On emotional triage (or Internal Medicine: a post-mortem)

Internal Medicine (12wks total, 3wks of each):

Outpatient Lehigh Valley Physicians Practice

Inpatient ECLS-B

Outpatient Specialties

Emergency Department @ 17th & Chew Hospital
Gastroenterology @ EPGI
Nephrology @ Valley Kidney Specialists

Inpatient GIMS-D


Outpatient Lehigh Valley Physicians Practice

My three weeks at LVPP served an excellent springboard into the Internal Medicine rotation. Our first week landed us in clinics around the Lehigh Valley area right before the Interns began, the first year residents fresh out of medical school.

That first week was quiet. The resident-run clinic seemed to limp along with a few follow-up patients for the experienced third-year residents. The calm before the storm.

The second week, I could barely find a place to put my bag and lunch. The fresh interns from around the country seemed more nervous than us third-years. They had to learn the EMR and how to place orders. They had to present to new attending physicians. We just needed to tag along and avoid taking up too much time.

By the third week, we had a solid rhythm going. In the mornings Dr. Dehoff would take us into a vacant wing of the hospital to teach us about EKGs. Then for the rest of the afternoon, we’d latch onto a resident and see patients either before them or with them.

I left LVPP with a solid (but transient) understanding of EKGs. I gained confidence in my ability to walk into a room with a patient and handle the interaction professionally. The rhythm of outpatient medicine felt fast and amnesic: one patient in depth, quickly, and then on to the next one.


Inpatient ECLS-B

This service serves as the meat-and-potatoes of the internal medicine rotation. During this three week block, we are assigned a patient or two a day. Each patient is admitted to the service because of some potential teaching value, usually an extensive medical history to dig through.

With each medication list, the pharmacology of second year comes alive. Someone comes in for a COPD flare while on chronic systemic steroids? They might have a low-grade pneumonia without the obvious symptoms because of the immunosuppression. Watch out for falls and fractures because of the osteoporotic risks associated with long-term steroid use.

Each morning, we meet up with our team of residents for the patient assignments. Then, we are given free reign to roam the fifth floor of the Kasych Pavilion. At nine, we meet up with the attending physician, the residents, and the third and fourth year medical students, for patient rounding.

Sometimes we sit for three hours in the conference room running the list and talking about patients abstractly. Other times, we spend three hours on our feet in the hallways talking about the cases. Occasionally, popping in for a group history and physical led by the attending or third-year resident. Because all the patients are located on the same floor, we are able to choose between walking and seated rounds. And of course, whether we have walking or seated rounds depends on the attending physician of the week.

During these three weeks, I learned the most and the fastest out of the entire Internal Medicine rotation. The attendings rotate with a desire to teach medical students and to foster learning with the residents. Each physician brings a different focus: Dr. Mishriki with the physical exam, Dr. Doherty on the pathophysiology of diseases, and Dr. Costello stressing the importance of medications and their potential side effects.

Additionally, I formed the deepest bonds with patients in this service. During one emotionally draining week, I held two separate end of life discussions with patients and their families. I spent the hour for lunch talking about troubles. I had earnest goodbyes where I expressed gratitude for meeting them and the deepest desire to not see them again, back in the hospital.

Leaving this three week assignment brought me halfway through Internal Medicine. I began to feel like the white coat fits.


Outpatient Specialty

Emergency Department @ 17th & Chew Hospital

A whiplash inducing change of the pace from inpatient to the Emergency Room. Most severe cases are directed to the Cedar Crest campus with the Level One trauma center. So here at the 17th and Chew Hospital, we see few emergencies and many cases that ought to be covered by a primary care physician.

This ER was a bit crowded and oddly designed, probably a retrofit or alternative plan for the space. I had a new attending physician every day of my Emergency Med week. The nurses and techs stayed the same. I became closer with the staff than the MDs or PAs that rotated through the service.

I performed my first DRE and GU exam on true, ailing patients. I swabbed a male urethra to PCR test for gonorrhea and chlamydia. My week wasn’t terribly exciting.

It didn’t need to be.


Outpatient Specialty

Gastroenterology @ EPGI

This independent GI consult and scope firm affiliates closely with LVHN. A common theme with the clinics that I’ve visited: the health network had either obtained outright or developed a strong relationship with small groups throughout the area.

The visits were quick. The physical exams cursory. The patient cases mostly follow-up. A mix of older and younger physicians, either a few years out of fellowship and comfortable in a routine or aged docs nearing retirement. All seemed sharp and intelligent, especially the hepatologist. None seemed particularly inspired. A daily grind with a clock-out.

