Hospitalists

  This month I'm working on a cardiology consulting team and with it, I've gotten a lot of exposure to the hospitalist side of internal medicine. Hospitalists are internal medicine physicians who only take care of patients in the hospital. They have no clinics and only deal with the short-term problems that the patient is hospitalized for. In effect, they do my internal medicine rotation all the time (except they are the entire team). It sounds terrible. One colleague called it "residency for life." However, it has it's benefits. It is essentially shift-work, so it has a pretty nice schedule. Most people go into it straight out of residency (so only 3 years after finishing medical school). Most hospitalists work a week on followed by a week off. So, a vacation every other week. They also get paid pretty well. 200000+ for working a total of 6 months each year. Because of these benefits, it's quickly becoming a popular choice.
  The problem comes with not having ownership of the patients. Without any continuity of care, hospitalists don't know their patients as well as internists who also have a primary care clinic. With the shift-work schedule, their is a lot of passing patients between hospitalists and resulting poor communication. Also, with 20+ patients a day, there isn't much time spent with each individual patient. Putting all this together, hospitalists tend to not think about each individual case as much. At least that's the trend I've seen when consulting for a hospitalist versus consulting for a resident-run team or a team run by a regular internist. This doesn't mean that patients under the care of a hospitalist are at risk. The more common result is that they are overtested and specialists are overconsulted. If you don't have time to think about why someone is having chest pain, you get a chest X-ray, CT-scan, EKG, an echocardiogram, stress test and lots of blood tests and you consult a pulmonologist and a cardiologist. One of these will figure out what the problem is and your specialists will tell you what to do about it. I've seen this pattern quite a bit recently, including one case in which the hospitalist ordered these tests and consults prior to seeing the patients or even reading their previous notes (the patient was transferred from another hospital and through testing had already shown that his heart was fine).
  Of course, there are great hospitalists who know their patients well, think hard about each of the cases and use hospital resources efficiently. However, there is a disturbing number who are wasting resources and their consultants time as well as running up the cost of healthcare.

General medicine is generally frustrating

Not because the medical decision making is difficult or the patients are a mystery. It's more that I spend most of the day doing work that really shouldn't be part of my job description. A typical medical admission is like this:

1. The ER or outside hospital has already diagnosed the patient, my job is to put in the basic orders to get them admitted and write a summary of what brought them in. Then, whether they came in with a diagnosis or not, consult a specialist and wait for their recommendations.

2. Fix their electrolytes, heart rate and maybe start them on some broad antibiotics while waiting for the specialist to see them.

3. Specialist sees them, gives recommendations, and I put in the recommendations into the computer system.

4. Wait for the patient to get better or wait for the specialist to tell me they can be discharged.

5. Figure out where they're being discharged to. Call medical offices to make them appointments. Call nursing homes, long-term care facilities to see if they'll take them.

6. Summarize everything that happened to the patient during their hospitalization.

Every once in a while, I feel somewhat like a doctor when I am answering patient's questions.

All important things, but, as you could see, there is very little actual medical decision making. It's very rare that I am reading up on various medical conditions and thinking about what tests to perform to figure out what's wrong with my patient.

Oh well. Glad I won't be doing that for the rest of my life.

You are what you eat

Blood just drawn from a patient with pretty extreme hypertriglyceridemia with triglycerides of near 10,000. There's more fat than blood in this patient's veins.

House of God

With my time off, I recently started rereading Samuel Shem's House of God (must read for any medical type that hasn't read it yet). A novel about an intern learning the truth about how things work in the hospital. It has a lot of dark humor in it, but there's a lot that (even as a med student), I could tell is based on a grain of truth. For example, the type of patients you see at the hospital. You'd think that they'd be a cross-section of the population, but they aren't. I assume it's because those with repeat hospitalizations aren't exactly your average Joes. Upon meeting the patient who hides under the covers whenever his discharge is discussed or the patient that wants to keep his rectal tube in because he's too lazy to get out of bed to go to the bathroom, I was immediately reminded of the characters in the book. I wouldn't like to get to the point where I think about my patients as GOMERS or follow the Fat Man's Laws, but at least some of my experiences with medicine so far say that I may have to face days where it'll get close.

