Internal Medicine – Day 9

Trying to figure out if I’m enjoying inpatient medicine because I’m working with people who are closer in age to me or if I actually enjoy it. Because of my schedule I’ve had to cut out a lot of things I used to do in my free time, video games and watching anime being big on that list. I actually don’t miss it at all. I mean I miss talking to my gaming friends who I only really am able to engage with on a regular bases through gaming, but I don’t crave playing which is assuring to me that my propensity towards these things was more a convenience behavior. And with the little free time I do I have, I really have to be more intentional about what I spend it on.

I feel like I’ve already learned and relearned so much on the 1.5 weeks I’ve been on this rotation. I’ve seen pretty good variety of things, while also getting a good amount of repeat pathologies to reinforce management of common presentations. I like the pace of the work. I don’t like that compared than outpatient, the vast majority of my time is spent in front of a computer. Inpatient medicine is definitely a different way of thinking, which I feel like I’ve been able to appreciate more with adult inpatient than kids, maybe. Or I just notice the difference more having spent so long in the outpatient, primary care setting. Not sure yet which I prefer.

TTITF:

(1) crushed/ crumbly ice (why are hospitals the only place you can reliably find good ice), (2) bandaids, (3) thin blankets that feel kinda cool when you put them on

Internal Medicine – Day 8

I will say that I very much enjoy some of the patient encounters on internal medicine. Compared to primary care or some of the other populations I’ve worked with so far, with in-patient medicine some of the patients are reckoning with their mortality in real-time which I find to be a fascinating and special experience. Being able to sit with people in their most vulnerable moments and having the opportunity to listen to their reflections in the face of acute illness is part of what brought me to medicine in the first place.

I some of the conversations I had with patients today were good examples of that, the contents of which I would like to keep suspended in the time at which they occurred. And even if I don’t remember what those conversations were far enough into the future I’d like to think they played a role somehow in my future development.

Another thought I had is that almost none of these experiences are taken to account in our evaluations. Most of our encounters with patient go completely unseen by our residents and attendings. And all they see are our awkward presentations as we fumble over our words.

TTITF:
Melty cheese, clear expectations, exceptionally large bunches of kale

Internal Medicine – Day 4-7

It’s been hard to keep up with these, but to be honest, in terms of experience, a lot of these days are more or less the same. I go in, rush to not be late even though I’m already waking up at 4:30 AM, starting looking at what happened to my patients overnight, start reviewing the charts of the new patients so I can decide which one I want to take, go get sign-out from the overnight docs, come back, do more chart review, go see my patients, start some charting, go on rounds, do more charting… wait I am just now realizing I went through all of this in the last post I think. It is interesting to see the different pathologies though, and to think about some of the more difficult etiologies of refractory problems. Also so far I feel like I’ve gotten pretty lucky with patients being pretty open to talking to me. I also feel like my Spanish is improving… slowly. Definitely been helpful to be hearing a lot of medical Spanish on a daily basis. I’m also learning a lot of other stuffy too.

We also got a new attending today. She’s little more formal, but also seems like we are going to have very clear expectations of us for this coming week. Wish me luck.

TTITF:
(1) Friends who talk to you about new things and make me think about things in different ways, (2) lasagna, (3) finding something you thought you lost forever.

Iced vs Hot

I recently came across this “life hack,” or rather this (quite elegant) rant from a disgruntled individual who took to the internet to promulgate about why he thinks iced coffee is a scam. He makes several well-reasoned arguments as to why, including value (with iced coffee you are getting less coffee volume per unit money because of the ice), science (some research found that ingesting hot beverages actually makes you cool down more under certain conditions), and respect for the art of coffee making (you “taste the qualities of the coffee” better when it’s hot). My initial instinct was to agree with him because from an objective standpoint, yes you are getting less volume of the thing your are “paying for” for just as much if not more than you would be getting sans ice; I like science and primary literature-based arguments (even though technically he cited a secondary source and not the journal article itself); and I myself can be a bit snobbish when it comes to wanting to enjoy things in their more “pure” form.

