Pulm: First Impressions

The drive to Tyler yesterday was fairly uneventful. Lisa and I are sharing a cabin while the others get cabins to themselves. On top of that, the UTHSC-Tyler is located on the outskirts of Tyler and literally in the middle of nowhere. It takes 15 minutes to actually drive into the town to get to the nearest grocery store or Chick-fil-A, as well as the UT-Tyler undergraduate campus. We're allowed to join the gym there for $25 so Lisa and I went there to get passes as an incentive to work out during our stay here.

Today was mostly orientation, as we learned MediTech (which was the same EMR used at Methodist so we've all seen it before) and toured the hospital. We also got a respiratory FIT test to make sure our "duckbill" masks were securely over our faces before we could see TB patients later on. They do this by making us wear a hood over our heads and then spraying saccharine into the hood, and if we taste the saccharine, we needed to start over. I tasted saccharine after one squirt. Kate and Amber lasted a bit longer, and Lisa made it all the way to the "walk in place" step before she tasted it. The tester lamented that this was the first time he had four people fail (Danny was late), but the second time around we all passed. After orientation, Jen came over to around dinnertime. Longview's not too far from Tyler so that made the visit possible.

Heme/Onc: Breast Day (Last Day!)

My last morning at the Center started out slow; I followed Sandy for about two patients before she "disappeared" (took her purse and went somewhere), so Dr. BR suggested that I follow Dr. RY, the breast cancer specialist of the group. I'd been wanting to work with her for sometime but never asked b/c she seemed so busy; Dr. RY is pretty famous in this part of town for her focus on breast cancer and women's health. As it turned out, she was also an excellent teacher and wanted me to learn everything I could about breast cancer in this one day I spent with her. For each breast cancer patient who came in, she asked me to do a breast exam right after she did (with the patient's permission, of course), and each patient was drastically different from the other. One woman had a unilateral mastectomy so I got to feel both the normal breast and the scarred tissue where the other breast used to be. Another woman had bilateral expanders s/p mastectomy on both sides, and those felt pretty firm (though I couldn't find the port where the saline is injected to make the expanders larger). Yet another woman had bilateral implants, and I was immediately stunned by how cool they felt to the touch. I recalled reading an article where a man wrote how he initially freaked out when he found out his girlfriend's breasts "weren't real," and now I understood what he meant. They just don't feel the same. We had one new patient, and Dr. RY spent an entire hour going over her medical history, diagnosis, and treatment options. Her explanations were such that an ordinary woman with no medical training could understand what was going on, so even if this was my first day of the heme-onc rotation and I knew nothing about breast cancer therapy, I could understand the way the drugs worked. The new patient had a rather small cancer that was removed by lumpectomy, but it was also grade II and lymphatic invasion, which is concerning for future recurrence. She was, however, very Type A and did not want chemo if it wasn't necessary (since the tumor had been removed with clean margins), opting for radiation only. Everyone has their own way of doing things. What impressed me the most about Dr. RY was her rapport with her patients. She sees only breast cancer patients (earlier today she and Dr. BR were trying to compare who had "crazier" patients), presumably all female (haven't seen a male breast cancer patient yet), and she builds relationships with them, woman to woman. There was one couple with whom she regularly joined in prayer at the end of the visit, and today she and Joi (her scribe) invited me to join them. The five of us then joined hands as Dr. RY thanked God for blessing our patient with good health, and I admired her for being able to pray with her patients on request. That's not something I myself would be comfortable with. Joi, after learning I played the violin, told me about a concert she attended in which the musician played a harp and described it as some of the most beautiful music she ever heard. I agreed; words can't describe what a harp sounds like when performed well. At the end of the day, I thanked Dr. BR, Dr. RY, and Helena for having me at the Center and they wished me all the best. I was sad to go; everyone at the Center had made me feel welcome, especially Drs. RP, MR, LM, and BR (with whom I probably spent the most time). As for my thoughts toward heme-onc, it really is a fascinating field and I can easily see myself going into heme/onc if not for the fact that I'm not a huge fan of research. We'll see what happens.

Heme/Onc: The Crazy Patient

The clinic was strangely empty today b/c there were only 3-4 physicians present at any given time; both NPs were out for the day. I worked with Dr. BR as usual, and when we saw how packed his schedule was, I offered to see some of his patients for him so then he'd only have to do a quickie on them. It worked well enough in the morning; I got to follow up on a lady I saw two weeks ago who went gambling in Oklahoma despite having a low white count (that wasn't about to stop her, and she earned $700) but there were still a few "crazy" patients that we had to see together. At one point Dr. MS (whom I've only seen twice before since I'm never at the Center on Thursdays) told Dr. BR there was someone she wanted him to meet, but that "someone" turned out to be one of the crazy patients. "Want to be my boyfriend?" she asked. I was around the corner so I didn't see the look on Dr. BR's face, but nearby the MAs were trying to hide their laughter. "I got a boyfriend," the patient continued. "He's a n*****." Now I was the one trying not to laugh as Dr. BR tried to tell her not to use that term (though it's apparently more acceptable if African Americans use that term on each other), and she asked if he was trying to get rid of her. By the time Dr. BR finally got away from that patient, he looked pretty beat up and Dr. MS was laughing. "When you said you wanted me to meet someone, I thought you meant someone young and good looking!" he said. Dr. MS just smiled and said, "I think she's going to transfer her care to you." Hopefully not.

