A friend asked me toward the end of my first week of neurology, "Are you still considering pediatric neurology as a possible career?" The short answer is yes. I was prepared to discover that in fact I did not like trying to coo my way through a neurological exam, or that dealing with the parents of very sick children would be nightmarish.
On the contrary.
Sure, most children aren't as cooperative as an adult, but I take it as a challenge to figure out how to get the information I need. For example, I needed a hide-behind-my-mommy toddler to close his eyes tight to assess facial muscle strength and symmetry. He wouldn't cooperate, no surprise. So I decided to play hide-and-go-seek. "Now close your eyes while I go hide!" Done.
I also noticed that, in general, the sicker the kid the nicer the parents. Knowing me, I will start plotting subjective parent pleasantness versus severity of child illness then calculate the correlation.
Another aspect of pediatric neurology that I like is that my entire approach to the neurological exam will be different depending on the child's stage of development. In one day, I saw a 9-month-old, a 2-year-old, a 5-year-old, a 10-year-old, and a 17-year-old. That 17-year-old would think I'm a lunatic if I busted out the finger puppets to assess his eye movements.
I'm excited for these next three weeks to see how my perception of pediatric neurology evolves.
Saturday, August 27, 2011
Friday, August 26, 2011
Pediatric neurology: Tools of the trade
Because little kids are afraid of doctors, and doctors are associated with white coats, I suddenly found myself with five fewer pockets to carry my tools and other miscellany that are vitally important to the survival of the third-year medical student. The situation is even more grave because neurology uses a lot more tools than most other specialties, and pediatric neurology even moreso. This is my solution:
It's an elephant-shaped lunch bag! So far, it contains:
I'm already running out of room in my spiffy new tool bag.
It's an elephant-shaped lunch bag! So far, it contains:
- Ophthalmoscope and otoscope (borrowed from a classmate): For the eye and ear exams. All of the exam rooms are fully equipped, though, so I don't really need to carry these around in clinic.
- Tuning forks (128 Hz): For vibration and warm/cold sensation. My attending calls it the tickler. "Tell me if you feel it tickling your toe!"
- Reflex hammer: For reflexes, obviously, but it's also a great stand-in toy and distractor.
- Safety pins and paper clips: For sharp/dull sensation. But I hardly use them because poking kids with sharp objects is not a good idea.
- Measuring tape: My attending says, "The only head circumference measurement I trust is my own."
- Tennis ball: To play catch! And fetch! Easy way to assess coordination and running gait. I take the kid out in the hall, throw the ball, and observe the kid as he or she runs after it.
- Crayons: To draw on the exam table paper and examine ability to draw various shapes.
- Finger puppets: A frog and a pink rabbit. Pure distraction for the little kiddos, helps with assessing eye movements and tracking.
- Bell: To test hearing; also a great distractor.
- Wooden blocks: Six of them. Ask the kid to stack them up to test fine motor development.
- A bottle and raisins: Ask the kid to put a raisin in the bottle to test grasping (whole hand versus three-finger pincer versus thumb and index finger).
I'm already running out of room in my spiffy new tool bag.
Sunday, August 21, 2011
Breaking bad news
One of my patients came in to the hospital for gastritis but ended up staying for a couple weeks because we discovered that she had acute worsening of chronic kidney disease secondary to diabetes and hypertension. Dahlia didn't seem to understand that out-of-control diabetes and hypertension directly caused her kidney injury. Up until this point, she had been asymptomatic. When sick people don't feel sick, and they lack education to understand the illness and money to buy medications, they tend to not take care of themselves properly.
"I know that you came here for your stomach problems, but the reason you're still here is because we found out that your kidneys aren't working well. We think you've been feeling nauseous because of your kidneys, not because of your stomach."
"Okay, doctor, what does that mean?"
"It means that we want to keep you here for a few more days to make sure your kidneys start working better and to get your blood pressure and diabetes under better control."
"Oh, okay doctor. Whatever you say I need to do to get better."
