I apologize in advance for making another "self-doubting/is medicine right for me" thread in this subreddit. Also, sorry if the title is a bit pompous. I assure you I am not the kind of person who 'reflects' on things, or at least I don't feel so entitled that I think every other person must know my opinion.
I am mostly a quiet person and I don't write or self-edit often, as will be evident if you keep reading.
You might also think I am heartless and lack empathy by the end of this. In any case I felt like writing this and thought this was as good a place as any to post.
It's been almost a month since I began my IM clerkship. It's my first hands-on experience in a ward.
Of course, as a sixth-year student, I have been in a ward before, but it was in the context of classes, which consisted of taking a history from Bed no.21 and then presenting it, being corrected on how to write up the history of present illness in an orderly fashion, which pertinent negatives I missed, which diagnostic hypotheses I should include and so on.
This is the first time I am in contact with actual patient care, and the therapeutic decisions being made. I would not call it boring, but maybe monotonous. And most of all, it feels pointless.
I know the ward is not the ER, I should expect the patients to be mostly stable and completing their assigned courses. And being the most junior member of my ward team, it's only natural that I am given the simplest patients, with no suddenly-dropping O2 sats or failing kidneys.
Here's what makes me feel pointless.
I'm assigned three or four patients – invariably, older ladies with some form of dementia who came in for dehydration, a stroke or pneumonia – that may have already been 'clinically discharged,' meaning they are stable enough to go home. We call these "social cases", their only active problem is their family can't/won't take them back, as they can't afford to care for another elderly member or put them in a home, so they're stuck in the hospital getting infected, and we're stuck with them, treating their infections.
Then, it's time I go and perform the world's worst H&P:
I ask them if they are comfortable, whether they have any pain or shortness of breath. Sometimes they're able to answer coherently! This is also where I test their temporo-spatial orientation, which is lacking in most cases.
I look at their conjunctivae and mucous membranes. Usually they're pretty pale, but this doesn't matter because for some reason every two or three days these ladies have their blood drawn (I wonder if this counts as dysthanasia) and their baseline haemoglobin is always around 7-8 g/dL. Once a week, one of them will slip to 6.9 or 6.8 g/dL so off I go to fill a prescription for 1 unit of blood. As a blood donor, I have to say it's disappointing that I am giving blood just so an 85+ y.o. lady who isn't really 'there' can have an haemoglobin over 9 g/dL for a few weeks.
I'll listen to their heart sounds, mostly because they might have an interesting heart murmur. Sometimes they may be tachycardic, not that it matters because afterwards I'll always check the nursing notes.
Auscultation of the lungs yields normal breath sounds, possibly fine crackles in the bases or rhonchi. I have to admit I haven't tested for the presence of whispered pectoriloquy in a while.
My abdominal exam consists of confirming the patient has normal bowel sounds, then palpating the abdomen while looking at the patient's face to check for hints of pain at the suprapubic area.
The final part of my act is feeling the patient's calves and feet to check for signs of oedema or DVT. No, I don't test for Homans' sign, but I'm guessing the sensitivity/specificity of my physical exam is about the same.
I'm not saying that physical examination is overrated, but it's hard not to be disenchanted with clinical medicine when this is the majority of contact that I have with patients. The thing is, I'm pretty terrified of being in the ER. I don't really 'need' the excitement of a semiologically-rich acute pulmonary edema in my life.
I check the nursing notes and the results of any bloodwork the patient might have ordered. If there's a fever, a creeping CRP or hyperkalemia I'll add it to my notes, the rest of which I mostly copy-and-paste from the day before.
Finally, I briefly summarize the patients I saw to the specialist and his residents, and they'll tell me whether to order another urine culture or an chest x-ray or something because 'they all get an ITU every once in a while'. I just feel like taking their blood every other day, correcting their anemias, giving them courses of piperacillin-tazobactam for their ESBL-producing ITUs, giving them resins for hyperkalemia, etc. is pointless, prolonging their suffering and not doing them any favors.
I don't want it to look like I'm hating every aspect of my clerkship:
I've learned how to take an ABG from the radial artery and I've done a few since, which is cool.
I like writing referrals of my patients to other specialties when it's needed and then reading their evaluations, even if I'm calling about a pressure ulcer in a bed-ridden patient with dementia and what I later get is usually something like "due to the patient's current state, there's no indication for surgical treatment and next time, call plastic surgery instead of general surgery as this is their job".
I like looking at head CTs of patients who have come in with a stroke, and trying to correlate it to their clinical status
I've had one patient that was 'only' 60 years old and a bit more interesting, who came in with drug-induced liver injury due to amoxicillin that he took for a dental abcess, despite the fact that 10 years earlier he had had the exact same thing. It was interesting because he was proper jaundiced. Also, the fact that we weren't sure if he was sliding into hepatic encephalopathy or if he was just 'weird', but after talking to him, I realized he probably had some sort of undiagnosed mental history, as he was unemployed and living as a shut-in since he was 20. I'd like to refer him to Psych but my specialist is resistant to the idea for now.
The thing is, I can guess all of these will become boring after a while. Just waiting for the CRP and ALT/AST to improve so they can get out of here. And since most medical graduates in my country end up going to IM, it's where I am more likely to end up. If by some miracle I do match into some other specialty that I might find temporarily more interesting, like Neuroradiology, it'll probably still become boring after a while. And every other patient will become like another one of those ladies, living in a hospital room, being pricked by nurses daily and languishing in diapers. Sometimes, I'll shake their hand, stroke their cheek, make a little joke and get a smile out of one of them, but that lasts a second and their lives aren't much better due to my actions.
Maybe I should've gone into Physics.
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