It's What's On the Inside That Counts: Internal Medicine

Storm coming in over Revere Beach

It did it's job, but I'm
ready to trade my short
coat for a long one.

     As of yesterday, I am done with PA school. One week from today I will go to graduation, put on my gown and hood, collect my diploma, and everything will be official, but in reality, I don't even have to do that. The final rotations have been completed, my last exams are finished, and there is nothing else I have to do. Once MCPHS processes all the paperwork, I am a Physician Assistant. For real. 

      Right now my brain can't quite process that. Perhaps I'm still too tired from the massive sleep debt I accumulated over the last three years. Perhaps my brain is still recovering from the five hour exam I took on Thursday. Perhaps it's because, while I am now a PA, the studying is not quite over. To practice as a PA, I have to be certified, which means taking, and passing, another 5 hour exam called the Physician Assistant National Certifying Exam, or "PANCE" for short. This also means that I will spend most of the next 3 weeks squirreled away in a study cave to prepare. For now though, I'm taking a quick break to finish my post on my 8th rotation.

My alarms for my 1st Saturday
shift. Thankfully my other
weekend shifts let me sleep
in an hour more. 

     My penultimate rotation was in Internal Medicine, which was all inpatient. Inpatient medicine is certainly a different beast from outpatient medicine. There are a few ways you could almost call it "easier." The patient is right there and they're not going anywhere, so it's easier to track their progress, labs and diagnostics can be done faster, and you can be sure that the patient is actually taking medications you prescribe at the right times, in the right doses, and in the right manner. Of course, I don't think anyone actually claims that inpatient medicine is easier than outpatient. The whole reason why patients are admitted and treated inpatient, is because they are too sick to go home, so the conditions you treat in inpatient medicine are naturally more complex and difficult than outpatient issues. It's also more difficult because, while every medical specialty involves some level of psychiatric care for a patient (from being a listening ear in primary care to being a reassuring voice before a surgery), inpatient medicine seems to demand a bit more from the clinician. No one is at their best when they're admitted to a hospital, and the internist has to recognize this. They also need to recognize that it might not be just the patient who needs psychological support and a listening ear, but also the patient's friends and family members.

This was the weather I
came back to after temps
in the 60s back in OR.

     To be honest, I think the friends and family members need more help than the patients more often than not. The worst might just be the friends and family members who are also medical professionals. If this surprises you, that probably just means you're not a medical professional, or related to one, yourself. People who work in healthcare tend to make the worst patients, or patient's loved ones. We know just enough to make us dangerous, but knowledge does not equal wisdom. One of my first patients was the only child of a nurse and a physician. The patient was great; her parents were difficult. The mother worked in geriatrics, and the father had been in public health and management for almost his entire career, so they knew enough to know the worst that could happen, but didn't have enough recent experience in young adult medicine to realize that their daughter was doing well, and was being well-cared for. They tended to become overly anxious without cause, which then tended to freak out their daughter. It made taking care of her a bit more difficult, but, at the same time, we all understood. They loved their daughter and, even though she was now a grad student in her early 20s, they would never stop trying to ensure that she was safe and healthy. I can't fault that. I also can't fault the family who had a hard time accepting that they had very little time left with their husband/father, but that's a story for another post. 

Technology: making it obvious just how frequently I failed at getting 8 hours of sleep (or simply 6 or more)
during this rotation.

My roommate and I considered this an acceptable
self-treatment for a rough week. Just add some
friends and a ridiculously dramatic Spanish tv
show and we were all set.

     Sometimes the person who most needs to be attended to is the clinician. For the students on this rotation, we typically worked 11-12 hour days, and never really had a break during those hours because we even had lectures during lunch.* Once you added in the commute, this often meant that I had just enough time when I got home each night to make and eat some dinner, shower, and attempt to do some studying or work on my resume and cover letters before crashing into bed so I could start it all over again the next day. Beyond the physical stresses, however, the rotation was also emotionally and psychologically demanding, though not all of the demands were directly related to the the rotation itself. On my second day in internal medicine I found myself bombarded by bad news. First there was the worrying report from a CT tech about the abdominal pain a relative had been having. It ended up being a simple appendicitis, but it was hard not to infer something much more ominous when the tech reported that he could see something in the scan, and that, though he wasn’t at liberty to say what it was, he did recommend that my relative have someone with her when they delivered the news. Until this error was cleared up, my family and I spent about a half hour assuming that cancer was involved. I’d just recovered from this unnecessary shock when I learned that something bad really had happened to a person I loved. A good friend of mine texted to inform me that she’d miscarried at 16 weeks. Her pregnancy had been high-risk from the start, so this had always been a well-known possibility, but that didn’t make the news any easier to hear, and it's always hard to watch a friend suffer and be powerless to make it better. Just over a week later I was nearing the end of another long day when I learned that another good friend, who had been diagnosed with preeclampsia and successfully delivered her baby three days before, was still in the hospital with high blood pressures. She recovered, and she and her baby are doing well now, but initially hearing about her felt like yet another blow to my already fragile emotional health. There was also an incident that occurred during my rotation that made it clear that the other students and I were not the only people in the hospital who were stressed and emotionally drained. 

