Essay by Carla Carlson
In an episode of the popular medical TV series “Scrubs,” J.D., an up and coming doctor, comes to view his mentor Dr. Cox as a superhero. Wearing his imaginary superhero cape, Dr. Cox struts around the hospital saving lives until a series of unfortunate oversights leads to a patient’s death. At that moment J.D. sees Dr. Cox for who he is, a doctor. At the beginning of this summer I had little experience into the world of practicing medicine outside shadowing a doctor for the Patient, Doctor, and Society class. Consequently, most of my experiences with doctors have come as a patient, and like J.D. I thought of doctors as superheroes who knew the answer and treatment for every ailment. However, throughout the course of my summer externship working with Dr. A., I began to realize what it really meant to be a family doctor. Everyday that I went in for clinic was like a “Scrubs” episode where I learned a valuable lesson about myself and the specialty of family medicine that will facilitate me when I become a practicing physician.
Episode One: Time is not an Issue
One of the preconceived notions that I had entering my summer externship was that doctors had many patients during the day and thus had little time with each patient besides figuring out what is wrong and treating it. This summer proved that notion wrong. I was so amazed with the personal time Dr. A. spent with each patient. Even before seeing what brought the patients in, he would catch up with them on what’s going on in their lives, how their families were doing, and even telling occasional jokes. It was like watching old friends shooting the hay over a cup of coffee. At first I would get nervous that we would run out of time to do the physical exam and other tests needed, but it wasn’t until a man came in complaining of shortness of breath did I realize why Dr. A. spent so much time chatting with patients. The patient who came into see Dr. A. had seen several specialty doctors with no avail about why he was having this problem, but before Dr. A. asked him about these other doctor visits Dr. A. asked him about how his home life was, his friends, his job, etc. The answers Dr. A. received back from the patient were very telling that this man was depressed and anxious. When investigating even further, Dr. A. found that the man had previously been on medication for anxiety and depression but had recently gone off of them. Finally after spending some time talking to the patient Dr. A. did some breathing tests in which the patient passed with flying colors. From these results Dr. A. decided that the reason for the man’s shortness of breath was that he had gone off his medication and proceeded to put him back on it. Had Dr. A. not took the time to chat with the patient he probably would have missed this diagnosis and sent the man to see another specialist. After that encounter I realized how important it is to not just have a differential check-off list in my head to get through, but to first just converse with the patient to get the broad spectrum of the patient’s life. When talking to Dr. A. about the case he told me that most of his diagnoses are made even before the patient sits on the table. Therefore, I learned that in family medicine talking and spending time with a patient is just as valuable as physical exam skill and diagnostic tests.
Episode Two: Family Doctors are Advocates for their Patients
Being a family doctor means that one encounters a wide range in ages and types of patients in their practice. In as much, when each patient would come into the clinic, Dr. A. would try to tailor his treatment to best serve the patient’s situation and need. However, from my experience this summer the most vulnerable patients are arguably in the elder population and those who are uninsured. With the hassles of Medicare and secondary insurance rules, many of these patients are left confused about their healthcare and how they will receive it. Time after time patients would come in confused about what type of medication their insurance would cover, and time after time, Dr. A. would patiently explain what medications would come in generics and where they could go and how to get it the cheapest. On numerous occasions patients would bring in letters from the insurance and drug companies and Dr. A. would read it and help them sort it all out. From these encounters I saw that family medicine means doing everything one can to provide the most complete and appropriate care, which sometimes means going out of one’s way.
Episode Three: No Sleep for the Weary
Rounds began at 7:30 a.m., clinic at 9 a.m., and rounds again after clinic five to six days a week plus being on call several times a month is the schedule the family doctors at the clinic followed this summer. Before beginning the summer externship I only had a slight idea of all the time that family doctors spent practicing. I was a little intimidated when I found out about Dr. A.’s schedule, but my first time on rounds I realized the importance of continuity of care that family physicians are able to provide which comes at the cost of long hours. There were multiple times this summer where a patient would come into the clinic and their condition would be serious enough where Dr. A. would have to admit them. Then throughout the day from the clinic he would receive updates from the hospital and after clinic was over he would go and check on them to see how they were doing. Then the next morning he would go and check on them again for morning rounds. I felt that by working with Dr. A. and seeing how grateful the patients and their family were to have the doctor continually checking up on them made all the long hours worthwhile. In this way I learned that family physicians are selfless and are willing to go to any lengths and spend any amount of time in order to insure great quality of care for their patients.