The more I thought about it though the sillier it seemed to me that this man was so fired up about this. Despite his good arguments, the one thing he doesn’t satisfactorily address is that some people may just enjoy iced coffee more. He uses the aforementioned study to argue against the point that people find ice coffee “refreshing” and “helps regulate body temperature.” But even if objectively it may not do that (though also it’s just a single study from 2012), if people believe it does and if they feel good drinking it who are we to deny them that. If people are willing to pay for something they enjoy they should have that right, even if it’s not good deal from a good-per-money standpoint, because the value is in more than the good itself. Also, something tells me not all baristas are toiling over the idea that customers aren’t savoring the hidden notes to be found in the giant vat of coffee they brewed in bulk at the start of their shift in anticipation of the morning rush (though of course those that do should be respected if it means that much to them).

And yes I am also being a bit dramatic, he is not advocating for denying anyone their right to iced coffee. I’m just saying that sometimes I think it’s ok to let people make their own potentially questionable decisions in life if it makes them even just a little bit happier for a trivial personal cost.

Internal Medicine – Day 3

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.

Internal Medicine – Day 2

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?

Internal Medicine – Day 1

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.

Inadvertently Omitted

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.

Family Medicine – Day 22

Another one down. These rotations have been going by so fast (at least it feels like that when they are over). As always, it was bittersweet having to say goodbye to this place that was my home for the past 22 days. The connections and relationships over these past few weeks were about to become a thing of the past. Was it a waste? I felt like I was emotionally invested here, but I really was just a blip in the day-to-day hustle-and-bustle of this clinic. Did I make an impact at all? Remember, if not it’s ok, you’re here to learn, not necessarily change lives or be remembered. Though I am sad I didn’t get to give a proper goodbye to all my attendings.

Overall thoughts on family medicine:

These rotations have kind of felt like a game show. We have all these doors in front of us, behind each is glimpse into in a life that we previously had little to no conception of. From what I saw of family medicine, this is definitely the work I envisioned myself doing when I decided I wanted to become a doctor. Sitting down with patients, listening to their stories, being invited to a have a peak into their lives, their worldview, their lived experiences, and leveraging that to provide the best, compassionate, patient-centered care that I can so they can go out and live their best lives, on their terms.

I saw a lot of that while I was here. But I also saw a lot of barriers to being able to do that properly or in the way I envisioned it. The paperwork. The bureaucracy. The scheduling. The missed communications (vs miscommunication). The redundancy. I can see how even with the best of intentions and the strongest of passions for this specialty (yes specialty, I will fight anyone who thinks otherwise), it can be easy to get lost and discouraged by all the red tape, but I also think thats where the art of medicine can really come in to play. We can’t necessarily change the circumstances in which we practice (at least usually not all at once), but we can change how we operate within those circumstances, just like in life. How we navigate our challenges and obstacles is what separates people for whom medicine is a profession vs an art. It’s a fine line I think, and easy to flip from one side to the other based on something as fickle as what side of the bed you woke up on that morning. We can’t expect to always have the good days. The days where we feel motivated. Where we feel the fire in our hearts. Where we feel our souls being fed. That’s just not the way life works. It may even be a bit much to expect more good than bad. 50/50 is acceptable (such is life in a world where rules are often made by people who are not personally invested in the communities they make the rules for), but every once in a while if you have those moments that remind what you’re here for; the stubborn old man who finally lets loose a hearty laugh. The little girl whose face lights up when you pull a dinosaur sticker out of her ear. The lady who came to you on the verge of losing everything, celebrating 2 years of sobriety. Those moments can make it all work it, and these are just some of the things I have seen in primary care and in having long-term relationship with patients and what draws me so strongly to this field.

That said, who’s to say I can’t have that if I choose to go down a different path. Maybe it will look a little different, but the feeling would be the same. Or maybe I can find a place where I can find work that sustains me, but also give me the financial stability and the time to do the work I think is important on my own terms. There’s still a lot to think about, and so much in medicine I still want/ need to see, but I’m thankful for this opportunity to experience life behind door number 1.

TTITF:
My gimpy, but resilient colocasia that I grew from a taro root from the grocery store instead of turning it into sinigang; unexpected moments of laughter; friends who are like family who still reach out even after long periods of not seeing or hearing from each other.

Family Medicine – Day 21

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.

TTITF:
Fast internet, old keyboards, sticky notes