Clerkship Diaries: Week 2, Pediatric Urgent Care
*DISCLAIMER: there is no medical advice here, my primary role is a medical student who's learning and not a writer, patient details have been changed to respect privacy*
Monday 1/14:
No morning conference today means we don’t have to be in clinic until 9 but I wasn’t sure... so I showed up at 8 AM anyways! I met some of the new residents and while they were settling in, even got to give them some IT pointers from my struggles last week. It’s amazing how much I’ve learned in one week!
I picked up one of the first patients of the day – he was a sweet sweet boy with so much energy and was really able to point out where he was hurting. He had a pretty classic case of a not uncommon pediatric rash; his mom had noted the rash on two classic places it shows up and I had this moment where I checked a third place and like predicted that there would be rash there! That kind of know-how is the stuff that amazed me about medicine before I started med school. My next patient had an unfamiliar presentation of the same ol same ol viral URI; it was fun going through each of his symptoms and getting a solid HPI and timeline. I had to pee so bad it hurt during the encounter so I gracefully excused myself and it wasn’t that weird! Dr Gutierrez also gave me solid feedback – offering the ranges of vitals, not editorializing too early. I asked the parents some developmental milestone questions and they got excited talking about their kid’s walking and talking and eating; those moments of excitement and pride and joy felt like a breeze of fresh air. Noon conference was a fantastic case. When I went back to clinic, I had a great adolescent encounter. Like I really enjoyed our encounter. We talked about setting a goal to drink more water which sounds sooo mundane but I had a lot of fun doing it!! I staffed one last patient – a precious 4 year old with the cutest glasses!
I remember feeling so tired this morning, wondering how I’d get through the day. My energy in the morning is not reflective of my energy during the day!! I saw 4 patients and wrote 4 notes (properly LOL because all the ones from last week were in the wrong place oops) and I was energized by the work. I needed some snacks later in the day but overall my energy was pretty good. ALSO! I saw a lot of ears today y’all! I looked into people’s ears! This is big! I am proud! I saw some normal tympanic membranes bless!
Lessons learned: Even if it doesn’t feel like I’ll have energy for the day when I wake up first thing in the morning, being in clinic and seeing patients is so energizing!!
Kudos to Dr. Gutierrez: for giving me concrete feedback that didn’t feel ~UCSF sugarcoated~
Tuesday 1/15: FCM
My FCM day was wild - imagine me walking up a completely unexpected high incline hill (we’re talking 3rd Ave from Irving to Parnassus) in the rain, knocking the clinic door; right after, I look to the side to find a man sleeping in the grass right next to me; he seems relaxed and says hey, to my credit, I didn’t bat an eye and responded warmly but on the inside I was shook because that was not what I had expected when I showed up to clinic!! Not too long after, I chased a young girl down the hall and was actually quite worried about losing her, and I watched the pharmacist get bit by a patient’s dog twice. We also made a home visit to a few blocks from the clinic to see a complex patient that was having trouble coming in. I saw patients tear up from the support they felt after an acupuncture procedure performed by their doctor. My preceptor waded through the layers of trauma some patients shared during their visits and was always ready with some sage advice for walking the path of healing. I saw some of the longest, most powerful hugs I’d seen in a while. I was reminded of the power of tenderness by my very first patient. I felt the energy of entire rooms shift. Two patients thanked me individually for nothing more than just being present during the encounter. There’s so much value to continuity of care. Today was a real adventure, and I’m excited that I get to be part of such a special clinic for the year. I “just shadowed” today but there’s a lot of merit in learning how an office ecosystem works and appreciating the work that those around me do -- so it was a really lovely day.
I was pretty tired all day and shadowing most of the time didn’t help. I could feel my shoulders and neck getting stiff. My body felt sore. But I was really touched by what I saw today. It’s clear Dr. Dallman makes a real difference by believing in people and supporting them. She’s very direct, and she always knows what to say. I want to be that person one day. There’s a lot to love about family medicine <3
Lessons learned: Western medicine sure has its limits when it comes to trauma; it was really beautiful to see the impact of some small acupuncture and scented oils on women who have been through some tough things
Kudos to: Dr. Dallman for taking me on even after the preceptors I was originally assigned to fell through!
Wednesday 1/16:
Today was hard. I really wanted to be in urgent care and wasn’t. The morning with Dr. Maggie Gilbreth was really nice; the kids were super sweet and she did a great job of being direct and conveying how non-jugdmental she was. I loved her energy.
