Tuesday, October 29, 2013

Lost at Sea

NB: I didn't have a full understanding of what internal medicine meant until I started med school, as a brief primer for those as confused as I was: after medical school trainees pic a field in which to train further one of the biggest subsets of that is 'internal medicine' or 'medicine' as we often refer to it.  These are physicians trained in the art of caring for the general medical problems of adults, their counterparts who focus on children are known as pediatricians. 

I had been looking forward to the start of my internal medicine rotation, its the real bread and butter of medicine.  The core of what all other medical training I have in the future will be built is the solid foundation I obtain during this clerkship.  I started my first day expecting to feel confused and lost but did not anticipate that feeling dragging on for the better part of a month.  My biggest frustration was that I spent so much time seeking out opportunities to learn but never finding quite the instruction I was looking for.  Although we do receive a fair amount of instruction in the M1/M2 years about note writing, in all honesty none of it really stuck because I didn't have to use it.

My first call night I sat around twiddling my thumbs, half of me hoping I could get a patient and the other half crossing my fingers I wouldn't have to.  As call wound to a close I happily drove off into the night feeling relieved that I didn't have to put on a display of my own ineptitude in front of my residents.  The next morning when I had to quickly scan over the admission history & physical done by the overnight resident and "present" that patient to my attending I regretted not having been able to do the admission on my own.

My second call night I was happy to receive an admission in the middle of the afternoon, my senior resident called me and told me to head down to the emergency room where the intern was already seeing the patient.  This time I was prepared, I had created a template for myself to make sure to hit every point necessary HPI, past medical, past surgical, current medications, social and family.  I pushed my way through the widely swinging ER doors and spotted the medicine resident across the nurses station and quickly made my way over.

"Oh Mrs. Jones, this is my medical student _______ who will be working with me," the intern quickly said to the patient

"Hi, its very nice to meet you. Can you tell me a little about what brought you into the hospital today?" I responded, addressing the patient

"You know, I've already asked her all of those things so if you had anything else specific you wanted to ask you can go ahead. Or I guess you can listen to her heart" the intern quickly chimed in.

"Oh okay, Mrs.  Jones would you mind if I listened to your heart?" I responded.  I proceeded to listen to her heart and then threw my scope around my neck and followed the intern out of the ED.

"So you can go ahead and write your note and then we'll talk about it, okay?" he told me as we quickly walked down the hallway back to the secluded computer labs on an upper floor of the hospital.

"Yeah, sure.  I may need you to fill in some details that I'm missing if you don't mind," it was all I could manage as I tried to hide my severe disappointment at what had just transpired.

I wrote a note on this patient, well as much as I could have.  I pieced together the information my senior had given me over the phone, what the intern was telling me and what bits and pieces I picked up at the patient's bed side.  It was so far from ideal.  I was fuming with anger.  I didn't have most of the information I had wanted to ask and even if I did I wanted to hear it first hand.  I didn't know how to put together a note or at least not the assessment and plan which is the only part anyone ever reads.  I flipped through old records to find notes that looking thorough and tried to mimic their style.  I had no idea what I was doing.

The next morning I was expected to present this patient to the attending, which I did poorly considering I knew next to nothing about this lady.

In many ways I can take responsibility for what happened, I could have gone back and asked the questions again.  I could have waited till she hit the floors, I could have gone in the morning but the point here is the entire purpose of the exercise was lost because someone didn't bother letting the medical student know what was going on in a timely fashion.

I understand we're at the bottom of the totem pole and everyone gets put through the ringer during clerkships.  I'm a hard person to suck the optimism out of but I'd have to say I can feel it slowly starting to seep out of me.  Its really starting to dawn on me the life altering choice a career in medicine has been.  My clinical life is probably at the lowest intensity it will ever be in my life but I already feel exhausted and overwhelmed by it.

Part of me thinks this is just the learning curve slapping me in the face and once I make it over this little hump it'll be smoother sailing.  Another part of me is worried that I'm never going to get good at this.

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