Week 12: Cardiology 2/2
Week 12
One of the highlights of my week is that I FINALLY figured out what 2/2 means - it means "secondary to". I should have just asked someone but it felt satisfying figuring out the mystery on my own. All done with cardiology now but feeling so good about my understanding of the heart as I go back to medicine!
Monday 3/25
I had a great workout this morning! I parked kind of poorly when I got the hospital and was about to adjust when someone parked right next to me and I was a lil mortified yall but I couldn’t pull out again so I just quickly walked into the hospital avoiding eye contact. Pre-rounding was ROUGH bc I couldn’t find a computer – all of the computers in the workrooms were reserved for nurses signing out, I wasn’t sure which rooms were used for which teams so I was just scavenging for a computer, ended up in the ED which is truly home base for me. I overheard some nurses talking about working at County (LA County – one of the best emergency medicine training programs in the country), they were chillin at the nurses station but said that they’d never get time to sit when they were working at County and how it was “balls to wall” and it just sounded like an adventure. It makes me wonder about the next step – where will I end up at for residency? I hope it’s somewhere exciting, where I feel like there’s so much learning, in a place that I feel supported and at peace in. I also hope that I continue to soak in the joy of “match day” long after the fact, and that on long days of being an intern, I remember distinctly this feeling of curiosity and excitement I have now as a third year for that phase of life that’s next. There’s a quote something along the lines on “remember what it was like when you wanted what you have now”, four years ago I didn’t know if I was going to med school or that I’d be in San Francisco, that I’d be growing as an activist and writer and baker and becoming the kind of leader I’ve hoped to be. It’s easy for me to get lost in the details of the day to day but life has really treated me so sweet and I am grateful to be right here right now and I hope I keep remembering that.
I slipped in for a bit of morning report and then went up to meet my patient and do a lil physical exam. He was a sweet guy who looked a LOT better than his admission note made him sound – so glad he’s doing better! I ran through my note with my amazing intern Jenn who helped me tease out the details and think about the big picture. Rounds were a lil rough sos but the attending had to step out for a cardioversion so we got a smidge of a break! I think my presentation went well. Rounds finished up just before noon conference, Liat said she was heading out soon and I should too! But I wanted to stick around to see a cath – as unreliable as the cath schedule is! Noon conference was a great discussion about LGBT health disparities led by the director of UCSF’s trans health center; she was funny and relatable and super informative. Afterwards, I went back to the cards room to work on my note. After I told people that my team had taken off, they asked why I was still there! It didn’t seem like the cath was going to happen so when team two offered to take me under their wing and bring me along to a family meeting, I was super down. After an awkward start, we had an in person interpreter and the renal consult (who I remember from FS day last week, she was my small group leader!) and it was a BEAUTIFUL moment wow!! This man was in his nineties, his four kids were around him and they asking the best questions like how can they take care of him now, what can they do to give him a normal life? Our team was also so good at communicating, I felt like they did an amazing job of being transparent and breaking it down into easy to absorb pieces, being kind and warm but also honest about prognosis. At one point, our patient said all anyone needs is their health and their loved ones to live a good life. It was so sweet.
I wanted to circle back to my patient from earlier today. He’d been NPO all day for a cath that probably wasn’t happening, I wanted to hang out but I was hesitant because we know so little about his condition until he gets his imaging done. I should have gone back to keep him company. I was in such a rush this morning to get what I needed done before rounds that I didn’t pause to make him feel heard, I hope he found his glasses and I hope he unlocked the cabinet. I don’t think anyone stopped by to give him an update on the plan all day, even after I said we would. Maybe it didn’t bother him but I feel like I could have done a better job. It’s hard being thrown in with someone knowing that I won’t get to see them again before they’re discharged most likely.
When I got home, I watched an episode of Tangled and let me just say WOW this show is just so good. It’s visually and artistically stunning, the characters are nuanced and they depict interpersonal relationships with clarity and honesty. I just love Rapunzel’s sense of adventure and need to explore the world, her sense of purpose in this elaborate new quest the writers have constructed for season 2. She didn’t ask for the gift she received, but we’ve learned that it comes with a dark side and her willingness to take responsibility for circumstances she was born into, her realization that she's part of a longstanding problem that’s hurting vulnerable people – that’s a great metaphor for what a lot of my generation has inherited. Best of all, I love her sense of wonder and how she gets excited about the little things but also can relate to how she gets annoyed (and proves them wrong!) when people write her off as naïve. And on top of all of this, the show is just so light and funny and makes me so happy. I can’t articulate why I’ve felt such a connection to this fictional character for wow almost a decade now – watching the movie my freshman year of high school was a gamechanger for me, her story helped me bridge starting my new life in college, the television show came out when I started med school and helped me appreciate feeling the wind in my hair after I cut it. Rapnuzel and her story have been a constant for me for a while, and it’s just such a treat to see her grow and see so much meaning in her show. I read this amazing article about the show is really a story about millennials and I couldn’t agree more.
Tuesday 3/26
I really love that my FCM clinic has so much community involvement and history – I didn’t know about its origin story but I love it and I love seeing folks from the neighborhood, many of whom have lived here for decades and decades, if not their whole lives.
This morning Dallman and I talked about feedback and thinking bigger than western medicine’s isolation of individual organ systems. We discussed the mind-gut connection and even how the electricity from our heart can be detected a few feet away as maybe why people tend to “pick up the energy of the people around them”. Our patients today were so lovely.
I saw a familiar face on my own. Then we went in to see an abuelita who had heart failure and anemia and we had to send her to the ED, I felt for her. This was a terrible situation, she wasn’t expecting it and didn’t like feeling helpless waiting on her granddaughter who had to leave work and not having her phone on her. The last thing she wanted to do was get hospitalized but slowly I could see her understanding that we thought this was important. I sat with her for a bit but I couldn’t say much because of the language barrier. She was telling me about how she had heard about a mother with terminal cancer who was leaving 8 young kids behind and how sad that was. No matter how rough you have it, there’s always someone who has it worse. Here I was feeling bad for this woman but she had found another outlet to channel her disconsolation.
