Practice of Medicine

My two month stint of Family Medicine has come to an end. Observing both the corporate and private practice side of things has offered a new perspective into this particular specialty and medicine in general.

Family Medicine

Family Medicine encompasses a little bit of everything. As a result, this leaves me a little uncertain how to best prepare for my upcoming shelf exam. There are the usual chronic diseases with a some acute illnesses, occasional small surgical procedures and the rare emergency. The clinical preferences of doctors are not always the preferred methods of diagnosis and treatment, and yet we are expected to know both. At least in the classroom setting, we knew what we were going to see on the exam. The clinical shelf exams, on the other hand, seem a bit more ambiguous.

It is easy to see a patient, ask them to explain their history, and perform a physical exam. The tough part is narrowing the differential diagnosis down to a select few pathologies, choosing the optimal tests to identify the real problem, and providing a treatment that will ultimately help the patient. On paper there is only one right answer, but in the real world the rules tend to have a little more freedom. The "practice of medicine," as students know it, is comprised of physician observation, trial, and error.

Every day I am learning more what it means to be "practicing" medicine. There isn't always a perfect solution and we may not have the answer to every patient inquiry. Nonetheless, we put our best educated guess on the table to be tested like any good experimenter would. We celebrate when we are correct in our assumptions and scratch our heads if wrong. Medicine is always evolving and we are simply trying to keep up. It is OK to "not know." Accepting that as a physician is hard, knowing that as a student relieves a lot of undue stress. After all, we are expected to make mistakes and learn from them.

Question of the Week

A 36 year old patient is brought in complaining of palpitations. Upon physical exam, you notice an irregular rate. He says he feels hot, anxious, and is tremulous. Thyroid studies yield elevated thyroid hormones. TBG is below normal. Examination of the neck is unremarkable. Which of the following is likely to be found in the patient?

A. A 20 year history of alcohol abuse
B. Exposure of the neck to radiation 20 years ago
C. A family history of heart disease
D. A personal history of Parkinson disease
E. None of the above

Answer & Explanation 

Culture Shock

Enfermera, hable por favor! 

The abrupt realization that I was in a clinic with lots of Spanish speaking patients had now become evident. The first few days had me shocked when the providers would yell those words down the hall for a translator who would arrive moments later.

Lessons in Living

Initially, I had no idea what to expect. With so many foreign patients frequenting this long standing walk-in clinic, translation was a normal part of the experience. The patients never seem to mind and usually chuckle at the doctor's attempts to communicate translated or not. His clientele of all backgrounds has come to love the medicine he practices which has been evidenced to me time and time again. When they tell me he has been their doctor since they were born, the doctor reminds them that's not long at all. He has taken care of six generations in some families!

When I'm asked what kind of doctor I want to be (usually referring to specialty), I reply "a good one." I don't think that means I will practice perfect medicine or always be right, but to me it means I will be appreciated for what I can do. The patients determine a doctor's reputation in the community, not the doctor. No matter their socioeconomic standing, they deserve adequate care and if they are satisfied, word will spread. This month in family medicine has been a unique experience in caring for patients medically and even more so in cultural awareness. All I can think is that one day it will by my turn to make a difference, will I rise to the occasion?

Question of the Week

A researcher is investigating the distribution of goblet cells in the respiratory system. She injects dye that will be picked up by goblet cells into an animal model. Where is the dye most likely to be absent?

A. Intrapulmonary bronchi
B. Larynx
C. Nasopharynx
D. Terminal bronchioles
E. Trachea

Answer & Explanation

Controversial Medicine

Microscopic science is hard to keep up with and the debate of ethical standards in relation to stem cells is still out for debate. On which side of the fence do you stand when it comes to organically derived medical procedures?

Stem Cells

I was recently asked to comment on a case between the FDA and two physicians vying for a new stem cell procedure. The orthopedists posit that they are using a procedure that implements host stem cells to repair orthopedic conditions. Their opponent, the FDA, argues that when these cells are returned to the patient's body they are considered a drug and not part of the patient's body. If the cells are to be classified as therapeutic drugs, a different set of guidelines is to be followed and FDA approval must be obtained for patient safety.

The physicians claim that the procedure is safe and has no place in the courts as the cells are simply being returned to their original host, but they are willing to fight the FDA to prove their point. Dr's Centeno and Schultz issued this press release about Regenerative and the FDA. If you knew there was a procedure that was safe and used your body to bring optimal recovery, would you be willing to take part even if it was new medical therapy? The thought of not enduring surgery to get results may actually be very comforting to some. To learn more about how patients can still avoid the need for invasive orthopedic surgery, see Regenexx SD link.

