Inpatient Medicine

As I've mentioned before, four weeks of this year are on the inpatient service: two on Pediatrics and two on Internal Medicine. I already completed my first week with the kids, so in my final three weeks of the semester I am spending seven full days on "Medicine." This week of Medicine is the closest we get to the hours that we'll work during residency. Morning report starts at 6:30am, and sign out occurs somewhere around 8:30pm (usually a 14 hour day). Wednesdays we have a slight break because we have lecture from 1pm to 5:30pm, and then have the rest of the night off. We work the weekends, with no break going into the next week of continuity clinics. Basically it's a long week, but I better get used to it. I'll be doing this for years and years to come. The 80-hour plus week is upon me.

The morning for the med student is usually fairly relaxed. At 6:30am we get the scoop from the night residents, hoping that nothing crazy happened the night before. Usually it's a lot of patients asking for more pain medication, and it seems that pain control often dominates the discussion during morning report (and rounds later). At 7am we get going on seeing patients. I generally see 3-4 patients, each of the Interns sees six patients, and the Chief Resident checks in on everyone. The Attending also sees all 18 peeps, and somehow keeps them all straight (I can barely keep track of the three patients I see daily - I hope this is a skill that improves over time). I've had the opportunity this week to read about all of my patients before rounds, which helps me know what I'm talking about when we're all together.

At 10am we "round." Rounds are where the whole team gets together and discusses the treatment strategy for each patient. On many services, Pharmacy, PT/OT, nursing, social work, and chaplaincy will also be present to discuss patients, but on Internal Medicine we have only had Pharmacists with us. All 18 patients are presented in a very systematic format (subjective, objective, assessment, and plan or "SOAP"), with specific attention to the overnight events. How long the presentation lasts depends on the Attending and the service. For example, my presentations in Surgery needed to be 15 seconds or less (surgeons are go, go, go); in Pediatrics they were between 1-2 minutes (peds is always a little more chill). Medicine is notorious for longer presentations, greater detail, and tedious rounds. While we rounded on six pediatric patients in 20 minutes, our Medicine rounds will last three hours - three times as long per patient. Needless to say, a second cup of coffee is mandatory. However, I actually have found that I enjoy rounding, although it is very Attending specific. The demeanor of the Attending physician makes or breaks those three hours, and I have been lucky to have very good teachers this week.

Everything is discussed in the rounding round, from medications to social issues. Pain control is the biggest topic covered though. There are an amazing number of patients who enter the hospital already addicted to prescription medications, and so many more patients who are in severe pain. Deciding whether to use NSAIDs (like aspirin), or the best pain-killers available such as narcotics (morphine, etc.), can be a tricky choice. The goal is to use the least amount of medication to keep the patient comfortable and the pain controlled, but balancing use vs. abuse is difficult. Sometimes it really comes down to a gestalt or gut feeling from the physician, and some docs are more willing to sign off on narcotics than others. How much a patient needs may also depend on how much time the physician actually spends with that person. Some people joke that in the future we'll all be out of jobs because machines will take over the world, but these are the types of decisions that a computer can't make. Dealing with pain is part of the Art of Medicine; a very difficult and subjective choice.

After rounds we start admitting patients. The Interns discharge any people ready to go, and then fill up the beds so we always have 18 on our service. Most of our admissions come from the Emergency Department, so I find myself constantly running down to the ED to take a history, do a physical, and then present to the Intern and the Attending. Here again, how you a present a patient totally depends on who you are talking to. Sometimes I just want to ask, "Do you want 5 seconds or 5 minutes? Just tell me and it'll make this all go smoother." But you're expected to get to know the individual docs and figure out what they want to hear. I do my best. If the physician starts looking bored, it's time to wrap it up. If they're snoring, just quit. Everyone gets interrupted, but ultimately if you move quickly and confidently, I've found the results are generally good. Some Attendings you will never please.

Admit, admit, admit, and then time to sign out, turning the patients over to the night residents! I have to be honest, being here over the weekend is depressing. Everyone else is enjoying the time off to catch up on work and sleep, and here I am back at the hospital (where the weekend meals are just terrible - Sunday is by far the worst...). But I better get used to it; welcome to residency. I'll just have to keep counting the days until Winter Break.