Another patient I saw told me about how she has a crew of 9 women who all went to second grade together who still live in the city and get together once a month. Our last patient was a true transformation story – she went from being wheelchair bound with swollen joints, unable to open her jaw from the swelling and pain to someone who loves hiking and knitting and her family and dances. She said she feels “even” now that her RA is under control, we talked about how magical it is to get her personality back and how chronic disease will always be a part of her life but how it doesn’t have to define her. The words felt a little trite but the emotion behind it was palpable. Dallman explained the rheumatologists are some of the best diagnosticians because rheum diseases present bizarrely, they have time to really get to know their patients, and they are very skilled at the physical exam. I loved all of that – maybe I need to explore rheum?? Unfortunately we couldn’t predict what her menopause would look like and how that would affect her RA – I wish we knew more about these things and had more to tell our patients!
Dallman said that she won’t work harder than her patients on their health. Not because she doesn’t care deeply but because it doesn’t end well. That’s going to stay with me.
Wednesday 3/27
I had a great workout but I was twenty minutes late to morning report and I would have liked to be there for the whole thing – so I’ll get to the hospital earlier tomorrow.
I visited my patient with heart failure, an older man with a salt and pepper beard and a laugh that fills the whole room. My intern popped in at the same time and when she went to listen to his heart, he said that he wanted me to listen too. I felt like he was looking out for me. His daughter was sitting with him, I joined her for a bit and heard about how our attending reviewed the results of the cath with them yesterday, tracing out the coronary arteries that wrap around his heart that’s working so hard to keep pumping. The footage is visually stunning, the bursts of liquid contrast pumped across vessels in a rhythmic motion but haunting when you’ve learned how to read these scans, when you know how wide the vessels are supposed to be and when you see them funneling in and contorting in response to years of obscured blood flow. His daughter is well versed in this language, she remembers that his left circumflex was 99% occluded and that his LAD had large blockage as well. Curious about her background in healthcare, I ask and learn that she’s studying imaging and radiology. She had a rotation at SFGH a few months ago, now she’s on the other side with a father in heart failure.
She wants a copy of the footage, she’s already completed paperwork and made a copy of identification records; I offer to look into it because there’s not much else I can help with, no other questions she has that I know the answer to. Later, I call up medical records and get tossed around the hospital directory, speak in a few circles to the woman on the other end of the line and she says she’ll start making a CD now – ready for pick up in 10 or 15 minutes. That’s the quickest turnaround I’ve had at the general yet. My intern congratulates me for being able to sort out the task, I wish I could revel in these little victories more. I walk over to his room and his daughter is already downstairs getting his angiogram footage, I think she would have been just fine without my intervention, but it feels neat –not messy like medicine usually is- to see this item through. I walk through his new medications with him; he came to the hospital without any regular medications, now he has 7 to take every day and two doctors to follow up with and one surgery pending. I’m not sure how much he remembers from our conversation, I should have used the communication techniques they drilled into us in week one of med school I think after I’ve left. I’m crouched down beside him so that we’re seeing eye to eye, when I start making my goodbyes, he reaches over shakily and kisses me on the cheek. I hesitate to share this moment with others later because it sounds creepy when really that moment was more tender than words can say.
In the afternoon, we visit Laguna Honda. I’ve driven past this sprawling medieval edifice every day sine clerkships started. We passed by it that very first day I moved to San Francisco on our ride from the airport. I read a book about its tender nursing and community of patients and slower pace and focus on wellbeing in its most holistic sense written carefully by a master physician-writer. My Prius chugs up the sprawling hill, we find the Florence Nightingale landmark easily and gather with classmates. We make small talk and await our guide. Thirty minutes in, half of us have left and he’s nowhere to be found. A few of us linger to explore the grounds, we walk around the old wards and through the overgrown shrubs and peek inside dusty windows, curious about who if anyone uses the space. The building is beautiful and rustic and recalls a simpler time. We walk down the hill into the new facility, we invite ourselves to tour the gym and learn they have not one but two heated pools. We catch a glimpse of the garden and walk outside. For a moment, I’d believe we’re in the courtyard of an overpriced luxury apartment building and not the city’s safety net rehabilitation facility. We see (and smell) the farm animals, we peek into the greenhouse, we admire the stunning mix of colors in a single tulip. We wave excitedly to the residents we cross along the way. It’s a magical afternoon and we hope that we get to return for the full tour.
When I got home, I took a nap, ugh I could have been more productive but I need to be better at just meeting myself where I’m at. Where’s the balance between that and pushing myself to get the work that needs to be done DONE though? Still trying to figure it out but I have room to be a lil more patient and less hard on myself.
Thursday 3/28
This morning was easy, we didn’t have morning report so I didn’t have to be done by 7:30 and we don’t actually start rounds until 8:45 so I got to take my SWEET time pre-rounding. I really vibed with the ICU team – I talked to his nurse and the precepting nurse was SO nice to me and helped me find his vitals when I was struggling. The respiratory therapist Clara was also really friendly and of course our sweet patient was such a warm guy despite all that was happening around him.
During rounds, one of our patients was 28 with heart failure and he didn’t have any genetic risk factors or CAD; our attending was puzzled about the etiology of his heart failure. I definitely zoned out a little during the H&P but I remember the night resident saying this patient drinks 12 beers a day so I whispered to my intern because I thought alcohol could cause cardiomyopathy. She told me to speak up so I did – and I think the attending appreciated my suggestion. Jenn fistbumped me after which was super satisfying. We left at 10 for intern report but the rest of the team continued to round. Unfortunately, they FINISHED BEFORE WE GOT BACK so I NEVER GOT TO PRESENT MY PATIENT SAD. I was actually really sad to be honest, I had spent a lot of time sifting through this ICU patient’s complicated history and felt like I had really zoomed into the few pertinent issues for the day and was excited to share that with the team. My senior Liat was SO understanding and apologetic though and that was really validating; if she had brushed it off like nbd then I would have been more sad - but she said that it sucked which made me feel a lot better. She also asked if I had lost an earring and I was so confused – turns out I had dropped an earring in the ICU and the respiratory therapist had mentioned it in their last phone call? Liat could have easily brushed that aside but she made sure I got my earring back.
