I woke up throughout the night, each time I attempted to estimate the time till sunrise using the ambient light that slowly invaded my room. I wasn’t particularly anxious about the upcoming day, instead I think it was the fear of the impending jolt from the alarm that bothered me. Or, maybe it is more so that I live with other people and I hate the idea of waking them up with me. Either way, I woke up well before my alarm to shut it off. Checked the weather, a balmy Boston 20 F (-6.7 C), awesome — it was time to start the day.
Today, was the start of our Renal module. However, I don’t go to class, with the exception of discussions, patient sessions, and skills sessions etc. Instead, I watch later, at my own schedule. There are lot of ways to do medical school, and to each their own. For myself, I was going to the Cardiology unit of our hospital to go on rounds. Right now, I’m doing my first conceptual pass (hopefully 1 of 2) through cardiology for STEP 1. So, I took advantage of opportunity to concurrently round on cardiology inpatients.
I’m not sure if it’s realistic to do this for each block that I review, but so far it seems like an interesting spin on things. But, I figured I’m already paying an exuberant amount in tuition, might as well get as much as I can out of the experience.
So, earlier that morning, the cardiology team was to see 16 patients; a lot of them were overnight admissions. The team consisted of two cardiology attendings, one interventional cardiology fellow, two cardiology residents, and three medical students (including myself). This amounts, to what I can only imagine from the position of the patient, as staring at people like they’re in a fishbowl. I learned a lot of things since the first time I did this in the summer: read-up before coming, bring scrape paper, penlights are worth gold, try or nothing will happen, and pee whenever allowed to (bathroom strongly suggested). However, I’m still learning a lot of things when allowed on these excursions. Through lecture, I’ve been “exposed” to the material for most organs and a myriad of drugs. However, in internal medicine those random one off facts I marked on multiple choices became patients where I needed to know about amyloidosis** subtypes AL, AA, and TTR came up, gout vs pseudo gout (and the beloved crystal birefringence question) and their drug side effects, side effects of calcium channel blockers and their indications including selectivity, was Takayasu vasculitis causing the patients chest pain, vasculitis[?] and the dermatology consult, pheocytochroma (the adernergics strike back!), which medications cause Lupus like symptoms, hypertension management (should have brushed up on JNC-8), epidemiology of chronic kidney failure (remember, it’s the first day in renal medicine), and did I say vasculitis? It was a long day, but I got a warm pat on the back, and I was asked when am I coming back? To which I replied, “Day after tomorrow”. I returned home, watched the day’s lecture that I missed, did some practice questions for boards, and read up on the things that I felt I should have known, and looked up a few things I saw that day.
That night before returning to the hospital, I wrote down a list of goals for myself so I wasn’t just hanging out and stayed aggressive about my education. The cardiology exam, at least how it’s taught here, is pretty hands on and intimate (interestingly, a lot of patients say they enjoy the attention):
- Check for splinter hemorrhages on every “likely” patients’ fingernail beds — heard it was a thing, would like to see it myself.
- Palpate as many pulses as I can get my hands on, especially the patients with Atrial Fibrillation or peripheral vascular disease — I was really bad at the “difficult to find” lower pulses, I need to get better at this for the future. So, I thought if I feel a ridiculous amount of pulses I’ll be someone useful in a room later.
- When given an ECG, interpret it — I’m pretty decent, i.e. I can do the stuff they taught us in class; but, seeing a cardiologist interpret these things is magical. As an undergrad, I still remember trying to read an ECG in Physiology, I remember being blown away by even the concept of the leads. Accordingly, my favorite portion of physics was the electromagnetism section. Under the direction of a phenomenal mentor, I went onto do electrophysiology projects; there I interpreted ion channels, and gained a little confidence in looking at squiggly lines. This past summer, I had to drudge through a hundred or so ECGs to screen patients for a study. Now, thinking back it’s sort of funny, it’s not all that dissimilar than what I learned in freshman physics when I was working with circuits.