On my final morning at the clinic, my assigned attending greeted me with a look of ‘Oh dear, you poor thing. Back again?’ and led me through the back hallways of the building at a brisk pace. Eventually winding into a dimmed procedure room with a tech, a nurse anesthetist, a physician with scope controls in hand, and an unconscious woman with the scope in her bottom. My attending passed me off without an introduction and left the room before I could turn and thank him.

Dr. Shah, a handsome brown man with those ageless qualities that could place him anywhere between thirty and late sixties. He introduced himself and the rest of his small team with a blank, focused look that I recognized from gaming. He worked the knobs and dials of the scope controls deftly and managed to hold a lengthy conversation while working the device. His eyes locked onto the screen in front of him, which displayed the feed from the small camera at the end of the scope. The unblinking focus reminded me of looking at friends while they battled a late-stage video game boss.

We talked at length and connected in our love of podcasts. I watched him perform two colonoscopies and one EGD. We parted ways with contact information, myself hoping to interview him in the future for my podcast. Later, I would run into him while out and about in the hospital.


Outpatient Specialty

Nephrology @ Valley Kidney Specialists

My week with nephrologists at the Cedar Crest campus went by quickly. The physicians released me early and frequently. I did not complain. The patients were all older and in various stages of overall health. For the most part, these were long-term follow-up patients with regular bloodwork checks and cursory visits to the clinic.

From a lifestyle perspective, I could see the draw: not very stressful work, simple visits, and good compensation. All of the nephrologists were intelligent. Like the GI docs, they didn’t seemed too engaged with their work. Never negligent. Always doing the work, but it always seemed like work.


Inpatient GIMS-D

Easy to compare GIMS with ECLSB. Instead of the patients all congregated on one floor, this General Internal Medicine Service (GIMS) had patients throughout the hospital and connected only through the sprawling computerized system. We met around 1030 for rounds with the attending of the week. These physicians seemed at the mercy of the almighty phone and pager, with rarely fifteen minutes of uninterrupted discussion or presentation before a phone call that must be answered or a page that needs a response.

Direct teaching sat behind the needs of the patients and the difficulties of running a service that is not bound by proximity. Instead of being able to ask one nurse about three of your patients, a resident might need to talk to four nurses for the details on two patients. When compared to ECLSB, we had few opportunities for the didactic learning sessions from the attending or the residents. Instead, I watched and observed the lives of the hospitalist physicians that juggled a dozen or so ailing patients spread out through the hospital wings. I saw the chaos that somehow cares for hundreds of patients a week, every week of the entire year.

The afternoons were usually free, with the residents releasing us after morning rounds. My first week of GIMS assigned me to night shift. Overall, a much more relaxed experience than ECLSB. No complaints from me, a great way to outro Internal Medicine.


Retrospective

The most important lesson that I learned over the past twelve weeks is emotional triage. During my first rotation at ECLSB, I locked onto a handful of patients and acted as medical student, therapist, nurse assistant, and palliative care consult. The experience was incredibly rewarding but at the cost of emotional strain and drain. I don’t think I could keep that pace and lifestyle up for five days a week, fifty weeks a year, every year until retirement. Either I would burn out and change careers or I would lose that empathy and fail to serve my patients effectively.

I could give each person that waits in a room for me everything that I have. It is much like knowing how to fight or choke someone unconscious: yes, it is a good skill to know and it can grant confidence in everyday situations. And no, you shouldn’t use it often, and the less often you utilize these skills is a sign of control, not weakness. Not everyone is ready to change.

Going forward as a physician, my most valuable commodity will be time. I have the same hours in a day as every other human on the planet, with a good chunk devoted to sleep, food, and transportation. I will have the ability to give a patient my entire day, to hear their troubles and to be present with them during hardships.

I cannot do that for thirty patients a day.

Learning how and when to expend my emotional battery has done the opposite of shut me down. It has opened me up.

Unlike the first few weeks of this internal medicine rotation, when I walk in a room I get a good read of a patient: are they ready for change, where are they emotionally, what do they need from me right now?

People are ready for change when they are ready for change. I cannot make them ready nor can I make them change.

I can only help them to the threshold and await them on the other side.


Long Form Sundays

On Death Podcast

3 thoughts on “On emotional triage (or Internal Medicine: a post-mortem)

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s