We went down to the ICU to write some orders and then Clara who I had met earlier today had saved my earring to give back to me! She said it was so pretty that she knew it belonged to me – SO SWEET. I felt a little awkward for causing trouble and it kind of made me want to not wear jewelry so easily lost and I honestly would have been FINE if I never got it back, I’ve worn that pair a lot over the years, but someone went through a little effort to return it to me because they thought it was worth doing. So it’s worth continuing to wear cute earrings (just need to make sure the backing actually fits!). Looking back on that moment, it was all women. I can’t imagine men caring enough about a earring but regardless it was really sweet and I am thankful.
Noon conference was fun, sushi day was great. I notice that I feel full more easily these days, I think I’m being more mindful of what I eat instead of just scarfing down meals. I really appreciate the chief resident Matt and the effort he puts into teaching us. I had texted Rohit before lunch to see if there were procedures – he said he’d keep me posted but I hadn’t heard back and I was done with my tasks for the day so I stopped by my ICU patient’s room just to chat! I had thirty minutes before didactics and we had a really good time. At first I asked him about his condition bc I hadn’t ever had a patient with that before. I felt like he was getting sad though so I tried to change the subject. He said he had lived a full life, and he recounted some of the highlights for me. He told me about his travels and his art and how he used to be teacher. I asked about the cat I read about in his note – turns out she died a year ago SOS we NEED to update his chart but it was sweet reminiscing with him. He hasn’t gotten another cat since because he knows he’d always compare her to the one he lost. He told me he felt lucky to live in the SRO he has with his partner – he mentioned that folks on the street will sneak in sometimes and sleep in the bathtub he shares with other residents and that they don’t always keep the space clean– but that his apartment was one of the nicest ones of its kind in the city and he felt lucky. I told him that everyone keeps saying how nice he is – and he was really touched by that. He said he loved his doctors at UCSF, I asked him what makes a good doctor? He said remembering that patients are human, that it’s not like herding cattle to get them to do things; that his doctors made him feel like he was their only patient.
He has had so many admissions in the last few months and the team is baffled about why he keeps coming back yet refuses hospice care; goals of care discussions haven’t made much progress and I was hoping that maybe we could help him turn a new leaf on this visit when I first approached his file. But today I didn’t want to bring it up. Honestly, I just wanted to get to know him and witness some of what he’s going through and make him feel heard and special. Maybe my goals should have been different, maybe I should be trying to save the hospital money from his readmissions or push our hospice narrative IDK but honestly it just felt good to chat and I promised I’d come back Saturday if he was still around and he said – deal.
Didactics were fun, I love doing cases with Matt! We had some NP students join us too which was neat. ALSO I had a new pen today and WHEW I felt like a new gal wow this pen is like a gel pen and writes so smoothly but does not smudge one bit, it’s amazing!! Rohit texted me and said I should leave LOL which was sweet ugh but I wish I got to hang out with him more and see those procedures.
After I left, I drove to TJs and did my groceries for the week. I drove to campus and hung out with Hallen for a bit, it’s always SO FUN catching up! And then I came home and worked on a few things and then made my EKG cupcakes woo hoo!
Friday 3/29
Today was a beautiful weekend. I slept in until 7:30, did a practice medicine shelf (and scored better than I thought I would!), and then got ready and ate breakfast. I got my nails done (they only charged me less than I expected get the SNS nails taken off and get new ones on) – so obsessed with these powder nails! The gray color didn’t quite turn out like I had expected but it’s growing on me. I picked up a banh mi for lunch and then discovered a new very hole-in-the-wall coffee shop (it’s actually not that new, apparently it’s been around for 10 years) but they served loose leaf tea in the cutest tea pot! So glad I hydrated well before my visit to PEARL SPA – my first Korean spa and wow it was liberating. I was trying hard to just be present and not too think hard about anything, I let thoughts float by. I kind of didn’t want to leave, I loved getting ready with all of their Korean beauty products and the women who worked there were so kind. I was craving Asian Box after so I drove up to the Marina, paid a little too much for parking, but got an early dinner and then set up at another coffee shop to do more work. The sun was out and it wasn’t too cold and I was visiting my fav parts of the city and just soaking in every moment and feeling so refreshed –
I was thinking today about how lots of people interact with lots of people through their work. The women at the nail salon, the man behind the eclectic counter at the coffee shop, the woman who scrubbed me down at the spa today – they all get little glimpses into people’s lives and interact with a large number of folks every day. It’s kind of like medicine, where you aren’t really sure what kind of impact you make on people but you try anyways, where you’re serving people something they value and you get the chance to try your best over and over again. I know the physician-patient relationship is different but it’s the only one where you get intimate glances into people’s lives nor is it the only kind you get to witness joys. These folks certainly aren’t compensated as well, I wonder how many of them have health insurance and where they go when they get sick
Saturday 3/30
Today was off to a good start. My workout was great and then no traffic on the drive in! I listened to a good podcast today that reminded me about the importance of pausing after we get age, sex, risk factors, and chief complaint in a patient case. Not to linger too long on stereotypes or anything but to remember that those are important pieces of information! The podcast also talked about diagnostic error and “localizing the lesion” when you make a mistake – so true. Most of my diagnostic errors when listening to these case-based podcasts have been due to gaps in knowledge – which I’m working on!
