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Inpatient Medicine
I did my second four week block of medicine at a cushy, suburban hospital. My attendings were more or less relaxed, young, competent, and interested in taking care of their patients, although some were unmistakable hard-core goofballs. For the most part, the learning environment was good.
The patients, for the most part, were grandparent-aged people with a very limited variety of mild, not so acute, medical problems. Most of these problems were contained in this list:
1) Mental status change
2) GI bleeding
3) UTI
4) Syncope
5) Chest pain/rule-out-myocardial-infarction
(Fascinating stuff. )
During my first four weeks of medicine, we had a patient with disseminated MAC from AIDS, a lady with a PEA code because she took too much K-Dur and then went on to develop positive cardiac enzymes after being transferred from the ICU, four encephalopathic liver failure patients (0ne of which had endocarditis), and a patient with a weird Parkinsonian syndrome. There was even someone with aortic regurgitation. During my second four weeks of medicine, I had a bunch of patients who were all mostly affected by medical issues that were like the boring bread-and-butter Case Files cases– without the sharp, distinct details and lab values that the cases provide to help guide your differential. I became excellent at talking to a lot of diaper-clad nursing home residents with pneumonias and UTIs. I would often discover, soon after talking to them, that most of them were unable to correctly identify the current year (2020 was a popular choice for some reason). In comparison to my earlier block, this inpatient block of pasteurized medicine felt like shopping in the dairy aisle at a Costco. The patients were all English-speaking, affluent people with nice clothes. They actually owned automobiles. It was amazing.
Medicine seemed like it followed a very specific pattern. At least at this hospital. People would come in with some sort of vague complaint superimposed on a host of chronic medical problems — pretty typical of any patient encounter, I guess. Our team would initiate a workup, admit, formulate some sort of working diagnosis and a differential diagnosis, and then follow the patient. The whole hospital stay was gauged at eliminating candidate diagnoses from the differential diagnosis list, or rearranging the order of the list with studies. So far, so good. Routine labs, tests, and studies would get ordered, come back day in and day out, none of them really helping to answer the question of “what could it be”?
None of the results clinched any diagnoses, or supplied any data that would really make a drastic change to the workup. Most of the results that came back were completely bland. But not like a bland urine sediment in renal failure, because in that case, a bland urine sediment at least supports some sort of diagnosis.
At this hospital, reading the vital sign flowsheets in the morning and then the lab results would only tell us stuff that could be roughly approximated to “well, we know that’s going on”, or, “so, it must not be that”. Eventually, the patients would get discharged when most of the workup was exhausted or when they could complete it as an outpatient. There were always changes in the labs that people would talk about – low hemoglobins that we were trending because we didn’t have a baseline value, or obscure liver enzyme elevations with completely negative abdominal ultrasounds, hepatitis serologies and HIDA scans as well as candidate offending medications to blame. There was a lot of test ordering, consultation with other teams, and debating during rounds. Not a whole lot was solved.
I talked to some of my friends who are now surgical interns. Their response was, “Welcome to medicine”.
We had a lady, Mrs. Frank, come in with vague abdominal pain, constant vomiting, and diarrhea. She was deathly obese, probably a BMI of 40, diabetic, hypertensive, with a helpless look permanently plastered to her face. This patient was on Plavix and aspirin, but was completely unable to remember any reason why she had been placed on either of these medications. She also seemed to be unable to remember whether she’d ever had a colonoscopy, and while I was busy trying to understand how this patient could have forgotten whether she’d had a colonoscopy or not (I like to think that as something you don’t forget), the attending decided to admit her.
We were able to get a large amount of past medical history from her previous medical records– thanks to several hours invested by yours truly– but we weren’t able to turn up anything that shed any light on the touted “differential diagnosis” list. We got colonoscopy records…negative. We got in touch with her PCP… unable to explain why the anticoagulants were prescribed, why she had had a colonoscopy. The patient was sitting there for a week, consuming clear liquids in front of the nurse while complaining of nausea and abdominal pain to the physicians, with nurse’s aides seeing her get up and go to the bathroom, without a single complaint. Upon questioning the patient was completely oblivious to anything that had ever happened to her. The working diagnosis was diabetic gastroparesis, but her symptoms weren’t changing in response to the metoclopramide we prescribed. The last day of my rotation, I declared on rounds that my plan was to get a psych consult.
I was annoyed. Most of the people my residents would get from triage had things we could never figure out. As much as I regarded myself at being good at putting puzzle pieces together, a great many of these patients were completely all over the place. And nothing ended up getting figured out.
The one thing I learned from the rotation is that while being a student sucks in many ways, there are people that look up to you and treat you with authority. Those are the other students – the students of the nursing trade. They, too, have the itch to impress, to do well, to reflexively excrete initiative in the same vein as medical students — and would always relay vitals in a blindly respectful way when asked. I remember having this poor elderly GI bleeder who was completely disoriented, shipped in from a nursing home, and producing 2 bloody bowel movements a day. On work rounds I enter the room as the nursing student is talking to the patient. She immediately turns to me and pulls me aside.
“She had a bloody bowel movement.”
“Really.”
“Yeah.”
“Are you sure it was blood?”
“You want to see it? Here, let me show it to you!”