One of the patients we saw was actually a man I saw in Weatherford with Dr. RP weeks ago; I remembered him b/c he and his wife live in Mansfield but were willing to travel a long way to Weatherford just to see Dr. RP. He was in horrible shape; his wife said he'd only had a few cups of jello in the span of one week and was so weak that he could barely lift his head (or himself off the floor when he fell). Fortunately all parties agreed that he needed to be hospitalized immediately and arrangements were made for him to go to Harris. Hopefully the waiting room will be empty so he'll get admitted immediately. I have to admit, I miss ER sometimes.

Dr. BR still had 2 patients to see at 12:15 but sent me upstairs to grab some food. Today's menu was Panera Bread, and as soon as the social worker saw me (she knew I was Dr. BR's student), she asked where Dr. BR was. I said he was still working, and she said that after yesterday's fiasco (we got up to the lounge at 12:45 to find almost no food left), she saved him a plate. I didn't think she needed to worry yet since there was still plenty of food to go around. Scott joked, "Tell Dr. BR he's such a girl, being so high maintenance." I later passed the message along, and Dr. BR retorted that obviously Scott doesn't know what it's like to go hungry since he's gained a lot of weight recently. LOL. That's one thing I love about the dynamic at the Center; everyone jokes around a lot yet gets along well. I don't know how many times Dr. BR has teased the NPs for "being old," since they have children his age, but Dr. LM gets a few insults in now and then as well.

Heme/Onc: Difficult patients

This morning I paired up with Dr. BR, but before we saw any patients I got to listen as Helena and Dr. RY discussed a "horrible" patient who turned up the drip on her Taxol (?) chemo so that she could finish a 3 hr treatment in just 15-30 minutes. "Did she not realize that she could have died from that?" said Dr. RY. Apparently this is not the first time this woman acted up though; there were stories being exchanged about her left and right for a while. We saw our pancreatic cancer lady again (fortunately she didn't bring any vases or flowers; the flowers she gave Dr. BR yesterday have all dried up but are still pretty), and then we got a patient that really made Dr. BR groan.

Mr. C was a 78-year-old former lawyer with head and neck cancer that has metastasized to his facial nerves and given him a right face droop, and one side of his vocal cords is paralyzed so that his speech is really soft and hoarse. Now he has trouble swallowing and will need a PEG tube for nourishment, which he is not too keen about. He and his wife were reportedly "angry" about the delay in treatment that led to his present symptoms when in fact he was the one who wavered between surgery and Cyberknife (he was afraid surgery guaranteed his facial nerve paralysis, and he "fired" the neurosurgeon b/c the neurosurgeon was pushing for surgery), and now he didn't want the PEG tube. He described having a PEG tube like being a "cadaver with blood flowing," which made no sense. Dr. BR patiently explained that many people have continued to lead fulfilling lives s/p PEG tube insertion and that it was not the end of the world. Even after the 20-30 minute discussion, however, the patient wasn't convinced, and his wife later contacted Dr. BJ, his previous oncologist (the former president of the Center who retired earlier this year) "just to talk" about their frustrations. *sigh* It was funny when Dr. BJ forgot which doctors worked which days; he said, "Guess that happens when you don't have a regular schedule." This was, of course, referring to the fact that he was retired, and the other doctors were quick to tell him to leave the workroom (for rubbing it in)

I got to follow Dr. LM in the afternoon and got pimped on CML and even the AML: M3. He asked me what the translocation of AML: M3 (aka APL) was, and thank goodness for Dr. Barone's lectures; I remembered the 15:17. Dr. LM looked impressed and said I was on a roll, and I later shared the story of the 15-17 year old teenager wandering in the "trans" district of some street looking for some DIC and hopping in a black sudan. The stain was "Sudan black" so Helena and Dr. LM didn't get that part at first, but they both got the DIC part down, hehe.