After a few more days with steadily climbing creatinine and continued worsening of kidney function, it became clear that Dahlia was going to need dialysis. If she was lucky, we'd be able to place a fistula for scheduled dialysis rather than start dialysis emergently.
Regardless, I took responsibility for talking to Dahlia about her worsening kidney disease and the need for dialysis. I dreaded the conversation. Like a good medical student, I printed out materials and prepared a pretty little speech to teach my patient about chronic kidney disease and dialysis. She only had one question for me when I finished: "Am I going to die?"
This question nearly knocked me to the ground. I wish that I could say that I provided a thoughtful and reassuring answer. But I didn't. Afterward, I went to my intern to see if he had any advice about how to handle this situation. "Ooooh, I can't believe you pulled the I-don't-have-a-crystal-ball line!"
I felt ashamed, even though implicit in his poking fun of me was the admission that once upon a time he too had fallen back on the crystal ball line. I wanted to be a doctor to my patient, not a medical student, an admittedly impractical aspiration given my inexperience in breaking bad news to patients.
This conversation continued over the next couple of days as her creatinine continued to creep upward, my patient languishing in the stench of her hospital-acquired depression. Each night on my way home from the hospital, I asked myself why I couldn't bring myself to tell my patient the truth. It didn't matter: I just had to tell her.
"The graph on the left shows you what your chances are of being alive five years after starting dialysis. You have an 80% chance of being alive at 1 year, a 60% chance of being alive at 2 years, a 40% chance of being alive after 3 years, and a 20% of being alive after 5 years. That means that for every five patients with diabetes starting dialysis, only one will be alive in 5 years. The outlook is a little better for people with kidney disease but who don't have diabetes; that's why we've been so concerned about controlling your blood sugar. Keeping both your blood sugar and blood pressure under control is the best way to keep you healthy and slow the progression of your kidney disease."
Dahlia's eyes drifted downward then darted upward and rightward and leftward then settled on the picture-perfect 9th floor cityscape that seemed to represent escape from this prison of disease and death. Her eyes looked everywhere except at me.
I finally realized that I had been afraid of burdening my patient with the knowledge of how she was going to die, and when, as if I could somehow protect her with a shroud of ignorance. How small and selfish I had been.
I looked out at the cityscape where Dahlia was still gazing with blank eyes.
"I want to go home."
"I know that you came here for your stomach problems, but the reason you're still here is because we found out that your kidneys aren't working well. We think you've been feeling nauseous because of your kidneys, not because of your stomach."
"Okay, doctor, what does that mean?"
"It means that we want to keep you here for a few more days to make sure your kidneys start working better and to get your blood pressure and diabetes under better control."
"Oh, okay doctor. Whatever you say I need to do to get better."
After a few more days with steadily climbing creatinine and continued worsening of kidney function, it became clear that Dahlia was going to need dialysis. If she was lucky, we'd be able to place a fistula for scheduled dialysis rather than start dialysis emergently.
Regardless, I took responsibility for talking to Dahlia about her worsening kidney disease and the need for dialysis. I dreaded the conversation. Like a good medical student, I printed out materials and prepared a pretty little speech to teach my patient about chronic kidney disease and dialysis. She only had one question for me when I finished: "Am I going to die?"
This question nearly knocked me to the ground. I wish that I could say that I provided a thoughtful and reassuring answer. But I didn't. Afterward, I went to my intern to see if he had any advice about how to handle this situation. "Ooooh, I can't believe you pulled the I-don't-have-a-crystal-ball line!"
I felt ashamed, even though implicit in his poking fun of me was the admission that once upon a time he too had fallen back on the crystal ball line. I wanted to be a doctor to my patient, not a medical student, an admittedly impractical aspiration given my inexperience in breaking bad news to patients.
This conversation continued over the next couple of days as her creatinine continued to creep upward, my patient languishing in the stench of her hospital-acquired depression. Each night on my way home from the hospital, I asked myself why I couldn't bring myself to tell my patient the truth. It didn't matter: I just had to tell her.
