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.

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."

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.

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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.

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.

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.

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.

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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.

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.

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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.

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.

Clinical case presentations

Case presentations are one of my favorite things about Internal Medicine, apart from patient care. They're essentially a patient's entire hospital course compressed into one hour. A resident, intern, or medical student presents a particularly interesting or educational patient to the entire group. The chief resident moderates the discussion, pausing at certain points to allow the group to further investigate the case. The idea is for the group to collectively "work up" a patient as we would in real life.

I enjoy thinking through the case in my mind, figuring out what questions I would ask or what other labs I would order, then comparing that to what the group comes up with. As a medical student, I find this exercise invaluable in using the interns and residents as models for how I should approach a patient. Plus, I feel so actively engaged in the case presentation that the clinical lessons seem to stick almost as well as seeing a real patient.

Case presentations are generally similar at PSL compared to DHMC; their differences are mostly due to individual personalities of the faculty moderators. At PSL, the faculty moderators tended to give the chief resident and the group discussion more free reign, adding to the discussion only when an experienced opinion was needed.

At Denver Health, though, the faculty moderator is an old-school personality locally famous for his chest x-ray readings and his bow-ties. He takes more control over the discussion, explaining his diagnostic approach step-by-step. Every piece of information you gather should inform your next question to the patient, he says. He also reinforces a systematic approach to thinking about all possible causes of a given set of signs and symptoms. I feel smarter just listening to him.

I hope other clerkships have case presentations, or something like them.

Realities of working at a safety-net hospital

One of the patients I'm following managed to put together quite the interdisciplinary team. We consulted: infectious disease, GI, neuro, psychiatry, nutrition, speech therapy, social work, physical therapy, and occupational therapy.

Despite so many people and so many resources devoted to this patient, she still insisted on returning to the poor lifestyle decisions that landed her in the hospital in the first place. She understood how her actions negatively impacted her health and that she would likely wind up back in the hospital with the same problems, or worse. "Why change now?" I had a dozen answers to that question, but none of them mattered. She didn't want to die, yet she also seemed to accept early death as a consequence of living the rest of her life on her own terms.

I think what I'm feeling now is the prodrome of disenchantment.

A familiar face on my team

I got really lucky with my team for the first two weeks of my Internal Medicine clerkship at Denver Health. My attending just happens to be one of my favorite professors from my pre-clinical years! He teaches biochemistry and endocrinology (nutrition and metabolism). Aside from being an excellent teacher, he's also just an all-around nice guy. He has a calming demeanor; just talking with him, you get the sense that he is fully listening and truly cares about what you're saying.

This is particularly helpful since I have been struggling a bit with some anxiety surrounding oral presentations. Over the past few days, I think that my oral presentations have been much better than they were last month at PSL. This is partly because I have more confidence stemming from more experience and exposure, though I also attribute this improvement in part to decreased performance anxiety in this new learning environment. It's not really what I was expecting from Denver Health.

Both my resident and intern are also excellent, but I'm only with them through the end of the week before they rotate to a new team. I wish that I had more time working with them, too.

Internal Medicine clerkship schedule at PSL

Presbyterian St. Lukes Medical Center

Call: When your team admits new patients.

Call is every fourth day ("call q4") at PSL. Residents and sub-interns (fourth-year medical students) are there for the full 30 hours; the two interns per team split the call day in two 12-hour shifts; third-year medical students stay until they get their 2-3 patients, but no later than midnight.

Rounds: When your team talks to the attending physician about current patients.

Rounds can be a bit confusing because they're held at different times depending on the day in the call cycle. Post-call rounds are usually at 7:30am, and the attending usually invites the team to eat breakfast in the physicians' cafeteria. Rounds are held at 8:00 and 8:30 on the second and third days after call, and they're held at 9:00 on call days.

Pre-round: When you visit with your patients in the morning and collect all new information (e.g. labs, studies, significant overnight events, physical exam).

I usually gave myself around 2 hours to pre-round on 2-3 patients. The earliest I got to the hospital over the past month was at 5am, and that was on a post-call day when I had 3 patients to pre-round on before rounds at 7:30.

My pre-round looks something like this:
1) Talk to the night nurse about overnight events.
2) Look in the patient's chart (both physical and electronic) to check for new orders or follow-up notes.
3) Start filling in my own follow-up note with the information I got from the overnight nurse and objective data like morning labs or any studies done since the previous morning's rounds.
4) Visit with my patient: get their perspective on how they did overnight.
5) Do a targeted physical exam.
6) Finish writing my follow-up note before rounds.

Classroom learning

In addition to clinical duties, I also had to attend various lectures and seminars. We had Morning Report every day from 10:30-11:30 and Noon Conference every day from noon-1pm. On Thursday afternoons, we also had to attend the Chief Resident Lecture Series from 2:30-4:00.

