Internal Medicine – Day 24

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.

Internal Medicine – Day 23

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.

Internal Medicine – Day 22

Expectations are a huge part of medicine. Whether you’re are a provider, a patient, a student, a family member, or in any other role your expectations and whether or not they are met is a major deciding factor in whether or not your healthcare experience is a good one. In many cases, it seems like it’s the physician’s role to help manage expectations for the care team and for the patient. As a student, I’ve noticed it can be easy to get caught up in chasing lab values as an objective marker of a patient’s health improving. So much conversation and decision making occurs in the workrooms, unbeknownst to patients. Orders get signed, patients get sent of for diagnostics, or get their blood drawn without much shared decision making or conversation. I’m not necessarily saying that the patients need should be consulted before making every single decision, that would be impractical, but they deserve at the very least to know the plan before it happens or as it happens if possible. We need to set expectation so they don’t think we are poking them just for nothing, and when we think about it this way I think we become more mindful as to whether or not certain things are necessary. On multiple occasions, patient’s were getting their blood sugars checked unnecessarily, just because the order was placed in the ED and never canceled as they are transferred, until I point it out to my seniors or attending. Often times the patients have not expectations, so they just go along with it because they assume we are doing what’s best. Having conversations with patient about their care should be the standard. Managing patient expectations should be a part of their care, not an afterthought.

Costco pizza, good public radio programming, innovative alarm clocks

Internal Medicine – Day 20-21

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.

Internal Medicine – Day 19

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.

Internal Medicine – Day 18

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?

Fidget toys, book sales, blue light glasses

Internal Medicine – Day 17

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.

Internal Medicine – Day 16

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.

Internal Medicine – Day 15

Last few shifts have been pretty quiet. My patients have been pretty stable, but aren’t quite at the point where they can be discharged. Plus we haven’t really gotten many new ones. Of course though, close to the end of my day a new admit came in from the ED and I was overdue for a new one so I volunteered. Based on the sign-out we got it sound like a pretty straightforward case of angina secondary to coronary artery disease. After taking our own history, it sounded like things may be a little more serious than we thought, but perhaps only slightly and with marginally higher suspicion of something more insidious happening.

Over all, it sounds like a pretty “bread-and-butter” cases as I hear people say so so often, so I’m glad I’m able to take this one on from the very beginning.

Internal Medicine – Day 14

I finally got to see a paracentesis. It’s one of those procedures that makes you think of old crude, medieval medicine. There’s fluid in a place where it shouldn’t be. How are we going to treat it? We’re gonna suck that shit out with a big ass needle and drain it into a giant milk bottle. Simple, yet effective (of course this doesn’t address the underlying issue, but we’ll put that aside for now). As much as we like to think of medicine as a strict science, a lot of it is intuitive/ common sense, as long as you know the science.

How do you treat an infection likely cause by this organism? Put something in the body that kills via a mechanism specific to that organism.

At the end of the day, doctors are just people who are out here making decisions based on the evidence available to them, especially with inpatient medicine. In outpatient the script is flipped. Patient’s have more say if the direction of their care, which on one hand is a good thing and navigating that is an art of its own, I’m not sure which I prefer. Inpatient feels more like science which I think is really fun. Outpatient feels more like life coaching and habit-shaping, which I think is also fun in its own way, but not in a science way, but it also aligns better with my philosophically. aowegawehgawiaejgoaehgueah

(1) People who are willing to be vulnerable, (2) stranger smiles, (3) made up phrases.