A Day in the Life: General Internal Medicine

Internal medicine. Perhaps the most notoriously soul-sucking of clinical rotations. I'll be spending eight weeks in it this year -- two down, six to go -- and actually, apart from the long hours, it hasn't been all that bad :) Here's how I spend a typical day:

0600 h: I leave for the hospital.

0620 h: I arrive on the ward, print a list of the patients, and copy down any new results (bloodwork, imaging, etc.) onto the list.

one benefit of starting early: watching the sun rise as I wander from ward to ward

0630 - 0730 h: I briefly check in on each of the patients I'm following (I always debate on whether to wake them up and usually have to in order to examine them). I speak with the nurses about how the patients did overnight, check the charts for updates, and look over the morning vitals. I start writing a progress note on each patient, but usually have to come back to finish writing it as before I know it it's time to go to teaching!

0730 - 0830 h: I join the other residents in the conference room for a teaching session by the senior resident.

senior resident teaching

0830 - 1300 h: I and two other junior residents meet our attending physician on the ward. We collect all of the charts for his patients and put them on a trolley to push around with us from room to room. We spend around four hours rounding as a team. I present the patients whom I saw earlier in the morning, giving a brief update on how the patient is doing, any pertinent test results and physical exam findings, and what I am planning to do in terms of management. We discuss the management as a team and I write orders in the chart and add to my progress note. I make a to-do list of things I need to follow up on for each patient (e.g. phoning to request a specialist consultation, filling out a test requisition form, etc.).

home base

1300 - 1400 h: I try to power through my to-do list as soon as possible after team rounds. It's best to consult other physicians and order tests as early in the day as possible, to avoid having them put off until the next day. I make sure to grab my lunch to eat while I'm working (#1 rule in medicine: eat when you can!).

multitasking

1400 - 1730 h or 1830 h: I go back to see each of my patients, finish my progress notes, and address any issues that may have been overlooked in the rush of morning rounds. Often I speak with family members in person or over the phone. Most patients have a social worker, occupational or physical therapist, dietician, or speech language pathologist involved in their care; I make sure I review their recommendations, as well as those from other consultants. I keep an eye out for new lab results that may trickle in during the day and adjust the patient's orders if necessary. I also respond to pages to address new issues as they arise.

getting through paperwork...and getting better at remembering to drink water!

We divide newly admitted patients amongst the residents. When I get a new patient I spend some time looking over the chart and electronic records to get an idea of the patient's diagnosis and plan. If not previously done, I have a "goals of care" discussion as early as possible. Fortunately, unless we are on-call, we are spared from admitting patients from the emergency department. It would be a lot busier if we had to do new admissions as well as manage patients on the wards (we did both at the teaching hospital where I did medical school...and were stuck there until late evening every day; I'm really glad we don't do that here!).

Most days our team discharges four or five patients home. This requires writing discharge prescriptions and a discharge summary, which must be dictated over the phone for transcription onto the electronic chart. Most patients will follow up with their family doctor after leaving the hospital, so I make sure I give the family doctor a phone call and fax over any pertinent information. Many patients are on warfarin, a blood thinner that requires a lab test to guide its dosing, so it's important that I clarify who will follow the patient's bloodwork and adjust their warfarin dose once they leave the hospital. Down to the little things like how the patient will physically get home, there is lots to be considered when discharging a patient. Fortunately we have wonderful unit staff to help sort everything out!

In general internal medicine there is a lot to be learned and seeing something first hand in a patient is probably the best way to remember it -- and we have plenty of patients, so lots of good learning! The days are pretty packed, but time passes quickly, and eventually I get everything crossed off on my patient list (it's a mess of scribbles by the end of the day!). The nice thing about working on a team is that with several minds put together it's harder for things to slip through the cracks. I have two other junior residents on my team, which is really great; we cover each others' patients when someone is post-call or at an academic session (and after my past two more isolated rotations, it's fun to have some company!).

Here are the learning/reference resources I use everyday in general internal medicine (nothing too exciting here...just the standard ones we all carry around).

Pocket Books (also available as ebooks):

1. Approach to Internal Medicine by David Hui
2. Pocket Medicine: The Massachusetts General Hospital Handbook of Internal Medicine by Marc Sabatine

Electronic Resources:

1. UpToDate -- A huge evidence-based database, well-organized for quick information finding. I'm lucky that my program pays for residents' subscriptions.

Apps:

1.  Medscape -- I use this free app to look up drug information; it's great that it works offline.

...and of course good old Google to find gems like this

(http://drug.wellingtonicu.com/Appendices/5/)