So to be honest, this afternoon wasn’t one of my finest moments. Instead of urgent care, I was in asthma clinic. And I didn’t know much about asthma at all. Quickly, I learned that we have to take extensive histories and I had to use an interpreter for both the patients I saw so it took twice as long. I wasn’t expecting that, and then asking the questions is hard because there’s a lot of ambiguity with these topics. I got some really direct feedback on my first patient (to the lines of “you didn’t collect any relevant history” - I had completely missed the few cardinal asthma questions because I was so focused on the giant intake form and fleshing out the patient’s prior history with exacerbations that I missed some basic stuff). The feedback was completely warranted, so I felt this wide mismatch between expectations and my actual performance. I took it too hard. The rest of the day was a blur, I couldn’t even find the room my next patient was in. He had two siblings in urgent care with serious issues; I didn’t even know what the parents were going through when I went to ask my asthma questions. It’s hard to provide context to what happened but when I was about to leave after writing my last note, Dr. Marmor sensed that I wasn’t doing too great. She sat me down to talk and y’all I started crying. I’m still embarrassed. How am I supposed to handle the big tough things when I can’t get this little asthma afternoon right? But part of what got me in this mess is minimizing things that clearly have an effect on me. I had a hard time today. But I can learn and adapt quickly. How to grow from this? Is it too optimistic to hope it doesn’t happen again?
The funny thing is that the preceptor who gave me that blunt feedback at first – she told me that I did a really great job on the second patient and had improved so much in one encounter. But the praise didn’t mean nearly as much to me as the critique did. I want to get better at taking compliments to heart instead.
Lessons learned: Yes my problems are small compared to my patients – feeling frustrated with a clinical task I’m not prepared for when parents are dealing with three different diseases in their three kids; feeling helpless when I can’t comfort my patients in their language when they have to navigate our country without speaking English; missing my own parents when I see the tenderness that my patients’ parents have for their sick kids – BUT if I don’t acknowledge that at some level, these little things affect me deeply in a way that affects my ability to function, then I’m not operating at my best.
Kudos to: Dr. Marmor for sitting with me, contextualizing my afternoon and showing me enormous grace and kindness in a weak moment.
Thursday 1/17:
Today was not a bad day. It was great actually, and I felt really connected to my patients. I shadowed again in the morning- the patients were SO cute (like they get cuter every day it’s unreal). There was one baby who was SO well dressed and was crawling all over the floor and loved playing with my rainboots. Another patient was a school age kid that I just got to sit and chat with for a little while and she filled in all the spaces in our conversation so I just had to listen and smile. Next we had an adolescent visit; we asked a LOT of personal questions about poop and he had to get a genital exam. There’s not a ton of room for dignity in these appointments. Dr. Chan didn’t have time to do a HEADDSS assessment but I asked if I could – I tried to make it as not-awkward as possible and I think it flowed smoothly. There was something about the last encounter that I couldn’t put my finger on; despite the discomfort we put him through, I felt kind of connected and was rooting for him. I wanted to keep up with him and see him go to college like he planned to and keep reminding him to drink water and all of that yknow!
I returned to the clinic after lunch and immediately picked up a patient yay! He had five different symptoms, and I was able to take an organized history on all of them. Dr. Marmor made a point to observe me during this encounter and had some really thoughtful feedback; she said that I was adjusted my tone between talking to the mom and her son to bring both of them into the conversation and make them both feel heard. I didn’t realize I was doing that! I was able to do a fairly thorough physical exam as well. After talking through my assessment with Dr. Marmor, I reported my findings to the R3 and then we finished the appointment together – definitely had to leave some knots left untied but hoping his PCP can help sort out the rest. I was really proud of the note that I wrote up. I twiddled my thumbs for a minute because we had NO PATIENTS ON THE BOARD for like a while; I picked up the very next patient who was having some eye issues. One of the attendings dismissed everyone because we weren’t getting any more patients but I was still seeing my patient so I couldn’t go! Unfortunately, we couldn’t figure out what was happening to her... but we connected her to an ophthalmology consult. When I was giving them return precautions, I apologized for not having more concrete answers, it was the most natural thing for me to be honest about the uncertainty and our limits, but in hindsight I probably could have been more “professional” and composed. But it felt nice being transparent, and I was able to tell them that we weren’t concerned about anything serious which I hoped put them at ease a little bit. I told them to call the clinic if anything comes up! For some reason I almost teared up at the end of the visit. They were so grateful and easy to talk to, and I wish we could have done more but I was still really happy with how I was able to leave it.
Kudos to: Dr. Marmor for being a true angel, for reminding me that I’m a person who’s whole and brings something special to the table, that I’m more than my worst moments.
Lessons learned: Every day is a brand new day to start fresh!
