After an exhausted but nervous laugh was elicited from Mr. and Mrs. Katz, Dr. Greco completed his admission exam of baby Elizabeth and showed me all the wonders of the normal newborn physical. We answered a slew of typical first-time parent questions and did some more reassuring before letting them know we would return the next morning.
Before we could leave the hospital, Dr. Greco had to enter his encounter with the Katz family into the electronic health records system. I could tell this was something he wasn’t looking forward to (something about the comment he made under his breath about computers being the “devil’s spawn”, I think?). Anyway, I offered to enter the findings since I was familiar with the same EHR software system from my last rotation. He gruffly agreed that if I insisted, I could do so, even though it was technically against hospital policy. As I tapped away on the keyboard I was almost certain I detected a sigh of relief when he was able to step away from the computer…
Chapter 5
Back at his office, Dr. Greco and I began to see the daily schedule of patients. My first surprise was how much more complicated they were than I would have predicted. My fellow students certainly had never worked with Dr. Greco when they commented on the runny nose aspect of his practice. We were combing the literature with almost every patient to make sure that we were considering every possible cause for a given symptom, every conceivable treatment for a given disease and innumerable interactions between different medical conditions and medications—since all of his patients seemed to have endless numbers of medicines and diseases!
After lunch, my esteemed preceptor was ready to turn me loose to see a few patients on my own. I wasn’t nervous, not only because I knew he would be reviewing everything and was the final decision-maker but in the end I was still convinced that my fund of knowledge was as good as it got. I wasn’t going to let some dinosaur who was intimidated by a simple computer get the best of me.
My first patient was a slam-dunk, I figured. She was a 22 year old waitress with a urinary tract infection. She came into the office having already been seen at an urgent care center for pain with urination. They gave her an antibiotic called macrodantin and sent her on her way. Three days later, she was no better. No problem, I figured. Just give her a prescription for something stronger like ciprofloxacin and move on to a real challenge. I even noted that she had a 101 temperature so she probably had pyelonephritis, a kidney infection. No wonder the macrodantin didn’t do the job. I did a quick exam and while she had no tenderness over the kidneys and a urinalysis showed no white blood cells and no other chemical indicators for infection, I wrote that off to the antibiotic being in her system. I couldn’t quite explain one other finding either. Why was she complaining of swollen glands in her groin?
I excused myself from the exam room and presented my findings to Dr. Greco. He did not give me a congratulatory high-five. He did not teach me the secret family medicine handshake. Instead, he said, “Dr. Vega, what other symptoms of urinary tract infection did this patient complain of? Did she have frequency or urgency?”
“Um…I didn’t ask”
“And how often is urinary tract infection associated with inguinal adenopathy? Did you consider examining those nodes with me and a nurse to take that into account in your final diagnosis?”
“Well…not exactly”
“What other disease entities might present with urinary pain, inguinal adenopathy and fever?”
“I don’t know”
“THAT, Dr. Vega is the BEST part of the presentation you’ve given so far,” Greco opined as he marched me back into the exam room.
He introduced himself to the waitress who had just become a lot more clinically interesting. Her history went something like this: “Well it hurts, ahem, down there pretty much all the time but a lot more when I pee. I told the doctors at urgent care that but they were convinced so fast that it was a urine problem that they had me out of there pretty quick. The lumps in my groin and the fever came on at the same time. I’m embarrassed to say this but it hurts even to wear underwear because when it touches near where my urine comes out it really hurts.”
“What do you think we should do next, Dr. Vega?” came the inevitable query from the man who was making me look like I should re-do my third year rotations.
“A pelvic exam, sir?” I squeaked.
As expected, the ensuing pelvic exam revealed white ulcers with red borders indicating a prime grade A case of genital herpes.
“Any thoughts on treatment, Dr. Vega?” Finally, he was giving me a big juicy fastball over the middle of the plate.
“Valtrex 800 mg three times daily for 7 days for the patient. A little more review reading for me, Sir.”
Dr. Greco allowed me a very slight approving nod.
I finally hit one into the gap for extra bases.
Chapter 6
I drove back to the medical student housing at Midcentral that night after 7PM. It had been a long day. As I glanced over the steering wheel at the sun setting over the farms and fields along the way, I thought about how I got here in the first place.
My story might sound much more romantic if I were the son of struggling immigrant parents and the first of my family to go to college. Romantic, but not true. My father is a mechanical engineer who graduated from Purdue and my mother a very good music teacher and accomplished musician in her own right who might have made it as a performer if she hadn’t decided to be a stay-at-home mother to take care of yours truly. I do speak decent Spanish but mostly at the insistence of my mother’s mother, mi abuela. Abuela did emigrate to the U.S but she didn’t struggle either. Her husband had a very successful fruit export business in central America, thank you very much, and they were happy and wealthy until the ruling party of that country decided that the members of my grandfather’s political party should not have a measurable pulse or blood pressure and my grandparents felt that maintaining their business was less important than maintaining their vital signs. So one night they gave it all up to come to the U.S.
