General Neurology & Stroke rotation at Boston University Medical Center

I spent the month of October at Boston University Medical Center rotating through both the General Neurology and Stroke services. I worked with several attendings and four of the neurology residents. I also met most of the other residents, all of whom are amazing.

A few great things about the Neurology residency program at BMC include the tremendous diversity of the patient population (i.e. ethnicity, pathology), the large volume of patients who come through the hospital's doors, the camaraderie among the residents, and the incredible support of the program director (PD). She's young, energetic and passionate about teaching and ensuring wellness among the residents. The Department Chair, the PD, and the associate PDs are all incredible and I felt so welcomed and supported by everyone (as well as the Neurology clerkship director and coordinator!).

Rotating at BMC has helped solidify my passion for Neurology. It also pushed me to reach new heights in my training. I'm still on a steep learning curve and I definitely have a long way to go, but I'm grateful for how much I was able to learn within just four short weeks. I honed my neurological exam skills by practicing the basics a thousand times on patients. I became more efficient with seeing consults and presenting the key portions (history, physical exam, and assessment and plan) to the attendings. I improved my ability to read different neuroimaging modalities, including CT scans and MRIs of the brain and vasculature. I enjoyed spending time speaking with patients who did not understand the pathophysiology of their neurologic diseases (i.e. stroke, seizure, etc). It is gratifying to demystify their clinical condition and encourage them to take charge of modifiable risk factors that may have led to the pathology in the first place (i.e. a young man with polysubstance use came in with a first-time seizure; a middle-aged African man with poorly controlled diabetes, hypertension, and hyperlipidemia presented with a stroke, etc).

Interesting cases

I'd like to mention a couple of interesting cases from the General Neurology service during my time at BMC. One unique case (Mr. A) deepened my excitement about Neurology, and another (Mr. B) emphasized for me the vital importance of social work involvement, especially for patients who have particularly complicated social situations. (To ensure HIPAA compliance, personally identifying information has been omitted/changed and certain details of these encounters have been modified to protect the patients and their families).

Mr. A 

A 55-year-old man ("Mr. A") with a history of pancreatic cancer presented to the emergency room with increasing generalized pain and worsening abnormal movements of the left leg. We (Neurology) were consulted shortly after his admission because the primary team was concerned about choreiform movements in the left leg. (Chorea = jerky involuntary movements that can be seen in neurological diseases such as Huntington's). Mr. A reported that the shaking of the leg began several years ago after a knee replacement surgery. 

Picture from here

We noted the shaking during our assessment, but our neurological examination was also remarkable for findings related to cerebellar dysfunction (the cerebellum is a region in the back of the brain that plays an important role in coordination and balance). We noted scanning speech (or "ataxic dysarthria"; his syllables were choppy, and the inflections and rhythm of his voice varied considerably), and frank dysmetria (impaired coordination) with some of our tests, including a finger-to-nose, heel-to-shin, and finger-chase (skip to 0:32-0:40). Because of these concerning findings, we immediately recommended that an MRI of the brain be ordered to take a closer look at the cerebellum. (The MRI later revealed chronic cerebellar atrophy).

Most of the time, Mr. A was very pleasant and cooperative. I looked forward to seeing him every morning during my pre-rounds. Unfortunately though, I often walked into his room right as he started eating breakfast. I tried to time my pre-rounding so that I would see him before the meals usually arrived on his floor, but regardless of the time, they always seemed to get there right before I did. It was unbelievable. "Why are ya'll ALWAYS comin' in here disturbin' my meals?" He barked. "I'm so sorry, Mr. A," I'd tell him. I felt awful, but thankfully I managed to calm him down most of the time. I was also able to convince him to let me ask a few routine questions and perform a quick examination. Then I would hurry off to rounds.

Upon further history taking, Mr. A noted worsening symptoms over the past several months with poor penmanship, inability to hold items stably in his hands, and difficulty walking. He reported first noticing these symptoms shortly after his first cycle of FOLFIRINOX therapy for the pancreatic cancer. Included in this chemotherapy regimen are the drugs: 5-fluorouracil (5-FU), leucovorin, irinotecan, and oxaliplatin. Though extremely rare, the drug 5-fluorouracil (5-FU) can cause an acute cerebellar syndrome (example cases: the first documented case was in the U.S. in 1964; 1996 case in France; 2015 case in India, etc).

