Sunday, August 12, 2012

Day in the Life of a Family Medicine Intern

As salaam alaikum,

It's been a while! Between being behind on my Qur'an reading this Ramadan and rotating through inpatient medicine, that supposedly gives me four days off, but two of those days are, like, 7pm-7pm days off (cheating!), I haven't had time to just sit down and chit-chat.

That, and this whole living one day at a time thing has led me to make some interesting life decisions that I have to process in a less public forum. It happens from time to time! I will be back, insha'Allah.

But alhamdulillah, I'm blessed to be in a wonderful residency program that suits all of my needs surrounded by loving co-residents and super supportive faculty, indeed, everything I need. I do miss home from time to time, especially after spending one month there before moving out west, but I recognize that I'm realizing part of my purpose of life by being here.

A while back, I asked if anyone had any questions about me that I don't address here, and the only question that came from that query (I'm still open to any!) was for me to describe a day in the life of an intern. I told that person, who posted anonymously (so I'm not sure who you are...hopefully you're still reading!) that I would wait until I was in the thick of my inpatient rotation and get back to you. So here I am, in the thick of my inpatient rotation, getting back to you.

You asked for a day in the life. I'll give you a day. I'm about to start night shift for six days...that should be really interesting, as well. For the sake of HIPPA, I'm not detailing anything about my patients. This is a public blog and I think the reason that I don't really post about the hospital is because HIPPA is sticky business. I'm also not going to give any hospital identifiers, etc. But it's fairly representative of my day, anyway, hehe.

So, I was on call last Sunday. Call isn't properly call any more. Back when I was a medical student, call meant overnight call, 24 hours. As an intern, you would come in at 12pm on one day and leave 12pm the next. This was awesome as compared to the days of 30-hour call that most of my attendings were trained in. As a medical student at the general hospital, our call was 10am to 12pm, because we had to be present for teaching. Sometimes we'd be in the hospital from 7am to 5pm, though, because of required classes.

So, last Sunday, I did weekend day call, from 6:30am to 8pm. Not bad at all. Even better than my Sub-I, where weekend call was 6:30am and you admitted patients until 8pm, so you could very well leave at 11pm or however long it took you to finish working up your patient.

But I don't mind the 6:30am to 8pm call on the weekends because this inpatient service is Q3, meaning you're doing long day call every three days. All other systems I worked in, you were Q4. There's something intrinsically more painful about working long shifts every three days instead of four.

To top it off, this is Ramadan, so most of the day, my few morning calories (I'm usually only able to eat fruit and drink milk in the morning...talk about stomach shrinkage) are gone before noon and I run on pure adrenaline in the evening. Alhamdulillah, I've been able to be a good intern the while fasting. It's been a good month.

So, last Sunday, I was on day call. I got in at 6:30am in time for group sign-out. Different from during the week, all of the patients are signed out to the interns and the seniors together. The seniors are the second and third years (oddly...I went to a medical school where second years were juniors). Sign out means you take the entire list with the important information about the patients and the night senior tells you what happened over night after giving a little one-liner about the patient to orient everyone. As the weekend intern on call, you pay attention to all of the patient's information, even though in the morning you're only rounding on 1/3 or 1/4 of the patients. The work is split between you, the night intern from the night before who is staying on to help with work rounds, the weekend rounder, who is a senior who stays through rounds and sometimes the day senior, who splits his or her time between the medicine service and the obstetrics service.

As the day call intern, you could round on anywhere between four and eight patients in the morning. Mercifully, our service hasn't capped, so weekend rounding usually means four or five patients.

After sign out, I peel off and work on progress notes for the morning. As a rule, anyone admitted the day before prior to midnight needs a progress note. Any other patients need a short addendum to their H&P or a small, separate note updated the plan. I tee up my notes, looking at notes left by specialists or attendings the day before and updating the plan accordingly. I also look at overnight events, vitals, new labs (sometimes not in yet, because they're drawn at 7am), and update the plan for patients.