- Appreciate as many murmurs and abnormal JVPs as possible, including appreciation of Kussmaul’s sign — I remember going through murmurs the first time, I was absolutely horrible at them. I recall going to a workshop for murmurs, a physician cardiology fellow said, “It’s really hard to appreciate the differences of the murmurs, until you hear your first one and identify it on a patient”. She was right. Though, I’m not a murmur master, I can finally tell the difference between murmurs and the maneuvers necessary to amplify them. About JVPs, when I was a premed my grandmother past away, just before she passed away I saw her grossly elevated JVP myself. Dr. Google told me what it meant, so I’m comfortable with appreciating their significance; I just want to make a habit of appreciating them (just in case).
- Get more aggressive about checking for pitting edema, including attempting to better grade and describe its character.
- Follow-up on critical patients to see if the presented planned for therapy had the luck of a good outcome — I could do this by doubling back after rounds, or simply hoping onto my laptop from home to check-up on patients the team is assigned to; i.e. patients I’m allowed to follow. One of my favorite patients we visited passed away, Friday night, just as the attending bitterly predicted. Some patients got better, the amyloid patient was being prepared for discharge, a few were scheduled for catherization, and one had died.
- Pay attention to the management of the kidneys — I’m currently in Renal Medicine courses, so I should try to keep in mind that I still need to pass that exam later. Not surprisingly, there was a lot of between Renal and Cardiology Medicine: a lot of people with heart failure also have kidney problems. So, I’m paying more attention to goals of removing or adding liquid volume to patients. There’s been a good amount of overlap between class “take home points” and the stuff I see on the floor about titrating diuretics is applied to the patient I will lay hands on.
- Be more cordial with patients, especially when I’ve heard they haven’t had visitors for a while — one of the first things you notice going in cardiology assigned patients is their cognitive decline, and sadly I’ve noticed it’s also the time where some stressed families distance themselves from the patient. A large part of the cardiology exam includes assessing patients’ cognitive level, while not discounting biases (including our own), their education level, and their health literacy.
I returned to the hospital, this time I given a locker in cardiology to keep my stuff safe I was told. The day before, I wrote down everyone’s names so I wouldn’t forget who’s who. I’m really bad with names, though great with faces — I’m trying to get better at the former — that morning I forgot to throw this on my checklist, to be better at names, but I made the update. I set off to complete my check-list, I did.
Now, I don’t ask “What the hell is that drug, and what does it do?”, I wonder to myself what’s the indication for using it and removing it off of patients medications list. I’ve seen a variety of patients, with a variety of attitudes about their situation: some of them beautiful some of them spiteful. Over these days, I heard my first tricupsid regurgitation; or rather, I appreciated my first definitive regurgitation — in fact, I was bombarded by murmurs, so that it was no longer an exotic finding. Listening to the jumble of words and lab values for patients became less daunting of a task. I now feel less bogged down by the language of medicine and instead I’m looking forward to the transition from classroom to hospital floor. Perhaps it’s my gift for holding my bladder, given that I don’t have to do any of the heavy lifting yet, I like rounds and the complications and the piles of medications to think about. Given I was hoping to just be a doctor in the future, it’s surprising to see that previous work in data entry and another later entailed backend electronic database management come to use with the electronic health record navigation. I’m a little sad to see the skill come into play, but, I’m ready for electronic record drudgery so often bemoaned (and rightfully so, given the context). Because the senior medical students above me were great, they were essential to my experience and learning. And as usual, from them, I’m left hoping to meet the standards they set-forth. The learning went all the way around, the residents learned how to teach better from the attendings, the attendings learned an extra tidbit from “research questions” done by others. And me, well, I learned from everyone: I have a lot more work to do, but I’m going in the right direction.
**reference: amyloidosis is actually pretty rare, but we’re a center for amyloidosis so the incidence here is high, i.e. less esoteric of a fact and not just warped medical-pimping.