Week #8 Assessment: A wonderful end to a wonderful clerkship.

Professor Edelsack,

This one will be the shortest entry of all.

--Salina Lai

Week #8 Assessment: A wonderful end to a wonderful clerkship.

Today marks the end of what I think is a worthwhile and rewarding clerkship at Gouverneur. A majority of the week (starting from Sunday) consisted of finishing the community project, writing thank-you cards, and biding farewells to the staff on the 4^th floor. Many of the PCA’s Priya and I worked with were sad to see us leave, but were really excited for our moving on to the next level.

I promised the staff future visits and baked goods (a promise which I will definitely keep!). According to Lulu, Dr. Stevens invited us to join the staff luncheon this Friday. I think it will be fun.

Week #8 will get a ONE, finally.

Community Project

The results from our statistical analyses were simply amazing.

One might think that if knowledge and cholesterol diagnosis is related, then knowledge & cholesterol medication usage might be, also.

But wrong! Diagnosis and usage are not equal. It was the single most confusing result we got from SPSS. Think about it: assuming usage logically following diagnosis (we didn’t take into account misdiagnoses, blotched prescriptions, or any mistakes in the process), and that patient education takes place with the physician after diagnosis, then won’t both groups be equally educated and hence receive similar median scores?

Anyways, my reasoning is somewhat biased on its own. We dealt with a random study population, so we really cannot cast any solid predictions in the first place. That is something to work on in the near future, if I have time, that is.

I am considering working with Dr. Stevens for a short while so we can plan an intervention based on the project. Now that Priya and I identified the patient population’s misconceptions and weaknesses in cholesterol knowledge, I am very excited and more confident about one actually taking place! It’s interesting how besides trying to plan new programs for the hospital, we also saw that the diabetes posters that had been hanging on the drab walls of the ward are not working too well. During data collection, shocked expressions among patients ensue when Priya and I pointed out to them that the answers were already in front of them.

Subjective

I spent lunch time with Priya compiling a list of doctors and PCAs whom we should give thank-you cards to. We had a 10-card limit (because there was so many in one pack), so we had to try to narrow it down to people who are the most memorable and made the biggest difference in our experiences.

For me, I selected Drs. Stevens and Song, and Lulu. Priya selected Drs. Hanley and Goldman. In conjunction, we wrote cards to Dr. Coun, the PCAs who helped us immensely (this includes Eddie and Irene), and Carmen, who spent hours helping us correct our Spanish translations. Priya is planning on buying more cards, because 10 simply weren’t enough!

Today was a quiet clinic day, so I didn’t have a chance to do any patient intakes. Lulu and I had a conversation about our plans in the future. Basically, she’s yearning for sleep, while I’m yearning more work. I suggested her to take a long vacation, and she agreed with me.

Turns out, we’re both Aquariuses. I was born on the 28^th, and her the 29^th. When she let me off at 3, we exchanged tight hugs.

I will miss her the most. Hopefully, I’ll get to see her again when I visit in the future.

This is the really sappy entry, as requested by Prof. Edelsack...

This week features "comments" from Professor Edelsack. Just to give you a glimpse of his...succinct-ness.

Time to hustle on that paper!!

Week #7: Just when everything starts to settle, Fieldwork ends.

Over the past 2 months, most of the floor staff has already asked me when my clerkship ends. I figure that it’s because they’re accustomed to the 2 Sophie students’ quick in and out during the year, so they are prepared knowing that we’ll leave.

This week, it became apparent that as the deadline approaches, many people whom I’ve became close to are also dreading it. Patients don’t get this problem, because most of them come back in 3 months, when I’m already long gone, although there is one family whom I’ve kept seeing for the past few weeks that I will miss.

Basically, Priya and I have decided to hand out “Thank You” cards to all the PCAs, nurses, doctors, and administrative staff who have helped us so much during our experience. Also, I promised the entire floor that I will come back with brownies and cookies (baked by me, of course) some time this year.

It’s difficult to sum up how I’ll tell everybody I am leaving, but here’s a list of people at Gouverneur that I will truly remember. Some people have given me their cell phone numbers, so it is possible that I can still keep in touch with them. JUST, DON’T MAKE PROMISES YOU MAY NOT BE ABLE TO KEEP, BETTER TO SAY NOTHING AND DO SOMETHING

• LuLu – I have been working with her since Day 2, and I have not only learned a great deal of clinical procedures (e.g. urine dipstick, peak flow, BP, working MISYS and unity) from her, but we also learned a lot about each other from all the time I spent in Team 3. She also let me share her locker, a brave thing to do indeed.
• Eddie – He works in the adjacent Team, but occasionally he’ll stop by and we’d chat about anything from my Type-A personality, patients, to music and writing. He revealed a lot about my personality (work ethic, temperament) that I had never realized, but he was able to observe because apparently, he is also an only child. He mentions that my “unique” work pace is commendable, and that definitely boosted my confidence when working with PCAs, patients, and doctors.
• Drs. Song, Coun, Goodrich, Liu, Robles, Hanley, and Stevens –
  Many of them let me shadow, and seeing actual patient-doctor interactions was the most enlightening aspect of my fieldwork experience. Observing their interviewing skills definitely prepared me for the flurry of patients (of different personalities, languages, size and shape) I was about to interview and survey. Dr. Coun was remarkable in that we discussed medical topics outside of the hospital that we were both interested in (pharmaceutical industry, “bad medicine,” etc.). Dr. Robles let us barge in at any time to take her brochures, since she works at the diabetes and weight management clinic.
  Of course, Dr. Stevens actually came out to be a very good preceptor. Not only was he knowledgeable, but he is willing to offer ideas and feedback on our community project. This month when I was finally able to catch up and talk to him, I felt more comfortable and less anxious about expressing my own opinions on certain things. I was relieved and surprised that he was so nice and accepting to me. I can also tell that he enjoyed talking to me more once I’ve opened up. If I have the time, I will definitely try to continue working with him if there is another opportunity to do so.
• Luisa the PCA and Carmen the receptionist – for kindly spending so much time looking over our Spanish surveys and correcting any errors. Editing takes major skills, I tell you.
• The Patients – There is one family (a mother-and-son duo) who visited Dr. Song numerous times since June, and every time they are there, they recognize me and immediately rely on me to see the doctor (sometimes patients don’t schedule appointments). Sometimes they nag because of the wait time, and LuLu prefers to not deal with them (understandable, since she’s been working for a long time). Dr. Song have told me that the son have mental problems that cause him to be extremely nervous around people (hence, his pulse and BP shot up the first time I met him and did intake). I remember last week when they were at the clinic again, and the son had some trouble drinking from the water fountain. I really wanted them to feel that we care, so I simply offered him a plastic cup to drink from. He was really glad about that and when I saw them again today; he was noticeably less stressed out (as seen by his vitals) and looked somewhat comfortable. At least that is better than sweating beads and having a sky-high heart rate: I felt like I made a tiny difference and the family felt the effects. I don’t know how to tell them I am leaving, though…not that I know whether I’ll see them ever again after today.

