The Life Raft for internal medicine

August 14, 2008 at 2:35 am (Life Raft)

Whereas the surgeons worked you to death, the internists are going to bore you to death. One of the frequent complaints about the internal medicine clerkship is that rounds take entirely too long. My own team would routinely spend about three hours going through a census of only 20 patients. Some of my classmates got thrown into groups which would take five hours every day to run through the list—and that’s after all of the pre-rounding has been completed, orders filed, test results analyzed, and patients reassured.

Internal medicine is the wastebasket of the hospital. All cases that other services refuse to take are deferred to the internists. I remember taking care of patients who clearly had neurological problems, were refused by the neurology service, and then we picked them up only to later consult the neurology team. You will get skin disorders, psychiatric ailments (including suicide attempts), and a variety of elderly patients who are near death’s door, but the family is too ashamed to finally just let them die.

Since internists have to deal with so many different diseases, they acquire a vast body of knowledge and a keen eye for looking at subtle differences between presentations. The internists will then happily share this knowledge to anyone within earshot, commenting on the sensitivity and specificity various laboratory studies, noting the laboratory artifacts that can give positive results for various tests, and devising treatment plans using the first, second, and third lines of therapy.

While I certainly respect internists and their knowledge base, hearing about it can be quite annoying. Internists were the little nerds on the playground who got their asses kicked whenever they tried to say, “But it’s my turn on the monkey bars.” Internists go home and fondle themselves while watching Patch Adams, vowing to one day heal their patients using only their words. Internists like to take out their sick brand of torture known as rounding on others. You’ll very likely sit around the table and toss around ideas about a patient’s medical status. The process is nicknamed mental masturbation because attendings seem to get off on the idea that discussing a patient’s laboratory values is such great fun.

The best attendings will be the ones who treat you as a member of the team. They will force you to get up early, see multiple patients, read about their diseases, and then present the information succinctly on rounds. At the time, they can seem like total hard asses because of all the hours you have to spend preparing for the next day. But the payoff is so rewarding. The worst attendings are the ones who treat medical students like know-nothing observers. Sure, life may be easy when you leave the hospital every day at 10 a.m., but it bites you in the ass when you take your Shelf exam and realize that you haven’t learned anything.

On medicine, your grade is directly proportional to your communication skills. Students who write long admission notes tend to get praised by the boss. For every one of my patients that I admitted, I would typically type up a five-page long note covering everything from the patient’s smoking history, to a differential diagnosis of upper abdominal pain, and a discussion of what the various laboratory tests mean. The longer your note and differential diagnosis are, the better your evaluation. Whereas surgeons use rounding as an opportunity for you to quickly list the facts and then rush to the OR, internists really don’t have anywhere to go during the day, so they use rounds as a way to pass the time. Therefore, you should make every opportunity to deliver good presentations in front of the residents and attending. One way to do this is to think about your patient’s presentation as a story. Your goal is to lead the audience into having the same thought process as you. Mentioning that a patient’s chest pain gets worse with inspiration is far more important than mentioning that he is sweating and has a fear of impending doom.

Whenever you go see your patient first thing in the morning, be sure to do a complete physical exam involving the cardiac, pulmonary, and abdominal systems, regardless of the chief complaint. Being thorough does not mean placing your stethoscope on the patient’s chest and then asking him to breathe deeply. It means that you need to sit the patient up, removed his gown, and listen to the entire back and chest. I’ve seen residents get burned by a patient with pneumonia simply because they wanted to rush through a physical exam and listen to the patient’s lungs only from the front. Waking someone up first thing in the morning and getting him to sit up or at least to roll over in bed takes just a few seconds at most. Missing a patient’s crackles, costovertebral tenderness, or an abscess on the back or buttocks is simply inexcusable. I distinctly remember having an HIV-positive patient with pneumonia who, despite our best efforts with oral medication, was not getting better during her hospital stay. Every morning I would go into her room and check her legs for edema just for completeness sake. One day I pulled off her socks to check the pedal pulses and several pills fell to the ground. She had been hiding away her medicine because she “didn’t feel like swallowing all these pills.” We immediately switched to intravenous antibiotics and she rapidly improved.

Some previous posts on internal medicine:
Let God sort them out
Letter from a patient
Every time a homeless person is admitted to the hospital, an angel gets his wings
The puppets of medicine
All this work, only to be outdone by a bag of Oreos