So I've actually gone over this several times - ideas for a blog entry. So finally, now when I should be studying for my shelf exam in about 2 weeks, I am instead sitting down to write the blog entry.
I want to first say that I believe that Medicine is a much glamorized profession. Especially these days with all the medical drama shows that exist. Greys Anatomy, House to name a few. ER if you want to go back further. I've never watched that one though. Before starting med school, and definitely before starting rotations, I actually thought on some level that it would be like it is on Greys with all the cool things all the time, all the drama-liciousness...that actually definitely still exists. Anyways. It really is not all it's cracked up to be. Definitely not glamorous.
Firstly, what we're taught in medical school is not carried over in real medical practice. Not always at least. My first month was in ambulatory medicine (kind of like family medicine) in which I learned a couple things from following a PCP (primary care physician).
(1) Your doctor at an office probably does not wash his hands before examining you.
Okay, that sounds pretty gross. But it's true. He never ever washed his hands prior to going into a patient's room and touching their face, abdomen, legs, etc. The only time I noticed that he would wash his hands was after touching someone's feet. So chances are, if you do not SEE your doctor washing his hands or use sanitizer which is present in the room, he probably did not wash his hands.
It's weird because we are very strictly taught that in medical school. Always always wash your hands before placing them on a patient. If you don't, you'll get points marked off from your head-to-toe exam. And they'll probably comment on it. In real life, patients do not comment on it.
In the hospital it's different. You can be almost completely sure that the doctor uses sanitizer (usually what is around now) before and after entering a patient room.
(2) That drug you're taking for your high blood pressure may not be the best one out there AKA your doctor is a pharm rep helper monkey.
We're told about the evil looming monster that is big pharma early on in med school. In fact, I'm pretty sure that this was the topic during our orientation week. AVOID AVOID AVOID!!! THEIR DINNERS ARE EVIL!!! THEIR STUDIES ARE COMPLETELY BIASED!!! DON'T TRUST THEM!!! DON'T USE THEIR PENS OR MAGNETS OR CUPS!!!
Yeah. But. Really, many many doctors have "sold out" and meet with tens of pharm reps several days out of the week and they also attend several pharma dinners a week maybe even giving the presentation for the new drug.
The doctor I followed would meet a pharm rep in between almost every patient getting free samples, telling them that he would gladly do a talk for them if they would send him the slides that THEY (EVIL PHARMA) prepared, eating their free lunch, drinking their courtesy Starbucks drinks. (Okay I had one of those too...)
Honestly I was quite flabbergasted. I knew pharma existed and was a necessary evil in the medical world (hey free drugs samples to pts that can't afford them!) but the extent was much more than I expected. The amount of time that the doctor spent talking to pharm reps cut into his patient's time continually.
(3) Your doctor may or may not have a legitimate reason for making you wait 30 min in the room before showing up.
This one is a little more complicated. Making an appt at 2:00pm and then being seen at 2:30pm is a common occurrence at doctors offices around the country. We usually chalk it up to the doctor being busy, overscheduling himself, having more important things going on...but, it's only SOMETIMES true. More often than not, I'd say the doctor just is running late, woke up late, doesn't leave the house on time, is talking to a pharm rep or whatnot.
I'd also say this is on the doctor. They do overextend themselves. Having patients in the hospital, rounding there then having to run to get to office appts on time can be difficult, especially if rounds take forever...but at the same time, it sucks to have to wait half an hour to be seen. Let's face it, everyone's time is precious, not just the doctor.
I actually encountered this one lady who waited about an hour for her appt, was almost going to walk out when the doctor FINALLY arrived. She was pretty upset throughout the visit though.
(4) Physical exams aren't always done on every patient.
So we do learn about doing focused physicals depending on the patient's chief complaint or condition, but honestly I couldn't see a real pattern from what my PCP was doing. Some patients he would check in their mouth, palpate the thyroid, check abdomen, but not all. And it had no real correlation with their chief complaint. Quite weird...................
Also, visits seriously take like 15 minutes, and they're almost all the same. I don't know if I could ever be primary care. It's so ridiculously routine.
"Any new problems?"
