You learn something every day if you pay attention

July 27, 2015 § 2 Comments

We’ve reached our last week of internal medicine practice and I’m looking forward to the change of pace that awaits us from next week. It’s been a rich learning experience and I feel so much more secure now that I have some hospital experience here in Norway.

From next week, Skjalg and I will be working in “hjemmetjeneste”. This is a government service that provides home care for patients, such as giving medication, making food or aiding with personal care. The number of visits a day for a single patient varies depending on their needs. In addition to the shifts in hjemmetjeneste, we will be working at the restaurant. Skjalg’s stepmom will be heading back to Thailand to visit her mom, so it is likely that we will need to pick up some more shifts. It’s going to be a tough month for us, but it will be really nice to fill in the financial hole created by the exchange rate this past year (we have to pay our tuition in dollar and our rent in euro and were hit quite hard this past semester).

Our schedule – without the extra restaurant shifts – for the next 5 weeks! Day shifts go from 7:30-15:00 and evening shifts from 15:00-22:45.

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Our time here at the hospital has been nice but we’re ready for a change. Since the first week, things have become quite monotonous. We start every morning in the large conference room where all of the doctors from the different departments meet and discuss new patients. Depending on the number of patients and associated discussions, this can last anywhere from 20 minutes to an hour, though usually closer to 20 minutes. After this, we head to our respective departments and sit down for more meetings.

The first is a meeting with all the doctors on the shift to discuss the patients. I find this really interesting (what I’m able to follow at least). A large projector displays all the necessary patient information, including lab values and any notes/referrals. There is also a program that shows any imaging results, CT scans, MRIs, X-rays, etc. One of the doctors told me that they like to be at least two when making a decision about a patient and prefer if they are three, with the third coming from a different department. I have to say that I am really impressed by the level of communication here.

During this meeting, the names of different medications are constantly brought up and discussed. We haven’t taken pharmacology yet, but I still want to get something out of it. My solution? I downloaded an app for felleskatalogen (catalog of pharmaceuticals in Norway) and look-up the various medications as they discuss them. I can also save the ones I look up to a list so that they are easier to find. The profile of each medication is extremely thorough and there is even an option to check the effect of medications on each other.

Following the doctor’s meeting, the doctors for each group (patients are divided into two groups by color, i.e. red and blue) meet with the corresponding nurse. During this time, they discuss the patients in more detail. The doctor usually asks how the patient has been doing, how they have been interacting with the nurses and if there is anything that stands out. Then they update the nurse on what was discussed at the earlier meeting and begin to discuss further treatment. This is usually over by 11:00/11:30 (depending on the doctor and cases) and after that, the doctors go to visit each of the patients.

After spending an hour or so visiting the 5-6 patients in the group, it’s time for lunch. At this point, I head up to grab my lunch from my locker in the medical student room. Well, sometimes. Usually I stay in the department until it’s time for me to go home, just so I don’t miss out on anything. The reason for this is that after lunch, the doctors sit down to paperwork. This is the time during which I can get lost in the shuffle. If there is something happening, you can bet I’m there! Otherwise, the doctors don’t seem to enjoy having a medical student staring over their shoulder….

One day, Skjalg and I took a patient for an echocardiogram. The doctor was in training, so she was good about describing the whole process for us. When she was done and the head doctor came in to check the results with her, Skjalg and I were allowed to continue examining the patient for our own benefit. The patient had chronic kidney failure and the doctors in my department suspected him/her of having amyloidosis. They were doing the echo to see if they could find any morphological changes in the heart. Amyloidosis is a disease where protein is deposited outside the cells in various organs/tissues. There are several types depending on the type of protein and this patient was suspected of having the age-associated type, senile systemic amyloidosis. When it was time for us to take the patient back to our department, the doctors actually thanked us for showing interest. I found this so surprising because to me it’s obvious that we are interested – we should be! It also made me wonder about what other students are like…

On another day, I got to see a kidney biopsy. I’ve never seen one before and am still so in awe about how it was done. For some reason, I had it in my head that it was more invasive and the sample much larger than it actually is. The patient lay on his/her back and the doctor visualized his/her anatomy via ultrasound. Then, once all the necessary sterile preparations were in place, the doctor attached a spring-loaded needle to the transducer and located the ideal point for the biopsy.

The patient was instructed to hold his/her breath (to stop the organs from moving with respiration) and the needle was engaged and in and out within a second or two. The sample was washed out of the needle with saline solution and then quickly examined by another doctor using a light microscope to ensure that the sample was sufficient (in the case of a kidney biopsy, they had to ensure that there were enough glomeruli to perform an accurate diagnosis). Meanwhile, 2 or 3 more samples were taken from the patient.

Once the samples were confirmed, we ran them over to the pathology lab for further processing.

