Wednesday, October 20, 2010

More transitions

This week I began a stint with the government.  I'm working in general internal medicine, which has been quite the culture shock.  I see patients with no fewer than five concurrent medical problems, and during the visits I generally manage to elicit at least two additional medical complaints from side pain to, "Oh yah... I've got this thing on my toe..."  This rotation is intimidating beyond what I had initially anticipated, but the biggest challenge for me has been the adjustment from the fast paced and well delineated world of general surgery to the much more relaxed paced (yet still incredibly busy) and nebulous world of internal medicine. 

A week ago I was doing rounds on a number of patients each with a clearly defined medical history and all of the necessary diagnostic testing at our fingertips.  We would be sent a patient complaining of right upper quadrant pain, for example, and they would have blood chemistries and blood cell counts already done or available within the hour.  They would have CT scans already performed and the scan would be accessible to us within two minutes. 

But this week I am working in a governmental systems with more "i's" to dot and "t's" to cross than I can keep straight.  When the patient comes in with a complaint, we are the ones trying to coordinate the labs and imaging which we won't see for at least a week.  We have records dating back YEARS that we must pore through to get to the bottom of the issue.  The conversation often goes, "I was seen by a doctor... whatshisname... over there at that one clinic?  Yeah, that guy.  Anyway, he saw me and ordered all sorts of tests.  He called my condition "somerandomname" and gave me these pills.  Itinilol or something like that.  Can't you just look at the records on your computer?"  Of course we do our due diligence and track down all of the records, complete and incomplete alike, and piece together the progress of the problem at hand.  It takes an experienced provider at least 20 minutes to get it all together, and it takes me easily three times as long.  It is frustrating, but rewarding.  I put together the pieces of the puzzle and get to the bottom of the problem, find a solution, and get the patient sent on his merry way.  My biggest challenge now has become determining which pieces play a large part in making the diagnosis and which ones are less important.  For example, a patient with unexplained weight loss, restlessness, insomnia, and excessively active reflexes doesn't necessarily have a thyroid condition as one would suspect based upon the textbooks. 

I think the issue that has come up is that as a student I don't have enough snapshots of what hyperthyroidism, renal artery stenosis, autonomic orthostatic hypotension, etc. look like.  I have pre-conceived notions of how these things might present, but these don't match with reality well because of my lack of experience.  My hope is that this will come to me quickly and that each time I see something new I will take a good mental "snapshot" of that condition and store it away for benefit to my patients in the future.  In the meantime, I need to be wary of trying to shoe-horn symptoms into a pre-conceived mold of what condition a person with mild peripheral nerve problems and large red blood cells has. 

What an exciting time!

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