Internal Medicine

WOWZAS. Internal medicine is truly the foundation of medicine. You see everything and anything and have to be prepared for what will walk through the door. The learning curve was steep for me, but I really appreciated the growth that came out of this rotation!

I loved being in a rural setting for this particular rotation because I got to see and do A LOT. We were outpatient in the clinic, inpatient on the floor, in the emergency room, and in the operating room (minor procedures). The perk of being an internist in a rural setting is that you have so much autonomy in practice and so much respect by your patients. There is a scarce number of specialists around, so sometimes you have to try to be their specialist. I also loved the patient population in the clinic/hospital that I was rotating in. They were all so incredibly sweet, willing to share their personal and medical stories, and allowed me to practice my clinic skills on them. Plus, I learned so much beyond medicine. I learned about the patient’s personal lives, their hobbies, coal mining, bee keeping, and so much more. This allowed me to build a better understanding of my patient’s daily lives and why they do what they do. My preceptor would frequently try to freak my patients out before I performed a procedure on them (such as a joint injection or venipuncture), but they were all so welcoming and were so willing to let me practice on them!

My typical week was Monday-Thursday 9am-5/6pm. I remember walking into the clinic on my first day and my preceptor was currently in a room with the patient. He walked out of the room, introduced himself, and immediately sent me off to see the first patient on my own. This threw me for a loop, but I learned to LOVE this. He never gave me the opportunity to hesitate. He helped me get out of my comfort zone and grow as a provider. I saw all the patients on my own. I would either report a summarized explanation of the patient’s visit or we would discuss the patient’s concerns in the room with the patient in front of us. I ended up performing venipunctures daily, intramuscular injection, intra-articular joint injections, ear canal irrigations, and EKGs. In the operating room, they let me perform a lot of the procedures. We removed skin lesions, cleaned abscesses, removed ingrown toenails, and performed joint injections.

Did I have assignments? Occasionally. He frequently had me go home and look up things that we saw that day. I ended up creating a document for all my notes of things I learned throughout the rotation. He also assigned me to do research on obstructive and restrictive pulmonary disease. I typed up a word document on pathophysiology, clinical presentation, diagnostics, and treatments.

Did he pimp me? OH YES. Daily. I remember my first question was: What percent of blood flow goes to the kidneys? And…the question was in front of a patient. Thankfully I guessed the right number (don’t know how in the world I did that).

Overall impression:

It was a GREAT rotation! Currently, I do not see myself working in internal medicine, however I am definitely still open to it! I would love to work at the hospital I rotated at, however I don’t see myself staying in West Virginia after I graduate. As I described above, I loved the autonomy my PA had and how much trust the other providers had in him as well. I loved that I had this rotation in a rural setting. Personally, I wish I would have been able to see more of the inpatient side of internal medicine, however I am very thankful for ALL that I was able to see! Being in four different areas of medicine during one rotation was pretty awesome!!

Personal tips for Internal Medicine:

-       Try your best! Internal medicine is a lot, but all you can do it learn from it. It will provide you with a lot of growth personally and medically. Go into the room and try to get a detailed history and physical exam.

-       Practice your clinical skills! Internal medicine is a great opportunity to practice your skills. Feel thyroids even if there is no thyroid complaint. Listen to the heart and lungs to between understand normal from abnormal. Practice diabetic foot exams on diabetic patients. Be bold and ask if you can perform the venipuncture or IV insertion.

-       If you don’t know something, tell your preceptor that you will look it up and get back to them, and actually do it!

-       Carry your Maxwell Guide pocket guide with you. This helped me a lot! It was a great reference for admit notes, discharge notes, procedure notes, normal lab values, and so much more.

                                                                  

-       Like podcasts? Check out Curbsiders!

One of the best pieces of advice I received is: The patient/parents don’t know if they are your first patient or you 1000^th patient, so act like it’s your 1000^th. Walk in with confidence, obtain a detailed history, and do your best to perform a detailed physical exam. Every patient is a learning opportunity.

Q&A:

-       How should I prepare walking into my first day of internal medicine?

o   Be open minded. Internal medicine is a lot. Go in the first day and just do your best. Take a detailed history and physical exam. If you don’t know something, that is okay! It is a great rotation to learn from!

-       Is it really the hardest EOR?

o   I believe everyone has a different area of medicine that they struggle with. I have heard a variation of answers of which EOR is the hardest. At one point, I have probably heard each EOR once as the hardest one. Personally, I did about the same on my internal medicine and pediatrics EORs. Find my study tips below J

-       What type of patients did you see?

o   Most of our patients were very complex and usually had HTN, hyperlipidemia, COPD, and type II DM. Want a list of what I saw? Check out the end of this blog!

-       How was being in a rural area?

o   Initially, I was nervous. I grew up and have always lived in fast pace, busy areas. Moving to Charleston, WV was already a big change for me so I was nervous as to what a rural area was going to be like. However, I loved it. The location was about 50 minutes away from where I lived. The patient population was amazing and I learned so much about how they lived life and why. I also got to learn a lot about the history and culture of the area I was located in.  