I’m getting Priya a small gift for being so kind (and tolerant) of my work ethics. As for Dr. Stevens, I hope he needs extra cough drops (he’s been sounding ill for the entire summer, and I noticed that his bowl of cough drops in his office tends to always refill itself…).

Basically, fieldwork will be pure fun after the community project is complete (not that the project isn’t rewarding). As I’ve stated before, just when everything starts to settle, Fieldwork ends. Just when I’m starting to enjoy the fun, I have to move on. This upsets me. I’m going to give this week a 2. YOU COULD CONSIDER STAYING ON IN AUGUST IF YOU WANT MORE EXPERIENCE. MAYBE YOU SHOULD TAKE THE TIME OFF AND RELAX….YOUR CHOICE…..

The Start of Week 7

I'm about to relive the horrors of all-nighters and panic attacks that my poor, poor soul underwent during my CHA era. I have exactly a week left to write up a kick-ass intro, methods (which includes statistical SPSS mumbo-jumbo, ugh), results (pending once survey #100 comes home), and a long, worthy discussion...with the help of Priya, of course.

And I've wasted the entire weekend figuring out what to do, once again. Don't do this, readers!

I guess it is time for me to dig out all the articles I went through this past month. Yikes, wish me luck.

Week #6 Assessment: On the home stretch…

This week gets a 3 for the three measly responses I received on my first day of survey administration, which was definitely not the best start. Fortunately, Priya and I made better progress and got more than 70 surveys done in 4 days. 100 surveys are possible, after all! Besides administering surveys, we also had a chance to talk to and educate patients on cholesterol.

Also, the department was running out of cholesterol brochures, but I got a refill shipment in 2 days and allowed us to distribute colored, user-friendly literature that people actually read through while waiting for their doctor…so much better than giving patients old, unattractive Xeroxed copies.

That was basically what we did all week long. Plus breaking the copy machine and draining printer toners from all those revisions and copying.

Community Project & Subjective: Survey etiquette and patient education (or educated?)

At the conclusion of last week, I was desperate because I still haven’t started surveying, and I had 3 weeks to rack in a considerable number of questionnaires. Based on the disappointing results from the pilot (and realizing how difficult it was to circle the floor “preying” on patients), we decided to try a new method and administer surveys to all intake patients in a particular team. I started working at Dr. Song’s team to target the Asian population, but realized that I always wasn’t so lucky because of her remarkable speed when seeing patients. Rarely do her patients have time after their visits, because many of them have to rush to their next appointments.

Priya gladly helped me looked for more patients, since her side of the floor is always bustling with Hispanic patients. When I was walking down the hallway, most of them looked bored from waiting. Surprisingly, some of them are eager to fill out the survey as I approached them with a clipboard. Usually, they are literate and can do the survey on their own, but most of the patients prefer someone to read and talk to in the process. One of the best things that happened this week was gaining attention from patients nearby who were more than willing and interested in being surveyed. All of them were happy after I gave them literature. As a result, we were able to get over 30 surveys completed on a single Thursday.

Residents spend more time with each patient, which corresponds to patient wait time. This gave me more time to spend with patients on the survey, as opposed to the rush on other days. Although it was quiet on Friday, I had the chance to sit down with curious patients and educate them on cholesterol and heart disease. One patient admitted that she would probably throw out the brochure I gave her if I didn’t explain to her the correct answers to the knowledge portion on the survey she had taken. Hearing this, I felt satisfied that I finally took a refreshing initiative to do more than the administer-and-thank routine.

The few things I was annoyed at was how we wasted some time editing minor grammatical errors that could have been corrected by hand on the surveys, and how utterly disorganized we were with our papers and brochures because we each have our own “survey kits” of blank questionnaires and literature. On Friday, I couldn’t stand it anymore, so I got some manila folders from the administrative office, and proceeded to reorganize our materials. A paid intern from another summer work program volunteered to help me with that (plus miscellaneous photocopying and assembling cholesterol literature handouts), since all he was only sitting around and playing games on his phone, anyways.

Subjective: Feeling accomplished.

The one thing I fear about administering surveys is being rejected, but I feel a lot better thanking them anyway and giving them literature. That way, they no longer feel harassed, and in some ways, I’ve done my job by educating them.

Patients are also happy when they are able to understand what they think are advanced medical topics. I realized this week that a lot goes into translating medical mumbo-jumbo into accurate laymen’s terms with popular appeal.

So this week, my community project experience is also the subjective portion.

5 down, 2 to go...

Week #5 Assessment: Not too shabby, though it could be better.

It was difficult to rate this week, since I sacrificed some patient time towards burying myself in the office working on my survey, so I didn’t do as many patient intakes as I did weeks prior. However, I did start to talk to patients a lot more whenever I’m with them. Some of them can get really chatty and personally, I really enjoy this “exhibition” of human personalities.

Since this afternoon, the finalized survey was translated, reviewed, approved, then tested on some patients, edited it (yet again) to shorten it, reviewed, reviewed again, then FINALLY…re-finalized. I was somewhat disappointed that my partner and I weren’t able to put the survey in full throttle, but work is work. This weekend will be laying out the framework (variables, coding, SPSS, Helena, etc.) so data entry would hopefully be (somewhat of) a breeze.