We also recommended a lumbar puncture to rule out any potential neuroinflammatory or infectious causes of the cerebellar findings. A lumbar puncture (or "spinal tap") is a procedure in which a needle is inserted between the vertebrae of the lower back to remove some cerebrospinal fluid (the fluid that bathes the brain and spinal cord) for diagnostic testing. Unexpectedly, Mr. A's CSF fluid was positive for the varicella-zoster virus (VZV). This further confounded the clinical picture, and we are not 100% certain if Mr. A's cerebellar dysfunction can be attributed to the 5-fluorouracil in his chemotherapeutic regimen (which the oncology team vehemently disagrees with) or the VZV infection. He was immediately started on anti-viral therapy to treat the infection.

Could Mr. A's cerebellar symptoms possibly be due to the VZV infection? He is a very interesting case! I grew excited to research the effects of 5-FU on the cerebellum (although there isn't much out there, I was initially convinced that this was causing his symptoms) and search for cases of adult VZV infection (without rashes) causing a cerebellar syndrome. There is not a lot in the literature about this! We are continuing to research Mr. A's case.

Mr. B 

Mr. B is a 40-year-old man with the most complex social situation I'd ever encountered in a patient. He presented to the ED after suffering a seizure while riding his bike on the way home from work. After he seized on the concrete ground, he was found to have severe facial injuries, missing front teeth, and a terrible headache. It was such an unfortunate situation. Mr. B was admitted for pain control, brain imaging, and proper arrangement to a safe location upon discharge. He has profound developmental delay and reports neglect and abuse from family at home. Though he has a stable job as a cleaning staff employee at a local school, he had no medical insurance and refused to return home. 

Social work and case management spent days trying to identify a safe location for Mr. B to be sent after discharge. He was medically stable and ready to go, but he claimed that his family was taking advantage of him. My heart went out to him. His circumstances were so unfortunate. He shared with me that he first came to the U.S. from the Caribbean in the late 90s at the age of 20 and was placed in elementary school at that time. He couldn't remember up to which grade he completed. It became clear throughout the course of Mr. B's stay (and particularly after completing a cognitive assessment) that he is very developmentally delayed and would be unable to live a fully independent life without the assistance of others with his medications, financial management, living situation, etc. 

Picture from here

He claimed that his family made him sleep on the floor of the attic for the past two months. He also mentioned that on some days his mother would lock the fridge and fiddle with the pipes somehow, preventing him from eating or drinking any water. Mr. B claimed that he was forced to drink water from the toilet bowl sometimes because he was so thirsty. He also reported that his mother locked him out of the house on a few occasions, forcing him to sleep by the dumpster outside. These abhorrent accounts left me speechless and raging with anger towards his mother. How can a mother treat her child like that? I had to continually tell myself that while this may be true, we only heard one side of the story. We didn't know for sure what was really happening at home.

I worried that things began to look grim when it was discovered that Mr. B had no medical insurance, no group home would take him given his circumstances, and his mother came to the hospital many days after he'd been admitted to insist that he return home with her. We called her number (and several other family members) for days but no one ever picked up. I struggled with disgust towards Mr. B's mother. It was wrong for me to judge her without fully knowing everyone's side of the story.

We all sat down to have a discussion about her son's care and living circumstances. It was decided that his mother would no longer be in charge of administering his medications, and social work would help him identify a new medical guardian. His mother confirmed that her son had been sleeping on the attic floor for the past couple of months. I was surprised to see that she actually seemed a little remorseful. We didn't delve into the other details of neglect and abuse that Mr. B shared with us, although to be honest I wish we had. 

Mr. B was discharged that same day. Unfortunately, social work could not identify a location other than his home. He is there for now, but we are hoping that his previous social worker can help him find a more permanent home situation.

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Neurology Intensive Care Unit Reflections

When I returned from Japan in early July, I spent July & August studying for Step 2 CK and CS, and I just completed my Sub-Internship ICU month in the NeuroICU this September. I flew to Philly this past weekend for a scholarship retreat, and I am currently in Boston for a stroke away rotation at Boston University Medical Center.

Residency applications were submitted on September 15, and we're in the process of hearing back from programs about interview invitations! It is both a nerve-wracking and exciting time.