-       What was your favorite part?

o   I LOVED PROCEDURE DAYS! Being in the operating room was so much fun. I loved everything about it. Also, I just loved that I got to explore multiple aspects of medicine. We had a pretty wild day in the ER where we saw two drug overdoses, intubation, central line placement, posterior shoulder dislocation, humeral head fracture, and so much more.

-       What was one of the hardest things?

o   Educationally: the learning curve was steep. I realized there is still so much I don’t know, but it was great because I got to learn so much! It was initially hard for me to face the fact that I really don’t know as much as I thought, however I grew thankful of this. We are constantly learning from medicine and always will be.

o   Personally: I was asked to leave the room by two patients. This was tough to handle because it made me feel incompetent. However, I learned not to take it personally! It wasn’t due to me, but just due to the fact that they wanted to speak with their personal provider alone. Unfortunately,  I think this is something that we will continually face as mid-level providers in medicine and all we can do is just keep moving forward.

End of Rotation Exam (EORs)

To study for my EOR exam, I make a study guide that followed the internal medicine blueprint and topic list. I also used ROSH Review for practice question and a practice exam. To me, ROSH IS WORTH IT. I think it has been SO helpful in EORs. I used resources such as PANCE Prep Pearls, SmartyPance, ROSH Review, and my lecture notes to obtain the material for my study guides. I typically spent the first two weeks creating my study guide. I spent the last two to three weeks reviewing the material. I would take my ROSH practice test about a week before my EOR date to see the areas that I needed to focus on. A helpful hint is to try to review a topic per day just to stay on top of information.

⇢ Want access to my EOR study guide? Click HERE

⇢ Link to PAEA Blueprint/Topic List:  Click HERE

What I Saw:

EENT

-       Otitis Media (Middle Ear Infection)

-       Otitis Externa (Infection of canal)

-       Sinusitis

-       Allergic rhinitis (including allergic shiners!)

Gastrointestinal

-       Crohns Disease

-       Small Bowel Obstruction

-       Constipation

-       Gastro-esophageal Reflux (GERD)

-       Hiatal Hernia

-       Celiac Disease

-       Irritable Bowel Syndrome

-       Diverticulitis

-       Cholecystitis

-       Hepatitis C

Musculoskeletal (MSK)/Rheumatology

-       Posterior shoulder dislocation

-       Humeral head fracture

-       Medial Epicondylitis

-       Low back pain (A LOT!)

-       Herniated Lumbar Disc

-       Osteoarthritis

-       Rheumatoid Arthritis

-       Polymyalgia Rheumatica

-       Fibromyalgia

Neuro

-       Seizure

-       Tarsal Tunnel Syndrome

-       Carpal Tunnel Syndrome

-       Neuropathy

-       Parkinsons

-       Restless Leg Syndrome

-       AV Malformation Aneurysm

-       Migraine Headache

-       Essential Tremor

-       Syncope

Pulmonary

-       Asthma

-       COPD

-       Coal Worker’s Pneumoconiosis (Black Lung)

-       Asbestosis

-       Bacterial Pneumonia

-       Sarcoidosis

-       “Cough”

Dermatology

-       Allergic Dermatitis

-       Dyshidrotic Eczema

-       Cellulitis

-       Diabetic ulcers

-       Melanoma

-       Basal Cell Carcinoma

-       Squamous Cell Carcinoma

-       Seb Keratosis

-       Acrochordon (skin tag)

-       Dysplastic Nevi

-       Epidermal Inclusion Cyst

-       Lipoma

-       Onychocryptosis (Ingrown toenail)

-       Plantar Wart

-       Verrucae

-       Foreign Body

Genitourinary

-       Acute Cystitis (UTI)

-       Prostate Cancer

-       Benign Prostatic Hypertrophy (BPH)

-       Erectile Dysfunction

-       Stress Incontinence

Psych

-       ADHD

-       Depression

-       General Anxiety Disorder

-       Sleep disorders

Endocrinology

-       Hypothyroidism

-       Type I and II Diabetes Mellitus

-       Diabetic Ketoacidosis (DKA)

-       Hypoglycemia

-       Hyperlipidemia

-       Hyponatremia

-       Hypokalemia

Cardiology

-       Hypertension

-       Angina

-       Atherosclerosis

-       Myocardial Infarction (MI)

-       Atrial Fibrillation

-       Atrial Flutter

-       Atrial Bigeminie

-       Aortic Stenosis

-       Mitral Regurgitation

-       Viral Myocarditis

-       Congestive Heart Failure

-       Peripheral Arterial Disease

-       Peripheral Vascular Disease

Hematology

-       Factor V Leiden

-       Iron Deficiency

-       B12 Deficiency

-       Folate Deficiency