I grew up in a typical American suburb and went to a typical public high school and got typical straight A’s. I chose Dickinson College because I wanted a high level liberal arts school with lots of flexibility in choices of study. Translation: I thought I was pretty smart but I didn’t have a clue what I actually wanted to do. During my second semester freshman year, my roommate Jim did what many college frosh have done before him-he got mononucleosis. Unfortunately, he got it with all the trimmings including liver and spleen involvement and took weeks to get better. Frankly, I didn’t like Jim all that much but I didn’t get mono and I was the only one around that wasn’t afraid to help him with meals, bring him his assignments and go with him to doctor visits. As time went on, I became fascinated with his disease process and that’s how I started to get interested in the idea of going to med school.
Once in med school, things went pretty easy for me. I don’t mean to sound arrogant here—I was just fortunate that my academic strengths were well-suited to the study of medicine. My knowledge of Spanish made learning medical terminology much simpler because a lot of that is Latin. I was never a math whiz but most of medical school science isn’t quantitative so you don’t need much math beyond algebra (though you are expected to know calculus for reasons I could never figure out). The first two years of med school are a lot like college. You study Anatomy, Physiology, Pharmacology, Biochemistry and other basic subjects. You read. You take notes. You take a test. You move on. The third year is required rotations involving hands-on patient care that everyone has to take like Medicine, Surgery, Pediatrics, Ob-GYN, Psychiatry, and things that introduce you to the broad world of medicine. The fourth year you take electives because that is when you are narrowing things down to which specialty you will study during residency. Residency is when you REALLY learn your craft. You emerge from medical school with the title doctor. But only after three to five or more years of additional training are you ready to be anything from a family doctor to a pediatric neu
rosurgeon.
Midcentral required a fourth year unit in family and community medicine because there was such a shortage of family docs that they were hoping that by making us slog through this purgatory that a few of us might get Stockholm syndrome and actually choose Family Practice as a residency/career.
After my first day with Dr. Greco, I was convinced by turns that family medicine could be awe-inspiring, incredibly challenging, humiliating and exhausting. Those impressions turned out to be correct, correct, correct and correct. I couldn’t wait to get back to the comfort of a surgical subspecialty.
Chapter 7
The next day my alarm went off at 5:30 AM and I was off to the races again. Since I had never come up against an academic challenge that I couldn’t master, I decided to view Dr. Greco and my family medicine rotation as exactly that: a mountain that I would climb and conquer—no matter what.
After we got back from the newborn nursery at Memorial, we started in with patients again. My first patient was a thirty year old plumber who had been seen a week earlier at the emergency room with “the worst headache of my life”. For doctors, this phrase ranks up there with “elephant sitting on my chest”. In medicine, there are certain key phrases that get you the big work-up no matter what. In this case, the plumber’s complaint made us worry about bad things going on inside his head, like bleeding, aneurysms, that sort of thing. Well, he had that evaluation in the ER, including a CT scan and even a spinal tap and the only abnormality that was found after all the expensive tests was on the CT scan: “normal intracranial findings. Mucosal thickening of the maxillary and frontal sinuses bilaterally but no air fluid levels”. This meant that his brain looked okay, but there were some possible sinus abnormalities.
The emergency physician diagnosed the plumber as having sinusitis and gave him an antibiotic. A week later, his headache was not much better. Enter the fourth year medical student. I asked him about his headache. “Actually,” he admitted, “I’ve had sinus headaches since I was a teenager at least once a week especially when the weather changes. I take Sudafed for sinuses and they get a little better. My mother has bad sinuses, too. I wind up going to the doctor at least 2-3 times per year and getting antibiotics which help sometimes. The headaches get so bad they sometimes make me throw up. I’ve missed some work because of my sinuses and my boss is starting to get ticked off, to tell you the truth.” I did notice he was massaging his right temple as we spoke and when I came into the exam room the lights were off. His exam was entirely normal including no yellow mucus in the nose and no sinus tenderness.
I presented the case to Dr. Greco and asked him how he usually managed chronic sinus headaches. Dr. Greco looked at me for a moment and said, “Dr. Vega, are you certain this is a sinus headache?”
I thought for a moment. Now I was early in my training, but I figured I had a 50-50 shot on this question and I was the student and he was the preceptor. So, I made the logical choice. With confidence I certainly did not feel, I gave my response:
“No”, I stated with authority.
“Good answer, Dr. Vega,” he replied with a barely perceptible smile, “I would suggest that you go back in the room and start over taking a history of this patient’s headache as if you knew nothing about the evaluation that has already transpired. Forget the CT and the diagnosis that was made previously. Start fresh. Then come back to talk with me.”
I went back to see the plumber, who seemed a little impatient by this time. I asked the questions the way I was taught from the beginning. Describe the headaches. Where are they located? How long do they last? Are there associated symptoms? What makes them worse? And so on. Pretty soon, a picture emerged.
