Friday, November 5, 2010

Block 4: General Medicine Wards

Wards. Of all the many tasks and rotations we do in our 3 years of internal medicine residency, we do this rotation the most. Plain 'ol, mostly boring, general medicine wards. Despite the utter boredom that is seeing the same problems OVER and OVER in patients who, for the most part, don't take care of themselves thus keep getting admitted OVER and OVER for these SAME problems, it is my favorite rotation.

Why, you might ask, is general medicine so boring? Don't people go into medicine for the intellectual challenge, the opportunity to evaluate, diagnose and treat folks w/ a wide variety of illness? Maybe that's why we go into it, but it sure isn't the reality. The reality is that we are well trained factory workers. We come to work and do the same thing day in and day out like people who work on assembly lines or who have cubicle desk jobs. And we don't even have our own cubicles.

5 medical problems make up probably 80% of the patients we see in the hospital on the general medicine service: congestive heart failure, "chest pain" (could be due to cardiac disease but mostly is not), chronic obstructive pulmonary disease and asthma, end stage renal disease, and infections (pneumonia, urinary tract infections, and skin infectious being the most common). And let me tell you, I can take care of these folks with both hands behind my back, blindfolded, and probably without even talking to the patients. It is the same treatments over and over. To the layperson, this should give you some confidence. When you or your loved one comes to the hospital with one of these problems (though since this is a blog geared towards runners I doubt many- if any- of you have these problems), your docs know exactly what to do. It's like a mechanic fixing a car, a Mcdonald's employee making a cheeseburger or your accountant doing your taxes. We'll do it right and it will be easy for us. It's nice to feel competent and able to handle your daily work-load. At the same time, this repetitiveness breeds a passivity that we as professionals have to keep at bay. Because you never know when you will finally get a patient that has a twist in their story- something that makes them different and interesting compared to the backdrop of BORING, BORING, BORING.

So, given this boredom, why is wards my favorite rotation? 3 reasons:

1. I know what's expected of me.

--In medicine you spend all of medical school and most of intern year trying to figure out what people want from you. What am I supposed to learn? How are these people going to grade me? How can I best help my resident? What does my attending like in presentations? It goes on and on. As a senior resident on wards, however, I know exactly what I need to do and most of it is fun--> serving as a resource for my interns/sub-intern and teaching the 3rd year medical students. Easy!

2. The hours are good and controllable.

--NO OVERNIGHT CALL. There is nothing I hate more than being forced to stay up past 8pm. Occasionally, rarely, I will stay up past 9 to socialize w/ friends, attend a wedding, or travel. But, only rarely. If I'm not in bed by 9, I'm miserable. Wards means sleeping in my own bed every single night and being home by 5 most days.

3. It's fun to work in a team room.

--On wards, each medical team sits in a room together. The 'team' consists of 1 resident, 1 or 2 interns, 1 sub-intern (4th yr med student) and 2 3rd year medical students. We sit in a room, each in front of our own computer and do work while we make jokes and laugh. Working with fun people makes going to work every day enjoyable, or at least less painful!

So what do we do all day as inpatient doctors on general medicine wards? There are 4 different types of days for us:

1. Call day- We get new patients from the ER, clinic, or outside hospitals. We evaluate, work-up and manage these patients.

2. Post-call day- We present all the new patients from the call days to our attending

3. Pick-up day- We get new patients from the overnight residents

4. Nothing day- No new patients- hurrah!

Day to day schedule:

7am: Get to work. "Pre-round" on our patients which means looking up their vital signs, labs, radiology studies and consult notes from the previous day). If we are on "pick-up" we hear about the new patients from the nightfloat residents who admitted them.

7:30-8:30: Educational conference called "Morning Report"

8:30-11am: "Rounds". This is when the entire team including the attending physician (our 'boss') goes form patient room to patient room to discuss the patients. We formally present new patients, discuss the past 24 hour events for the old patients and make daily plans for all the patients. This is the part of the day that fluctuates dramatically based on the attending. It can vary from fun with lots of jokes to very painful with lots of criticism. I've dealt with both.

11:00-noon: Mad dash to get our work done before noon conference.

Noon-1pm: Educational conference

1pm-3pm: Finish daily work. Our work includes writing a progress note on every patient, calling consults (cardiology, oncology etc), working on discharge papers, putting in orders, calling families and outpatient physicians to give updates.

3pm: Go HOME! Unless we're on call in which case we are busy seeing and admitting new patients from the ER. Then we can't leave until after 7, usually b/t 7-9.

Well, this post is long enough. That's a day in the life of an internal medicine resident on general medicine wards. As with most jobs, your days are made or ruined by the people you work with and, in general, the folks in medicine are smart, fun folks who like to laugh a lot. That's the main reason I'm still a doctor!


  1. Well, I started reading this blog because of your running - had no clue you were a resident physician. Now I'm impressed, because clearly you managed to keep running through at least some of your medical education. Good for you!

  2. Very interesting Dr. Nelson--would have to agree that the people make it worth it, but there is no boring in medicine. A day as a medicine resident is like a box of chocolate--you really never do know what you're gonna get!

  3. I love getting a peak in the life of Dr. Nelson:) I actually find this really interesting because I know nothing about medicine and what's involved with being a resident.