In the early 1970s, Abbie Hoffman wrote Steal This Book—a manual for survival “in the prison that is Amerika.” It served as a guide for countless revolutionaries who are still politically active today by occasionally swaying PTA meetings, eating Ben & Jerry’s ice cream, and avoiding investment portfolios that include land-mine manufacturers. But to my dismay, while perusing the “First Aid for Street Fighters” section, I noticed Hoffman neglected to offer advice for a student on an internal medicine rotation. To remedy this and to assist my fellow internal medicine revolutionaries, I put together the following guide. Here goes nothing….
When you arrive on the wards, you’ll have to accept the fact that you’re beginning a new life. At first the wards may seem overwhelming. But don’t worry; you’re an infant in the world of clinical medicine, and everyone will be impressed if you can eat, sleep and poop. The important thing is to pay attention, watch what others do, and learn.
Your first breath will begin when you join your team and receive a pager. A pager may seem exciting, but after two days, you’ll abhor it and develop odd beliefs and behaviors. If a pager goes off next to you, you’ll breathe a sigh of relief and say, “That was too close,” as you peek from behind a desk as if there were a page-operator sniper hiding behind a gurney, seeking out new targets. I personally suffer from beeper agnosia, a disorder in which you cannot tell if your pager is going off or if it’s one down the hall. I’ll get paged and just start glaring at people for not answering their calls. Eventually, I’ll look down and see the telltale “duplicate” displayed on my pager’s LCD screen.
As you may know, internal medicine has a number of subspecialties, such as pulmonology, cardiology and rheumatology. If you’re on a service with a specialist, you’ll notice that your resident will present a patient corresponding to that specialist. For example, heart-attack patients will suddenly have elaborate musculoskeletal exams with a rheumatology attending.
You might also discover that more aggressive students (see my column about gunners in the March 2002 issue of The New Physician) will frequently change their chosen specialties overnight to match the attending. For the cardiologist: “Ever since I was a child, I have been fascinated by the heart. The chance to be a cardiologist is what fueled me through medical school.” Next week, with the nephrologist: “The real draw of medicine is the way the body keeps everything in balance. Why is it that the kidneys get so little respect in our society? I mean, all kids learn about the heart and brain in kindergarten, but what’s so great about them compared to the body’s tireless twin filters?”
The first developmental milestone will be the acquisition of language skills. People use newspeak on the wards. You’ll frequently hear such statements as “Did you d/c the rule-out MI in 4007?” The other person will respond with something like, “Nah, they spiked; so we had to get ID involved.” Sounds confusing, but after a few days, you’ll know exactly what this means. The more you abbreviate, the happier your co-workers will be.
It’s also important to remember that other health-care workers don’t have names on the wards. Even if there’s only one orthopedic surgeon in the hospital, her name is “Ortho.” Let’s practice using this naming technique. The proper phrase is, “Did Ortho see our patient yet?” Now you try it. Good. This rule applies to ancillary staff as well. “Social work is trying to find a placement.” “Nutrition wants to know if we can advance Ms. Smith to solids.” Got it? Excellent.
Next, you’ll be taught to walk. Walking involves understanding how to interview, examine and present a patient. You’ll help admit new patients to the floors and then write up histories and physicals, or H&Ps. Your first H&P will probably take four hours, as you interview the patient about his entire life history and then thoroughly test every organ system. No matter how much time you prepare for your first presentation, it will probably go something like this:
“Mrs. Jones is a 56-year-old African-American male. No, wait, a 65-year-old Caucasian female. She fell on her wrist and hurt it earlier this morning. X-rays show a fracture over…uh…. I forgot to write down where.” You’ll go on and offer any details you have at your disposal, including whether her pets received rabies shots, whether Mrs. Jones wears a seatbelt, and, of course, you’ll stress the fact she has no history of military service. After you finish, you’ll quietly berate yourself for forgetting to mention that she was never incarcerated.
Your resident will then look at you and impatiently say, “Is that all?”
At which point you’ll say, “Yes. Oh, wait, she also had really bad chest pain before she fell. She said something like, ‘Oh, no, not another heart attack!’ She also had three heart attacks a few years ago and said she felt the same way this time. And some lab test called troponin and CK were abnormally high, and her EKG showed ST-T wave changes.”
After you learn to talk and walk, then you’ll learn to read. Everyone involved with your patient’s care will place new information in the patient’s chart. Although charts contain all of the details on your patient, you’ll discover the knowledge is locked safely away through encryption techniques of illegible writing that would even befuddle that really smart guy in the movie “A Beautiful Mind.” You’ll leaf through the chart and see page after page of progress notes that look as if the entire hospital staff were drunk off their asses or were riding pogo sticks while writing their notes. Watching someone trying to read a note is like watching an archeologist decipher a lost language. The following is a typical conversation between two people reading a chart:
“Is that Mr. Anderson’s EKG?”