Now that everything seems so prospective, this week deserves a very nice 2.

Community Project: Translating and goals…

My relation with Dr. Stevens improved this week (or maybe because everyone is tired after 7PM on Thursday), and we finally had a friendly discussion on who/what/where the project should be aimed at. After making some minor changes on our draft survey, he proposed an idea that we could make posters and Plan of Action forms for cholesterol, just like what Gouverneur & NYCDOHMH did for hypertension and diabetes. I also had a neat idea to revise the current hypertension focus group program so that it includes aspects on cholesterol. A whole group on cholesterol is ideal, but I didn’t want to venture so far without knowing how these patient education programs get funded.

My goodness, how cool would it be to see an actual intervention taking place after our project? No more dusty, unused brochures stashed behind an old shelf, I hope.

For now, we are going to order nyc.gov health bulletins and tri-fold brochures to distribute to patients post-survey. Plus, we’re planning to package these pamphlets nicely (paper clip, topped with a high-quality, $0.15 ballpoint pen from Staples®) beforehand. Our idea was patient appreciation and quite possibly, interest from onlookers at the sight of “incentives” being given out around the ward.

One of the big problems we encountered when thinking about our goals was the ambiguity and complexity of the topic. Unlike diabetes, which emphasizes A1C as a crucial factor, topics such as hypertension or cholesterol tend to be repetitive in terms of variables. All 3 focus on LDL. HTN and cholesterol both involve physical activity and medication use. Maybe I can center on specific variables on a lipid panel, but the aforementioned variables are seemingly important, too.

That was why our survey ended up being too thorough and became “Jeopardy”. My current concerns are the length, the relevance of some seemingly necessary variables, and the time it takes for an intake patient to complete it without complaints (or a doctor barging in and interrupting the session). Priya’s first survey participant already complained about the length, so just as I was getting Dr. Hanley’s approval, I had to immediately run back to shorten it and salvage only the obviously important questions. In the process, I was able to remove several questions which I realized were repetitive. So after being re-finalized (for the final time), surveying will officially being on Monday morning: I decided to take my off-day to administer them.

If it’s something I learned from this week, it’s how to be nice when approaching patients (a lot of practice done during intakes), and how to modify language settings on my home computer so I that can type Chinese characters using pinyin without copying and pasting from an online dictionary. It was a pain to translate by doing the latter at Gouverneur, where I was not allowed to access most websites or tweak administrative options.

Professionally, I shouldn’t leave a mess in the office whenever I go out to lunch, or leave Lulu’s locker wide open after I’m done storing my possessions. Keep those in mind, Salina!

Subjective: Connections and a surprise.

After talking to a number of patients, reading journal articles, seeing stacks of prescriptions for hypertension, diabetes, and cholesterol medication always coming out of the printer one after another, and seeing virtually no distinct “line” that separates guidelines for each disease; I’ve concluded that most patients had to go through the torture of managing pills and foreign lifestyle changes because they fail to fully understand that they’re all connected: having one disease increase one’s risk for another, and vice versa. Besides explaining to patients what this triple threat is, physicians and educators absolutely need to acknowledge this interrelationship.

Personally, I feel that those Plans of Action should be given out separately and as a conglomerate, if necessary. Patients need to know that even though they’re in the clear for blood pressure, 150 mg/dL of LDL in their bloodstreams is still not good news.

Now, here is the story of the week:

Several weeks ago, Dr. Song gave me a copy of an old Chinese pamphlet about cholesterol that she claimed to give out to patients occasionally. The information is very friendly (with an anthropomorphic “healthy heart” mascot waving his hands on the cover), focused and concise, but the Xeroxed format didn’t give it a favorable impression. This is not the worst part.

You see, Xerox machines are remarkable tools, because some of the most primitive pranks and practical jokes relied on them. Who knows how many times that pamphlet had been duplicated, but lo and behold, too subtle to be noticed by the unsuspecting patient, were 2 middle fingers drawn on the mascot’s hands and blackened teeth, making the mascot look less healthy than he was supposed to portray. I figured that someone must have drawn them on the original and they were consequently passed on. I had forgotten about notifying Dr. Song until on Thursday, when I had to use it to look up some Chinese terminology.

I decided that I’ll show it to Clara, the head nurse. On my way to her office, I bumped into Dr. Hanley and a medical student. Their reaction was classic: mouth wide open, and stifled hysteria. By then, we were all trying not to burst out laughing.

Dr. Song’s response was a disappointed one. “A malicious, malicious prank,” she sighed.

When one nurse found out, she proceeded to rant about all types of problems she encountered in the hospital, especially those dealing with race. She went into the clashes between Latino and Chinese groups, where both staff and patients were involved. Currently, most doctors are being relocated to different locations on the floor based primarily on their language proficiency, so both Spanish- and Chinese-speaking patients can be better served by staff who speaks their native tongue. The nurse wholeheartedly supports this, reasoning that this was done based on necessity. Unfortunately, many people still use this as an excuse for being discriminatory, especially since one Team booth out of the entire floor had been renovated while the rest are furnished with decade-old furniture and are wearing down with age. Some are jealous, accusing this move biased and preferential.

I am so impressed that she speaks out not just at me, but publicly throughout the hospital. Of course, she has gotten criticized and judged based on her race, but this does not let her down one bit. She told me that she is willing to do this until she retires.

I plan on letting my passion for medicine run its course. I always felt like that is the only thing that cannot be readily destroyed. After hearing her stories, I start worrying not what my true interest really is, but how I’m going to survive in the workplace under all this pressure. Actually, any workplace.

To all future HMS II takers:

Week #4: Getting warmer...

Week #4 Assessment: I will not complain about it.

I will keep this entry nice, short, and precise.

