherapy.

            After getting my peak into gyn onc, I do wonder if I still may like regular OB/GYN.  But I am running out of time to decide, and after my experiences in my surgery rotation and my enjoyment of my cancer research, I like the path I’ve already started trailing down.  Cancer surgery!