I cut a corner today. I had heard my patient had an episode of chest pain overnight, my intern had filled me in on the big picture and deep down, I KNEW I should have fleshed it out more (OPQRST is the easiest thing and takes like 3 minutes!) when I was in the room but for some reason, I just didn’t. We weren’t all that concerned but still, for my learning and for the possibility that something worse was happening – I should have asked more about it. When I was presenting him, I couldn’t answer a basic question my attending asked about the chest pain. It was a little mortifying, like I have one job with this presentation and I couldn’t do it as well as I had hoped. It’s a learning moment that will stick with me, I don’t want to feel like this again, that I cut a corner I could have and should have done a better job with. I know better than to ignore new complaints. The rest of the presentation actually went really well, the team briefly toyed with the idea of it being a PE but immediately I said he was on anticoagulation so that’d be unlikely and even so, would we change our management? It was exactly the right response and felt good that I knew my patient and knew the situation well enough to have an immediate answer.
After rounds, we visited my patient. He had to go up on his oxygen requirement and the team felt like he might not go home at all if it stayed at that level. I sensed that the conversation wasn’t going well – but in hindsight, how could I expect any conversation like that to go smoothly? We paused for a bit but realized he wasn’t retaining much so we promised to circle back later to give him some space to process. The team was direct but kind. It’s hard to know what to say in these situations. After we left, Jenn wondered how many times he’s had this conversation before – when we were in there, I thought it was sad that we were seeing him towards the end, that we had to be the ones to break this news to him BUT he could have easily heard this spiel from multiple other teams given the number of readmissions he’s had.
We went back to see him later in the day and he had gone down on his oxygen – and was doing just fine! We were shocked but also not that surprised. He’s probably back at his baseline and if he wants to go home, it looks like we’ll able to send him back. He said he worked hard to improve his breathing. I wasn’t convinced this morning that he had much control over his oxygen sats but this afternoon, I’d reconsider my stance on that. He said he’d love to go home, that there’s still some living he has left to do. From my perspective, him going home with his limitations doesn’t seem like all that much of a life BUT I don’t know what his home life is like! I don’t know what kind of joys and loves and prides he has outside of the hospital. But I trust that he knows what’s best for him and I’m hoping that we can get him home soon.
I had some time to chat with the attending and Dr Win was a little confused about our expectations and background as MS3s - he wasn't sure if we were getting much out of the rotation but I assured him that I was learning lots. It’s nice to know that we aren’t the only ones confused about our role here. Liat saying that reading up on your patients as their cases unfold is the best way to learn. We consulted on a patient I had seen two weeks ago when I was on medicine – and he remembered me! I saw a swan-Ganz catheter insertion (and standing around for one hour not really knowing what was going on felt like good practice for surgery lol sos). Jenn wanted to teach because the afternoon was slow, I told her I need frameworks for rheum so she whipped out an amazing vasculitis one and WOW that was beautiful.
At the end of the day, I was reflecting with Jenn about how my goal for this rotation was to pick up patients and improve my presentation skills but I ended up being a white cloud, out of three full call days, I barely got one patient. It sucks but it’s not really in anyone’s control. Instead, to make the most of the rotation, I really had to be present during the day, pay attention and follow clinical reasoning carefully during rounds, be willing to speak up and ask questions, be proactive about following along to see physical exam findings and procedures. I did learn a lot, I didn’t DO as much as I expected to but at least I can look back on these two weeks of cards knowing that I did my best in the circumstances we had, and that I don’t have regrets about not maximizing my learning.
On the way home, I was craving a lil TJs so I made a pit stop. Mom and dad called, they said they had just talked to a friend whose daughter was so rude to her mom and just wrote off all of her advice and their mom had been upset when she talked to my parents. Mom and dad surprised me when they reflected on how nice I am to them and how much it means that I really value their perspective. It made me pause to remember that I have UNREALLY AMAZING parents but that even the best parents can get not-so-great kids, and that one way I can keep expressing my appreciation for them is something I’ve always done. Ugh I love them so much.
Sunday 3/31
Today was light. Not much to preround on. I felt pretty energized during rounds and was able to keep up. We had some interesting cases come in today – a LOT happened right after I left yesterday! The team called me a white cloud bc the whole time I was there, no patients came in and our workload was light but as soon as I left, things sure picked up. It’s also tough because there’s just two residents admitting and holding the cross cover pager which is like unreal now that I know what those concepts are.
After rounds, we visited our new patients. I wish we could have called an interpreter for our Chinese gentleman. Our next guy was really interested in what his physical exam findings meant – that was a good reminder to ask patients if they’d like us to explain along as we discuss their case. Then we saw my patient- I’ve felt something shift in our dynamic. Earlier in the week, we were so convivial and had this light, airy interaction; after we broke the news to him about him not being able to go home, I sensed a wall come up between us. He wasn’t overly defensive, but I felt like he was more guarded around me, and I wonder if he felt safe to say what’s really been going on, knowing that any new symptom or change could be reason we keep him here indefinitely. It felt like we had gone from being on the same side to pushing up against each other in some way. Of course I don’t expect him to keep showing me grace and warmth, especially after our bombshell that we could have better contextualized in his history of repeated admissions but I’m just saying that I felt a little unsettled and unsatisfied by the denouement. Logistically, I’m happy that he’s going home because that’s what he wants but emotionally I haven’t quite caught up.
We saw a case of viral pericarditis which is still wild to me and then took a look at the Swan-Ganz catheter again. I had some one-on-one time with the attending as we walked up to another patient room and I got to ask him a question about preload and afterload that has been bugging me all rotation and he just chuckled and told me I was overthinking it. I went back to see Jenn, there wasn’t anything else I could help with but we talked feedback and how to improve. She said that outstanding med students look for ways to help, they’re present, they make an effort to teach their patients and spend time getting to know them. She gave me a few pearls for how to make my presentations shine. And she encouraged me to speak up more and reminded me that it’s OKAY to be wrong but that I can always “show my work” for partial credit and for individualized feedback on how to tweak my thinking.
