I chose to spend my elective rotation with our program director, Christine Bruce, and clinical coordinator, Trinell Genga, at their outpatient office on Penn State Hershey’s main campus. It was a privilege working with them (no brownie points here, I’m graduated already). Seriously, Chris is one of the main reasons why I chose Penn State over (much warmer) schools in the south. So when Chris offered to be my preceptor for my elective rotation, I could not turn it down.
Outpatient internal medicine was probably the best rotation to prepare me for both the PANCE exam and practicing in the real world. Considering I did my family medicine rotation early in clinical year, it was nice to have this ‘refresher’ before graduating.
I discovered early on that I was out of practice in many things (including treating a common cold). The principle of use-it-or-lose-it is as much true for medicine as it is for lifting weights (I suppose that is why they call it “practicing” medicine).
As you might imagine, it was a little nerve-wracking to rotate with my program director and clinical coordinator. Chris especially likes to “pimp” students in front of patients to see what they know. This is frustrating at times because I found myself frequently forgetting simple things that I never would have missed on a test. However, the questions she asked were no different than those I might field from a patient. In fact, some of my best educational moments came when I made mistakes in front of Chris (I will never miss the diagnosis of Meniere’s disease again).
The patient population in the clinic was not much different than in family medicine, except that there were perhaps fewer pediatric patients. The level of acuity was similar as well. In other words, while there were plenty of stuffy noses to go around, there were also some unforgettable moments with complicated patients, poor prognoses, and end-of-life care. Family medicine has its share of heartbreaking moments, too.
Perhaps my most memorable patient was an elderly man who had recently developed acute leukemia. He and his family spoke little to no English, and his daughter acted as translator. Much of our struggle was in simply providing access to care for this family (getting them catheters, oxygen, etc.). Our patient was the patriarch of his family, who clearly would go to the ends of the Earth to see him comfortable. It was not easy knowing that there was little that could be done medically to help him. The memorable part was simply the warmth of his persona as he faced the pains of a terminal illness. At every moment, you could tell that his concern was, scarcely for himself, but for his family.
Another memorable patient was an elderly woman who was suffering from dementia. The patient’s daughter was in attendance and was clearly struggling as the caretaker. A sense of guilt was palpable in the room as we discussed transitioning the patient from the home into a facility. The patient, herself, understood bits and pieces of what was going on and repeatedly brought up suicide. She accused the daughter of abandonment and brought up painful family memories from decades in the past. All of this as though she was trying to build some sort of production out of her daughter’s guilt. Through the furrowed brow and the shouts of anger, though, I could see that she was afraid. She was just afraid of the inevitable and the unknown, the loss of control and the beginning of the end. So I held this demented woman’s frail hand and did my best to calm her. I cannot imagine for a second having to face dementia in my old age or how terrifying it could be to lose one’s mind. It was obvious in this encounter how the role of a provider extends well beyond medicine. A caring/compassionate personality is just as critical to patients as your knowledge base.
1. Review the next day’s patients before bed. This is something you should do not only to impress your preceptors, but also in your future clinical practice. Brush up on certain diseases as well as look up any medications you are not familiar with. Of course, it will pay off huge when your preceptor is pimping you in front of a patient.
2. Give thorough patient-presentations to your preceptors. This is one of those rotations where your preceptors don’t want you to give them an abbreviated version of the story. They want to hear a well organized presentation from start-to-finish. Also be sure to include patient education and follow-up in your plan. After having had several rotations where my preceptors were more conversational about presentations, I almost forgot how to do them.
3. Use tactile-fremitus in your exams. And eegophony. And whispered pecterliloquey. You learn these physical exam techniques during your didactic year, and then may never see a provider use them your entire clinical year. I promise, though, they are useful. This rotation was the first time I saw providers actually doing these exam techniques (and they turned out to be really useful!).
4. Study during your elective rotation. I am sure that this varies between different programs, but the requirements for our elective rotation were less stringent than other rotations. We could choose to either take an exam or write 10 one-page essays on topics of our choice (very few chose to take a test). Don’t use this rotation to fart around, though. This is a great opportunity to fill in some of your knowledge gaps and prepare for the PANCE exam.
5. “Patients don’t care how much you know until they know how much you care.” This is something Chris Bruce said to us repeatedly throughout our education. As I mentioned above, personality matters. Often, demonstrating that you care is more therapeutic to a patient than what you’ve written on your prescription pad.