Heme/Onc: Tumor Board patient

This entire week I'm at the Center downtown, and I spent yesterday and today working with Dr. MR. He's one of the heme/oncs who seems to like having a student around b/c he can teach while we're in the patient's room. Sometimes, however, he talks as though the patient isn't there and uses a lot of medical terminology which has the patient feeling (and looking) left-out and confused. With him around, I'm introduced as Dr. ____, which feels anticlimatic b/c in less than 2 months I will be Dr. ____. It's a scary, yet exciting thought. Tumor Board was this morning, and as expected, Dr. MR had me present our patient from last week. I hit the important points and then asked the other oncologists whether they'd treat my lung cancer patient, who is not a surgical candidate, with radiation only or radiation plus chemo. His mets were in three isolated regions, so they COULD be hit by radiation only, but the chances of micrometastases was also high. Ultimately, the doctors thought that a combination of both chemo and radiation would give the patient the best shot at survival (aside from CAD, he's a pretty healthy 78-year-old). Afterwards Dr. MR said I did a good job in presenting our patient, and I was happy to hear it. Now if only Dr. RP could have seen me; that could have helped my grade. But he'll learn about it if he asks the other doctors for feedback.

We saw our patient and his (neurotic) wife later this afternoon, and when Dr. MR brought up the topic of chemotherapy, they looked surprised. "We met with Dr. L (the radiation oncologist) earlier this morning, and he didn't say anything about chemotherapy," said the wife. "We thought he only needed radiation." This led to about 5-10 minutes of confusion as Dr. MR tried to explain where we were coming from while the wife was indignant over hearing two different things from two doctors. "I don't think we should have chemo," the wife said, and Dr. MR, obviously wanting to avoid an argument, said that we could try radiation first and if that doesn't work, then consider the chemo. The wife seemed satisfied with this, and so did the patient. But when they left, Dr. MR shook his head. We had another patient come in whose wife was in late-stage dementia, and Dr. MR commented that he would rather be dead than in that state. Not the first time I've heard comments like that from doctors.

I told Dr. MR that I'd matched in Philadelphia. He didn't respond to the name "Drexel" but as soon as I said "Hahnemann University Hospital" he knew exactly which program I was talking about (HUH didn't merge with Drexel until a few years ago). "That's an excellent teaching hospital," he said. "You'll learn a lot there." The other doctors overheard us talking about Philadelphia so I told them I matched there, and they offered their congrats. Dr. BR offered to get in touch with some of his friends up there and ask them about places to live in Philly for me, which I thought was nice of him. "City of Brotherly Love," he said. Dr. MR added, "Just be sure you get off at the right stop at the subway," meaning that Philly can be dangerous. Yes, I know.

Heme/Onc: After the Match

This morning I brought the TCOM 2009 residency list that Dr. D sent out for Dr. RP to see. He seemed concerned by the low number of IM applicants (about 15), whereas we had about 8 psych and 16 ER, among others. I think our class has a lot of specialty representation this year, including one psych/neuro (Matt) and one FP/psych (unknown). Only Clark matched at JPS for family medicine, which was a big surprise since I know a lot of FP classmates had interviewed there and ranked it pretty high. Dr. RP then voiced his opinion that JPS was not DO friendly. I definitely got that impression from the surgeons, but not so much in FP and ob-gyn. I wouldn't know about psych since I didn't do my rotation there, but Jacob and Aaron matched so there should be less discrimination psych-wise. Dr. RP said that when he first came to work at Harris, the people up there tried everything in their power to get him kicked out b/c he was a DO, never mind that he was a former chief fellow at MD Anderson with excellent credentials. *sigh* I hope I don't have that problem in the future.

The last day at this clinic was fairly uneventful until our last patient was seen (SCLC patient with 3 sons with her; at least she has a good support system) and Dr. RP reminded me that I had to play my violin for the clinic in order to get an A (joking). So I played a few tunes from "Canon in D," "Spring" from Vivaldi's Four Seasons, and "West Side Story." Dr. RP also found some sheet music from "Schindler's List" that I was able to sightread, and he said there was something nice about hearing music live. I think so too =)

After work I stopped by the Poly Clinic to see Dr. RR, my family medicine preceptor who'd written one of my LORs. I hadn't seen him in almost a year, and he looked like he had more white hairs than before, but he recognized me almost immediately. I told him where I matched and he said I deserved to go where I wanted to go. I said, "I have to thank you as well. The school said your letter was the best of the bunch." (which was true). Dr. RR brushed it off, saying that I was a good student who worked hard. He said that when he started his internship at JPS, he was paged almost as soon as he walked into the door b/c his team was on call that night. Wow. I hope my first day of work isn't like that =P

