I Survived: Internal Medicine

It's been more than 2 months since I finished my medicine rotation, and in some ways, after finishing medicine and surgery, it's the perfect time to reflect on it. I was incredibly nervous to start on internal medicine as my first clerkship since it is one of the most demanding core rotations, but I am so happy about how it worked out. Medicine is the foundation for all other specialties, and I learned SO MUCH during these 2 months. With that in mind, here is a breakdown of the rotation, as well as some tips that helped me survive: 

The team 

     The medicine rotation was 2 months long for us, all on inpatient hospitalist teams. Our team generally consisted of an attending physician, a senior medicine resident (R2 or R3), 2 interns (R1), and a medical student. The interns each carry 5-10 patients (know all their labs, put in all their orders and notes, check in on them every day, coordinate with consulting teams, answer pages, and "scut"--even though now I realize how important scut really is). The senior resident supervises the interns, develops plans for patient care, and ensures that all the work is done. The attending is the higher level boss who makes the critical decisions about diagnosis and treatment based on information presented by the residents.

     As a med student, you are expected to co-carry 3-5 patients with the interns. However, the emphasis is on learning pathophysiology and developing treatment plans for practice rather than executing them, as compared to an intern. Since you have fewer patients, you are expected to know more about each patient and delve further into their disease and psychosocial background than the rest of the team. 

My first medicine team! Miss them. 

The weekly schedule

     I was at the VA hospital for the first month, and at the county hospital the second. At the VA, call was q2q3 long call (which means we were "on call" for example Mon-Wed-Sat) and at the county, call was q4 long call with q2 short call (ex. Mon-Thurs with Tues short call). What the heck does all this mean?! I didn't know before starting, either. On long call days, our team accepted patients that were admitted overnight as well as new admissions throughout the day (7 AM - 7 PM). On short call days, the team only got patients admitted overnight. 

A day in the life

5:30 AM: Wakeup, Keurig some coffee, and get ready/drive to the hospital. No traffic, yay!

6:45 AM: Arrive at the hospital and pull up the charts on my patients.   

7 AM: "Sign out," or a report on overnight events or new patient admissions, from the night team. I tried totake notes on all the patients so I knew what was going on during rounds.  

7:30-9 AM: Pre-rounding. I looked up the vital signs and lab values on my patients, as well as visited their rooms to do a brief physical exam, check in on them, talk to their nurse, etc. 

9 AM-10 AM: Morning teaching conference for all residents and students. This was usually a real patient case that one of the teams presented, and everyone else chimed in on strategies of how to approach it. 

10 AM-12 PM: Attending rounds. The style of rounds is highly variable depending on the attending, but usually, the interns or I would formally present our assigned patients to the attending outside the patient's room.  Then, discussion time.  This is the prime time that the "treatment plan" is refined-- types and dosages of medications, tests and imaging studies that need to be ordered, etc. The attending asks questions, explains his or her decisions, and teaches the team during this discussion, so it is a great opportunity to learn how to think like a clinician.

     The thing that struck me the most was how no one, not even the attending, knew the definitive "right answer," but instead would try to fit the data to a likely "clinical picture" of heart failure, pneumonia, etc. After the discussion, the entire team would go into the patient's room to talk to and examine the patient, as well as clarify any questions about their symptoms.  Sometimes rounds ended by 12 PM, but most often, they continued after noon conference.

12-1 PM: Noon teaching conference, with lunch. Usually a review on a high-yield topic in medicine. I usually brought my lunch (my go-to jar salads), although for some people, free lunch was one of the highlights of medicine!

1 PM-??: This was more variable. Often attending rounds were finished up, and then everyone did the work of implementing the plans from rounds, writing progress notes on each patient for the medical record, and discharging patients that were ready to go home. SO much sitting in front of the computer. On long call days, we got new admissions, and I usually picked up 2 new admissions with interesting pathologies to co-follow with the interns (the best part of being a med student--they assign you the cooler cases and patients!).    

