Family Medicine at Bronx-Lebanon

Green book elective
Woof.
I've been putting off this post for some time now. Family Medicine was my second rotation and I finished it back in May, but I'm just never that enthusiastic writing about subpar experiences. Not that the whole experience was bad, but finishing with inpatient didn't leave a happy lasting impression.

Here are the basics of Family at Bronx-Leb:
Six week long elective that's divided into 3 weeks of inpatient and 3 weeks outpatient.

I started off with outpatient and you are assigned to any of the 4-5 clinics that are part of the Bronx-Lebanon tree and I ended up at the Tiffany clinic. I'm sorry I can't speak of the other sites, I just know nothing about them. What's cool about Tiffany is that there's only room for one med student and you work side by side with the attending, who happens to be Dr. B, and who also happens to be my favorite attending of the last six months.

Let me paint you this little picture: I had just finished three months of internal medicine at Mount Vernon, which essentially means I know nothing apart from doing blood draws and ABGs.  I gained ZERO confidence with my ability to communicate and examine patients, I had no clue how to write notes, freaked out with the idea of doing a physical, and didn't even know how to begin to diagnose somebody. Naturally when you tell your attending you've already done the three months of internal medicine, they ACTUALLY think you can do all these things already! Fancy that.

Imagine my horror with the very first patient we see together Dr. B orders me to do a physical. Ummm... what? I stood there in all my idiotic glory and said, "maybe you should do this first one so I can see how you like to do them." He just kind of smirked at me, clearly saw that I was a bundle of nerves and did the physical. When in doubt the three things all doctors do (as far as I can tell in my limited experience) during a physical regardless of field are:  1. listen to the heart  2. listen to the lungs,  3. palpate the abdomen. Turns out Dr. B also likes looking in everyones' ears and mouths. Fair enough.

After the patient left he asked me exactly how much did I learn in internal medicine. When he discovered it was next to nothing, he just said "fine, you are going to learn everything you should have learned right here these next three weeks". And that I did. Within one week at Tiffany, I was interviewing patients alone, doing physicals, EKGs, Strep tests, pregnancy tests, pap smears, vaginal cultures. I came in everyday around 8:45, started by 9 and kept going till 4. We would see around 20 patients a day from prenatal visits to adults. During the down times we just chatted about all sorts of things and he would teach as well. I discovered he was a pretty awesome guy and I couldn't have been luckier to end up with an attending as chill, patient, and friendly.

After leaving Tiffany the most valuable asset I gained was confidence. I didn't realize how nervous and borderline awkward I was with patients. I am not a socially awkward person by any means, but for some reason in the hospital/office setting, I was so nervous and jittery. Patients could sense it. And I felt that way because not only did I not know what I was doing, I had no experience. Everyone's gotta start somewhere and for me it started at Tiffany. In those three weeks, I became confident and comfortable with what I was doing, asking, saying, and that's something I've been able to bring to all my other rotations and for that I'm forever indebted to Dr. B.

As positive as my experience was in outpatient, it was that negative in inpatient.
Family Medicine is on the 16th floor of the main hospital. They divide the 15 or so students into two different schedules for inpatient. The lucky folks (those with a last name beginning with M-Z) get the three day schedule during the week. These people work Tuesday, Wednesday, Thursday from 7 am to 9 pm. The unlucky people work the same ridiculous nonsensical hours but on Friday, Saturday, Sunday, and Monday. That's right... 4 days AND they must work the weekend! And just to add insult to injury every Thursday at 4 p.m. are the family medicine ground rounds and everyone in both inpatient and outpatient must attend (they take attendance for godsakes! Yes, we are children)  The people working the weekend shift, are forced to come in on their day-off to the Bronx just to attend this one hour, useless lecture. And it would be all well and good if we all just lived in the Bronx, but there are students living out in Brooklyn or Queens who literally spend hours everyday commuting to and from the hospital. It's just plain mean to ask these people to show up.

You'd think with my above rant, I was one of the unlucky SOBs (not shortness of breath) with the terrible schedule. Hahaha nope, not the case. But still, I feel for my other classmates. It's in no way fair.