Brenner and Rector's The Kidney, 8th ed. Figure 17-9. Adjusted 5-year survival of U.S. incident dialysis patients by modality and primary diagnosis. (From U.S. Renal Data System: USRDS 2005 Annual Data Report: Atlas of End-Stage Renal Disease in the United States. Bethesda, MD, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, 2005, p 131.)
"The graph on the left shows you what your chances are of being alive five years after starting dialysis. You have an 80% chance of being alive at 1 year, a 60% chance of being alive at 2 years, a 40% chance of being alive after 3 years, and a 20% of being alive after 5 years. That means that for every five patients with diabetes starting dialysis, only one will be alive in 5 years. The outlook is a little better for people with kidney disease but who don't have diabetes; that's why we've been so concerned about controlling your blood sugar. Keeping both your blood sugar and blood pressure under control is the best way to keep you healthy and slow the progression of your kidney disease."
Dahlia's eyes drifted downward then darted upward and rightward and leftward then settled on the picture-perfect 9th floor cityscape that seemed to represent escape from this prison of disease and death. Her eyes looked everywhere except at me.
I finally realized that I had been afraid of burdening my patient with the knowledge of how she was going to die, and when, as if I could somehow protect her with a shroud of ignorance. How small and selfish I had been.
I looked out at the cityscape where Dahlia was still gazing with blank eyes.
"I want to go home."
Sunday, August 14, 2011
Fragmentation of team-based clinical learning in hospitalized adult care
Over the course of my 8-week Internal Medicine clerkship, the composition of my team changed a total of 8 times. Settling into a smooth team dynamic with a new resident or attending takes at least a few days. Once I got used to working with one set of people, the teams were shuffled around, and I had to restart the process of getting to know a new resident or attending. This instability frustrated me.
Resident work hour restrictions
Why is the system like this? Part of it has to do with resident work hour restrictions, which currently limit residents from working more than 80 hours per week, averaged over 4 weeks. They further restrict interns from working more than 16 consecutive hours and upper-level residents from working more than 24 consecutive hours. Medical students have to follow these restrictions, too. My understanding is that there was much more continuity of team composition, and patient care, before resident work hour restrictions were put in place.
I was talking to one of my residents about this lack of continuity, for medical students and residents alike, and how that takes away from clinical learning. He described how he had taken 30-hour calls with the rest of his team as a third-year medical student; he also agreed with me that medical students get short-changed under the current system.
The way I see it, a solid clinical education, at all levels of training, is very much in the best interest of patient care. So again, why is the system like this? The movement to restrict resident work hours was aimed at increasing patient safety and reducing medical errors due to fatigue. It dates back to the sad case of Libby Zion, a young woman who died after mismanagement by two sleep-deprived residents.
Effects of fatigue on performance
A 1997 study published in Nature reports that being awake for 21 consecutive hours is equivalent to a blood alcohol content of 0.08% (the legal limit for driving). Furthermore, every 0.01% BAC increase was found to correlate with a roughly 1% decline in psychomotor performance on a standardized task, and that correlation was linear.
Before the new work restrictions, residents were ending their 30-hour shift at an equivalent BAC of 0.17%, or more than twice the level at which society has decided that it is unsafe to drive a car. With the new work hour restrictions in place, residents are ending their shift at an equivalent BAC of 0.11%, an improvement, but still over the legal driving limit.
My opinion
Medicine is regarded as a conservative institution for good reason. By graduating from medical school and completing residency, physicians gain a vested interest in the status quo. Institutional change doesn't come easily to medicine, so these new resident work hour restrictions are monumental.
I agree with the restrictions on resident work hours from a theoretical standpoint, and I appreciate them for protecting my future sanity and my future patients' safety. I sure wouldn't want a drunk internist to care for me in the hospital, or a drunk surgeon to operate on me. However, based on my (admittedly limited) two months’ experience with hospitalized adult care, it seems to me that these work hour restrictions have unintended negative consequences, not the least of which is a more fragmented clinical experience for third-year medical students. In trying to balance adequate physician training with work hour restrictions to protect patient safety, there are no easy answers.