I scarfed down my lunch because I was so hungry but then drove home, chatted with mom for a bit. I watched some TV and then went to Marla in the outer Richmond! I got THE most delightful pot of “four flower” tea and then caved and got a lil peanut butter brownie as well and actually got a solid chunk of work done. I might try to do more coffee shop studying right after I finish at the hospital because it worked so well. I went on a short lil run to the beach after, it was a beautiful day and I sure love this lil corner of town. I stopped by Andronico’s on the way back to get my granola (and saw Libby!!) and then filled up my tank and drove home.
xoxo
Juhi
Monday 3/25
I had a great workout this morning! I parked kind of poorly when I got the hospital and was about to adjust when someone parked right next to me and I was a lil mortified yall but I couldn’t pull out again so I just quickly walked into the hospital avoiding eye contact. Pre-rounding was ROUGH bc I couldn’t find a computer – all of the computers in the workrooms were reserved for nurses signing out, I wasn’t sure which rooms were used for which teams so I was just scavenging for a computer, ended up in the ED which is truly home base for me. I overheard some nurses talking about working at County (LA County – one of the best emergency medicine training programs in the country), they were chillin at the nurses station but said that they’d never get time to sit when they were working at County and how it was “balls to wall” and it just sounded like an adventure. It makes me wonder about the next step – where will I end up at for residency? I hope it’s somewhere exciting, where I feel like there’s so much learning, in a place that I feel supported and at peace in. I also hope that I continue to soak in the joy of “match day” long after the fact, and that on long days of being an intern, I remember distinctly this feeling of curiosity and excitement I have now as a third year for that phase of life that’s next. There’s a quote something along the lines on “remember what it was like when you wanted what you have now”, four years ago I didn’t know if I was going to med school or that I’d be in San Francisco, that I’d be growing as an activist and writer and baker and becoming the kind of leader I’ve hoped to be. It’s easy for me to get lost in the details of the day to day but life has really treated me so sweet and I am grateful to be right here right now and I hope I keep remembering that.
I slipped in for a bit of morning report and then went up to meet my patient and do a lil physical exam. He was a sweet guy who looked a LOT better than his admission note made him sound – so glad he’s doing better! I ran through my note with my amazing intern Jenn who helped me tease out the details and think about the big picture. Rounds were a lil rough sos but the attending had to step out for a cardioversion so we got a smidge of a break! I think my presentation went well. Rounds finished up just before noon conference, Liat said she was heading out soon and I should too! But I wanted to stick around to see a cath – as unreliable as the cath schedule is! Noon conference was a great discussion about LGBT health disparities led by the director of UCSF’s trans health center; she was funny and relatable and super informative. Afterwards, I went back to the cards room to work on my note. After I told people that my team had taken off, they asked why I was still there! It didn’t seem like the cath was going to happen so when team two offered to take me under their wing and bring me along to a family meeting, I was super down. After an awkward start, we had an in person interpreter and the renal consult (who I remember from FS day last week, she was my small group leader!) and it was a BEAUTIFUL moment wow!! This man was in his nineties, his four kids were around him and they asking the best questions like how can they take care of him now, what can they do to give him a normal life? Our team was also so good at communicating, I felt like they did an amazing job of being transparent and breaking it down into easy to absorb pieces, being kind and warm but also honest about prognosis. At one point, our patient said all anyone needs is their health and their loved ones to live a good life. It was so sweet.
I wanted to circle back to my patient from earlier today. He’d been NPO all day for a cath that probably wasn’t happening, I wanted to hang out but I was hesitant because we know so little about his condition until he gets his imaging done. I should have gone back to keep him company. I was in such a rush this morning to get what I needed done before rounds that I didn’t pause to make him feel heard, I hope he found his glasses and I hope he unlocked the cabinet. I don’t think anyone stopped by to give him an update on the plan all day, even after I said we would. Maybe it didn’t bother him but I feel like I could have done a better job. It’s hard being thrown in with someone knowing that I won’t get to see them again before they’re discharged most likely.
When I got home, I watched an episode of Tangled and let me just say WOW this show is just so good. It’s visually and artistically stunning, the characters are nuanced and they depict interpersonal relationships with clarity and honesty. I just love Rapunzel’s sense of adventure and need to explore the world, her sense of purpose in this elaborate new quest the writers have constructed for season 2. She didn’t ask for the gift she received, but we’ve learned that it comes with a dark side and her willingness to take responsibility for circumstances she was born into, her realization that she's part of a longstanding problem that’s hurting vulnerable people – that’s a great metaphor for what a lot of my generation has inherited. Best of all, I love her sense of wonder and how she gets excited about the little things but also can relate to how she gets annoyed (and proves them wrong!) when people write her off as naïve. And on top of all of this, the show is just so light and funny and makes me so happy. I can’t articulate why I’ve felt such a connection to this fictional character for wow almost a decade now – watching the movie my freshman year of high school was a gamechanger for me, her story helped me bridge starting my new life in college, the television show came out when I started med school and helped me appreciate feeling the wind in my hair after I cut it. Rapnuzel and her story have been a constant for me for a while, and it’s just such a treat to see her grow and see so much meaning in her show. I read this amazing article about the show is really a story about millennials and I couldn’t agree more.
Tuesday 3/26
I really love that my FCM clinic has so much community involvement and history – I didn’t know about its origin story but I love it and I love seeing folks from the neighborhood, many of whom have lived here for decades and decades, if not their whole lives.
This morning Dallman and I talked about feedback and thinking bigger than western medicine’s isolation of individual organ systems. We discussed the mind-gut connection and even how the electricity from our heart can be detected a few feet away as maybe why people tend to “pick up the energy of the people around them”. Our patients today were so lovely.
I saw a familiar face on my own. Then we went in to see an abuelita who had heart failure and anemia and we had to send her to the ED, I felt for her. This was a terrible situation, she wasn’t expecting it and didn’t like feeling helpless waiting on her granddaughter who had to leave work and not having her phone on her. The last thing she wanted to do was get hospitalized but slowly I could see her understanding that we thought this was important. I sat with her for a bit but I couldn’t say much because of the language barrier. She was telling me about how she had heard about a mother with terminal cancer who was leaving 8 young kids behind and how sad that was. No matter how rough you have it, there’s always someone who has it worse. Here I was feeling bad for this woman but she had found another outlet to channel her disconsolation.
