Category Archives: medicine

Post-Medicine Rotation Update: On Studying and the Shelf

The internal medicine shelf exam was a rough one. Thankfully, I expected as much. Several upperclassmen and classmates who had taken this test before me warned me that it would feel less like “an internal medicine shelf” and more like a hodgepodge of questions from all subspecialties. They weren’t kidding. I was really glad I had taken 5 other shelf exams before this one. My main (read: only) goal last Friday was to finish all 100 questions on the test and not run out of time like I did on surgery. I met that goal with a few minutes to spare–in fact, after I made sure I had bubbled in all the intended spaces on the scantron, I watched the remaining 2 minutes tick away on the online clock being displayed on the projector screen. Even though I was still sitting in that chilly classroom, surrounded by the sound of papers rustling and pencils tapping, counting down those seconds was like counting down the time on New Years Eve.

Because of the expectations of the clerkship, there wasn’t as much time to study compared to other rotations. Like many students before me, I focused on the 1300+ internal medicine questions in UWorld instead of trying to read through a review book or two as I’d tried to do on previous rotations. Aside from the time I spent flipping through the Pocket Medicine “purple book” (so helpful I’d call it the must-read of 2014) and scrolling through UpToDate when I had a question, UWorld was just about all I used to study for this shelf. I won’t see my score for another 6 weeks, but I feel like this strategy helped me to retain a bit more than if I had tried to keep with my more ambitious approach from other rotations–less is more, if you will.

You’re all caught up on my life now. Immediately after the exam on Friday, we third years gathered in the student lounge for an “end of clerkships” party with catered hot chicken (a Nashville favorite) and ugly Christmas sweaters galore. I went out for Indian food with a few friends that night and headed home the next day. I’ll be with my family from now until the first week in January, and I plan to catch up on books, family time, music projects, and sleep while I’m off campus.

After we went our separate ways that Friday afternoon, some of us realized that that would really be the last time all of us would be together as a class until we graduate in 2016. The next stage of our medical education allows us to take more ownership of our schedules and meet requirements at different times and at various places across the country and world if we so choose. For example, when I return to Nashville after my break, I will be starting my 3 month research rotation, but others will be staying home to take Step 2 or to just relax for a month before starting again. I think I’ll have a lot more free time during January, February, and March than I’ve had over the past 9 months, and I plan to take advantage of that for sure. But I’ll miss the moments of class solidarity that having a more structured course schedule afforded us. Perhaps we’ll find creative ways to keep in touch while we’re all out carving our own paths over the next year.

Post-Medicine Rotation Update: Weeks 7-8

We finished up Internal Medicine by spending several half-days in clinic over the course of about 2 weeks. The clerkship director described this as the “diastolic phase” of the rotation to complement the pressure of the “systolic phase” of the inpatient services.

Each student was assigned to work with a few attendings in several subspecialties. We weren’t evaluated for these two weeks, so it really gave us a chance to learn about common reasons for outpatient visits and see examples of ways that a clinic could be run. The attendings had differing expectations for us medical students; some wanted us to see patients independently, others wanted us to simply shadow them.

I was assigned to work with two attendings: one in primary care and one in endocrinology. They had completely different approaches to my role in clinic; the former suggested that I see particular patients independently (for new visits, hypertension followups, acute complaints of cough, etc) while she saw others and had me write one brief note each day that I worked with her, while the latter had me simply observe him in each patient room while we saw patients coming for workup of potential thyroid dysfunction, maintenance of poorly controlled diabetes, and other chief complaints.

I kept fairly busy outside of clinic as well. Throughout the week before the shelf exam, third years were required to take part in a 6- or 7-hour in-person and online assessment of our progress with topics from various specialties. We saw a total of 6 standardized patients, with chief complaints dealing with each specialty, received feedback for our encounters, and took a basic science test online afterward. It was an exhausting experience, but it was really cool to see how our 9 months on the wards had allowed us to perform better in these sessions than we had in the much less thorough ones we were required to do during our first year.