----
Late update: Several of my colleagues are of the opinion that resident work hour restrictions have less to do with team discontinuity than the mismatch between the schedules of medical students, residents, and attendings.
One person said:
Another person agreed, saying:
I observed the same phenomenon during my Internal Medicine clerkship and agree that it probably more directly led to team discontinuity. However, particularly at Denver Health, it seemed to me that this off-cycle rotation of medical students, residents, and attendings was made worse by a call cycle structured partly as a consequence of resident work hour restrictions.
Resident work hour restrictions
Why is the system like this? Part of it has to do with resident work hour restrictions, which currently limit residents from working more than 80 hours per week, averaged over 4 weeks. They further restrict interns from working more than 16 consecutive hours and upper-level residents from working more than 24 consecutive hours. Medical students have to follow these restrictions, too. My understanding is that there was much more continuity of team composition, and patient care, before resident work hour restrictions were put in place.
I was talking to one of my residents about this lack of continuity, for medical students and residents alike, and how that takes away from clinical learning. He described how he had taken 30-hour calls with the rest of his team as a third-year medical student; he also agreed with me that medical students get short-changed under the current system.
The way I see it, a solid clinical education, at all levels of training, is very much in the best interest of patient care. So again, why is the system like this? The movement to restrict resident work hours was aimed at increasing patient safety and reducing medical errors due to fatigue. It dates back to the sad case of Libby Zion, a young woman who died after mismanagement by two sleep-deprived residents.
Effects of fatigue on performance
A 1997 study published in Nature reports that being awake for 21 consecutive hours is equivalent to a blood alcohol content of 0.08% (the legal limit for driving). Furthermore, every 0.01% BAC increase was found to correlate with a roughly 1% decline in psychomotor performance on a standardized task, and that correlation was linear.
Before the new work restrictions, residents were ending their 30-hour shift at an equivalent BAC of 0.17%, or more than twice the level at which society has decided that it is unsafe to drive a car. With the new work hour restrictions in place, residents are ending their shift at an equivalent BAC of 0.11%, an improvement, but still over the legal driving limit.
My opinion
Medicine is regarded as a conservative institution for good reason. By graduating from medical school and completing residency, physicians gain a vested interest in the status quo. Institutional change doesn't come easily to medicine, so these new resident work hour restrictions are monumental.
I agree with the restrictions on resident work hours from a theoretical standpoint, and I appreciate them for protecting my future sanity and my future patients' safety. I sure wouldn't want a drunk internist to care for me in the hospital, or a drunk surgeon to operate on me. However, based on my (admittedly limited) two months’ experience with hospitalized adult care, it seems to me that these work hour restrictions have unintended negative consequences, not the least of which is a more fragmented clinical experience for third-year medical students. In trying to balance adequate physician training with work hour restrictions to protect patient safety, there are no easy answers.
----
Late update: Several of my colleagues are of the opinion that resident work hour restrictions have less to do with team discontinuity than the mismatch between the schedules of medical students, residents, and attendings.
One person said:
Our M3 rotation cycle doesn't match up with the monthly resident switch, and then the attendings all have 10 days on inpatient straight and then they switch. So our high composition turnover was simply due to the fact that attendings, residents, and medical students all have differing cycle duration through a given team.
Another person agreed, saying:
It is hard enough to line up Residents with each other. Let alone attendings with their resident teams. And, as always, the bottom of the barrel is the medical student who gets last dibs.
I observed the same phenomenon during my Internal Medicine clerkship and agree that it probably more directly led to team discontinuity. However, particularly at Denver Health, it seemed to me that this off-cycle rotation of medical students, residents, and attendings was made worse by a call cycle structured partly as a consequence of resident work hour restrictions.
Friday, August 12, 2011
A much-needed vacation
I'm done with my Internal Medicine clerkship! It feels especially good because now I have a whole week of complete freedom and relaxation before starting my Neurological Care clerkship at The Children's Hospital. This is a much-needed vacation, and I suspect that it will fly by all too quickly.
