We had a substitute attending. Both the attendings I’ve worked with so far have been pretty young. Like late 20’s early 30’s looking. He was a super friendly guy with a very amicable and loose way of talking, as if we were his buddies and we were hanging at the bar. Except instead of beers we all had black coffee. And instead of sports, we were talking about anion gaps and how to spot right bundle branch block on an EKG. He put a lot of pressure on me when I was up to present my patient. He wanted me to read an x-ray and give a full assessment and plan for a patient, who I honestly had no idea what was going on. As we went through the presentation I maybe started to piece somethings together as processes were running in the background while I was speaking, trying not to repeat myself too much. When he actually asked for my assessment, I paused for a while, and stammered a bit, but eventually pulled a diagnosis out my ass, and he actually agreed. At first I thought he was doing one of those things where they just humor you at first as a teaching point and make you defend your case and describe your thought process even if you’re wrong. It felt good, and even for all the stress I had throughout the process I appreciate that he made me go through it and also didn’t make me feel too stupid when I said dumb things. Overall I’d say it was a good day for learning.
I got my first patient today. History of pretty severe brain damage coming in for some generalize weakness. He was also in a pretty well-guarded and kinda hidden ward. I got lost trying to find it when I left the workroom to pre-round on him. And when I did I kinda followed some people who looked like they knew what they were doing, and then had to ask around cause the patient was not where our list said he would be. When I finally did find him, I wasn’t able to get much info between the language barrier (even with an interpreter) and the cognitive impairment. Fortunately he did understand enough (I think) to let me do some physical exam so I wouldn’t come back completely empty handed, though also just watching him move (he was feeding himself at the time) did also give some good general exam findings that I could report on. After that the day pretty much business as usual. Rounding then charting. My guy was pretty stable so after a quick consult, we were able to discharge him. My note was in and I was done. First patient, in-and-out.
It’s definitely a lot different here compared to family medicine. A lot of people talk about how crazy IM is, but to me, even in peds, it kind of feels like there is a lot of downtime compared to family medicine, at least from a student perspective. In FM, I was constantly doing something. Constantly alternating between seeing patients, to charting, to seeing the next patient when they were ready. No time to catch a breath in between. That said it is still early, and I don’t have the patient load of an intern (or even a sub-I) so that def part of it (but similarly in FM I didn’t have a full load). Yet why does it feel like there so much less time in the day?
1 hour of orientation. That’s it. 1 hour for possibly the most time intensive rotation of medical school. On paper it’s 12 hours a day, 6 days a week. Thankfully it’ll be a little less than that most days if the residents are nice (though I feel bad because they actually need to stay the whole time). At orientation we just went through kinda of basics of the rotation, assignments, etc. and afterwards we went straight to the wards. I was excited because the person who was listed as my senior resident was someone I had met before volunteering and had run into a few times during the outpatient portion of my peds rotation. Super chill guy and was looking forward to being able to work with him some more. The other 3rd year on the team with me and I got a little lost on our way to our team’s work room but we made it. We met the senior and the 1st year residents. They all were super friendly and welcoming. It was a really good day, rounding with them, getting to know them. And then I find out today was their last day on the team before they switch to their next service… sad 😥
Overall though, IM was more or less what I expected. Very similar to in-patient peds, just a bit… older. But we spend the day reading out patients, then running around to see those patients and talking about them, then coming back to the work room to write about those patients. Since it was our first day, we didn’t get to have our own patients yet, but it was a good glimpse into how the team operated. Because of that we didn’t have much to do and that made it a little slow after rounds since there also were no new admissions. Thankfully, they sent us home a little early after the cutoff for new patients. Tomorrow is when it really begins.
Sometimes when (if) I proofread what I write I notice that I will have completely left out whole words from sentences, words without which the sentence doesn’t make a lot of, at least in the absence appropriate context. I find that it happens most often when I pause to think. As if that word is a cliffhanger that never made it on the page, except there’s less drama and more confusion.
Language is a crazy thing. I’ve always thought of as separate from the various things that separate humans from other animals, but the more I think about it the more I realize it really just falls in the category of abstract thinking; our ability to believe in/ assign value to things that don’t have “concrete” existence (at least that’s my understanding of the concept of abstract thinking, please correct me if that’s not quite accurate [though saying such a thing reinforces the point I’m about to try to make]). Among other things in that category are money, religion, and crypto (which is like abstract-ception). These things have value because we say they do. There’s function and purpose to it of course, that’s why from an evolutionary standpoint it stuck around and helped humans be so “successful” in such a meteoric fashion. We use made-up symbols and sounds to communicate ideas about made-up things that we associate with tangible things, but only with people who believe in the same made-up sounds, symbols and things.
But these beliefs run so deep that even if important made-up things are we can still often make sense the idea being communicated, even if we are talking to someone we’ve never met before who just happens to share our abstract beliefs. Or in some cases we can even use a key or a decoder to relate our made-up beliefs to the completely different made-up beliefs of another person.
Or sometimes those symbols and sounds can be used to talk about something completely meaningless and non-sensical that only makes sense in the mind of someone who likes to talk about things he doesn’t fully understand.