That usually takes me 30 minutes to an hour, depending on how many patients I'm carrying and their complexity. My inpatient service has an open ICU, meaning we admit patients to the ICU and we follow them as they go to the step-down unit and back on the floor and everything in-between. It makes for great quality of care, but takes away the stress of having a dedicated ICU rotation as a family physician who doesn't plan on being a hospitalist.

After getting the notes together, I go and round on my patients. It's nice, because our electronic medical records include not only notes, but vitals and medication administration records, so unlike medical school, rounding doesn't mean looking at the EMR, finding the gray chart for any paper progress notes and nursing notes left, finding the green chart for the vitals and the slender blue charts for medications. I have no idea how I rounded on so many patients in that system while writing paper progress notes! Going to a program with a great EMR is great to improve efficiency.

So when I round on patients, I go in and see them, and that's it. It usually takes me 45 minutes to an hour to see four to six patients in the morning, usually because 1-2 of my patients do not speak English or have big families present (or both). Since we have patients who speak Asian languages, I do use an interpreter, and those visits usually take twice as long, also because not all of the specialists bother to use an interpreter (d'oh!) so sometimes I have to clean-up misunderstandings. When I see the patients, I ask them how things are going, update them on the plan for the day and for the coming days, ask if they have any questions, and then conduct a focused exam. Our program has a low intern cap (only 8!), and ICU patients count as two. Our service caps at 24. I trained at places where the list capped in the 30s, but they also had four interns on service and not just three. Since we have sub-interns usually, they help us carry part of the list.

After I see the patients, I update the note with my exam, any alterations in the plan based on my discussion with the patient, refresh any new labs and studies, and then print them out in preparation for work rounds. Work rounds are table rounds. Attendings come to our workroom and we go around the table, presenting our patients in five minutes or less.  For me, this is different from what I was used to in medical school, because usually for new patients, you gave the more full, seven minute H&P that was complete with HPI, PMH, etc. The most I give these days is an abbreviated HPI, relevant past medical history, pertinent positives in exam and then spend most of my time on my assessment and plan. One of the hospitals I did rotations in during third year had special rounds for the new patients. All old patients were presented in brief SOAP format.

So work rounds, almost all patients, even new ones, are presented in SOAP format. That's because, unlike my old system, we staff patients as they are admitted to the on-call physician. In the other system back in medical school, patients were staffed by the floor attending in the morning, thus requiring a fuller H&P.

Anyway. I'm still not past morning rounds, and I feel like I've written a lot! I'll keep going...

During rounds, the attendings may teach a few pearls or teach some topics, depending on how many patients they are carrying. We usually round with three or four attendings who represent the clinics where our patients are coming from. We round with the hospitalist for any ICU or step-down unit patients. We update our plans according to discussions during rounds and then make sure our notes are in and signed before around noon. At noon, we do teaching.

I work in a community hospital, but I come from a place where there was noon conference every day. In exchange for that type of system, my program has weekly teaching every Tuesday afternoon. When on inpatient, you only make that teaching once a month. As an intern, you're only required to make teaching 50% of the time. Topics repeat, so you're not left out, necessarily.

So, the Sunday on call started like any other weekend day on call. During the week, your senior also rounds on your patients (but doesn't write a note) and you meet before work rounds and go over the plan, but on the weekend, it's up to you.

After that, the night intern from the previous night gets to go home after his or her 7pm-11am shift, the weekend rounder also goes home, and all that is left is you and the day senior, who is also covering obstetrics, to cover the list, which may have anywhere from 14-24 patients, and take care of any admissions.

So that Sunday, two patients were being transferred from a neighboring hospital's emergency department and were to be admitted to our service. They came at the same time, unfortunately, and hit the floor at the same time. My senior, who can also help with admissions, asked if I would like to do both admissions or split them. Being the self-sufficient girly that I am, I said no, I'll do both admissions. That's my job as an intern, I feel. The seniors in my program provide a lot of support for interns for discharge paperwork. Though discharge summaries are the job of the intern, sometimes your seniors will help you, because they are due within 24 hours of discharge for patients discharging to home and upon discharge for patients discharging to facilities, and sometimes, your plate is too full as an intern to make those deadlines. On the weekends, seniors will sometimes do some of the admissions. I trained in systems where that was always, always the job of the intern, even if you get slammed. You peak in on the patient, you "skeletonize" orders, you see your sickest patients first and work backwards, H&P be damned!