Friday 1/18:
The morning started out reflecting on a patient who coded the night before; they were perfectly healthy the day before that. It was definitely every pediatrician’s worse nightmare, and you could sense a different energy on all the teams today. The morning in urgent care was nice though; I started with a 4 yo with a mix of viral symptoms; her mom had talked the whole time but then at the end of the visit, she opened up and gave me another a chief complaint - which felt so gratifying because she wanted to talk to me. We made sure we gave them solid return precautions before we sent her home. Also can I just say how time flies when you’re in urgent care!! I picked up my next patient at 11:15; she was having a common chief complaint with a complication that concerned me (turns out it was NBD lol oops). She had the smallest dog that was just a lil pile of fur. I tried asking her some open ended questions at first and she was not a fan; the close ended yes/no questions were way more effective. It’s interesting how much I’ve moved into close ended questioning in urgent care because I’ve noticed that open ended questions don’t actually put my patients at ease, they’re usually just like unamused with the vagueness; close ended questions give folx something concrete to latch on to which seems to improve our overall rapport.
After noon conf, I worked on my notes and then picked up a sweet 3 month old. The baby smiled at me at first which was sweet before we did the history. She needed more of a workup; I’m glad I stayed for her nasal swab and the urine collection to see how it happens! The girl was so unhappy when I held her legs down; so unhappy that she started peeing!! The nurse caught some of it but still had to thread a catheter in. I got I really got to be there every step of the way; during the initial history and second interview, during both of the tests, and then calling her afterwards with the results. I’m not sure if it mattered to the mom, but it felt really nice to me to close the loop. The rest of the afternoon got a little busy and it felt like people didn’t have the same capacity for teaching – which is totally fine! I’ve been spoiled these last two weeks with lots of attention and and individualized lessons. I tried to staff patients but with no avail. Around 5:15, I started reading up on a new patient when the attending dismissed us students and MAAM you did not have to tell me twice!! I erased my name from the board and was outta there before I could look back! Maybe not the way I wanted to end my urgent care rotation, but it was a way of respecting my boundaries - something else I’m trying to work on during clerkship year too.
Lessons learned: Not every day is a good day where people have enough energy to teach, and that’s okay, I’m not going to let a few people’s moods affect my learning!
Kudos to: Dr. Whittle for seeing a patient with me super efficiently and then sending me a follow up email about what we discussed later – on a Friday night!
Monday 1/14:
No morning conference today means we don’t have to be in clinic until 9 but I wasn’t sure... so I showed up at 8 AM anyways! I met some of the new residents and while they were settling in, even got to give them some IT pointers from my struggles last week. It’s amazing how much I’ve learned in one week!
I picked up one of the first patients of the day – he was a sweet sweet boy with so much energy and was really able to point out where he was hurting. He had a pretty classic case of a not uncommon pediatric rash; his mom had noted the rash on two classic places it shows up and I had this moment where I checked a third place and like predicted that there would be rash there! That kind of know-how is the stuff that amazed me about medicine before I started med school. My next patient had an unfamiliar presentation of the same ol same ol viral URI; it was fun going through each of his symptoms and getting a solid HPI and timeline. I had to pee so bad it hurt during the encounter so I gracefully excused myself and it wasn’t that weird! Dr Gutierrez also gave me solid feedback – offering the ranges of vitals, not editorializing too early. I asked the parents some developmental milestone questions and they got excited talking about their kid’s walking and talking and eating; those moments of excitement and pride and joy felt like a breeze of fresh air. Noon conference was a fantastic case. When I went back to clinic, I had a great adolescent encounter. Like I really enjoyed our encounter. We talked about setting a goal to drink more water which sounds sooo mundane but I had a lot of fun doing it!! I staffed one last patient – a precious 4 year old with the cutest glasses!
I remember feeling so tired this morning, wondering how I’d get through the day. My energy in the morning is not reflective of my energy during the day!! I saw 4 patients and wrote 4 notes (properly LOL because all the ones from last week were in the wrong place oops) and I was energized by the work. I needed some snacks later in the day but overall my energy was pretty good. ALSO! I saw a lot of ears today y’all! I looked into people’s ears! This is big! I am proud! I saw some normal tympanic membranes bless!
Lessons learned: Even if it doesn’t feel like I’ll have energy for the day when I wake up first thing in the morning, being in clinic and seeing patients is so energizing!!
