Clinical experience and IM

[TheDBird90]

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I've heard the main way you learn during residency is from patients, rather than reading. What exactly do you mean by the phrase, "learning from patients?" Since medicine is an art and a science, do you learn the science of it by reading (preclinical years, CME, etc.) and the art by practicing with real patients in the clinical years and through residency?

And why is Internal Medicine so important? It seems like that rotation is the key to doing everything else (or at least makes other clerkships easier). For some reason, it constitutes about 60% or so of the Step 2 CK. Why is IM the most important subject to learn? I feel silly for asking these questions but I guess that's what these forums are for. 🙂

 

[sliceofbread136]

You get a new patient, figure things out and usually read some stuff on up to date. Maybe learn a thing or two.

IM is such a big part because it is the basics.

 

[LizzyM]

IM includes: allergy, immunology, pulmonary, cardiology, rheumatology, infectious disease, gastroenterology including hepatology (liver disease), endocrinology, nephrology (kidneys), oncology, hematology, geriatrics, and some I may have forgotten. Plus internal medicine deals with preventive care including contraception as well as first line diagnosis and treatment of psychiatric disorders such as depression and anxiety.

 

[typhoonegator]

Learning from patients means that the practical problems posed by the patient forces you to confront your own knowledge inadequacies in addressing them. A patient presents in congestive heart failure. What is CHF? How did they get CHF? How are you going to treat their CHF? How are you going to try to prevent it in the future? The first order of answers to those questions are fine for the medical student, but there is so much nuance that you can spend your career in there.

The goal in medicine is to never stop learning from your patients. I trained in the shadow of the great C. Miller Fisher in stroke neurology. I recall a story in which a resident was presenting admissions post-call, and prefaced a case as a "routine lacunar stroke". Fisher jumped up, exclaiming "Let's go see the patient immediately; I've never seen a routine lacunar stroke before!" That resident did not have a good day, I can assure you.

 

[TheDBird90]

Learning from patients means that the practical problems posed by the patient forces you to confront your own knowledge inadequacies in addressing them. A patient presents in congestive heart failure. What is CHF? How did they get CHF? How are you going to treat their CHF? How are you going to try to prevent it in the future? The first order of answers to those questions are fine for the medical student, but there is so much nuance that you can spend your career in there.

The goal in medicine is to never stop learning from your patients. I trained in the shadow of the great C. Miller Fisher in stroke neurology. I recall a story in which a resident was presenting admissions post-call, and prefaced a case as a "routine lacunar stroke". Fisher jumped up, exclaiming "Let's go see the patient immediately; I've never seen a routine lacunar stroke before!" That resident did not have a good day, I can assure you.

Hmm, so is 'managing' patients just a fancy way of saying how to take care of them? That's another term I've heard before.

So, you're saying patients give you direction in what to study?

 

[Ismet]

Hmm, so is 'managing' patients just a fancy way of saying how to take care of them? That's another term I've heard before.

So, you're saying patients give you direction in what to study?

Yes.

Most patients don't present like the book tells you they will. If the book says that disease X has symptoms A-F and the patient is only presenting with symptoms B and D, maybe disease X isn't the first thing you think of. Especially in pediatrics. We had a pretty baffling case when I was a med student on peds with a teenager with abdominal pain, then developed acute kidney failure, THEN after 2 weeks developed a purpuric rash consistent with HSP (Henoch-Schonlein Purpura). It's not an uncommon pediatric disease, this was just a very weird/backwards presentation of it.

You never stop learning from your patients.

 

[LizzyM]

What you might mean when you say, "patients give you direction on what to study" would be that, maybe as a shadow or as an M1 you see a 90 year old woman with swollen ankles, shortness of breath, and a rapid pulse. What might be wrong with her? The attending physician diagnoses congestive heart failure. You might not know much about that condition and what you've seen will send you to your books to learn what it is, how it happens, and what can be done to treat her and to prevent others from developing this condition.

You also learn how patients respond to various treatments and which side effects may be most common in your patient population.

You learn how to explain things that might seem obvious. (I heard about a woman who was injecting insulin into an orange and then eating the orange because that was how she'd been shown to administer insulin with a syringe.)

You learn how people talk about their bodies. (A terrible pain in my heart might be my way of saying I'm heart broken and sad -- or it might be a heart attack.)

 

[TheDBird90]

OK. So if you don't understand something you can just ask your attending, even in residency. I hope I can shadow someone soon, as this is all very interesting. Maybe algorithms help solve simple cases, but maybe more complex cases require experience with patients like this.

 

[Ismet]

OK. So if you don't understand something you can just ask your attending, even in residency. I hope I can shadow someone soon, as this is all very interesting. Maybe algorithms help solve simple cases, but maybe more complex cases require experience with patients like this.

