Chapter 33: 4th year

 Chapter 33: 4^th year

The fourth year of medical school was certainly the best. It’s a time for exploration and confirmation of some decided career path. I had decided on internal medicine and was excited to do rotations in only fields I was interested in. My first rotation was the infectious disease consult service at Seattle’s community hospital—Harborview. I worked in a small, windowless room, with one other medical student and the infectious disease fellows. The fellows were wonderful and deliberate about giving me time and space to develop differential diagnoses and plans for the patients I was assigned. It was a busy service and I often had 2 new patients per day. What I loved most about the service from the medical side was how important history and physical exam became. While tests and imaging were important, often the culprit infectious agent could be pinpointed from the history alone. Likely my proudest moment from the rotation was when I diagnosed a patient with Brucella vertebral osteomyelitis based on his history of drinking unpasteurized milk while living in Mexico. The culture from surgery confirmed theorganism, which became a problem because apparently everyone exposed required prophylactic antibiotics to prevent infection—lesson learned, make sure the lab knows which organism you think that you’re dealing with.

              The team was also phenomenal to work with. Certainly one of my favorite teams from all of medical school. The fellows were deliberate about teaching nearly every day. I learned more on that rotation than I believe I did on most that came before. The fellows were also huge soccer fans, and so when the Women’s World Cup began, we filled out our own brackets and made sure that it was always playing on one of the computers to watch the progress. We had a wonderful attending physician who offered a free lunch to the winner of the bracket. And so each morning we went through new patients, then old patients, then the soccer games played and upcoming. Then, depending on time, would do some early teaching.  We also occasionally had something called “micro rounds,” where we went down to the lab and looked at the cultures that were running. Seeing the process of how organisms were identified in the hospital and learning about the instruments that assist in the process greatly helped me understand how the whole process operated, which greatly benefited me during later rotations and when starting residency. And so the rotation ended. One of the fellows, the one who liked women’s soccer most, won the bracket.

….

              The next rotation was at the same hospital and was the nephrology consult service. I wanted to do the fields I was most interested in first. The team was similarly composed, this time with two fellows, one resident, and an attending. Again, I was given a good amount of independence and time so that I could truly experience what it might be to become a nephrologist. It was a busy and fun service. We managed consults for acute kidney injury as well as any patient on dialysis. Early on our attending Dr. Y tought me about how Dialysis worked and the varriables and management of it. Once I learned, I got my own patients on dialysis to manage. I absolutely loved it. I found dialysis to be fascinating, especially as a prior chemistry major. I began to get excited each morning to look at the patient’s labs and decide on which electrolyte baths and anticoagulation to use (obviously on patients that were on continuous dialysis as opposed to intermittent). The attending eventually did a teaching session on acute kidney injury, and eventually presented three versions of basic work-ups depending on suspected etiology. It was a useful way to remember the causes and the way to test. While I loved the nephrology rotation, I did miss the diagnosis from history that was possible in infectious disease. However the physiology and chemistry and pathology involved with nephrology was much more interesting for me. And while both infectious disease and nephrology both interestected greatly with underserved communities (which was a goal for me) I ultimately decided that I would eventually like to pursue nephrology. There were many reasons for this. Th fellowship seemed more enjoyable, and the career opportunities greater. And so the rotation ended. I now had to pack my stuff up and get back to Spokane, Washington.

              My next rotation was at the first hospital I ever entered and interviewed a patient at: Sacred Heart Hospital, in Spokane. It seemed like a good return journey. I was going to do a sub-internship there, which was basically where I acted like a first-year doctor (an intern), almost as a trial. , while I was there. Thankfully, my housing was easy because my good friends Ariana and Dana offered me a room in their flat for free, which also meant I got to hang out with them and their wonderful dog Margo often

              I drive over. Ariana greets me and gives me a key. I thank her and say hi to Margo, who is wonderful—a soft and intelligent Duck Tolling Retriever. They’ve cleared out a room for me and left my old bed that I had left with them several years ago, which apparently Margo has come to love. And so most mornings or evenings Margo comes in to lay on the bed. I deeply miss having a dog and think this is wonderful.

              The next morning after moving in is the first day of the rotation. I drive to the hospital and use my old parking pass (which surprisingly, works) and walk up to the team room that I’ll be working with. There are 2 other residents, one 3^rd year medical student, and an attending. As an acting Intern I’m given a couple patients right up front. Despite it being busier than prior rotations I love it—getting to take care of many patients at once is much more fun. I quickly get caught up on the patient’s diseases and their current treatment plans, then go talk to them and introduce myself and confirm all of the things that I’ve read. I like all of the patients, they’re kind. One patient in particular has Leukemia. He will be here a while. I feel bad for him because he is incredibly kind and gentle, along with his wife who is there with him. We’re working with the oncology and hematology service to start rapid treatment in the hospital with potential bone marrow transplant before he leaves. We’re treating him for an unknown infection at the same time. Basically he has no immune system but he’s getting a fever, so he gets strong antibiotics. Each day he asks the same thing—which I’ve grown to deeply understand—“when can I go home?” I tell him I wish I knew a date and time, but essentially tell him each day “not yet,” and then check if there’s anything we can get him that will make things more comfortable; but he never has a specific answer. I make sure he has a nursing communication that says it’s OK that his wife can stay any day for however long she wants, because the last thing we need to take away from this man is his desired company.

              The team is fantastic and they do their best to treat me as though I really am a first year resident, which I greatly appreciate. The workload is enormous. Somehow I keep up, and I’m grateful to have the practice in a familiar place before actually going to residency. Every so often I’m given the opportunity to do teaching for the third year medical student. By now I’ve bought a book with several chalk talks to help prepare in general for residency called—“the fundamentals of internal medicine.” With this book and my prior rotations I’m able to give a few good talks. This makes me feel like I am really on the way to becoming a real doctor. Eventually, our attending Dr. K gives me feedback and tells me I’m doing an incredible job and wants me to come to their residency program. It feels like high praise and I deeply consider it; however, I still want to pursue a more academic residency with research in order to get to nephrology more easily (not that it actually matters that much because nephrology is such a noncompetitive specialty). I appreciate the feedback. It makes me feel like I really am ready for residency. The rotation eventually comes to an end, my leukemia patient gets his bone marrow transplant and is eventually able to go home. I still don’t know if he was cured, but I hope for him each day.

              My last rotation of choice was pain medicine back at Harborview. I picked it because I had noticed during third year that pain was a common and major problem, and wanted to know how to manage it better prior to starting residency. It was overall a fantastic rotation, where I learned an enormous amount about opioid dosages, alternative medicines, and interventional therapies for pain. It would serve me well later. It was there that I learned a great deal about Ketamine as an an opioid sparing pain therapy, which I would hope to employ later to good effect.

              My next rotation was a required 4^th year rotation. I would be doing Neurology in Kalispell, Montana. The school put me up in a nice home with other students who were doing rotations in the same area. They also provided free access to a gym, which was nice for after each day. I spent each weekday at a neurology clinic with a neurologist. We mostly saw patients together, which was a relaxing change of pace from my prior rotations. The Doctor also had a neuroimaging fellowship, and so he taught me a great deal about reading brain MRIs while I was rotating through. I found this to be the most helpful part of the rotation. It would later help when I was looking at my own MRI in order to understand what was going on, and the changes that had happened. In fact, while the initial ED doctor who looked at my MRI when symptoms first started told me that the radiologist did not believe it looked like a glioblastoma, when I looked at it I felt it was certainly a glioblastoma, which helped me prepare when the diagnosis finally came. And so I’m grateful for that early training in brain MRIs.