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!

Spoiled

Last weekend I worked at a vaccine clinic. It made me extremely grateful for my current job!
Most of the clients were pretty nice, but several were just plain grumpy. I don't really see that anymore at my job. The assistants/techs were also nice but not very skilled at restraining pets. The techs at work, however, are rock stars.
This weekend I'm doing another vaccine clinic - hopefully it goes better this time, but I'm not holding my breath.

Measurement

One of the hardest things about leaving veterinary school (for me, anyway) is that there are no more concrete measures of success like grades. How do you tell if you are a good doctor? How do you measure improvement?

Is it the number of cases you see per day?
Financial measures like average client transaction amount or gross production?
The number of thank-you cards and gifts from clients?
The number of lives you save?
Getting corrected (or reprimanded) fewer (or zero) times?
The number of cases you can resolve with just one visit? Without referring?
Feeling satisfied at the end of the day, as though you made a difference?
The number of new procedures you learn?
The number of clients who ask for you specifically?
Having techs and support staff respect you? Like you?

I don't have a good answer right now - in all likelihood it is a combination of these factors and more. I *think* I'm doing a pretty good job, especially being out of school less than one year, but I can't prove it definitively. That's a difficult thing to deal with when you're a ridiculous goal-oriented Type A person.

Good at death?

It seems as though the best compliments and thanks I get from clients are my euthanasia cases. I'm not sure why that is - maybe it's the same reason why oncologists seem to have very grateful and nice clients?
Perhaps the clients have accepted what is going to happen. Maybe they appreciate that I explain what is going to happen, explain again as it happens, and ask them if they're ready for each step. Maybe there's something about having gone through it myself as a client multiple times that makes me more empathetic - I'm not really sure. All I know is that I've received positive Yelp reviews, really nice thank-you cards, or profuse verbal thanks from just about all of my euthanasia cases.
It's a running joke with my friends from veterinary school now - that I'm "good at death."

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 ...

The emergency queen rides again

This week has been slightly crazy at work. We're a general practice open daytime-only and yet I've managed to have an emergency every day; the other doctors have had a few as well.
Here's what I saw:
Tuesday - foreign body ingestion
Wednesday - bee-sting allergic reaction
Thursday - urinary obstruction
Today - hit-by-car AND bit-by-dog

Good thing I renewed my membership to the emergency special interest group! I'm also planning to go to their conference this fall. If these things are literally going to walk in the door when I'm on duty I should keep learning how to best treat them, right?

New goals

Here are my goals for the rest of 2013:

1. Get 3 pull-ups in a row (strict would be great, but kipping is okay too)
2. Get 3 toes-to-bar in a row
3. Take a vacation and go to a conference (I'm planning to go to IVECCS in San Diego in the fall, but AAFP in Dallas looks good too)