My first rotation, Internal Medicine at QHC, went very well and was beneficial in my comfort around patients when taking a history, performing a physical exam, and interpreting imaging & lab results. This rotation also made me feel comfortable as part of the patient care team, at the onset I felt as though I did not belong but by the end this proved untrue. I really enjoyed my time on the internal medicine floor due to the team-based care. Attendings, interns, and residents gave great feedback and provided a great environment for learning. Unfortunately there are no PAs working on the internal medicine floor at QHC, it would have been an extra benefit to see the exact role of a PA.

I was assigned to the silver team. I really enjoyed working with the multidisciplinary team, which would include: attending physician, resident, interns, pharmacist, social worker, nurses, multiple medical students, and 1 PA student. It was great to have a team that included pharmacist, social worker, and nurses when discussing all patients. This made sure that everyone was informed about each patient and on the same page regarding treatment and plan. The concerns of the entire team were always taken seriously and addressed, if the pharmacist felt that a treatment was not optimal then it would be reevaluated, if the social worker felt that a patient was not ready to be discharged or needed other types of services then they would be provided. The team worked really well together and trusted that each part was looking out for the best quality of care.

The attending physician rotates every 2 weeks, so I learned from 2 different attending physicians during the course of my rotation. They both had different styles and different expectations for their students. It was great to learn from different people and see how much I learned from each even in a short span of time. With the first attending we did not round at bedside, the team would go see our patients in the morning then he would come in the afternoon for us to present and discuss the plan. With the second attending we would almost always round bedside and present in front of the patient. This was very nerve-wracking at first. I am used to saying what I find during the exam but to do the entire case presentation including assessment and plan was a whole other animal. After doing it in front of the first patient on our first day my perspective completely changed. The patient actually liked it more and they felt like a VIP, they had a team of 8 people come to their bed to hear just about their condition and examine them. Obviously all patients did not feel the same way, but a lot seemed to like it more because they felt cared for and also were part of the team for that moment in control of their medical decisions and outcomes.

One of the most beneficial parts of the week were morning meetings before going to the floor. At these meetings the residents would discuss all of the newly admitted internal medicine patients of the day across all teams. One of the chiefs would run the meeting to provide insight and feedback about the cases. He would also educate about different tests and disease states, or tell us how medicine is very different compared to when he was a student. These meetings were a great way to start the day because we would always learn a lot and get a quick preview of which patients we might see that day. One of the first morning meetings we had there was an admit for heart failure exacerbation, the physician went through the list of medications to see whether the care provided outpatient was sufficient according to the guidelines. The doses and medications were suboptimal for systolic heart failure. Even though this patient was not admitted to the team I was with, I will remember how to manage systolic heart failure going forward due to this 1 patient discussed at the meeting.

There were a few memorable patients that I hope I learn from and remember as I continue my education. One in particular that sticks out is a person in their 50s who has neck cancer. We received the patient from the ICU, so while their condition wasn’t currently critical they did not have a good prognosis. The family came in for an end of life discussion with the attending and showed a photograph of the patient from just 1 year earlier. They looked fit and healthy, if I didn’t know the situation then I would not believe they were the same person. The patient had their tongue surgically removed as part of the cancer treatment and couldn’t speak, their body was breaking down from the cancer, the treatments, and from disuse. The patient communicated by writing and kept writing that they just want to go home. The family wanted them to stay in the hospital to continue treatment. I don’t think I’ll ever forget this family that was still holding out hope that their parent would get better and walk home, or the patient that just wanted to go home and spend the end of their life surrounded by family instead of in a hospital. I hope I remember not only the patient, but the tact used by the attending and the entire team when discussing end of life with the family. They wanted to be as honest as possible without destroying any hope, is there a right way to tell someone that their parent is dying? They were discussing DNR/DNI and it became clear that the family thought that meant to completely stop caring for the patient, one of the residents spoke the same native language as them and explained it in a way that helped them to better understand what DNR/DNI included.

One place I definitely need to improve is to do more procedures. The way that the internal medicine floor works at this facility doesn’t leave a ton of opportunity to draw blood or place IVs. Morning labs are often drawn at 5AM by a phlebotomist, and IVs are often placed in the ED before the patient is admitted. There were times when we needed stat or repeat labs throughout the day which allowed me or another student to draw them and bring them to the lab, but this was not a daily occurrence. The procedure that I did fairly often was a COVID test via nasopharyngeal swab. Any patient that was transferred to another facility or lived in a group setting would require a negative COVID result before being transferred. Moving forward I plan to try and see more patients as their initial interaction, and to do more procedures when appropriate. My next rotation is OB/GYN at Woodhull which should provide me the opportunity to do procedures including but not limited to blood draws, speculum exams, pap smears, etc. I hope to learn from a provider who will show and teach me how to do these procedures in a way that is both effective and comfortable for the patient. This is a very sensitive exam and field, and a field that I am completely unfamiliar with. When asked to do something I plan to say yes and learn how. For me, the best way to learn is to be hands on. I am looking forward to learning a lot of new things during my next rotation.

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