Saturday, October 31, 2015

Herbal Intern Reflection 1: J.B. 9/23/15




J.B. was a male patient in his late 50s. He had been coming into the AOMA clinic for treatment of his Scleroderma for about one year. Though the Scleroderma was diagnosed as systemic, it presented locally from his elbows to his fingertips bilaterally. The skin was extremely tough and when he first came to clinic he had no mobility in his hands at all. At the point I started seeing him as an herbal intern the skin from his elbows down to just above his wrists was vastly improved. He also had about 75% mobility back in his hands. His differentiation was “Local Qi and Xue Yu, LV and KD Yin Xu and SP Qi Xu.” He was also trying to gain some weight back that he had lost during the worst part of his symptoms. He had gas, bloating, loose stools, low appetite and also chronic sinus congestion. He had been prescribed Fu Zi Li Zhong Wan previously but upon inspection of his tongue we found it to have a thick yellow coating while his pulse was long and wiry. We came to the decision that the Fu Zi Li Zhong Wan was too warm for the time being and it was his damp(-heat) symptoms that needed to be addressed. We decided to switch him to Liu Jun Zi Tang and give him some dampness reducing dietary recommendations.


            About a month later his digestive symptoms were almost completely resolved. His appetite was good, he had gained 4lbs and he had no more gas, bloating or loose stools. The only thing was that his tongue had remained unchanged. I was perplexed by this and asked my supervisor, Dr. Song, if that meant our formula choice was wrong or not. I was curious to understand how to gauge the outcome of this formula choice, by the tongue or by the symptoms. Dr. Song informed me that this is a common outcome for the type of formula we chose, as it is meant to be taken long term and it can take a little while to see the full results, but the fact that there was symptom improvement did in fact attest to our correct formula choice.

Intern Reflection 2: R.G. 3/12/15




R.G. was a male in his 60s with a history of Hashimotoes. This Autoimmune disease had caused eye pain and bulging. R.G. had received surgery on his left eye which contributed to blurry double vision, scar tissue formation and restricted eye movement. His official diagnosis was Graves’ Opthamalopathy. When I first saw R.G. he had been coming to the AOMA clinic once a week or so for about 6 months. He had been receiving electrical stimulation on GB 1 at 20Hz for 15 minutes each treatment and reported left lateral muscle strength improvement. R.G. had a positive attitude toward his treatment and prognosis and the environment of the treatment room was light and friendly.
            I was glad to report in my SOAP notes his opinion of lateral muscle improvement and his overall feeling that the treatments were effective. On reflection of this case what I find interesting is the absence of any objective treatment outcome assessments. This is disappointing because R.G.’s is an interesting case that I would have appreciated having information about how well the electrical stimulation was work. It would have been useful to know for future treatments if the voltage was correct, if the length of time it was administered was enough etc. I feel in a case the best objective assessment tool would be photographic and video evidence. Not every patient is as positive and trusting towards alternative treatments and in a private clinic these tools could be beneficial to patient retention.

Saturday, October 24, 2015

Self-reflection and Learning Goals 2: Level 2




Weakness: Remembering to do and performing the correct physical assessments. I find this especially difficult when the supervisor doesn’t have any specific requirements for doing them. It is also especially hard to remember to do the assessments when they are not needed for musculoskeletal issues but rather for internal organ issues.

Strength: A good rapport with patients. Good communication skills, honesty and empathy. Knowing how to communicate with patients about things at their speed. Needling technique, point location, diagnosis and differentiation. I believe I improved greatly in my intake, asking the correct questions in the most logical order. I feel I’ve also improved in my presentation to the supervisor.

Self-identification of learning goals and learning plan: My learning goals in level 3 are to watch closely and listen attentively to the instructors. I don’t want to let the fact that I have a comfortable base to work from let me rest on that. I want to keep asking questions and attempting to push my skills and knowledge.

Self-reflection of goal achievement: In my first "Self-Reflection and Learning Goals” from term 2 of Level 1, I sited my weakness as my ability to ask the correct differentiating questions during intake. I feel I have definitely accomplished this goal. Of course there are always times when you forget something specific, but I feel my perception of patterns has improved greatly.

Practical Exam Reflections



Practical Exam 1
During the first part of the exam I was asked to needle a few specific points and then needle a few more and say what they were. I had gone over my point locations for all the most common points but being a brand new intern my idea of common points was different than the text creators. I was able to find one of the two and I was able to pick two more but the fourth was indeed a “common point” but I hadn’t yet come to know it as one: SanJiao 6. What I learned from this was to push myself and my supervisors to include more points in my prescriptions and not just rest on what I know best.
In the second part of the exam we were taken to a treatment room and asked to do an intake and assessment of a patient with only the information that they had a cough. I remember just telling myself to do every physical exam having to do with the lungs, which I did. I also asked her if she suffered from acid reflux, to which she said yes. I felt lucky at that moment because it was only through my personal relationship with someone who suffers from acid reflux that I knew it could cause a persistent cough, especially at night and when laying down. This was the first time I realized how essential our personal relationships and experiences are to our knowledge bank.
In the final portion of the exam I was taken into a new room for charting. This was by far the most difficult for me. With a time restriction of 30 mins I felt like I could never complete everything I needed to do. My first mistake was not trusting my instincts and charting that her acid reflux was part of her diagnosis, though I did include it in my SOAP notes. My second mistake was not checking the clock until I only had 5 minutes left. At that point I still had to complete my whole point prescription, which at the time I was still very new at. I quickly wrote down what I could and finished with a complete intake form. I learned two things from this final part: one, trust your instincts. With a solid foundation in diagnostics you can and should always trust your instincts. Two, time management, always keep an eye on the time. This extends past charting of course and is endlessly useful in all aspects of treating.




