Of note

Today, I would like to officially note that I have finished wards (and a week of palliative care medicine) and definitely have all kinds of interesting things to say about these subjects that requires much further thought process and time spent typing away, but in lieu of those deep and important matters I will say this

WE ARE GOING TO THE RALLY TO RESTORE SANITY OHMYGODI'MSOEXCITEDICANHARDLYSTANDITOMGOMGOMGJOHNSTEWART!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

That is all.

We'll see.

A classmate asked me the other day how I was liking my time on the wards. One of his other friends, apparently, is loving the experience and genuinely considering internal medicine as a specialty. So it got me thinking--do I like medicine?

I did, after all, come into this rotation excited about the possibility because I have thought about doing med/peds. You know, in case looking into ears all day would be too boring. Also, the idea of being able to follow a patient throughout their life, rather than booting them out the door at 18, is intriguing, especially if you consider the possibility of subspecializing within med peds (for example, a friend of mine wants to do a med/peds cardiology fellowship so that she can treat congenital heart diseases in babies, and then follow her patients through adulthood too). So what's it been like, hanging out on the wards, the front lines of adult medicine? The most I can say, really, is that it's a mixed bag. Perhaps it's too soon to tell.

The Good: As with most general specialties, I enjoy the thought process. Looking at the patient's history, vitals, labs, imaging, developing the differential, figuring out what might be wrong and how you could test for it and treat it. It's a fascinating mystery that unfolds before your eyes.

The Bad: In medicine, once you've figured out the diagnosis and treatment plan, you often end up sitting around babysitting the patient with nothing else to do, either waiting for nursing home placement or consults or confirmatory tests or imaging to come back. I have a patient right now who has been with me for weeks while we try to figure out why he has diarrhea. For the past several days, we have done nothing but order some tests and wait for the results. We're helping him, yes, but not actively so, and that's frustrating.

The Good: You see some really interesting cases. On our call day on Wednesday, we took on a new patient with an incredibly rare type of cancer, one with a rare form of nephrotic syndrome that we're still teasing out the cause of, one with new-onset congestive heart failure, and one with (possibly) a very strange and dangerous form of pancreatitis.

The Bad: You also see some really not interesting patients. Our service is typically filled with patients who are either being treated for a COPD (emphysema) exacerbation, or who have cancer and are just waiting to get their chemo. Not that these diseases are not important, but they don't require a lot of work or thought, much like the original "looking in ears" problem. Also, even some of the interesting patients are, to put it frankly, gross. I have a patient with a chronic bone infection that smells AWFUL. Like, you know what room this person is in because you can smell it from down the hall. In kids, you can look past these things because they're kids and it's cute and you feel sad that they have this gross thing, but with adults, it's just kind of...gross.

The Good: Sometimes, your patients are very kind and thankful and wonderful. I had a patient last week with cellulitis who was effusively gracious about my help in getting him out of the hospital so quickly, and it was moving to have him feel so grateful. It felt good to feel needed and useful.

The Bad: Sometimes, the patients suck. My diarrhea patient (see above) is a cranky, nasty person who frequently tells me what an idiot I am because I ask questions that he has already answered--to someone else. We had another patient on the team whose family screamed at us en masse because we suggested that his confusion might be a result of alcohol withdrawal. I'm sure this is true of many medical specialties, but it's frustrating when you get yelled at for trying to help people.

So yeah. Medicine is interesting, and it's kind of hard to narrow down exactly how I feel about it. I'll have to see how my subspecialty parts of the rotation go. After next week, I spend a week on palliative care service, three weeks on infectious disease (which I'm really excited about), and two weeks on another subspecialty (likely endocrine). If I'm still on the fence, I'm considering doing a week long career exploration elective in the spring in one of the med-peds outpatient clinics to get a clearer picture of what "real life" practice is like. So we'll see.

