Internal Medicine is Driving Me Crazy

Discussion in 'Internal Medicine and IM Subspecialties' started by Amazonee, Jun 1, 2008.

  1. Amazonee

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    I have always loved to take care of patients. I've loved internal medicine since my first year of medical school. But now,i am questioning if this is the right profession for me.
    WHY: Because the long rounds drive me crazy..We always have like 12-14 patients in our census but by the 5-8 patient, i am completely lost. My mind wonders everywhere and i lose interest. Table rounds take like 3hrs and walk rounds an extra 1-2hrs and this drives me nuts. After rounds, i feel so tired and uninterested. I just wonder how the interns and residents go back immediately to start writing notes and putting-in orders after these grueling rounds..I..because this could be me next year should i make a wrong decision now....
    My question is-Is this experience unique to me or does everyone experience this frustration as a 3rd yr med student? If its is, then Internal medicine may not be for me. I have tried lots of time to talk myself out of IM but i just can't. I can't find anyother profession i could enjoy since i really love patient care and hope to specialize someday..
    Please any advice/suggestions will be greatly appreciated
    Thanks..
     
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  3. elwademd

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    it's ok to not like every single aspect of a specialty. i actually would think you weren't being real with yourself if you absolutely loved everything about a specialty whether it be internal medicine or something else.

    as far as rounds go, we had a thread here a week or so ago on the issue that you should read if you haven't already:
    http://forums.studentdoctor.net/showthread.php?t=525460

    i'll quote myself from that thread:
    don't get me wrong, i think rounding is necessary, but i do think that long rounds day in and day out is inefficient and draining.

    as far as being interested, i think that the more the patient feels like is your patient, the more interested you are. i.e. the more involved you are, the more interesting it may seem.

    as far as preparing for intern year, do a sub internship in internal medicine early in your 4th year so that you can revisit internal medicine and see if its for you or not. hopefully you'll be given more responsibility, and get a better view of what you could be doing. i'd also suggest an icu rotation if your medical school has it and you have time in your schedule.

    i don't think your experience is necssarily unique, but i'm sure there are plenty of other members who feel like you, but don't make threads. hopefully we'll have more threads in the internal medicine forum so that current residents and attendings can try and help guide the younger generation.
     
  4. grendelsdragon

    grendelsdragon Synesthetic

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    Long interminable rounds are not necessarily intrinsic to internal medicine training programs. It tends to be more related with a particular attending who might enjoy the sound of his/her own voice. However, there are a few caveats worth considering.

    1. When an internist finishes training and moves on to practice, you no longer need to group round (unless you are teaching).
    2. The knowledgebase that one needs to acquire in internal medicine is amongst the broadest of any medical specialty. Lots of rounding is important in the early phases.
    3. I disagree with the above poster regarding the topics to cover during rounds. For any given chief complaint, I am a strong proponent of quickly reviewing a broad differential diagnosis (with emphasis on first ruling out the highly morbid and mortal illnesses) before narrowing your focus to the diagnosis at hand. For example, in patients who present with acute chest pain you should always entertain ACS, pulmonary embolism, aortic dissection and tension pneumothorax in addition to the more pedestrian causes like pericarditis. In a lifetime of practice, I guarantee that you will kick yourself more than a few times for having overlooked a dangerous diagnosis for a more expeditious and convenient diagnosis (wit the patient's having suffered a bad outcome as a result). The best way to decrease the frequency of these events is attention to detail and practice. I say "decrease" because it is impossible to completely "avoid" these instances because it comes part and parcel with the practice of medicine. For this reason, you will probably observe that the most experienced and skilled physicians tend to be fairly conservative in the way they conduct rounds.
    4. I am a bit surprised at your impatience with rounds considering your level of experience (MS1). I would be shocked and amazed if you are bored from complete understanding and comprehension. If you say you love patient care, you will have to take the time to learn the trade. You may find yourself more engaged as your knowledgebase increases.
    5. If you are trying to "talk yourself out of IM", maybe you should. Not everyone enjoys the cerebral aspects of medicine. You may find yourself enjoying more procedurally oriented specialties.
     
  5. Strength&Speed

    Strength&Speed Need more speed......

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    my advice. don't do internal medicine. if you don't enjoy the rounds now...i guarantee you'll hate them later
     
  6. Linus2007

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    Have to admit I felt the same thing on third year rotation. It was also very attending dependent. Some would be very, very long and others would be quicker. It didn't really deter me from IM though. Especially since academic medicine differs from private practice and I think perception of rounds changes when you get further along.

    Third year I just focused non my patient and maybe listened out for potential pimping sessions or to fill out orders. Everything else was just background noise (We usually go over our cap limit at our hospital so rounds do last a long time). However as a 4th year I really paid more attention to rounds and post-call rounds as I had to cross cover for the interns or sign out for them and thus it was really important I knew what was going on.

    So don't be discouraged from IM if the only thing is long rounding, if you don't like other aspects then don't pick it. Rounds is very dependent on attendings and as you go further along they become more and more important to know which meant my interest increased.
     
  7. Finding Chi

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    Rounding is part of Internal Medicine. It is attending dependent to a degree, but even the most efficient IM rounds will probably last a few hours on a busy service. It's the nature of dealing with multiple complicated problems.

    Does it get better? Yes. As you learn more, you understand more and the conversations become more interesting. As an intern and resident, you're primarily discussing the management plans you came up with and implemented on call or prior to rounds - so the feeling of "boy I hope I didn't royally f**k up this pt's care" also keeps you attentive.