This week gets a 2, since it’s one of the better weeks where I didn’t have too many problems in terms of patient care and my community project. Actually, I made a lot of progress on my case study, but my survey remained somewhat stagnant. On Tuesday and Friday, I did mostly intakes and shadowed Dr. Coun. I caught a break on Thursday afternoon when I got access to my case study patient’s charts, where I got loads of information that would greatly help me with formulating questions. In addition, I also took some time and walked around the hospital with Priya just to familiarize myself with the locations of most of the departments, which came in handy when I get approached by all sorts of patients asking me for directions.

Otherwise, I met some interesting patients, as always.

Community Project: Breakthrough, finally!

I was almost desperate for a case study when I got my break on Tuesday with one of Dr. Song’s morning patients. He seemed pretty pleasant and easy to talk to, and was chatting away about his lifestyle while I was taking his blood pressure. I was excited when he agreed to be my case study! Within a 10-minute period, I was able to elicit where and with whom does he live with, his work place, his hobbies, and how he takes care of himself. Then, I managed to observe him with Dr. Song before he politely told me that he needed to talk about something private with the doctor, so I left the room. Afterwards, I received his work number and schedule. I plan on giving him a call for a telephone interview some time next week.

On Thursday afternoon, Lulu showed me how to access his charts through MISYS, and I spent roughly 6 hours on the computer going through his medical information. My access is strictly limited to notes taken by his PCP, psychiatrist, and social worker, so it might be a disadvantage to not be able to look at his cardiologist’s notes, since he has a serious, chronic heart problem. Then again, that sort of info is leaning towards diagnosis.

Upon looking at his social work, I found almost a year’s worth of psychotherapy notes, which revealed some things that were so…opposite to what he was displaying from my first impression. He went through a lot of physical and psychological turmoil. This puts me in a difficult position when it’s time to make up interview questions, as there are so many potholes I’ll have to avoid for fear of creating an uncomfortable conversation (or a worst-case scenario: the patient pulls out of my case study).

Right now, I’m still wary of letting the patient know that I looked at what were probably his most intimate thoughts, but looking at these notes, I can almost predict the types of answers he’ll provide. Besides the information I gathered, it would be intriguing to compare his answers versus what’s really going on in his life, but I guess that is better left as a personal reflection. At least I know now what to avoid in my questions, but then again, this will just make me want to probe him with the specific problems he’s going through just to see how he’ll respond to them.

Subjective: generics and acupressure.

This week, I came across several cases dealing with drug costs (which strangely corresponded with the premiere of SiCKO today, hmm…). I was extremely busy doing intakes for Team 3 this week, so I ended up shadowing Dr. Coun again on Thursday morning. I clearly remember a 64-year-old Hispanic patient who showed Dr. Coun his box of Claritin, but was recommended to purchase generic loratidine at his drug store instead. I was so impressed by Dr. Coun, who circled the drug name on the box, and carefully explained to him that Claritin was “just another name” for its less-expensive generic version. I also remembered another patient who exclaimed how she was able to buy her $120 drug in Brazil for $10. Dr. Coun then recommended her to Gouverneur’s pharmacy, which provides any prescription for $10 and won’t charge more than $40 for any number of drugs. Plus, some essential medicines and prescriptions filed by Medicare members may even be free of cost. But as with any affordable pharmacy in the U.S., one would ominously encounter long lines at the counter, which is what I see almost every day from morning to night.

Another funny thing about this hospital is the number of people I found clustering in different sectors of the building. I found more people waiting in the financial office than the urgent care center.

I also met a Chinese patient who started boasting the wonders of acupressure during intake. Apparently, her arm was injured from transporting her husband in a wheelchair and physically supporting him constantly. She admits she had tried physical therapy, but it didn’t work. Eventually, her friend persuaded her to try acupressure, but she was reluctant about spending $28 on a session so she waited it out for 3 weeks before she could no longer withstand the pain. According to her, the acupressure treatment itself is painful, but it definitely worked (it IS painful indeed; I found bruised spots on some parts of her arm…yikes!).

I was amused when she admitted that sometimes, she discontinues some of her non-essential drugs (i.e. vitamins and hormones) because she’d try to use herbal remedies instead, even proclaiming how her liver function went up and her cholesterol lowered by 50 points after using ginseng. I simply told her that she could have just gone on a healthy diet and probably achieved the same result. Besides, I warned her about the risks of not telling her PCP about her lifestyle (i.e. possible interactions). But she just smiled smugly. Haha, that sneaky woman. It’s even funnier when I myself do the same.

Overall…

It looks like every aspect of my fieldwork is running smoothly: my case study outline is pretty solid, and my relations with hospital staff and patients definitely improved over this past week. Nevertheless, I think it’s time to step up my working pace by administering surveys all day for the next 2 weeks.

"How are you doing, Mrs. B- I mean, Miranda?"

This is a short article I ripped from a Thursday amNY on June 21, 2007.

Semana numero tres...

Week #3 Assessment: Newbies, Dr. Stevens, and Advocacy.

This week gets a 3. The workload is building up, but slowing down simultaneously. On Thursday, the department welcomed a new batch of PCAs who shadowed for the remainder of the week and practiced doing intakes, too. Basically, Priya and I were sometimes left with almost no intakes (except for the wee hours from 5-7 on Thursday, when a lot of them left), which made me feel like my presence was superfluous.

On a lighter note, I did tons of translations this week, including processing pre-op paperwork for an elderly woman, and helping an uninsured male patient apply for emergency Medicaid before his surgery so he won’t have to be burdened with astronomical medical bills. Dr. Stevens is somewhat suspicious of my Mandarin, though. I can hear and speak it, but I guess I’m not fully confident enough to utilize my skill. With the male patient, he was accompanied by his friend who can speak a little Cantonese, so I was constantly looking at him to make sure they both understood me. I did the same thing in the financial office when he was trying to apply for Medicaid and the process went well. In the end, I was somewhat embarrassed at myself, but I absolutely love challenges like this.

By the way, I learned how to do a breast exam and how to find someone’s liver by scratching their abdomen and hearing for sounds. Dr. Stevens wouldn’t let me see a rectal exam done on one of his patients, though.

Community Project: Studying potential case studies.

