Tuesday, July 22, 2014

The View Sure Is Nice



Working in a county health facility that functions as the lowest safety net for organized health care delivery in one of the most economically depressed and violent areas in Northern California has been a study in the human condition. It has been a little over a year since I worked with a doctor designing a study to compare levels of violence induced trauma between people in Israel vs Vallejo. The study never got off the ground, and at the time I didn't have a full understanding of exactly what kind of insights an investigation such as this could provide; now, however -- I can appreciate why the doctor I was working with had this idea in the first place.

In my small sample size of over 5 weeks seeing family medicine, women's health and chronic viral (HCV, HBV and HIV) patients, there is one element that has played a part in almost every patient encounter. That element is addiction; whether it be the patient's own current or past addiction to drugs of all kinds or food or a patient who has major life struggles associated with a loved one struggling with addiction. I've seen patients outright change from friendly, seemingly reasonable humans with whom I felt I could properly communicate with to a tortured person exuding desperation, demanding that pain med regimens be maintained or started despite clear violations of patient-doctor contracts stating that no other drugs can be present in a screen. I've seen chronic and disabling health issues and diseases wholly attributable to addiction -- again, drugs or food. I've come to decide that there may not be any coming back from 20 years of hard drug use. This seems to be that tipping point -- 20 years of shooting and smoking meth takes a person and just destroys so much that if they managed to escape HCV or HIV from needle use and endocarditis they are left with a mind ravaged and incapable of reaching any potential ceiling of function they had. This is not to say that a person can't clean themselves and have a relatively good and satisfying life afterward, but there is a price to pay and the debt load is high after 20 years.

Tangentially related and with a risk of waxing a little philosophical -- I realized that I've been recognizing and dealing with patterns of balance on large scales. Through the lens of addiction I see people who have taken advantage of tools which allow for a life to be sped up or slowed down; there is a reason why, in general, the drugs of abuse which have the most addictive power are uppers and downers. Tweakers, or abusers of methamphetamines are on a schedule so that they are actually living more of a life (or, in some non-intentional hippy kinda way, using up 'life-force' or some esoteric idea of a person's vitality with which a person can spend as they desire as if it were currency) in the span of 24 hours compared to a "normal person," or, at least a non-tweaker. Classic downers literally use up a neurotransmitter called GABA, which is the physiological inhibitor of excitatory action -- users of benzodiazapenes or barbiturates basically speed up our brain's slow down pathway, at its most rudimentary level. I even see pharmaceutical drugs in this light, in so much that a drug may be given in the hopes that a physiological process balance be altered. Sometimes it is in efforts to return to a previous balance that has been interrupted, sometimes we push the fulcrum to a non-physiological balance for the sake of other pathologies.

Again, this whole process has been a study in the human condition, but as far as our patient population is concerned, it is an investigation of imbalance -- of a type that a trendelenburg test won't usually identify. I say all of this not to disparage the patients but as more of a fleshing out the idea of exactly what opportunities I have before me. It took me 6 weeks to wake up to the idea that maximizing my education is, most of the time, simpatico with the patients needs as well. Whether it be scouring area research centers for specialists for some rare condition, calling a patient a day after the appointment with a website for cheap prescription glasses, or trying to talk down an angry patient from whatever metaphorical ledge they're threatening to leap from, it all ads up to the type of education I've been hoping for since 2006 when I decided to go back to the school in the first place.

The actual medicine is great too, of course.

Tuesday, July 1, 2014

passed

Word came down at the end of last week that I passed the 1st of many board exams and that I could officially pass go and collect $200, meaning that I could continue playing doctor at the local county health clinic.

It has nearly been 3 full weeks since I took that board exam, and in some ways I still feel a little traumatized by the whole thing -- not so much from the actual 8 hours of answering the questions, but more-so the run up; the anticipation, the fear, the adrenalin, the realization that one specific slice of 8 hours sitting in a testing center has significant implications and influence in what the rest of my life will be. Its not the end-all-be-all by any means, but it is a number (meaning the exam score) that will follow my name for the next 20 months, until the day in early 2016 when I find out what kind of medical residency I match into. And, when I say traumatized, I think it really boils down to not getting any time to grieve the process -- and process my body's grievance stemming from the mental and physical abuse I put myself through -- studying for 15 or so hours per day for over a month. This was the finishing touch of a couple of very taxing years. In fact, for over 2 years medical students look forward (with a mix of dread and killer instinct swirled together) to this exam -- years of anticipation! For most of us, we take the exam, and within a week or less we are jumping head first into our clinical education phase, where we have patients address as doctor and we are asked real questions in earnest from patients, in hopes we have some answers to their very real problems. To go from abstract, esoteric, molecular science and pharmaceutical mechanisms of action to dealing with patients and their problems in the span of 3 days, for me, was an exercise in integrating two very important perspectives -- patient care and protocol with best medical practices, which are based in the science behind it all. Its nothing if not supremely interesting and engaging. 

I am thankful now, more than ever for my years spent working in an Emergency Department. It gave me the ability to feel very comfortable with patients -- including when they are unhappy and difficult to deal with. It has given me a honed sense (for a newby) of when I'm being given a pile of bullshit for a story or history. That said, I'm not here to oust drug seekers, but still, despite their nefarious intentions, still provide that patient some kind of care. He or she may refuse to listen, and they may get angry with the decision to not dispense narcotics, but if we can still have a discussion about other aspects of health, and discuss the reasons why narcotics can't be given -- emphasizing the health risks and evaluating the other health dynamics at play, I can still walk out of the patient's room feeling like it wasn't a waste. The importance of giving a person the time of day and honestly inquiring as to their wellbeing does wonders for a power imbalanced relationship such as the doctor-patient one, and should not be forgotten, even in the most challenging clinical encounters. Sometimes ya just gotta call the sheriff though. 

Family medicine hasn't been at the top of my list of medicine to pursue -- and maybe this happens at every rotation, provided you're with people you like and respect (such as is my situation now), but the versatility provided through doing FM is more impressive than I previously thought. Maybe in month or two I'll be up on the DSB proclaiming my love of all things surgical and my pending future as an orthopod. We'll see.