General Med - A wrap up (part 2)

On a More reflective note...

The rotation as a whole was draining, but fantastic. One of the key things it did was cement my clinical skills, which I must admit were lacking a bit having started this year with Psychiatry - where you DO NOT touch - and General practice - in which examination is very problem based and often sub-standard [done through shirts (limited exposure) and poor positioning for the sake of convenience and time].

There were days when I was totally enthused, and days when I felt exhausted and completely discouraged. But coming out at the end of it, I feel much more confident and I feel I'm clinically more efficient (and unfortunately perhaps a little more impatient with verbose patients).

In summary, I feel in this rotation I learned the most, but it took the most out of me...

General Med - A wrap up (part 1)

Well I apologize that I haven't written more for this general med term. I meant to. The term was very hectic and when I finally got a moment to think, I just didn't want to write.

The tone of the rotation dramatically changed toward the end. It went from being part of the med team, being part of rounds (generally experiencing life as a junior doc on general med) to one of, looking for long and short cases, trying to fit in study where you could around all the scheduled tutes and generally in exam prep mode. It was a necessary shift in focus (if we would hope to pass the exams) but after that the registrars/consultants seemed less inclined to involve you in the care of the patients.

The assessment (like all so far this year) consisted of 4 parts worth 25% of which one part was the consultant's mark. On this rotation the other 75% was from 2 short cases and 1 long case done on the last day.

The Long case was a patient on the ward. You were told the patient name/bed number and went straight to that patient. You had an hour alone with the patient (mostly uninterrupted, there is always morning or afternoon tea or the tv hirer or some physio/nurse interrupting which you have to quickly deal with) to take a detailed history, work out active problems (noting inactive ones) and taking a detailed social history intergrating all with a physical exam. You then have ten minutes to organise your thoughts then you have to formally present the problem to 2 examiners (one being the specialist looking after that patients presenting/main issue). You are then asked to list problems, investigations, and might have to interpret an ECG, blood gas analysis or chest xray. You are pimped for about 10mins by the two examiners. An example might be... Mr S is a 60 yr old man who presented with increasing SOB and productive cough of two weeks duration. This is on a backgroud of Chronic airway disease, Ischaemic Heart disease, Hypercholesterolaemia, Hypertention and poorly controlled Diabetes Mellitus. He has a cumulated 90 pack year smoking history, still smokes and has been on oral prednisolone (30mg) for 9 months now for frequent exacerbations of his COPD".
The problem list might constist of

1. Diagnostic and Management problem of Increasing SOB (DDX: Exacerbation of COPD or pneumonia, Lung cancer, Heart failure etc) - Including tapering steroids if possible (risk of osteoporosis, high glucose levels)
   
2. Management of his IHD (Incl. Cholesterol, HTN etc)
3. Management of His Diabetes Mellitus
4. Assist lifestyle modification (Stress reduction, wt loss, quiting smoking)
5. Assist with rehab to work or short-term financial aid (welfare etc)

The two short cases immediately follow where the examiners then take you to patients (often brought in especially for the exam) with nonurgent, but often interesting pathology. You have 10mins per patient to examine ("Mr x presents with increasing shortness of breath on exertion, please examine his cardiovascular system") Short cases took 10 minutes. Obviously, not all cases are cardiorespiratory in nature, they are very common however and these were the first I thought of as typical examples.

My Medicine term... half-time commentary

Wow time flies! I am half way through my medicine term already and I have written very little. The pace is much faster and I have been busy.

A typical day:
Get to the hospital a bit before 8am, print the lists for the day, this can be quite daunting post take (the day after the consultant for our team was on call) check outstanding bloods/radiographs (x rays) and see how patients are going (on paper). By 8am the rest of the team has arrived, and doing similar things (except for the consultant who just turns up). We go see the critical/less stable and the new patients first.

The consultant walks in to the patients room first, followed closely by the registrar and resident (who is holding the chart) with the med student/s following in the rear usually holding charts for the few patients either before or after this one and they draw the curtains closed. The consultant is usually all smiles "Hi Mrs... how are we today?" while the patient is tell their story, the Reg is telling the key changes over the last 24hrs (the resident was the one who actually arranged the tests and chased up the results). The consultant seamlessly gets to the guts of the problem in less than 30 seconds and if there is an interesting sign, gets the students to elicit the sign. (if the student fails, he is shown and the patient is in awe of the consultant...he is the guru.. If the student finds it, the student is excited but it is assumed that anyone could elicit the sign, the patient is in awe of the consultant..he has taught them well...either way the consultant is revered). The consultant pimps the students for a differential diagnosis or the pathology of disease x (the med student now has homework...he had better know the next time this comes up!) and then asks the registrar for a management plan. Generally, the registrar nails it, but inevitably he forgot a key aspect, the consultant corrects him and the registrar or resident writes the plan up. The resident adds the tasks e.g. order a gastro consult, get psych referral or do an ABG to his ever going scut list. The team moves on.

