Since my last entry, I've completed the Internal Medicine, Psychiatry and Obstetrics & Gynecology clerkships. I will do a (somewhat) brief reflection for each. Currently, I am on the Pediatrics clerkship and will end the year with Family Medicine.
Internal Medicine
On IM, I was excited to pre-round on and present my patients every day. I woke up every day at 4AM and arrived at the hospital at 6 to pre-round. We usually rounded as a team with our attending at 8 or 9, and afterwards we'd spend the afternoon calling consults, following up on labs/imaging/other orders, and attending lectures.
One of our most interesting patients was a middle-aged woman who was a direct admission to our service from her primary care physician. She presented with intermittent episodes of confusion. These episodes of confusion were really interfering with her quality of life. She would forget where she even was sometimes and what she was doing there (i.e. in the passenger's seat of the family car, at family events, and even in her doctor's office during a visit). She had a history of hypothyroidism, multiple vascular risk factors, heart failure, and many other things. Now she was found to have elevated levels of ammonia WITHOUT liver disease or medication use, two things that would most commonly cause hepatic encephalopathy. She’s a very interesting case. When the senior resident did a physical exam, she had very obvious asterixis (subtle flapping of the hands when the arms are held out in front of the body; indicative of elevated ammonia levels). We initially sent for a liver ultrasound, but that came back normal except for some heterogeneity (which means some fat), but nothing serious.
So after much more workup and everything coming back negative, we then considered a genetic cause of her elevated ammonia levels. One of the neurology attendings wanted to send for a work-up of OTC (ornithine transcarbamylase) deficiency, an enzyme in the urea cycle. Usually these urea cycle enzyme deficiencies present early in life, but in rare cases they can present later on. Call me a weirdo but this got me excited. I mean, I felt terrible that our patient was so distressed about her medical issues, especially this relatively new one now of confusion. We had no idea what was going on with her at the time, but I have to admit that the mystery of her condition had me enthralled. (Months later we learned that her hyperammonemia was due to a splenorenal shunt, which had not previously been seen on imaging).
One other thing I loved about Medicine was the opportunity to interact with and speak to so many different teams in the hospital – physical therapy, social work, nursing, other medical specialties, nutrition, speech pathology… I truly enjoyed getting their perspectives on the patient because we all bring our own expertise and skillsets to the table.
Psychiatry
Psychiatry was my most relaxed rotation. It was nice because I was able to accomplish quite a few of my personal goals outside of my clerkship duties (i.e. preparing to apply for away rotations, reading for pleasure, working on research projects, setting up meetings, etc). At times, though, it was a little annoying because it was such a drastic change from the fast pace of Medicine.
I enjoyed speaking with patients about their mental concerns. I saw patients with schizophrenia, bipolar disorder (and having active manic episodes), major depression, suicidal ideation, and much more. Psychiatry isn't heavy all of the time though. My attending and I had a few humorous encounters on the consult-liaison service at the VA hospital. One of these encounters is described below:
One of the general medicine teams consulted us because their patient, Mr. J, an older white man with a history of bipolar disorder, reported sleeping only 11 hours in the past 9 days. He was also found wandering into other patients' rooms and trying to initiate a conversation about Jesus. When we spoke with Mr. J, he said that he felt energetic and "alive" without sleep. My attending replied, "Well, Mr. J, you won't be alive for much longer if you continue to deprive yourself of sleep." Mr. J was sitting on the edge of the bed and listening to my attending. He had very dark circles and swelling around his eyes, and he was easily distracted during our discussion. He spoke with a strong Chicago accent. One moment we were speaking about adjusting his medications, and the next moment he started singing a song about red balloons. Our encounters with Mr. J were always entertaining, and oftentimes I had to refrain from laughing out loud at his antics and jokes. At one point in the discussion, Mr. J tried to defend his lack of sleep: "Albert Einstein was a genius, and he only got 4 hours of sleep in one YEAR." Mr. J spoke strongly, but one could tell that he wasn't completely serious; he had a little smirk in the corner of his mouth. I couldn't help myself. I was standing off to the side and tried to hide my laughter, but I couldn't suppress it any longer. My attending started chuckling as well, "I'm pretty sure that's not true...No, I'm certain it's not. It's impossible." We shared a few more laughs before finalizing the changes we would make to his sleep and bipolar disorder medications. His sleep improved over the next few days.