Thursday, August 11, 2011
Homecoming: Return to the library
We had to return to campus today for standardized patient testing as part of the Hospitalized Adult Care evaluation. Since we also have the Internal Medicine shelf exam tomorrow, and since I was already on campus, I figured that I might as well study at the library. It feels good to be back in the library: no post-traumatic stress disorder from my Step 1 studying days. I had almost forgotten what a good study environment the library is compared to studying at home and at coffee shops.
Wednesday, August 10, 2011
Daily routine at Denver Health
My daily routine while working on the Medicine service at Denver Health was surprisingly predictable.
I woke up between 5:00-5:30 am to get to the hospital between 6:00-6:30 am, which gave me enough time to pre-round on my patients before rounds at 8:30 am. Rounds usually lasted until 10:00-11:00 am, depending on how efficient we were and how many patients we were carrying.
From the end of rounds until 12 noon, I took care of my patients. This included things like consulting various specialists (infectious disease, renal, etc...), following up on labs and studies, and ordering new labs or medications. At Denver Health, medical students can place orders, but they must be signed by a licensed physician, usually the intern or sometimes the resident.
Then we had Noon Conference until 1:00 pm, lunch catered.
Afternoons were also generally reserved for patient care. If I finished earlier in the afternoon, I would go back around and visit with my patients, then study until around 5:00 pm, then check in with my patients one more time, then ask my intern and resident if there was anything else I could do to help out before going home. On late days, I would stay until 7:00 pm or so.
Overall, I would guess that my average day was 11 hours long. I worked a couple 9-hour days and several 14-hour days, but the rest were between 10-13 hours. Of course, that's not counting the time spent at home studying or reading up on my patients.
----
I attribute the regularity of my schedule at Denver Health to its rolling admissions structure. At Presbyterian St. Luke's and many other hospitals, doctors take call (i.e. admit new patients) every fourth day; that's not the case at Denver Health. Instead, the medicine team with the lightest census (carrying the fewest patients) takes the next admit. This makes good sense to me: whoever has the least amount of work admits the next patient.
However, this isn't the traditional model. Some interns and residents don't like rolling admissions because it eliminates post-call days, which are essentially an extra day off. From my perspective as a third-year medical student, though, I love this set-up because it secures for me a steady flow of patients. On any given day, if I wanted a new patient I could generally get one. That meant a lot to me in terms of my educational experience.
I woke up between 5:00-5:30 am to get to the hospital between 6:00-6:30 am, which gave me enough time to pre-round on my patients before rounds at 8:30 am. Rounds usually lasted until 10:00-11:00 am, depending on how efficient we were and how many patients we were carrying.
From the end of rounds until 12 noon, I took care of my patients. This included things like consulting various specialists (infectious disease, renal, etc...), following up on labs and studies, and ordering new labs or medications. At Denver Health, medical students can place orders, but they must be signed by a licensed physician, usually the intern or sometimes the resident.
Then we had Noon Conference until 1:00 pm, lunch catered.
Afternoons were also generally reserved for patient care. If I finished earlier in the afternoon, I would go back around and visit with my patients, then study until around 5:00 pm, then check in with my patients one more time, then ask my intern and resident if there was anything else I could do to help out before going home. On late days, I would stay until 7:00 pm or so.
Overall, I would guess that my average day was 11 hours long. I worked a couple 9-hour days and several 14-hour days, but the rest were between 10-13 hours. Of course, that's not counting the time spent at home studying or reading up on my patients.
----
I attribute the regularity of my schedule at Denver Health to its rolling admissions structure. At Presbyterian St. Luke's and many other hospitals, doctors take call (i.e. admit new patients) every fourth day; that's not the case at Denver Health. Instead, the medicine team with the lightest census (carrying the fewest patients) takes the next admit. This makes good sense to me: whoever has the least amount of work admits the next patient.
However, this isn't the traditional model. Some interns and residents don't like rolling admissions because it eliminates post-call days, which are essentially an extra day off. From my perspective as a third-year medical student, though, I love this set-up because it secures for me a steady flow of patients. On any given day, if I wanted a new patient I could generally get one. That meant a lot to me in terms of my educational experience.