Practical Exam 2
                The first part of the exam tested me on my physical exam skills. It was straight forward and went as expected. I don’t feel like I learned anything new or useful during this part. The second part of the exam was much more interesting and complex. I was given a patients chart that had been coming for a few sessions and had provided some new blood work which he wanted me to explain to him. In essence the CBC and previous charting indicated that the patient was over consuming alcohol and Tylenol and it was affecting his liver. The job presented in the exam was to analyze the information and explain it to the patient in a way that was both within our scope of practice and also in a way that would not offend the patient. Having been in clinic at this point for about a year and also having been in the service industry for 4 years served as a great source of confidence and assistance with undertaking this difficult task. Something my proctor said during my review that stuck out to me was that at one point I was too casual with my word choice. Though I am glad to have my background in the service industry and feel it serves me every day, I do need to continue refining my professional diction. The other thing that was pointed out to me came from my “patient.” He said that while I was explaining the CBC he would have liked to have been looking at it with me. He felt like he understood less and would have retained less without looking at it with me. This was especially interesting to me because I’m also a visual learner and therefore I would have appreciated the same thing from my practitioner. It’s always best practice to try and remember how you would like to be treated when treating a patient. It will also make you a more humble and empathetic practitioner.

Intern Meeting Reflections

  1) Intern Meeting Fall 2013 
The Quality Enhancement Plan: Getting a resident
I believe this was one of the first meetings I attended about the QEP and how it would affect me. I am part of the second cohort to be on the QEP track. When I found out that as a new intern I would be provided with a resident I felt a huge weight lifted off me. I was ready for clinic but of course I was also very nervous and to some degree felt like first time interns get thrown to the wolves. Knowing that there would be someone in the room with me from beginning to end was so comforting. I had a positive experiences with all my residents and I learned a great deal about the ins and outs of working in the clinic.
                I am excited and proud to be a part of a school that continues to strive to improve themselves. I know they were required to do this, but I feel they did a thorough and thoughtful job and I’m looking forward to seeing how they continue to improve themselves in the future.
 
 2) Intern Meeting Winter 2014
Conflict Resolution: Thomas Kilmann Model
In the Thomas Kilmann Conflict Model there are five possible outcomes to conflict: competing, accommodating, avoiding, collaborating, and compromising. In the clinic environment there are many differing types of relationships ranging from your treatment partner to your supervisor to your patient. We discussed the ways in which we might use this model to best resolve conflict.
     I find that personally I do not shy away from conflict and tend to appreciate the ways a peaceful conflict resolution can improve a relationship. Soon after this meeting I found myself in conflict with my treatment partner. They would ask my patient questions while I was in the middle of my intake. This not only annoyed me, but I felt it undermined my relationship with my patient. To be fair, we had never talked about a protocol for our partnership and therefore I suspected they didn’t know what they were doing was causing a conflict. My partner and I have a history of working together in various roles and based on our previous encounters I was worried they would not take any type of confrontation well. My instinct was to avoid. Just pretend it wasn’t happening and wait for the term to end, but I could feel my annoyance with them building to the point it was spilling into other parts of our relationship. I decided to pursue a “collaborating” model and confronted him the next time we were in clinic. The results were fine, I could tell they were somewhat miffed but they immediately complied and said they understood. Our relationship was a rocky one to begin with so after the confrontation when it went back to being rocky I figured that was the best result I could have hoped for.

3)  Intern Meeting Summer 2015
Coaching Psychology: Improving connection to and compliance of patients.
During this intern meeting we were shown techniques for discussing issues with patients and learning how to develop a plane with patients, not just for them. Asking questions such as: "what are your goals for this?" Or "what strengths you’ve used before to help you in other challenging situations?"
Since attending this meeting, and taking Clinic Communication Skills 3 with Lorena Monda, I have been able to apply these skills in my work with patients. I have found it especially effective when discussing the use of herbs and dietary modifications. The latter especially can be extremely difficult for patients to comply with, even if they truly want to.
Commitment to act: I would like to try and utilize some of these questions even more in my treatments. I believe that including you patients in the treatment process will produce better, more long lasting results for them.


        4) Intern Meeting Fall 2015
Charting: If you didn’t chart it, it didn’t happen.
I have noticed this happens in two different areas. One, when recording e.stem, interns will leave off the Hz and the length of stimulation. These are both vitally important for replication of the same treatment by the next intern. Two, when recording Tuina clinics over and over I have seen merely the word “Tuina” with nothing else.
Commitment to act: I have always made sure to chart as many specifics about the e.stem as possible and will continue to do this, even in my own future practice. I started in Tuina clinic this term and since this intern meeting I have made sure to always include what specific techniques, routines  or manipulations I have used as well as length of time for each.

         5) Intern Meeting Fall 2015
Physical Exams: Organization and break down
In this training session we went over all the appropriate exams and as Lesley was writing them up on the board she put them in categories: musculoskeletal, neurological, vitals, auscultation, etc. Physical exams have been an area I always feel unsure of myself in. I think part of it has to do with the number of PE we learn and have to sort thru in clinic at the drop of a hat. When Lesley started categorizing them it made me realize that so much of what I already do (vitals) are PE and also that by putting them into categories it helps simplify choosing the correct ones.
Commitment to act: I would like to work on my confidence in asking for patients to do PE for me. I would also like to encourage myself to simply do one PE per patient no matter what. In that way, allow myself to practice some of the PE that are less common.