We changed things up a bit today thanks to the new schedule we received yesterday. Today I was on an ED/ consult service. It was a pretty sobering experience. There were a lot of suicide attempts, and a lot of young suicide attempts. On top of that I felt like my attending was kinda numb to it all, which I suppose in some ways I guess you have to be. It seemed like he was kinda numb to everything. The suicide, the psychosis, the volatility. I was mostly shadowing today and there were several times throughout the day were I felt like I should say something almost on behalf of the patient or out of my own guilt, but I held my tongue because who the fuck am I.
I also got pimped a lot on pharmacology which is one of my absolute worst subjects, which is saying something. I’m pretty sure I got every question wrong. Definitely the swift kick in the butt I needed to gear up a bit more (also I had the option yesterday to stay with the very chill attending that I was with the first 2 days).
Even though in terms of net experience today my needle moved further away from psychiatry, I will say I found a lot of value in talking to patients on my own and something I look forward to doing more of.
These first couple days have been a bit strange. It feels like no one has really known what to do with us. The clerkship director I guess has just been getting back from some time off and the inpatient attending who we have been working with just doesn’t seem familiar with having students work with her at this hospital. We made it work as best we can and the other student and I were able to do some learning today. Today I got collateral (supporting second-hand account of patient’s condition) from someone I had been curious to talk to. This person basically confirmed a lot of the story of patient himself, some of which sounded almost unreal, but the fact that they are real very much supports his diagnosis. We interviewed a lot of patients as a group today. I realize that I may not make a good psychiatrist because every time the patient talked about pain or a weird heart thing my instinct was to OPQRST them and break out my stethoscope.
Later we did get to speak with the director and get out schedules and kinda have some structure brought into the tumult that has been our lives the past 48 hours.
Also it’s burrito week in SB, and my classmate and I got the Super Cucas burrito. It was good. I still prefer their Cali burrito though. We also went to the farmer’s market which they hold INSIDE THE HOSPITAL COURTYARD. I got a pie.
After I got out the hospital I went to volunteer with my old street medicine org. It was really nice to be back. Sitting in the park talking to folks just made me think about how much I miss this work. In this setting and even in the hospital and in the clinic, I love talking to patients, whether its about medicine, their health, or just about how their birthday is coming up and they reserved a stage to play music and invited all their musical friends and they want everyone in the community to be there.
Then after that I got another burrito.
It seems almost a fitting juxtaposition that I attended the ISMS last week and I am now starting my psychiatry clerkship this week. At the conference there was a lot of discussion about how we as a society and especially as a medical community talk about mental illness and how the pervasive stigma towards mental illness impacts the care patients receive (I’ll post about this over the weekend). On my first day in the hospital I got just a small glimpse into the manifestation of that stigma and the inadequacies of our current systems as it exists in higher level psychiatric care.
Beyond that it was a good first experience in inpatient psychiatry. I think psychiatry is interesting in that the manifestations of mental illness are primarily behavioral, so I don’t expect them to present as concretely in real life as I do in a textbook. That said the patient I saw today had pretty textbook mania. It kinda makes you wonder sometimes if patients have done their research and are just intentionally saying the “right” things, but that’s maybe my implicit stigma and bias seeping out (’cause also why would someone fake mania). I’m looking forward to how the rest of this rotation is going to go.
This was my first time attending the International Street Medicine Symposium. I’ve been wanting to go since I first got involved in street medicine back in 2017. Overall it was a very inspiring and humbling experience. Being in the presence of all these amazing, compassionate people who are doing the work, for me highlighted how much more I could/ should be doing just based on the amount of work that needs to be done. From the talks throughout the conference there was a lot to think about and reflect on and it’s hard for me to articulate exactly what I learned. I wrote a lot of discombobulated notes in my journal since I was getting bombarded by ideas left and right and I need to organize them all into somewhat comprehensible thoughts.
I will say I have really missed actually working in the streets; working with the street team, talking to clients, listening to their stories.
There a ton of reflections from this experience that I will be hopefully fleshing out over the next week/ between my scheduled psychiatry clerkship programming (orientation is today).
Not sure what else I have to say that I haven’t already said about this rotation. I’m a little tired of always saying it’s bittersweet to be ending a rotation, even if it’s genuinely how I feel. At the end of the day I went around to let the patient’s I was taking care of know that it was my last day. There was the gentleman with a Wernicke/ Korsakoff encephalopathy who everyday would forget who I am and yet also believe I was somehow a good acquaintance of his outside of the hospital. There was the woman I just met today with a pretty complicated social history and a newly complicated medical history, who despite all that appeared to be coming in for a relatively simple drug rash. Last but not least, there was the gentleman who came in telling us he wanted to die, which turned out was out of desperation given his social situation and alcohol use, and he just wants a place to feel safe.
