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
For all of you who are starting medical school this month I wish you well in your future endeavors with your medical career. As part of orientation week, the dean of your university is going to give a heart-warming speech about helping others and heeding the call of duty. At the end of the day you’re going to feel like a real member of the team and that your purpose at this school will be to become a scholar, a healer, and a gentleman.
I got the same speech when I started medical school three years ago. And indeed, I did feel mighty confident in my university’s ability to teach me to become a fantastic doctor. What I wish had happened is for the dean to have told us the truth. Had he done so, that speech would’ve gone something like this:
Welcome everybody to Half University! I’m happy that you’re all here with us to embark an endeavor to become a physician. Although four years sounds short, this will be one of the most time-consuming and hardest experiences you’ll ever go through. When you interviewed here we told you that each and everyone of you are a valued member of our team. That was all a lie. You are really nothing more than a burden to the residents and the attendings at this institute. Oh sure, you will run into some fantastic teachers during your first two years here. But the vast majority of staff members will see you as nothing more than a nuisance. You will get in the way of their ability to see patients quickly. As punishment you’ll have to endure hours of torture through a humiliating process that we call pimping. Be prepared to be asked any and all questions regarding your patients—including their astrological sign, what their dietary habits are like, and what’s the half-life of the medication we’re using to treat their disease.
We’ve really got you by the balls now. There’s no other way to become a physician in the United States than to go through one of the AAMC member schools. While I don’t doubt that anyone of you is smart enough to learn all the basic sciences on your own in one year, we’re going to make you spend two years to learn the same material because instead of giving you time off to study, we’re going to make you come in for Physicianship Training so that you can learn about everything from Medicare reimbursements, to how Hispanics think, to our political views on health insurance and the non-insured—all in your first year of medical school, where none of this information will be applicable for many years to come. All the while, were going to charge you an excess of $60,000 to learn something that you could teach yourself for free.
Look to your left; look to your right. In years past one of those two individuals would have flunked out of school because of the academic demands placed upon them by this university and others. However, we currently have a doctor shortage in this country. Therefore, we are forced to find ways to advance everyone of you through each year until you finally graduate. Now look to your left; look to your right. One of those individuals will sink into a horrible depression over the next four years in the realization that he or she should not be here. However, due to economic and familial pressures, that individual will stay on and possibly kill a few patients before getting their M.D.
You are a burden. Let me reiterate to you that neither the residents nor the faculty truly have any desire to teach you. The residents will dislike you so much that they will have you go down to the radiology suite to fetch x-rays just so you they can be without your presence for several more minutes. The residents will threaten you and say things like, “I evaluate students based off of their enthusiasm. If you aren’t willing to go that extra mile and get my x-rays, I must question your commitment for this field.”
All of you have your own individual reasons for coming to medical school. Many of you use your personal statements and your interviews as a chance to try to fool us on the admissions committee that you have nothing but pure intentions of serving others. For some of you, this statement is true. Unfortunately, our system will find a way to wear you down. For others, this statement was utterly false—and the only reason you’re here is to either make money or to win the affection of your parents who never paid attention to you while you were growing up. Whatever your reasons are, they don’t matter anymore. Your desire to work in South America or Africa as a medical missionary is not going to help you when you’re trying to memorize anatomical tables of muscles. Realize that this is going to be hard no matter who you are.
All of you were at the top of the bell curve when you were in high school. And then you went to college where you continued to be at the top of the bell curve. Now that you’re in medical school, we’ve got to remake the bell curve. I can assure you that half of you will be on the bottom side. So study hard and do your best. That is all you can ever give.
Your medical school experience, particularly in the third and fourth years, will be shaped entirely by the people you are around. For some of you, you will hit the jackpot and have a team where the interns are on top of everything, the residents love to teach, and your classmates are eager participants. Others of you will be stuck with ignorant interns, student-hating residents, and classmates that you will constantly cover for. Those four weeks will be your private hell.
That is all I can tell you at this point. But trust me on the studying.
I took STEP 2 this week. Four cans of Red Bull, six bathroom breaks, and nine hours later, I’m one step closer to getting a license. It’s just like STEP 1, except I actually knew what questions were talking about this time.
I posted a reader take on kevinmd this weekend. With a fake story about witch doctors and socialized medicine, how can you go wrong?
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Looking over my previous post about how to conduct yourself on surgery, I realized that I left out an important point about pre-rounding and presentation on rounds. Part of your job as a medical student will be to wake up all of the patients first thing in the morning so you can ask them about their pain level, bowel habits, and any overnight events. You will also conduct a very short physical exam. Depending on which service you’re on, you might have as many as six patients that you have to see and write notes on in one hour. Since timing is so important, I used the following lines of questioning with every patient:
How did you sleep last night?
How’s your pain right now? Can you rate it on a scale from 1-10? Where is it located?
Any nausea, vomiting, or diarrhea? Have you passed gas?
How’s your appetite?
Did you get out of this bed yesterday to walk around?
Are you using the incentive spirometer? (You should have the patient demonstrate that he knows how to use the spirometer.)