NeuroICU reflections

I wanted to briefly recount a few interesting patient encounters I had while in the NeuroICU last month that taught me so much about the sacredness of life. (Personally identifying information and certain details of these encounters have been changed to protect the patients and their families. Real names have been changed).

Adam

Photo from here

Our team took care of a 35-year-old man (let's call him "Adam") who suffered a traumatic brain injury. He had fallen off a ladder and hit his head on the day that he was opening a new business. Shortly after the fall, he got into his car and began driving. He crashed the vehicle and was immediately brought to the emergency room by the police. Upon further investigation by the police, blood was found on the ground nearby the ladder at his new business. He likely suffered an epidural bleed into his brain. We assumed that he was driving to the emergency room but no one was with him when this happened, so no one knows if that was indeed where he was going. We also reasoned that the car accident resulted from loss of consciousness or a seizure. Unfortunately, the accident worsened the initial head injury that he suffered.

Not a day went by without a family member in Adam's room. They were religious and prayed regularly at his bedside. Unfortunately, Adam's condition did not improve significantly throughout the 3.5 weeks that he was in the ICU. All of the attendings did not think he was going to make it, but the family wanted us to move forward with every intervention indicated (including a feeding tube, breathing tube, etc). We found ourselves walking on tiptoes when speaking with the family, because for any extremely small improvement in the patient's condition (i.e. the presence of corneal reflexes or a gag reflex on neurologic exam) they believed that meant he was getting much better. He was not opening his eyes, following commands, or showing any sign that he could hear us, even after we minimized the sedation he was under. "Can we take out the breathing tube today?" "Does the corneal reflex mean he will open his eyes tomorrow?" "Is he getting better Doctor?" were questions we got every single day. We were very careful to not give false hope and instead emphasize that it may be a very long process before seeing any improvement, if any at all.

Adam has been transferred to another facility for further care. My heart goes out to him and his family. Who knows, maybe he will make a miraculous recovery and prove all of us wrong.

Walter

"Walter" was a 57-year-old man with a history of lung cancer who suffered a massive stroke. He had an 80-pack year smoking history (40 years x 2 packs/day) and was diagnosed with cancer only a few months before the stroke. The cause of the stroke was likely due to his lung cancer (hypercoagulable state of malignancy). It left him debilitated, completely aphasic (he couldn't speak at all), and unable to care for himself. I visited him every morning during pre-rounds and rounds, spoke with his family about his hospital course, and became very invested in his care. He did not understand what was going on around him (he had expressive and receptive aphasia, could not follow simple commands, and did not verbally respond to our questions). His ocean blue eyes simply stared at you. Our attending soon mentioned during rounds that it was important to have a serious discussion with the family about the very small chance of any meaningful recovery given the severity of Walter's stroke. I didn't know who Walter was before the stroke, but after hearing more about the person he was from his family during a Palliative Care meeting, it took a lot for me to hold back tears as they decided it would have been Walter's wish to transition to comfort care.

He loved life and experiencing new adventures. He was only 57-years-old!! He was nearly my own father's age. I couldn't imagine what his family was going through. It is so difficult to witness the death of patients we grow close to. I believe that it is okay for healthcare providers to get emotional and accept that sometimes things are completely out of our control. The best we can do is lend compassion and a listening ear to patients and their families during these times of immense pain and grief.

Brian

"Brian" is a 26-year-old guy who was hit in the head with a bowling ball. Yes, you read that correctly. A BOWLING BALL. This was such a jarring case. When I shared this story with my sister she scolded me for not leading with the fact that the patient recovered fully and did extremely well afterward. So there you go, I'm leading with that now. Brian did not die. He was in a bowling alley with friends and suddenly got into an altercation with another guy after they bumped into each other. I don't know the details, but shortly after the start of the altercation, the other guy grabbed a bowling ball, lifted it in the air, and brought it down with full force to Brian's head. Dear God. Yeah, that was my reaction too. Again, no one really knew the details of the fight, but NOTHING would warrant the blow to the head that Brian suffered. I believe that the idiot was caught and tried to the full extent of the law. 