Another patient I saw told me about how she has a crew of 9 women who all went to second grade together who still live in the city and get together once a month. Our last patient was a true transformation story – she went from being wheelchair bound with swollen joints, unable to open her jaw from the swelling and pain to someone who loves hiking and knitting and her family and dances. She said she feels “even” now that her RA is under control, we talked about how magical it is to get her personality back and how chronic disease will always be a part of her life but how it doesn’t have to define her. The words felt a little trite but the emotion behind it was palpable. Dallman explained the rheumatologists are some of the best diagnosticians because rheum diseases present bizarrely, they have time to really get to know their patients, and they are very skilled at the physical exam. I loved all of that – maybe I need to explore rheum?? Unfortunately we couldn’t predict what her menopause would look like and how that would affect her RA – I wish we knew more about these things and had more to tell our patients!
Dallman said that she won’t work harder than her patients on their health. Not because she doesn’t care deeply but because it doesn’t end well. That’s going to stay with me.
Wednesday 3/27
I had a great workout but I was twenty minutes late to morning report and I would have liked to be there for the whole thing – so I’ll get to the hospital earlier tomorrow.
I visited my patient with heart failure, an older man with a salt and pepper beard and a laugh that fills the whole room. My intern popped in at the same time and when she went to listen to his heart, he said that he wanted me to listen too. I felt like he was looking out for me. His daughter was sitting with him, I joined her for a bit and heard about how our attending reviewed the results of the cath with them yesterday, tracing out the coronary arteries that wrap around his heart that’s working so hard to keep pumping. The footage is visually stunning, the bursts of liquid contrast pumped across vessels in a rhythmic motion but haunting when you’ve learned how to read these scans, when you know how wide the vessels are supposed to be and when you see them funneling in and contorting in response to years of obscured blood flow. His daughter is well versed in this language, she remembers that his left circumflex was 99% occluded and that his LAD had large blockage as well. Curious about her background in healthcare, I ask and learn that she’s studying imaging and radiology. She had a rotation at SFGH a few months ago, now she’s on the other side with a father in heart failure.
She wants a copy of the footage, she’s already completed paperwork and made a copy of identification records; I offer to look into it because there’s not much else I can help with, no other questions she has that I know the answer to. Later, I call up medical records and get tossed around the hospital directory, speak in a few circles to the woman on the other end of the line and she says she’ll start making a CD now – ready for pick up in 10 or 15 minutes. That’s the quickest turnaround I’ve had at the general yet. My intern congratulates me for being able to sort out the task, I wish I could revel in these little victories more. I walk over to his room and his daughter is already downstairs getting his angiogram footage, I think she would have been just fine without my intervention, but it feels neat –not messy like medicine usually is- to see this item through. I walk through his new medications with him; he came to the hospital without any regular medications, now he has 7 to take every day and two doctors to follow up with and one surgery pending. I’m not sure how much he remembers from our conversation, I should have used the communication techniques they drilled into us in week one of med school I think after I’ve left. I’m crouched down beside him so that we’re seeing eye to eye, when I start making my goodbyes, he reaches over shakily and kisses me on the cheek. I hesitate to share this moment with others later because it sounds creepy when really that moment was more tender than words can say.
In the afternoon, we visit Laguna Honda. I’ve driven past this sprawling medieval edifice every day sine clerkships started. We passed by it that very first day I moved to San Francisco on our ride from the airport. I read a book about its tender nursing and community of patients and slower pace and focus on wellbeing in its most holistic sense written carefully by a master physician-writer. My Prius chugs up the sprawling hill, we find the Florence Nightingale landmark easily and gather with classmates. We make small talk and await our guide. Thirty minutes in, half of us have left and he’s nowhere to be found. A few of us linger to explore the grounds, we walk around the old wards and through the overgrown shrubs and peek inside dusty windows, curious about who if anyone uses the space. The building is beautiful and rustic and recalls a simpler time. We walk down the hill into the new facility, we invite ourselves to tour the gym and learn they have not one but two heated pools. We catch a glimpse of the garden and walk outside. For a moment, I’d believe we’re in the courtyard of an overpriced luxury apartment building and not the city’s safety net rehabilitation facility. We see (and smell) the farm animals, we peek into the greenhouse, we admire the stunning mix of colors in a single tulip. We wave excitedly to the residents we cross along the way. It’s a magical afternoon and we hope that we get to return for the full tour.
When I got home, I took a nap, ugh I could have been more productive but I need to be better at just meeting myself where I’m at. Where’s the balance between that and pushing myself to get the work that needs to be done DONE though? Still trying to figure it out but I have room to be a lil more patient and less hard on myself.
Thursday 3/28
This morning was easy, we didn’t have morning report so I didn’t have to be done by 7:30 and we don’t actually start rounds until 8:45 so I got to take my SWEET time pre-rounding. I really vibed with the ICU team – I talked to his nurse and the precepting nurse was SO nice to me and helped me find his vitals when I was struggling. The respiratory therapist Clara was also really friendly and of course our sweet patient was such a warm guy despite all that was happening around him.
During rounds, one of our patients was 28 with heart failure and he didn’t have any genetic risk factors or CAD; our attending was puzzled about the etiology of his heart failure. I definitely zoned out a little during the H&P but I remember the night resident saying this patient drinks 12 beers a day so I whispered to my intern because I thought alcohol could cause cardiomyopathy. She told me to speak up so I did – and I think the attending appreciated my suggestion. Jenn fistbumped me after which was super satisfying. We left at 10 for intern report but the rest of the team continued to round. Unfortunately, they FINISHED BEFORE WE GOT BACK so I NEVER GOT TO PRESENT MY PATIENT SAD. I was actually really sad to be honest, I had spent a lot of time sifting through this ICU patient’s complicated history and felt like I had really zoomed into the few pertinent issues for the day and was excited to share that with the team. My senior Liat was SO understanding and apologetic though and that was really validating; if she had brushed it off like nbd then I would have been more sad - but she said that it sucked which made me feel a lot better. She also asked if I had lost an earring and I was so confused – turns out I had dropped an earring in the ICU and the respiratory therapist had mentioned it in their last phone call? Liat could have easily brushed that aside but she made sure I got my earring back.
