Spencer C. Knox, MD

Internal Medicine Resident Physician, PGY-3

Tag: medical

My Last Month of Wards as a Resident: Reminiscing

With only one week remaining in my final month of Wards (adult inpatient medicine), I’m finding the moment bittersweet.  Undoubtedly, there’s a sense of nostalgia.  I remember my first day of Wards, not knowing the answer when an RN asked me, “Can the patient in room [632] eat breakfast?”  I remember hours spent answering the onslaught of pages from the floor pager when on-call.  I remember the metamorphosis when my title changed from “intern” to “senior,” and all of the new expectations that came with the new position.

Internal Medicine residency is rigorous, but it’s something I am so incredibly thankful for.  Wards is considered one of the more rigorous rotations, since it includes working six days/week and 24+ hour calls.  The remarkable amount of information I have learned throughout 12 months of Wards, over the past two and a half years of residency, has molded me into the young physician I am today.

Time Management:  According to Each Year of Residency

Since beginning residency, “efficiency” has signified different things.  Intern year, solid time management equaled seeing all of my patients and writing all of my notes before the unwritten deadline (e.g. when our attending liked signing them).  Slowly but surely, I ultimately learned to formulate my own medical treatment plan independent of my senior.

Second year marked another keystone moment in my training when suddenly I had to manage a list of 20 patients, two interns, and a medical student.  Time management at this stage meant staying on top of admission orders, completing admission med reconciliations, updating medication/treatment orders, and answering “upper level” management questions that were filtered via the interns.

Now in my third year, I am working on fine-tuning my practice of medicine and deeper learning.  It’s expected that I know how to treat common illnesses, but third year residents also need to expand on our relatively small knowledge base so as to better care for patients.  Increasing efficiency when admitting patients, prioritizing sick patients, and identifying who may soon become very sick is consequential.  Finally, learning how to coordinate with the RN and even radiology technicians can have a management-altering impact!

What I Hope to Take With Me

  • Remember the lessons learned from both positive and negative patient outcomes – be mindful of improvements to patient care.
  • Each attending has something amazing to contribute – take a few positive elements from each one and formulate my own ideal way to practice medicine.
  • Always approach each new intern/resident with respect.  Also understand that I may teach them something valuable, even if it seems mundane to me.  Conversely, I need to keep an open mind and realize that a junior may know something I don’t!
  • Prioritizing and time management is imperative!  It can help enhance medical care, and even save lives.

Fellowship Candidacy

Life in residency is always busy.  Time flies by.  I am nearly three months into my third and final year of residency (PGY-3).  I was scrolling through social media earlier today, and noticed a familiar big announcement:

The start of a brand new cycle of residency applications is a momentous event.  For MS4’s, it marks the official beginning of what will be a life-altering season.  Interviews will be sent out to deserving applicants, and both the programs and applicants work towards a match.  I can’t help but remember the feeling of pure joy at the sight of each invitation email.  It’s been over two full years since I went through the process.

Right now, as I enter the fourth month of my last year of residency, I can say that I am so very honored and happy at my current residency program.   I like my co-residents, and call many of them friends.  Attendings have been extremely supportive.

Now, I am a candidate for a fellowship in Gastroenterology (GI).  I recently went on my first interview for a 2018 position, and felt very, very honored to be in the presence of so many professionals who are making GI their life’s work.  Meeting current GI fellows and attendings is extraordinarily invigorating.  I can see myself diagnosing and treating patients with disorders of the small intestinal including Celiac Disease and malabsorption.  I want to make it my career to protect and prevent complications of Barrett Esophagus, IBD, colon cancer, and various other downstream problems of the gastrointestinal system.  A Gastroenterology fellowship would mean the world to me!

Introduction to Esophageal Problems

The very first entry in my GI & Hepatology study outline series will set the stage/define major descriptors of proximal GI (esophageal) symptoms and help with categorizing pathology.

Dysphagia = the sensation that food and/or liquid is not appropriately going through the mouth/throat/esophagus.  Typical symptoms:  “food is getting stuck / impeded.”