Monday, August 8, 2011
Getting sick in the middle of a clerkship
What happens if I get sick in the middle of my Internal Medicine clerkship? I know that I wasn’t alone among my classmates in worrying about this question as third-year began. We’re expected to work 12+ hours per day, six days per week, and we’re not allowed to have any personal life or suffer any illness that would cause us to miss a day of work. That’s a little melodramatic... but not overly so.
Well, I did get sick: a low-grade fever, chills, sweats, fatigue, and nausea. I didn’t have any upper-respiratory complaints and probably wasn’t contagious, so I showed up at the hospital at the usual time. I mustered enough energy to attend to my patients properly before rounds, but I had to pass on taking a new patient. My resident took note of this because I had been gunning for a new admission the night before.
I almost didn’t make it through rounds. I somehow presented my patients to the team adequately and answered a few pimps, but the rest of the time was a haze. Rather than actively participating in rounds, it was all I could do to save face and act like I wasn’t about to collapse on the ground.
After rounds, my resident told me that I should go home. Can I really? Will my resident think less of me for it, i.e. will this negatively impact his evaluation of me? I felt uncomfortable leaving right after rounds because that meant my intern would have to pick up my slack. “If it’s okay with you, I’d like to stay until I take care of all my patients.” This just meant ordering some labs, following up on some studies, and doing some other miscellaneous tasks that would save my intern some scut.
“Sure, but I don’t want to see you here past 12 noon.”
Deal.
I crashed right when I got home and slept for four hours straight, the kind of hard afternoon sleep that the body demands when it needs to mend itself.
----
It seems to me that the personality of the resident greatly determines how the sick-in-the-middle-of-a-clerkship situation plays out. I very easily could have been working with a less sympathetic and understanding resident. Having a nice resident basically bought me the afternoon off when I really needed it.
I can also see how the particular clerkship might matter. Getting sick during an inpatient rotation such as Internal Medicine negatively impacts continuity of care. Even though I did everything I could to tie up loose ends before leaving, I fell behind the ball on the status of my patients by missing a whole afternoon. During an outpatient clerkship like Adult Ambulatory Care, in contrast, patients are seen in discrete 20-30 minute appointments. Missing an afternoon of outpatient care doesn't impact my ability to see new patients the next day. Also, missing any time during a short 2-week rotation might be more problematic.
Here's to hoping that I don't get sick again for the rest of third-year.
Well, I did get sick: a low-grade fever, chills, sweats, fatigue, and nausea. I didn’t have any upper-respiratory complaints and probably wasn’t contagious, so I showed up at the hospital at the usual time. I mustered enough energy to attend to my patients properly before rounds, but I had to pass on taking a new patient. My resident took note of this because I had been gunning for a new admission the night before.
I almost didn’t make it through rounds. I somehow presented my patients to the team adequately and answered a few pimps, but the rest of the time was a haze. Rather than actively participating in rounds, it was all I could do to save face and act like I wasn’t about to collapse on the ground.
After rounds, my resident told me that I should go home. Can I really? Will my resident think less of me for it, i.e. will this negatively impact his evaluation of me? I felt uncomfortable leaving right after rounds because that meant my intern would have to pick up my slack. “If it’s okay with you, I’d like to stay until I take care of all my patients.” This just meant ordering some labs, following up on some studies, and doing some other miscellaneous tasks that would save my intern some scut.
“Sure, but I don’t want to see you here past 12 noon.”
Deal.
I crashed right when I got home and slept for four hours straight, the kind of hard afternoon sleep that the body demands when it needs to mend itself.
----
It seems to me that the personality of the resident greatly determines how the sick-in-the-middle-of-a-clerkship situation plays out. I very easily could have been working with a less sympathetic and understanding resident. Having a nice resident basically bought me the afternoon off when I really needed it.
I can also see how the particular clerkship might matter. Getting sick during an inpatient rotation such as Internal Medicine negatively impacts continuity of care. Even though I did everything I could to tie up loose ends before leaving, I fell behind the ball on the status of my patients by missing a whole afternoon. During an outpatient clerkship like Adult Ambulatory Care, in contrast, patients are seen in discrete 20-30 minute appointments. Missing an afternoon of outpatient care doesn't impact my ability to see new patients the next day. Also, missing any time during a short 2-week rotation might be more problematic.
