Author: nanimov

This second half of my Sub-I went by super fast. After the team change I felt like I had to pick up more responsibility for various reasons. Part of it being that I was the only person on the team with prior experience with the large majority of our patient and knew their cases pretty well, so even with patients I wasn’t directly following, the interns and senior looked to me to get a sense of the patients’ overall trajectories and trends. In one case, we had a patient who kinda kept cycling between health and decompensation (often right before we would be planning discharge), and I had a random thought to ask about potential ingestion that were not on his med list. Turns out he kept getting this supplement from home that was tanking his blood pressure. This was more of my own imagination and the influence of watching House than my personal relationship with the patient, but it still felt good to be the one who figured it out. We also had the most jaundiced, healthiest-acting person with likely terminal liver disease that I had ever seen. It looked like he had been colored over with a highlighter, but he was always in a good mood, feeling good and just overall a nice guy. I’m sad that my sub-I ended before I was could see one of the patients I had been working with the whole time. I had gotten to know the family and was seen as the primary point of contact from the medical team. Our plan for this last week I was on was to have a goals of care discussion with the family. The patient and family asked if I could be there, but sadly my last day was the day before. I hope he did well and is now on the way to a decent recovery.

Having this rotation right after doing a month of inpatient family medicine was nice. I think I definitely confirmed that I want to at least train with inpatient components and possible continue being able to do inpatient after residency.

This week as gone by super fast. Not too much to update on. Still the usual feelings of not doing enough but at the same time feeling like I’m miles ahead of where I used to be and that I am making real contributions to the team and patient care. I did get feedback from the attending this week who said that he thought I was doing well and above what was expected of me which felt good, but can’t help that voice that says it’s not really real.

I think for the first time, one of the patients I was following passed away while in the hospital. It was very sad and I fear that her last days were not the most comfortable (she had Alzheimer disease and was constantly fighting us off, even her daughter). The patient past away early in the morning before shift change and with the family in the room. My resident spoke with the daughter afterward which I think was really impressive example of empathic medical condolences, something I would like to be able to practice, but feels like an opportunity I probably won’t be allowed to have until I’m a resident myself.

Otherwise this week we also got a bounceback, though it’s questionable whether or not she needed to be admitted, but it’s ok I don’t mind, she is a very nice lady, easy to talk to and she would help me practice my Spanish.

It’s been a long week, but I don’t feel super drained. I have a baseline tiredness, but I feel relatively energized to go in to the hospital. The only terrible, worst-ever thing is the traffic to get there and go back home. It’s the worst.

Weekends are half-days on at this hospital which is kinda interesting, but it makes the 6 day work week a bit more bearable so that’s nice. Today I picked up a new altered mental status (AMS) patient. These cases are always interesting because the differential for what could be causing it is so broad (also I don’t mean to refer to patient’s as their presenting problem, but in these I’m trying to depersonalize the story as much as possible). We get to do a lot of test and narrowing things down. The unfortunate part is that, at least in the cases of AMS that I’ve seen, sometimes we never get a hard and fast answer. Either it resolves because we are treating multiple things at once or it never resolves despite us addressing most of the typical things that would cause it and the rest of the work up is negative (diagnoses of exclusion are often unsatisfying to me).

Anyways we did a quick rounds with a different attending (from our sister team), finished our notes, our senior signed out and we got to go home by the early afternoon.

For those that know me, you know I really hate traffic. It is one of the few reasons I would not want to live long term in LA. It’s not just the enormous waste of time and resources the traffic causes, but it also is just a full-frontal confrontation with everything that is wrong with society. Perhaps I’m being a bit dramatic, but when I look at traffic all I can think about is how much car exhaust is being spewed into the atmosphere and how sucky our public transportation is and how selfish we are as individuals to have personal vehicles and how unaffordable housing is so people live far from where they work and how we just accept all of this as our reality.