My roommate looking at a
sculpture the size of a whale
heart when we spent a couple
stolen hours at the PEM.

     The hospital where I did my rotation was preparing for a huge switch to a new computer system. At one point they decided to learn how the new alert system worked. The only problem was that they forgot to put the system into test mode, which led to people all across the hospital receiving pages stating that there was an active shooter in one of the lobbies. I was in lecture at the time, and initially we weren't sure what to do since only one girl received the page. When someone else got it, however, our teacher (an excellent Infectious Disease doc who looks like a mix between Jim Broadbent's versions of Professor Kirke and Professor Slughorn) sprang into action, corralling people from the hall into our room, turning out the lights, locking the doors, approving the suggestion to flip tables and make a blockade, and calculating the angle bullets shot through the doors would enter the room. He did it all in just a couple minutes, and by the time the the mistake was discovered and pages were sent out to everyone to apologize for the false alarm, we were already all in position. The levelheadedness of the doc, and his clear instructions kept us from being frozen in place in fear or uncertainty and, while everyone in that room thought the mistake was horrible, we weren't traumatized by it. Some people were. Some even needed counseling and trauma therapy afterward. The possibility of an active shooter in a hospital is just too likely to easily dismiss. Many people at the hospital knew the doctor at Brigham and Women's Hospital who was shot in an exam room last January. I myself had been just down the street when it happened, the sound of sirens disrupting my class. That experience, and the false alarm on my rotation, certainly drove home the point that healthcare workers are at high risk of experiencing workplace violence, often from patients, and that this risk is increasing (before anyone starts suggesting that the solution is to arm security guards at hospitals and healthcare facilities though, you should really read this New York Times article or listen to this episode by This American Life). 

This is an actual Emmy. It belonged to one of our
patients. He had it brought in on the day he was
discharged so we could take pictures with it.
And yes, I am very red in this picture. I'd just
come running from a lecture and a white coat
over a sweater is toasty.

     If my time in Family Medicine could be described as admitting what I don't know, then Internal Medicine could be described as learning to be confident in what I do know. There are few things more terrifying than when your preceptor tells you, "I'm not telling you the plan. You're in charge. You tell me the plan, you write the orders, and I will sign them." It feels a bit like jumping off a cliff. There's no safety blanket. You know that if you get it right, it will be amazing and will prove that you might just make a competent PA after all. The fear, of course, is that you will get it wrong, there will be no one to blame but yourself, and you will have to live with the consequences. Now the truth is that, when my preceptor told me to come up with a plan and refused to discuss it with me until I'd set in stone, he wasn't truly leaving me on my own. If I'd really been on the wrong track, he would have corrected me (the care of the patient trumps a learning experience any day), but the other truth is that he didn't need to.Whether I acknowledged it or not, I was ready. I'd been formulating plans for patients since day 1 of rotations, and while my initial input into the care plans for patients had been limited at the beginning of my clinical year, I'd spent rotation after rotation reinforcing what I'd learned in school, learning from those with more experience, and discovering how the theories of medicine play out in the real world so that, when the time came, I could provide my patients the best possible care. That is, after all, the goal: to become a PA. This also means, of course, that oh so soon I will be responsible for the care of many people. I better start getting used to it, even if it scares me half to death. So I did it. I made the plan, I put in the orders and, even though he didn't ask me to, I explained my reasoning to my preceptor. He simply nodded, signed the orders, let me tell the nurse the plan, and that was it. And it worked. My patient did well. When she was discharged her husband told me she loved me, and she tried to convince me to work with her PCP. And it felt amazing. And when my preceptor told me that the next day he wasn't going to help me with the plans for any of my patients, it felt less like jumping off a cliff and more like accepting a challenge. 

Locker on my last
day: so many notes.

     There is still much I don't know, and I need the humility to acknowledge that and to keep pushing me to learn. However, sometimes what you don't know is just how much you are capable of, and how much you already know. Sometimes you need the push into the pool to make you realize you can swim.** Internal Medicine, and my awesome preceptors, did that for me. In PA school it's easy to get discouraged, to think that there's no way you'll ever learn everything or that you've made a horrible mistake, so those moments of recognizing how much you already know are invaluable. Those moments, and the confidence they built, are part of why I loved this rotation so much. Yes, had it lasted just one week (or possibly even one day) longer the schedule likely would have driven me to illness or a mental breakdown*** and I did start to look forward to the end, but leaving was bittersweet. I only hope that I can continue to carry the lessons they taught me into these next weeks as I study for and take my PANCE, and then into the months that follow as I begin my life as a PA.

*Those lectures were catered, however, which was an incredible blessing, both physically and financially.
**Perhaps this is not the best metaphor for me considering I drowned as a child and later failed swimming lessons three times, but you get my point.
***The schedule is really only feasible for the attendings and PAs at the hospital because they work 1 week on, 1 week off, and they don't have to use their "free time" to study, write resumes/cover letters, and apply to jobs. And 3 of the other students on this rotation with me did, in fact, have to miss days due to illness.