A different kind of funeral

In addition to all the transitions in my life as I leave classroom learning and enter clinical rotations, there has also been another big announcement which I'm still processing. Due to cuts in Medicaid funding in the state, the ambulance company I worked for is closing. While it isn't a change that will upend my life (I've only worked 6 shifts in the past 6 months), it does directly affect friends who relied on those jobs and the benefits they provided and indirectly brings me a certain sadness.

It was a difficult transition for me when the company lost the 911 emergency contract for the city the North station is in and where I spent most of my time. Many people transitioned to the company which won the contract and many more just went on to other things entirely. When I went there after the change, the place was a ghost town - empty bays, plenty of seats on the couch, empty beds at night, barely a peep at shift change. The South station always had a whole different type of personality, plus upper management in the station, and was just not a place I ever felt as comfortable.

Now, the entire company is closing and I'm watching an outpouring of grief on Facebook from current and previous employees.  I've never seen a Facebook funeral before - maybe it is more like a wake, with everyone sharing their memories of good times. While no company ever has fully satisfied employees, most are choosing positive statements and support for the displaced employees over any sort of nitpicking.

Thank you to the people who have served both the North and South cities, providing great EMS care and supportive training for the ever-growing community of EMTs.

And then there were six

Days of vacation that is.

Tonight is my last shift on the ambulance before school starts up again and has been full of the typical nonsense, so no great excitement there. The upside to working during the break has been the small influx of cash (good because I'm not convinced I have the appropriate shoes or clothing for the weeks ahead) but more importantly the time to reconnect with people I miss getting to hang out with.  People with personality and a life outside of medicine. Not that medical students aren't fun people, but sometimes the accumulation of Type A personalities in a single building can really suck the fun out of everything.

The arrival of an actual schedule for my first clinical rotation has made the reality of 3rd year hit home and I'm beginning to realize that there will shortly be a physician looking at me and wondering if I know the difference between elbows and rectums.  Fingers crossed that the routine of orientation will settle me down enough so that I can remember the difference when asked.

Vacation

Whew - boards are over (for now!) and summer is rampaging by my windows.  This is the "last" vacation I'm supposed to have as a medical student, 5 weeks between boards and hospital orientation for clinical rotations.  Others in my class are going on fantastic trips, getting married, moving to their clinical sites, or doing any number of fun things.  I am not doing those things.  Someone at K's fire department asked me how my summer was going and I told him vacation was great! He pointed out that I may be the only person he's ever met who classified working 24-36h a week on the ambulance and doing an unpaid research project as "vacation".  I replied that if I didn't have to memorize any information, it counts as vacation. Waiting on board scores, reading for fun, seeing actual patients, doing a little data mining - ahhh, vacation.

Distraction

I find a lot of peace in spending time with my dogs usually. There is just something nice about a soft furry body leaning against my leg and a warm head under my hand.  But Spencer injured his leg a month or so ago and I've been consistently distracted with trying to make sure he's getting taken care of, including the expensive orthopedic surgery he had this week.  He's now on "crate rest" for a week and significantly limited activity for 3 months.  Shortly, he is going to be one very, very bored dog. This is also the dog that has eaten 2 seatbelts, a bunch of wood pieces, paper and cardboard, ripped up carpet and completely ate one of my slippers as well as generally causing havoc even when he isn't bored.  I'm worried for the safety of the house...

What's in a name?

Our school recently hosted a fascinating speaker discussing a number of health care policy issues with us.  One issue which really caught my attention is whether physicians should be calling themselves primary care providers.  We've all been told there is a shortage of physicians in areas like family practice, outpatient internal medicine and pediatrics at a time when these are the physicians our health care system is relying on to provide cost-efficient patient care.  This shortage is now being addressed by adding nurse practitioners and physician assistants to the primary care arena with a shorter training time and reduced compensation, all for the same results (I'm going to avoid the argument of whether the results really are the same).  Why should you pay a physician to give immunizations?  Any nurse can read a vaccination schedule and give you a shot.  Why would you want a doctor to treat your GERD?  In most states, PAs can write the prescription you need.  So what do physicians have to offer in primary care?