  • Oropharyngeal phase – food bolus from mouth into hypopharynx and proximal esophagus
    • “Transfer Dysphagia” – cannot START the swallow maneuver.
    • Symptoms:  coughing, food entering nares, choking; hoarseness and/or dysarthria (neuromuscular weakness/dysfunction)
    • At direct aspiration risk due to inability to clear food/liquid from epiglottis (look for perpetual pulmonary infections)
    • Examples:  cricoid webs, iron deficiency, mass compression, ALS, stroke, dementia, Myasthenia Gravis.
    • Best initial test = modified barium swallow (videofluoroscopy)
      • Test begins with liquid phase, proceeded by solid phase
      • If overall test is normal, symptoms are NOT oropharyngeal in nature.
    • Treatment
      • Dietary modification and swallow exercises (speech language pathology)
  • Esophageal phase – from proximal esophagus to stomach.
    • Symptoms:  lower chest discomfort, can be to solids (mechanical blockage) or liquids (motility issue) or both solids/liquids (motility).
    • Examples:  Achalasia, systemic sclerosis, strictures, cancer, vascular dysphagia, Schatzki ring, or webs
    • Best initial test = upper endoscopy (EGD)

Pyrosis = heartburn, or regurgitation of gastric (acidic) material into esophagus.  #1 GI complaint in the US.  Think about it if symptoms occur 1 hour after eating.  Must first rule out cardiac problems!

Odynophagia = PAIN with swallowing, related to inflammation and mucosal damage.

Globus feeling = symptoms include lump/ball in throat, can be constant when patient is not swallowing.  Consider barium swallow or nasal endoscopy to rule out organic disease.

Bibliography

  • ACP MKSAP 17:  Gastroenterology and Hepatology, pgs. 1-2
  • Image:  F. Netter Anatomy illustration

PGY-1 “Intern” Year In Review

It’s time for the obligatory “year in review” post, and I couldn’t be more proud.  Intern year is an emotional rollercoaster, marked by episodes of triumph and failure.  The year is almost over, and I am (anxiously) awaiting my second year of residency training.  Finishing intern year (first year) is a huge milestone in my professional medical career.  Many medical students ask me:  “Any advice for my first year of residency?”  My answer:  The learning curve is supremely steep; the first few months – really the entire twelve months – are extraordinarily difficult no matter your rank within your medical school class.  Personally, I worked hard to maintain a top ranking position within my med school class, but still felt the full burden of the many lessons that intern year teaches.

Dr. ________, (you) are responsible for official-record documentation

From Day 1, most specialties require new baby doctors, aka “Interns,” to be responsible for patient History & Physical’s and Progress notes.  These are the real-deal.  Gone are the days that your medial student notes are reviewed by the resident or faculty mentor and then set aside for your next practice H&P/progress note.  Other physicians, residents, and nurses will read your documentation and you will be judged accordingly.

Dr. ________, can patient in room 618 eat?

I was asked this question during my first official pre-rounds on adult wards.  I had no idea if the patient could eat and had to consult with my senior resident.  You as the new intern will be asked this simple, yet important, question.  Answering wrong means the vascular surgeon won’t be able to operate as scheduled.  Your patient could continue to suffer and your consultant surgeon won’t be happy.  Synthesizing pertinent data points is no easy task for a baby doctor, but you will learn quickly.  Trust your seniors to help you early on, and remember your cases.

Patient in ED bed 23 needs something for pain.

Many rising PGY-2’s will probably agree that the first days of intern year are scary in that YOU are now responsible for some of the orders (and likely all of the orders as your PGY-1 year progresses).  Every medication has its therapeutic (good) effects and adverse effects (some potentially deadly!).  I’ll never forget some of the very first few pages I got from floor and ER nurses asking me for medication orders.  For IM, the very long list includes pain control, blood pressure reduction, fast heart rate control.  A ubiquitous order request is for pain control.  Everyone, including the layperson, is aware of some of the deadly effects of opiate pain killers.  Yet, as an internal medicine, surgical, etc. intern, you’ll be asked to evaluate a variety of cases that require high-intensity pain control medications.  This happens month one of residency.  This is another instance where your senior will help guide you, in most cases.  It’s scary yes, but be prepared for it and you’ll get through it too!

Summary

Intern year was amazing.  I love Internal Medicine.  It’s a cerebral specialty – your thinking will either positively, neutrally, or negatively affect your patient’s wellbeing.  That’s powerful.  The learning curve from medical student to intern year (first year of residency) is STEEP.  Just when you feel you know everything about Atrial Fibrillation with Rapid Ventricular Rate, you’ll be presented with a new patient who hosts a complex medical history and be forced to rethink how to care for this particular patient.  Other specialties are not dissimilar; I enjoy talking to everyone about ways they’ve needed to evolve their thinking.

Intern year = baby doctor learning the basics of the basics, lessons required to become an independently practicing doctor.

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