Saturday, August 29, 2009

The end of internal medicine

Well, at least the end of it for me (for now). Wednesday was my last day of the internal medicine rotation and the last two days were the end-of-rotation exams. The rotation itself was actually pretty fun. There was some waiting around not doing anything and there were times when I felt pretty useless. But, overall, I learned a lot, saw a lot of interesting cases (and a lot of not so interesting cases), got to feel like I was the part of a team taking care of people, and got a chance to get to know some interesting people.
Do I want to go into internal medicine? It's hard to say since I only got to experience what life is like for hospitalists. I only saw the specialists tangentially. I wouldn't want to be a hospitalist (things are too hectic and once you see something interesting, you call a specialist). However, from what I saw on the wards, infectious disease and rheumatology appealed to me the most. There is a lot of detective work in both of them and a diagnosis could quickly lead to an effective treatment (Interestingly, these were the two fields that I felt I was the worst at when it came to exam questions). Radiology is still at the top of my list, but going through a more patient-based rotation does make me consider other options. We'll see as the year goes by.

Some advice...
- enjoy your time, at least with my experience, there really wasn't any pimping. There's no reason to feel stressed.
- don't let your first few days' experience set your mood for the rotation. Every time you have a change there is some awkwardness and confusion. It will also take a few days for your team to get warmed up to you. You'll find your place soon.
- don't feel like you have to stay on the wards forever. If someone tells you to leave, leave... it's not a test. You've got a lot of studying to do, and everyone on your team understands that. If nothing is going on, ask if there's anything you can help with, the answer will be "no", and you could leave.
- Spend extra time with your patients. You've got the luxury to actually spend time with your patients. If they're up for it, spend some extra time with them. The more you know about your patient, the better resource you are for the team (plus, the patient will trust you more than the rest of the team, if they've made a connection with you).
- If your school allows it, try to get some experience in a different hospital. It'll give you a better idea of what's constant and what's variable in internal medicine.
- prepare to feel defeated if you're taking the SHELF (nationally standardized) exam. Holy crap the SHELF exam sucks ass. None of my studying prepared me for that test. Even knowing what the exam was like, I don't think I could have effectively studied for it. It is not a good assessment of how much you've learned on the wards. I've never came out of an exam seriously thinking that there's a possibility I could fail until now. Luckily, everyone else in my class felt the same. And from people who have taken it in the past, the results end up being better than you expect.

Now I get a whole weekend off before Surgery starts on Monday. I start with ENT, then have Orthopedic surgery, followed by a month of general surgery.

Old song, but it's been stuck in my head ever since I saw a patient with Wenckebach heart block last month

Wednesday, August 19, 2009

Informed consent preventing testing?

I recently saw a patient that had pneumocystis pneumonia - an infection that pretty much only occurs in immunodeficient people and is an indication for HIV testing. In many states written consent from the patient is required prior to HIV testing. Consent prior to HIV testing dates from the late 1980's when HIV was a new, stigmatized disease that was essentially a death sentence. States enacted laws to protect patients from health care workers testing them for the deadly disease without them knowing. Now, however, HIV is a treatable disease that, if caught early could allow the patient to live a relatively normal life. The greatest barrier in decrease of HIV-related mortality and the decrease in the spread of HIV is knowledge of HIV status. There was a recent study in the American Journal of Preventive Medicine that showed that states with a written consent law have a decreased rate of HIV testing than those without. And another study showed that the cumbersome requirement for obtaining written consent from the patient has discouraged physicians from performing HIV. I personally think that that HIV should not be singled out as requiring written informed consent prior to testing (I think it continues the stigma associated with HIV). Either all testing for sexually-transmitted or blood-borne infections should require written informed consent or none of them should. But, it's pretty bad that physicians are avoiding the test only because they have to obtain written permission from their patients.

Sunday, August 16, 2009

Jesus is my co-surgeon

The hospital that I'm working at now (St. XXXX) is affiliated with the Catholic church. I am not a big fan of mixing religion with anything, but I really think that it's unfortunate that so many church-affiliated hospitals exist. For most patients it's not a big deal and it rarely affects them. Sure, there are crosses in every room, Bible quotes in the hallways, and bright notes on the front of charts saying "Sacrament of the sick given" (apparently that's more important than "Allergic to penicillin"), but I pretty much see that as (really bad) decoration. There are some things, though, that I think are not appropriate in a place that is meant to take care of the entire community (especially since people in this half of the state really have no other choice in a major hospital).

One is that there is a rather long, loud morning prayers on the intercom every day (usually at a time when we're rounding on patients). It's not just, "let's take a moment of silence" or something else equally nonspecific... rather it is usually a five-minute sermon on what Jesus or some saint said. Even though it's a rural part of the country, not everyone is Christian or religious (and they're definitely not all catholic). The last thing I'd want to hear when I'm sick in bed (especially if it's during the five minutes that my doctor is talking to me) is what Jesus wants me to do.

