My First 2 Rotations as a 4th Year
The start of our clinical rotations as fourth year medical students was delayed by two months due to COVID-19, which was frustrating for sure, but I know it could have been worse. I was really excited to get back to seeing patients in the month of June. We have a lot more control over the rotations we do in our fourth year, which is largely why many say that fourth year is the best year of medical school. It allows us to finally choose rotations that are related to the specialty we want to go into as residents next year. For my first month back into patient care, I ended up on a 2-week Pulmonary rotation by chance due to some last minute changes, but it turned out to be a great first rotation as a fourth year. My second 2-week rotation was with Neurology, which I had asked for. Here I’ll reflect briefly on these two rotations, and my first month as a fourth year overall.
Pulmonary
After having a 3-month period without patient interaction, I was both excited and nervous to be returning to hospital rotations. The saying “if you don’t use it you lose it” is so true especially in terms of using and practicing clinical skills and knowledge, at least the way my brain is wired. The first few patient interactions I had I felt awkward, but was still able to get all of the information I needed. I was surprised that I hadn’t forgotten any major areas of my history & physical exam, and I guess that is evidence that I did come a long way during my third year of medical school. It’s also worth saying that adjusting to wearing a mask constantly while in the hospital wasn’t very difficult. I did buy a few small “ear saver” bands off of Etsy because my ears did start to get sore after a few days, and it’s forced me to speak up a little louder which overall is good for me.
That being said, the residents quickly reminded us, “you’re fourth years now,” and as a fourth year student there would be higher expectations. These, in part, include seeing 2-3 patients a day (as compared to third year when you’d see 1-2), and having a more developed assessment and plan for your patient. The first few days of having to review multiple patient charts and see multiple patients each morning I definitely felt a little rushed, but I was again happily surprised that it only took a couple of days to adapt. I appreciated the residents and attendings for being clear in their expectations of us as fourth years, as there are still many rotations where the expectations are less clear. It also worked in our favor that we were with the same Pulmonary Fellow for both weeks, so he was able to give us valuable feedback as he saw our progress from day to day.
Many of the patients the pulmonary consult service was following were COVID-19 patients, and patients with a tracheostomy tube in place.
As a medical student, we are not allowed to see patients who have been tested and have confirmed COVID-19. However, our resident team did allow us to follow along with the hospital course without physically seeing the patient. For our presentations to the attendings, we would just defer to the resident for the physical exam findings and the patient’s subjective report of how they’re progressing. Learning about how these patients are managed was, of course, very relevant and interesting. It was terrifying to see how sick some young patients (< 50-60 years old) were, especially those with comorbidities such as diabetes, high blood pressure, obesity, or other immunocompromised states. It was also a first for me to hear attending physicians talk about patient management with so many unknowns at play. I had grown accustomed to the attendings always having at least a well-reasoned hypothesis as to what the right course of action is, but it was unsettling to hear how truly unsure everyone is. I had known that physicians are all at a loss, as expected because this is a novel virus, but listening to the conversations and following the actual patients definitely unsettled me in a different way.
Following our patients with tracheostomy tubes also piqued my interest for different reasons. First, I hadn’t really had formal teaching about tracheostomy tubes (commonly shortened to “trach’s”), so I was glad to be learning about management and some physiology related to them.
[A brief side note on trach’s for my non-medical student/future medical student readers: The term “tracheostomy,” broken down… the suffix -stomy =a surgically established opening, so a tracheostomy is an opening in the trachea. This hole/opening is called a stoma. If a patient has a tracheostomy (hole), they will also have a tracheostomy tube in place holding the stoma open. This tube acts as a breathing tube that is usually in place much longer than the “endotracheal” tube (tube inserted into the trachea/windpipe). However, I just learned on this rotation, this stoma can close up rather quickly, so a tracheostomy is not always a permanent way for the patient to breathe.]
But, what really stuck with me about these patients was less about the physiology and had to do with how chronically ill many of them were. Many of them had hospital stays that spanned several months, so at first I felt overwhelmed as I was reviewing their charts. Once I improved at getting a general impression about the patient with these complicated hospital stays, I started to think more about the patients’ quality of life and paid particular attention when the team talked about it. There are many indications to have a tracheostomy, and the goal of the physician managing the trach is to get the patient weaned off of the ventilator (breathing machine) if possible, and to get them off of the tracheostomy tube / back to breathing on their own. However, we were following several patients who would likely remain dependent on the ventilator, on their tracheostomy tube, and on a feeding tube (commonly a “PEG” – percutaneous endoscopy gastrostomy tube), for the foreseeable future and for some the rest of their lives. With some of our patients, the team would wonder if the patient would have wanted their current quality of life. Once the patient can no longer communicate decisions for themselves, we rely on their family members to make the decisions. I’ve briefly been in that position in my personal life, helping to make medical decisions for a loved one, and I know that it’s one of the hardest positions to be in.
Following these patients really reminded me of the importance of having conversations with our patients and their families about “goals of care” wherever possible. As a hopeful future emergency medicine doc, this will definitely be part of my job. However, those conversations are much better for the patient when they can be had ahead of an ER visit, ahead of a critical presentation. I am interested in learning more about Palliative Care, in part so that I can have additional training about having these difficult conversations with my future patients, and I really enjoyed listening to the Pulmonary-Critical Care attendings talking about this topic.
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Neurology
I had requested a neurology rotation because it relates directly to emergency medicine, and I have always found neurology to be interesting (my Bachelor’s is in Neuroscience). In the ER, I’ll see all types of neurologic complaints including acutely ill stroke patients, so I wanted this rotation to continue getting more exposure to the field. The higher expectations of fourth years continued, and we would see up to 3-4 patients per day. I was really excited to feel helpful to the residents and to be seeing more patients more quickly. I knew that in my next rotation, my Emergency Medicine Sub-Internship, I would be seeing lots of patients each shift, so the more practice I could get the better.
Neurology is a unique rotation because the wide range of neurologic pathologies are unique. I saw so many interesting cases and learned so much. To name a few: There were a couple of patients with a new diagnosis of Parkinson’s. I saw a patient with Moyamoya which is a rare disorder affecting the blood vessels of the brain. There were lots of patients with seizure disorders of all types, and one of the most common things we saw were stroke patients both chronic and acute. In fact, stroke patients are so common that the neurology service is broken down into two teams at the hospital I rotate at. There is a general neurology team and a stroke team.
The stroke patients were interesting to learn about, but also very sad at times. It was interesting to review brain imaging, see where a lesion was, and then see the resulting physical exam findings and symptoms. The patients with devastating physical deficits were sad to see. It was also unfortunately remarkable to see up close how dangerous silent diseases like high blood pressure, diabetes, and high cholesterol can be, especially when more than one is present. Patients are usually asymptomatic with high blood pressure and high cholesterol, and often only mildly symptomatic with diabetes. I think this is part of what causes some patients not to take their diagnosis seriously, and unfortunately for many this is what causes them to be unaware of the disease in the first place. We saw some patients that didn’t know they had one or all three of those chronic diseases until they were coming into the hospital for a stroke. This really emphasized the importance of access to care for patients of all backgrounds, and the importance of having a primary care provider.
One of the neurology attendings is one of the kindest and happiest doctors I’ve ever gotten to work with. It left such a positive impression to see the attending walking through the hospital and greeting every staff member that we passed, most by name. He verbalized constantly that every member of the team at every level is an important part of patient care, and I truly appreciated working with someone who demonstrates that in their actions. This created more work for the attending, as people were quick to stop him in the halls for consults, but he was always kind and patient regardless of how busy he was. I hope to be that type of happy and positive leader someday.