Internal med observerships

[ACHQ]

Hi,

 

I was wondering whether single day observerships ("one offs") in CTU would be useful to determine whether one would enjoy internal medicine (or inpatient GIM/CTU). Or is it useless because patient care is usually over several days/weeks so it would be hard to gauge.

 

I'm wondering because when I did some observerships in this way, I didn't find them as exciting as I was hoping for (I have a lot of friends in internal med that love internal, so admittedly I had high expectations). Is it because I wasn't really involved in their care? Is it because internal is more "cerebral" and so observing could be boring?

[Lactic Folly]

It's hard to determine in a vacuum. You need to do observerships in other potential career possibilities, and compare them with respect to your experience in internal medicine. I do think that being an observer could be part of why you didn't feel involved, if it was difficult for you to follow the rationale behind actions taken (would need someone to explain everything to you), or to feel that you were making a difference in patient care.

 

I'll also ask if you are looking for excitement as in igniting a passion that will fuel a career, or as in lots of action/cool things to see. Ideally you are searching for something that can bring you long-term satisfaction, and while observation helps you gain a sense of whether you fit into the culture, it can't replace talking to people for insights into how their profession matches their values or challenges them.

[ACHQ]

.

 

I'll also ask if you are looking for excitement as in igniting a passion that will fuel a career, or as in lots of action/cool things to see. Ideally you are searching for something that can bring you long-term satisfaction, and while observation helps you gain a sense of whether you fit into the culture, it can't replace talking to people for insights into how their profession matches their values or challenges them.

 

I think more of "lots of action/cool things to see" kind of deal. It also felt that most of the patients there had been there for a while and were at the tail end of their stay. It also seemed like a lot of note writing and meetings. I was looking for the stuff that people rave about in internal, that is complex DDx, Tx plans etc...

[A-Stark]

Hi,

 

I was wondering whether single day observerships ("one offs") in CTU would be useful to determine whether one would enjoy internal medicine (or inpatient GIM/CTU). Or is it useless because patient care is usually over several days/weeks so it would be hard to gauge.

 

I'm wondering because when I did some observerships in this way, I didn't find them as exciting as I was hoping for (I have a lot of friends in internal med that love internal, so admittedly I had high expectations). Is it because I wasn't really involved in their care? Is it because internal is more "cerebral" and so observing could be boring?

 

I don't think they'd be especially useful. Rounds tends to be pretty boring unless you're actually making decisions or involved in patient care. I generally like CTU but I get sick of it eventually too with the daily grind of admissions and discharges and potassium replacement. For IM observerships, you're better off going to clinic or emerg consults or subspecialties.

[A-Stark]

I think more of "lots of action/cool things to see" kind of deal. It also felt that most of the patients there had been there for a while and were at the tail end of their stay. It also seemed like a lot of note writing and meetings. I was looking for the stuff that people rave about in internal, that is complex DDx, Tx plans etc...

 

Yes. But if you're looking for "lots of action", you will not find it on CTU, though there will sometimes be interesting findings to see.

[Lactic Folly]

I think more of "lots of action/cool things to see" kind of deal. It also felt that most of the patients there had been there for a while and were at the tail end of their stay. It also seemed like a lot of note writing and meetings. I was looking for the stuff that people rave about in internal, that is complex DDx, Tx plans etc...

 

Yeah, the workdays of most fields in medicine are not composed of lots of action (even in ER, there's not as much as you'd think, unless you're going to all the traumas... and certainly, CTU is the wrong place to look!). Maybe labour & delivery or ICU, if it's possible for a preclerkship student to shadow there.

 

However, as before, how entertaining something is to watch is not the same as how much you would like to do it over the span of decades, e.g. enjoying watching surgery is different from wanting to pursue it as a career. Though if you dislike the OR environment, that's probably a good sign surgery isn't your best choice.

 

I think your CTU experience is actually compatible with complex DDx and Tx, as you put it (though I'll let the IM people speak to this)... such patients would engender long and complex notes, have lengthier stays for all the workup and treatment, and yes, meetings to discuss all the attendant issues. Do you perhaps enjoy just the diagnostic aspect and less so the long term follow-up? Are you content to stabilize and point in the right direction? Do you enjoy procedures more? These are all things to consider.