Episode Four: Horses instead of Zebras
When sitting in class during physiology and anatomy my first year of medical school, I learned many of the extreme diseases that would disturb the functioning of a given cell/organ in the way that would describe how the cell/organ worked. However, most of these extreme diseases used are rare and usually do not present in a family clinic setting. Still, even though I knew these diseases were rare, whenever a patient would come into the clinic this summer I would find myself “diagnosing” them with these rare diseases even if they only had a few symptoms similar. An example of this is when a patient presented with extreme thirst and urinary frequency. My mind immediately jumped to diabetes insipidus. When I presented my diagnosis to Dr. A. he proceeded to tell me the phrase “horses instead of zebras” and at that moment I knew he was thinking the patient had diabetes mellitus, a more likely cause of the symptoms. Over the course of the externship Dr. A. would repeat this phrase several times and he would work with me to come up with the most common cause. In spite of this, we did have some “zebras” this summer and when the most likely cause was not the reason for the symptoms we would refer the patient to the appropriate specialist. I feel this was a valuable lesson to learn as a student participating in a family medicine clinic because when a patient gets sick a family doctor is usually the first person the patient will see, and it would not be beneficial to the patient or the health care community if the patient underwent tests and received treatment that they really didn’t need. In this way, I learned that family doctors have a role of being sort of a gatekeeper in order to ensure patients receive the correct care for their ailment whether it is from the family doctors themselves or from other specialty doctors.
Episode Five: Family Doctors treat Families
The idea that family doctors treat families seems obvious but I didn’t expect to see so many people from one family during the course of the summer. One week a husband would come with his wife to a visit and the next week we would see him for a routine physical and then the week after their children would come in for sports physicals. Many times I would see a last name on the chart of a patient we were about to see and I would think that we have already seen that patient this summer but it would end up being a relative. By working with families, I think family doctors have an advantage in treating their patients because if a problem is affecting one patient it may be affecting others in their family or just getting to know members in the family helps the doctor better communicate and relate to their patients. I saw this in my summer externship when treating a couple with three children. The couple had been in by themselves both for physicals, and had been in several times for well-child checks for their children. With the last well-child check of their daughter, even I felt like I knew the family. Unfortunately after coming back to clinic after one weekend Dr. A. and I found out that the couple’s newborn baby had died from SIDS. It was a devastating loss to both Dr. A. and the whole clinic staff, but because Dr. A. had this relationship with the family, it will be easier in the upcoming visits to talk with the family not only about what brings them in, but they will be able to confide in him with how they are doing emotionally and mentally. From this summer externship I learned of the valuable advantage that family doctors have by treating families.
Episode Six: Anyone, Everyone, and Anything
The most fun thing I learned this summer is that family doctors get to treat everyone and everything. This summer I saw acute conditions such as having to put in stitches, doing in office vasectomies, treating hives, cutting out sebaceous cysts, caring for colds and allergies, giving children their booster shots, figuring out mysterious rashes and bug bits, and pretty much anything one could think of. However, with all the acute conditions most of the patients we saw this summer were being treated for chronic conditions such as diabetes, hypertension, hyperlipidemia, heart disease, asthma etc. The great part about treating patients with chronic conditions is that family doctors have terrific opportunities to try and help their patients with lifestyle changes in order to try and help and even reverse their conditions. It was so exciting to have patients come in who quit smoking or lost weight and were so proud of their accomplishments. Additionally, this summer I saw every age from babies being brought in for well-childhood checks to visiting elderly patients at the nursing home. I also saw every personality and type of patient from serious to funny and from blue collar to white collar. Everyone was equally represented. From this summer externship I learned that family doctors are versatile in handling any type and every type of cases and there is never a dull moment that goes by in the clinic.