We went down to the ICU to write some orders and then Clara who I had met earlier today had saved my earring to give back to me! She said it was so pretty that she knew it belonged to me – SO SWEET. I felt a little awkward for causing trouble and it kind of made me want to not wear jewelry so easily lost and I honestly would have been FINE if I never got it back, I’ve worn that pair a lot over the years, but someone went through a little effort to return it to me because they thought it was worth doing. So it’s worth continuing to wear cute earrings (just need to make sure the backing actually fits!). Looking back on that moment, it was all women. I can’t imagine men caring enough about a earring but regardless it was really sweet and I am thankful.
Noon conference was fun, sushi day was great. I notice that I feel full more easily these days, I think I’m being more mindful of what I eat instead of just scarfing down meals. I really appreciate the chief resident Matt and the effort he puts into teaching us. I had texted Rohit before lunch to see if there were procedures – he said he’d keep me posted but I hadn’t heard back and I was done with my tasks for the day so I stopped by my ICU patient’s room just to chat! I had thirty minutes before didactics and we had a really good time. At first I asked him about his condition bc I hadn’t ever had a patient with that before. I felt like he was getting sad though so I tried to change the subject. He said he had lived a full life, and he recounted some of the highlights for me. He told me about his travels and his art and how he used to be teacher. I asked about the cat I read about in his note – turns out she died a year ago SOS we NEED to update his chart but it was sweet reminiscing with him. He hasn’t gotten another cat since because he knows he’d always compare her to the one he lost. He told me he felt lucky to live in the SRO he has with his partner – he mentioned that folks on the street will sneak in sometimes and sleep in the bathtub he shares with other residents and that they don’t always keep the space clean– but that his apartment was one of the nicest ones of its kind in the city and he felt lucky. I told him that everyone keeps saying how nice he is – and he was really touched by that. He said he loved his doctors at UCSF, I asked him what makes a good doctor? He said remembering that patients are human, that it’s not like herding cattle to get them to do things; that his doctors made him feel like he was their only patient.
He has had so many admissions in the last few months and the team is baffled about why he keeps coming back yet refuses hospice care; goals of care discussions haven’t made much progress and I was hoping that maybe we could help him turn a new leaf on this visit when I first approached his file. But today I didn’t want to bring it up. Honestly, I just wanted to get to know him and witness some of what he’s going through and make him feel heard and special. Maybe my goals should have been different, maybe I should be trying to save the hospital money from his readmissions or push our hospice narrative IDK but honestly it just felt good to chat and I promised I’d come back Saturday if he was still around and he said – deal.
Didactics were fun, I love doing cases with Matt! We had some NP students join us too which was neat. ALSO I had a new pen today and WHEW I felt like a new gal wow this pen is like a gel pen and writes so smoothly but does not smudge one bit, it’s amazing!! Rohit texted me and said I should leave LOL which was sweet ugh but I wish I got to hang out with him more and see those procedures.
After I left, I drove to TJs and did my groceries for the week. I drove to campus and hung out with Hallen for a bit, it’s always SO FUN catching up! And then I came home and worked on a few things and then made my EKG cupcakes woo hoo!
Friday 3/29
Today was a beautiful weekend. I slept in until 7:30, did a practice medicine shelf (and scored better than I thought I would!), and then got ready and ate breakfast. I got my nails done (they only charged me less than I expected get the SNS nails taken off and get new ones on) – so obsessed with these powder nails! The gray color didn’t quite turn out like I had expected but it’s growing on me. I picked up a banh mi for lunch and then discovered a new very hole-in-the-wall coffee shop (it’s actually not that new, apparently it’s been around for 10 years) but they served loose leaf tea in the cutest tea pot! So glad I hydrated well before my visit to PEARL SPA – my first Korean spa and wow it was liberating. I was trying hard to just be present and not too think hard about anything, I let thoughts float by. I kind of didn’t want to leave, I loved getting ready with all of their Korean beauty products and the women who worked there were so kind. I was craving Asian Box after so I drove up to the Marina, paid a little too much for parking, but got an early dinner and then set up at another coffee shop to do more work. The sun was out and it wasn’t too cold and I was visiting my fav parts of the city and just soaking in every moment and feeling so refreshed –
I was thinking today about how lots of people interact with lots of people through their work. The women at the nail salon, the man behind the eclectic counter at the coffee shop, the woman who scrubbed me down at the spa today – they all get little glimpses into people’s lives and interact with a large number of folks every day. It’s kind of like medicine, where you aren’t really sure what kind of impact you make on people but you try anyways, where you’re serving people something they value and you get the chance to try your best over and over again. I know the physician-patient relationship is different but it’s the only one where you get intimate glances into people’s lives nor is it the only kind you get to witness joys. These folks certainly aren’t compensated as well, I wonder how many of them have health insurance and where they go when they get sick
Saturday 3/30
Today was off to a good start. My workout was great and then no traffic on the drive in! I listened to a good podcast today that reminded me about the importance of pausing after we get age, sex, risk factors, and chief complaint in a patient case. Not to linger too long on stereotypes or anything but to remember that those are important pieces of information! The podcast also talked about diagnostic error and “localizing the lesion” when you make a mistake – so true. Most of my diagnostic errors when listening to these case-based podcasts have been due to gaps in knowledge – which I’m working on!
I cut a corner today. I had heard my patient had an episode of chest pain overnight, my intern had filled me in on the big picture and deep down, I KNEW I should have fleshed it out more (OPQRST is the easiest thing and takes like 3 minutes!) when I was in the room but for some reason, I just didn’t. We weren’t all that concerned but still, for my learning and for the possibility that something worse was happening – I should have asked more about it. When I was presenting him, I couldn’t answer a basic question my attending asked about the chest pain. It was a little mortifying, like I have one job with this presentation and I couldn’t do it as well as I had hoped. It’s a learning moment that will stick with me, I don’t want to feel like this again, that I cut a corner I could have and should have done a better job with. I know better than to ignore new complaints. The rest of the presentation actually went really well, the team briefly toyed with the idea of it being a PE but immediately I said he was on anticoagulation so that’d be unlikely and even so, would we change our management? It was exactly the right response and felt good that I knew my patient and knew the situation well enough to have an immediate answer.
