I’ve been hearing forever about hospital rotations, but today I finally started my first one: inpatient medicine.
Inpatient Hospital Rotation
For the last year I’ve worked in clinic settings learning the ins and outs of outpatient primary care. But for the next two weeks I will be learning about inpatient medicine, the practice of treating patients who are admitted to the hospital. I’m working with a team at Mather VA hospital in Sacramento, California on the TCU and medical/surgical floor. It’s a very clean, modern, tastefully decorated place.
The first order of business was learning the hierarchy of medical professionals on our team. It’s so universally understood that no one explains it to you!
The team is comprised of:
- Us (two second-year PA students)
- A dental intern – a dentist who is straight out of dental school. They do a rotation just for the exposure, and from the looks of it, he wasn’t finding it too relevant. It was his last day, and he seemed glad.
- One intern – this is a doctor who is straight out of medical school, doing her one-year internship.
- Three residents – a first year (which means he was an intern last year), a second year (add another year), and the attending (a third year intern), who for all practical purposes runs the show.
- The chief resident (in charge of everything, including the attending, but rarely, if ever seen).
Internal Medicine’s Personality
First off, we didn’t walk around the unit as a group of dumb, eager students in over-starched lab coats, clustering around the residents like they always do on TV. Instead, we all sat around the table and talked about the patients. After much discussion, the clinicians fanned out to either 1) see their patients on their own, or 2) sit in front of a computer digesting their patients’ records. It wasn’t sexy or adrenalin-filled. In fact, if there is one word to describe Internal Medicine, that word is chill. So far there are no big, ball-busting blowhards like you see on TV, no one “pimping” the students. From what I hear, that’s way more the style of surgery.
Everyone is very casual, friendly, and all seem to go about their day without much discussion of what is going on – there is plenty that is just picked up through osmosis, I guess. My fellow students who have already done this rotation assure me that within a few days, the routine becomes pretty, well, routine.
As usual, I have to steer well clear of talking about any specific patients, but I can say that the difference between these patients and the ones we see in clinic is that they are much sicker. These days, no one gets admitted to the hospital unless they are 1) very ill, or 2) at risk of becoming very ill or dying. It’s just too expensive. Here are a few characteristics that describe the patients we see:
- Multiple comorbidities. This is a fancy medical way of saying that the patients have multiple and usually many medical problems at once. The first patient I followed had a list of 27 medical diagnoses!
- Multiple “consults.” Consults are when the internal medicine docs call in specialists in various areas to give them advice on specific issues. The most commonly called-for consults seem to be Cardiology, GI, Surgery, and Nephrology. For instance, the team might call Nephrology to discuss how much kidney function the patient will regain with treatment, and if there’s anything to do that they aren’t doing already.
- Multiple medications. Most patients are on 10 or more medications, which becomes a delicate balancing act.
- Chronic health problems. Most have one or more of: Type II diabetes, hypertension, coronary artery disease, kidney disease, cancers, chronic obstructive pulmonary disease (COPD), etc. Often these are in the background, and something more acute/emergent (heart attack, stroke, congestive heart failure, pulmonary embolism, a GI bleed, etc.) brings them in on top of their ongoing/chronic problems.
- Older males. We’re at a VA hospital, so that’s the biggest population – former soldiers who, more often than not, have lived a pretty unhealthy lifestyle (alcohol, smoking, poor diet, drugs, etc.). Psychiatric conditions, including PTSD are not uncommon.
- The patients, in general, are very friendly and appreciative for their care.
We started following one patient each today, which doesn’t sound like much, but it’s plenty. For each patient, the electronic medical record system provides an avalanche of data – vitals, labs, imaging studies, previous consults, old records, and much more. You quickly realize that the most challenging part of the work is sifting through the mounds of information to formulate a story about what is going on with the patient, and what to do about it. For example: say the patient had a stroke. How can we determine what type of stroke it was – hemorrhagic, ischemic, or embolic? Knowing the type, what was the likely cause – atrial fibrillation, DVT, a damaged AVM, a carotic plaque that broke off? And finally, what to do about it – anticoagulate, change blood pressure medication regimen, heart surgery?
We each interviewed our patient, did an exam, and read copious amounts of chart information. Tomorrow we will see what has changed and how to proceed. We may formally “present” the patient to the team, which is basically summing up everything that we know and think about them, and seeing what the attending thinks. Down the line we will probably follow more patients each day, along with being familiar with the other patients that our team is caring for.
I’ll let you know when we get the routine down…[subscribe2]