The end of the day

I got lucky that both of the residents who I worked with over the past month were laid-back and considerate of my time. They usually told me to go home rather early in the afternoon, sometimes even as early as 2pm. I didn't really know what to think about this, at first, especially given all of the horror stories I've heard about Internal Medicine being one of the hardest clerkships.

Typically, when my resident told me to go home earlier than 4-5ish, I would go find one or both of my interns and see if there was anything I could do to make their life easier. This amounted to scutwork, yes, but these were the kinds of tasks and chores that I'll have to be doing myself when I'm an intern. Plus, I know that both of my interns appreciated my scutwork services because it helped them get out of the hospital earlier. If both of my interns sent me home, too, I'd either study for the shelf exam in the hospital's library (I'm not exactly a procrastinator) or I'd actually go home and relax or go for a run.

Overall, I had a few 18-hour days and a few 8-hour days, with most of my days falling somewhere around 10-12 hours. It'll be interesting to see how my schedule at Denver Health compares.

Loose ends

I left loose ends at PSL.

The most important loose end is a patient who we admitted quite awhile ago. This patient has a rare disease with a very poor prognosis, and there were several times over the past month when we thought that he might pass away. I have observed with great interest the dynamics between the medical team and my patient's family and how those dynamics have impacted his process of dying.

I care very much for this patient. The last time I saw him awake, I held his hand to comfort him. There really wasn't anything else I could do to help. He looked up at me and whispered "Thank you." I could barely hear his words over the noise of the breathing machine and the mask over his mouth. The meaning was in his eyes. A single tear rolled down his cheek, and I caught it with my finger.

Then I squeezed his hand one last time and left. It was so much more difficult for me to leave him than to hold his hand.

Preparing for the Hereafter

My resident came to me with a new patient who he wanted me to follow: “This is an elderly lady complaining of dizziness and fatigue [details changed]. On a scale of 1 to cute, she’s cute.” He was right. I immediately made a connection with Alice [pseudonym]. Even through her pain and discomfort, she was always pleasant and smiling and quietly encouraging me as a student of medicine in her gentle Southern twang. An aura surrounded her that she had experienced a lot of life and had perhaps learned some of its secrets.

When it came time to discharge Alice, I was selfishly sad that I would no longer have the pleasure of her company. That was when I decided that I would ask her if I could visit her in her home as part of a required assignment for this clerkship.

The point of this assignment is to emphasize the human component of the patients we see. My perception of my patients is very much colored by the only environment in which we have interacted, the hospital. I may have had some enjoyable conversations with Alice, and I may have met some of her family and friends, but my perspective of her throughout her hospitalization was necessarily one-dimensional.

What is her home environment like? I knew that her son was taking care of her, but what is the exact nature of that relationship? How does she manage her medications? How does she get around the house? What does she do for fun?

Alice and her son welcomed me into their home. It’s a small house located on a busy street, and it’s equally busy inside bursting with plants and pictures. Alice was in the living room when I arrived; I watched her get out of her chair and make her way to her motorized wheelchair 10 feet away, assisted by her walker. The whole process took about 2 minutes.

Alice explained that she likes to move about by herself, but her son is usually nearby to help her if she needs it. She further explained that her son does all the chores around the house, including managing her medications and preparing food. I noted the dozen or so medicine bottles perched on a tray built into her walker and the smell of an early dinner coming from the kitchen, where her son was humming and cooking away.

I asked her about her hobbies and what she does to keep herself busy. Without trying to hide her disappointment, she described how she had previously been very active in her church community but is now unable to get out and socialize. She doesn’t leave her house much at all. Even getting to her doctor’s appointments is a big deal.

Then she voiced her biggest concern: “My son is getting tired. It’s a big job taking of caring of me. I don’t know when I’m going to have to move into a nursing home.” I realized that this issue must weigh heavily on her mind. I didn’t have any easy answers for her.

We spent the rest of our visit together looking at pictures on the walls and talking about the people from her past who she has loved. Then it was time to leave.

“Goodbye, Alice. Thank you for your hospitality.”

“There ain't no goodbyes, honey. I’ll see you in the Hereafter.”

Reflections on Internal Medicine at PSL

My internal medicine clerkship at Presbyterian St. Luke's hospital comes to an end tomorrow. Reflecting on the past month, it has overall been a good experience. I have learned a lot, very quickly. The steep learning curve has at times been frustrating, but I've been fortunate to have been surrounded by co-workers and teachers with a lot of patience and who also seem to enjoy teaching. It makes a huge difference. I'm sad to leave PSL but am excited for new Internal Medicine adventures at Denver Health.