My last full day in Family Medicine (as a medical student). And I was with a new doc. From what she told me, sounds like she’s relatively new out of residency and still building her practice. Her schedule did have a lot of Ob, peds, and new patients. I really enjoyed her style though. She was very autonomy oriented, as I hope to be, always trying to get a sense of what the patient had in mind as far as plan/ treatment/ what they would be open to before making her own suggestions. It’s not that the other docs ignored patient autonomy, but some encounters did seem like they were very much centered around numbers and lab values vs centered around the patient (not to detract from any of the docs I worked with, they were all amazing and showed their compassion and demonstrated patient-centered care in other ways).
Now I’m not sure if that is a product of her maybe being a little younger than the other docs, have to do with the fact that she had a more contemporary medical education relative to the others, or due to the fact that she may not be quite as far along on the jaded/ burnt-out scale compared to the others. Definitely wish I could have worked with her more.
I saw 2 fresh patients who were establishing with her. I thought I had done a good job of eliciting their health goals with their new doctor without injecting my own agenda. They both had a primary goal of weight loss. And I went through kinda the different options and approaches and seeing which they would be interested in pursuing and patted myself on the back for being so patient centered. But then my attending basically wrecked me after I presented the first of those 2 patients and was like, well did you ask to see if she had already done her own research and have a specific plan in mind as far as her weight loss? How could I be so dumb? The patient didn’t have a specific plan in mind, but I thought it was a good things to ask, and so I did with the second patient. She also had no idea. BUT STILL I think it’s good to recognize patient’s ideas and expectations regarding their healthcare and be able to address it even if you think whatever it is they have in mind is no recommended and you have to tell them that, because at least they will know that you considered it and care about what they have to say.
Fast internet, old keyboards, sticky notes
I always wondered why they were there. Why do they roll in with the waves just to burrow back down into the sand? Why don’t they just stay underground? Do they have to come up to eat? We used to catch them and feel them scamper around in our hands. I used to be afraid they would burrow through my skin. We would collect them in our 10 gallon plastic bucket and try to observe them undisturbed by the tumult of the tide, though perhaps more for sport than any investigative endeavors.
Interestingly at night, they don’t seem as eager to make their subterranean retreat. Maybe it makes sense because their predators may be asleep, but why even hang out? Is there more food? Is it cozy up on the surface? What is it is about nighttime that makes them so much more bold.
It’s really interesting seeing all the different personalities and practice styles of all the different physicians. It makes me wonder how I’ll be once (if) I get my shit together. Will I be the type to bring my computer/ device in with me? Or will I take notes on a paper towel? Or will I try to keep the story straight mentally in my head? Or maybe there will be a new cool standard of technology (Google Glass-esque?).
Will I try to address all of my patients issues in our “15” minute visit and give them a hard cutoff in order to get to the next patient? Or will I take as much time as I need with each, even if that means making other patients wait a long time and me having to work through lunch?
Will I be the doc that MA’s complain about at lunch?
Will I be the one patients switch to? Or the one they try to switch from?
Will I work to live or live to work? I’m not sure yet which one is better. I feel like neither one is ideal.
I’m afraid of indifference.
It was a day of affirmations. I got a lot of comments from patients today that I was doing a good job. It felt good to be affirmed that at least from patient perspective I was doing ok. Not that this was the first time, but the ratio was just higher today. Part of it may have been that I didn’t feel as pressured today to get on to the text patient. Part of it may have been the fact that most of my patients were English speaking. It just so much easier to make a personal connection with someone who speaks the same language, despite my best efforts to be very personable through a translator with the Spanish-speaking patients. That’s why I need to really become better at my Spanish, thought today I also had a primarily Tagalog-speaking patient. There was a patient today who wanted to practice her English which was a good opportunity for me to practice my Spanish. We still had a translator to mediate some of the harder medical terms and longer sentences, but it was a good experience. I NEED MORE PRACTICE.
Today is what I imagine a day in primary care to be like. Running from patient to patient, barely having time (if any) to catch your breath before the next one is ready to be seen. Not feeling like you have enough time with them, but also hoping that they don’t have more issues to talk about because you have to run to the next exam room. And I only was seeing 4 of the 11 patients this morning. Charting through lunch while I take bites of the adobo I packed as I tab and scroll through the patients chart, typing intermittently. Lunchtime isn’t even over and the first patient of the afternoon is already roomed, vitaled, and ready to me seen. The afternoon was slightly more chill. Patient were less complex and their conditions were all pretty well controlled. Also I heard a lot of murmurs today. Last patient was a joint injection in the thumb which was pretty cool, and I actually ended up getting out a bit early.
Days with this attending are always kinda chill. He picks out patients for me to see beforehand so I know what’s coming up, there’s space between patients, and I don’t have to frantically look at 4 different charts not knowing which one I’m going to end up seeing. That said, I did have to a rectal exam for a patient with some abdominal pain and rectal fullness. Not sure if my attending had planned for that. Then I did kinda your standard diabetes/ hypertension/ high cholesterol patient. And then a 9-day-old newborn weight and color check. Some good variety.