Anyways, I typically feel happier and more energized when I get to the hospital. Today was a pretty chill day. We were on call, but didn’t really get many admits fortunately, though I was kinda hoping for some because my patients right now are pretty straightforward and I want new things to think about. But if any came in after I left, I will pick them up tomorrow. I keep telling myself I will be productive when I get home after being at the hospital, but I want to do is vedge (I deem this the proper spelling cause veg and vej simply are wrong) and sleep. While I enjoy what I’m doing, I’m looking forward to my day off.

The theme today was “goals-of-care.” With really sick patients who are nearing the end of their life or for whom are treatment options are limited, we have a discussion with the patients and their families regarding what the goals of care are and through shared decision-making, figure out how we are going to proceed in light of the present limitations. Fortunately I wasn’t leading any of these discussions today, but was able to be a witness to my senior residents having these kinds of discussions under multiple circumstances, including during a patient’s acute decompensation. This event was a whole experience in itself. Perhaps surprisingly, this is the first time I can think of where I was present and involved in a code. It wasn’t a code blue, it was a code sepsis, but it was still exciting, not in a fun way, but in a “spring-into-action-I’m-not-sure-if-I’m-being-helpful-but-I-want-to-make-myself-available-and-also-I’m-a-little-scared” kind of way.

First (couple) day jitters are gone and I am definitely feeling a bit more confident in my presentations and also just with talking to and caring for my patients. Two of my patients are primarily Spanish-speaking and it’s kinda crazy to see how far my Spanish has come from 10 months ago. It’s still not perfectly fluent, but I can mostly get through brief interview and updates with patients without the use of a translator (though I always offer or have one on standby). I also spoke with a patient and their family today, and they told me how impressed they were with me which was a nice bit of affirmation that always just hits different than being give positive reinforcement by residents or attendings, for some reason it feels more real.

Today I got to pick-up some patients today. It’s always hard to try present and round on a patient who is new to me. Overall it just had different vibes to my last rotation. Family medicine and internal medicine definitely have different energies, but maybe it’s more the hospital itself vs the residency culture. Still having a good time for what it is, but also I still don’t really have any actual responsibility. I can’t imagine when the time comes where I actually have to make real decisions for patients in a way that impacts their health. The thought is also motivating for me to be the best I can for their sake.

This is going to be my first time working in the Kaiser system. I’m curious how it’s going to be after spending so much time in county systems. Today was pretty low key because it was orientation day, so they didn’t even have us follow any patients. It’s also the first week on wards for the interns on our team so that will also make thing interesting. I came and joined them in the middle of rounds, the presentations were pretty formal which I feel like hasn’t been the case in my recent rotations, but maybe that was just my perception. There were some interesting patients on the list who I was hoping to follow if they are still there tomorrow.

The last day of a rotation is always the worst; having to say goodbye to the people who you’ve come to know over the past few weeks or so. Fittingly all the patients I was following from yesterday were being set up for discharge today and I was able to do my part in making it happen. We had some good discussion on pragmatic ethics and also in celebrating the good in patient for whom we can’t give a neat answer for their symptoms.

I still have.a lot of thinking to do, if anything doing this rotation made my decision harder, not easier, but I’m not sure what I expected. It would have been easy if I hated the program, but (1) I have never hated any rotation so why would I start now and (2) I loved the program. I did get a chance to talk with a doctor who made some salient points to help balance out my thinking so I guess I’m just going to need to do some more soul searching.

Big shout out to all the residents who made my experience so awesome and to all the faculty who put up with me.

The more I think about it, the more I can imagine myself at a program like this. There is so much opportunity to really do everything. There’s no competing with residents from other specialties to be involved in various activities whether it be trauma, surgery, ICU, etc. On the other hand, this program is in a unique area. If I want my practice to reflect this full spectrum training, I may end up needing to either stay or go somewhere more rural. Which may not necessarily be a bad thing, it’s just something I will need to consider for myself.

What I do know, is that if I did train here I would be more prepared than at any other program to just be dropped in a random area and be able to practice medicine (if that sentence makes sense). And this idea of being prepared for anything is something that has always been a part of my philosophy in life.

But yea the theme of the day was really imagining a future in which I was a resident here, and surprising to myself I kinda liked what I saw.