Internal Medicine (IM) was my 3rd rotation! IM is known for being the one rotation where you can do the most as a medical student. It’s also notorious for long rounds, long problem lists, and long hours. But for me, it was my favorite rotation and currently what I’m interested in!
Schedule
- Hours on inpatient team 6 days a week
- 06:00am to 07:30am: Chart review, pre-rounds
- 07:30am to 12:00pm: Rounds
- 12:00pm to 12:30pm: Lunch
- 12:30pm to 07:00pm: Write notes, answer phones, check on patients, new admits, obtain collateral/update family, study
- Hours on inpatient geriatric consults 6 days a week
- 07:00am to 09:00am: chart review
- 09:00am to 10:00am: table rounds
- 10:00am to 1:00pm: rounds with attending and team
- 1:00pm to 1:30pm: lunch
- 1:30pm to 5:00pm: write notes, call family/obtain collateral, study
Daily Duties
- Pre-round on our own or with intern, 2-4 patients (for those unfamiliar, pre-rounds is when we review vitals, labs, PRN meds given, overnight events, and then go see patient, perform focused interview and exam)
- Our patient list on Inpatient was about 8-10 patients
- Our geriatrics consults was BUSY! Our patient list was always 15-20 and at one point we had 24 patients. I carried about 4-5 patients, but it is also a consult service which means we are not their primary team.
- Rounds with attending and team, present our patients (rounds is when we go see the patient as a whole team)
- Write notes on patient encounters, obtain collateral information/update family, answer phones from nurses/specialists/other healthcare members.
Reflections
What I LOVED!
- Jack of all trades!
- Internal medicine (along with family medicine) is a specialty where you need to know a little bit of everything. During my pre-clinicals and throughout my rotations so far, I’ve found that I just love everything!
- Complexity of patients on inpatient setting.
- I liked inpatient way more than I thought I would! Although patients are much more than their disease, it’s still intellectually stimulating to see how diseases grow so complex. It’s always a challenge when you have to figure out how to treat a patient with 5 or more problems while also considering their age, complications, socioeconomic status, etc.
- Being the primary team for the patient and helping patient make the decisions.
- In the outpatient setting, internists are often the primary care providers (unless they sub-specialize, which they would become specialists e.g. cardiologists).
- While some believe that internists in outpatient settings simply refer patients to specialties, it’s provider-dependent. Some will only refer if they need a specific question answered or a specific service/procedure done. Others consult or refer patients only if they need additional expertise to treat a patient adequately (this is how it should be in my opinion!)
- Similarly, in the inpatient setting, consults are done if a certain service is needed, if a provider requires more knowledge to treat a patient with a complex condition, or if a provider simply prefers the specialist to handle certain conditions of the patient.
- Ultimately, in both the inpatient and outpatient setting, the primary care team is the primary team that decides what is best for the patient and presents those options to the patient, which means recommendations that specialists give may or may not be followed.
- Time spent with each patient is much longer, but again varies by attending and by setting.
- Inpatient lists are often 8-12, however rounds are often 4-5 hours! Some patients only take 5-10 minutes to see, while others may take 30-40 minutes if goals of care conversations are being held.
- In outpatient setting, you see about 30 patients a day more or less.
- Continuity in outpatient setting.
- Although I was not on an outpatient setting, I’ve experienced the outpatient setting before. As a future internist, I’d like to practice on an outpatient basis as well because continuity of care is something that is important to me.
- Chronic disease management, a thankless job, but one that can save patients from the leading causes of death in the United States (heart disease, lung cancer, chronic lower respiratory diseases, stroke).
- In an ideal world, we would have less need for surgeries and procedures if only chronic disease was managed better in this country.
- It’s understandable why many students do not find chronic disease interesting. It’s already been extensively studied, we know a lot about it, which makes it far less interesting than rare diseases or cancers that require complicated surgeries.
- But that’s why I say it is a thankless job because many people do not realize the larger picture. Chronic disease management if perfected could eliminate so much of the leading causes of death in this country, save our country a ton of money, reduce our reliance on procedures/surgeries, and encourage a more prevention-focused healthcare system rather than a problem-focused one.
- Being the patient’s constant and having the privilege to know them the best, potentially for the rest of their life.
- Goes hand in hand with continuity of care, but I think it’s a privilege for primary care physicians (PCPs) to have the ability to know the patient inside out. PCPs know their social histories, mental health histories, and medical history, which means they are most equipped to know what treatment plans suit the patient’s preferences and needs.
- No surgeries and minimal procedures!
- Compared to surgical specialties, Medicine is a LOT of critical thinking and problem-solving rather than skills and hands-on work.
- Personally, I am not an advocate for surgeries or procedures! I view it as a last resort for patient care, which is why I wouldn’t want to pursue a surgical specialty.
- I’m also not good with my hands!
What I Disliked
- Inpatient metrics and focus on discharging patients.
- Unfortunately, the healthcare system affects patient care on an inpatient level as well. Providers are often pressured to discharge patients as fast as possible because paychecks are influenced by how long your patients are hospitalized for.
- Inefficiencies of academic hospital.
- At times it can be frustrating as a medical student when you, the intern/resident, and attending with the whole team, goes and sees the patient on 3 different occasions. On pre-rounds, you discuss a plan with the intern/resident. Then on table rounds, you and the attending may come up with a different plan. Then when you see the patient with the entire team, that plan might change.
- It sometimes feels as if you’re jumping through multiple hoops just to arrive at the same or different conclusion!
- This also makes rounds last incredibly long!
- Limited breadth of diseases seen in outpatient setting.
- This is a common barrier that prevents many medical students from pursuing primary care. It’s just not that “interesting” in the outpatient setting. However this is a trade-off I’m willing to make.
General Takeaways
- Opportunity to be the patient’s primary provider and advocate.
- Continuity of care in outpatient setting and lifelong relationship that the patient values most.
- Chronic disease management is a thankless, but necessary duty.
- Jack of all trades, knowing a little bit of everything type of specialty!
While I may be slightly biased because I’m interested in IM, this was my honest reflection! I hope this was helpful.
With lobe,
Kelly