To maximize this last week, our plan is to spend at least two days in the emergency room, if they’ll have us. I regret that I haven’t spent more time there because it seems like there is so much more to do. Since I’m assigned to the kidney department, it hasn’t felt right to run off to the ER if there is something that I could there. But knowing if there is going to be something to do or not has been challenging! Instead, my days have been: attending four or so hours of meetings, going on rounds and then joining anything possible in the afternoon. By the time I’m done there, it’s almost a bit too late to head down to the ER (we’re supposed to finish around 15:00/15:30).

Now that I’m 3 weeks in and feel more comfortable here, I realize how little of an issue it would have been to just go whenever I want. There isn’t really any structure here, at least in my personal experience. I’m assigned to a department and I follow around whichever doctor will have me (usually the most senior doctor) and if I’m not told that I can join anything that day, I’m kind of on my own. I’m at a level of my education where I’m just not very useful. Once we have taken pharmacology (4th year) and have more clinical practice (4th and 5th year), we’ll be able to do a lot more. As I wrote to a friend earlier today, I’ve learned two things during this past month: (1) we know a lot, (2) we know nothing.

As you can probably tell, I’m currently in a mixed state of satisfied and disappointed. I wish there had been a bit more structure and guidance, but at the same time understand that this is not always possible in this environment. There have been good teaching moments sprinkled throughout the practice, for which I am very grateful:

  • One of the doctors, Dr. J, was a great teacher when he wasn’t busy. He taught me about different types of dialysis and even sat down with me for 20 minutes to explain the exact mechanism behind peritoneal dialysis – with drawings and everything. Despite his many years as a doctor, he’d retained his ability to think like a student and would often explain things in list form with plenty of theoretical details. Unfortunately he went on vacation after the second week, so I didn’t have much time with him.
  • Another doctor, Dr. T, was in a teaching-mood one morning and explained the importance of each of the lab values as we went through them. I furiously wrote these down and then properly answered a question when I was pimped by Dr. J a few days later. The question was, “What is the reason behind the increased leukocyte count?”, to which I answered, “Treatment with steroids”. I didn’t execute my answer very well though. I wasn’t sure that I had the right answer and mentioned that I thought I’d heard Dr. T say it earlier that week. Dr. J said I was right but joked that I’d cheated. Another doctor, Dr. Q, then asked if I knew the mechanism behind it. When I shook my head, he explained that steroids decrease the expression of the adhesion molecules that enable leukocytes to exit the blood into the interstitial space. So, there are technically the same number of leukocytes in the body, but more in the blood because they are stuck there. Pretty cool!
  • Last week, we had a doctor in (for just the day) who constantly asked me if I had any questions. This was really nice because I tend to write down things I am curious about, look them up later and then if I don’t find anything I ask. While we were waiting for the nurse to come for the doctor-nurse meeting, he pulled up a random patient’s EKG on the projector screen and told me to diagnose it. I was a bit flustered, since we’ve learned everything in English, but was pleasantly surprised at how quickly it all came back. My analysis was a bit bumpy – mainly because the speed is different (Norway uses 50 mm/min, whereas the rest of Europe 25 mm/min) – but I got it right in the end: acute right myocardial infarction.

A last experience – and an extremely valuable one at that – came with yet another new doctor, Dr. P. (Since it is summer and most Norwegians take their vacations during summer (Norwegians have the right to 3 weeks of vacation during the summer and 2 weeks outside of the summer), the doctors in the department have changed almost every week). One of the patients in our department is terminal and Dr. P had to set up a meeting with his/her significant other and sons to inform them there are no more options for treatment. The patient, whom we can call Blue, suffered for a long time with chronic kidney failure and received a kidney transplant last year, which unfortunately didn’t go well. Blue ended up with an infection and has been on a downward spiral since then.

The meeting ended up being three: one with Blue’s significant other, one with the most involved sons and one with the others (who were on vacation during the first two meetings). Each of these meetings lasted at least an hour long – which left me pleasantly surprised! I was present for the first two so that I could witness first-hand what it is like to deliver bad news to a patient’s family. I feel so lucky to have had that opportunity, as Dr. P has an especially good bedside manner. I’ve been on several rounds with him now and really admire the way he talks to the patients. He’s the kind of doctor that I hope to be one day.

That’s enough for today! Hoping the rest of the week goes smoothly, maybe with a few bumps for learning’s sake 😉

P.S. My stats page shows me which posts are read that day (not who or when). Someone looked at this one today – Perpetual fluctuation is the essence of the perpetual universe – and I’m so happy they did because it was just what I needed to “hear”. Such a treat to be able to look back like this! More than two years ago…so much has happened since then!

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§ 2 Responses to You learn something every day if you pay attention

  • Antonio Fiorentino says:

    One busy physician! Take time to enjoy some free time

  • Charkie says:

    Our lack of pharma has been a steep learning curve for me, too! I can’t wait for that class to get a better overview of the subject. (ask me again in October!)

    I’d be interested to hear how Dr. P. delivered the bad news and what you learned from it.

    Hope your last week is going well with lots of learning opportunities. 🙂

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