Medical Mondays: Internal Medicine

Hello everyone! Happy Thanksgiving to my Canadian folks. Hope you are doing well and staying safe & healthy.

Disclaimer: The views expressed here are my own and do not reflect the views of the program that I matched at.

It has been a busy several weeks. I am currently on my final (4th week) of my Internal Medicine off-service rotation. I will give you some information on generally how my days are and my thoughts on IM so far. I am in CTU – the Clinical Teaching Unit. Our group is comprised of: An attending, two senior residents, two junior residents and two medical students.

On non-call days:

I try to reach the hospital by 7:30 am. I go into the resident “meeting room” on the floor and my name would be written on the board with patient names underneath it. I am responsible for these patients for the day (usually 5-6). Sometimes these patients are known to me as I had been following them previously or at times I will be given newly admitted patients.

I take the next 30 mins to log into the hospital EMR and look up the latest labs & imaging results for these patients and note them down. Then I head over to the patient room, look at their chart to see what has been done overnight/the past couple of days. Anything concerning? Any changes in treatment? Anyone from other specialties whom we consulted come and see the patient (occupational therapy/physio therapy/ GI / cardiology / oncology etc.) and what were their notes and recommendations?

If I see the nurse I speak with them and ask them whether they have/had any concerns and how the patient is doing today. I then go see the patient and follow up on how they are doing, complete a physical exam and write (more like scribble….) a note in their chart in SOAP format.

I try to finish seeing my patients and write notes by 10:30 am, as we meet back in the team room at this time. (I usually don’t finish writing down all my notes before we meet, so I end up going back afterwards to update the Assessment & Plan.) We sit down with our group and go through our patient list AKA “Run the List”, reviewing each patient, today’s concerns and what we want to do next. Concerns can be -> something in their lab work (electrolyte imbalance / WBC increasing / blood cultures came back positive etc.), the patient reports more pain and is not doing better, reviewing imaging results etc. If patient is ready to be discharged then we update their discharge summaries.

We usually finish running the list by 11:45 am. Several days a week there is teaching in the lecture hall at 12 pm, so we go down for that after the meeting. The teaching is usually about an interesting patient case and very interactive. Lunch is provided to us at this time.

After teaching, for the rest of the afternoon, I usually run back to the floors and finish up my notes, write orders. I also update: patients & their families if I need to, any discharge summaries for patients who may be leaving the hospital soon. Also, update the “resident handover note” which is the portion of the EMR where I write in information about my patients and any treatment/management plans, so that when the next resident is assigned to this patient they are up to date.

After 1 pm there may be patients I may have to see in the ER who could potentially be admitted onto the floor. I would go and assess them, write a note and discuss it with my senior and then write an admission note. This is a lengthy process and personally for me it take a good 2 hours for one admission.

My day typically ends by 5 pm, sometimes 6 pm.

On call days (5 days in my IM rotation):

Reach the hospital at 7:30 am.

As mentioned above, go through the same schedule (non-call days) up to 1 pm. Then I go downstairs to the ER, write my name and pager number on the “white board” so that I can be paged by the senior resident if there are any admissions to be done for the night. If there are no patients to see in the ER when I am downstairs at 1 pm, I go back upstairs and work on the remaining notes for my CTU patients.

The rest of the night I am responsible for: 1) my patients I was assigned to for the day 2) the rest of the patients on our CTU team (another 25 pts) and 3) going to the ER for admits. Some nights can get pretty busy where I am paged numerous times for our CTU patients while I am seeing an admit in the ER. So I will have to leave the patient in the ER temporarily while I run upstairs to sort things out.

The types of things I have been paged for are: medication clarifications, elevated BP management, headaches, nausea, vomiting, chest pain, fluids, antibiotics and even pronouncing time of death.

Story #1: On my first night on-call (my FIRST day of internal medicine!!) I was paged to pronounce time of death on a patient at 4 am. It was my first time. I completed my exam, pronounced time of death and then called the patient’s loved one. Receiving a phone call at 4:30 am about your loved one passing away is a shock. I tried my best to approach it very delicately and compassionately. The family came into the hospital, I was able to speak them and they spent time with their loved one who had just passed away. I completed the death certificate and they thanked me for being there. It was a very humbling experience for me. I have been in the position where my grandmother passed away and the doctor taking care of my grandmother was very compassionate. The memories from that day were sad, but we will never forget how kind and compassionate the doctor was. I strive to emulate the same characteristics.

Thankfully I am never “alone” on on-call nights. In addition to the amazing nursing staff, there is always a senior resident I can page if I have any concerns in the middle of the night about how to manage a patient. I accept my limitations and I want to practice SAFE medicine.

Story #2: A patient had a BP of 200/180 with headache. She did not have a previous history of hypertension and she just started radiation treatment to her brain for lung cancer that had metastasized to her brain. Was her hypertension and headache due to the rads treatment? A brain bleed?? Usually I would give a patient their usual antihypertensive medication if they were on it, but she was not on any! I spoke to the patient, completed a quick neuro exam and then paged the senior for advice and we were able to start her on the appropriate medication which brought her blood pressure and pain down and I continued to monitor her throughout the night.

I usually have three admits in the ER throughout the night. Other admits go to other residents who are on call that night as well. By 7:30 am the next morning I meet my attending and review the admits and what has been done in regards to assessment and plan. The attending will then have me write more orders if anything was missed or change the plan that was initially thought. Some teaching is also done during this time.

After reviewing the admits, I go upstairs and meet my senior resident and let them know of anything important that took place with the CTU patients.

Finally by 10 am the next morning I am done with the review and I leave to go home -> my post-call day. I then come back the next day at 7:30 am for my regular no-call day.

Internal medicine has been a challenge for me for several reasons:

• I graduated years ago and have not had any experience in a Canadian hospital, it was (and still is) quite a challenge to learn how things run in the hospital
• There is SO MUCH to know in Internal medicine and I struggle with the knowledge aspect – how to treat electrolyte imbalances, acute kidney injuries, which abx to use, reading EKGs etc. there is a LOT I need to study and review.
• I am working on increasing my confidence when it comes to Making Decisions (MD)- when I am paged about a patient (how to treat their sudden increased BP / what fluids to start or whether to even start fluids / sudden chest pain / deteriorating patient…)

I am learning so much and very thankful for the help I get. The nurses are amazing! Any questions I have in the middle of the night when I am clueless and don’t know what I am doing, they are always there to assist me and keep me calm. The other residents and attendings are super helpful and are amazing teachers. They are always ready to teach me and review things with me. I have so much respect for those in internal medicine. They work so hard and are very knowledgeable.

I do look forward to getting back to family medicine: I really miss women’s health and ob/gyn, peds and also the clinic setting. The lifestyle and work hours in family medicine are nice. Working long hours in IM, I missed my baby and husband. There were days when my baby was not feeling well and I was in the hospital on-call unable to be at home with him. That sucked.

Anyway, one more week of IM and one more block (Psychiatry next!) before I am back to family medicine 🙂 I am doing my psych rotation at the hospital next to my parents home, I look forward to being home with my parents!

What did you think of my post? Leave your thoughts & comments below!

Peace, Love and Happiness. Stay healthy and safe everyone.

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