What really bothers me, though, is the fact that church doctrine dictates medical decision making. Catholic-affiliated hospitals (which care for approximately 20% of the patients in the US) all follow the US Conference of Catholic Bishops' Ethical and Religious Directives . Since it affects a fifth of patients in the country, it's a must read for healthcare workers. Some of the more striking parts are:

- #24: The institution ... will not honor an advance directive that is contrary to Catholic teaching.
- #25: Each person may identify in advance a representative to make health care decisions as his or her surrogate in the event that the person loses the capacity to make health care decisions. Decisions by the designated surrogate should be faithful to Catholic moral principles.
- #36: A female who has been raped should be able to defend herself against a potential conception from the sexual assault. If, after appropriate testing, there is no evidence that conception has occurred already, she may be treated with medications that would prevent ovulation, sperm capacitation, or fertilization. It is not permissible, however, to initiate or to recommend treatments that have as their purpose or direct effect the removal, destruction, or interference with the implantation of a fertilized ovum.
- #41: Homologous artificial fertilization (that is, any technique used to achieve conception using the gametes of the two spouses joined in marriage) is prohibited when it separates procreation from the marital act in its unitive significance
- #45: Abortion (that is, the directly intended termination of pregnancy before viability or the directly intended destruction of a viable fetus) is never permitted. Every procedure whose sole immediate effect is the termination of pregnancy before viability is an abortion, which, in its moral context, includes the interval between conception and implantation of the embryo.
- #47: Operations, treatments, and medications that have as their direct purpose the cure of a proportionately serious pathological condition of a pregnant woman are permitted when they cannot be safely postponed until the unborn child is viable, even if they will result in the death of the unborn child. (pleasantly surprised about this one)
- #48: In case of extrauterine pregnancy, no intervention is morally licit which constitutes a direct abortion.
- #52: Catholic health institutions may not promote or condone contraceptive practices but should provide, for married couples and the medical staff who counsel them, instruction both about the Church's teaching on responsible parenthood and in methods of natural family planning.
- #53: Direct sterilization of either men or women, whether permanent or temporary, is not permitted in a Catholic health care institution. Procedures that induce sterility are permitted when their direct effect is the cure or alleviation of a present and serious pathology and a simpler treatment is not available.
- #54: Genetic counseling may be provided in order to promote responsible parenthood and to prepare for the proper treatment and care of children with genetic defects, in accordance with Catholic moral teaching and the intrinsic rights and obligations of married couples regarding the transmission of life.
- #61: Patients experiencing suffering that cannot be alleviated should be helped to appreciate the Christian understanding of redemptive suffering.

Painting in physicians' break room. Yeah, Jesus has helpful tips for the surgeon, but when a luxurious long hair from his uncapped head falls in the peritoneal cavity, the patient won't be too happy.

Sunday, August 9, 2009

I take (some of) it back

So a week into my rotation in a more rural setting, I'm feeling a bit better. Last time I complained about several things, the most worrying of which was a lack of effort in teaching by the residents and attendings. I don't think I was being completely fair, since comparing a large academic hospital with a smaller rural hospital is not appropriate. The residents and attendings don't see too many medical students, so it makes sense for them to not know where we fit in the scheme of things. It took a few days, but things are going more smoothly now. Although I don't feel nearly as productive as I did at my home hospital, I also don't feel like the burden that I did for the first few days. Also, I know it's difficult for them, but they've gotten better at thinking about what would be beneficial for a med student to see or do. Hopefully the next three weeks will continue moving in the right direction.

P.S. paper charts still suck

P.P.S. everyone really is a Republican, but the blatant anti-healthcare reform postings have been removed.

Monday, August 3, 2009

More rural internal medicine

I am now in a different part of the state, in a relatively small town at a hospital catering to small town communities spread over this region of the state. I'm not exactly happy with the differences in how things are run from the major academic institution that I'm used to, but I'm hopeful about what I'll gain here. Here are some differences:

1. Less specialists - there are still consults, but (so far) the consult team seems less like they run the show than they do at my academic institution. Patients with an MI are seen by cardiology, but are not necessarily taken care of by a cardiology-specific primary team. This is good news for me because I will likely get exposure to a wider variety of patients than I did back at home.

2. Slower pace - my service caps at 6!!! That is considered a light day back at home. Also, you can only take patients on your call day!! As a result everything else goes at a slower pace. I thought it would be a good thing to have more time to think about, discuss and care for each patients, but really, I think the result here is that people just work slower. On the bright side, I get out earlier.

3. Teaching - I can't say much about this since I've only been with my team for a day, but people seem less enthusiastic about teaching here. I'm pretty proactive with asking about what's going on with each patient, but it seems like I've had to ask several times to get an answer. When coming up with a plan, the resident and intern usually quickly talk about it (quietly) with each other, leaving me out and forcing me to ask more questions than should be necessary (the lack of electronic charting makes it even worse). Finally, the answers to my questions are usually very short. For example, when I ask "Should we be concerned for a pulmonary embolism?" they say "No it's not a PE" versus at home where they actually explained what argues against it. I feel a lot more like a burden here than a part of the team. Maybe it was just today (or just the specific people I've been working with), so hopefully I'll feel better about it when I get more familiar with how things are run in the next few days.

4. Paper charts - I don't care what people say about electronic charting, but paper charts just plain suck. We live in the 21st century and shouldn't have to hunt around through dozens of pages of poorly written and half-torn sheets of paper to find what we're looking for.

5. Everyone's a Republican - I expect this in more rural parts of the state, but everyone (nurses, attendings, and patients) leans pretty far to the right. I just can't respect a physician who actively watches Fox News in the break room (actually, I fear for their intelligence) and I'm really concerned about the fact that propaganda against health care reform is posted all over the nursing station. It's not fun to work in a politicized environment, especially in such a hierarchical system as a hospital.

Hopefully my opinion of this half of my internal medicine rotation changes in the next few days, but if it doesn't, at least I'll appreciate going back home (even if it is for surgery).