He had throbbing right sided headaches in the temple that made him nauseated and got worse with bright light and loud noise. On a scale of 10 they were as severe as 8. The reason this headache was the worst of this life was that it was 9/10 and it lasted a day longer than usual. He always assumed they were sinus headaches because his nose got congested during the headache, they got a little better with Sudafed, they got worse with changes in the weather and his mother—who had the same type of problem--always referred to hers as “sinus headaches”
I returned to Dr. Greco feeling a bit embarrassed once again but at least confident that I now knew the diagnosis. “Dr. Greco,” I announced with what remained of my professional dignity, “This patient has migraine headache.”
“Absolutely correct, Dr. Vega,” he nodded with approval
Damn I’m good. The little voice of rebuilding ego said inside me. I then went on to outline my plan of treatment which Dr. Greco helped me refine. He wrote the prescriptions and I wrote the note for the record. Most importantly, the patient was really impressed that our little office figured out what the big shiny emergency department couldn’t.
“Dr. Greco,” I ventured, “I am curious about one thing. I don’t mean to sound critical, but why is it that you and I in this office were able to make this diagnosis and some very smart doctors in the ER went off in a totally different direction?”
“Dr. Vega, that is a very good question. First of all, the atmosphere in the emergency room is very fast-paced. They are trained to ‘rule out disaster’ first and then look for the mundane later. Sometimes, they simply don’t have as much time as we do here. And finally, they get a little technology-centric over there. So they did the evaluation, saw a mild abnormality on the CT and figured they would focus on that since the exam was otherwise normal. That is why you must always start with the patient and finish with the technology, not the other way around.”
I had a lot more climbing to do on that mountain.
Chapter 8
It was day number three of what was supposed to be Wiping Runny Noses 101 and yet was turning out to be one of my most difficult rotations yet. I spent my evenings reading up on the subjects that I felt I wasn’t as proficient in as I wanted to be and somehow I always fell asleep before I could complete my reading.
A little after lunch I went in to exam room 2 to see eighty-six year old Norman Weinkopf with progressively bizarre and disturbing behavior. Dr. Greco had known him for many years and his previous notes reflected a man who lived in an apartment which was attached to his son’s home. This allowed him to have a measure of independence but allow for support from his family. He had demonstrated gradual memory loss over time and had stopped driving a few years earlier but still played bridge twice a week and did his own cooking, cleaning, laundry and other daily activities.
Unfortunately, according to the family member who was accompanying him today, in the last few months the old gentleman had become increasingly confused, agitated and unreliable. He had left the stove on all night on several occasions. And once he had gone for a walk around the block and had to be guided home by a neighbor because he got lost. He became suspicious of delivery trucks thinking that people were coming to rob his home. He thought he saw his wife on the front lawn (she had died several years earlier). All of this information was discreetly placed in a note to be read by the doctor before entering the exam room so as not to embarrass the patient.
This was a clinical picture with which I was familiar from my medicine rotation so I felt prepared. I smoothed my shirt and tie, put on my best professional expression of empathy ready to make the most astute clinical observations when I opened the exam room door and ohmigod can you believe the girl who is sitting with the old guy she is the most beautiful creature I have ever seen in my life must pull myself together must concentrate on most likely causes of mental status changes can you believe that sundress her legs go on forever must not lose my composure that can’t be sweat running down my forehead okay okay you can do it…
“Hello Mr. Weinkopf. My name is Carlos Vega and I am a physician in training working with Dr. Greco. How are you today?”
“There is nothing wrong with me young man but my granddaughter here and the rest of my family are convinced that I’m crazy or something just because I forget a few things??
?.
“Dr. Vega, I’m Jillian Weinkopf and I guess you read a little about my grandfather…?”
“Yes, thanks for the heads-up. Mr. Weinkopf, since it’s been 6 months since you saw Dr. Greco, there are some standard questions we often ask our older patients just to catch up on their health. Would that be okay with you?” concentrating concentrating, if I look right at him, I can almost forget her sparkling eyes and light up the room smile…
“Well, if it’s just something standard, I guess it couldn’t hurt. But I tell you, there’s nothing wrong with me”.
“Great, you yourself mentioned that you ‘forget a few things’. Now at this point in your life, that would hardly be considered surprising…”
“Right, I’m no spring chicken.”
“Okay, so I’m going to ask you a few other questions that involve memory, just to explore that a bit further, would that be alright?” auburn silky hair, smooth skin mean nothing to me…
“Sure. Go right ahead.”
“Right. So can you tell me what year it is?”
“That’s an easy one, it’s nineteen….well ninety something. You know, since I retired, I don’t pay much attention to the year. It’s not really important to me.”
“Fine. What season is it?”
He looks for a window (but there isn’t one). “Well, I’d say it’s fall”.
“Next, what month is it?”
“Let’s see…I’d say it’s around March”.
The interview progressed in much the same way. When asked where he was, he named the town he had lived in 15 years ago, not the town we were in now. He got some questions right but many others wrong. This is called a mini mental status exam and while some patients with memory problems such as Alzheimer’s can do okay on it, if you score poorly, there is a definite problem. Fortunately, he had no other ‘red flag’ symptoms such as falling, weakness, loss of bladder or bowel control and so on. His physical exam was otherwise pretty normal, except that he clearly hadn’t showered and his clothing was stained and dirty.