I still feel the urge to operate like that, but this program splits the work and we'll even call in backup. I actually like this, because it improves patient safety.

Anyway, I was admitting my first patient, who required an interpreter. That patient was on the floor for almost an hour with skeletonized orders before the interpreter showed up. While I was in with the patient, I got a page that the second patient was on the floor and needed orders. That was fine, I figured. I'd be done with this patient soon enough.

Then, in the middle of my admission, I get a page that a patient that I'm cross-covering for wants to leave AMA, against medical advice, and to come talk to them. I had a patient leave AMA earlier, frustratingly, only to return a few hours later to the emergency department. But I was in the middle of the admission of this patient. I would respond to that page within the next five minutes, but I wanted to tie things up. Next thing I know, I hear a violence code called over the loudspeakers and get a second page that the violence code was called on my cross-cover patient, and I needed to be there, now!

I explain the situation to the interpreter, tell her I'll be back in 10-15 minutes, and run to the step-down unit where security guards are already surrounding the area. By the time I get there, the patient is still in bed but belligerent. I talk them down and convince them to stay. Somewhere in there, I page my senior's personal pager through my phone and he comes running in. I stay for about 15 or 20 minutes more to ensure that the situation deescalates before I return to admitting my patient with the interpreter. Because of the interruption, though, I'm now behind admitting the second patient, and my senior skeletonizes orders for her and looks in on her. Within the hour, I admit both patients and work on their H&P's. My senior in the meantime is getting slammed in obstetrics and I have my wish, to be on my own admitting patients.

I staff both patients by about 6pm, meaning I give an over-the-phone H&P to the admitting attendings, who make any updates to my assessment and plan. I tidy up the rest of the note and update our sign-out, which is a word document that lets the night team know what is left to be done for patients and any cross-cover issues to know about (like the cross-cover patient with the tendency towards violence and leaving AMA).

Time flies when you're super busy, and before we know it, it's time to sign out patients. The senior lets me do sign out for my own patients and then they usually sign out the rest. In the mornings on weekdays, the night intern signs out to the day intern who follows the patient, and the night senior signs out to the day seniors and signs out obstetrics to the maternal-child health resident. And then I tidy up anything undone and I'm kicked out by 8pm so I don't violate duty hours.

This past week, the week that began with that Sunday, I worked for 83 hours. The cap is 80. I technically do not violate duty hours because I have to work less than 80 hours on average for the entire rotation. This is the only week I'll violate hours. On nights, you work 12 hour shifts and you only do six nights in a row, so I'll probably work 76 hours that week (including the one night where I stay on until 11am). I've fasted Ramadan while working nights before...it's just odd, because you only eat during a small portion of the night. You realize just how short the night is in the summer when you do that.

...so that is a standard day in the life of a family medicine intern on service. It was a pretty tranquil day with just two admissions. My co-intern got slammed on Friday with, like, four admissions between noon and six. I just did call on Saturday and admitted no one, but discharged a bunch of patients. Diuresing the list, if you will. The days vary, but that's good, or else you'd be constantly tired...

I just slept for about 10 hours last night, from 9:30pm to 8am, waking for salat and suhoor. I need to also nap during the day prior to my shift, insha'Allah, although, unlike the rest of the rotation, I'll be able to drink caffeine to keep me awake!

Anyway, I'm here, still in bed, lounging around before I go into the hospital at 7:30pm to begin my night.

Let me know if anyone has any other questions for me! This was a long post, sorry, but I haven't written something not a discharge summary in a while!

1 comment:

  1. Kalsouma IdrissMay 5, 2014 at 4:07 AM

    Hi,

    I don't know if you still keep up with this blog but I am a fellow Muslima born and raised partially in Chad, Africa. I'm an aspiring doctor-to-be. I would love to be able to speak to you more in depth. My email is idrisskalsouma@yahoo.com if you don't mind speaking with a complete stranger.

    Jazakallah,

    Kalsouma Idriss

    ReplyDelete