Here are the Fat Man's Laws (courtesy of Wikipedia):

1. GOMERS DON’T DIE.
2. GOMERS GO TO GROUND.
3. AT A CARDIAC ARREST, THE FIRST PROCEDURE IS TO TAKE YOUR OWN PULSE.
4. THE PATIENT IS THE ONE WITH THE DISEASE.
5. PLACEMENT COMES FIRST.
6. THERE IS NO BODY CAVITY THAT CANNOT BE REACHED WITH A #14G NEEDLE AND A GOOD STRONG ARM.
7. AGE + BUN = LASIX DOSE.
8. THEY CAN ALWAYS HURT YOU MORE.
9. THE ONLY GOOD ADMISSION IS A DEAD ADMISSION.
10. IF YOU DON’T TAKE A TEMPERATURE, YOU CAN’T FIND A FEVER.
11. SHOW ME A BMS (Best Medical Student, a student at the Best Medical School) WHO ONLY TRIPLES MY WORK AND I WILL KISS HIS FEET.
12. IF THE RADIOLOGY RESIDENT AND THE MEDICAL STUDENT BOTH SEE A LESION ON THE CHEST X-RAY, THERE CAN BE NO LESION THERE.
13. THE DELIVERY OF GOOD MEDICAL CARE IS TO DO AS MUCH NOTHING AS POSSIBLE.

I would really like to think that #12 isn't true.

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

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.

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).

Equal education?

Throughout third and fourth year of med school, students work with a team of residents and attending physicians either alone or with another med student. At least in internal medicine, each student has his/her own patients and reads up on and follows those patients. Different teams may specialize in different types of patients and even within a single group, the types of patients followed by one student (by chance) could end up being very different from those followed by the other. This leads to a lot of variability in what each student learns from their experience on the rotation. For example, most of the patients that I've followed in my internal medicine rotation so far have had liver disease or a bile duct/gall bladder problem. I've read up on these conditions a lot and think that I'd do a pretty good job at examining, diagnosing and treating a patient with these disorders. But other students on the rotation with me have completely different patients, some have more cardiology patients, others have more kidney patients, and each (I assume) are more familiar with those conditions than I am. I hope that it evens out soon... these practice questions that I've been doing for the final exam really shows the bias in my experience with patients. I switch teams (and hospitals... and cities) next week, so I hope to get some exposure to the type of patients that I haven't gotten a chance to see yet.

btw... (can't believe it's already been a month, only 22 more to go).

Social Health

3 weeks into medicine now and things are pretty busy, but I'm having a lot of fun and learning a lot. I'm still missing a lot of the knowledge, but I definitely feel more comfortable around the hospital and with patients. One thing I've noticed though is how important social situation is to health. Yeah, it seems obvious, but working in the hospital really opened my eyes about it. Of the dozens of patients I've seen, only two of them have a stable living situation. The major reason behind this is lack of access to healthcare. People who are living stable lives likely have the resources to take care of their health and even if they have a problem that can't be prevented (like a genetic clotting disorder), they can keep a close eye on it and live a relatively healthy life that doesn't require them to be hospitalized much. People who have unstable social situations have bigger things to worry about than why their stomach hurts when they eat or why they're slowly starting to turn yellow. They don't catch their clotting disorder until they get a large clot in a major vessel (i.e. the portal vein) and get life-threatening (and much more costly) health problems like losing their liver. A little early education and a $4 a month drug could have prevented a hospital stay of several hundred thousand dollars and a death in the 20's.