     Sometimes we had afternoon or evening rounds on all the patients again with the attending, but more often we just checked in on our patients ourselves. The earliest I got out on a non-call day was 4 PM. The longest I stayed on a long call day was 10 PM, but that was only if I had gotten 2 late admissions. Generally I was done with writing progress notes on old patients, seeing my new patients, and writing their admission notes by 9 PM. Even though call days were long hours, being on a team made it so much better. Often the attending or the senior resident ordered dinner for us, and we all bonded on those crazy nights. 

10 PM: Arrive home, shower, talk to mom/Aditya, and crash by 11 PM. Repeat!  

Here are some tips on how to thrive on the rotation: 

• Think like an intern: Take notes on "to-do" lists during rounds for each patients. Then, without them asking me to, I would say, "Hey, [intern], I'm going to page renal on our patient X. Is that OK?" You'll learn so much about how to communicate with other teams, and your interns will be grateful for the help.  

• Talk to your patients when you can: Most of the team is so busy, they don't have time to get to know patients in-depth. My favorite part of non-call days at the county hospital was around 5 PM, when I had finished my work for the day, and I went in to chat with some of my patients. I was privileged to truly get to know an incarcerated patient and a homeless HIV+ patient, among others. These are patients that I will never forget and inspire me to keep working towards a career in medicine. I also called my patients after they left the hospital, both for continuity of care to make sure that they went to followup appointments and weren't feeling sick again, but also so that I could tell the team. They always appreciated learning about how a patient they had worked so hard on was doing. 

• Read about your patients: It's really frustrating when people tell you to do this, because you're like HOW. What does that mean? It took me a while, but I got a system down for reading about patients: before, during, and after. Before: when I got a new patient, I read briefly about their chief complaint in Pocket Medicine and jotted down a quick differential before I even went to see the patient. It's important to think broadly, because you might get a report from the ED that the patient broke their leg during a fall, but in reality, it was a syncope (fainting) episode that you as the medicine team need to work up. During: after doing the history and physical, I read about the patient's condition while writing my note, usually on UpToDate. I also looked up primary literature on relevant topics, such as a particular trial (medicine LOVES evidence-based decision-making) or a case-study if it is a rare pathology. Not only do you learn how to comb through medical literature, but you will impress your attending when you talk about it the next day on rounds. After: post-rounds on a new patient, I read one more time, reconciling what I had researched with what we actually did for the patient. So much of medicine relies on clinical judgment, and each patient presents slightly differently from the classical presentation. I read about those similarities and differences so that I could pick up on them for the next patient I had with the same disease. 

• Develop your version of the condensed physical exam: At the VA, I checked jugular venous distension and leg edema on every patient because so many of them were in heart failure. I also developed quick versions of the cardiac, lung, abdominal, and neuro/muskuloskeletal exams that I would perform routinely so I didn't miss something big. By the end of the rotation, I had done this so many times that I felt like I could do it in my sleep. 

• Don't worry about the shelf so much: This might be controversial, since a lot of med students say you should always study MORE. I tried to read Step Up to Medicine, Case Files, etc, but I quickly abandoned them and just did as many UWorld questions as I could, and made flashcards for them on Anki. I felt like I knew so much just from remembering our patients and the teaching sessions. When in doubt, SLEEP >>>> studying :)  

• Don't sweat the small stuff: While my brain exploded with awesome learningz for 2 months, it was at times very stressful--having to be on point for presentations (especially if you don't like public speaking), the long hours, and of course, poor outcomes on patients. I stress ate junk food in the team room a lot during the first month to cope, but by the second month, I went back to my old mantra: this is your real life. Try to remember that even if you are trying to well on the rotation, you are in the profession for the long haul. You are here to learn how to take care of people, not just get a good evaluation. Figure out ways to stay connected to non-medical things and people, stay healthy, and keep from being physically and mentally burned out even when you're so busy and tired--it might be calling an old friend, going for a late-night run, whatever. THIS is what will help you keep loving your job.   

That's it! What are your questions about the internal medicine clerkship?