When I went into Brian's room one morning during my pre-rounds, he was surrounded by scared family members, including his mother and sister who had a number of questions about his recovery. I gently explained the findings on his CT scan of the brain (he suffered a fracture and a little bit of bleeding below the skull), the medications he was receiving for pain control, and why we were monitoring him for seizure activity with an EEG (electroencephalogram). Just a couple of days into his stay in our ICU, Brian recovered tremendously and was able to walk around the unit with the physical therapist. I was so happy to see his improvement! He is doing well today.

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Thanks for reading this entry! There will be more to come shortly, including updates on my stay in Boston and the Neurology residency interview trail :)

RIKEN Center for Brain Science in Japan

RIKEN Center for Brain Science
(There are many more buildings on the campus)
Photo from here

I spent this past week in Japan for a one-week summer lecture course through the RIKEN Center for Brain Science. They hold both a one-week lecture course and internship course every summer for students from all across the globe. For the students in the one-week lecture course, we were provided with most expenses covered by the organization. (I learned that they also receive support from IBRO, the International Brain Research Organization headquartered in Paris). These expenses included hotel accommodations and transportation (to and from Tokyo, and to the hotel).

This was an invaluable experience and I’m beyond grateful for this opportunity to travel to Japan to present my research, learn about the research that other young and established neuroscientists are working on across the globe, and explore a little bit of Japan during the first week of July. I was one of 2 medical students selected for this program (2 students were obtaining Master’s degrees and the remaining 28 students were in PhD programs). I presented the work that I’ve been doing with an epileptologist at my school through the Loyola University Medical Center. We have been elucidating the neuropsychiatric side effects of perampanel (fycompa), a second-line anti-epileptic medication for patients with focal and secondarily generalized tonic-clonic seizures.

The lecturers selected for the summer course are well-known neuroscientists from all across the globe. For example, we heard from the PI (principal investigator) of a lab in Israel who was the first to discover hippocampal space cells in bats in his efforts to understand the neural basis of behavior. Another PI at the RIKEN Center for Brain Science developed a number of technologies (fluorescent probes) that are widely used in a number of other labs in order to investigate the functions of specific signaling mechanisms implicated in various neurological disorders, such as Parkinson’s and Alzheimer’s.

Again, I can’t express enough thanks to RIKEN and IBRO for creating this opportunity for students around the world.

Okay, now I’ll discuss a few things regarding the differences between Japan and the U.S., and one unexpected stressful event that I encountered on my journey to and from Tokyo. Everything ended up working out though, thankfully.

A few differences between Japan and the U.S.

These are a few differences that were salient to me and that I can think of off the top of my head. I’m sure I’m probably missing a few other big ones, so if you are familiar with Japanese (and U.S.) culture, please feel free to add!

Everything is TINY. And I mean everything: the meal portion sizes, the cups, the hotel rooms (well, at least the ones we stayed in), the soda cans (see to the right), the snacks…. I’m used to everything being so big in the US. I remember on my flight from Shanghai to Tokyo, I was served a cup of water that was literally half (or even a third) of the cup size that is typically served on domestic U.S. flights. I remember staring at the cup for a while, then finishing the water in two gulps.

·       There is quite a bit of strictness in Japanese culture. A couple of big examples are the signs up in the subways that say “No running” and instructions for people to form lines before getting on the train. Needless to say, this is very different from how things are done in the New York subway system, for example. No one forms lines to get on the train. You just get on. And people are running all the time. (People were running in Japan too, but not as many as you would see here in the states).

·       The toilets are high-tech. I have never seen toilets like this before. I did not touch any of the buttons during the first part of my stay because I had no idea what they meant, but after hearing some of the other students talk about the features, I decided to try it out for myself. These toilets are unique because you can press buttons that will essentially squirt water into your private areas once you are finished using the bathroom. This “cleaning” option is different for men and women, and can be adjusted to fit your own anatomy. There is also a drying feature.

·       Japanese food has a much milder taste than American food in general. We love to douse our meals in salt, pepper, sugar, and other spices. Japanese seasonings and flavors tend to be more moderate. Overall the meals are healthy!