Like the season finale of “Scrubs” ends the show for the year, my summer externship ended my clinical experience until next summer’s rotations, and like a season’s worth of lessons learned, I feel like I learned much about the world of family medicine. I know there is much more to learn, but I feel grateful that I was given the opportunity to work with Dr. A. and all the staff at the clinic. Additionally, I’m glad that I learned that it’s okay not to be a superhero but instead to be what we should be, a doctor. Dr. A. told me that a good family doctor “knows what they don’t know”. Thus a good doctor is NOT a superhero who knows everything. Yeah, when I’m a family doctor I’m going to know most of what comes into the clinic, but when a patient comes in with something I’m not sure of what it is I can send them to see someone who does. Therefore, I can truly say that by participating in this summer externship I have learned valuable lessons into what it means to be a family doctor.
Essay by Bethany Hyduke
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The names of the patients in this essay have been changed in order to protect their privacy.
My first year of medical school was demanding to put it lightly. I was prepared for the intellectual challenge, but there was nothing to prepare me for the emotional exhaustion I felt by spring semester. When I thought about how I wanted to spend my last summer vacation, I knew back then that it needed to be in a way that would get my head out of books. What I didn’t realize when I applied for a WAFP summer externship, was that I would be reminded about why I love medicine. A year of challenging myself beyond what I could imagine mentally, left me feeling defeated, and as much as I hate to admit it, jaded. I felt fortunate and very grateful to be granted an externship. I had a strong feeling that spending a summer with a family practice doctor would be a great learning experience and was confident that it would allow me to see a broad range of people, all with unique stories and medical concerns. Most of all, I was thirsty for time with people. As I reflect back on the experience, I can confidently say that my externship with Dr. Maurer went far beyond all of my hopes.
On the third day of my externship I met Carla, a woman who was 40 weeks pregnant. I stood over to the side of the room listening to Dr. Maurer discuss her pregnancy with her. They discussed her gestational diabetes which was found a few months earlier. “You are still controlled with diet alone, that’s great,” Dr. Maurer congratulated. It was clear to me as they talked how much the patient trusted and adored her doctor, that the two women shared a unique bond. Carla listened intently to every word, this wasn’t her first pregnancy, but it was the first of her children that Dr. Maurer would deliver. We all laughed as she told us about her husband whose excitement was increasing daily, he wanted to help during the delivery. We reviewed the reasons for her to call Dr. Maurer, listened to the baby’s heartbeat, and then sent the expecting mother on her way.
Three short days later, I received an early morning phone call that Carla had gone into labor. Given my limited exposure clinically, it isn’t surprising that this would be my first time witnessing a baby’s birth and I was excited. By the time we got to the hospital, she was fully dilated and the labor had fully progressed. I met her husband, John, who greeted us wearing a baseball glove, joking that he was going to catch is soon-to-be born daughter. His joking stopped as soon as Carla groaned in pain, when he went over to his wife, reached around and massaged her back through the rest of the contraction. He clearly loved joking, but also took his role seriously and coached her breathing. After changing into scrubs, we checked the heart rate monitors, and Dr. Maurer taught me how to watch the computer screens for accelerations or decelerations in the baby’s heartbeat.
Soon we were called back into Carla’s birthing room and things began moving quickly. A large table appeared out of nowhere with instruments under a sterile drape. A nurse broke apart her bed so that the bottom of the bed disappeared and Carla’s legs were placed in plastic stirrups and then turned to me asking what glove size I wore. A wave of panic came over to me when I realized I might be expected to do more than watch but I was directed to stand over the shoulder of a resident who would also be helping us. In that place I would be able to see and hear everything. Now, Dr. Maurer was teaching again, walking the resident through the maneuvers and her preferred approach. Carla continued to push through her contractions and in what felt like only moments later, the baby’s head became visible. John rose to new levels of excitement, talking to his unborn daughter and encouraging his wife to keep pushing. “I can’t believe you guys get to do this all the time,” he spoke to us, “You must love your jobs!” We smiled from beneath our surgical masks. After a few more minutes of pushing, in one very fast moment, a baby’s face and body were visible and her cry filled the air. Clamps, suction and towels flew through the air, and a pair of scissors went into John’s hands. With tears in his eyes and a wide smile across his face, he cut his daughter’s umbilical cord. For several moments, I watched the scene in awe. I felt honored to be allowed to witness this family’s precious moment. The intensity was overwhelming. John was in the bathroom, wiping tears of happiness from his face. The baby was warming in an incubator, and Carla was relaxing and looking over at her new daughter. After taking care of Carla, Dr. Maurer walked over to the baby, her job wasn’t done yet. Walking me through each step, we performed this baby’s first physical exam. As I listened to her heartbeat, I was in a state of wonder. Just a few short days ago, I was listening to the same heartbeat through many layers of her mother’s body and now she was crying in front of me. She was a perfect newborn.