On the same day as my scheduled assessment event, we got a small group together to participate in the National White Coat Die-In, a “black lives matter” demonstration organized and supported by medical students across the nation in light of the events surrounding the deaths of Michael Brown in Missouri and Eric Garner in New York, as well as other unarmed black men who have been killed by police in the recent past. We had a small turnout due to our decision to participate at the last minute, but we were all proud to be a part of a movement like this.

A few days later, I joined a few classmates for a free aerial silks class at a local fitness venue. I was pretty horrible at it due to fear of flipping upside down and/or falling and hurting myself, but I was able to strike a few poses. My entire upper body was sore for days afterward–in fact, I still can’t lift my arms all the way above my head a full week later! I’m on the fence about whether I’ll take more silks classes and work on overcoming my fears, but a classmate and I are considering showing up for a few pole dancing classes at the same facility, just for kicks.

Post-Medicine Rotation Update: Weeks 5-6

My last inpatient rotation was Oncology, back in VUH. Even though many of our patients were quite sick or had very poor expected outcomes, I really enjoyed this part of the rotation; in fact, it might have been my favorite part. For one, I felt like my team was fabulous. For the first part of this two weeks, I worked with the intern who’d been on my team for the first week at the VA and the 2nd year resident who’d been with us briefly on Morgan. I felt like I worked very well with and learned so much from both of these residents, so I was quite excited to come to a team of familiar faces. In some ways, I was able to better adapt to this service because I did not also have to figure out how to interact with a group of new people on my first day. In addition, the attending I worked with was one of the most compassionate physicians I’d ever worked with. Even when we were running late on rounds, she treated each patient as if we had all the time in the world to listen to them. She wasn’t afraid to speak honestly about her interests and dislikes in the field of oncology as well as her feelings about what the patients and families really needed from our team.

The oncology service itself is highly specialized, which was more than a bit overwhelming. While rounding with the team on the first day, I heard so many acronyms and names for cancer treatment regimens that my head started to spin. In addition to studying for the shelf when I could, I also spent time trying to at least know the mechanism of action of some of these drugs so I wouldn’t be completely clueless on rounds. I’m glad I did this, because my attending usually expected us to include some of this information when presenting new patients each morning.

These two weeks didn’t feel terribly hectic to me, partially because my residents were fairly laid-back and partially because I got 4 days off for Thanksgiving in the middle of the rotation. Our patient list stayed a manageable size. I picked up one new patient just about every day, but I spent less time on the notes than I had before. Because the daytime admissions were somewhat more predictable (patients were often admitted from clinic or expected to come in specifically for chemotherapy), I didn’t stay on campus as long as I did on Morgan.

As expected, this was one of the more emotionally taxing services I rotated through. Each day, our team interacted with 30 year olds with stage IV cancer and families who were faced with the realization that their loved one’s prognosis was poor. I was surprised that these cases didn’t seem to consciously affect me. In fact, although my time on the wards has involved some somber environments (the NICU, the Palliative Care Unit, the neurology stroke service, etc), I feel like I haven’t “dealt with” what I’ve experienced in a tangible way. I’ve recently been spending some time thinking about what that says about me as a person and how that will lend itself to my role as a physician. I haven’t figured that out yet. But I’ve got some time, I think.

Post-Medicine Rotation Update: Weeks 3-4

After finishing up on Morgan, I did two weeks on one of the six general medicine teams at the VA. I was the only medical student on this team. At first, I missed having a classmate to work beside, but I soon realized that being alone compelled me to answer more questions and interact more with the team; in addition, I was no longer as tempted to compare myself to others. I was also thankful for the slower pace of this service, as it allowed me to spend more time with patients and actually focus on learning instead of trying to get a set amount of work done.

The only things I don’t like about the VA are the lack of WiFi in the hospital and the medical record, CPRS. Because it’s only accessible at the VA, students have to stay at the hospital to finish the bulk of their notes, which typically makes for some late hours. Obtaining the proper access codes for the computers often takes weeks and can be a frustrating process as well. In an unexpected turn of events, I never got full access to CPRS, so I wrote very few notes while I was there (I promise I actually tried to get this fixed)! This added to the less hectic pace of the service.