 

As an aside, this is not to do with you at all, but I'm reminded of an anesthesiologist I worked with who asked for feedback on a medical student elective. The student said they'd been hoping to see some codes in the OR - (the doc's reaction) ... after a while, boring is good

[A-Stark]

I think your CTU experience is actually compatible with complex DDx and Tx, as you put it (though I'll let the IM people speak to this)... such patients would engender long and complex notes, have lengthier stays for all the workup and treatment, and yes, meetings to discuss all the attendant issues. Do you perhaps enjoy just the diagnostic aspect and less so the long term follow-up? Are you content to stabilize and point in the right direction? Do you enjoy procedures more? These are all things to consider.

 

I'd say that a much better experience of "real" IM would come in clinic or emerg. CTU work is more about prioritization and management of sick and/or complicated patients, but I don't think there's anything about our notes that are "complex" or even always that long.

 

As an aside, this is not to do with you at all, but I'm reminded of an anesthesiologist I worked with who asked for feedback on a medical student elective. The student said they'd been hoping to see some codes in the OR - (the doc's reaction) ... after a while, boring is good

 

Haha. I'd say that you need no further evidence that said student should go into emerg and definitely NOT anesthesia.

[Lactic Folly]

I'd say that a much better experience of "real" IM would come in clinic or emerg. CTU work is more about prioritization and management of sick and/or complicated patients, but I don't think there's anything about our notes that are "complex" or even always that long.

 

Yes, I think someone shadowing in clinic or emerg would get to see more active diagnosing and treatment planning.

 

Re: notes, I may be relying on my own experience early in clerkship - with all that was going on with my sick/complicated patients, the only way I felt I could fully understand their medical issues was to write out all the details and lay them out in an organized fashion (kind of like studying in undergrad). No doubt I spent (some/much) more time on this than average, but it helped me learn. The more senior, the more succinct

[A-Stark]

I've found lately that my notes have gotten a bit longer but I write them at least 5 times faster, and expend more space on my assessment and plan than regurgitating lab values that you can (and will) just look up anyway. But the problem list is indeed the essence of IM - you just make better lists as time goes on.

 

I bet

would make a good internist.

[ACHQ]

Yeah, the workdays of most fields in medicine are not composed of lots of action (even in ER, there's not as much as you'd think, unless you're going to all the traumas... and certainly, CTU is the wrong place to look!). Maybe labour & delivery or ICU, if it's possible for a preclerkship student to shadow there.

 

However, as before, how entertaining something is to watch is not the same as how much you would like to do it over the span of decades, e.g. enjoying watching surgery is different from wanting to pursue it as a career. Though if you dislike the OR environment, that's probably a good sign surgery isn't your best choice.

 

I think your CTU experience is actually compatible with complex DDx and Tx, as you put it (though I'll let the IM people speak to this)... such patients would engender long and complex notes, have lengthier stays for all the workup and treatment, and yes, meetings to discuss all the attendant issues. Do you perhaps enjoy just the diagnostic aspect and less so the long term follow-up? Are you content to stabilize and point in the right direction? Do you enjoy procedures more? These are all things to consider.

 

You bring up some good points. I think I enjoy the diagnostic aspect, including interpreting tests/imaging doing an appropriate work up as well treatment plans. I think that's what I meant by "action". I felt I didn't see much of that in CTU, most of the patients seemed diagnosed, worked up and pretty much treated (or undergoing treatment), and it was more so checking up to make sure everything was "ok". Maybe I have the wrong idea of CTU or internal? Or maybe I went on some boring days? What do I know I'm just a first (soon to be 2nd) year

 

I actually have a shadowed a few times in the ER and found it more like that. Its funny you mention that even the ER isn't as much "action" as people think, and I thought so too and still enjoyed it. Maybe this means something

 

Thanks for all the advise guys!

[A-Stark]

I think you did end up with some boring days. It can be a totally different thing when you're actively admitted during the day (usually different CTU teams take turns at that over a certain cycle), and oftentimes patients are just hanging out til they're weaned off O2 or get cleared by OT/PT/SW or simply to expedite other investigations. Your residents and staff were probably grateful for the "boring" days, because sometimes you're running around calling consultants, ordering repeat lytes, re-assessing pain meds, etc.

[Jochi1543]

Internal medicine in theory and internal medicine in practice are polar opposites. Theoretically, internal medicine is very interesting, cerebral, there's a lot of exciting discussions, etc. Realistically, your ward will be 90% occupied by failure-to-cope seniors who have been there for months waiting for placement and cannot be discharged to the care home because they have bacteriuria; you are going to be swamped with paperwork (try a 30-page package for every admission - and up to 7 admissions a night), sleep-deprived, and surrounded by others who are equally exhausted and on edge, which will inevitably lead to conflicts and a strained work environment.

 

I never met so many miserable residents and staff as when I was on internal medicine.

