Monthly Archives: May 2015

Immersion Phase Update: Pediatric Genetics (4/27/15 – 5/22/15)

I spent another month at the Children’s Hospital, but this time I was on the outpatient side of things, in pediatric genetics clinic.  This elective is not one that most people decide to take, especially if they’re not going into peds.  But I’d come into medical school thinking that a career in pediatrics–maybe genetics–was a strong possibility (before med school, I’d even toyed with the idea of becoming a genetic counselor).  I shadowed a geneticist one morning as a first year and saw a handful of interesting patients and diagnoses.  By the end of that half-day, I wasn’t sure whether it was the career path for me, but I was glad to learn more about the process (3-year pediatrics residency plus a 2-year genetics fellowship).  Anyway, I digress.

Fast forward to last fall, when we registered for Immersion Phase courses.  At this point, I was still pretty clearly divided between psych and peds.  But I knew that no matter when or what I decided, I would take the peds genetics elective.

On this elective, I saw patients with genetics counselors and attending physicians during their normal clinic days and times.  Most of the time I shadowed the providers and interacted with our patients and their siblings, but sometimes they had me take the lead on getting the patient’s history, performing the physical exam, or even drawing out a pedigree to glean more information about family history (we learned some of the basics of pedigrees in school, but they are a lot harder to draw than they look). When I first started taking on roles in clinic, I spent lengthy amounts of time with the patients and probably slowed things down quite a bit, but I think I started to get faster in the last few days.

The best thing about this month was the fact that I got to meet patients with diseases I’d previously only read about.  One such disease is Lesch-Nyhan Syndrome, whose features–abnormal muscle tone, self-injurious behavior such as biting the hands, sometimes even gout and arthritis–are due to a defective protein  that causes the body to not be able to recycle the building blocks of DNA.  The hand-biting can get so bad that most people with this disease have to get their teeth extracted to prevent permanent damage.  The patient we saw in clinic with Lesch Nyhan Syndrome was at the point where tooth extraction was part of the discussion.  I was asked to do a 30 minute presentation during the month, and I chose to talk about this particular patient both because I remembered this disease from my Step 1 studying days and because it sort of relates to psychiatry.  I can send any of you my presentation slides if you’re interested, but I’ll warn you that it might be better as a cure for insomnia than as an educational tool.

Learning about the tests available to facilitate diagnosis was also quite exciting. The field has made many advances, even in the past few years.  Some patients we saw were return patients from a couple of years ago, who had been told at that time to come back when a new test might be available to help them.  We were able to then offer those new tests in an effort to find a genetic cause of their symptoms and come up with a more concrete plan for long-term management.  Some insurance plans, such as TennCare, are also expanding their coverage for some tests.  I hope to be able to follow some of the patients that I saw, just to see if their test results reveal any answers a few months down the road.

In addition, there are a number of research opportunities for individuals with diseases that are likely genetic but poorly understood at this time.  One such opportunity that was recently introduced to Vanderbilt is the Undiagnosed Disease Network (UDN). The providers I worked with often recommended patients to this program when all of the genetic testing that had been done for them to date was not able to give a definitive diagnostic answer.  The idea at that point is that there may be new genes that have some as yet unknown role in known genetic disorders, or that patients may be presenting with genetic disorders that the scientific community has not discovered or studied yet.  UDN’s job is to help fill in some of the knowledge gaps that currently exist.  I hope that I am able to keep up with UDN proceedings somehow, because it is an exciting opportunity for Vanderbilt and the patients the institution serves.

In addition to the genetics elective, I also took a section on medical error and coping with making mistakes, something that I will invariably have to deal with when I am a physician despite having thought only a very small amount about it now.  And I took an “advanced communications” course, in which we learned how to provide care that seeks to meet patients where they are in terms of cultural background, level of education, degree of comfort with the clinical environment, and other factors.  We completed several assignments for this course, which included giving patients a “math test” of sorts to determine health literacy as well as rewriting a medical document to be at a 5th grade reading level (it is definitely as hard as it sounds).

All in all, this month included a lot of lost sleep preparing for clinics and pulling together presentations as well as a lot of moving parts during the day.  But despite the logistical hiccups I complained about on occasion, I can truly say that this class allowed me to see some aspects of medicine that I would not be able to experience otherwise.  I’m not going to be a medical geneticist, but my work as a psychiatrist will likely require some level of understanding of the genetic contribution to disease, as it is known that family history plays a huge role in many aspects of patient care in that specialty. 