The cases at the VA made up for the “zebras” I encountered on Morgan. During my time there, our team took care of several heart failure patients with symptoms of “volume overload” (leg swelling, rapid weight gain, shortness of breath), patients with liver disease who came in with jaundice, and patients with chest pain who required care under the Acute Coronary Syndrome protocol, which includes steps to manage heart attacks.

All told, I enjoyed the VA. While there, I began to realize that although I surely have much to learn, I know more than I think I do. Thanks to the encouragement of my patients and the residents I worked with, I started to feel confident about my ability to become a good doctor.

Post-Medicine Rotation Update: Weeks 1-2

A classmate and I started out on one of the “Morgan” general medicine teams at VUH with a resident, an intern, and a 4th year doing a sub-internship. We each carried 2 or 3 patients at a time, often following them from admission to discharge. When we weren’t in class or talking to our patients, we spent our time writing notes, observing bedside procedures, helping put in orders, making phone calls, obtaining outside records, and learning about topics that the residents chose to teach us in their free time.

Although I expected to encounter “bread and butter” cases that would teach me about management of congestive heart failure or proper workup for chest pain, I didn’t see many in my first two weeks. There’s a quote often used in medicine that reminds us to consider common diagnoses before those that are more interesting but less likely: “when you hear hoofbeats, think horses, not zebras.” However, I encountered a handful of “zebras” myself. One of the more memorable cases involved a woman with a recent history of adverse reactions to multiple antibiotics who had come in with a fever and subsequently was found to have a very low white blood cell count. When it was determined that her symptoms were likely a reaction to yet another antibiotic, our attending wondered if there might be an overarching disease that might explain her numerous illnesses. I’ll have to visit her electronic medical record to see if there are any new developments.

Unlike several inpatient teams that admit every day, the 4 Morgan teams have their own unique call schedule. Each team cycles through an “accept” day (hearing about overnight admissions that morning), a “short call” day (admitting a set number of patients before 2pm), a “long call” day (admitting patients from the time the short call team is capped to 5:30pm), and a “pre-accept” day (no admissions). My classmate and I were often with the team until 7pm–sometimes even later. Writing notes on admission days was tiring–for internal medicine, medical students are typically expected to not only write a thorough history and physical but to also include an in-depth discussion of a particular topic related to the patient’s case, complete with references. I stayed up late many nights to finish notes before bed and found myself fairly drowsy during the day. I’m honestly surprised I didn’t acquire a taste for coffee.

Despite this, I tried to make time for self-care any way I could. Even though Morgan was a very time-intensive service, I still managed to DJ (read: provide a spotify playlist) for the school-wide Halloween party (I went as a mouse this year) and share a reflection I wrote at church one Sunday.

Post-Medicine Rotation Update: Intro

Great news! I am unofficially a 4th year med student. I took my last shelf exam a few days ago and joined my classmates in celebration of the close of our time on 3rd year clerkships and the beginning of new chapters for all of us.

Internal medicine was a tough rotation to finish with. With its long hours, high expectations, and expansive breadth (and depth) of information, it was a tough rotation, period. I’ll be honest–I wasn’t quite looking forward to it when I started, but I enjoyed it a LOT more than I thought I would. 6 of the 8 weeks were spent on various inpatient services. While on inpatient, students were expected to perform the usual tasks–seeing patients before rounds, presenting to the attendings, and helping out wherever we could. In addition, we also saw new patients with our teams, wrote admission and progress notes, and sometimes put in orders for labs and medications with supervision. Our time on inpatient also involved attending “morning report,” at which interesting recent cases were presented and discussed among the housestaff, and several lunch lectures on numerous educational topics. The constant provision of free food was pretty good on my wallet (although I probably spent enough on chai lattes to balance things out), but my waistline took a bit of a hit for sure.

Anyway, I digress. During this rotation, I spent 2 weeks on a general medicine team at VUH, 2 weeks on a general team at the VA, 2 weeks on Oncology, and a portion of the last 2 weeks in clinic. Keep reading for more details.