I don’t know what got into me yesterday. Today was much better. He let me see more than half the patients by myself. Now I’m subconsciously competing with him, listening to his history-taking and informative spiel, and seeing if I can say every bit of it myself, first. Probably ~70% there today.  Most of the patients were by themselves – no siblings running around wild. The morning was mostly adolescent girls, with complaints very applicable to gynecology. And they smiled at me. Always very encouraging. The afternoon was mostly little babies. The only antibiotics for the day were for an “ear infection;” which kid did not have a fever, and did not look very fussy; but he had already had several, by the age of three, and I didn’t get a good look in his ears. So quite possibly there was something in there. I diagnosed allergic dermatitis, and patellofemoral syndrome; admittedly without asking a couple important questions, but I did get the diagnosis.

I also really need to stop making snap judgments. This doctor is really great at relating to his patients, taking time to listen to the moms, making sure to address all their concerns, and being very conscientious about the preventive stuff – which is no doubt beneficial, I just don’t have the patience for it. His partners see twice as many kids as he does; perhaps he could stand to be a bit more organized and prioritized. But what his partners do is, if the baby at her six-month check-up also has an ear infection, they treat the ear infection, and tell mom to come back in a few weeks for the “well child visit.” Which is ridiculous, and a waste of the mom’s time, almost purely for the sake of billing more thoroughly for the two visits. A six-month old is not usually so complicated that, with another 3-5 minutes, you can’t cover both an acute issue and general “wellness.” (And I am trying really hard to respectful of “well child checks,” because I have a strong preconception that doctors are for sick people; and wellness and preventive medicine were not even on the radar when I thought about becoming a doctor.)

On the other hand, I’m still cringing with almost every patient, because part of my preceptor’s method of making the most of his billing for every one of his conscientious visits is to check everything, every time, regardless of whether it’s indicated. Thus, urinalysis, and fundoscopic exams for everyone. Mmph. It’s not so bad, though, because he undoubtedly spends time and effort on each patient that can’t really be documented, except by throwing in these makeweight bits of the physical exam. On the other hand, I’m probably going to learn more about the business part of medicine here than anywhere else in med school. This office apparently had some financial difficulties a couple years back, which led to a revamping of the partnership, and a good deal of business education for the doctors.

We stayed in the office an hour late this evening. The last patient of the day was an Indian girl in a reclining wheelchair, accompanied by father and brother, and mother in a traditional dress. At first I assumed she must have cerebral palsy: she had the spastic flexures, complete lack of response to what was going on, and a G-tube. Her parents were concerned with her breathing. After listening, he asked the nurse to check a pulse ox, which turned out to be 88%: into the hospital. While he was filling out the direct admission orders, he showed me her chart, and explained that she had been a completely normal child until age 4, walking and talking and all. Then she began to regress badly, and all he knows is that she has some kind of severe neurodegenerative disorder, probably genetic, since an older sister already died of it, and her parents are cousins. He first met the family last fall, when they presented with another acute issue. He and the father (the mother doesn’t speak much English) are working on finding a good neurologist who might be able to make a more specific diagnosis. It’s so tragic. Cerebral palsy is bad enough; but for a healthy child to suddenly start degenerating – ! So they came to the office thinking she had a cold, and ended up having a discussion about what life support measures they want if she has respiratory failure. (The feminists really got to me at some point: As the father was telling the doctor pretty firmly his views on that, I was wondering what the mother thought, and whether she would have any input, handicapped as she is by being unable to communicate without the father’s interpretation. But they looked pretty close, including the younger son, who kept caressing his sister.)

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