We left the hospital later and streams of questions came through my mind and mouth, and my brain began putting everything together. Dr. Maurer patiently and kindly answered all my questions. We talked about the root of why she loved her practice. That she could see people through such pivotal moments in their lives. She treated Carla through her pregnancy and will continue to see her as she ages. She will see this new baby as a teenager someday. And, like John I thought, “No wonder you love your job.” Being a doctor is difficult, but being allowed into the precious moments of life makes it extremely rewarding. Beyond that, walking through someone’s life with them, knowing the root of their concerns, holding their deepest trust, is humbling. Something I don’t feel worthy of. Ultimately, my family practice externship gave me experience beyond what I could have asked for. It brought be back in touch with why I am here, why being a physician is a fulfilling responsibility, because of the relationships.
Essay by Alyssa Kasper
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“Welcome to Seymour, Wisconsin, Home of the Hamburger,” the sign read as I drove into Seymour on the first day of my summer externship. Welcome is exactly how I felt in clinic with Dr. Tomasz Miaskowski, my preceptor. Dr. Tom welcomed me into his practice for the summer. His patients welcomed me in on every exam. Through these experiences, I felt welcomed into the field of family medicine. Witnessing the interaction between Dr. Tom and our patients taught me what it means to be a physician. The lessons I learned can best be described through a series of case studies.
Lesson #1: Patience. The very first day I was in clinic, I met a patient in her seventies. At first, it seemed to me like she was “with it.” However, when questioned about her health history, her response to everything was, “oh, I had that about five years ago.” Her memory problems made office visits difficult. She was often accompanied by her brother, but one day she showed up alone. The reason for her visit was unclear, she had been seen a few days previously and she was not due to follow up for another few weeks. Dr. Tom, though his schedule was full, took the time to weasel out the reason for her visit. She was out of strips for her glucose monitor. Although it was frustrating, Dr. Tom was patient with her, and because of this patience, the patient received the care she needed. Patience with patients is a vital part of being a family physician.
Lesson #2: Home. There were a few patients that came in weekly. One such patient was a man nearing his nineties. The patient had multiple health problems: leukemia, anemia, and a weak heart. It was important to him to remain at home. While he wanted to feel better, he also wanted to maintain his independence. Dr. Tom realized this desire and treated the patient accordingly. When things got tough, we arranged for a visiting nurse to visit the patient’s home. Listening to the patient’s desire and helping it come true made the patient more comfortable with the treatments prescribed. His comfort at home helped him comply with the treatment plan. Although there is no cure for all of this patient’s ailments, his comfort and his dignity were maintained.
Lesson #3: Year. Seymour is a small farming community. Many of our patients put off their health concerns and only came in when things got bad. Many of our patients neglected to have the “yearly checkup.” Many patients went several years without seeing a physician. Establishing a good patient-physician relationship was difficult because of the infrequency of their visits. Seeing these patients in clinic made me realize how important the relationship is between the patient and the physician. It also made me realize the importance of yearly health maintenance visits. I met one patient late in my externship that was severely ill because he put off seeing a physician. The patient had not had an office visit in years. He had severe hypothyroidism and even needed to be hospitalized. The “yearly checkup” is important not only in maintain health but also for maintaining the relationship between doctor and patient.
