Mile 6650: Aha! That could be it!

Above: The weirdest sign I saw on my May 2010 roadtrip. Talk about a one-stop tourist trap. Kissimmee, FL along Route 192.

It's been busy. There's no time to sit back and relax. Things aren't stopping. And for me, stopping could be dangerous.

BUT I LOVE THE BURN.

Week 6 here at my internal medicine rotation. I finally got the layout of my hospital down, know when and where to get coffee on my commute, what entrees at the cafeteria I should have/avoid, and even where the "secret rooms" are to do my work.

The importance of the IM rotation for anyone comes not in just getting to work in a hospitalist format, but also learning the art of medical thinking... something that I am still in awe of and want to master.

ONE CAN NEVER SAY A DIAGNOSIS IS CLEAR CUT.

It never is (unlike many medical dramas on TV put it). Its a common fallacy I run into. To me, Step 1 thinking is all about the "clear-cut" ness and classical cases, but coming into Step 2 and Step 3, things are completely different. If Step 1 thinking is taken into clinical medicine, fairly significant diagnoses can be missed, and one can head down the wrong road of management. Medicine kinda breaks the rules; it is unsafe to always think that X + Y + Z = A always. After a set of what we call "differential diagnoses" are given out (these are the lists of possible things that are going on), it is up to the clinician to rule out specific ones (especially ones with the most deadly prognoses along with the most common). A good set of differentials actually leads to better diagnostics and therefore, management.

Our tools to solving the patient's issues include the history we take on the patient, the physical exam, and laboratory tests. Each one of the tools has an advantage / disadvantage, usually measured in terms of cost (dollars and cents), usefulness of the info returned by the test, and time-to-benefit ratio (waiting 3 days for confirming something that might kill you in an hour isn't exactly a good thing). Some of the best clinicians I've seen at the hospital will perfectly balance all three by picking the right questions, exam procedures, and tests to confirm and rule out diagnoses (somehow they make the puzzle pieces fit). I'll admit, to use all these options efficiently is an art, and my mentors (attendings, seniors, and even the new interns) are always able to think of something I can't.

It's amazing that a lot of them say that the history is usually the best place to find out the diagnosis. However, even for the best clinicians, there are times where cases where the diagnosis is so unclear or takes an unexpected turn that a "Hail Mary" throw of tests needs to be done. But they're so good that this is usually last resort only.

The art of being a clinician is easy to put into words, but mastering it in practice is going to take more than 6 weeks to accomplish.

Mile 5998: Fritos & Coffee

Above: Roadside stands like these are available all thoughout Georgia. I get my load of honey-roasted pecans each time I pass here.

EVEN WHEN ITS ONLY FIFTY-DEGREES OUTSIDE,
MY WINDOWS ARE DOWN.

Every minute seems to blur into another, as the weeks pass by faster and faster. We're already in our third week (about to start our fourth), and it was only yesterday that I remember we were getting into the realm of things. The one thing I like about the internal medicine (IM) rotation I currently am at is that it satisfies the standards that I had set at Mile Zero on my journey very well. Doing this rotation actually makes me rather excited about IM. Our work on the floors has the quality of intensity, something I have been desiring for some time.

The following is a normal itinerary for me on a weekday.

6:00 AM - I leave home early. In Chicago, traffic accumulates with every minute lost in the morning, so this is the absolute goal for departure. Although I don't have to be at the hospital until 7:30, I'd rather do some reading in the resident's lounge than waste more time stuck in traffic. I usually get to the hospital about 6:30 AM, and when I get there, I'm loading up patient data from the computers and visiting the patients I'm following before my intern arrives.

7:30 AM - My intern arrives. The first thing he does is make coffee at the maker in the resident's lounge. On the table in front of the maker is an aluminum tray with a few juice cups and bags of snacks that the hospital delivers for the on-call team for the night. He usually isn't able to grab breakfast in the morning, so he grabs a bag of chips and opens it up for breakfast. Not leaving my resident alone with the morning ritual (even though I already had my Frosted Wheat Puffs and Ovaltine earlier this morning), I usually pull up a bag of Fritos (or Cheetos, as a viable alternate) and get a cup of coffee.

This is a superb example of a resident-recommended diet.

8:00 AM - I round with my intern, releasing the data from the labs I pull in the morning and the data I pulled on the history of the patients I'm following. These rounds are walking-intensive (involving going up and down several floors and down several wings) and can slow down whenever patient demands in the ICU or on the floor come up. I usually find myself walking around in "shadow mode" sometimes, leading myself to walk exactly in the footsteps of my intern (which could have me backing up into walls or other health care staff).

10:00 AM or thereabout - On some days, we have what they call "teaching rounds," with a senior attending physician along with our group of interns and students (about 8 in total), which involves a component of lectures, bedside patient presentations, and resident/student presentations. This is one of the lecture components provided. I believe that lectures are good to recap what's going on in the hospital. Getting lost in the demands that the rotation/residency provides is easy; we can't forget we have to learn every step of the way.

12:00 PM - We have another didactic lecture over lunch, on a hot health topic. This usually takes place in the lecture hall and makes our day more efficient, by giving us a good time to combine eating while our learning. Time management and efficiency is critical to operating and being successful in residency.

1:00 PM - I sit down and write progress notes on patients I'm following. The afternoon is usually left to admitting new patients, taking their histories/doing physical examinations, running actions/plans past my intern, and reading up on their cases. Medical education is very reliant on real cases, and that's a good thing. It's not the same reading about a topic in a book. Each medical case encompasses critical thinking skills and problem solving. Memorization won't get a physician anywhere.

5:00 PM - By this time I'm ready to leave the hospital if I did everything right. Sometimes there are exceptions, either late (or multiple) admissions, falling behind on notes, and the occasional assisting the intern, so he can get stuff done earlier. But in the end, I don't see the way I work with my intern as senior-junior, but in many ways it ends up as a team. I think that's just really cool, because that team combo has enhanced my learning experiences in medicine.

6:00 PM - After some time in traffic, I stop by one of the nearby Caribou Coffees or Starbucks and pick up a good iced coffee that powers me for the rest of the day. That night, I read up on primary literature for my cases and lectures, and I finally get to bed by about 11:00 PM.

And with that (and some occasional changes day-by-day), it's simply rinse and repeat for the next day at work. Weekends are a tad shorter (ending by 3:30 PM), but the same routine above follows. I'll be shooting out more specifics on what goes on during my internal medicine rotation, so stay tuned.

Mile 5855: Shortie: Whoa!

Above: Jurassic Park truly exists, Folks. Along I-65 in Kentucky.

THIS EXPERIENCE MAKES ME GO
WHOA!

I was talking to my friend Nik about not writing for 3 weeks, and I said to myself, "Wow, I went about 500 miles without letting you know where I went. That's kinda like going to Nashville and leaving you behind in Chicago."

Sorry. Let's get you caught up.

The last three weeks have been some of the busiest med schooling I've gotten so far. At a teaching hospital in Chicago, I'm currently doing Internal Medicine. The program set up is a shadowing of an intern both on the wards and in the ICU (depending on what patients are assigned to him). And I've done a lot of walking, writing, and paging (the last one's my favorite... I get to proclaim myself as a "medical student" on the phone!). I've seen some awesome cases at the hospital left and right, presented in front of interns and staff, and felt an intensity that I've been wanting to have in medicine for a while. Sometimes I get home with a load of primary literature I need to dig through!

But I'll tell you this, an intense rotation can be quite exhilarating, but it can also be more tiring too. All in all, the work here makes me love medicine so much more. My homework: get you some concrete examples of my experience this weekend. I won't leave you behind on the trip for much longer.