Part of the problem is the confusion between the individual mechanical activities of practice and the intellectual understanding of the mechanisms of disease, options for treatment, consideration of interactions and future consequences of disease and treatment. There is a level of care between primary (wellness checks, simple conditions, immunizations) and the tertiary care offered by specialists. This is the expanded role that physicians can cover which NPs and PAs do not and should not. These are the patients with multiple long-term diseases, the patients with conditions not yet controlled by medication and who are not yet sufficiently sick to need a specialist.  This is secondary care.  It is generally acknowledged that not all patients are going to need this level of care, but my personal preference as a patient is that I'd prefer to be treated by someone who is able to provide that level of care and not just a referral to a specialist.

The speaker's argument was that physicians are doing themselves a disservice by allowing or encouraging people to lump them together with NPs and PAs under the primary care title when it doesn't reflect the value and additional skills they bring to patients.  Something to think about.

Frustration

Not that I have a desire to be a primary care doctor. Not that I don't think they have a challenging job for which most folks are less than grateful.  BUT, if I have to trade 5 phone calls with your office for a simple medication refill for a scrip I've had for YEARS (which is somehow never simple from their end), you're doing something wrong. I would have given up at the first refill, despite the fact that every time I see my doctor, she touts the benefits and safety.  All because her office continually blocks my access.

Docs want to talk about how they don't have time to spend with patients any more but nobody wants to talk about why doctors are sometimes the ones providing barriers.  Our curriculum covers all sorts of stuff about patient interactions, billing, procedures, ethics, non-compliant patients, on and on, but nobody is discussing how something like this can be improved to benefit both parties.  I'm sure it costs money for the office to have a nurse sitting around doing nothing but making phone calls for this (yet I can never get through to a live person) and I know it causes the patient great aggravation to submit an electronic request for a prescription, wait 2 days, then start playing telephone tag with the office.  There has to be a way to streamline this for both parties so it doesn't take a week and 2 hours of time to authorize the use of a non-narcotic, non-addictive prescription medication.

Grind

No matter how worn down you feel, that wheel just keeps grinding away.  Medical school just doesn't quit.  Instructors come and go and I'm still sitting in the same seat, feeling the same struggle to memorize, synthesize and apply.  At least we're on to GI so when I'm feeling down I can make diarrhea jokes...when you're sliding into first and your pants begin to burst, diarrhea, diarrhea. That song is now stuck in your head, you're welcome.

Lottery

Since this fall, I've been a bit concerned about the lottery process for third year rotations.  There were four places I was willing to be happy about going out of ten possibilities.  The downside was that those four places had less than 25% of the student slots.  I had a strong first choice that would allow me to spend much more time home with K while the others would keep me living within 2 hours of him.  Every time I thought I had a strategy for lottery day, I would check the list again and find myself discouraged at the likely outcome of the strategy.  My future rested on a single ping pong ball.

I fully acknowledge the ridiculousness of that statement though.  It isn't my future, it isn't anything more than a place to spend a year learning to be a physician.  Yes, I was concerned about the quality of the education offered but that is extremely hard to determine from my seat in the classroom.  So much of a clinical experience depends on the specific physician, resident, nurses, etc. I will be working with and the attitude and skills I present to them.  Dr. Jones might be a terrible fit for me but a great match for the student in the next seat, but we have no way to figure that out and are left stressing over the details of location, housing options, call schedules and things we really shouldn't care this much about.

The lottery room opens and everyone heads over to their first choice site and ping pong balls go in the bucket. 1 seat is removed for the loser lotto, and my choice has 7 seats to fill with 10 balls in the bucket. I'm nervous and messaging madly with K who is peering in a window because he's not allowed inside yet. Ball after ball gets pulled and then we're done, 7 happy students. My ball is still in the bucket. Wait! My ball is still in the bucket.

There is a quick second round which is irrelevant because there are only two locations with seats open outside the lottery and those two are nobody's second choice. I joke around with the first year students running the lottery and accidentally find the girl who will be pulling the balls in the loser lotto, making sure to tell her that she's "looking" for #58. Now, K gets to come in to help me decide where to go when my ball finally gets pulled. I still have options, there are five seats left at the four places I was willing to go.  All the balls go into the bucket.

Before I even realize that we've started, they pull the first ball.  #58.  K looks at me and wonders why I'm not moving.  I'm waiting for them to realize there was a mistake, or it is a joke, or I'm not really sure what.  I get my first choice spot, crushing the hopes of the two other students who wanted it - including the friend I've sat next to in class for two years.  I leave feeling happy about my luck and upset for those still in the room, there isn't anyone in there I don't know well.  Even though the story ends happily for me, it still feels like a terrible night and a painful way to make a difficult distribution of students across clinical sites.