Thursday, August 26, 2004
All Good Things Must Come to an End
Well, today is the last day I'll be on an Internal Medicine rotation and I'd like to give some thoughts on the whole process...
First of all, the mileage varies widely from preceptor to preceptor. Some people have really long days filled with scut and rounding, while others have really long days filled with teaching, rounding, and fun. The common denominator seems to be really long days. This isn't too bad, however, since you are busy the whole time and (as a student) when the day is over noone pages or calls you for patient problems. This is why being a student rocks. The reason being a student sucks is 1) the same reason above - noone calls you, so you are always the last to know; 2) You can't technically make any treatment decisions, order any tests, or give orders for your patient that is in excruciating pain. You still have to call the intern/resident/attending or wait until rounds later in the day; 3) Everyone looks at you and calls you "that student" behind your back. I've heard it - it really happens; 4) The nurses always try to show you up. This really bothers me - why do they do this? I never did this when I worked in a teaching hospital. Of course, I worked in the ED where the view of physicians in general is a little different. Oh well.. whatever.
Overall, I was pretty surprised at this past month. I thought it was going to royally hoover, but all-in-all, it's been a pretty good time. Of course, it doesn't hurt when you have a great preceptor that takes time out every morning to teach for an hour. Hopefully, that'll help when it comes to the shelf exam tomorrow. Another reason I was surprised is that for a tiny hospital, they see a fair amount of pathology. Nothing like at the county hospital, which probably only beats it because of sheer volume, but we still had some pretty interesting cases.
Now for the downsides:
* Not enough pathology. This is a common complaint at smaller institutions. All the super-sick people go to the larger hospitals in town. Of course, it doesn't help that those huge hospitals are like a 3 minute ambulance drive away - pulls alot of stuff away from us. As I said above, they see some just not enough for what I would like as a resident-in-training.
* Too many consults. Ohmigod! How is it that at the county hospital, where there are at least 6 times the number of patients, the surgical services can manage their own medical issues but here they can't? It's very frustrating to be called at all hours for another consult on a surgical patient for management of their "medical issues" which amount to hypertension and diabetes - things even a 3rd year medical student can manage (can anyone say "continue home medications?")... Oh yeah.. we're talking surgeons here.... :) Of course, if it weren't for the consults our census would have been only about 12 patients.
* Patients stay too long. The beautiful thing about team call is you play the "who can we get out" game. The point of this came is to drop your census as low as possible before the next call (which occurs 3 days after you get off your previous call). Patient turnover is much more rapid than when everything is run by a private physician who really has no incentive to move patients along. For instance, I have had a patient with CHF for 4 days now - she is fine and she probably could have been discharged back to her nursing home 2 days ago. However, since we are not playing the game, we are waiting for her to ask to go home - which she finally did - today. I'm not saying this is a bad system - this is routinely how hospital admissions worked years ago and it is a viable option. However, for a hospital that continually complains that it is going bankrupt, it may not be a financially viable option. We need to work a bit more on what (in the ED) is called throughput - getting patients in and out.
Despite these few things, I really enjoyed this rotation - aside from dictations. Which is why I'm going into EM. You don't dictate crap. You see your patients, scribble orders, circle some words and check some boxes and you're done (god, I love the T-system). Then you look for placement - out the door or in the hospital. Lickety-split. None of this "you may now begin your dictation" crap.
My team was great, as was my team at county hospital. Thus far, I have been very fortunate. Even the other students that were with me on this rotation were cool - which is fortunate, since I didn't really talk with any of them prior to this month and had no clue what to expect. Thanks you all for making the month fun!
You too, Drs. C, B, and M!!
