Short Coats

I just finished a 12 day stretch of work with no days off, that included three 28 hour shifts, on my internal medicine rotation, a ten week rotation that it the core of all medicine. The concepts reviewed in this rotation are the basic building blocks that hold up all other aspects or specialities in medicine. This rotation takes care of very sick patients who are put in the hospital because there is disease or illness in their internal organs - the heart, lungs, kidneys, gastrointestional tract, or blood, to name just a few. I've had patients with pneumonia, angioedema (swelling of tissues due to leaky blood vessels - in the case of my patient, his throat swelled up), AIDS (and the subsequent fungal infection in his brain), acute kidney failure, heart failure after a myocardial infarction (heart attack), endocarditis (bacterial infection of the heart valves), and blood loss due to a tumor in the stomach. As a medical student we are fortunate to only be responsible for one or two patients at a time, while the resident and intern have to know everything about all ten patients that our team takes care of (which I will have to do in only a year and a half).

Having only one patient to be responsible for at a time allows us ample time to talk to the patient, to practice our history taking and physical exam skills, and most importantly, to review the mechanisms and treatment of the diseases so that we can sound competent when we present our patient at the daily rounds. Rounding compromises walking around the floor to each patient's room, and discussing the "case" out in the hallway. There is a very strict order of how information about a patient is given to the rest of the team, and this is standardized across all medical schools and residency programs in the US. You start with a brief one liner that describes who a patient is, and why they were admitted. For example, "Mr. J is a 50 year old man with longstanding hypertension and coronary artery disease admitted for chest pain." You then go into what's called the HPI - history of present illness, which is a chronological account of how the current illness presented itself, a description of the symptoms, onset, duration, therapies previously tried, and any pertinent information that can help the listeners start to whittle down the potential list of what could be the problem for this patient.

After the HPI, you then launch into any other medical conditions the patient has, and what the status of that disease is, or how it is managed. Then it's onto family history of diseases (for example, it would be important to know with Mr. J that his father had his first heart attack at age 45). Then it's social history, where the person lives, what they do for a living, married, children, etc... plus their habits with tobacco, alcohol, and drugs. Then it's a list of their allergies, and medications.

Then you present what you found on physical exam, what the heart, lungs, abdomen was like, paying appropriate attention to those physical exam findings that will having a bearing on what the person was admitted for (you don't need to know Mr. J had clear tymphanic membranes in his ear, but you definitely need to mention what his heart sounds were like - regular rate and rhythm, and murmurs, rubs, or gallops?). Then it's on to the lab findings, where you list out the chemistries and blood cell counts, all the data that internal medicine doctors rely on to give them clues to what's happening with the internal organs. And if you've gotten an x-ray or a CT scan, you need to talk about the results as well.

After all this information is given, the most important part comes, the part where med students sweat the most. The assessment and plan. The "so what do you think about all this information, and what do you want to do for the patient?" You have to list each problem the patient had, whether in terms of their presenting symptoms (Mr. J's chest pain), or their past medical history (his hypertension), and any physical exam findings (say a heart murmur), and any lab abnormalities (say he has hyperkalemia - that's too much potassium in his blood).

No problem right? Well the first week the attending that we worked under wanted this presentation in 5-7 minutes. To make matters worse, while I am speeding through my presentation trying to decide what information is most crucial and cannot be left out, the attending is looking at the computer, most likely looking at the lab results I am trying to relay to him. By the way, the attendings and residents already know everything about the patient, and don't really need the medical student's presentation to make any decisions about care for the patient. This whole process is for the benefit of the student, which is hard to imagine given that most of the time the residents aren't paying attention, and are clearly just wanting you to hurry up so they can get their work done. At the end of my first presentation, the resident looked at his watch and said, "that was 9 minutes."

The second week was totally different in that the new attending gives us 15 minutes for our presentations, which feels so wonderful to have the time, and she actually listens to everything we say, to the point that we have to comment on every single abnormality, ones that the previous attending just blew off. I can say while the new attending means much more work, I prefer her thorough style because it forces me to look up reasons for any abnormalities, to understand the patient completely. It does of course mean that I have to get to work early, so that I don't make the mistake of not knowing why. As I've said before, I think most of the stress of this third year comes not just from the long hours, but from the constant evaluation that is occurring by the residents and attendings - those that will give you your grade, and have a say in your future. It's like constantly being on guard, hackles up, in preparation not for a discussion between equals, but for interactions that question your knowledge and skill as a doctor. I can't tell if the stress of this comes from the high expectations I have of myself (my inherent perfectionism) or from the unreasonable expectation that doctor's should know it all. All I know is that each day that goes by is one day closer to that MD next to my name, that day when I can no longer hide behind the short coat of a medical student.