Kudos to Dr. Gutierrez: for giving me concrete feedback that didn’t feel ~UCSF sugarcoated~
Tuesday 1/15: FCM
My FCM day was wild - imagine me walking up a completely unexpected high incline hill (we’re talking 3rd Ave from Irving to Parnassus) in the rain, knocking the clinic door; right after, I look to the side to find a man sleeping in the grass right next to me; he seems relaxed and says hey, to my credit, I didn’t bat an eye and responded warmly but on the inside I was shook because that was not what I had expected when I showed up to clinic!! Not too long after, I chased a young girl down the hall and was actually quite worried about losing her, and I watched the pharmacist get bit by a patient’s dog twice. We also made a home visit to a few blocks from the clinic to see a complex patient that was having trouble coming in. I saw patients tear up from the support they felt after an acupuncture procedure performed by their doctor. My preceptor waded through the layers of trauma some patients shared during their visits and was always ready with some sage advice for walking the path of healing. I saw some of the longest, most powerful hugs I’d seen in a while. I was reminded of the power of tenderness by my very first patient. I felt the energy of entire rooms shift. Two patients thanked me individually for nothing more than just being present during the encounter. There’s so much value to continuity of care. Today was a real adventure, and I’m excited that I get to be part of such a special clinic for the year. I “just shadowed” today but there’s a lot of merit in learning how an office ecosystem works and appreciating the work that those around me do -- so it was a really lovely day.
I was pretty tired all day and shadowing most of the time didn’t help. I could feel my shoulders and neck getting stiff. My body felt sore. But I was really touched by what I saw today. It’s clear Dr. Dallman makes a real difference by believing in people and supporting them. She’s very direct, and she always knows what to say. I want to be that person one day. There’s a lot to love about family medicine <3
Lessons learned: Western medicine sure has its limits when it comes to trauma; it was really beautiful to see the impact of some small acupuncture and scented oils on women who have been through some tough things
Kudos to: Dr. Dallman for taking me on even after the preceptors I was originally assigned to fell through!
Wednesday 1/16:
Today was hard. I really wanted to be in urgent care and wasn’t. The morning with Dr. Maggie Gilbreth was really nice; the kids were super sweet and she did a great job of being direct and conveying how non-jugdmental she was. I loved her energy.
So to be honest, this afternoon wasn’t one of my finest moments. Instead of urgent care, I was in asthma clinic. And I didn’t know much about asthma at all. Quickly, I learned that we have to take extensive histories and I had to use an interpreter for both the patients I saw so it took twice as long. I wasn’t expecting that, and then asking the questions is hard because there’s a lot of ambiguity with these topics. I got some really direct feedback on my first patient (to the lines of “you didn’t collect any relevant history” - I had completely missed the few cardinal asthma questions because I was so focused on the giant intake form and fleshing out the patient’s prior history with exacerbations that I missed some basic stuff). The feedback was completely warranted, so I felt this wide mismatch between expectations and my actual performance. I took it too hard. The rest of the day was a blur, I couldn’t even find the room my next patient was in. He had two siblings in urgent care with serious issues; I didn’t even know what the parents were going through when I went to ask my asthma questions. It’s hard to provide context to what happened but when I was about to leave after writing my last note, Dr. Marmor sensed that I wasn’t doing too great. She sat me down to talk and y’all I started crying. I’m still embarrassed. How am I supposed to handle the big tough things when I can’t get this little asthma afternoon right? But part of what got me in this mess is minimizing things that clearly have an effect on me. I had a hard time today. But I can learn and adapt quickly. How to grow from this? Is it too optimistic to hope it doesn’t happen again?
The funny thing is that the preceptor who gave me that blunt feedback at first – she told me that I did a really great job on the second patient and had improved so much in one encounter. But the praise didn’t mean nearly as much to me as the critique did. I want to get better at taking compliments to heart instead.
Lessons learned: Yes my problems are small compared to my patients – feeling frustrated with a clinical task I’m not prepared for when parents are dealing with three different diseases in their three kids; feeling helpless when I can’t comfort my patients in their language when they have to navigate our country without speaking English; missing my own parents when I see the tenderness that my patients’ parents have for their sick kids – BUT if I don’t acknowledge that at some level, these little things affect me deeply in a way that affects my ability to function, then I’m not operating at my best.
Kudos to: Dr. Marmor for sitting with me, contextualizing my afternoon and showing me enormous grace and kindness in a weak moment.
