Final third year clerkship reflections (Pediatrics, Family Medicine)

Photo from here

I completed my third year of medical school last Friday! I'm so grateful to have made it through the year. What a journey!

The morning after my Family Medicine final exam (on Friday) I flew to Jamaica to visit my extended family and I am here currently. I will post another entry about this trip later.

My final two clerkships of the year were Pediatrics and Family Medicine. Here are a few quick reflections on salient experiences during each rotation:




Pediatrics

During my Pediatrics rotation, I completed 2 weeks of inpatient, 1 week of nursery, and 3 weeks of outpatient. 

Photo from here

While on inpatient, we had a couple of interesting cases, such as a 10-year-old girl who came in with chest pain of a non-traumatic etiology (which you rarely see in a child) and a 1-year-old boy who had eaten some callus remover cream that was left by his crib on a tall bookshelf since before he was born. (Both turned out completely fine).

I enjoyed my outpatient experience, but to be honest I absolutely hated the drive. The clinic was located in Chicago nearby Lake Michigan. It took me at least an hour 15 minutes to get there in the mornings (during rush hour), and it would take at least that long to go back home (during rush hour again). That hour and 15 minutes could have been spent at home studying. On my final evaluation of the experience, I recommended that this site be offered as an option only to those who actually live in the city. Otherwise it's truly a hassle and stressful inconvenience for those living in the suburbs.

Photo from here
The poor baby's rash looked a bit worse

During my second week of outpatient, I had one experience that taught me the importance of confidence during patient encounters. A 6 month-old boy came in with his parents who were freaking out (more so the mom) about this terrible, ugly rash all over his body. It was dark red, blotchy, mostly in the neck region, but also in the popliteal (back of knee) and antecubital (in front of elbow) fossas. The baby was as happy as can be, smiling, playful, and looking up at me with curious eyes, but the mom continued to freak out. By the end of my questioning I couldn't quite pinpoint why the baby's rash looked so terrible. They tried using a number of different ointments and creams, but none of them worked and they must have worsened the appearance of the rash. The mother suddenly straight up asked me, “What do YOU think this is?” So, sucking at peds derm, and not knowing what this was, I piggy-backed off of what the ED (emergency department) docs said when the patient first presented to the ED a week ago. It was a candidal infection. My attending confirmed this, and we prescribed an anti-fungal ointment.

I was hard on myself after this encounter. I mentioned the ER doctor's note but ended up deferring profusely to my attending because I had no idea what this rash was. (On the Step 2 CS boards exam we simply cannot defer to a superior or we will fail. In real life as an attending you also obviously cannot defer, so I've been trying hard these last rotations to stop doing it often). In a lot of cases, however, I feel that I speak intelligently to patients and share my knowledge and understanding of their concerns. I will, however, continue to defer to superiors if I have no idea what the answer is. I guess the big message here is that I need to stop doing it eventually. Once we are attendings we can’t defer to anyone (except maybe another specialist).

Family Medicine

While on Family, I completed 6 weeks at another site about 15-20 minutes away. This was my best rotation for the entire year. I'm not kidding. What a great way to end the year. The attendings and residents (and even the medical assistants!) were passionate about teaching, and they always seemed excited to have me there. Excited to have ME, a lowly med student. I truly felt valued on this rotation. It seemed that the friendliness of the teams improved throughout the year, and I could feel myself becoming happier as I moved from one rotation to the next. (I had Surgery first and ended with Family).

We saw a number of super interesting encounters, many of which I documented in a required "critical incidents log" due at the end of the rotation. Our clerkship director wanted us to jot down a couple of sentences of reflection for a couple of salient experiences each week. I couldn't help myself and documented paragraphs for each encounter. If I am asked to reflect on something I take that seriously. This whole blog is a reflection in itself.

I will just mention one of these encounters here:

One day a 40-year-old woman with a history of autoimmune hepatitis came in for a follow-up after starting a new medication that her hepatologist prescribed. Initially, she was prescribed something else, but that medication caused her to experience violent nausea and vomiting. She was then switched to this new medication, but the day after starting it, she began to complain of bleeding from multiple orifices - her left eye became bloodshot red (which prompted her to see an ophthalmologist that same day), she had a few nosebleeds, and she was experiencing bloody stools. Her primary doctor (the PGY3 resident I was working with) instructed her to stop the medication, but her hepatologist told her to continue taking it. She and her husband were confused. Feeling strongly that the medication was causing her to bleed, they heeded the resident’s advice instead and stopped the treatment. Immediately the day after she stopped it, the symptoms disappeared.

Doctor ignoring patient
Photo from here

Her hepatologist continues to insist that the medication was not causing the bleeding. The patient had been seeing this hepatologist for a long time, but she and her husband were growing frustrated with his care. After every visit with him, they left his office confused and unsure about what was even discussed. The patient also mentioned that she feels more clarity about her autoimmune hepatitis after her visits with the family medicine resident than with the hepatologist himself. By the end of this visit, I grew angry for the patient (maybe even angrier than she was). We all agreed that the hepatologist’s quality of care was terrible. His communication with the patient was poor. During their visits, he barely looked at her and her husband. He proceeded with a number of lab tests and workup without even clearly explaining to the patient what he was doing and why he was doing it.

By the end of the visit, I was more than annoyed with this specialist after hearing about what he put the patient through. When the family medicine resident spoke with one of the attendings about this case, the attending mentioned that physicians should never forget the three A’s: availability, affability, and ability. Medicine isn’t just about doing tests and diagnosing patients. It is a human profession. We need to know how to carefully, articulately and compassionately communicate with our patients. In my opinion, if any physician is not doing this, quite frankly he/she should not be in medicine. It does not matter how much knowledge they carry. The knowledge is important, of course. I am not minimizing that. I believe, however, that it is more important to have interpersonal skills and to take care to communicate with patients in such a way that they understand the next steps in their care.

This was my most recent salient encounter in Family Medicine and it left an indelible mark on me as I progress through my training.

Thank you for reading! :)