When is too much really too much??

When I was a medical student, I felt that my "job" really consisted of 2 things. 1) I was responsible for talking to a patient. Getting to know them. Taking a great history, doing a full physical. Trying to gather EVERY single little piece of data possible to try to figure out how our team could possibly help this person suffering from whatever ailment they would have. 2) I would put the above information together, and come up with a differential diagnosis, diagnostic studies, labs that needed to be ordered, as well as come up with a treatment plan based on what I've learned in the countless hours I've spent reading books, notes, journal articles, etc. What I never really had to do as a medical student was actually IMPLEMENT most of what I would write down as my plan. We have the luxury of putting all types of treatment, no matter how invasive or possibly unnecessary it was. All it was for us was a learning experience, and it was to help us think of all the possible options.

Now as an intern, things are definitely different. First thing is, I don't have NEARLY the amount of time I used to have as a medical student to spend time chatting with my patients, gathering every piece of information I could possibly gather, and doing a COMPLETELY thorough physical exam. Of course, I will get as much history as I can, especially the information that would be pertinent to the case, and I do a complete physical, but focus it primarily to those organ systems involved with the disease process for each specific patient. ll of this while being paged by the nurses that someone's heart rate is in the 150s and someone else's potassium is too high. Then comes the diagnostic imaging, labs, and treatment plans. Cost is now something that I need to think about too. Before, it didn't matter what I wrote on the chart really, but now, when I order something (radiology, blood work, etc), someone's got to pay for it. This makes me think of the best approach to take, without wasting resources to come to a diagnosis. As for treatments, some patients should not have the most invasive procedure available just because it's an option, but rather based on each clinical situation.

Case in point. I will change some of this information around so that I don't violate any HIPPA rules here. Plus, I'll be vague. A patient that I'm following is nearly 100 years old. Although there are medicines that treat his/her condition, he/she seems to be failing these treatment options currently, and I'm starting to feel like I'm not getting anywhere. I've spent HOURS researching his/her disease, coming up with treatment options, deciding what path is next, discussing the options with my resident and attending, and even the patient's family. Of course, there is some definitive treatment, BUT it's highly invasive and for this patient, it just may not be appropriate at 100 years old. Plus, there is the whole issue of DNR/DNI. As a medical student, we learn about these ethical issues, but we don't need to actually DEAL with them. Now, I'm being faced with making some decisions of whether taking more invasive routes with this patient is really worth the risk. Of course, as an intern, I'm NEVER left alone to make these kind of decisions (THANK GOODNESS!!) and I have an extremely supportive resident and attending to help in this process.

The question becomes, when do you just cut your losses and decide that enough is enough?? Is the right thing to just try and manage this patient with medicine, despite the fact that it hasn't worked as well as we had hoped so far, and just see what happens? Also, there's the issue that the LONGER a patient like this stays in the hospital, the more likely they are to get sick with some kind of infection, pneumonia, etc.

Needless to say, this patient is very cute at around 100 years old. I've had this patient since my first day on service as a real doctor. Losing him/her would probably be a big blow for me, considering how much time I've invested in the treatment, planning, discussions, and research for the best option available to him/her. Our team is doing our best to help this patient get back to him/her previous status, but it seems like a rough road so far. We'll just see what happens....

And in response to the comments left by Paul, I am VERY careful when I cross the street at Brookline and Longwood :) I find that despite the "walk" signal across the street from me, I still dodge traffic every time I cross the street! Also, yes, the CIO must be great!

First Day of Work!

Wow! That 3 letter word just about sums it up. What an experience! Being an intern is extremely different from being a medical student. People actually EXPECT you to DO stuff for them, like give pain meds, talk to families, etc. Things that medical students weren't paged for before.

That being said, my first day went by great! I have a phenomenal resident who took the time to sit down and go through EVERYTHING with me. Everything from how to use the computer, manage my time efficiently, and even what to say/do for the pages I got as the cross-coverage intern (covering other teams patient's after they left since I was on call). Surprisingly, we made it home by 11 PM, MUCH earlier than expected. I even ended up doing 2 admits, AND two discharges along with all the other work for the day!

Some things of note.
1) The computer system is AMAZING!! Everything is efficiently at your fingertips. All the systems seem to complement each other, data is constantly saved, and putting in orders for your patient are easy as a few clicks. Even printing out prescriptions is automatic, I just click the print button, and sign away!
2) Ancillary and nursing staff are second to NONE! They truly are the backbone of this hospital. If the physician wants ANYTHING done, he/she can put the order in, or tell the appropriate person, and it's DONE! This is definitely something that wasn't as easily done back down south. Although, of course, this has something to do with personnel staff, and sheer numbers of them.

Well- apparently internship also causes a person to not be able to complete posts!! So now, I've basically gone through a whole cycle on the wards, gotten a better grasp of the computer system, and trying to improve my clinical knowledge!

Some interesting differences between my new hospital vs my old is the way the teams are made. At my medical school, once a patient is admitted to a hospital inpatient service, that patient is now the patient of the ward attending. All the residents, interns, medical students, etc all work with only that ONE attending on the service. This makes things much easier. My understanding was this hospital that I am currently at was more or less like that system as compared to an older system where many different attendings could admit to a ward service. I guess my assumption was incorrect. Although MOST of the patients on our service does get covered by our firm attending, despite them having an outside physician, there are still some patients who are followed by an outside attending which means I've got to call them and inform them of the status of their patient. THAT'S annoying. I don't feel like I'm learning much on those patients from the attending. I'm teaching myself about those patients and their conditions, and of course my superb resident who is also a great teacher teaches me as well.

Oh, one last thing, the upper level residents I've worked with so far are AMAZING! Their clinical knowledge is phenomenal for their level of training... I am very impressed. And, this also makes me hopeful that one day, I can be like them!

Hello Bean Town!

So I'm finally here! It's definitely been a huge adjustment to move up here from the south. First thing to note is... last week, on thursday, it was in the upper 50s!! For the middle of June, that's downright insane! And, of course, I don't have any clothes for that kind of weather with me here such as a light jacket... oh well. It's better now.

Living in the city has been great. To be able to walk everywhere, use the T, and to have the whole city just under your fingertips is absolutely amazing. What a great concept! Of course, being a southerner, I could not part with my car so I've left it with family in the suburbs. Although I don't expect to use it much, when I do, I will be grateful to have it and not rely on public transportation to take me from state to state.

The hospital is amazing. That being said, the whole medical/academic area in Boston is amazing! To have that many hospitals, higher education schools, and research centers jammed into a 3 block area is fascinating. The work that comes out this area is simply phenomenal, and blows my mind away. The hospital itself is impressive. Although they are older hospitals, there have been many renovations, new buildings, improvement, and countless pieces of technologies built into the system that makes it truly a first class hospital. Everyone that I've met so far has been very nice, welcoming, and seem to be great people to work with. Although I haven't actually started working yet, that will start this coming weekend.

My apartment is perfect from the hospital. Less than a 10 min walk! Now THAT'S a novel idea. I would never have had that luxury in Louisiana where I had gone to medical school, or even to the ones in New Orleans. Living within a 10 minute walk of either location is probably not the safest places to be. To make things even better, at nights, I can hear the crowd at the Red Sox games!

Well, that will conclude this post for now. I will add more as we get deeper and deeper into the hospital and orientation wraps up. Oh, just a side note, we have been asked to choose our "benefits" package. For me, this is a first. I've never held a job where I've had to do that... what a strange concept! It REALLY is a REAL JOB! Which also means, I've got to become a REAL doctor soon enough!!!