Thursday 1/17:
Today was not a bad day. It was great actually, and I felt really connected to my patients. I shadowed again in the morning- the patients were SO cute (like they get cuter every day it’s unreal). There was one baby who was SO well dressed and was crawling all over the floor and loved playing with my rainboots. Another patient was a school age kid that I just got to sit and chat with for a little while and she filled in all the spaces in our conversation so I just had to listen and smile. Next we had an adolescent visit; we asked a LOT of personal questions about poop and he had to get a genital exam. There’s not a ton of room for dignity in these appointments. Dr. Chan didn’t have time to do a HEADDSS assessment but I asked if I could – I tried to make it as not-awkward as possible and I think it flowed smoothly. There was something about the last encounter that I couldn’t put my finger on; despite the discomfort we put him through, I felt kind of connected and was rooting for him. I wanted to keep up with him and see him go to college like he planned to and keep reminding him to drink water and all of that yknow!
I returned to the clinic after lunch and immediately picked up a patient yay! He had five different symptoms, and I was able to take an organized history on all of them. Dr. Marmor made a point to observe me during this encounter and had some really thoughtful feedback; she said that I was adjusted my tone between talking to the mom and her son to bring both of them into the conversation and make them both feel heard. I didn’t realize I was doing that! I was able to do a fairly thorough physical exam as well. After talking through my assessment with Dr. Marmor, I reported my findings to the R3 and then we finished the appointment together – definitely had to leave some knots left untied but hoping his PCP can help sort out the rest. I was really proud of the note that I wrote up. I twiddled my thumbs for a minute because we had NO PATIENTS ON THE BOARD for like a while; I picked up the very next patient who was having some eye issues. One of the attendings dismissed everyone because we weren’t getting any more patients but I was still seeing my patient so I couldn’t go! Unfortunately, we couldn’t figure out what was happening to her... but we connected her to an ophthalmology consult. When I was giving them return precautions, I apologized for not having more concrete answers, it was the most natural thing for me to be honest about the uncertainty and our limits, but in hindsight I probably could have been more “professional” and composed. But it felt nice being transparent, and I was able to tell them that we weren’t concerned about anything serious which I hoped put them at ease a little bit. I told them to call the clinic if anything comes up! For some reason I almost teared up at the end of the visit. They were so grateful and easy to talk to, and I wish we could have done more but I was still really happy with how I was able to leave it.
Kudos to: Dr. Marmor for being a true angel, for reminding me that I’m a person who’s whole and brings something special to the table, that I’m more than my worst moments.
Lessons learned: Every day is a brand new day to start fresh!
Friday 1/18:
The morning started out reflecting on a patient who coded the night before; they were perfectly healthy the day before that. It was definitely every pediatrician’s worse nightmare, and you could sense a different energy on all the teams today. The morning in urgent care was nice though; I started with a 4 yo with a mix of viral symptoms; her mom had talked the whole time but then at the end of the visit, she opened up and gave me another a chief complaint - which felt so gratifying because she wanted to talk to me. We made sure we gave them solid return precautions before we sent her home. Also can I just say how time flies when you’re in urgent care!! I picked up my next patient at 11:15; she was having a common chief complaint with a complication that concerned me (turns out it was NBD lol oops). She had the smallest dog that was just a lil pile of fur. I tried asking her some open ended questions at first and she was not a fan; the close ended yes/no questions were way more effective. It’s interesting how much I’ve moved into close ended questioning in urgent care because I’ve noticed that open ended questions don’t actually put my patients at ease, they’re usually just like unamused with the vagueness; close ended questions give folx something concrete to latch on to which seems to improve our overall rapport.
After noon conf, I worked on my notes and then picked up a sweet 3 month old. The baby smiled at me at first which was sweet before we did the history. She needed more of a workup; I’m glad I stayed for her nasal swab and the urine collection to see how it happens! The girl was so unhappy when I held her legs down; so unhappy that she started peeing!! The nurse caught some of it but still had to thread a catheter in. I got I really got to be there every step of the way; during the initial history and second interview, during both of the tests, and then calling her afterwards with the results. I’m not sure if it mattered to the mom, but it felt really nice to me to close the loop. The rest of the afternoon got a little busy and it felt like people didn’t have the same capacity for teaching – which is totally fine! I’ve been spoiled these last two weeks with lots of attention and and individualized lessons. I tried to staff patients but with no avail. Around 5:15, I started reading up on a new patient when the attending dismissed us students and MAAM you did not have to tell me twice!! I erased my name from the board and was outta there before I could look back! Maybe not the way I wanted to end my urgent care rotation, but it was a way of respecting my boundaries - something else I’m trying to work on during clerkship year too.
Lessons learned: Not every day is a good day where people have enough energy to teach, and that’s okay, I’m not going to let a few people’s moods affect my learning!
Kudos to: Dr. Whittle for seeing a patient with me super efficiently and then sending me a follow up email about what we discussed later – on a Friday night!
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