Category: Medical

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.

TTITF
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.

TTITF
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.

One key requisite to becoming an expert in a given field is to be given consistent real-time feedback regarding your performance. I think this clerkship phase of my medical education is a good set-up for such feedback. The thing that gets in the way though is a mix of pride and evaluation threat (people don’t want to get a bad eval because they asked or said something wrong/ dumb [this is a whole ‘nother conversation about how these evaluation are constructed]).

I brought some of these concerns up to my new attending during a conversation about expectations and he did a pretty good job of alleviating them and making me feel heard. The beauty of this part of our medical education, in my opinion, is that we as students have the opportunity to make mistakes in a safe environment that won’ actually negatively affect a patient’s health while also opening opportunities for timely feedback. If I’m afraid to look dumb, I’m denying myself learning experiences that are probably way more potent that me just reciting the “correct” management plan that I read off of UpToDate or from the night float’s note.

Our attending has been challenging us a bit more recently. Sometimes he asks things that are difficult for me to answer or I have no idea what the answer is. Even though it’s a bit demoralizing confronting just how much knowledge I still lack, it’s also motivating to think about how much there is still to learn. Being able to recognize patterns and put together a story of disease is kinda exciting. Being able to predict what labs will turn up, can having those predictions confirmed when your suspicion is correct is a really nice feeling. That’s what I’m going to be chasing coming into these last couple weeks of IM.

We run into a lot of logistical red tape with inpatient medicine (not that outpatient doesn’t have its fair share). Understaffed floors, impacted services making it take an absurd amount of time for a patient to get a simple procedure or study done, papers going here and there, inefficient communication chains. At the end of the day the people who really face the consequences are the patients. How do we make hospitals more efficient? How can we overcome egos (good luck with that in the hospital)? I have some ideas, but I’m still just a lowly medical student and have a lot to learn about the hospital and medical system. But maybe by the time I get to that point I’ll be too jaded and consumed by the system to want to do anything about it.

This morning I felt extra energized after my first real weekend in a while. I even was able to make my coffee instead of getting it at the hospital. When I got there though, idk, the sleepies hit extra hard. Maybe it’s cause my patients right now are kinda sleepers; not much direct management required, and not a lot of patient interaction. Medically they are quite interesting, but just today not much to do and also their diagnoses are pretty slam dunk, not a lot of critical thinking necessary. I find though that sometimes patients will have certain lab abnormalities that I want to work up, but my attending or residents don’t really care about them. Even if exploring them won’t change our management or necessarily help us get them out of the hospital, I’m curious to know the mechanism, and having the freedom to run my own tests would help with that. Alas, these are real people we are dealing with so we can’t just order all the tests and do all the things willy-nilly to see what happens.

But what if there was a virtual environment where you could do that?

TTITF
Fidget toys, book sales, blue light glasses

This team is very, let’s say thorough… which is a good thing, it just usually means we spend a lot of time perseverating on certain medical decisions and/ or teach points. I think it’s been great for my learning, but also it means I’ve been staying at the hospital into later in the day. Also lately I feel like my thought and ideas and contributions have been more entertained than with previous attendings which has been nice. Not sure if it’s because this attending just enjoys teaching and being more hands on or if my suggestions/ thoughts have become more viable, probably a mix of both, but also probably more of the former. But I kinda like just sitting in the room talking about differentials and tests and evidence and stuff.

I feel like I’m breaking out a bit more for the first time in a while. Not sure what it is. If it’s the long days. The lack of sleep (though I’m not sleeping thaaaat much less that usual). The 10+ hours a day in a mask. The internal medicine diet. The stress. Part of me thinks it might be as simple as this new sunscreen I’ve been using that is very oily, but I only put it on when I’m driving home. Maybe it’s a combination. I will say it’s nothing like it was before, but definitely surfaces bad memories (though my scars are already a constant reminder and source of insecurity).

I have an actual weekend coming up, so hopefully that will help clear things up. Or if nothing else help narrow down the etiology.

Definitely been thinking a lot about what I want my future in medicine to look like these past 3 weeks and I feel like I’m getting closer to an answer, but still probably not anywhere close to a definitive answer. Yesterday I ran into the clerkship director of my Ob/Gyn rotation while getting pho and he had a lot of interesting insight.