I decided to take advantage of my schedule’s flexibility (the people there really don’t care about where I go, as long as it’s appropriate for my project) and went hunting for literature and annual reports. We struck gold in several places:

• The public relations department. The director gave us a whole program guide with the history and overview of Gouverneur.

• The financial and administration offices which were right across the hall from me the entire time. I got some financial spreadsheets on payor coverage in the department.

• Google. I found one of NYU Department of Asian Studies’ working papers on redistributing NYC demographics, which included a 100-page case study of Gouverneur in one of its appendices.

Basically, we have sufficient data, resources, and countless brochures (times 3, because they’re multi-lingual) for our ethnography. Personally, I didn’t see walking around the hospital, asking certain professionals about where to find info, and smiling a lot in front of receptionists as much of a challenge.

For the whole week, the pilot surveys were sitting in a corner while we proceeded to finish up ethnography and began searching for potential patients/families for our case studies. Before Wednesday’s seminar, I began to personally put more emphasis on observing patients in terms of their feelings and reactions to hospital stimuli, as opposed to clinical characteristics, which a lot of the information could be found on their charts. At the same time, I want to see if individual patients and families are any different when interacting with physicians and hospital staff. One of my most memorable cases occurred on Tuesday, when I was shadowing Dr. Liu. A family of 3 – a 77 y/o Hispanic female with her 82 y/o husband and middle-aged daughter – visited their doctor for a checkup. All 3 were using walkers to assist with mobility, and the mother was also in a wheelchair. The daughter, who had trouble walking herself – had to manage medication for her parents (I counted a total of 23 prescriptions filed for both of them on that day), who had a plethora of problems (depression, asthma, DM, HTN, COPD, hyperlipidemia, aplastic anemia, etc.). While talking to them, I learned that the daughter’s husband is also sick with hypertension. The daughter is obviously under a lot of pressure from managing so many people, but the way she neatly organized her parents’ blood sugar, blood pressure, and medication schedules is incredible. I can’t help but wonder how many doctor’s visits and meetings with financial counselors, pharmacies, medical equipment companies, and health aides was required to train her like that. Most importantly, it would be great to find out how Gouverneur is helping the family; it’s remarkable how many services this hospital provides, regardless of their disorganization and sometimes chaotic processes.

Our first week dealing with case studies is disappointing. When we inquired about it with Dr. Hanley on Thursday, she questioned why we didn’t just interview the patients she had that day. Then on Friday, I was working with Dr. Stevens’ team with Priya and he gave me permission to observe some of his patients for the case study. He warned me that they speak Spanish, but I was willing to give it a shot. Then while we were in the office seeing his patient, he caught me by complete surprise. Here is how it went:

Stevens: [While doing a physical exam] when would you like to speak with my patient?

Me: I will after you’re done.

A few minutes after he finished the physical exam…

Stevens: You can talk to my patient now.

Me: [awkward silence, trying to regain my composure and mobilize myself into Spanish-mode] So…how long…

Stevens: “Cuánto tiempo....”

Me: [thinking] Damn it.

More silence.

In the end, I managed to learn that the patient had chronic asthma for over a decade, finds it really easy to take his medication, lives in Brooklyn, has no trouble commuting to Gouverneur because his appointments are quarterly, and that he enjoys his job as a delivery man. After this patient, I decided to challenge myself again with another patient, but I ended up saying nothing but “Cuidate.” Next week, I am definitely doing my case study on the Chinese population. And I definitely need to tell myself to stop being so pensive towards these patients, especially those who speak Spanish.

Subjective: Culture, EBM, and a cute kid.

My highlight of the week was shadowing Dr. Coun on Thursday morning. He was a very pleasant physician: walks into his office relaxed and sings songs while he’s running errands, very nice, speaks fluent Spanish, and has pictures of his cute 2 year-old son plastered all over the walls of his office. More interestingly, he’s very much into Pharm-free attitudes: he puts white labels over boxes of tissues and alcohol prep pads with drug brands printed on them.

Dr. Coun is also a resident preceptor, so he’s very used to students observing his practice and is very knowledgeable about just about every clinical subject I brought up, even mentioning that he’ll note any clinical pearls he might encounter that day.

Before his patients visited, he mentioned how home health aides (HHA) have made a big difference in the quality of patient care, as he explained to me that one of his patients was spared from a time-consuming doctor’s visit; she only needed medication refills, so Dr. Coun could simply file the orders over MISYS and have the patient’s HHA pick it up. Dr. Coun also mentioned that most HHA are immigrants, and that particularly gained my attention because many NYC immigrants’ home countries place a big emphasis on family values, just as my Chinese culture does. It might be possible that some patients prefer HHA over visiting nurses; based on Dr. Coun’s remarks, many HHA are very caring and sometimes treat the patients as if s/he is family.

While going over some chart reviews, Dr. Coun emphasized the importance of EBM. After seeing a patient, diagnosed with prostate cancer, with fluctuating PSA levels, Dr. Coun expressed his contempt for the inaccuracies of PSA testing, how false negatives may happen and how difficult it is to explain to a patient about this possibility. I also learned that although prostate cancer is often chronic and so passive to a point where it frequently goes away on its own, many doctors opt for aggressive treatment that are sometimes unnecessary. We then went into physicians’ tendency to order expensive CT scans at the onset of a “My (insert name of body part here) hurts” complaint. Personally, I feel that physicians doing such things are being ignorant about the intricacy of the decision-making process required for a diagnosis, and instead they are taking the easy way out by diagnosing using brute force: similar to someone trying to open by lock by using every possible numerical combination, or a desperate student solving a difficult math equation on an exam by substituting x with the entire number system. Even worse, my insecurities with this issue leads me to thinking that some doctors are able to get away with malpractice because apparently, results from fancy exams are very, very persuasive; if doctors couldn’t find anything with an MRI, then “they’ve done everything they could.” With that, Dr. Coun advised me to avoid practicing “bad medicine” in the future, an advice I am more than happy to follow.