“No, I think it’s surgery’s post-op note. How else would you explain this twin QRS complex after a PVC?”
“I think this is an ID note, and it says, ‘Purpuric rash like elephant skin.’ She must be talking about that thingy on Mr. Anderson’s back.”
“No way; it’s a psych note, and it says, ‘Patient sees leprechauns.’ That word is ‘leprechauns’ not ‘elephant skin.’”
Rather than relying solely on a progress note, you’ll learn to use other parts of the chart like a Rosetta stone to decode the handwriting. “Hmm…. I can’t read this, but GI ordered a HIDA scan. This squiggle must mean ‘rule out cholecystitis.’”
Sometimes a consult will be so illegible that you’ll try to compensate by relying on another service’s exam. “I have no idea what the cardiologist wrote, but the nutritionist thinks Mrs. Smith has an inferior wall infarction.”
During this stage, you’ll also learn the importance of sharing. You’ll hold on to patient charts for long periods of time, and other services will come by and ask to quickly see a chart, put in a consult or write in orders. These interruptions may seem rude at first—like an unexpected trespasser in your bathroom stall—but you’ll learn to use them to find out more about your patient. This is how you do it: Ask who’s requesting the chart and if they have any news on your patient. This will save you the trouble of having to try to read the note later, and the person may teach you something. Don’t forget, if they ask, “Who are you?” the correct answer is “Medicine.”
Once you know how to read, it’s time to learn to run. There is no better way to learn this than staying for an overnight call. During call, a medicine team will sit around and wait for a resident’s pager to go off. In a typical scenario, a resident will receive four consecutive pages. The first will be the ER, with five new admissions that didn’t make it to the other teams before they hastily left. Two or three of these admissions will be critical, requiring immediate tests and consults the ER neglected to do. The next page will be from a nurse telling the resident that two of his patients are crashing. The third page will be from a headhunter desperately seeking new physicians. “Have you ever considered the career opportunities in rural Delaware?” The last will be a nurse from the floors asking if Mr. Adams can have an extra bag of chips.
The team will divide up the tasks and then regroup. The residents will see the crashing patients on the floors and the patients in the ER. You’ll be in charge of the potato-chip dilemma. Give Mr. Adams the bag of chips and be on your merry way. Do not bring up the chip incident unless your resident asks you about it. Otherwise, you’ll spend the night chasing your resident to present Mr. Adams, while your resident is trying to save patients from dying. You would sound something like this: “Mr. Adams is a 46-year-old male with a 25-year potato-chip-bag history. He denies any sexual dysfunction, and he had his appendix removed at age 14.”
Now let’s learn to ride a bike. Medical students will perform dozens, perhaps even hundreds, of rectal exams while on a medicine service. Your resident will send you to perform one, reassuring you it’ll be a great learning experience—as if the wisdom of the ancients were located within the caverns of your patient’s rectum. Let me fill you in on a little secret: Though rectal exams are a necessary part of every H&P, they aren’t fun for you or the patient. That’s why you’re the one stuck doing them.
The motto for all procedures in medicine is see one, do one, teach one. Unfortunately, this method of learning passes down the bad with the good. After watching residents and attendings do rectal exams for an entire year, I picked up the following useful tidbits:
- Tell the patient you’re performing a rectal exam; the element of surprise will not help you.
- Get all the equipment you need before you start. It’s not a good idea to have your patient drop his pants and then tell him to wait while you shuffle off to find gloves down the hall.
- Place lubricant on your finger, but don’t overdo it.
- Tell the patient he’s going to feel pressure, and insert your finger. Feel for prostate abnormalities (in those patients who have prostates), and ask him to squeeze to test for tone. Then get your finger out as soon as possible; do not begin long stories with your hand inside the patient. Offer the patient a few paper towels when you’re done.
- Don’t touch the developer bottle with your feces-covered glove! You will contaminate it for future users and cause a mysterious outbreak of infectious colitis.
- Don’t leave a used hemocult card in the patient’s room. Check to see if the card is positive; then throw it away. They make poor souvenirs at best.
- Return the developer bottle; don’t leave it in the room. If you don’t, you’ll spend half an hour looking for it during the next rectal exam.
Finally, all medical students must learn to fly. Time passes quickly while you’re on the wards. If you’re not careful, you’ll spend all of it at the hospital. Finish your work quickly, and then ask your residents if they need help. Leave when all your work is finished. Others can take care of problems arising after hours. On the flip side, it’s not always possible to leave before 5 p.m. There’ll be times when a patient will keep you on the wards after hours. Never just run out on him or tell him you’ll speak to him about whatever is on his mind tomorrow. Abrupt endings without a sense of closure are never appropriate.
Anyway, that’s all you really need to know. The rest should be a piece of cake. I hope you find this guide useful, and may the revolutionary forces be with you.
Simon Ahtaridis is a fourth-year medical student at Temple University.