"Do you need any refills on any medications?"
"Try to eat less white carbohydrates, less fats, sweets."
"Hmm you need bloodwork done again."
"See you in a month."
(5) Why use EMR (electronic medical records) if it makes you slower!?
My PCP was in the process of transferring all his records to EMR, so half of his pts were EMR half were old fashioned manila folder paper style. He'd actually DREAD the patients that were EMR because then he'd have to drag his laptop into the room. And the appt would take an extra 15min and there would be a lot of awkward silence in between where he was slowly single finger typing in the CC and then backspacing the whole thing if he made a spelling mistake, clicking on checkboxes for ROS, clicking dropdowns...
I can understand using EMR if you're faster with typing than writing or something, but hey, if you're EMR and your appts with that are taking significantly longer, then why? Also, poor pt who is just spending half their time with the doctor waiting for him to click or type.
Not applicable to all doctors. The dermatologist I shadowed was super fast (but he had a nurse doing the typing for him) and saw about 28 pts in the time span I was with him (an afternoon).
Secondly, I don't have much of an idea about what I'm supposed to be doing as an MS3 on the team. I've gotten such a variation depending on my team and where I'm at. I'm at the end of my rotation and only now do I think I understand that I should be LEARNING about the disease process, management, care, planning and necessary tests. Not putting in morning lab orders, medication orders, consults, imaging, what have you. I probably spent a month doing all that crap and not really getting too much out of it. Thank goodness my latest team heavily heavily emphasized learning. Although now that we're switching for the last two weeks, I'm not sure what will happen. Which brings me to my third point...
There is way too much time wasted in the hospital trying to get things done for a patient, talking to other services, waiting on labs, etc. To be honest, I feel like all the note writing can be done in a span of 1.5hrs. SOAP notes at least. Full admit H&Ps can take a while. But seriously, SOAP notes are just the subjective from that day/morning/overnight and then a PE which for the most part doesn't change too much, and the A/P which you copy and paste from the prior day and then adjust based on what you choose to do/results you've gotten/etc. How does this take hours upon hours? Putting in orders for labs doesn't take forever either. Click click click. I had to do morning lab orders my 2nd month and it seriously took like 10 min for all the patients on the team.
So so so much time is wasted trying to communicate and get things done. Putting an order in doesn't mean it's going to get done (sadly) so you have to constantly call call call to make sure it's being done, which then begs the question, what is the point in having a computer system in which to put the order so someone else can see it and do it if you have to call them anyways?
Being on medicine also means you end up hating surgery. Why? Because surgery always seems to find some excuse to NOT do surgery on your patient.
"But this G-tube is the only thing keeping the pt in the hospital! Once he gets it then he can go get chemo for his cancer!" "No can do, his creatinine is high. Risk." "But renal said that it's not a contraindication and he can go get his G-tube!" "Sorry, we have to wait for it to return to normal."
"But if he doesn't get this surgery, his chance of dying is 100%!" "Sorry, his chance of dying on the table is 70-80%, we can't chance it, it will look bad on our record." -______________-
Too ridiculous. Always putting things off until the patient is way way too bacteremic or has stayed for over a week. Frustrating. I suppose that this sentiment can go in any direction though. My most recent attending has a bone to pick with renal who many times does not start dialysis for pts until their creatinine is ridiculously high and only then do they contemplate putting in some sort of access.
But overall it really is a lot of waiting. Many times treatment cannot be properly determined until the cultures are back and cultures won't be back for days so you treat empirically. Or you can't do anything until the imaging is back and who knows how long it'll take radiology to come do the portable xray?
STAT really isn't that STAT either. If you REALLY want STAT, then you probably have to call down a million times and state to them exactly how dire the situation is to get it done. Otherwise, it may not be done at all (true story, STAT CXR not done for 3 days).
Ah. Anyways.
In conclusion, your experience will ultimately depend on your team. Work with fantastic people, you'll have a fantastic time.
I am extremely grateful to the interns, residents and attendings who never talked down to me as a student, who actually valued my opinion on the treatment course of a patient and included me as a real team member.
Who knows? I didn't hate medicine. Maybe I'll want to go into this later.