With that said, I feel that I should be more wary with my cholesterol literature. This is why even with the NCEP guidelines (which I believe is a good source because the NIH is pretty reliable), I always back-reference, hopefully to find the original studies so that I don’t fall into the diaspora of “bad medicine” traps which I feel are extremely deceptive. But more importantly, responsible physicians should always keep themselves updated, as they are ultimately being held accountable for every decision they make.

Overall…

I need to improve my relationship with my preceptor, and to also establish better rapport not only to individual patients, but the entire hospital population that includes patients, nurses, and PCAs (one of them thinks I’m very type-A, aggressive, and hyper; but everybody has their own working pace…). As always, I need to practice Spanish and Mandarin. My Spanish got better with the immersion, but Mandarin…eh.

Pilot Blues.

For your information, I wrote this while I was very, very upset in the break room at Gouverneur. My voice is shot, my feet are sore, and my head is drained out.

So I shadowed Dr. Song today and decided it was cool to time her patient's visits. She took an average of 10 minutes/patient, which is pretty speedy. It would have been even faster if she didn't see some of Dr. Passloff's [who wasn't here] patients, who all have extensive rap sheets of ailments and medications. An African-American patient had a total of 9 prescriptions, not including his diabetes stockings. I asked him afterwards how does he manage all of them; he just smiled and chuckled.

Observations:

· The hospital posters are obsolete! One of our questions involved HDL & LDL and which one is the “bad cholesterol.” Only 2 out of the 14 pilot surveys got the question correct, and one of the participants answered the question after he finished seeing his doctor. The funny thing is, enormous posters on diabetes’ triple threat (A1C, BP, LDL), with “LDL = BAD CHOLESTEROL” printed in large-type font, were all over the walls of the department. Priya brought up an interesting point about the positioning of these posters. It almost seemed as if the posters were strategically posted in places where people are least likely to be; one would report for the appointment at the Team booth, then would have to make a full 270° turn to face the wall the posters are on. Also, the lighting is poor and even with the large font; one might have to squint to take a better look at the poster.

Problems encountered while doing pilot:

· Mistaking multiple choice for giveaways. When listing the choices available for high cholesterol’s health effects, the patients answered “yes” for every single choice. It’s apparent that the patients were merely reaffirming each choice that they thought was a correct answer.

· The Likert scale was extremely difficult to explain to participants, especially Spanish-speaking patients. They mostly answered “agree” initially, but changed their answers to “extremely agree” when we asked them to differentiate their degree of certainty. A similar problem occurred with “disagree” answers.

· Some questions sucked.

o Question 2 is poorly structured. We did not include a choice for “I don’t know.” Also, most people know about good and bad cholesterol, but not HDL & LDL. But which one is more significant? The acknowledgement that good & bad types of cholesterol exist or an alphabetical difference?

o For Question 5, which instructs participants to select their sources of information about cholesterol meds, many put down “pamphlets around the 4th floor” as an answer. We should include already available resources in the hospitals (i.e. posters, pamphlets, etc.) as a choice.

· “Is this a survey, or an interrogation?” [aka I got grilled by my preceptor today]

o The clinic is only selectively busy in the afternoon, as doctors see patients at varying rates. We picked a busy cluster to interview some Hispanic patients. Usually, we’d sit next to them while conducting the survey, but seating runs out at times and we are forced to stand over the patient, giving him/her an imposing (and possibly intimidating) impression. We actually got grilled by Dr. Stevens because he caught Priya & I standing over our participant. He pulled a chair from nearby and ordered us to sit. That was, by far, the most embarrassing moment of this week.

o Is kneeling/crouching over an option?

· Our Spanish sucks, enough said. Fortunately, Eddie & Reyna gladly helped us out (especially Reyna, she used her entire 15-minute break to help us translate the questions!). It’s also a problem when we can’t understand a patient’s refusal to participate. But this time, the expression (it wasn’t even a disinterested look, it was more like a scoff) was enough.

· Timing matters.

o One of the patients had to be excused in the middle of the survey to see the doctor. Priya waited for him to come out before resume asking him questions. This may affect the answer to Question 14, which asked when the patient last had his/her cholesterol levels checked. From our experiences, some patients were visiting their physicians to check their blood work results, which automatically places them in the group that had their cholesterol checked recently. There is a big difference between “I never had my cholesterol checked” and “Less than 3 months ago.” This will strip the face validity of the variable if this problem occurs again during the actual data collection; any crosstab using Question 14 as a variable might get screwed up.

o A really good way to solve this problem (which worked wonders with my Chinese-speaking patients, as they are much more talkative when they no longer have to wait in the halls. I’m postulating that having their physicians close by makes them feel safer about what they’re participating in…) is to administer surveys to patients seeing doctors in a specific Team during their intake. While the PCA checked the patient’s vitals, I proceeded to administer the survey in Cantonese, and she cooperated fully. The intake room will also offer some high-quality privacy. This brings us to…

· The resistant Chinese patient. The first question dealing with T/F and other knowledge questions intimidated her. She stated that she knows absolutely nothing about cholesterol, and that she’ll be in “deep trouble” if she gives a wrong answer. Eventually, she completely rejected the survey and withdrew from participation without ever finishing the first page. That was one of the biggest problems encountered for the pilot. Personally, I know that I can’t blame them, because hospitals are scary places, but that totally pinched my nerve. At that moment, I didn’t want to be reminded that I will inevitably come across and take care of patients like her.

I was double-damnnnnned today (in a good way!). When I spoke Spanish while surveying Hispanic patients, I got "damnnnn" by the PCAs & nurses. The same goes to the Chinese PCAs when I spoke Cantonese. I always knew languages were important, but their usefulness didn't hit me hard until today.

After a painful afternoon, we managed to get 14 pilot surveys completed. Yay!

Monday #2

ONE literature (NCEP Guidelines) reviewed. The only (and the most important one) down.

3-day weekends until the end of this = JOY

Nothing is better than basking under an incandescent light while enjoying hot tea and the chilly 70° weather. Plus not doing anything for the remainder of the afternoon because I can put it off until Monday.

This means time to catch up on summer readings! Lately, I've done some BN shopping sprees and bought numerous books. For all I know, I've cracked their spines & read the inner covers since Spring semester, but never continued.