After rounds, we visited my patient. He had to go up on his oxygen requirement and the team felt like he might not go home at all if it stayed at that level. I sensed that the conversation wasn’t going well – but in hindsight, how could I expect any conversation like that to go smoothly? We paused for a bit but realized he wasn’t retaining much so we promised to circle back later to give him some space to process. The team was direct but kind. It’s hard to know what to say in these situations. After we left, Jenn wondered how many times he’s had this conversation before – when we were in there, I thought it was sad that we were seeing him towards the end, that we had to be the ones to break this news to him BUT he could have easily heard this spiel from multiple other teams given the number of readmissions he’s had.
We went back to see him later in the day and he had gone down on his oxygen – and was doing just fine! We were shocked but also not that surprised. He’s probably back at his baseline and if he wants to go home, it looks like we’ll able to send him back. He said he worked hard to improve his breathing. I wasn’t convinced this morning that he had much control over his oxygen sats but this afternoon, I’d reconsider my stance on that. He said he’d love to go home, that there’s still some living he has left to do. From my perspective, him going home with his limitations doesn’t seem like all that much of a life BUT I don’t know what his home life is like! I don’t know what kind of joys and loves and prides he has outside of the hospital. But I trust that he knows what’s best for him and I’m hoping that we can get him home soon.
I had some time to chat with the attending and Dr Win was a little confused about our expectations and background as MS3s - he wasn't sure if we were getting much out of the rotation but I assured him that I was learning lots. It’s nice to know that we aren’t the only ones confused about our role here. Liat saying that reading up on your patients as their cases unfold is the best way to learn. We consulted on a patient I had seen two weeks ago when I was on medicine – and he remembered me! I saw a swan-Ganz catheter insertion (and standing around for one hour not really knowing what was going on felt like good practice for surgery lol sos). Jenn wanted to teach because the afternoon was slow, I told her I need frameworks for rheum so she whipped out an amazing vasculitis one and WOW that was beautiful.
At the end of the day, I was reflecting with Jenn about how my goal for this rotation was to pick up patients and improve my presentation skills but I ended up being a white cloud, out of three full call days, I barely got one patient. It sucks but it’s not really in anyone’s control. Instead, to make the most of the rotation, I really had to be present during the day, pay attention and follow clinical reasoning carefully during rounds, be willing to speak up and ask questions, be proactive about following along to see physical exam findings and procedures. I did learn a lot, I didn’t DO as much as I expected to but at least I can look back on these two weeks of cards knowing that I did my best in the circumstances we had, and that I don’t have regrets about not maximizing my learning.
On the way home, I was craving a lil TJs so I made a pit stop. Mom and dad called, they said they had just talked to a friend whose daughter was so rude to her mom and just wrote off all of her advice and their mom had been upset when she talked to my parents. Mom and dad surprised me when they reflected on how nice I am to them and how much it means that I really value their perspective. It made me pause to remember that I have UNREALLY AMAZING parents but that even the best parents can get not-so-great kids, and that one way I can keep expressing my appreciation for them is something I’ve always done. Ugh I love them so much.
Sunday 3/31
Today was light. Not much to preround on. I felt pretty energized during rounds and was able to keep up. We had some interesting cases come in today – a LOT happened right after I left yesterday! The team called me a white cloud bc the whole time I was there, no patients came in and our workload was light but as soon as I left, things sure picked up. It’s also tough because there’s just two residents admitting and holding the cross cover pager which is like unreal now that I know what those concepts are.
After rounds, we visited our new patients. I wish we could have called an interpreter for our Chinese gentleman. Our next guy was really interested in what his physical exam findings meant – that was a good reminder to ask patients if they’d like us to explain along as we discuss their case. Then we saw my patient- I’ve felt something shift in our dynamic. Earlier in the week, we were so convivial and had this light, airy interaction; after we broke the news to him about him not being able to go home, I sensed a wall come up between us. He wasn’t overly defensive, but I felt like he was more guarded around me, and I wonder if he felt safe to say what’s really been going on, knowing that any new symptom or change could be reason we keep him here indefinitely. It felt like we had gone from being on the same side to pushing up against each other in some way. Of course I don’t expect him to keep showing me grace and warmth, especially after our bombshell that we could have better contextualized in his history of repeated admissions but I’m just saying that I felt a little unsettled and unsatisfied by the denouement. Logistically, I’m happy that he’s going home because that’s what he wants but emotionally I haven’t quite caught up.
We saw a case of viral pericarditis which is still wild to me and then took a look at the Swan-Ganz catheter again. I had some one-on-one time with the attending as we walked up to another patient room and I got to ask him a question about preload and afterload that has been bugging me all rotation and he just chuckled and told me I was overthinking it. I went back to see Jenn, there wasn’t anything else I could help with but we talked feedback and how to improve. She said that outstanding med students look for ways to help, they’re present, they make an effort to teach their patients and spend time getting to know them. She gave me a few pearls for how to make my presentations shine. And she encouraged me to speak up more and reminded me that it’s OKAY to be wrong but that I can always “show my work” for partial credit and for individualized feedback on how to tweak my thinking.
I scarfed down my lunch because I was so hungry but then drove home, chatted with mom for a bit. I watched some TV and then went to Marla in the outer Richmond! I got THE most delightful pot of “four flower” tea and then caved and got a lil peanut butter brownie as well and actually got a solid chunk of work done. I might try to do more coffee shop studying right after I finish at the hospital because it worked so well. I went on a short lil run to the beach after, it was a beautiful day and I sure love this lil corner of town. I stopped by Andronico’s on the way back to get my granola (and saw Libby!!) and then filled up my tank and drove home.
xoxo
Juhi
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