Playing doctor

This week's rotation, Community Practice-Medicine, is one of my favorite rotations so far this year. It's also been definitely the most demanding and most challenging rotation, and the rotation on which I've learned the most.

You already heard about CP-Surgery in September, so let me give you a brief rundown of how CP-Medicine works:

This week there are 7 senior students on Community Practice, 4 juniors on CommPrac-Medicine, and 5 juniors on CommPrac-Surgery.

Tuesday, Wednesday, and Thursday are surgery days. There are 6 surgeries scheduled each day, so 6 senior students are on surgery in the morning, with the 5 surgery juniors along with them.

That leaves 1 senior student and 4 juniors to handle all the morning appointments (which start at 9 am and happen every 15-30 minutes until 12 pm; actually appointments go all day with the last appt at 6 pm, but juniors don't take any appts after 11:30 so we can get to class). With 5-10 appointments every morning, that means that each of the 5 students has been handling 1-2 appointments a day.

(On Monday and Friday, there are no surgeries, so all of the juniors and seniors help with morning appointments.)

On Monday, we juniors mostly paired up with seniors to follow them through appointments and learn the system of checking them in, where to way the dogs, what exam rooms to use, how to take a good history, how to present treatment options, do physicals, present cases to the supervising clinicians in the treatment areas, fill out fee sheets, and complete electronic medical records.

On Tuesday and subsequently, we got thrown in on our own. What you do is this:

* Sign up for appointments before rounds at 8 am; read up on your assigned case's history if you have time and they've been here before
* Watch the appointment schedule on the computer; appointments turn from yellow or pink to green when the client has checked in
* Head up to the reception area
* Get the day's paperwork from the receptionist
* Get the patient's chart from Medical Records if the animal has been to the VTH before
* Find the patient and owner in the lobby
* If a dog, take them over to the scale and get a weight (cats get weighed in the back)
* Find an exam room (unoccupied and preferably clean)
* Get a thorough history of the animal's general environment and wellbeing, and anything specific to a particular complaint that caused the owner to bring the pet to the VTH
* Do an initial physical exam (sometimes a challenge if it's just you and the owner, and the dog is fidgety or hyper)
* Present any initial exam findings or proposed diagnostics or treatment to the owner
* Have the owner wait in the exam room or lobby
* Take the dog or cat back to the Community Practice treatment area
* "Present" the case to the supervising clinician (i.e.: "This is Johnny. Johnny is a 3 1/2 year old castrated male domestic short hair cat. Johnny presented today for routine wellness exam and vaccines. Johnny is kept as an indoor-only cat with one other cat in the home. His vaccines up to this point have been up to date. His diet is Z/D dry food due to possible allergies or IBD... [yada yada yada])
* Discuss any abnormal physical findings with the clinician
* Clinician repeats the physical to see if you missed anything
* Clinician asks what you want to do (vaccines? blood work? other diagnostics?)
* You agree on a treatment plan, then run back up to the owner to get approval (sometimes this entails 3-4 back-and-forth trips while you get questions answered)
* Head back to Community Practice
* Get whatever you need ready: draw up vaccines, fill out vaccine consent form, fill out rabies certificate, draw and process blood or urine samples, run chemistry profiles or heartworm tests, vaccinate the animal, etc.
* Fill out prescription requests; take to pharmacy
* Fill out fee sheet; take to business office
* Return pet to owner
* Go over any physical exam findings, client education, recommendations for treatment or changes at home, etc.
* Answer any questions the client has
* Go back to Community Practice after client leaves and valiantly attempt to get a head start on writing up the medical records for the last visit before your next appointment shows up
* The following day, make a follow-up phone call to every appointment from yesterday

And an additional goal is to teach us how to manage appointments efficiently, i.e. a goal of getting clients out the door within 60 minutes. Gaaaahhhh...

Here have been some of my appointments this week:

Monday: 2 year old cat for vaccines; 8 year old cat for vaccines, bloodwork, and urinalysis (which we did ultrasound-guided: cool!)

Tuesday: a 3-dog family (9 year old border collie mix, recheck from respiratory illness 2 weeks ago associated with autoimmune disease; 5 year old golden, heartworm test and preventive; 13 year old golden, heartworm test and preventive, CBC/chemistry panel, NSAIDs for stiffness [probable arthritis] [did not happen due to elevated liver enzymes on her chemistries], and oral joint supplements); then a 16 month old golden who came in for routine vaccines

Wednesday: rectal prolapse!

Thursday: 6 year old Airedale belonging to one of my sophomore-year pharmacology professors (his wife brought in the dog), needed heartworm test plus CBC/chemistry for NSAID prescription for joint disease (thankfully the blood results on this one were fine)

Friday: who knows! I'm hoping that since there will be 16 of us to handle the morning appointments, I won't get stuck with any on my own, and preferably will be paired with a senior student so that I don't have any personal responsibilities as far as writing up records. And so that I get done by noon and actually get a lunch break.

Let's talk a little more about what it's like psychologically to be a student on Community Practice.