Other things that happened this month: my mom came up for part of Mother’s Day weekend to spend time with my relatives.  I’ve started going back to church on Wednesay nights, and despite the fact that I go to bed a little later on those nights, I know for sure that this sacrifice is well worth it, as I have begun to connect to a community that I love and appreciate and that I feel appreciated me.  The “bible study girls” in my med school class resumed our monthly potlucks this month, which are always quite refreshing evenings of fellowship.  And my class held Parent Weekend this weekend, during which families were afforded a glimpse of what life is like for us students, including tours of the hospitals, suturing and knot-tying practice, and–an old favorite–organ recital, where we used to stand in a circle and pass pathological specimens around to learn what disease processes actually look like in the body.

Actually, we are on our way back to Memphis now.  I am taking my next month “off” to study for Step 2 CK, the next part of “the boards.”  I take it on 6/17 (prayers please); I’m a little nervous, but it will be good to go home for a while to study since I haven’t been back in almost 5 months.  In addition, the week after I take the test, I am going to Detroit with my church for the National Baptist Congress of Christian Education.  Before I head back to school, I’ll hopefully have time to attempt to get my driver’s license, figure out where I want to apply to residency (since that’s the question everyone, including myself, has been asking of late), and write my personal statement.  Nashville, I’ll see you in July!

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Immersion Phase Update: Child Psychiatry Consult Sub-Intership (3/30/15 – 4/24/15)

Last month, I returned to the psych hospital for my sub-internship (sub-I).  I worked on the child and adolescent consult service and really enjoyed it–miss it, in fact.   Primary teams at the children’s hospital contact the psych consult team to assess patients for various reasons–recommendations for psychotropic medications, evaluation for management in an inpatient psychiatric setting, provision of outpatient psychiatric resources, etc.  We saw child and adolescent patients who had been admitted for suicide attempts, increased aggression, psychosis, catatonia, and more.

I feel like I learned so much from every moment of the rotation.  During my first few days, I marveled at how much I had forgotten about psychiatry and half-joked that I needed to spend my nights and weekends reading DSM-5 or studying pharmacology (something I never thought I’d be interested in doing).  I attended adult morning report and lunchtime case conferences as I had during the psychiatry core clerkship.  My attending often offered quick facts about diagnosis and treatment of various conditions while discussing patients with the team.  I was even able to give a brief, informal presentation to the team on a chosen topic (synthetic marijuana).

The team also let me take on quite a bit of responsibility during my 4 weeks with them, as if I were already a resident.  Sometimes I interviewed the patient while another team member talked to the family for collateral, or vice versa.  Other times, I saw both the patient and the family separately and presented the case to the resident, fellow, or attending afterward.  I wrote several initial consultation, follow up, and brief notes daily.  Although initial meetings with patients or family members proved awkward on occasion–due to multiple interruptions by other care providers, patients being difficult to rouse or “guarded” with respect to their personal information, or nurses confusing me for a visitor because I opted not to wear my white coat–most people eventually became very comfortable with my presence.

I still remember being slightly nervous about how I’d fare on the first day of my sub-I, but those feelings subsided fairly quickly.  The familiarity of the overall environment definitely helped.  I felt like I’d gotten to know a number of the psych residents during my rotation in June/July 2014.  When I returned last month, many of them were genuinely excited to see me–especially after I told them I was strongly considering psych as a career–and continually offered to help me with anything I needed, including the residency application.

Life outside the psych hospital was busy as well.  Due to an unexpected change in the deadlines for the research course, I ended up having to miss the annual national SNMA conference in New Orleans, which took place during the first week of the sub-I (4/1-4/5), although I did play a pretty big role in making sure others from Vanderbilt were able to represent our school and our region well.  I spent the first week writing an abstract, creating a miniature version of a research poster, and giving a “presentation” via iPad to meet course requirements.  In addition, I finished my part of the work on the information needs taxonomy project that I’d participated in during the research rotation.  I had to spend a considerable chunk of the first two weekends in April meeting with the other medical students to meet this goal–including a few hours on my birthday–but reaching the end of the list of 3000 portal messages was extremely satisfying.

I also celebrated my 24th birthday on 4/12!  My parents came up to Nashville for a few hours the day before to accompany me on a Walmart trip and grab fried fish sandwiches at one of our favorite dives.  On the actual day, I went to church (that Sunday saw the congregation all meeting together for a single service at a new time), was treated to lunch by some church friends, and went to the Chapman College end of the year party in Brentwood.  If that wasn’t enough of a celebration, a few nights later my Little treated me to dinner at Sinema, a pretty fancy restaurant in town, and gave me very thoughtful gifts.