·       Bowing down. In Japanese culture it is commonplace to bow down to someone else out of respect, especially for greetings or expressing thanks. You may see a slight nod of the head, but more often people will bend at the waist. The most common phrases/words that I have learned were:

• Hello - Kon'nichiwa
• Good Morning - Ohayō gozaimasu (O-HI-OH GO-ZAY-MAS)
• Thank you - Arigatō gozaimasu
• Do you understand English? – Eego wakarimasuka? (EGO WA-KA-REE-MAS-KA) which I only used once. I felt that it might’ve been rude to ask someone that, but it was a recommended phrase to learn in a youtube video that I watched.

Flying into Shanghai

Stressful events during the journey
When I left Chicago, I flew first into Shanghai. I had a 13-hour layover there. Upon arrival, I was told that I could not check in for my next flight to Tokyo until the following day. One of the airport workers recommended that I check in to a hotel 15 minutes away from the airport. The stay would only cost $40. I agreed. Once I arrived and checked into the hotel, I realized with horror that I forgot to pick up my poster tube at the baggage claim. It contained my research poster for the poster session at the conference. We'd been instructed a million times through e-mail to bring it with us. China Eastern did not allow me to take it onto the flight because it would take up too much space in the overhead bins, so I was asked to check it as a second luggage (free of cost).

I was not used to traveling with anything other than my regular suitcase and my large Vera Bradley carry-on bag which I take everywhere with me, so it completely slipped my mind to pick up the tube. I tried to connect to the hotel’s WiFi to call the airline free of charge on my g-mail account. I wanted to confirm that they had my poster tube and that I could pick it up the following day when I returned to the airport. The WiFi didn’t work at all for me, and I was without service, so I rushed to the front desk of the hotel and asked if I could call the airline on their telephone.

The woman couldn’t understand a word I was saying. I don’t speak Mandarin, and she basically didn’t speak much English. We ended up using a translator app on her phone. When I asked if we could look up the number for the airline on her cellphone, she said through the translator app, “I don’t know how.” That was her answer to most of my questions. I tried not to grow frustrated with her. My immediate thoughts were, “Just look it up on Google!!” (I did not remember until my journey back that mainland China essentially blocks the use of everything on people’s personal electronic devices, including Google. Yahoo works, though. However, most people override this block by connecting to special VPN apps, but I wasn’t sure if this woman knew how to do that).

Eventually, we obtained the number (I'm not sure how), but I ended up waiting for a very long time on the phone. No one picked up.

“Sorry,” the woman said, hanging up the phone for me. “Try tomorrow when go back to airport.”

I agreed. I was growing tired anyway. The 14-hour flight from Chicago took a lot out of me. “Xièxiè [thank you],” I told her. 

At the airport the following day, things became even more stressful because of the language barrier. I first stopped by a China Eastern customer service desk and asked where I could speak with someone about the poster tube I accidentally left on the baggage claim yesterday. They sent me down to the first floor.

I went down to the first floor and stopped by another service desk. The woman told me to go back up to the third floor. I said, “No, I’m sorry, I was told to come down here.” I noticed that the China Eastern baggage office was located on this floor as well, but there was security that prevented me from going over to that area of the airport. 

I tried to explain my situation once more to the woman, who said I needed a boarding pass before I could pass through security on this floor and speak with the baggage claim office.

So I went back upstairs, waited in line for 45 minutes to check in to my flight to Tokyo, and asked the man who checked me in about the poster tube that I left behind yesterday. Guess what he did? He sent me downstairs.

I went back downstairs to the same desk, and told the woman that I obtained my boarding pass and was sent down here by a worker upstairs. She told me to go back upstairs and speak with another help desk. "I call the office already and they no pick up. You go upstairs and speak to desk there."

By this time I grew very frustrated. I felt that no one was trying to help me, and it seemed like everyone’s goal was to simply get rid of me and pawn me off to someone else. I had had enough, but I remained calm even though I was churning with agitation on the inside.

To make things worse, the woman at the service desk on the first floor made no effort to hide her own annoyance with me. She demonstrated the worst attitude that I’d ever encountered in any customer service professional. I was shocked by her rudeness; I’d done nothing to deserve it. I was the one who should have been irritated because no one was helping me! This whole situation had been a colossal waste of time, and boarding time for my flight to Tokyo was quickly approaching. I really needed my poster for the conference.

