APM

Today’s inane image of the day:

Last weekend, the Oakland County Medial Society sponsored team of us to participate in the Shades of Pink Foundation‘s “A Walk in the Zoo” event. It was really early on Saturday morning, and pretty chilly out, but it was for a great cause and I had a wonderful time seeing all the animals at the Detroit Zoo.

Last semester when I saw an in-patient for the first time, the overall experience was exceedingly positive. I didn’t have any confidence in my ability to diagnose anything, but that wasn’t the purpose of the encounter. Furthermore, it was still my first semester of medical school; no one expected me to be able to integrate the patient’s symptoms with a clinical diagnosis and course of treatment. There was nothing to lose.

My first experience left me wishing for more time with the patient and a sense of purpose when I returned to my textbooks. It reminded me that medical school wasn’t only comprised of hours of time with my head spinning; there was a light at the end of the tunnel called 3rd year clerkships, and with each passing day I came closer and closer to being able to practice medicine. However, during our most recent clinical experience, I walked away conflicted. The premise of the exercise wasn’t too different from the first, but we were responsible for doing a bit more with the physical examination. And with an OSCE looming on the horizon, I was happy to have an excuse to practice.

After we met our preceptor for the day, we headed to a different unit to see our patients. This time, we had 2 different patients to interview and do a pertinent physical examination on. Prior to walking into the patient’s room, the preceptor told us the chief complaint so I felt prepared to solicit more information. We walked into the room and following a brief introduction, I sprung into action.

Our patient’s story tumbled out without any resistance; it caught me off-guard how easily pertinent facts could be collected from her responses. After collecting what I needed, I moved on to an abridged physical examination and wrapped up my encounter with that. We thanked the patient and left the room to discuss the encounter.

My preceptor’s feedback was mainly positive, but he noted that I was a bit nervous [well, yeah!]. There were a couple of things that I failed to obtain, but it was a learning experience so these things are to be expected. We then moved on to our second patient, and my partner conducted the interview and physical examination while I took notes. He finished promptly and we moved outside to wrap up the experience.

It was as I was walking out of the long hallway of the hospital when a wave of dissatisfaction and frustrated rolled in. As one of the patients listed medications, I recognized a couple of them but ended up misclassifying one of the drugs. Even though I am still a first-year student, I am just about halfway done with my preclinical years. Shouldn’t I at least be proficient in recognizing and identifying basic information that I already learned? How will I be comfortable with all of this knowledge for the boards and clerkships if I cannot keep simple material I learned a month ago in my head?

I know that I still have time. I know that it’s still early. But I am disappointed that the medicine I keep learning seems to slip away so quickly. My knowledge feels transient and fleeting. I just want to be able to feel just slightly confident in my ability in something but it seems that I am far from it.

[This is an account of my first encounter with an in-patient from a little while back — I have provided only minimal details about the patient to maintain compliance with HIPAA.]

After a firm handshake with each of us, our preceptor embarked purposefully up two floors to our first in-patient encounter. As we walked, I peeked into the rooms with the door left ajar and wondered what brought each individual to the hospital. I absorbed the environment full of harsh fluorescent lighting and the doppler effect of whirring machinery. As long white coats hurried past, I admired how they could make that swoosh sound of purpose that mine lacked.

Prior to meeting with our mentor, my partner and I discussed who would conduct the interview — he agreed that it was his turn [being the go-getter that I am, I offered to go first during previous patient encounters] and admitted to feeling nervous. Even without the pressure of being in the spotlight, I still felt like this was a test. An assessment of whether I truly possessed the humanistic, yet deductive ability required of physicians.

We walked up to the room and our preceptor grabbed the chart to secure a name. Before entering the room, he asked about the vital signs and I remember mumbling, “temperature, blood pressure, pulse, respiratory rate and sometimes pain.” At this point, I felt my own vital signs conveying my anxiety over meeting our first patient. Even though we were only charged with recording the history of present illness, it still felt like a tall order to fulfill. After all, many patients present with numerous chronic conditions, mounds of prescriptions and an extensive medical history. Since anything from the past could have contributed to precipitating the present condition, it didn’t seem like an hour was nearly enough time to gather every piece of the puzzle.

I don’t quite remember the rest of the conversation outside of the room, but I remember walking into the double room to greet our patient. Our preceptor introduced himself, then my partner, then I did while extending my hand to shake hers. Upon walking in, I was taken aback by her look of helplessness and how uncomfortably out of place she seemed — I envisioned that her life outside of the hospital involved young children and rosy cheeks from a slight chill in the autumn air. Her hand felt warm when it greeted mine, but I cringed slightly when my thumb brushed against her IV lines — I was scared that I might have grasped her hand too firmly.

My partner settled to the right of the patient while my preceptor pulled up two chairs for us to sit at the foot of the bed. As I opened a blank Word document to take notes, I heard quiet sobs from the other side of the curtain; I felt like we were unwelcome and intruding on an intimate moment. The “interview” commenced, but it was more like a guided tour of how to obtain important information. Our preceptor mentioned countless tricks he employed while he was still practicing [he’s currently retired] and by the time we were halfway through the interview, I already felt like I was only absorbing fragments of information. It was like a disorganized concept map in my head. I heard familiar and unfamiliar terms, but the lines connecting the ideas stopped appearing after a little while. By the end of the interview, I only really understood the diagnosis, but not the logic that brought us there.

Before leaving, we had to record the patient’s vital signs [minus temperature]. My partner went first, then I went ahead. Although we had practiced taking each other’s blood pressure, it wasn’t nearly enough practice to feel comfortable. I fumbled to put the cuff back around her upper arm and pumped it up to some large pressure value then listened carefully for the distinctive “lub-dub, lub-dub” Korotkoff sounds until they faded into oblivion. She sounded like she had a strong heart and I confidently reported a value similar to my partner’s. As I started to remove the cuff, our preceptor came over and noted that we had placed it on the patient backwards.

We thanked our patient profusely on our way out of the room. In the hallway, we discussed the interaction then parted our separate ways. At that point, I don’t remember anything else from that day besides the feeling of floating in a cloud of contentment. Despite the little mishaps of the encounter, the experience temporarily put the magic back into medicine and reminded me that someday the endless hours of studying and stress will pay off.