Lesson #4: Schedule. The people of Seymour feel free to walk into the clinic and they expect to be seen. These patients throw a wrench into the schedule. While these patients made the schedule crazy, Dr. Tom realized that it was important to keep the schedule. One example sticks out in my mind. One afternoon I was having lunch when a child came into the clinic with a board nailed to his finger. Dr. Tom removed the board without problem, but it put us behind in the schedule. For the rest of the afternoon, he apologized to patients for being behind. He respected the patients’ time and they respected his. He gave each patient the attention they needed, and, by the end of the day, we were caught up in the schedule. Keeping the schedule is more than being able to see the maximum number of patients in a day; it is also showing the patient that you respect them. This helps to build strengthen the relationship between the physician and the patient.
Lesson #5: Integrity. One patient, a woman in her forties, was being treated for diabetes and chronic pain. An MRI revealed that she had serious problems with her back, which generated serious pain. The patient, however, had previously abused narcotics. The patient was forthcoming about her past. However, it came to light that she had violated her pain contract. Dr. Tom, put in an awkward situation, maintained his integrity. He referred her to a pain specialist for her pain, and treated everything but her pain. Although the patient-physician relationship was strained, the patient understood his position, and respected him for maintaining his integrity.
Lesson #6: Communication. On one of my first days, I was introduced to a woman in her seventies, who must deal with chronic back pain. While her pain was being managed by a pump inserted by pain specialist, Dr. Tom took care of the rest of her ailments. On this visit, our patient was experiencing a reaction to her pain medication. The patient did not know what medications were in her pump and Dr. Tom had yet to receive the dictation from the patient’s latest visit to the specialist. Fast forward two weeks. The patient returns again with the same symptoms and the dictation is still not available. During these two visits, I realized the importance of communication. Effective communication from the specialist would have resulted in prompt treatment of our patient. Instead, relief took weeks for the patient. Communication between physicians is vital for effective patient care. By the end of my externship, I had seen this patient six times, her pump medication had been changed, and she was feeling better.
Lesson #7: Interpretation. As is the case in life, not every patient was always completely satisfied. One patient, a woman in her fifties with chronic headaches, serves as an excellent example. The patient had an MRI of her brain. After receiving word that the test, which she had just paid for out of her pocket, was negative, she was upset. Dr. Tom, however, was happy because the test was negative. He took the time to explain to her that the negative test was a good thing, and that we now had reassurance that there was nothing structurally wrong with her brain. After a few minutes, the patient understood that the negative test was a good thing and would save her money in the long run. In life, people will interpret situations differently. As a physician, it is important to make sure the patient interprets the situation correctly. The proper interpretation will help to direct treatment.
Lesson #8: Affiliate. The clinic in Seymour is what I like to call a “one doc operation.” Dr. Tom was the only physician in the clinic. However, his practice is affiliated with a hospital. Because of this affiliation with the hospital, he knew which patients were hospitalized and how they were progressing. An example of the importance of affiliation came when a patient went to another hospital in nearby Green Bay. She went to the hospital, was admitted, stayed for several days, and, upon her discharge, came back to see Dr. Tom. Because she went to a different hospital, we hadn’t received any of the records. Although we were able to obtain them, we were not able to review them before her visit and we could have been better prepared. On the other hand, we had another patient who went to the affiliated hospital. We were able to check her progress each day, read what the hospitalist had to stay, and we were adequately prepared when she came for a visit after she had been discharged. The affiliation with a larger system made it possible for us to provide excellent care to our patients.
Lesson #9: Nurses. Dr. Tom had me spend some time with our nurse. He told me that it is important to realize that while the physician sees the patient and makes the diagnosis, the nurse plays an important role in treatment. In Seymour, the nurse was a vital part of the operation. She drew blood, she scheduled referrals, she assisted on procedures, and she gave immunizations. Spending some time with our nurse, Stacy, made me realize how important it is to appreciate the help of the support staff. Without our nurse, the clinic would not run smoothly. I learned that it is important to respect and appreciate the nurses who help with every patient.