72 hrs later

So, as I mentioned before, we were told that we'd feel a bit more comfortable about starting the wards 72 hrs into it. Well, I just got back from my 3rd day in the wards and I do feel a bit more comfortable. I've figured out the basics of the computer system and I've gotten a little bit better with rounding, presenting patients and writing notes on my patients. So, after 72 hrs here's my impression on internal medicine (and maybe being a 3rd year med student as a whole):

The goods (in no particular order):

1. Getting to be where the action is.
Yeah, I don't get to actually do much, but each day I do get to closely follow a team of doctors debate and make many potentially life-altering decisions on several people.

2. Applying all that medical knowledge to real people
I finally see how many of those lists and seemingly endless facts finally make some sense. I'm far from being comfortable with them, but at least I get to see them applied to real life. And, applying it to real life goes a long way to putting those facts in memory. For example, knowing that low platelets can be an effect of liver failure is much easier when you've seen that Mr. X, your patient with liver failure needs to get a platelet transfusion before every procedure.

3. Talking to patients
This is actually the most satisfying part of going into the hospital. I get to spend some extra time with my patients and actually get to know them. They're pretty bored and enjoy talking to me. I feel that by spending more time with them, I get to better understand their expectations, fears and frustrations. It never ceases to amaze me how honored I feel when a stranger opens up to me and tells me everything about them.

The bads (in no particular order):

1. I'm useless.
I get to be part of a team of physicians that help make a very sick person well again, but I am completely useless. As a medical student, almost nothing I do has any consequence on the patient's stay, and the few things I get to help with, the team really doesn't need my help. Sometimes I feel like I'm in the way. The only part that makes me feel like I'm actually having an effect is when I get to relay the patient's concerns to the doctors because I get to spend more time with them (see the goods).

2. I don't know anything
This may be specific to me since I took 4 years off between finishing 2nd year of med school and starting 3rd year. I've forgotten a lot of facts. Everyone around me is nice and I haven't pimped at all, but the really easy questions that I get, I still have trouble answering. It hasn't all come back to me yet, but then again it's only been 3 days.

3. Studying
Along the lines as #2 and also specific to the fact that I took 4 years off. I've had no reason to memorize lists of facts in the last 4 years and I haven't bothered finding a good way to do it. I remember at one point in the second year of med school, I would learn the pathophysiology of an entire organ system in a week or so before the final exam. Now, I don't even know where to begin. I'm hoping this comes back to me also.

4. Of course, the hours
No matter what, I can't get used to getting up at 5 am (or before) every day. I've gotta learn to sleep earlier.


In all likelihood, these opinions will change in another 72 hours. Overall, I like internal medicine so far. I'm learning a lot and it's not completely exhausting (yet). We'll see how I feel about it as I get more into it. Stay tuned.

mfp

All right! 3rd year of med school officially started and with it, after another long orientation, I got my first patient. Unfortunately, because I showed up in the middle of the day, I had to pick up a patient who has already been in the hospital for weeks. This means going through a lot of charts (dozens per day, by various MDs, nurses, pharmacists, therapists, etc.) There are two problems with this: 1) I have no idea how to use the hospitals computer system and have to click around for several minutes before I can get to where I need to go. 2) So many abbreviations! I know that doctors like shorthand, but just with this one patient, there are a dozen abbreviations that I've never seen before. Some even have multiple meanings. I've figured a lot out from context: SBP = systolic blood pressure, but SBP treated with cefotaxime is spontaneous bacterial peritonitis... seems easy to figure out, but when your eyes are glazing over the 24th progress note, its easy to confuse the two. Others, I still have no idea... the google helps, but I'll just have to break down and ask someone about some of them tomorrow.

We were told that within 72 hours most of this will make sense, but I have a hard time believing that. We'll see. Meanwhile, I gotta figure out how I'm going to preround tomorrow morning (see the patient before the residents and attending physician does) and prepare myself to present my patient to the attending (focused, yet thorough - seems like an oxymoron to me).

mfp = my first patient