What's next for me? Family medicine: the final frontier. I'm getting all the medicine out of the way, so I can work on my sewing (surgery), catching (OB/GYN), and corralling (pediatrics) later. Of course then there's the pitchfork (Psych) and yoga class (OMMMMMMM....). But it's off to the West side for family medicine, where the monkey suits will reign supreme. Have I told you I hate monkey suits? ¶ 2:46 PM
First of all, the mileage varies widely from preceptor to preceptor. Some people have really long days filled with scut and rounding, while others have really long days filled with teaching, rounding, and fun. The common denominator seems to be really long days. This isn't too bad, however, since you are busy the whole time and (as a student) when the day is over noone pages or calls you for patient problems. This is why being a student rocks. The reason being a student sucks is 1) the same reason above - noone calls you, so you are always the last to know; 2) You can't technically make any treatment decisions, order any tests, or give orders for your patient that is in excruciating pain. You still have to call the intern/resident/attending or wait until rounds later in the day; 3) Everyone looks at you and calls you "that student" behind your back. I've heard it - it really happens; 4) The nurses always try to show you up. This really bothers me - why do they do this? I never did this when I worked in a teaching hospital. Of course, I worked in the ED where the view of physicians in general is a little different. Oh well.. whatever.
Overall, I was pretty surprised at this past month. I thought it was going to royally hoover, but all-in-all, it's been a pretty good time. Of course, it doesn't hurt when you have a great preceptor that takes time out every morning to teach for an hour. Hopefully, that'll help when it comes to the shelf exam tomorrow. Another reason I was surprised is that for a tiny hospital, they see a fair amount of pathology. Nothing like at the county hospital, which probably only beats it because of sheer volume, but we still had some pretty interesting cases.
Now for the downsides:
* Not enough pathology. This is a common complaint at smaller institutions. All the super-sick people go to the larger hospitals in town. Of course, it doesn't help that those huge hospitals are like a 3 minute ambulance drive away - pulls alot of stuff away from us. As I said above, they see some just not enough for what I would like as a resident-in-training.
* Too many consults. Ohmigod! How is it that at the county hospital, where there are at least 6 times the number of patients, the surgical services can manage their own medical issues but here they can't? It's very frustrating to be called at all hours for another consult on a surgical patient for management of their "medical issues" which amount to hypertension and diabetes - things even a 3rd year medical student can manage (can anyone say "continue home medications?")... Oh yeah.. we're talking surgeons here.... :) Of course, if it weren't for the consults our census would have been only about 12 patients.
* Patients stay too long. The beautiful thing about team call is you play the "who can we get out" game. The point of this came is to drop your census as low as possible before the next call (which occurs 3 days after you get off your previous call). Patient turnover is much more rapid than when everything is run by a private physician who really has no incentive to move patients along. For instance, I have had a patient with CHF for 4 days now - she is fine and she probably could have been discharged back to her nursing home 2 days ago. However, since we are not playing the game, we are waiting for her to ask to go home - which she finally did - today. I'm not saying this is a bad system - this is routinely how hospital admissions worked years ago and it is a viable option. However, for a hospital that continually complains that it is going bankrupt, it may not be a financially viable option. We need to work a bit more on what (in the ED) is called throughput - getting patients in and out.
Despite these few things, I really enjoyed this rotation - aside from dictations. Which is why I'm going into EM. You don't dictate crap. You see your patients, scribble orders, circle some words and check some boxes and you're done (god, I love the T-system). Then you look for placement - out the door or in the hospital. Lickety-split. None of this "you may now begin your dictation" crap.
My team was great, as was my team at county hospital. Thus far, I have been very fortunate. Even the other students that were with me on this rotation were cool - which is fortunate, since I didn't really talk with any of them prior to this month and had no clue what to expect. Thanks you all for making the month fun!
You too, Drs. C, B, and M!!
What's next for me? Family medicine: the final frontier. I'm getting all the medicine out of the way, so I can work on my sewing (surgery), catching (OB/GYN), and corralling (pediatrics) later. Of course then there's the pitchfork (Psych) and yoga class (OMMMMMMM....). But it's off to the West side for family medicine, where the monkey suits will reign supreme. Have I told you I hate monkey suits? ¶ 2:46 PM