A tale of three patients

As I'm making my way through my month on the wards at the local VA hospital, I find myself slowly moving out of the realm of "OMG I'M SUCH AN IDIOT HOW DID I EVER PASS THE FIRST TWO YEARS OF MEDICAL SCHOOL" and more into the "ok, I may not know everything we need to do for this patient but I am at least competent enough to reason through what is for sure not happening and discuss with the resident the rest of what might be happening." In other words, yesterday for the first time I admitted a patient and was probably more than 75% correct about what was likely to be wrong with him and how to go about figuring out the exact diagnosis and treatment. I am also starting to feel slightly more comfortable about how to get around the hospital, call consults, talk to families, what my responsibilities are in terms of patient care, etc. It helps, of course, that I have a wonderful new team (for the most part)--one of the new interns is incredibly smart and with-it and also a really fun guy, and our upper level resident is much more approachable and less PIMP-tastic* than the previous one. My comfort level may change with the arrival of our new attending on Friday morning, but I'll hold out for my hopes that the progression of learning and competency will continue.

Today, I was carrying (aka in charge of seeing and taking care of) three patients. These three patients are interesting and challenging in different ways, and I think their stories are a really good representation of what medicine is as a career, a specific specialty, and a learning experience. So of course, for myself and posterity and all three people who might read this blog (Hi, mom!), I thought I'd share.

Patient A was the first patient that I "picked up" last week, who came to us with some pretty nasty diarrhea. A has multiple medical issues, mostly the result of years of rampant and untreated diabetes. A's medical problems are many, but we aren't really doing anything for most of them other than maintaining his current medications while we try to get his intestines under control. When I first met A, he was unhappy with me because I had to repeat a great deal of questions that he had already answered, and his attitude has not improved much since. Each morning that I speak with him, A typically tells me at least once or twice how little I know, how I am not paying attention to him, etc. This despite the fact that yesterday I stayed in his room an extra 20 minutes in order to cut his breakfast food up and assist him in getting ready to eat it. It can be amazingly frustrating to work with a patient who cannot understand that you are trying to help them, and A has been a learning experience if for no other reason than to learn how to do with people who will not be satisfied no matter what, and to treat them with just as much compassion as the kinder, easier patients.

Patient B was my next patient--a kinder, older lady who was recently admitted for a lung problem and was found to have a mass elsewhere in her body that we discovered essentially by accident. She is doing quite well, recovering nicely, but really needs to have the mass removed before it becomes a problem. Our surgeons want to remove the mass in the next few days while her lung function is still doing well, but she refuses to make a decision until she talks to all of her (many) children. We have stressed to both her and her spouse that sooner is better than later in terms of safety of surgery, and while the spouse seems to understand, she adamantly refuses to make a decision. I understand completely that this is a frightening choice that could have dire consequences, and therefore I have worked diligently to not rush B, but simply to present her with the situation as we understand it. Unfortunately, this too can be frustrating as you watch time tick away, betting against the clock that in the two weeks it might take to reach a decision that B's lung function will not deteriorate to the point that there are no more choices available.

Patient C is my most recent acquisition, a lovely gentleman with some intestinal issues. He and his family are sweet and wonderful and easy to get along with, and we will hopefully have a diagnosis for him soon so that he can go home and return to his normal and happy life. I look forward to seeing him every day, and the only challenge he presents is that of remembering how I treat him when I go see my other patients.

Medicine is interesting. I'm not sure if I love it or if this experience will tip me into the idea of Med-Peds over Peds, but if nothing else I feel like I'm learning a lot.

* To "PIMP", sometimes said to stand for "Put In My Place," is the process of attendings or upper level residents quizzing medical students on the intricacies of their patient's disease, some other random disease, or sometimes just ridiculously useless information that the attending or upper level feels the student should, by now, know. Usually comes with a negative connotation, as in those attendings who will continue pimping until the student doesn't know an answer, at which point the attending will ridicule said student for being an idiot who doesn't think his/her job is important enough to study for (even if that student had answered the first 99 questions correctly).