As the students, we act 95% as the veterinarian. In most cases (all routine, healthy animals, and most mildly ill pets), I as the student am the only person who interacts with the client. The doctors rarely leave the treatment area, and merely give us suggestions (if we need them) on what issues to address with the client or how to present our proposed treatment plan.

When I bring back a dog to present to a clinician, I am responsible for having established a positive relationship with the client. I must have obtained an accurate history (another mantra for this year: "Your history provides 60-80% of what you need to make a diagnosis"). I should have completed at least a cursory physical exam in the client's presence, and am responsible for a full, thorough PE, even if I have to do part of it in the back with someone's assistance.

I am in charge of raising any concerns the client has brought up, or any issues I've found on PE.

I propose the plan for the day: what vaccines will we be doing? Does the client want a heartworm test? What kind of heartworm preventive do they want? Do they want flea/tick preventive? Do they want a fecal exam? Deworming? Want to sign up for a wellness plan? Are they interested in routine wellness bloodwork?

If it's a sick animal, that can get more complicated. Say the dog presents with what the owner perceives to be a urinary tract infection. I should know and be prepared to tell my clinician that I want to obtain a urine sample via cystocentesis and submit it to the diagnostic lab for urinalysis and urine culture. I should know which antibiotic I want to prescribe for the dog in the meantime, until the culture results come back. I should be prepared to look up dosages and write prescription requests for said antibiotics, and discuss how to administer the meds and potential adverse side effects with the owner.

I have to keep a list of any issues that have come up in either my history-taking or physical exam. Does the dog need a dental? If so, how will I present that to the owner? How will I explain dental disease and its consequences? What details will I give them about the dental cleaning itself? Is the dog overweight? If so, what diet recommendations do I have? What kind of exercise can they do? What will they substitute as treats for the high-calorie commercial dog cookies they've been giving? How will they be able to monitor the dog's weight loss?

If I forget to talk about anything during the appointment, it's my responsibility to get in touch with the client later that day or tomorrow, and go over anything I left out.

It's my job to make sure the lab gets the blood and urine tests done, check on the results, and relay them to the owner.

I am responsible for following up with a phone call the next day to see if the dog had any side effects from vaccines, if they came up with any questions, if they've been able to administer oral meds successfully to that annoyed cat, etc.

Whew. I'm exhausted just thinking about it.

I guess this is one of those areas where the more you do it, the more you improve. Even in just the last 4 days, I already feel so much more comfortable in appointments than I did at the beginning of the week. But that doesn't mean I don't have a looooong way to go.

Here's another thing: Even while you are supposed to be acting as the doctor, a lot of what you do is tech stuff. The thing is, Community Practice is a great place to practice some technical procedures -- stuff like jugular and cephalic blood draws, cystocentesis, administer subQ/IM/IV injections, expressing anal glands, etc. It's stuff we HAVE to be able to do as doctors, and things that most of us need a lot of practice on, but in reality, it's possible to find a job at a great hospital that has fantastic techs who can do all of that stuff for you. However, you've got to be able to do it yourself in a pinch. It's the vet who has to get the blood sample from the sick 17 year old dehydrated emaciated cat when nobody else can.

As students, we're also supposed to be getting familiar with some other sorts of procedures -- drawing up vaccines, running chemistry panels, calculating drug dosages, filling out rabies certificates, completing fee sheets, etc. Again, a lot of that is stuff that competent techs can legally do for you in a practice setting.

So that's one reason that appointments can take so long. You might be thinking, "Wow, striving to stay under an hour for a routine vaccine appointment? My dog is healthy and just needs one shot! How long can it take?"

Well, it makes a heckuva lot of difference when you've got a tech doing 90% of the miscellaneous tasks for you, and you can concentrate on your 4 "doctor areas": diagnosis, prognosis, prescription, and surgery.

For example, after my prolonged 3-dog-family appointment on Tuesday morning, I ended up having to take an 11:30 am vaccine appointment by myself. I spent about 10 minutes getting a history on the dog and doing a brief physical. When I got back to the treatment area, the supervising doctor (who was acting as my "tech"; as she describes herself, "I'm the best-paid tech in the whole hospital") had already gone through the dog's record and found out he needed a second vaccine in addition to what the owner thought was due. She had drawn up my rabies and distemper vaccines. She had filled out the rabies certificate and vaccine consent form and the fee sheet. All I had to do was present the dog, wait while the doctor repeated my physical, let her know of my plan for the day (renew the wellness plan, deworm, vaccinate, send home a fecal sample collection container, and educate about dental health and maintaining the dog at an ideal weight), pop the vaccines in the dog, give him some deeeelicious dewormer, and get him back up to mom. Piece of cake: only 35 minutes from in to out.

I guess the moral of that story is: A good technician is invaluable. Don't forget how important your techs are, and give them the credit they deserve. They can make your life so much easier if you trust them and know they are competent.

Well, since I've wasted enough time blogging, I suppose it's time to head to bed. Friday bonus: show up for Grand Rounds at 8:30 instead of regular M-Th rounds at 8 am!