After the woman sent me back upstairs I ignored her instructions and walked directly up to one of the security guards to request entry into the baggage claim area. I wanted to speak with someone in the office. The security guard told me to wait a moment, so I nodded and stood off to the side as he continued screening the IDs of airport staff through this "Staff Only" entry. After 10 minutes of waiting and no communication from the security guard (not even a glance), I realized that he had no intention of helping me. “Are you kidding me?!” I wanted to scream. I glanced at my watch. 15 minutes until boarding time.

I went back to the service desk to once again ask the woman if there was any way possible that I could speak with someone in the baggage claim office. She called the office, finally reached someone, and this individual met me in person with my poster tube. FINALLY.

If I spoke fluent Mandarin none of this would’ve happened, I can tell you that. However, you’d expect that workers in an international airport (which receives millions of overseas passengers every year) would have a stronger command of the English language.

~*~*~

I think I will end with this story. I’m grateful that everything ended up working out in the end.

I never thought I’d say that I’m actually looking forward to returning to Chicago to study for my board exams.

Thanks so much for reading!!

Visiting family in Jamaica

I spent five days in Jamaica at the end of June visiting my mother’s side of the family. My mother grew up in Spur Tree, a rural community in the parish of Manchester. This trip was a wonderful opportunity to spend time with the family (including my grandmother, great-aunts, great-uncles, and family friends), learn more about our rich history, and be immersed in the culture while living in the community for a few days.

Diagnosing family members

The MCP and PIP joints are classically affected in
rheumatoid arthritis. Photo from here

While there, my great-aunts and uncles continued to express how proud they were of me for pursuing a medical degree. I found myself inadvertently making diagnoses left and right, which was especially easy to do coming off the Family Medicine clerkship. My aunt came to me first with complaints about joint pain in her hands. Upon further questioning, the history seemed to fit the description of rheumatoid arthritis, with the pain most prominent in the proximal interphalangeal (PIP) and metacarpophalangeal (MCP) joints. She also demonstrated slight ulnar deviation of the MCP joints (her hands tended to fan outwards away from her body). See photo below.

Ulnar deviation of the MCP joints in rheumatoid arthritis.
Photo from here

I recommended that she take a non-inflammatory medication like ibuprofen for the pain and encouraged her to see a physician in the town for a more thorough evaluation. She refused to see a “Jamaican” physician and preferred to wait until her next trip back to New York to see her physician there. I also noticed that a couple of my uncles had the classic Bouchard and Heberden nodes of osteoarthritis in the PIP and distal interphalangeal (DIP) joints of both hands. 

Photo from here

I didn’t think it was appropriate to bring it up out of the blue (“Oh by the way Uncle so and so, your hands are looking a bit mangled these days.”) They have upcoming visits with their physicians and hopefully will have these concerns addressed then.

One of my family members also expressed having a poor appetite for the past couple of weeks. This has also been in the context of a few significant stressors so I immediately became concerned about possible depression. I’d completed a number of PHQ-9 (Personal Health Questionnaire) depression screenings in the Family Medicine clinic recently, and poor appetite is a symptom to look out for as having occurred in the past couple of weeks. The next day I gently mentioned the poor appetite to my family member, and upon further discussion I was no longer concerned about depression. It certainly helps that this family member is surrounded by wonderful family and friends, which are protective factors.

There was another random instance when my mind began churning with concern over a situation that occurred years ago. During dinner one day, my aunt shared a story about our cousin who gave birth to her first child a number of years ago. In the two days following the birth, she suffered from an awful headache. I immediately thought of a possible bleed (post-partum hemorrhage) in the brain, though she did not suffer severe symptoms (according to my aunt), and the headache eventually resolved. I was so surprised that she never paid a visit to the emergency room for further evaluation.

The Baker family history (brief)

Anyway, let's stop the medical talk and move on to my family's interesting history. To the right is my legendary great-grandmother, Mrs. Frances Ernestina (“Miss Tina”) Baker (also known as “Mama” to her descendants), born September 1, 1904 in rural Nuttingham, Manchester, Jamaica, and passed away at the age of 107 in August 2012. Everyone in the community knew and respected her. She was a powerful matriarch who gave birth to and raised 10 children. She also raised four grandchildren, including my mother. I’m grateful to have met my great-grandmother in her 90s when I was younger.