My two principal goals for the coming month at Denver Health:
1) Continuing to improve my oral presentations
2) Improving overall efficiency

Internal Medicine Intern Guide

My intern gave me a present today: her old copy of a guide for Internal Medicine interns. The chief resident was passing out new editions today, so my intern didn't need the old printing that she had herself inherited from someone in a previous class. From the way she gave it to me, I got the impression that this would prove to be a very valuable gift; I didn't realize just how valuable until I heard one of the fourth-year students ask if there were enough copies for the sub-interns to get one, too. There weren't.


Flipping through the booklet this afternoon, it looks like there's a lot of general advice for new interns (e.g. how to stay sane, how to work efficiently, how to act professionally) as well as "the experienced approach" to a spectrum of disorders and diseases commonly encountered on the Medicine service. Most of this advice can be equally well applied to third-year medical students. Just like interns, we are also experiencing one of the most dramatic transitions in our careers.

Here are some words of wisdom that I think are especially useful for third-year medical students:

Always at the forefront of our minds has to be the patient. They are the reason we all have jobs, and caring for them in a compassionate, professional, and intelligent manner is our ultimate endpoint. ...

Your patients will come to you scared and looking for answers. Your mission... is to learn to help with these two things. The diagnosing and treating can be tricky and time-consuming without always being fruitful. Sometimes you will find the cause and realize that there is nothing to be done to cure it or halt its course. This is why it is the second most important thing you can do for your sick patient. The first is helping to alleviate the fear that comes with being ill. When done right, this goal can be accomplished almost every single time, in almost every single patient.

Make an effort to see your patients for who they really are: people, just like you, with families, goals, dreams, and desires, who see all those things being thrown into disarray and peril by a gnawing pain in the gut or a sudden flash of pain across the chest. Every "interesting" or "cool" case for you is a potential threat to their existence. Be mindful of this. While we have come here to learn and expand our knowledge, it is only because of the patients and what they are going through that this is possible.

So be respectful of patients and their families. Understand that anger and irritation on their part is not directed at you, and do your best to not take it personally. When you take the time to understand that a patient's anger might actually just be one of the stages of loss or dying, this becomes much easier to accept. Learning to step outside yourself and think in terms of the patient first will help to bring all of these things into perspective.

...Your time in the hospital over the next few years is going to be an incredible life-changing time for you. Understanding that it is the same for your patients will make it all that much richer, and you will become a better doctor for it.

A bad interaction with a nurse

I had a nurse tell me recently that I "need to figure out how things work around here." My offense: I interrupted her when she was talking with another nurse because I needed my patient's vitals. It was 5 minutes before rounds, and the most recent vital signs in my patient's chart were from 7pm the previous evening. I was polite about it ("I'm sorry for interrupting..."), but it would have been very bad showing up at rounds that morning without my patient's vitals.

Later in the afternoon, I went to check up on my patient before she was sent down to surgery. My patient wasn't allowed to eat or drink anything since breakfast, so it was no surprise that she asked for some water when I asked if there was anything I could do for her. Yeah, nice try. That same nurse happened to be in the room during this exchange. Before I could reply, the nurse jumped in: "You might be able to fool him because he's new here, but I've been working here for 20 years, and you can't fool me!"

I felt belittled and undermined. Realistically, my patient most likely didn't catch any hidden meaning in the nurse's comment. I probably wouldn't have thought twice about it, either, if it weren't for her icy response to my interrupting her earlier in the morning.

This nurse's behavior in my opinion was both unprofessional and unacceptable. So what did I do about it? Nothing. Just vent to my friends and on this blog. I have been fortunate up until now in that almost all of the people with whom I have interacted on the wards have conducted themselves professionally. Medical students (mostly third-years) tend to get a lot of flak because we're thrown into the world of medicine with little practical experience. We have to start somewhere.

If this nurse continues to undermine me in front of my patient, I will talk to my resident about it and ask him what he thinks I should do to fix the situation. This is what I would say to the nurse:

I respect the work you do as a nurse and your 20 years of experience - in fact, I rely on your experience as I'm learning how to be a good doctor. But I need you to respect my role as a student and the process of my medical education. I felt undermined when you highlighted my inexperience in front of my patient. Please don't do that again.

Ummmm....

Today when presenting a patient to the attending physician, my intern tallied the number of times I said "um." I racked up a whopping 45 demerits. I understand that this may sound kind of nit-picky or perhaps mean if taken out of context. To clarify: I have a very good working relationship with this intern, and she's one of the nicer people I know. Also, she had warned me a few days ago that she would start doing this.

The idea is that I need to develop more fluidity in the way I communicate with my colleagues. Instead of saying "um," I should pause. Easier said than done. I've been saying "um" or some variant of it for my entire life! Moreover, almost everyone uses filler words in everyday speech. It's no small task to change this habit that's so deeply-ingrained not just personally but also culturally.

Still, it's good to be aware of this issue, and I'll of course give my best effort to minimize the number of times I use fillers when presenting a patient.