[A-Stark]

Internal medicine in theory and internal medicine in practice are polar opposites. Theoretically, internal medicine is very interesting, cerebral, there's a lot of exciting discussions, etc. Realistically, your ward will be 90% occupied by failure-to-cope seniors who have been there for months waiting for placement and cannot be discharged to the care home because they have bacteriuria; you are going to be swamped with paperwork (try a 30-page package for every admission - and up to 7 admissions a night), sleep-deprived, and surrounded by others who are equally exhausted and on edge, which will inevitably lead to conflicts and a strained work environment.

 

I don't know what your centre was like, but this is pretty far off the mark for most places I've been to as a student and resident. And I can't imagine how any centre could be so inefficient as to require 30-page admission packages. Even at most laborious level I've experienced, that's a good deal more extreme.

 

Anyway, CTU/MTU is not really what IM is, and in the community internists rarely work as hospitalists.

 

I never met so many miserable residents and staff as when I was on internal medicine.

 

Clearly you didn't spend enough time on gen surg.

[Alastriss]

I don't know what your centre was like, but this is pretty far off the mark for most places I've been to as a student and resident. And I can't imagine how any centre could be so inefficient as to require 30-page admission packages. Even at most laborious level I've experienced, that's a good deal more extreme.

 

Anyway, CTU/MTU is not really what IM is, and in the community internists rarely work as hospitalists.

 

 

 

Clearly you didn't spend enough time on gen surg.

 

Wow jochi that sounds like a really crappy CTU experience. I would agree that is the extreme of what I've seen. You do get your fair share of bread and butter as well as a lot of interesting cases.

[ACHQ]

I think you did end up with some boring days. It can be a totally different thing when you're actively admitted during the day (usually different CTU teams take turns at that over a certain cycle), and oftentimes patients are just hanging out til they're weaned off O2 or get cleared by OT/PT/SW or simply to expedite other investigations. Your residents and staff were probably grateful for the "boring" days, because sometimes you're running around calling consultants, ordering repeat lytes, re-assessing pain meds, etc.

 

Thanks for the info.

 

Although I totally get being grateful for "boring" days (especially when you deal with this day in and day out), being a med student and not knowing much about internal medicine as specialty (other than the theory), would have been nice to see it more in practice.

 

I had done a bit of clinics in IM (sub-specialty not GIM) and it didn't appeal to me that much, so I wanted to check out inpatient IM.

[bloh]

The problem with IM is that that the form that most non-IM people (ie. students and most juniors) are exposed is awful because it's nearly all scutwork. You barely do any medicine and most of your day is involved organizing things, following up on things or writing notes/dictating.

 

A lot of cool stuff does happen around you but you're knee deep in scutwork to really give a damn and appreciate it.

 

When you think about the rest of IM it ends up getting more interesting:

 

R2 - mostly subspecialty consult service where you get asked to answer very specific questions about relatively cool things

 

R3 - you again do ward consults, see patients first hand in the emerge or run the show on a particular ward (ie. make sure your scutmonkeys are doing their job). Things are a lot more interesting when you're making decisions and being actively involved in things. This is the exact opposite of team rounding where only 10-20% of patients you round on you actually have to be awake for.

 

 

It's similar to other fields (surgery, O&G, etc) but the scutwork is appreciably larger on internal that it overwhelms all other aspects.

[ACHQ]

The problem with IM is that that the form that most non-IM people (ie. students and most juniors) are exposed is awful because it's nearly all scutwork. You barely do any medicine and most of your day is involved organizing things, following up on things or writing notes/dictating.

 

A lot of cool stuff does happen around you but you're knee deep in scutwork to really give a damn and appreciate it.

 

When you think about the rest of IM it ends up getting more interesting:

 

R2 - mostly subspecialty consult service where you get asked to answer very specific questions about relatively cool things

 

R3 - you again do ward consults, see patients first hand in the emerge or run the show on a particular ward (ie. make sure your scutmonkeys are doing their job). Things are a lot more interesting when you're making decisions and being actively involved in things. This is the exact opposite of team rounding where only 10-20% of patients you round on you actually have to be awake for.

 

 

It's similar to other fields (surgery, O&G, etc) but the scutwork is appreciably larger on internal that it overwhelms all other aspects.

 

I've heard the term "scutwork" a lot but don't know what it exactly refers to, anyone want to clarify

[leviathan]

I've heard the term "scutwork" a lot but don't know what it exactly refers to, anyone want to clarify

Work that needs to be done that has little or no educational value. Also work that could be done by someone with little or no medical education.