My inpatient hospital medicine rotation is over, and it ended much differently than it began. You’ll recall from my inpatient hospital rotation: Day 1 post that the word for hospital internal medicine was chill. But…
Soon after I wrote that post, things changed. I learned a another term: attending dependent, as in “It depends on who is your attending…” The attending is the physician who is in charge of any hospital department at any given time. They rotate frequently, doing one or two week-long stints per year in the role, and most, when not attending, work the hospital’s outpatient clinics. Often they are medical school faculty. Since I was in the hospital for two weeks, and the attendings were each there for a week, we worked with two different attendings.
And when I say different, I mean it.
Our first attending, Dr. A (from the previous post), was a competent, quiet and non-demanding guy. He really didn’t care what we did, so long as the patients were well cared for. He answered questions when we had them, but there was little or no pimping. He asked us to make a presentation “on something,” so that he would have something to evaluate us on. Pretty straightforward.
Until week 2, when we met Dr. B, who was Dr. A’s polar opposite. He came in like a cyclone, walking fast, making decrees about how rounds would go, and putting everyone on notice that there was a new sheriff in town.
- Patient reports should be recited from memory.
- The team should crowd around the patient’s bedside.
- Patient presentations should be delivered in the third person (as if they weren’t there — he even shushed a patient who interjected during a report!)
Yes, Dr. B was old school.
The first patient presentation made to Dr. B didn’t go well.
The resident had been up all night, admitting new patients, focusing on keeping them all alive until reinforcements arrived at 7:00 AM. Exhausted from lack of sleep, he struggled to remember the relevant details of the patients’ stories, past medical histories, labs, etc., and at times even mixed the patients up. When pimped by Dr. Y, he stammered. After the presentation, Dr. B pulled the bleary-eyed resident aside (well within earshot) and told him sternly: “It’s going to be a long week if your performance doesn’t improve a lot.”
I should add here that as serious as he was, Dr. B was the only physician I worked with that week who could respond to the emotional content of the patient’s words. This is a skill I used a lot as a psychotherapist, but sadly, haven’t seen enough in medicine. For instance, if your patient is recalling how his pain started and he tells you how scary it was, it helps to acknowledge that you get it. All you need to do is say something like, “Wow, that does sound scary.” Once you do, the patient is usually able to let go of it and continue with the next part of the story. If you don’t acknowledge it, the patient often stalls, trying to get across how scary it was, and the interview falters.
Anyway, Dr. B could do it, and it impressed me. He was actually very warm with the patients.
But with us, Dr. B was a real ball buster. He would stare motionless while we struggled to present all of the relevant patient story, history, physical exam findings, labs, treatment plan, etc. from memory, and abruptly interject questions like, “And the etiology of the patient’s renal failure?” and “Do you mean you rehydrated the patient, or that you corrected his hypovolemia?” [Yes, there is a difference, I learned] If we said something dumb or didn’t have the answer, he would bust our chops right there in front of the patient. Yikes. It kept me on my toes!
What It Was Like (as a PA student)
I was one of the team – no more, no less.
Although I didn’t write the orders on my patients, (you can’t until you’re licensed) I interviewed them, examined them, thought through their diagnosis and treatment plans with the residents, and presented them to the attending just like everyone else.
My verbal presentations truly blew in the beginning. But all of the pressure from the attending steepened my learning curve dramatically. I had some screw ups and moments where I kept quiet because I didn’t fully understand what was going on with a patient. But in general, I felt well prepared, and was treated as an equal. I also came in with a few correct answers to pimping questions when the rest of the team drew blank. More than anything, I just tried to soak in as much as possible.
Over the course of the week, Dr. B’s demeanor changed. As we began to snap into line, he became less disparaging and more encouraging. He took the time to teach us the right way to organize our patient presentations (it’s harder than it sounds). He brought in bagels, and one day even fruit from his garden for the team to enjoy. He wanted to know what kind of objectives our program had for our rotation, and what we wanted to learn. He created many learning opportunities, and he clearly loved teaching. At the end of the week he gave us a detailed evaluation, and suggestions for improvement. In short, he cared enough to expect great things from his team, and I was honored to be able to work with him.
Although I can’t share any identifying details about patients, here’s a list of some of the diagnoses that my team assessed/treated:
- acute pancreatitis
- pleural effusion
- A skin condition so rare that naming it here could be considered identifying information for the patient.
- Acute myelogenous leukemia
- congestive heart failure
- Alzheimer’s dementia
- GI bleed
Along with these patients, my classmate and I spent a morning in the GI lab observing endoscopies and colonoscopies, and a morning in the dermatology clinic helping to treat and dress wounds (diabetic foot ulcers, skin cancers, and the like). It was a learning feast.
The Highlight of My Week
On one occasion, when the intern and resident were stumped, they asked me to go in reinterview a new patient. It just wasn’t clear what was making him so sick. So I took my time and asked many questions. After about 20 minutes, he shared an important tidbit of so-far undisclosed medical history, and a light went on in my head. I used the tidbit to search for a rather specific pain that had not yet been identified by the patient. When I found it, I knew the diagnosis. I shared my assessment with the team, and delighted in their response: “Ah haaaaa.“ Score one for the PA student.
So my two-week rotation began feeling a little limp, and ended with some real starch. Though it was hard, as Dr. B was trudging around, arms folded on his chest, putting us on the spot, I was secretly thinking: Now I’m having the rotation I always pictured.