There were still other fun events, believe it or not.  The a cappella group gave an informal concert at a senior living facility in town; we were encouraged by people ages 60-100+ who had gathered to listen to us and thanked by delicious cookies from the staff.  Also, after missing the opportunity for 2 straight years, I FINALLY got to join some members of the worship team to sing on the steps of the church for the Country Music Marathon runners and walkers (we’re around mile 8); seeing marathon participants mouth the words of the songs, record video of us, or stop and dance were some of the most rewarding moments for me.  All told, it was a month of hard work but also a month of balance and self-care.

Immersion Phase Update: Research (1/6/15 – 3/27/15)

I kicked off Immersion Phase with 3 months of research.  I chose a faculty member in the informatics department as my mentor.  I worked on several projects over the course of this rotation.  

For one project, I worked with a few other students to analyze 3000 messages from the hospital’s patient portal.  We used a consumer health needs taxonomy, essentially a list of distinct medical, logistical, and clinical knowledge needs, to categorize parts of each message by entering this information into a huge spreadsheet.  This required a considerable amount of hours to meet as a group and discuss the content we had independently categorized; I actually didn’t finish working on it with the other students until mid-April when I was already off research.  A smaller related project dealt with unanswered questions written by pregnant women in journals during their pregnancies.

A second project looked at the information needs of pregnant women and their caregivers through interviews and surveys and analyzing the resulting materials.  After observing a few of these research visits I was able to lead them myself.  I also de identified the transcripts for several of the interviews using HIPAA guidelines and analyzed a few of them using the same taxonomy as the first projects.

My third project was kind of my “baby” versus the others that I had merely been added on to.  This project was centered on a pediatric consultation service for health information technologies–anything from websites to phone apps that could be used to manage patient care.  We wanted to see if talking to patients/families and offering them resources would have an effect on their level of engagement in their care.  It took 2 months for this project to be approved by the International Review Board, which was quite frustrating, but it was still nice to be able to do “trial runs” of this service and talk to parents and family members who found it useful and worthwhile to study.  I even attempted to use the concept for a concurrent quality improvement class I was taking.

All told,  I really took too much on in these 3 months.  This rotation was definitely a lesson in standing up for myself and learning how to say no–a lesson that I sill have yet to master.  I had expected to be less overcome by stress in these months, but honestly I felt the pressure of the work.  If I could do it over again I’d figure out a way to do less.

In addition to all of this, I was finally able to think seriously about my future career as a doctor.  After meeting with various providers and spending some time contemplating, discussing, and praying, I decided to choose psychiatry over pediatrics.  Even though I am interested in both, I feel that the former will be more fulfilling to me in the long run and will allow me to pursue “lifelong learning” instead of just throwing the term around.  Feel free to ask me about this decision!

Other fun things I did included potlucks with the girls’ Bible study group, the second annual Dr. Vanderbilt Pageant at which I sang, danced, and served as a “hype girl” for one of the faculty contestants performing an individual rap, the 4th year match day where we (and they) found out where they would be doing their various residency programs, a dance performance at Cadaver Ball, an a cappella performance at second look weekend (in our new Radial Grooves custom scrub tops!), an Odesza concert with a friend from church (now obsessed with both them and Big Wild who opened the show), and much more!

Immersion Phase: Intro

Hi friends,

It’s been a looooong time since the last update.  Sorry about that.  Things have been even busier than I anticipated them being after clerkships finished up.

The Vandy Med Class of 2016 has entered the “Immersion Phase”–a stage in our medical school career that, to me, is all about exploration.  This phase started in January after we finished our core clerkships and will continue until our graduation a year from now.  Each course that we take now is 1 month long.  We have 11 requirements to meet, including at least 3 months of research, 1 month each of primary care and emergency medicine, a “sub-internship” or “acting internship” (where you basically do the work of a first-year resident even though you’re still a med student), and various other types of courses.  We also take longitudinal classes with their own collection of required blocks such as quality improvement, communication, ethics, and problem-solving.  In addition, we have “flex months” that we can use for vacation, Step 2 studying, residency interviews, or more classes.  One great thing about this phase is that, with the exception of emergency medicine, there are NO MORE SHELF EXAMS!  Gone are the days of putting in a full day’s work at the hospital and then coming home to hit the books like a traditional student (or thinking about studying while not actually studying).  For anyone who’s in medical school now with a more traditional curriculum, think of this as an extended 4th year.

Aside from this and the next 2 posts, my Immersion Phase updates will likely come at the end of each 4-week block, provided that I can get and keep my act together.  Keep reading to follow along. 😉