Do you get people warning you against reading bestsellers? I'm still amused by the way books like The Secret or Blink labeled by English gurus as literary taboos. Actually, anything popular - books, music, movies - almost always immediately ends up on the butcher's block and often gets pelted with accusations that there's "nothing deep" about them.

I feel that reading bad books isn't a waste of time. You won't know what are good books until you've read atrocious ones, too. Oprah's Book Club is an exception to this, where she takes a required 6th-grade reading (that has already earned years of recognition and awards, mind you) and boost it on the market as if OBC is as credible as say, a Pulitzer. I really hate to admit that it actually promotes its book list pretty well, but it's also a bit sad to see how literary-deprived Americans are.

By the way, I'm currently reading Harriet A. Washington's Medical Apartheid: The Dark History of Medical Experimentation on Black Americans From Colonial Times to the Present. I'm into books about crimes, torture, racism, propaganda, and The Holocaust; it's just my thing.

Week 1: The Perfect Excuse for Every Inconsistency & Mistake Committed

Have you ever heard of blogging requirements? Usually, I think while I type, so I feel like this is such a tempting way to slack off on my entries and simply lace an outline with transitions and complete sentences.

Anyways, I managed to pull off 28.5 hours this week. I worked alongside Lulu, a patient care associate (PCA), and did mostly intakes. Besides that, I shadowed a bunch of doctors, drove my partner close to insanity, and spoke some of the worst Spanish and Mandarin in the clinic.

Monday
The first day is always scary, and it's no surprise that I was so nervous that I couldn't speak properly. Actually, I forgot how to talk, period.

Clara, the head nurse, was amazing and so helpful to both Priya and me. Right from the start, she took us on a tour around the floor, introduced us to the PCAs, nurses, and doctors, and even took us out to lunch and showed us around the neighborhood. I got the feeling that she was more comfortable around me, since we both speak Cantonese. Eventually, she'd talk about hospital issues, such as the bleakness of the dim, understaffed clinic, or how the ladder separating RN's and LPN's is virtually gone. Apparently, the only difference a nursing school education makes is a set of keys to the narcotics cabinet. It's funny how we're always trying to destroy social class every where else, but yet we also strive to preserve our occupational class: in the end, anything we do revolves around our own benefit. Imagine evening out physician salaries.

I can imagine working as the head nurse in a place as dingy as Gouverneur. The soporific gray- and maroon-themed atmosphere is far from energizing. I feel almost embarrassed walking down the hallways in my leather heels (which made a LOT of noise, by the way); every time I take a step, the clacking echoed and the morning patients, who were quietly sitting on the side and waiting for their name to be called, woke up and cast a curious (sometimes annoyed) glance.

The visitors' kids were ridiculously bored by the ward, which is why they absolutely love climbing and jumping on the orange plastic chairs that bordered the hallways. I occasionally see patient care associates (PCA) jump out of their booths to curb them from making such a racket.

In the morning, I shadowed Dr. Goodrich, who sees Spanish-speaking patients. Initially, I thought it was a family clinic, but then I realized that "internal medicine" includes not only adults, but an overwhelming number of elders, too. I was surprised at several reasons:

1. DIABETES DIABETES DIABETES. Every patient in that room suffers from Type II Diabetes, or some type of complication from it. During my shadowing, Dr. Goodrich proceeded to show me how he reviews their digitalized charts on the Gouverneur/Bellevue MISYS program, which I thought was so cool because it eradicated atrocious penmanship and made the system paper-free. Most of their blood sugars are nicely controlled, but some wildly fluctuated. With many of the cases, hypertension and mixed hyperlipidemia tagged along.
2. MEDS! Dr. Goodrich starts each visit by asking for their medication. Patients will either hand him a thick stack of prescriptions, or empty their stash of pill bottles. His first patient even took out a potpourri of wintergreen analgesics for his rheumatoid arthritic shoulder. Another phenomenon I observed was the remarkable similarities of the drug list each patient usually had: 70/30 insulin, Atenolol, Lipitor, 81-mg aspirin...all medication designed for DM II, high cholesterol, and BP management. A lot of the visits were for the purpose of changing the dosage, too. This is mostly because there was no change in their health. Some patients admitted that they were "lazy" to take all the pills. Nobody complained about side effects, which is what my Community Project is about.

Overall, it was exciting to shadow Dr. Goodrich. I observed a cortisone shot administered to the arthritic shoulder patient! I never knew there was a...militaristic technique for applying iodine beforehand. "Spiral out and make a sterilized zone," as Dr. Goodrich said.

Professionally, I shouldn't have sat while shadowing. Dr. Goodrich also seemed pretty shocked I didn't have at least 10 minutes' worth of questions. Shadowing is serious stuff, as I'd now think of it as the precursor to actual rotations. I gotta stop messing around and start preparing myself next time.

Tuesday & Wednesday
I actually had to write out the weekly log requirements in my notebook so I can have a filter to work with if I experience sensory overload like I always do.
I focused on patient intake on both days, so I worked with Lulu, a really cool patient care associate (PCA) who works at different "teams" (Gouv have teams of doctors situated at different sectors throughout the clinic floor).

On Wednesday, I was at Team 3 with Dr. Song (who knew Kathy Zhang and had kids who went to Stuy, coincidentally). I did only vitals that day: weight, pulse, and blood pressure. I was on a nervous high with my first patient, who spoke Mandarin and was somewhat confused as to where to go for his appointment. I tried really hard to speak in bad Mandarin, directing him to the room and telling him what I'll be doing. Lulu had to check my BP readings several times, and got different readings each time she checked. I was even more embarrassed when Dr. Song manually changed the BP reading on the printout I had prepared for her as part of the intake process.

The 2nd day also introduced me to the world of pharmaceutical reps, when an Asian Crestor rep visited each team. Apparently, HHC (the public corporation that includes Gouv & Bellevue) prohibits drug sample distribution, but long-term (or should I say recurrent?) drug reps who have familiarized themselves with the hospital employees often come around and "chat" on why other drugs are weak. They'd also pass around their laptops so the staff can update their information (can anyone guess why? haha). The guy teamed up with Clara and tried to persuade me into dermatology and just about any lucrative specialty. Interestingly, they also lamented the downfall of primary care.

