18 weeks of practice

It’s the beginning of my fourth year of med school and I just finished my four-week sub-internship rotation in Internal Medicine. The rest of the year is filled with mostly research, random electives, applications, interviews, and unscheduled time. Thus, I’ve had an uncomfortable realization: this is it. This is essentially as mature as my medical understanding will be before I get “MD” stamped behind my name in June.

That’s so scary. That’s so weird! Next year, my job will be caring for inpatients on the general medicine floors and the intensive care unit. Yes, I’ll have supervision, but starting from that very first day I’ll be managing the lives of very sick people. Whoa.

Do you know how much experience I have doing that? Just 18 weeks. 18 weeks of managing inpatients, that’s it. It amounts to helping care for 70-80 patients, plus maybe 200 others that I’ve followed indirectly. And I’ve never worked in an ICU. Even if I add the 32 weeks in the ORs or clinics or psych, it doesn’t sound like enough, does it…

Here’s the thing about med school and Internal Medicine in particular: we’re so disconnected from the patients we’re purportedly treating. I think 50% of the day is spent sitting in a cramped workroom prodding at the electronic medical record (EMR) on a computer. Phlebotomists draw the blood, lab techs run the tests, and results pop up on the EMR. Patient transport whisks around patients, techs perform studies, and consultants transmit reads through the EMR. When we put in orders, we do it by prodding the EMRs, then pharmacists arrange treatment and nurses deliver it.

Another 30% of the time we spend “rounding,” which boils down to deliberate academic discussions about our patients. Rounding is valuable time, for sure, because that’s when we make the actual medical decisions. However, in the age of evidence-based medicine and defensive medicine (i.e. against litigation), it feels so much like knee-jerk reactions to numbers. Kidney injury -> order hydration. Heart failure -> order diuretics. Chest pain -> order EKG plus meds. To facilitate this, we often wheel along a COW, or a “computer on wheels.” That means more EMR prodding!

That leaves that last precious 20% of time that we spend with our patients. Sadly, even the medical interviews we perform feel redundant. By the time they reach the medicine floor, they’ve been interviewed by nurse triage, the ED resident, the ED attending, and specialty consultants. The last holy ritual in medicine we have — the physical exam — matters so little in the hospital. No one these days would treat abdominal tenderness without a scan. Cardiac murmurs on auscultation mean nothing until verified by an echocardiogram. When someone complains of shortness of breath, we auscultate their lungs, and then we order an x-ray basically no matter what we hear.

And one more thing. OMG the people we see are so sick. Sometimes I forget how skewed my sample is, but there are so many selection filters. The healthy and the mildly ill go to clinic, the ED sends away the non-urgently sick, and the downstairs floors manage the straightforward cases. That leaves the sickest of the sick for us on the gen med floor.

Doesn’t anyone else get frustrated by this? This apparent mindlessness of these occasionally fruitless medical battles? For 18 weeks I’ve been trained to flounder on the EMR and what do we actually accomplish?


Wait, let me take a step back.

First of all, my cognitive biases make me remember the frustrating minority of patients. For most, we treated them, they got better, and they went home, and that’s why they’ve drifted out of my memory.

The super sick are the precise reason why we’re here. That’s why we train so hard. That cursed EMR is the best we have to coordinate our fantastically multifaceted healthcare apparatus. We round for hours to ponder the interactions between their multitude of medical problems. In debilitated patients, existing symptoms confound new complaints, and when any additional insult can tip them over the edge, we diligently investigate everything.

And who am I kidding, medicine is far from mindless. We’ve built a repertoire of thousands of knee-jerk reactions, and we try to check each decision in a vast web of intersecting considerations. We learned the realm of medical possibility to direct our queries of medical literature. We trained to be able to “eyeball” patients: one glimpse at a patient from across the exam room and we can prioritize between them and tasks for eight other patients. And we practiced doing all that when stressed, scared, and sleep-deprived.

I suppose the temptation to dismiss all that thinking as mindless indicates that med school has succeeded in educating me, huh. Next year, I won’t be frightened by the high stakes, scared of the workflow, or intimidated by medicine in general. Maybe those 18 weeks on the floors (+32 other weeks) taught me what I needed to learn after all.