Posts tagged residency

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Smile by Aoi Teshima (original by Nat King Cole).

Post-call and post-CTU rotation, I drove home in a different state of mind. It is now the end of my first rotation. So much is changing, and so much has changed. I reflected on the hard situations I have been in, the long nights on call, and the tragedies I was involved in. It has been such an emotionally draining rotation. Let music be my medicine.

All joking aside though Tom, you do look different compared to four weeks ago.
A comment from one of my new residency classmates after a block of internal medicine, where he purposely left it ambiguous.

Embrace

The echoes of my steps resonated within the expanse of the hospital garage. As I made my way to the end of the aisle to my stall, a couple caught my eye.

A tall man, his hair only beginning to turn grey, faced a woman of similar age, dressed in a beautiful white summer dress. Next to them a car, its trunk agape, half packed with a box of personal belongings and a white plastic bag full of clothes sat waiting. Still, they stood, pausing, ruminating.

They stared longingly into each other’s eyes, a deep seeded pain overwhelming them as tears trickled down their delicate features. A warm embrace as they held each other tightly and wept.

I wondered what terrible tragedy had befell them. Did a loved one’s health take a turn for the worst? Did a loved one just pass away? Did their mother, father, daughter, or son, just perish from this earth? I could not help but wonder.

But it was not my place to ask.

I watched helplessly as they buried their heads in each other’s shoulders and comforted one other.

I continued walking.

The Problem With Shorthands

I saw a patient on the ward on call recently where the patient’s complaint was some mild shortness of breath. Upon reviewing the progress notes, one of the issues low down on issues list was titled PE.

My heart skipped a beat.

Pulmonary embolus. My thoughts raced at the possibility that this patient had a recurrence. I quickly went back to see the patient but found that his story and physical exam did not quite add up to what I had imagined. I decided to go back and read the chart notes carefully again.

The more I read the notes in its reverse chronology, the less this PE sounded like a pulmonary embolus until I finally found the source, some ten pages back, buried in the middle of their already thinned chart.

Pleural effusion.

Over time, a relatively benign finding had been unintentionally shortened to a grave and emergent issue by the student writer. I breathed a sigh of relief.

It was yet another reminder of how shorthands and acronyms can cause miscommunication.

Knock on Wood.

First Paycheque

I rushed home today after finishing call to log on to my computer. It is my first pay day, and I was anxious to know if my payroll application had gone through. It did.

While the electronic transfer only takes into account a week’s worth of pay due to delayed processing, the amount transferred was still more money than I had ever received on a single pay stub.

Low Battery Warning

On call again. Half way through my shift, my pager has started to flash its low battery warning. No. Not now. Not when I still have follow ups that need to page me.

It is yet another issue to deal with, keeping me on edge, preventing me from sleeping.

Please do not die on me tonight.

The First Week: Thoughts on Being a Doctor

Today marks the end of my first week as a doctor. To say the least it has been exciting, interesting, but above all, scary.

I have hit the ground running here, starting my first rotation in internal medicine. The days thus far have been long, hard, and busy. Everything feels more real, more high stakes; after all, I am now the one who needs to make the decision overnight. 

However, every resident feel like this when they begin practice. What I would like to share instead are some of my other experiences:

  • People are addressing me as doctor: This continues to feel very out of place to me. While I now do refer to myself this way, I still ask people to address me as Tom.
  • I can give verbal orders over the phone: As a medical student, I was never allowed to give a verbal order over the phone. In order to start investigations or medications, I always had to go to the ward and write it myself. Not anymore.
  • What orders should I give over the phone?: While I used to have time to think on my way to the ward as well as the luxury to phone the resident for approval, this is no longer the case. I cannot emphasize enough how awkward it is to be asked for directions on the spot. “Can I call you back?” or “Let me lay eyes on the patient first.” are my go-to phrases now.
  • Accepting my orders as they are: On very few instances when a pharmacist is on hand, no one has questioned my orders. It is a scary burden to carry as a new resident. “Is what I am about to order safe?” Unfortunately, no switch flips on in our head when we become a resident, granting us all the knowledge and competence we need to make these decisions on our own. Even for some of my simpler orders, I still run them by my senior resident first.
  • The work does not change: Honestly, while the responsibilities have increased, the work we must do is the same. That also means that time for sleeping, eating, and peeing is still at a premium. Already, I have done a 36 hour straight call shift. And more are to come I am sure.
  • Billing: I never had to learn about earning money as a medical student but now it is part of my daily life. The flip side to doing all of the clinical work is all of the paperwork, now billing included.

There are still two years ahead of me in this residency and much to learn, see, and do. Expect more thoughts on this transition in the future.

Rusty

Being off service for three months has made me more rusty than I thought. There was no greater wake up call than realizing I had forgotten how to approach some simple problems on the ward.

While it is July 1st and most all of the seniors and attendings expect a bit of an adjustment back to clinical work, my performance today was disappointing.

Back to the books.

Four Stages of Competence

In the 1970s, Noel Burch described four stages of learning any new skill and it could be summarized as follows:

  • Unconscious incompetence, where one does not recognize a deficit;
  • Conscious incompetence, where one does recognize a deficit and how to improve their skill;
  • Conscious competence, where one is competent but requires concentration to perform the skill, and;
  • Unconscious competence: where the skill has become second nature.

Everyone strives for unconscious competence. The mastery of a skill has become so complete that you can do it effortlessly. The scariest state to be in is the first stage. “You do not know what you do not know.” That can be a terrible position to be in, especially when a patient’s life is on the line.

That is why receiving feedback is so important. That is why we train for so many years, under the watchful eye of so many experts to be a master of the craft. Sometimes, in order to make that transition to the next step of our competency, it requires someone else to point out where we need help.