She opens up the biohazard trash can, revealing a giant diaper containing a massive, black-cherry-colored splatter of crap. As the aroma of partially digested blood wafted up towards our nostrils, she looked at me. The look on her face was one of disgust, but also one of semi-triumphant assertiveness, as if she were onto something – as if she were helping to unlock some major medical mystery. My team was completely aware that she was bleeding per rectum. That was her admitting diagnosis – GI bleed. I thought to myself, this person really believes.
It was kind of cool. But ultimately, depressing.
Random overheard things from third year
Following are a couple of random conversations I have stored in the back of my mind from the first half of this year. They are remembered as brief snippets of time, the evidence that I was once in the thick of something intense, hopelessly unique to each specialty, and are meant somehow to illustrate each rotation by some sort of emotional memory. Most of them involve me being made to look like an idiot by an attending, but some of them hopefully shed some light on the uniqueness of the dialogues that medical students are privy to. Someday when I have forgotten all of my medical school experiences, I will look back on these random memories to guide the way I felt during this ridiculous period of my life.
***
1) On OB/GYN, while I was in the OR, scrubbed into a laparoscopic vaginal hysterectomy:
90-year old GYN surgery Attending: “What is the origin of the uterine artery?”
Me: [at a loss for words, but then collecting myself and answering after pause] “Common iliac artery.”
Attending: “Well, technically, you’re right, everything comes from God. But what is the answer to my question”
2) In Neurology morning report:
Resident: “the patient is an 89 year old woman who was worked up for syncope. She presented to the hospital last night when I was on call because she felt dizzy at another hospital which found her to be…”
Chairman: “Stop. This is ragu. You are in the ragu business. You know what ragu is?”
Resident: “Sauce?”
3) On Medicine, when I was feverishly presenting a case of a CF patient with HCV and status post liver transplant on teaching rounds:
Attending [interrupting]: “Hold on one second…why did they have a liver transplant?”
Me: “The patient told me they were ‘born with cirrhosis’, but they weren’t able to elaborate further, I am guessing they had some sort of cirrhosis early on in their lives. I am not sure when they contracted HCV so that may be a cause too.”
Attending: “Born with cirrhosis, huh? Is that the name of a movie? Born With Cirrhosis… Anyone heard of it?”
4) On OB GYN, where I was privy to a conversation between a resident and the precepting attending in maternal-fetal-medicine clinic:
Resident: ” So this patient has a lot of stuff going on, G2P1001 at 30 weeks by 1st trimester ultrasound with HIV and gestational hypertension. She is an immigrant from a 3d world country, questionable thyroid nodules as per patient, but denies any hyperthyroid symptoms…”
Attending: “Where her thyroid function tests at? You get a thyroid function test on her?
Resident: “No.”
Attending: ” ‘sup with that?”
Resident: “I did not order the test the last visit.”
Attending: “…Whas’ wrong with you?”
5) On Neurology rounds:
Chief Resident: “So Mrs. X, I know you want to go home, but how are you feeling today? “
Patient: “I feel aight. Don’t feel too great ’bout my neighbor though.”
Chief Resident: “What’s wrong with your neighbor?”
Patient: “She hood! I am going to bust her ass!”
6) Another one from Neurology. Examining a patient with acute change in mental status and testing judgment/abstraction:
Resident: “Want to know a huge coincidence?”
Patient: “Sure.”
Resident: “My wife and I got married on the same day.”
Patient: “What’s so special about that?”
Resident: “Good!”
Patient: [pointing at the table with a tray of dinner on it] “Guys, you really got to get these tubes out of here. I have been staring at them all day. You have to go and clean this stuff up.”
Resident: “Tubes?”
Patient: “It’s tan and we’re walking!”
***
Germanized
Usually, I get about 2-3 spam messages in my email box every few days. But rarely do I get mail that is addressed to someone else.
Yesterday, I got completely random email from some random person that had evidently sent it to someone else with the same name as me. It wasn’t spam, because it had a bunch of random email addresses on it that seemed like they were valid, and the body of the email actually had some text that seemed like it was a personal message. It was, however, in German.
I don’t speak German, so, for kicks (since I only have 100,000 things to do before my medicine shelf in 10 days), I decided to translate it. The direct translation through a free translation website, http://translation2.paralink.com:
“Hello her dear strong!
problem based learning
Currently status post 6 hours of problem-based learning/small group homework for a case working up a urinary tract infection, where I was forced to look up, among other things, the evidence based medicine behind post-coital voiding and wiping direction in the prevention of UTI. With my shelf coming up in 3 weeks (or less), oral examination to prepare, looking all this stuff up has been a trying experience.
Assessment: Annoyed.
Plan: go to bed right now and do MKSAP questions in grand rounds tomorrow.
Physical Examination
In an outpatient setting, the physical examination needs to be focused, as I belabored in another post (which was way too long).
Focus is a great thing, but in this case (and in all cases, really) the physical exam is focused by your differential diagnosis. DDx determines the physical examination scope and depth, so you don’t spend inordinate time doing rote things because you are just doing them. If your DDx is off or non-existent, your physical exam is an exercise in going through the motions.
Chronicles of an Eastern Seaboard Med Student 