Here's to hoping that I don't get sick again for the rest of third-year.
Tuesday, August 2, 2011
Expectations of a third-year medical student on Internal Medicine clerkship
My new attending sat down with me to discuss his expectations of me during the next couple of weeks. Previous attendings have also sat down with me to have a sort of introductory conversation, mostly so they can get a sense of who I am and where I"m at in my training. This was different, though, because my new attending enumerated for me exactly what he expected of me, in no unclear terms.
1. I should be carrying between 4-5 patients at any given time, and I should know all of my patients inside and out.
2. I should read as much as possible about my patients' diseases (pathophysiology, diagnosis, clinical presentation and course, treatment) since that more than anything will reinforce my learning.
3. History and physical exams should take about 20 minutes.
4. Initial patient presentations should take about 7 minutes, but I can take as much as 10 minutes if the patient is complicated. They should be structured.
5. Follow-up presentations should take no more than 5 minutes. They can be a little less structured.
6. During oral presentations, I should avoid reading from a paper and instead talk directly to my attending as much as possible. If I did a good job talking with my patient, then all the information should already be in my head.
7. I should be familiar with all of the other patients on our service, since I may be asked about any of them.
8. I should attend all rounds. They are sacred. That means no skipping rounds to go watch a procedure.
Some of this advice is common sense. Some of this advice is specific to my stage of training. The rest of it, though, is wonderful general advice for any third-year medical student on the Internal Medicine clerkship.
1. I should be carrying between 4-5 patients at any given time, and I should know all of my patients inside and out.
2. I should read as much as possible about my patients' diseases (pathophysiology, diagnosis, clinical presentation and course, treatment) since that more than anything will reinforce my learning.
3. History and physical exams should take about 20 minutes.
4. Initial patient presentations should take about 7 minutes, but I can take as much as 10 minutes if the patient is complicated. They should be structured.
5. Follow-up presentations should take no more than 5 minutes. They can be a little less structured.
6. During oral presentations, I should avoid reading from a paper and instead talk directly to my attending as much as possible. If I did a good job talking with my patient, then all the information should already be in my head.
7. I should be familiar with all of the other patients on our service, since I may be asked about any of them.
8. I should attend all rounds. They are sacred. That means no skipping rounds to go watch a procedure.
Some of this advice is common sense. Some of this advice is specific to my stage of training. The rest of it, though, is wonderful general advice for any third-year medical student on the Internal Medicine clerkship.
Monday, August 1, 2011
The storage clipboard
The storage clipboard has changed my life. Well, it's at least improved my organizational skills in the hospital. When I didn't have any clipboard at all, my white coat was bursting at the seams with papers of various sorts (progress notes, blank order sheets, uptodate articles, etc...). I even had a system to help organize what went where: reference and educational materials in the right inside pocket, work-related papers in the left inside pocket.
Needless to say, this didn't work very well. I started using a folding clipboard that fits into my white coat pocket. That worked fine for a few weeks, but I got frustrated with it because any papers it was holding would get roughed up if I ever folded it. What's the point of a folding clipboard if I never fold it?
Thus, we arrive at the storage clipboard. I don't mean to get into the business of product endorsement, but this thing has revolutionized the the way I "practice" medicine. I'm going to honor my Internal Medicine clerkship for no other reason than that I have this storage clipboard.
Needless to say, this didn't work very well. I started using a folding clipboard that fits into my white coat pocket. That worked fine for a few weeks, but I got frustrated with it because any papers it was holding would get roughed up if I ever folded it. What's the point of a folding clipboard if I never fold it?
Thus, we arrive at the storage clipboard. I don't mean to get into the business of product endorsement, but this thing has revolutionized the the way I "practice" medicine. I'm going to honor my Internal Medicine clerkship for no other reason than that I have this storage clipboard.
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