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).


  1. Oh Noes! That's where I'm doing my first month of medicine, as well! Perhaps I will have a more engaging resident team...

    And don't worry about surgery. Surgery rocks! And I'm still saying that after a month on service. Go Big Blue!

  2. and perhaps my team will be more engaging once they get more comfortable with me being around (and I get more comfortable with them). I shouldn't really judge things on the 1st day... but I did anyway. I'll have an update soon.

    Glad surgery is going well. I'm looking forward to it now!

  3. On everyone being a republican:

    Politics isn't appropriate in the hospital. No ifs, ands or buts. And the next time you see it coming up, say so. "well sir, I think we're never gong to agree on those issues. Free speech aside, I think some topics are unprofessional in the work place. " is one i've used before.

    On teaching:

    When you're out in the boonies and not with a hospital that's as focused on education there is a different method to get anything out of it.

    "Should we be concerned about X," is perfectly appropriate at an academic hospital. At a community hospital, I suggest checking a resource like uptodate, emedicine(both online resources) or pocket medicine to assist you in making a decent differential. Then give a specific plan to rule in or out your differential. If you include a disease on your differential, that they were going to blow off like PE, they should explain why they aren't following your plan.
    If they don't, then you have an opportunity to say "so where did I go wrong here, in including X"

    I know, that doesn't help on things you don't think of before initial presentation. It's by no means a perfect system, but it's one of the few ways I've found to force someone to educate me, whether they want to or not.

    Also: Specifically for pulmonary embolism, get a smartphone/iphone/ipod/blackberry/paper guide that includes "Well's criteria" for PE, and PERC ruleout criteria for PE.

    If someone meets all of the PERC criteria, that is very sensitive to rule out PE without getting any tests - for example, the dreaded D dimer. Similar, but more nuanced rules, apply to Well's criteria.

    /end of pedandtic gibberish

    I do hope you don't continue to feel like a burden though. That's not a fair position to put a medical student in. You should have a clear role, where you contribute.

  4. Thanks for the tips. Things have actually improved in the last week as the team has gotten to know me better. I'll have an update soon.