I enjoyed the Psychiatry clerkship overall and I have a newfound appreciation for this field, but I
don’t know if I can work with depressed, schizophrenic, anxious, and suicidal patients
for the rest of my life. The things we talk about with these patients
(i.e. suicidal ideation, abuse) are very heavy, and I don’t know if I can
take that home with me every day. I felt sad a lot on this rotation. It pushed me to reflect even more often than I normally do.
Obstetrics & Gynecology:
The six weeks I spent on the OB/GYN rotation were quite interesting and unlike any other specialty we are required to rotate through. The six weeks are divvied up into three 2-week assignments.
I spent the first two weeks on the Benign Gynecology service. Here, we saw the "bread and butter" of OB/GYN: conditions such as endometriosis, pelvic pain, dysmenorrhea, fibroids, etc, and surgeries/procedures like hysterectomies (removal of the uterus), myomectomies (removal of fibroids), and dilation and curettages (aka D&Cs, which were often done to remove fetal tissue from the uterus of a woman who had unfortunately suffered a spontaneous abortion). Many more conditions are seen and procedures done; this list just scratches the surface.
I spent the next two weeks on the Ambulatory service. I attended different clinics which consisted mainly of routine gynecology and obstetric visits. I did see a few interesting cases, such as a Bartholin's cyst on a woman's labia minora that would soon undergo marsupialization (a special procedure to ensure that the cyst would not recur). I also saw a woman my own age who was recently diagnosed with hypothalamic secondary amenorrhea. She didn't have a period for the majority of her life, and only recently underwent a workup for her amenorrhea. All imaging and tests did not find any abnormalities, so she was given this diagnosis of exclusion: hypothalamic secondary amenorrhea. Currently, she is taking birth control pills which help stimulate a normal menstrual cycle for her.
I spent the last two weeks on the overnight Labor & Delivery service (11PM-7AM). It was tough adjusting my sleep schedule, and to be frank, I hated the hours. Things were pretty slow, and I only saw one vaginal delivery and one C-section for the entire two weeks (the other medical student also saw one vaginal delivery and one C-section).
I enjoyed helping with the vaginal delivery though. The patient was in her late-20s and having her first child. Her husband was at the bedside whispering words of encouragement into her ear as she screamed with each contraction. The delivery room was crowded with several nurses, two residents, the attending, myself, and the patient's husband. The patient initially struggled so much with pushing that our attending wanted to proceed with a C-section. I didn't want the patient to have a C-section. She was only 28 years old, having her first child, and yes, she may have been bad at pushing but she just needed more encouragement. She didn't need a C-section and its associated complications in the future. I then personally assumed the responsibility of making sure that our patient would have a vaginal delivery.
During the next contraction I yelled, "PUSH, Mrs. C, you can DO it!" Everyone stared at me. The nurses weren't as loud as I was, and the husband was simply whispering in her ear. I was holding her left leg.
"AGGHHH!" Mrs. C responded to my shout with a huge push.
"Good!" Our attending said in surprise. "Make the rest of your pushes exactly like that one!"
"Take a deep breath, and push again, HARD this time!" I yelled. "YOU GOT THIS!" I probably sounded like a maniac but I didn't care. Mrs. C was responding well to my shouts, and the baby was on his way out into the world.
We continued like this for a bit longer until the baby boy finally popped out. He was immediately given to the Pediatric team. My resident then fanned me over to deliver the placenta. It was incredible.
This past Easter weekend I went to Philadelphia for the American Medical Education Conference (AMEC) through the Student National Medical Association (SNMA). It was a perfect networking and professional development opportunity. The mission of SNMA is to support and promote the advancement of black minorities in medicine, but it is not an exclusive organization. It just so happens that the majority of attendees at AMEC and members of SNMA are African-American students, residents, and attending physicians.