We commonly look to the FDA to recommend and ensure product safety and tend to trust their judgment both as patients and providers. In this particular case, however, their control might be infringing upon the rights patients have concerning their own body parts. Is this patient safety or medicinal dictatorship?


Question of the Week

A physician-scientist is conducting an experiment in which she tries to stimulate growth of cartilage in vitro. She wishes to use a substance to stimulate histogenesis. Which substance would be best suited to her purposes based on its stimulation of cartilage growth in vivo?

A. Cortisone
B. Estrogen
C. Thyroxine
D. Vitamin A
E. Vitamin D

Answer & Explanation

Medicine in Words

Although I never thought I would be saying this, the last two years have gone by so quickly. The new medical students just arrived for orientation and are sitting in the chairs we once occupied. My chronicled experience is but one among many fellow students.

Sharing the Journey

I can honestly say that I would still be confused if it were not for the students who went before me that took a minute in the hall to explain how to best prepare for what was to come. The confusing calendar of classwork, clinical rotations and residency that we describe to our family and friends dozens of times over was as foreign to me as a new language. The internet has made it easy to find answers in a matter of seconds, but the genuine experience can be lost along the way. For that reason I started this blog to share my experience with others who might be looking for an answer to the question, "what is medical school like?" Until recently, I had difficulty finding any such documented experience.

Not long ago, I was invited to be a contributing author on the combined blog, "The Differential." It is certainly an honor to be among students from around the world who share their ups and downs in regards to their medical education. Our blog is hosted by the well known medical resource Medscape, which increases the exposure our posts receive more than we could achieve on our own. After a little research I learned that there is an entire community of medical provider blogs on their site. At any stage in your training and for almost any specialty, there is a blog just for you. When you get a minute, I recommend creating an account and exploring some of the writings for yourself. Should you have any suggestions, I would love to hear them.

Question of the Week

A 6 year old girl is being evaluated for short stature. She is at the 12th percentile for height and the 34th percentile for weight. Vital signs are within normal limits. And physical exam shows widely spaced nipples and a high arched palate. Karyotyping shows 45XO. Which is she most at risk of developing?

A. Bipolar disorder
B. Breast cancer
C. Mental retardation
D. Mitral valve prolapse
E. Osteoporosis

Answer & Explanation

Treatment Options

The urgent care has its fair share of injuries and acute illnesses of which infections are common. It came as no surprise that my precepting physician asked me the best antibiotic treatment for specific infections. Although slow on the start-up, by the end of the month I was right more often than not.

Treatment Modalities

Bacteria have been known to take over our illness for centuries. The fight to halt their progression is still in its relative infancy as companies develop the latest antibiotics to cover certain strains of bacteria. Recently, the war against these microscopic armies has faced some retaliation via mutated strains that have developed resistance. One well known suspect is the staphylococcal organism responsible for Staph infections. Growing resistance has required a new approach to treating these infections. Despite having an arsenal of antibiotics for treating infections already in progress one company, Oasis Advanced Wellness, has a line of products that are intended to augment the immune system and avoid illness in the first place.

I was recently introduced to Oregasil, an oregano oil, that claims to have natural antibacterial properties. Its chemical component carvacrol not only inhibits the growth of certain bacteria, but it is said to taste like pizza! When was the last time you took medication that actually had a good taste? In laboratory studies, this compound was reported to be comparable to the standard antibiotics streptomycin, penicillin and vacnomycin. It is very unlikely that your doctor will prescribe a product like this, but is good to know that such formulations exist for those who prefer the natural approach medicines.

Another interesting product they offer is their Bio D-Mulsion supplement. There is a growing percentage of people who are deficient in Vitamin D. Usually we consume it through our diet, but the largest amount is actually obtained through our skin when we are exposed to the sun. For those who do not get adequate amounts of ultraviolet radiation they are at risk for health complications from Vitamin D deficiency. Thus there truly is a place for supplementing this crucial vitamin when not obtained naturally. Among its benefits, Vitamin D is known for strengthening bones, improving cardiovascular integrity, and boosting immunity. When considering your overall health, start with the basic vitamins and minerals and you'll be on the right track.

Pimped Question of the Week

A patient comes to the clinic with a 6cm, indurated, and raised lesion under the skin of the axilla that is warm, tender and erythematous. They state that they were bitten by a spider while they were sleeping, but did not see it upon waking. What is the most likely organism in the lesion and what is the initial recommended treatment?