The lessons I learned from Dr. Tom and our patients in Seymour will stay with me forever. During my externship I learned the importance of the relationship between patient and physician. I learned how to communicate with patients and other physicians. I learned how important it is to have excellent support staff. Most importantly, I learned what it means to be a family physician. I will cherish the memories, the experiences, and the patients that I had in Seymour, Wisconsin, “Home of the Hamburger.”
Essay by Laura Paulson
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“Laura, it’s time!” Opening sleepy eyes and grabbing for my glasses, I suddenly realize where I am; resting in a hospital bed wearing scrubs and waiting to witness my first delivery. The excitement had been building since the day I walked through the Memorial Health Center’s (MHC) front entrance and met Dr. Amy Falkenberg in the Family Center and now it was time, time to see a child enter this world. Anticipating this summer externship I had envisioned many things I wanted to see and do but my imagination could not live up to what I experienced. Entering medical school I knew I wanted to work in primary care and know my patients as more than the smashed finger in room four or shortness of breath in room six, however I was unsure if I wanted to be a Family Practitioner or a Pediatrician. The night delivery and other experiences over the summer have helped me find direction for my future career.
Directed to the Family Center in MHC on my first morning I did not know what to expect, I walked down a hall that would become very familiar and through the double doors to meet Dr. Falkenberg, who was nothing like I had expected. She stood there dressed professionally but casual and what struck me the most, no white coat. I had become accustomed to doctors in their white coats but the missing coat was appropriate in this environment, it making the encounters feel more casual and comforting to patients. Dr. Falkenberg has been at MHC for less than a year and yet in this short time she has made amazing relationships with her patients and most felt comfortable enough to allow me the chance to learn from them. I cannot imagine a better way to learn than by experiencing patient interviews, finding out their concerns, diagnosing their problem and providing the proper treatment or sending them to a specialist for additional care. I want to be the doctor that patients feel comfortable with and confident in to entrust their concerns.
Family medicine in this rural health center includes many different practices, which focus on pediatrics, women’s health, geriatrics, or any combination of patients with backgrounds as individual as the person. The variety gave me the opportunity to see patients from all walks of life, only in family practice can you have a delivery, well child, new OB, and declare the death of a patient all before lunch. The exciting variety has shown me that family medicine can encompass anyone who wants to see a doctor. Pediatrics is the field I thought fit me best, working with children and their parents towards a healthy future, I still want to work with pediatric patients but now I see them as just one part of my future practice. I want to work with parents on their health, which I believe will directly effect the children’s health. I do not feel compelled to stop at children and their parents because I have discovered that geriatrics is an interesting population. I found nothing can light up your day like a sweet grandmotherly woman telling her life story or an elderly gentleman who works harder than men half his age and I want to help ensure these people stay as healthy as possible. The OB patients are my favorite, the future mother’s excitement listening to her baby’s heartbeat and the concern they feel for the life inside them as well as the changes in their body and worrying what is normal or not. I had the opportunity to see women going through the different stages of pregnancy, from the first visit to the weekly check ups leading up to delivery and the care for mother and child that follows. I would like to be with my patients through life’s stages and not just certain people but the whole family no matter the age.
The decision to start down a road toward Family Medicine was made in the delivery room that June night. Knowing what I was about to see gave me an adrenaline rush; filled with excitement I threw in my contacts and sped down the hall to the labor and delivery room. Inside the room I found a first time mom who was ready to push being my first delivery I had no idea what to expect and I cannot imagine forgetting how I felt. The room felt more like a home than a hospital but the rows of instruments on the sterile table told you what was happening. I started to feel a little lightheaded and needed to leave the room but only for a minute then I got right back into the action. “Okay it’s time to push,” said Dr. Falkenberg, taking a deep breath I moved in a little closer, there are no words to describe the beauty of a child entering the world and in what seemed like no time a baby boy took his first breath letting out a tremendous cry and went straight into his mother’s waiting arms. It is amazing seeing a life’s beginning and makes me wonder what is in store for this mother and child as he grows. At that moment I realized, I want to work with the mother and child to help them stay healthy and live their lives to the fullest. This defining moment has pushed being a pediatrician from my mind because I know I want to work with all ages particularly women and family practice is the road that will help me fulfill these dreams.
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