It’s incredible to hear of her story from my aunts and uncles as they share their memories of growing up with her. Mama was a strong disciplinarian; she did not mess around. You knew not to cross her, or else you would get whipped with whatever she could get her hands on (usually a stick haha). My aunts and uncles have an abundance of stories about her scary beatings. But you know what? (And I know not everyone will agree with this) – Those beatings helped build their character and whipped them (literally) right into shape. I honestly believe that many children are not disciplined enough growing up, and as adults they are more likely to run amuck and get involved in catastrophic situations. (I’m speaking specifically about American children from what I’ve seen in my own experience growing up in the school system here).

My mother's elementary school: Fairfield Primary School
in Manchester, Jamaica

I visited Mama’s birthplace and her parents’ (my great-great grandparents’) burial ground in Nuttingham, as well as her own burial ground at the Ebenezer United Church where my mother, aunts, uncles, and cousins attended every Sunday as children. I also visited the elementary school and high school that my mother attended.

It has been incredible to experience the cultural context in which my mother was raised. It is nothing like the cushy, comfortable lifestyle that tourists may experience at the resorts near the beaches in Montego Bay or Negril, for example. When I told my friends and colleagues that I was going to (or recently returned from) Jamaica, the beaches must’ve been what they imagined. I’ll tell you this – that is not "real" Jamaica at all. The last time I visited family in Mandeville, Jamaica was 6 years ago. This time around, I admit I again experienced a little bit of a “culture shock” especially with regards to:

·    the bathing (there is no hot water from the spigot so you need to boil the water and mix it with the cold water in a basin to bathe)

·    driving on the roads (it almost seems like a free-for-all out there; on some of the roads in Mandeville there is no clear single or double solid line separating the left and right sides), and

·    the walks through the marketplace in Mandeville (some people will stare at you and automatically identify you as a foreigner; it doesn’t matter if you’re black and haven’t said a word for them to hear that you don't speak patois).

During my layover in Fort Lauderdale, FL on my way back from Kingston, I had a long chat with my mother on the phone. She mentioned that she wouldn’t trade her upbringing for anything in the world, not even for the upbringing of her kids. My siblings and I, born and raised in the U.S., grew up more privileged than our parents. We didn’t have a lot growing up to begin with, but my parents grew up with even less, especially my mother. My mom was raised in the 60s and 70s in rural Jamaica without electricity (they did everything by candlelight in the early mornings and late evenings), plumbing (they used outhouses and bathed in a big metal tub), telephones, or cars (they walked everywhere, including to school and church (which were 4 and 5 miles away from home, respectively). My mother loved it and hopes to return to her home and spend the rest of her life there.

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Thank you for reading!!

Final third year clerkship reflections (Pediatrics, Family Medicine)

Photo from here

I completed my third year of medical school last Friday! I'm so grateful to have made it through the year. What a journey!

The morning after my Family Medicine final exam (on Friday) I flew to Jamaica to visit my extended family and I am here currently. I will post another entry about this trip later.

My final two clerkships of the year were Pediatrics and Family Medicine. Here are a few quick reflections on salient experiences during each rotation:




Pediatrics

During my Pediatrics rotation, I completed 2 weeks of inpatient, 1 week of nursery, and 3 weeks of outpatient. 

Photo from here

While on inpatient, we had a couple of interesting cases, such as a 10-year-old girl who came in with chest pain of a non-traumatic etiology (which you rarely see in a child) and a 1-year-old boy who had eaten some callus remover cream that was left by his crib on a tall bookshelf since before he was born. (Both turned out completely fine).

I enjoyed my outpatient experience, but to be honest I absolutely hated the drive. The clinic was located in Chicago nearby Lake Michigan. It took me at least an hour 15 minutes to get there in the mornings (during rush hour), and it would take at least that long to go back home (during rush hour again). That hour and 15 minutes could have been spent at home studying. On my final evaluation of the experience, I recommended that this site be offered as an option only to those who actually live in the city. Otherwise it's truly a hassle and stressful inconvenience for those living in the suburbs.