Third-year medical student as point of patient care

As I was presenting a patient to my resident, the nurse interrupted me to tell me that my patient's blood pressure was elevated. She then asked me what I wanted to do about it. She asked me. I was taken aback for a moment, looked at my resident, but he was looking right back at me waiting for an answer.

My answer: I thought that the high blood pressure was likely caused by pain and that we should just monitor her vitals and administer her regular blood pressure medications since her blood pressure had previously been well-controlled.

I looked back at my resident. Did I get the "correct" answer? He disagreed and recommended giving an extra medication to lower the patient's blood pressure immediately. Even though my recommendation didn't match my resident's, he did agree that my reasoning and recommendation were also valid.

What felt good, though, was that the nurse came to me with a question about my patient, not to my intern or resident. First, it tells me that I'm doing something right if the nurse perceived me as my patient's primary point of care. Second, it made me look good in front of my resident. I thanked the nurse for that, later.

Why I love working at PSL

First, the people: I really like my team. That can make or break an experience, as I've learned from talking with some of my classmates. More than that, though, as I observe the other Medicine teams at PSL, I haven't seen anyone about whom I thought, "Wow, I'm glad I'm not working with that person." Even the surgeon who we recently consulted for a patient was personable, enjoyed teaching me, and was interested in me as a person. When most people are like that here, it makes for a healthy and enjoyable environment.

Second, the food: All lunches are free. At first, I thought that lunches were just provided at noon conferences and lectures. Two noon lectures were canceled last week, and everyone still made their way downstairs for lunch. "You mean they give us lunch even when there isn't a lecture?" I had a hard time wrapping my mind around that idea. Also, my attending likes to invite her team to the doctor's cafeteria for breakfast on post-call mornings to talk about our patients. They also give us a stipend for the month for food at the cafeteria. Basically, I won't be going hungry on this rotation. Being well-fed is a big deal for a medical student.

I also enjoy being around my classmates and watching them go through the same process that I'm going through, which is something that I didn't get to experience during Adult Ambulatory and Rural Community Care.

I also love being able to ride my bike to work.

All in all, I'll be sad when my month here at PSL is over.

Learning how to present a patient

Communicating with other doctors about a patient is a critical skill in medicine, one that is typically developed during the third and fourth years of medical school and honed during internship. The idea is to tell the patient's story in such a way that all relevant objective information is included, without editorializing, but the listener is able to form an idea in his or her mind the likely diagnosis and a list of other possible diagnoses.

It can be frustrating for medical students to develop this skill - it certainly has been frustrating for me. When I'm presenting a patient, I have the sense that my presentation is jumbled and inefficient, but I don't have a clear idea of how to improve it without losing the quality of information I'm trying to convey. Or, I know how I could improve the presentation but am not yet quick enough on my feet to do it on the spot.

I got two new patients yesterday while on call. I worked them up (which means interviewing them and doing a physical exam) and presented them to my intern. This first run-through was informal and messy but really served to help me organize my thoughts for when I would present to my resident.

My resident asked me to give a more formal presentation. These can be a little anxiety-provoking for me because it's a one-way communication rather than a conversation. I talk uninterrupted even if what's coming out of my mouth is pure garbage; if I pause to gather my thoughts, the person listening stays quiet rather than filling that pause with a question. Longer pauses can become very uncomfortable.

After finishing my presentation, my resident said, "Good! That was good. But let me tell you how you can make it better." We then went through my presentation section-by-section, highlighting ways in which I could better organize the information to tell a more clear story or present that information more concisely.

"Now present to me again." Really? Listening to a third-year medical student present a patient can be a painful experience. I've gotten plenty of feedback on my oral presentations in the past, but no one had ever asked me to present to them again immediately afterward.

So I presented to my resident a second time, and that presentation was much more organized. "Good! That was much better. But I'm going to show you how you can take it to the next level." We then went through my presentation a second time. He talked more about what the person listening to my presentation expects to hear, and when, in order to form a clear clinical picture in his or her mind. He also talked about how to more strategically present certain information, or leave out other information, in order to guide my listener along a particular line of thought.

"Now present to me again." Again? "Incredible!" I thought to myself as I prepared for the third presentation. This teaching process could have been intimidating if my resident were not so nice and laid-back.

One of my interns had been sitting nearby while this was all happening. When we finished, she came over to tell me how lucky I am: "What he's doing is amazing. No one ever did this for me, but I wish someone had."

I do realize how lucky I am that my resident took the time to teach me how to present a patient well. Not only that, but he did a really good job teaching me. First, let me make all my mistakes. Next, point out my mistakes and tell me how I can fix them. Next, let me try it again, hopefully making fewer mistakes than before. Then, repeat.

Before that session, I had felt like I was spinning my wheels in my efforts to improve my presentation skills. Now I feel that I have some traction.