Things that Internal Medicine has taught me so far…
Before I start I need to vent – If another person asks me what Internal Medicine is, I am going to lose my mind. When you say Orthopedics people are like “Oh a bone doctor!” and when you say Paediatrics they say “Ag, sweet man, little children!” but when you say Internal Medicine they look at you with a blank expression until you say, “like heart attacks and stuff” and then they say, “oh right!” but still look confused. Have people never heard of a physician? I don’t get it, but I’m also not going to explain it here. I just needed to get that off my chest.
Now with that out the way I can get to the point of this blog post – the things I have learnt in Internal Medicine after my first two and a half months.
Number One: I know nothing. If a consultant asks me what I think is wrong with the patient, I think of my differential diagnosis and then say the complete opposite. Most of the time my differential diagnosis (when it isn’t “I have no effing clue”) is way off, and when I do get it right, its because someone else suggested it. It is okay though, at least I am humbled.
Number Two: The history taken by an intern is not trust-worthy. This is not the intern’s fault. It’s a phenomenon called “Consultant Syndrome”. For some reason, internal medicine patients will, without fail, tell the consultant something completely different from what they tell the intern. I can’t actually account for how many times a patient has told me he is not coughing (replace with any other symptom) and then on the consultant ward round: “Yes, yes doctor, I am coughing too much.” Really, now you decide to speak up? And what does “too much” even mean?
Number Three: Always examine your patient, thoroughly. But also remember that no matter how thorough you are, the consultant will always be more thorough. You will miss something or misinterpret something. It’s just the way it goes. I remember one day, I was so pleased with myself that I had picked up that the patient has cerebellar signs (google it), I even based my whole differential around it, and then the consultant was like, “Oh, I think he just has proximal muscle weakness which makes him appear ataxic”. I refer you back to point number one – my differential was, once again, way off. Humbled indeed.
Number Four: Fake it till you make it. This lesson basically summarizes points number one and three, and actually applies to all disciplines in medicine. Most of my time in internal medicine is spent walking around, thinking, “I have no idea what I’m doing.” But if you throw around phrases like “Hypertensive Heart Disease” and “Uremic Encephalopathy” people will think you are clever. Well at least your patients will. The other doctors will probably just think you are full of shit.
Number Five: Death is imminent, and probable. It sounds morbid, but it’s true! My first week in Internal Medicine, someone died everyday. And the ones that were still alive were: “Not for ICU, not for active Resuss”. Although, it can be quite a relief to read that on someone’s file – it sounds terrible but its honest. One of my biggest fears on call is that the ward will call and say they have started CPR on someone. In EC at least you have colleagues to help you and in ICU everything is geared for resuscitation, but in the ward it’s just you and a couple of nurses and one little resuss trolley and it’s scary AF. So when you arrive in the ward and read “Not for active resuss”, in a patient’s notes it’s a (selfish) relief. On the other hand though, it can also be so frustrating. So many of Internal Medicine patients are so ill that there really is nothing more you can do for them. Death is imminent and you are just waiting around to certify it.
Number Six: Everyone has TB until proven otherwise. Wear your mask. No one is safe. The guy who I thought has some cool cerebellar disease – he actually just has TB. The one who came in complaining of painful feet – TB. HIV positive – TB. HIV negative – also TB. But he’s not even coughing – still TB. The patient’s family member – also TB. Trust no one.
Number Seven: Do not go into the EC unless absolutely necessary. It’s almost like EC doctors have an “out of sight, out of mind” thing going on. If they can see you their threshold to refer is significantly decreased. I would know, I also worked in EC. It doesn’t happen as much to me as to my consultants and more senior colleagues. Probably because the EC doctors know the patient is better off in their hands than mine. But if they see a Internal Consultant hanging around, I can guarantee the EC doctor will pull out an ECG.
Number Eight: Finally, don’t argue with the patients who have “googled statins” and come to the conclusion that they are “dangerous”. Even though they have no clue what Internal Medicine is, they think they are qualified to analyze scientific articles and draw conclusions from them. They will not be convinced. To those patients I just want to say one thing about Dr Google – he’s the guy that will diagnose your bronchitis as stage 4 lung cancer. He’s also the guy that will recommend you treat your TB with garlic. Even me, the intern who knows nothing, whose history is not trustworthy, who is just faking it till she makes it – knows more than Dr Google. And if I don’t – my consultant is going to do a ward round in the morning and fix all the mistakes I made anyway.