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Working with challenging patients in the hospital

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During my M4 year, I had the opportunity to work as a sub-intern on a general medicine team. It was an amazing experience for me to utilize my medical knowledge from the first 3 years of medical school and act as an advocate for my patients. I had a patient who had a recent extensive course of hospitalization before our team admitted him. He was recently diagnosed with invasive high-grade papillary urothelial carcinoma of the ureter and underwent right nephrectomy right before being admitted to the hospital with a fever of unknown origin. He ended up being diagnosed with infective endocarditis and required a long course of IV antibiotics before he could go home.

 

Not only was his case a diagnostic challenge, he was also very tired of having to stay in the hospital, as he had been in and out of the hospital for the past 3 months and now had to stay in the hospital with his new diagnosis of infective endocarditis. This quickly became evident to our team as he started to decline lab draws and medications, and his wife and two daughters quickly became worried about his physical as well as emotional well-being. At first, I was not sure how to approach the situation, as I had not had much experience taking care of patients with depressive moods in the general medicine setting. However, after spending even a few minutes everyday to get to know my patient better, I began to understand that he was on board with the treatment plans in the hospital but just wanted to go home. One morning, he flatly told me that he’s leaving against medical advice because he is so uncomfortable in the hospital. I told him that he is free to leave if he wants to, but we would love to see him stay in the hospital because our team is working really hard to get him better and asked if it would be better if we moved lab draws to late morning instead of at 5-6 am. At the end of the conversation, he said he would give it another try, and he ended up staying in the hospital until the last day of my rotation. I was able to say good-bye to him and his daughters on my way out of the hospital and wish him the best of luck in the future.

 

This sub-internship experience was very significant for me as it confirmed by decision to pursue internal medicine residency. I truly loved working with my team and working with my patients. I felt that I was making a positive influence on my patients’ lives not just as a source of medical knowledge but also as an advocate for their well-being. I am very proud of my grade from my sub-internship and especially comments on my communication skills with my patients. After this rotation, I began to jot down quick reflections and thoughts on my clinical experiences after on my computer. When I look back at these reflections, I am reminded that I am so fortunate to be able to pursue a career that allows me to make positive impact on someone life everyday. My plan is to continue this habit of jotting down reflections as I develop as a physician. I believe that I will be more resilient during challenging times.

 

 

Improving communication between gen med team and consultants

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Over the last few months, I have been working on a quality improvement project with five other M4s going into internal medicine residency. We discussed our experiences working as sub-i’s on gen med teams and aspects of medical care we could potentially improve. After our discussion and consulting Dr. Heacock, our faculty advisor, we decided to work on improving communication between the general medicine team and consultants to reduce the length of stay for hospitalized patients. We have seen delays in providing care for the patient due to the primary general medicine team having to wait to hear back from consult teams usually via a note on EPIC. We thought asking the consult team to notify the primary team quickly after rounding on each patient. Our project is ongoing at the moment, but we heard from the clinical data analyst that the length of stay has dropped slightly after implementing intervention. One of the feedback we did receive was that some consult teams tableround in the morning then round on patients in the afternoon and finalized decisions after rounds which meant that their plans were not formulated until late afternoon, which is already too late for the primary team to implement the plan on the same day.

I really enjoyed my discussions with my teammates who were passionate about improving quality of care in internal medicine. We each came up with various ideas how we could improve communication between the general medicine team and consultants by voting on each idea and picked the idea with the highest number of votes. I found that it can be challenging for medical students to come up with realistic ideas for quality improvement projects as we have not yet spent a lot of time in the hospital yet, especially enough consult teams to understand their different rounding styles.

My goal is to continue to engage in quality improvement projects as a resident, fellows, and attending physician. I plan on actively looking for areas of inefficiency in medical care and jotting them down as I continue to practice medicine and reflect on my practice. My plan is to take a few minutes every week  (especially at mass) to think about my clinical experiences. I would like to establish rapport with clinical data analysts who will be instrumental in assessing the effect of my intervention.

 

Manuscript publications during M3 and M4 years

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Over the M3 and M4 years, I have been fortunate enough to have published 3 first-author manuscripts from my PhD projects, all of which are on pathophysiological mechanism of heart failure using intact human myocardium. As I look back, it took many hours to submit my manuscripts and revise them based on reviewer comments. However, it never really felt like work for me to engaged in this process.  I have realized that I enjoy thinking about cardiac physiology and communicating my findings in manuscripts. I think it’s also important that I have found time to do so in an efficient manner during my clinical years on rigorous rotations and multitude of assessments.

My goal is to work as a cardiologist at an academic medical center where I can teach students/residents/fellows in the hospital and clinic and produce translational research. I know that time is precious and you have to be able to fit your academic activity into your schedule somehow which may be challenging. During M3 and M4 years, I have learned that I must set aside a concrete amount of time to dedicate to work on manuscripts instead of setting vague goals. Otherwise, I would procrastinate and create more work for myself at the end. Fortunately, I have become more efficient in manuscript writing over the years and have realized you can never achieve a “perfect” manuscript but must do your best to get your thoughts into the paper first and make adjustments after the reviewers have provided their feedback. During residency, I plan on setting aside even a number of hours every week dedicated to scholarly activity with specific goals in mind. As a fellow and attending, I believe that I will have slightly more time to work on projects compared to my time in residency. I plan on staying academically active by making specific goals to achieve for the hours that I assign for those activities.