4th Year: Enter the Sub-I. Top 5 Things That Changed

I remember walking onto the floors of my first rotation exactly one year ago. It was like spectating an intense game of basketball right from center court.

“Oh excuse me am I in your way?”
“Oh ya, let me get that for you!”
“Hey, want some water?”

Feeling out of place was an understatement, and most days I looked forward to didactics and morning rounds because at least they offered some semblance of structure. But even in the middle of those sessions I would still feel a creeping sensation of ineptitude that would crawl up my legs and settle somewhere between my stomach and chest. Attendings and residents would rattle off imaging results, lab values, and H&Ps like they were naming the colors of the rainbow and I was still splashing around in the basic science pond proud of the fact that I knew that Hurthle cells were “pathogonomonic” for Hashimoto’s Thyroiditis.

Yup, as long as you didn’t ask me to read the EKG, point out the lesion on a CXR, or pretty much do anything of value I would be the best MS3 ever. Oh ya, I was kind of scared of the patients too. I just didn’t want to hurt them! So much was my care that I reserved myself to pretty much obtaining the entire history from the notes written by prior doctors. Good thing I chose medicine, I hear it’s all about caring.

So after being let out by our residents today, my first day of a Medicine Sub I, I couldn’t help but smile at all the progress that had seemingly taken place (without me knowing). Here’s the top 5 things that I found to be different.

1. I no longer drown in massive amounts of data

When you’re confronted with a patient with 4 comorbid conditions, 10 medications, several recent admits, multiple symptoms, and a story that keeps changing it’s kind of hard to know where to start. Lipids? Electrolytes? Medications? Maybe I should just go get a soda. Well no more carbonated beverage coppe outs. After a year’s worth of studying you start to see how everything is connected, and how the past medical history, natural pharmacology of medications, and other factors all work together to create the context of a presenting illness in real time. Most importantly however, you learn to just focus on what’s important  rather than on everything all at once.

2. I immediately organize all my facts into a format that I can easily access 

The transfer of information is vital to the success of any hospital. We see it happening on computers, on paper, by phone, and via beeper. One of those mediums are people! Being able to communicate in a manner that is understandable and efficient takes practice. Each attending has slight variations in preference, but adhereing to the standard format (History, PMH, PSH, FamH, SocialH, etc.) is usually a great place to start. I’ve known this for months but putting it into practice was challenging.  Now all my patients exist like that in my head, so I can rattle off some pretty good details hours later without too much effort.

3. I feel comfortable talking to patients (because I know the differentials)

There’s nothing that adds silence to an already quiet room than asking a patient about a chief complaint, and then staring at them without any follow up questions that make sense. This changes quickly after Step 2 CS and it is very welcomed. I had a patient just today who came in with syncope. Not only did my mind rush to arrythmias, volume deficits, electrolyte imbalances, seizures, strokes…I also had one or two questions that could quickly eliminate each, it made me feel like a real doctor!

4. I stopped asking residents to explain me things, and instead try to solve problems with them

A year ago I had the unrealistic expectation that everyone was just going to teach me everything. Call it a relic of basic sciences when your superiors were actually professors and this was expected. Fast forward to clinicals and you’re dealing with people in a work environment. Sure teaching happens, but you’re at a hospital, not a university! Everyone wants to see you using your own brain! And when you have some insight to share do it! It’s always appreciated. What isn’t is passivity.

5. I wonder what will happen to a patient after discharge

“How long before he stops taking his medication?” “Will she start drinking again?” “Who’s going to take care of him when he leaves?”. At the end of it all, medicine is much more than understanding pathology and how medication works. It’s about actually improving people’s lives, and becoming a true healer. I guess after you get a solid grasp on the fundamentals you get to see the most important piece of all, the patient.

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