Next, listen to the patient’s heart, lungs, and abdomen. You’re looking for any chance of atelectasis, new murmurs, and bowel sounds. If the patient is on the first postoperative day and had abdominal surgery, you may very well not hear any bowel sounds—hence why it’s so important to ask if the patient has passed gas since the operation. And make sure to do a real physical exam. That means that you will have to set the patient up in bed, if possible, to do a proper lung exam. I’ve seen many residents claim that the patient is healthy when they’ve only listened to the anterior chest. They later get burned when they discover that the patient has a lower lobe pneumonia. Don’t let that happen to you. Getting an immobilized patient to sit up—or even roll over—takes only a few extra seconds.
Finally, check to see what the patient is getting via IV. While the orders may say that the patient is to receive 100 mL per hour of 1/2 normal saline, you might be very surprised to see that he is now receiving 150 mL per hour of 0.9 normal saline. Also make a note of the color of the urine in the Foley bag—whether or not it has any blood, as well as look at any drains. The color of the fluid in the JP drain should be either clear, pink, or green if you are expecting bile. The output in a drain should never contain frank blood, but a serosanguinous fluid is acceptable. I also knew a few attendings that wanted us to change the patients’ dressing before rounds each day. Check with former students to learn the attending’s preferences.
Whenever I’m pre-rounding on a patient, I usually try to find the nurse who took care of him the night before to ask about any overnight events. While your patient might tell you that he slept well throughout the evening, your nurse may tell you that he was up vomiting all night. If the nurse is unavailable, then try to find her notes.
You should be able to complete all of the above steps in less than three minutes.
Now you need to look up all of the patient’s overnight lab work, including any new imaging studies. You should write your note by detailing what the postoperative day is, what was the surgery, all the information that you gathered earlier, and what day of antibiotic treatment the patient is on. Leave out any past medical history. An example note looks like this:
S) Mrs. Smith is a 67-year-old female who is postoperative day number three for a gastrojejeunostomy. There were no acute events overnight. The patient states that she currently has a 2/10 pain level and is well controlled by current medications. Clear liquid diet is well tolerated. No N/V/D. Patient is ambulatory.
O) List your physical exam findings as well as any new labs.
A/P) Give a very short assessment and plan, but focus more on the plan. Examples might be “Advance to soft diet” or “Chest x-ray to rule out pneumonia.”
When you give your presentation on rounds, recite the information from the subjective part, list the vitals, mention only pertinent findings from physical exam—otherwise just say, “heart and lungs sound normal”—and then give your plan for the day.
Rounds stop being nerve-racking around week two.
Addenum: Someone pointed me to the surgical review by Pestana. It looks good, but given that I don’t know the copyright status of the outline, I’m hesitant to post it here. You’ll have to do a search for it.
All around the country premeds everywhere are anxiously awaiting the start of medical school at the beginning of August. They will bring with them many hopes and aspirations as they begin their careers toward becoming future MD’s. They will have many questions such as which organizations to join, whether or not to go to class, and who is going to kill the first patient. But nothing is more anxiety provoking at this time then trying to decide which stethoscope to purchase.
While there are many options to choose from, I would caution fresh medical students to stay away from the electronic stethoscopes. I have never use these devices. While I’m sure that their built-in microphones will help listeners catch even the faintest heart murmur, there is something to be said about learning the physical exam the old fashion way.
First and foremost you must buy a cardiology grade stethoscope. That includes a diaphragm, a bell, and a dual lumen tube. Instantly disqualified are the nursing-grade stethoscopes that your parents got you as a gift when you were accepted to medical school. You should plan to spend at least $100 on a quality model.
Currently, the most popular stethoscope amongst medical students is the Littman Cardiology III. there is no shortage of users willing to sing its praises. It comes in numerous colors, drug companies give away accessory products specifically designed for it, and it has the appeal of being able to say, “I went with the Littman.”
I don’t like it. I haven’t been able to hear as well with it as the marketing propaganda would claim. The fans will instantly cry out, “But it has a tunable diaphragm.” To which I would respond, “Do you even know what a tunable diaphragm is? And furthermore, if you pay any attention to the research that was conducted on stethoscopes beginning over 50 years ago, you’d realize that a tunable diaphragm is the exact feature that a stethoscope should not have.”
I prefer the Welch Allyn Tycos DLX. The sound quality is much, much better compared to the Littman. It has interchangeable ear pieces that come in various varieties of stiffness so that the user can choose based on comfort level. Finally, the diaphragm can be easily changed to a pediatric version. All I have to do is unscrew the adult version and then replace it with a pediatric one to convert my stethoscope into a listening device for the kids.
Take a look at the pictures below:
What now bitches? I’d like to see you pull that off with a Littman. Its users will be required to buy two stethoscopes to follow both adult and pediatric patients. I know several people who purchased new stethoscopes just to go through the peds rotation. I took a more sensible approach.
I was sent this article about workers in Japan. I’d like to see them work American residency hours. What’s more, I’d love to see if anyone outside of medicine cares if a resident dies from “overwork.”