Photo from here
The poor baby's rash looked a bit worse

During my second week of outpatient, I had one experience that taught me the importance of confidence during patient encounters. A 6 month-old boy came in with his parents who were freaking out (more so the mom) about this terrible, ugly rash all over his body. It was dark red, blotchy, mostly in the neck region, but also in the popliteal (back of knee) and antecubital (in front of elbow) fossas. The baby was as happy as can be, smiling, playful, and looking up at me with curious eyes, but the mom continued to freak out. By the end of my questioning I couldn't quite pinpoint why the baby's rash looked so terrible. They tried using a number of different ointments and creams, but none of them worked and they must have worsened the appearance of the rash. The mother suddenly straight up asked me, “What do YOU think this is?” So, sucking at peds derm, and not knowing what this was, I piggy-backed off of what the ED (emergency department) docs said when the patient first presented to the ED a week ago. It was a candidal infection. My attending confirmed this, and we prescribed an anti-fungal ointment.

I was hard on myself after this encounter. I mentioned the ER doctor's note but ended up deferring profusely to my attending because I had no idea what this rash was. (On the Step 2 CS boards exam we simply cannot defer to a superior or we will fail. In real life as an attending you also obviously cannot defer, so I've been trying hard these last rotations to stop doing it often). In a lot of cases, however, I feel that I speak intelligently to patients and share my knowledge and understanding of their concerns. I will, however, continue to defer to superiors if I have no idea what the answer is. I guess the big message here is that I need to stop doing it eventually. Once we are attendings we can’t defer to anyone (except maybe another specialist).

Family Medicine

While on Family, I completed 6 weeks at another site about 15-20 minutes away. This was my best rotation for the entire year. I'm not kidding. What a great way to end the year. The attendings and residents (and even the medical assistants!) were passionate about teaching, and they always seemed excited to have me there. Excited to have ME, a lowly med student. I truly felt valued on this rotation. It seemed that the friendliness of the teams improved throughout the year, and I could feel myself becoming happier as I moved from one rotation to the next. (I had Surgery first and ended with Family).

We saw a number of super interesting encounters, many of which I documented in a required "critical incidents log" due at the end of the rotation. Our clerkship director wanted us to jot down a couple of sentences of reflection for a couple of salient experiences each week. I couldn't help myself and documented paragraphs for each encounter. If I am asked to reflect on something I take that seriously. This whole blog is a reflection in itself.

I will just mention one of these encounters here:

One day a 40-year-old woman with a history of autoimmune hepatitis came in for a follow-up after starting a new medication that her hepatologist prescribed. Initially, she was prescribed something else, but that medication caused her to experience violent nausea and vomiting. She was then switched to this new medication, but the day after starting it, she began to complain of bleeding from multiple orifices - her left eye became bloodshot red (which prompted her to see an ophthalmologist that same day), she had a few nosebleeds, and she was experiencing bloody stools. Her primary doctor (the PGY3 resident I was working with) instructed her to stop the medication, but her hepatologist told her to continue taking it. She and her husband were confused. Feeling strongly that the medication was causing her to bleed, they heeded the resident’s advice instead and stopped the treatment. Immediately the day after she stopped it, the symptoms disappeared.

Doctor ignoring patient
Photo from here

Her hepatologist continues to insist that the medication was not causing the bleeding. The patient had been seeing this hepatologist for a long time, but she and her husband were growing frustrated with his care. After every visit with him, they left his office confused and unsure about what was even discussed. The patient also mentioned that she feels more clarity about her autoimmune hepatitis after her visits with the family medicine resident than with the hepatologist himself. By the end of this visit, I grew angry for the patient (maybe even angrier than she was). We all agreed that the hepatologist’s quality of care was terrible. His communication with the patient was poor. During their visits, he barely looked at her and her husband. He proceeded with a number of lab tests and workup without even clearly explaining to the patient what he was doing and why he was doing it.

By the end of the visit, I was more than annoyed with this specialist after hearing about what he put the patient through. When the family medicine resident spoke with one of the attendings about this case, the attending mentioned that physicians should never forget the three A’s: availability, affability, and ability. Medicine isn’t just about doing tests and diagnosing patients. It is a human profession. We need to know how to carefully, articulately and compassionately communicate with our patients. In my opinion, if any physician is not doing this, quite frankly he/she should not be in medicine. It does not matter how much knowledge they carry. The knowledge is important, of course. I am not minimizing that. I believe, however, that it is more important to have interpersonal skills and to take care to communicate with patients in such a way that they understand the next steps in their care.

This was my most recent salient encounter in Family Medicine and it left an indelible mark on me as I progress through my training.

Thank you for reading! :)