My Medicine Clerkship: First Impressions

Day 3: Still feeling overwhelmed.

I'm spending the first four weeks of the clerkship doing "inpatient" at a Veterans Administration (VA) hospital in the suburbs. A brief description of the way this hospital works:

• There are four 'general medical wards' teams (Teams A, B, C, or D) and two 'CV med' teams (Cards 1 and Cards 2). I'm on Team A.
  
• Each ward team is comprised of an attending, a resident, two interns, and one or two medical students.
• Call is taken as a team q4 ('q4' means every 4 days).
• 'Short Call' means that the team admits new patients until 12:00 pm. It caps at four patients or up to 6 night float admissions on a busy night.
• 'Long Call' means that the team admits from noon until 10:00 pm. Long Call caps at 10 patients. The Long Call team must remain in house until 10:00 pm, except on Fridays, during which the team admits overnight until 8:00 am Saturday morning.
• The pour souls on the CV med teams are on call q2 (every other day). Ouch.

An intern is someone who just graduated medical school, Post-Grad Year 1 (PGY-1). After that year, in internal medicine, they're referred to as residents: junior resident (PGY-2) or senior resident (PGY-3). Once the residency is completed, the physician can then be referred to as the attending physician. I think. These things aren't very clear to me.

Anyway, I meet with my team for Morning Rounds. Basically, the intern (or medical student) presents in about 2 minutes or less any updates regarding each patient and it sounds something like:
"Mr. Smith is a 76-year old was admitted to the emergency room at 11pm last night complaining of shortness of breath. He was first diagnosed with COPD 10 years ago. His history also includes Obstructive Sleep Apnea (OSA) and seizures. The symptoms of dyspnea improve when the patient sits up and breathes through pursed lips. The patient is compliant with his medications, but not compliant with his C-PAP device. His hematocrit this morning is 58.1, his blood pressure is 98/57, his pulse is 85, respiratory rate 20, and O₂ sat is 92%."
The team then agrees on a plan.

What's striking to me is how young the team is. The resident leading the team is only starting her third year after graduating medical school. The people doing most of the scutwork are the interns (with some help from the medical students, who - between you and me - are still pretty freaking clueless at this point). Remember, like 6 months ago, the interns were still in medical school. Does this scare you? It really shouldn't - every case is overseen by the attending physician, who has tons more experience.

*******

I spent five years in graduate school, so much of the material I learned in Biology of Disease is a distant memory. It's starting to show. I was asked several questions today by the attending physician, and I think I fell short of satisfactory. Some questions regarding the incidence, presentation, and prognosis of cancer of the esophagus.
Incidence is about 1 per 20,000 people. Usually, when esophageal cancer presents in the clinic, it's in its later stages, so the prognosis is relatively poor: 5-year survival rate is between 5 and 14%. With metastasis, it's around 2%.

Another question probing whether I understood the mechanism behind the hyponatremia of one of the team's diabetic patients. I couldn't remember.
Our patient's blood glucose levels were beyond the range of the instrumentation, above 600 mg/dl. To put it simply, if you remember your high school chemistry, the increased sugar concentration in the serum results in hyperosmolarity, causing water to be drawn out from within cells. This dehydrates cells and also dilutes serum sodium.

I think the attending gave up asking me questions at this point. Boy...I've got some serious catching-up to do in the next few weeks.