If you don't understand something, the first thing you should do is read about it. If you still don't get it, or if something clinically isn't making sense with what you're reading, then of course discuss it with your attending.

 

[HuskyMD Emeritus]

It's OK to ask your intern, resident, fellow or attending. The information they teach you may be very thorough, textbooklike, or may be just based on their clinical experience which can be quite biased. It is your job to read about the disease. This will consolidate what you have seen in your patient.
When my interns ask me, I will give an outline of the illness or problem, then tell him or her to read up on it and give me a talk on that subject.

 

[TheDBird90]

Yes.

Most patients don't present like the book tells you they will. If the book says that disease X has symptoms A-F and the patient is only presenting with symptoms B and D, maybe disease X isn't the first thing you think of. Especially in pediatrics. We had a pretty baffling case when I was a med student on peds with a teenager with abdominal pain, then developed acute kidney failure, THEN after 2 weeks developed a purpuric rash consistent with HSP (Henoch-Schonlein Purpura). It's not an uncommon pediatric disease, this was just a very weird/backwards presentation of it.

You never stop learning from your patients.

OK, I still don't get it. I guess part of the problem is having Asperger's syndrome. So management of patients means, generally, taking care of them. But does that mean alleviating their sickness/condition, or actually curing it? Both, when the cure is available?

 

[LizzyM]

OK, I still don't get it. I guess part of the problem is having Asperger's syndrome. So management of patients means, generally, taking care of them. But does that mean alleviating their sickness/condition, or actually curing it? Both, when the cure is available?

Yes, management means periodically evaluating the patient's response to treatment and progression of disease through physical exam, interview (called "taking a history"), diagnostic tests (blood, urine, etc), and sometimes X-rays, other diagnostic imaging, and/or biopsies and then prescribing treatments to alleviating symptoms and/or correct underlying dysfunction, preventing progression of disease, and, when possible, offering treatment that cures the condition.

Many diseases cannot be cured but can be managed with medications and changes in lifestyle (diet, physical activity, sleep, stress) so that the patient can be comfortable and live a full life. In some cases the disease can be cured but the cure produces other issues that require management such as anti-rejection drugs for patients who have had organ transplants.

Some of what we mean by learning from your patients can be thought of like this... let's say that there is a relatively new drug for a very common condition. The label says that the dose can be between 10 and 40 mg. You may start out reading the labeling and some of the papers that have been published about this drug, what it does in the body, what the unwanted side effects are and how often and how well it gives the results you would hope for in your patients. You begin prescribing it and ...here's where you start learning from your patients. As you get more experience with the drug, you begin to observe that in your patients, 10 mg twice a day is a dose that has the intended effect with minimal side effects. Some have good results on only 10 mg once a day and some need 40 mg to see results. You begin to understand the common side effects and can caution patients about taking the drug after meals or at bedtime to minimize unwanted side effects. That's part of what is meant by "learning from your patients". It is no substitute for reading the literature but to read the literature and never care for patients is said to be like studying navigation but never going out to sea.

 

[TheDBird90]

Yes, management means periodically evaluating the patient's response to treatment and progression of disease through physical exam, interview (called "taking a history"), diagnostic tests (blood, urine, etc), and sometimes X-rays, other diagnostic imaging, and/or biopsies and then prescribing treatments to alleviating symptoms and/or correct underlying dysfunction, preventing progression of disease, and, when possible, offering treatment that cures the condition.

Many diseases cannot be cured but can be managed with medications and changes in lifestyle (diet, physical activity, sleep, stress) so that the patient can be comfortable and live a full life. In some cases the disease can be cured but the cure produces other issues that require management such as anti-rejection drugs for patients who have had organ transplants.

Some of what we mean by learning from your patients can be thought of like this... let's say that there is a relatively new drug for a very common condition. The label says that the dose can be between 10 and 40 mg. You may start out reading the labeling and some of the papers that have been published about this drug, what it does in the body, what the unwanted side effects are and how often and how well it gives the results you would hope for in your patients. You begin prescribing it and ...here's where you start learning from your patients. As you get more experience with the drug, you begin to observe that in your patients, 10 mg twice a day is a dose that has the intended effect with minimal side effects. Some have good results on only 10 mg once a day and some need 40 mg to see results. You begin to understand the common side effects and can caution patients about taking the drug after meals or at bedtime to minimize unwanted side effects. That's part of what is meant by "learning from your patients". It is no substitute for reading the literature but to read the literature and never care for patients is said to be like studying navigation but never going out to sea.

Wow, now it makes much more sense. Thanks a bunch.