By lunch time the Consultant is usually gone. The rounds are mostly done (anyone left is usually not urgent and the registrar and resident see them without the consultant). The consultant is off either doing paper work, attending a meeting or teaching the registrar and the resident is madly running around trying to get things done on his scut list plus writing up medication orders and fluid orders. The registrar is called if any curly questions need to be answered. The med students go to tutorials (often happen to coincide with a free lunch) and then go and see people on other wards who have interesting signs and practice exams.


Generally, I am loving this rotation. I enjoy the acuity of it (well at least compared to GP) and the time to think (compared to a 15 minute consultation in GP land) - You have time to look something up if you don't know (you are expected to know to a higher level than in GP and even though there are consults available form other services, they are your patients and you do most of the work). I love the team work - nurses, pharmacists and allied health (physios, speech pathologists, psychologists etc). I think I am very well suited to the hospital environment. However I like the Monday-Friday 8am to 5pm (with occasionally weekend shift) though. Naturally, I am an evening person but my current schedule dictates I function well in the early AM. I am a very sensitive sleeper (can't sleep in cars, public transport, with light, without ambient noise etc) and if I sleep in, even once, on the weekend, or do an evening shift at work (which often has me all wound up with the cool stuff I saw), it takes me most of the week to get settled back into the early morning routine. I am wondering how a career in anaesthetics will be possible? will I learn to be less fussy about my sleep? I hope so!!!

'Real' Medicine

I am one week into my first 'real' medicine rotation (I use this expression with tongue in cheek, because the undifferentiated patient and all their issues and concerns encountered in general practice is in many ways truly patient focused medicine). It is great though. It is interesting to see really sick patients and the accompanying end of life issues and to see someone improve or get worse so quickly. Pathology and treatments are discussed in much more depth, and because everyone is teaching and learning education is a high priority.

General impression of how things run...

Team work is the rule, however it is far from a democracy. For those who don't know the (medical) hospital hierarchy is as such:

• Specialist/Consultant
• Fellow - extra post fellowship training (1-2 yrs) Optional
• Registrar (training to specialize) OR Principle House Officer (not in training spot)
• Resident - Senior House Officer (PGY2+) then Junior House Officer (PGY2)
• Intern (PGY1)
• Med student

A consultant has the final say, directs treatment and has ultimate responsibility. He (or she) is in the position most of us aspire to eventually be in. A registrar (equivalent to a senior resident in the US) is the consultant's right hand man and as they have chosen that specialty (in this case General Medicine) they stay for longer periods and know the service well and function with a reasonable degree of autonomy depending on seniority.

Next is the Resident. He is either a Junior House Officer (JHO), who is 1st year after an intern, or Senior House Officer (SHO), second and subsequent years. They are still trying to get clinical experience, pass exams and get into a training position. They rotate every 10-12 weeks and the standards vary greatly depending on their experience and amount of learning they have done (some are real slackers) and so their responsibility is varied and they tend to do the after hours cover, relieving rosters etc. The intern (if present) also rotates about every 10 weeks and as they need to impress to get signed off and get a good recommendation for a JHO job, do the scut work (otherwise the RMO has to do it).

Then finally comes the medical students. There are often too many of us per team (2 in mine) and we walk around and generally get under peoples feet. Sometimes it seems we are treated better than the interns, about on par with the RMOs. Perhaps because we are outsiders/visitors and the consultants want to give a good impression/sell their discipline to encourage the best applicants try for their team. But it is pretty clear that we are outsiders, have no responsibility and so low in the pecking order we are not really in it. Allied health plays an important role and without speech therapists, occupational therapists and physios a service wouldn't run smoothly at all. The nurses are very important. They interact with the patient and do a lot of the dirty work.

Now this is just an observation...please don't lynch me!!
Often there seems to be an unsaid power struggle between Allied Health and middle level doctors. It is subtle and usually not a problem in well run units, but seems quite real, just under the surface. As the nursing staff and allied health staff are assigned to the ward and often don't change for a long time they are often trying to assert themselves against the more frequently changing doctors. The consultants have absolute say, they are rarely challenged. The registrars although newer to the service often have a great deal of training and knowledge and mostly come out on top. The resident though are usually not game to argue with Allied health or nurses outright and smart Interns usually don't even put up a fight, knowing that they have to get things done for the consultant and if the other staff don't want to play nice, it will be very hard for them.

Maybe it is all in my head...not sure though