2nd Opinions

I've had a few 2nd opinion appointments lately - some for skin issues, some for (ugh) internal medicine issues.

Sometimes I want to scream "Really?! You really expect ME, who has been a doctor for only 16 months, to provide a second opinion?! Are you high?!"

Appointments like that scare the beejesus out of me. I feel like such an imposter.

Emergency conference

A few days ago I returned from the IVECCS conference in San Diego. It was fantastic! There were 7 or 8 different learning tracks ranging from complex specialty center care (ventilators and the like) to things useful for a general practitioner like me. There was also a technician track with 2 different lectures to choose from at any given time.

Here are some examples of the lectures I went to:
Anaphylaxis
Lymph node cytology
Blood smears
Respiratory distress in cats
Anesthesia for patients with pre-existing disease (heart disease, diabetes, etc.)
What's new in the treatment of parvovirus infections

In addition to the excellent learning content, I got to catch up with many of my friends from my old hospital where I was a tech as well as friends from vet school. I also had time to visit the San Diego Zoo, Sea World, and to go to this crossfit box for a workout!

Here are some of my favorite pictures from the trip:

Turtles at Sea World

Flamingoes at the zoo

Manta ray at Sea World

Hilarious!

Next year the conference is in Indianapolis. I'd love to go again but may choose a different conference such as a feline-focused one.

It worked!

I'm still surprised from time to time when my treatment plans actually fix a problem with a patient. It seems to be those cases where I have to reason my way through the case and make up a plan for something I've never seen before. Since there is absolutely no way to learn a rote approach for every single possible problem in veterinary school you have to go back to basics and think your way through a lot of problems from scratch.


I'm also (sometimes) surprised when my clinical suspicion is later proved to be right through diagnostics or through a specialist referral.

Good surgery day

I performed my first cryptorchid (testicle(s) not in the scrotum) surgery on a kitten today! I'd done one before on a dog but:
a. Dog testicles are WAY bigger than kitten testicles
b. The dog at least had one testicle where it should be so I only had to locate the other one (the kitten did not have either testicle in the scrotum)

Fortunately I have an awesome mentor at the shelter who talked me through an approach that worked like a charm!

All in all I performed 7 surgeries in 2 1/2 hours. That's not impressive if you're a shelter vet, but for me it's pretty darned good.

Happy 1-year to me!

Tuesday marked my 1-year anniversary as a practicing veterinarian. Whoa.

I've learned a TON over the past year - things like:
- Common skin masses and what their cytology looks like (things like histiocytomas weren't covered very well in school)
- Perfecting my "canine allergic skin disease" talk
- How to perform a cysto without ultrasound guidance
- Getting a LOT more skilled at drawing blood from the jugular vein (hey, I learned on peripheral leg veins and was much more comfortable with those)
- How to pretend I'm confident (even when I'm not) in front of clients (and then research the crap out of it later so that I actually come up with a good answer for them)
- I'm apparently pretty good at euthanasias (got another thank-you card this week for one)
- What my standards of medicine/care and ethics are (hint: not a good fit with my previous clinic)

Looking forward to the future now that I'm (finally) doing what I was meant to do!

Adding to the database

Veterinary school can only teach you so many things. You learn the basic pathophysiology behind diseases and how to treat them. However, you need a lot of clinical experience before you develop intuition - the art of practicing medicine.

To do this, you need to see case after case and keep mental notes for later. That's why a veterinarian who has been in practice for a long time may come up with differentials that don't (yet) occur to me. Yes, there is a danger of falling into a rut based on what you've seen before, so you need to be careful to not jump to a diagnosis too soon.

Right now I'm enjoying adding to my "file." Two recent cases in point:
- Young dog, started eating lots and lots of dirt recently. I recommended a fecal, which showed that the dog had Giardia (an intestinal parasite).
- Another young dog had partial hair loss that looked similar to Demodex (mite) cases I'd seen before, however a skin scrape showed no mites. Dr. Boss saw the case later and diagnosed bacterial infection based on impression smears - they said that they've seen short-haired dogs present like this and agreed that yes, at first glance it does look like Demodex. I'd never considered bacteria!

Mistakes

It seems like at least once every week or two I make a mistake and get talked to by the management about it. I get it - it's your money and reputation on the line, it's a new hospital, and I need to be made aware of my mistakes so that I can improve. Frankly I WANTED a place where I could get some feedback (both positive and negative) so that I can become a better doctor!

The latest one was where I didn't explicitly spell something out in the medical record - essentially the client did not agree to the recommended plan so we compromised. We discussed the consequences and risks of said compromise and I put it in the discharge instructions but wasn't explicit enough in the rest of the medical record. Long story short, the thing I warned the client about happened and the client didn't want to pay. Since it wasn't documented super-well in the record (note: my record was NOT finalized because I wanted one of the doctors to review it first, but the client came back before I could get that done) the management comped about $200 worth of services for that client. Oh, and as it turns out the client didn't want to see me or the other doctor on duty that first day but her preferred doctor was off and it was an urgent issue. I'm expecting some more meetings next week to discuss it - sigh. Lesson learned.

D says it takes about 1000 "atta boys" to make up for 1 "oh shit." I need a helluva lot more atta girls ...

Inexperience

Sometimes It’s hard being the most recent graduate in the practice. There are clients who have followed some of the other doctors over the (10-20) years and who have a lot of history with them. I’m certainly not offended when they prefer to schedule their appointments with the doctor they know – particularly if their pet has a long and complex history.

I had one such client agree to see me a couple of days ago because I was the only one with appointments available and their pet was sick. Our practice has a policy of doing blood draws and injections in the exam room wherever possible, so I attempted to do so. If I had known (or picked up on?) the fact that the client was SUPER protective and nervous about their pet, I would have brought the pet to the back. Instead it took a couple of attempts to do the blood draw (my fault) and a couple of attempts to get the injection fully in (the tech’s fault).

The client emailed their “regular” doctor and asked them to take over the case as a result, which is hugely embarrassing. Now that doctor (who is my boss and an owner) wants to talk with me and the tech about how to improve.

I know that this is how you learn but it really bruises the ego. One of my mentors says that veterinary medicine is a constantly humbling endeavor – whenever you feel like you know what you’re doing you get knocked down a couple of pegs.

Getting the routine

I still really like the new job. Some days it's a little slow, but days like today are great. Most of my cases today were really interesting (intestinal foreign body, fluid-distended abdomen, fever and lethargy, and a few others) and I am learning a ton by working with the other doctors!

I'm still figuring out the computer system, which lab tests are which, and things like that but overall I think it is going well. The only down-side is that I don't get to do as much surgery as in my previous job. The up-side is that I see a lot more complicated medicine and emergency cases than I used to.

The Crossfit open is going fairly well. Last week's workout left me coughing and sneezing (a sure sign of a tough workout for me aerobically) and this week's workout was challenging - I didn't get a high score because I haven't (yet) mastered toes-to-bar. Oh well!