nANIMOv

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.

TTITF
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.

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.