At the end of their visit, the nurses often ask him for pens. He'd then leave a handful on the table that the staff would happily devour. I got a Crestor pen as a "treat," that I am planning on happily destroying during my fieldwork presentation.

Just adhering to recurring themes, Clara showed me how to do a microfilament test to check limb and appendage sensitivity for diabetics. Hopefully, I get to actually do the test on a patient later this month.

On Wednesday, Dr. Selina Siu (same name!) was seeing a mixed variety of Asian and Latino patients. My highlight was a random group of Russian-speaking lifeguards who barged into Team 6 for their mandatory physicals, all needing urine and vision tests, plus their vitals taken. I was pretty excited to learn how to do urine dipstick, but after locking myself in the utility room and waiting 30-second intervals for each square on the stick to change color SIX TIMES, the stench of cups and cups of pee got to me.

Thursday
We finally met up with Drs. Stevens and Hanley, as they've instructed us to do some literature search in advance. I was already pretty frustrated at the fact that Dr. Stevens deferred our earlier scheduled meeting because he had to "run off to a meeting". I understand how busy the Chiefs of Medicine can be, but that's unprofessional and borderline irresponsible, if you ask me.
Priya and I piloted a draft questionnaire that Dr. Steven initially prepared on clinic patients. Thursdays are especially busy, and the clinic is opened until 7 (i.e. 10-hour shift!). We had some problems communicating with Hispanic patients, but we solicited some common trends by some semi-structured interviewing:

• Patients are paranoid about cholesterol meds' side effects. A Hispanic patient even claimed to get stomach pains and nail fungus after taking her medication.
• If they have high cholesterol, they would consider medications as their last resort.

Generally, there were some mixed answers when asked about adherence. While most would discontinue and tell their physicians if they experience side effects, others would discontinue secretly for the fear of upsetting their doctors. One person even proudly proclaimed that he would listen to his cardiologist no matter what. Overall, I think this is good information for revising our questionnaire. During lunch, Priya and I stumbled across a lot of problems while trying to write our statement of purpose, objectives, and target population. I was even a bit frustrated because while the target population is patients, employees and health professionals, the survey is patient-oriented. In the end, we fixed up our objectives and revised the format of the survey, which puts us roughly 2 weeks ahead of schedule, whoohoo!

In general, I could also sense that Priya was intimidated by Gouverneur; if the patients didn't speak Chinese, it was Spanish. Very rarely did we meet patients who spoke purely English. Luckily, I'm in a better position, but speaking merely coarse chunks of Mandarin and Spanish poses problems for me, too. And I do admit I was being a bit inconsiderate towards her, giving her some of my worst attitudes when we hit a road block. But I feel that fieldwork is all about responsiveness and initiative, which is why I tried take advantage of the "first week" and drove myself to my limits. Actually, it felt pretty good. This could be the onset of target-driven workaholism, how great is that?

Overall, Priya and I are still interviewing in pairs: I maintain the eye contact while Priya takes meticulous notes. I feel like this is a great system to get information, while keeping ourselves vivid so that the patient doesn't feel like they're talking to an automated blood pressure computer in drug stores.

Friday
I shadowed Dr. Song today for her morning patients. I admire her a lot because she could speak Mandarin and Cantonese - a remarkable skill in this clinic. All her patients were Chinese, and my Mandarin slowly improved as I learn basic terms, such as "blood pressure," "pulse," and "medical student". The third one is often used to introduce myself before each patient: another professional habit I eventually got used to since the first day.

Learning about interviewing and probing patients was the most rewarding experience this week. Strangely, her whole list of patients complained of pain in different parts of the body. Besides physical exams and questioning (duration, type, and degree of pain), she also showed me how she isolates "real" cases that requires attention and "nonspecific" cases where she could clearly tell that the patient was "stacking complaints" - a habit where patients would start reporting miscellaneous ailments gradually, instead of immediately, for the sake of receiving additional diagnoses, medication, and a sense of reassurance. She told me the patient seemed depressed, which is interesting because most of these Chinese elderly patients live alone and suffer from depressive episodes. A few days ago, one patient waiting for a doctor was wailing in the hallways for the doctor not being on time. I felt like I wanted to run over there and tell her it will be alright.

“In Conclusion”…

On a 1-5 scale, I'd give this week a 3, since I felt like Priya and I could've gotten so much more responses (we got roughly 15). Also, my team work attitude wasn't the greatest, and Clara had to advise me to bring a white coat and my stethoscope to fieldwork from now on (buzz word: professional attire!). I absolutely despise wearing a long white coat before I'm an MD, though. I can't escape onlookers on the hallways seeing me gracefully walk down the aisle, which was really my attempt to not limp: my shoes were killing me.

I’m giving myself a deadline of next week to perfect all the nuts and bolts of professionalism. Amazingly, I got to work on time every day. Now that is an accomplishment.

Oh, I also lived with this for the entire week. As a result, my right lower lip was swollen, and I couldn't talk or smile properly. :(

yikes, canker sores!

Ooooorientation.

Day 2 of Orientation. The 1st day involved role-playing of an all-too-problematic home visit and regretting that I should have kept a tally on how many times "rapport" and "professionalism" were said from 8:30-2:00pm.

Besides unprofessionalism, bad French might as well be a crime at Sophie Davis ("cul-de-sac" turned into cult-de-sack, and so on). Capital punishment involves Edelsack's calling the cops, like he does with "plagiarism" from "Error! Bookmark not define!" warnings on MS Word. Ah, the memories from just a few weeks back...

This is Day 2.

Citizens Advice Bureau came and lectured us on entitlement benefits, which sounded all the same to me. I would be appalled if I had to memorize the 10+ acronyms she force fed me, but it's not comfortable either to suspect that most field workers/volunteers probably had no clue what they specifically are, either.

Small group sessions involved more worst-case-scenario studies.