What I didn't like about inpatient was that it was mostly scut work. I spent my mornings filling out billing sheets oddly enough. Exactly why am I responsible for how much the hospital is supposed to be making on these admissions? I would run blood or urine down to the lab. Sometimes I would spend 20 minutes on the phone making appointments. My resident was usually pretty self-sufficient, but I do remember this one instance where he was on hold on the phone and I was next to him typing a note. He got tired of waiting and just handed me the phone and asked if I could just let him know when a human came on....? Hm. I wanted to say,"why don't you just put it on speaker so neither of us have to waste our time holding the phone," but I didn't. I sat there, 6 inches from him waiting for a human voice. Finally when someone spoke I handed it back to him and said nothing.

Mornings went by fast enough on the 16th floor. Myself and one other AUC student shared one resident so we split the 10 patients our resident was responsible for. After doing the billing sheets, we would write down the vitals and all new test results that were in for our patients. Our resident would round on the patients before the real rounds with the attending just to see how everyone's doing. Sometimes he would even let us know he was doing it (sarcasm noted). This was another thing I was getting frustrated with, while my colleague and I were getting all the new blood work, imaging results, new admission information, our resident would see all the patients without telling us anything. We would finish getting our information, walk over to our wing only to find our resident in the last room, finishing up. Then he would tell us we could go ourselves to the rooms if we wanted. Maybe I'm thinking too much on behalf of the patient here but I can't find anything more tiresome than having a resident come in asking you questions, doing a physical, then two med students asking the same questions and doing the same physical, and then the attending plus chief resident plus all of us all over again to do the same thing AGAIN all in the space of two hours.  By the second week we worked quick and just stalked our resident before he went rounding.

After that the attending would come in and then we would round with him. He'd ask us students for the vitals and other pertinent lab results. Then the pimping... oh boy this guy loved to pimp and be so incredibly mean about it. If you didn't know or if you made an educated guess, he would just look at you or shake his head with a look of such utter disbelief you would feel like the stupidest person on the planet. Fortunately, I heard about the antics beforehand, so I was prepared. I had the thick skin on and let everything roll off. I'm wrong roughly 50% of the time and when he would make comments I just didn't care. I would just continue talking, guessing, answering, as if nothing happened. And over time I came to discover that's what he wanted all along. Show no fear. Continue to be engaged and vocal. If you don't know, say you don't know. If you get something wrong, go look it up and never forget it. I did all these things and it paid off. If I got something wrong the first week, he would ask me the same question the following week and I would nail it.

If you happen to have the same attending as me, know these two things (Seriously... everything, since he asks EVERYONE repeatedly and if you get stuff right, he likes to go to the nitty gritty):

1. There are FOUR ways to diagnose diabetes mellitus.
- Random glucose over 200 mg/dL WITH SYMPTOMS
- Fasting glucose over 126 mg/dL on at least two different occasion
      - BONUS: "fasting" is when you haven't had anything for 8 hours
- glucose tolerance test over 200 mg/dL
      - BONUS: wait 2 hours after taking 75 grams of grams of glucose
- HbA1c over 6.5%

2. Criteria for DKA
- Dehydration
- Blood glucose over 250 mg/dL
- Urinary ketones 3+ or serum ketones positive
- Bicarb <18 nbsp="" p="">less than 18
<18 nbsp="" p="">- pH 7.3 and below

After rounds with the attending, we usually just wrote progress notes. We did about one or two a day. I guess this is the one skill I was happy to gain during this three week stint. Learning to write notes is always a good thing, practice is a good thing. After notes were done, afternoons were boring. The evenings were boring. The hours just slugged on. I hated it. If given the choice I would rather work the 5 day  9-4 schedule of outpatient.

I would take long lunch breaks around 1pm. I would try to seem busy till we had teaching at 4. Teaching was a nice change of pace in the middle of the day, so I never minded it. It was something to do, something to be engaged in. Once teaching ended at 5, we would wait around for new admissions. I think I did 3 admissions during my time there. You do a full blown interview and physical of the patient and write it all up on the computer. Problem was, however, admissions would come in around 6:30 (just about that time when people are preparing themselves to leave). Then you would get an admission and since the whole process takes at least an hour, you just end up staying a lot later than you anticipated. Well at least this is how it went for me.

Conclusions:
Outpatient awesome (Tiffany clinic in particular)
Inpatient made me want to die, but mostly because of the unreasonable hours.
I think I would have rather done family med elsewhere.