Match Day

We were given the opportunity to call the school at 10:40 a.m. today to find out where we matched, but I was determined to do things the old fashioned way and wait until noon to check my match status online. I wanted to see the name of my future residency program with my own eyes; just hearing it over the phone wouldn't be enough to convince me of anything. The morning was pretty slow (at one point we had a 1 hr break between patients) so Dr. RP, Shandy, Martha, and I chatted about places to visit in Colorado (Shandy's going on vacation there in June with her family), music (Dr. RP's mother-in-law teaches piano), and American Idol. I mentioned that I couldn't watch American Idol b/c it makes my ears bleed (the problem with having perfect pitch), and Shandy asked if I played any instrument. I said I played the violin, and she said I should bring it tomorrow and play for everyone. "It'll get you an A if you do," joked Dr. RP, so I agreed. Even if my grade wasn't at stake I would have done it =P

At 11:55 a.m. I checked my email and got the following:

Drexel Univ COM/Hahnemann Univ Hosp-PA

I was not surprised to learn that I'd matched at Drexel; I had my best interviews there and had a pretty good feeling that I'd probably end up at Philadelphia. With that, I told Dr. RP and the others where I got accepted and then called my mom and sister to tell them the news. At first my mom didn't know where Drexel was, but when I said Philadelphia, she said, "Oh! Your dad likes that program, too!" I was relieved that my parents were happy with where I ended up; they've been to Philadelphia before and think it's a nice city to live in.

Dr. RP let me take the rest of the afternoon off so I could meet "the gang" for lunch at Cousin's. Everyone was smiling and happy that this whole waiting game was over. Then of course we went to Blue Mesa to find out where everyone else was going. It was the first time most of our class has been together in over a year, and it didn't matter whether we knew each other well or not, everyone was conversational and asking where each other ended up. Even Dr. D stopped by briefly to offer his congratulations. It was a nice way to celebrate our achievement, and everyone there was smiling and happy. That's all that matters =)

Heme/Onc: Counting Down

These last two days in FW have passed by pretty quickly. Yesterday during Tumor Board (which was nearly empty b/c half the doctors are out on spring break with their kids) I was asked to give differentials for a man with a "ring-enhancing lesion" in his head, and later one of the doctors suggested that I present a case at Tumor Board next week. Fortunately we came across a case that seems present-worthy: a 78 year old man with resected lung cancer presents with a new mass along his incision site. Also saw my first new breast cancer patient today. The woman was in her mid 50s and had a 6 cm mass in her right breast. To be fair, she never suspected that she had cancer b/c she'd had lipomas in the past and assumed that her breast mass was also a lipoma. It wasn't until a neighbor of hers got diagnosed with breast cancer that she became concerned, but right now, 6 cm is way too large for a lumpectomy. She had two options: mastectomy followed by chemo, or neo-adjuvant chemo in hopes of shrinking the tumor followed by lumpectomy/mastectomy. The patient didn't really understand her treatment options and what the difference between chemo first or second meant, so we referred her to a surgeon to assess the tumor size and see whether s/he is willing to remove the breast or let the oncologists try to shrink the tumor first. Her ER/PR/Her2 results had not come in yet, so the doctor was able to spare her from being overwhelmed with that additional info.

Match Day's tomorrow, and I can't stop wondering where I'm going to end up for the next 3 years or so. Chicago? Denver? Philly? LA? DC? San Antonio? Austin? Cleveland? Lots of choices, and all in different cities so I could end up anywhere. Guess I'll find out tomorrow. In the meantime, this was a video we watched at the office today that made everyone laugh their heads off. And people wonder what we do when we're not working. ;)

Heme/Onc: "Black" Monday

What was supposed to be a stressful morning turned out to be pretty good when I got the email saying that I'd matched =) And it looks like all my friends matched, so congratulations to everyone! I'm not going to jump on the bandwagon and post "I matched!" on Facebook, though, because while I'm glad to know I have a position waiting for me, I don't think I'll really be able to be happy and celebrate until I find out where. So I'll save that news for Thursday.

One of the techs made lunch for the entire clinic today, and she really outdid herself and made a true Southern meal: cornbread, chicken dumplings, purple hull peas, and jambalaya. Shandy was shocked when I told her I'd never had purple hull peas before and said she could eat an entire pot of them. I've never been a huge fan of peas, but you know what? These peas were good. Dr. RP commented that I wouldn't be able to get a good Southern meal like this at any of the places I applied to, which is probably true. But it was still delicious.

I saw several familiar faces in the office today. One was a guy with metastatic lung cancer who's almost completely lost his voice due to recurrent laryngeal nerve paralysis. Another was the colon cancer patient who didn't want chemo and ended up in the hospital with a 3 cm cerebellar brain met; interestingly enough, he asked Dr. RP if cancer could ever be cured. Dr. RP said that there were thousands of people doing cancer research every day in hopes of a cure, but afterwards he wondered why this patient would ask such a thing when he didn't want chemo even though it could have cured him (and now it's too late).

Corpus Christi housemates together again...

Anita and I with Elizabeth (and her baby) =)