    That said, if you are not interested in medicine topics, and you don't enjoy occasionally pontificating about the finer points of the renin-angiotensin system etc, IM may not be the field for you.
     
  8. muscles

    muscles student of the month

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    I disagree. Don't be mistaken -- nobody enjoys 4 hour rounds, even people who go into internal medicine. I had this dilemma last fall when trying to decide whether or not to do internal medicine. Personally, if I had to choose 3-4 hours of rounds v. 3-4 hours standing in the same place watching an attending perform surgery as a surgical resident, I would rather round...
     
  9. Acherona

    Acherona Senior Member

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    well if you go into a subspecialty of internal and are doing mostly clinics and consults you won't have to do much rounding. You don't ever have to do wards if you don't want to. You just have to get through residency which is only 3 years.

    I'm in 3rd year and can totally sympathize. I loved surgery rounds: AVSS and passing gas :D One thing that helped me in internal was getting to know the patients. After weekend call I found I was able to pay attention more because I could picture everyone they were talking about and knew the active issues. Try to pretend you are the senior resident and have to know everything.

    On the other hand if you are that bored even when you are paying attention maybe you just don't like internal medicine. My worst rounding experience was in NICU and it didn't matter what I did I just couldn't pay attention, I was so not interested in talking ad nauseum about the ventilator settings and TPN.
     
  10. Amazonee

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    I totally enjoy the topics in Internal Medicine. I love to think and work things through- like making plans, work-up etc, infact thats the reason why i love IM in the first place. I enjoy rounds when i am part of the admission-got the initial H&P and made parts of the plans before next morning rounds. I love to read-upon the topic or diagnosis i made immediately because it helps me rienforce the knowledge i have.
    The problem i have is when the rounds get very long, and they are talking about patients i know nothing about. It gets very draining and i just completely lose interest... ....
     
  11. Acherona

    Acherona Senior Member

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    yea, well like I said just try to pretend that all the patients are yours. Ask yourself why they are ordering this or that test. When the intern is presenting the H&P, try to guess the Impression/Plan and see if it matches. If you don't know why something was done, ask. Take like 20 mins to skim through the admission notes and latest progress notes for all the patients. Then you can even participate on rounds when they are talking about the other patients. I think you will be a lot happier if you do this and you will learn more to boot.
     
  12. elwademd

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    i should have edited my comments, as they were pulled from a thread about marathon rounds, and how to improve efficiency. is it necessary to, at some point, go over a broad differential diagnosis? sure it is.

    but in the 4th week of the rotation... on the same team... with the same attending... on the 12th chest pain patient... who's a bounce back and cocaine user... who admits to using cocaine just prior to onset of chest pain... again... and the team's post call... and you're already 30 minutes late out of hospital/too noon conference... and you still have 5 patients to see... maybe that's not the time to go over the broad differential for chest pain, and then take 10 minutes to go over hiatal hernias and how they can cause chest pain and be mistaken for acs. there's a time and a place.

    sometimes, the attending is not necessarily on the same page with his/her residents, and therein lies a problem. perhaps a problem of wider scope in medicine in general, which is communication, or lack thereof. while a team is post call, the attending wasn't necssarily up all night. and the attending may not have to go to clinic. thus, having more time... not realizing the team is post call... and the team being respectful enough to let it go... and suffer through marathon rounds.

    don't get me wrong, not all attendings are like this. i'm about to finish in 27 days and 1 hour (not that i'm counting), and i hope i'm not like that! but we all know of a few attendings who are.

    so yes, it's important to have a broad differential diagnosis in your mind. because you find what you look for, and you look for what you know. but at the same time, while long rounding is appropriate from time to time, there's a time and a place, and it isn't appropriate everyday.
     
  13. grendelsdragon

    grendelsdragon Synesthetic

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    I feel your pain. You may note that I started my post with a statement about attending-specific experiences. That being said, the attending is ultimately liable and responsible for all the patients on the team. It is his/her responsibility to look beyond work rounds and see the forest before the trees, while housestaff tend to concentrate on getting things done (an important synergy for learning and efficient patient care).

    I did my residency with Q3 call in days before work hour restrictions and patient capping. I can definitely sympathize. However, it also tends to be the 12th chest pain admission in the middle of the night that can be complicated. I have seen patients with deep anterior ST depressions initially diagnosed with ACS who actually had a large pulmonary embolus with RV strain. I have also seen elderly patients with rest angina who on exam had critical aortic stenosis, and who might have died if anyone gave them SL NTG. The playwright Jonathan Larson (author of RENT) went to 2 hospitals with chest pain and was sent home both times only to die from aortic dissection. Recently a girl playing soccer had chest pain after the ball hit her in the chest and she died in the emergency room, with a post-mortem diagnosis of pneumothorax. These types of examples are everywhere. It is also why seasoned physicians tend to be less cavalier about the 12th RO/MI.

    Sure, everyone is impatient and tired post-call, but it is in the morning of admission that a fresh perspective of a new admission is most needed (and where critical errors in judgement are often caught). Even though the attending has not been up all night on call, he/she is ultimately responsible for the patient. However, it is also every attending's job to run rounds as efficiently as possible.
     
  14. Finding Chi

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    Then things will get better for you. Figure, as a student you admit maybe 25% of the pts on a give call night. As an intern, you admit 50% and as an upper level you admit 100% (obviously some variation from program to program). So you'll know most of the service well... not that it still won't drag from time to time...
     

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