Internal Medicine at the VA Hospital

Well I knew this would be a tough rotation, quite different from the pleasant ones so far. I'm getting to the VA between 6:30am and 7am to read the latest notes (reports, labs, procedures) on my existing patients. Then at 8am we have morning "rounds" which is just a meeting with all the attendings, residents and students. We go over a case in detail (all the DDx) then have a short lecture. The attendings may have some specifics for the group as whole that relate to the lecture topic.

From 9am to 10am, we have to finish seeing any patients we didn't get to before 8am and be ready to present them to our attending. Team meetings from 10am to 11am are a little intimidating because they are when you get pimped to death and it's your primary opportunity to shine in front of the Doc who will write your review and/or LOR.

After you sweat your way through that, it's another hour to do anything that came out of the attending's feedback, then get to work on your SOAP Notes for the day. Depending on the day, you can have new admits come in during this time which require a lot more work: a full physical exam; a detailed history; and a long H&P report.

Lunch for all the residents and students is usually provided by a drug rep. After the rep's 5 minute spiel, we have a lecture or a game of IM knowledge such as team jeopardy. The senior residents obviously dominate the latter, but even students sometimes get to dust of some tidbit we remember from Boards. My team won yesterday because one of our Podiatry students was on our team and she knew the derm symptoms for rheumatology diseases cold.

The afternoon is spent writing up progress notes, handling new patients, following procedures and trying to learn as much medicine about your patients as possible. I'm using WA Manual and UpToDate as my primary sources, but I sure wish it was easier to master this stuff. There's so much to know!

For example: the differential diagnoses, presentation of symptoms for each possible diagnosis, tests for each, accuracy of those, studies proving the accuracy of the tests, treatments, studies on efficacy of treatments, potential side effects/complications, etc.

And this patient population is VERY difficult! "Train wreck" has been used frequently. I have to present on a patient this Friday for Professor Rounds at the VA and then on campus next Tuesday on a typical patient. He was confused about meds and thus non compliant. Volume overload made him short of breath with pleural effusions. Then his pacemaker failed as we watched his EKG. Then before he could get transferred for pacemaker replacement he had an MI!

Of course, he also had diabetes, hypertension, CHF, CAD, stents, renal failure, neuropathy, ulcers, a previous stroke, and the list goes on. I was worried when we got him back after the pacer replacement that he also had in pneumonia, but that's one thing we have been lucky on so far.

It's really a wonder that more patients don't just keel over. The attendings and residents manage to keep them alive. Even when, as one patient told me this morning, they just want to go home and die due to the pain. Usually it's temporary and they aren't serious, but we certainly deal with those kind of issues and questions all the time.

The beneficial aspect of all this is I think I am learning a ton. The patients and the little tidbits I get from residents and attendings are important knowledge that should stick better having seen it in real life. Of course, I'm still supposed to be reading all the time, but a panic attack about residency a week or two ago has me staying up until 2am every night researching programs online instead of reading. I have less than nine months to start sending in applications!!!

And I had call on Saturday so I couldn't study last weekend. Now that my residency program spreadsheet is mostly done, I can focus more on the reading. I also need to hone my reporting skills. Our attending is a real stickler for detail. He is very bright and, in a nice way, can pretty hard on our sr. resident, two interns and two students including myself. Lives are at stake and he's training us to be competent so I appreciate his prodding and relentless pursuit of improvement and learning.

The new patient report, an H&P, is a very complex document, especially for these patients. Getting all the information is difficult enough from complex patients and electronic medical record system at the VA, but then there's researching the findings and the diseases processes and finally tieing everything together so there's no loose ends. Does every drug have an evidence-based purpose and do you know the study proving it? Is every abnormal electrolyte explained by your problems list and addressed by your plan? Is your plan, (tests, meds, procedures, etc.) have evidence to support it as being the most efficacious in terms of patient outcome and dollar value?

I'm pretty sure I don't want to go into medicine. This anal retentiveness for knowing every differential diagnosis, every bizarre disease and every new study that comes along to contradict current methods is a bit too cerebral for me. Reminds me of a lecturer in first year that summed up American medicine as; "make sure your patient dies with their electrolytes in balance". Too true! It makes you miss surgery where you just fix stuff. So I'm probably more committed to rural family practice than ever.

My residency research has cost me a lot of sleep, but I'm getting more comfortable about my options. Becky and I are looking pretty hard at procedure heavy programs in Colorado, Utah, Washington and some fallbacks in San Diego, Phoenix, Indiana, Montana and elsewhere. There's a lot to consider: OMM/DO acceptance, procedural training, operative training (hernias, appies, tonsils, etc.), trauma exposure, climate, patient volume (want 100+ logged scopes), pay, moonlighting, technology, call, cost of living, reputation, etc. I have pretty much excluded opposed programs. This is where there are multiple residency programs, so the Family guy admits a patient and then has to send them to specialists if there's any interesting pathology. As a rural Doc I won't be able to rely on specialists at my beck and call. Plus it's more interesting to handle those cases and do those procedures myself.

Finally, this spreadsheet may help me repair my rotation schedule. I just found out last week that my surgery paperwork for Maricopa County Hospital was needed within two months of scheduling my rotation, not two months of the start. So without telling me, they gave my January spot to someone else! Now I'm waiting to see if they come through with something else. In the meantime, I'm researching which of the programs I'm interested in that have MSIII rotations. All have MSIV "audition rotations" to check out potential applicants. Only some have Peds, Surgery and Family rotations that I need in the next few months. The downside is this is time away from the family, I will incur travel costs and it may put me in front of program directors when I'm not as well trained as they are expecting. The one upside I can see is that it will give me a chance to check out more programs. I really only have 2-3 audition rotations at the beginning of MSIV year.

More scrambling due to errors out of my control! Makes me long for owning my practice. Well, now that the sugar coma from last night's Halloween loot has worn off it's time for some sleep.