The population they serve at county is not always an easy one, but that’s part of what makes the work rewarding; feeling like we are helping people in their most vulnerable moments. Yet I can’t help but think about the role our healthcare system plays in perpetuating some of the barriers and inequities that get patients sent to us in the first place. But maybe that’s a discussion for another time.
Right now I will just focus on appreciating the small role I was able to play in my patients’ care and hope that in some way I was able to make their experience and the care they received a little bit better.
My second to last day on the wards. And it was a short one since I had meetings/ didactics in the early afternoon. As we approach the end of the rotation as does the bittersweet denouement that oft accompanies it. I know it’s lame to talk about and don’t tell my classmates because it’s taboo not to talk about how tired and overworked you constantly are, but I’m kinda gonna miss my early mornings. I’m kinda gonna miss hanging out with my team in the workroom. I’m kinda gonna miss running around the hospital on my own visiting and talking to patients, whose lives I feel fortunate to have played a teeny tiny role in. I enjoyed inpatient medicine a lot more that I expected, definitely not brining me any closer to a decision for my career.
Ice cream, small shops that sell things I can’t afford but are nice to browse, community gardens
I felt bad for the first year residents today. They were new on the service and it was our senior’s day off. I could sense that they were a bit overwhelmed understandably, but also they handled the whole thing super well. I’m trying to imagine having the type of pressure that they were experiencing, more or less having these patient’s lives in your hands. Of course they still had the attending to supervise and approve their decisions, but also the attendings usually aren’t micromanaging, and generally trust the team to carryout all the tasks that were discussed.
Also one of the patient’s was sent to the ICU for a decline in his respiratory status which I imagine was probably a scary and stressful experience for the intern (likely even moreso for the patient if he was aware enough to remember), which made me think about how through this rotation I have not been in any emergent events with my patients which is fortune, but also I will inevitably will face one some day and when the time comes I hope I’m ready professionally and emotionally.
Crispy tater tots, sweatpants, used bookstores
I don’t mean to sound cheesy, but I’m actually so happy I went into medicine. I can honestly say I love what I am doing. Sure days can be hard sometimes, but these days I constantly feel like I’m working at the edge of my ability so I’m challenged and stimulated on a regular basis, but not so far that I feel lost and out of my depth. And even the actual doctors who I work with seems like they are still being challenged, the difference is they know how to deal with things and make decisions without consulting a secondary source every 5 mins.
IM has been good to me and I’m a little sad that it’s coming to an end, but also glad to be able to get a normal schedule back.
Friendly neighbors, good street parking, crispy but not dry chicken tendies
The physical exam has always been one of my favorite parts of medicine. Finding tangible evidence of an underlying pathology is such an intellectually gratifying experience. As a medical student though it can feel like we do physical exam just for the tradition, like we’re just going through the motions, in favor of more sophisticated diagnostic techniques.
Today though, physical exam changed our team’s management of a patient in a way that the CT scan and labs could not. If I had skipped doing a thorough neuro exam (in truth did a subpar exam when I first saw the patients, but went back to do more complete one after realizing I didn’t have enough data), we potentially could have missed a pretty severe etiology of this patient’s altered mental status, which initially seemed relatively benign based on the CT and labs. This was my first time finding cerebellar deficits in a patient who was otherwise minimally mentally altered (he did ok on the MOCA, not great, but ok).
I love finding murmurs. I love hearing crackles and finding pitting edema. Of course not for the patient, but as I mentioned for some reason seeing these manifestations is a gratifying experience purely from a scientific perspective. Like it’s proof that physics and chemistry and biology work more or less in the way you think they do. Especially when you can work towards their resolution or explain why they are benign through the same logic.
I am once again confronted with the huge, enormous weight of language in medicine. Today I had a long conversation with a patient regarding the long-term implications of her potential diagnosis (pending some studies). I feel like I did a decent job at communicating in a patient-centered way through a translator, I can only imagine how much more effective it could be if I spoke fluently. A lot of the non-verbal and inflexion gets filtered through a translator, and sometimes it’s hard to tell if what I’m saying translates well into whatever language I’m translating to. My Spanish has definitely improved, but it’s definitely not at a point where I can do a whole patient encounter on my own (except in some cases when where the patients are experiencing a significant change in mental status).
The other day we had a Korean-speaking patient and we needed a translator to talk to his family. It took an hour before we were able to get one on the line through the phone interpreter service we used, and they probably have been doing back to back translating for the whole day.
How many times do we label patients “poor historian” simply because we can’t communicate with them properly. Perhaps they don’t feel comfortable speaking through a translator. Perhaps our words don’t translate well. My dream is to be a polyglot primarily because the connection you are able to establish with people through language is really unlike any other.