With Pediatric clinic in the rear view mirror, it was time to actually work in the hospital as part of the Internal Medicine (IM) team. And boy was the first week a rude awakening. I felt like a med student again - so completely inept to manage my patients, round efficiently on them, and give succinct handover. The plus side is that I'm on a great team consisting of a senior IM resident, an R1 IM, an R1 anesthesiology, myself, and three med students. R1s typically carry ~6 patients. The first days are always the hardest because all your patients are new to you and you're trying to catch up on their story so that you can properly manage them. In doing that, you don't take the time to think about what's actually going on with them or what differential diagnoses are still on the list to be ruled out. The med students only have 2-3 patients. So they have more time to read up and discuss all kinds of zebra diagnoses, which always makes for a great learning experience for all of us. Apparently, I was given a lot of hard cases, but I feel like the other R1's had equally complex patients but were just better equipped to handle them.
The hours take some getting used to, especially after a couple months of relatively cushy hours. We have morning report at 7:30, but I always want to get to work at least 30 mins early to do a quick check on my patients. Then after morning report, time flies, you forget to eat and pee, and then it's 7pm wondering if your kidneys are ok, let alone your patients. The first two days I didn't leave until after 8. Friday was my first call shift. I got to work Friday at 7am and left shortly after noon on Saturday and got about 3 cumulative hours of sleep. Exhaustion is putting it mildly.
As the weeks carried on, I got the hang of things and became more proficient at managing my patients. In my 4 weeks in IM, my most memorable patient was a 97 year old woman whom I had discharged after a week's admission. The day I discharged her, I happened to be on call that night. So it was an unfortunate surprise to be consulted on her back in the ER escorted by the executive director of the senior's facility she resides at. With complex patients like these, it's a trying task to discharge them without them bouncing back. You need to stabilize them medically and ensure supports are in place for their transition back home. If something doesn't get settled in time, you're increasing your risk for bounce back. In this case, we had organized home care three times a day and home OT/PT. One thing that was forgotten - calling the facility to let them know the patient would be returning and checking if it was ok. My job is to medically stabilize patients and get them out of the hospital promptly so as to reduce their exposure to hospital acquired infections. But as I said, for patients like her, there are so many other components that I have no part in that can completely derail my plan. I hadn't even dictated her discharge note by the time I re-admitted her in the ER. It resulted in a 4 day admission to coordinate 24 hour home support at her facility. The CNL (Clinical Nurse Leader) of her ward insisted that everything was in place and she could be discharged. Again, medically she was stable so I discharged her again. This time I dictated her and marked it as a priority in case she bounced back again. Low and behold, she was back in the ER the next morning. I nearly spent my entire day coordinating with her family doctor, her case worker, and our transition services team to ensure every last damn thing was in place, transport was arranged, and then I personally called her facility to say she was on her way back. My senior and attending told me I moved mountains that day. I'll take the win, even though it was battle. The next day, my attending told me he enjoyed reading the Part Three of her trilogy of discharge notes. I think it's because he knows exactly the tone that goes with the words on the page.
There are many things I've learned during this rotation, but one thing that's become glaringly obvious to me is that my confidence is my saving grace, quite nearly to a fault. My demeanour and superior communication skills either disguise or provide the smoke and mirrors to distract from my knowledge gaps. In some ways, it's nice to know that I can charm the pants off anybody (just ask the switchboard lady who immediately changes tone and starts shooting the breeze with me as soon as I say "Hi, it's Dr. Yip..." even though we've never met in person). On the other side, I feel like I'm not meeting the mark in terms of clinical competence and I'm not being called out on it. I don't know if people don't notice, or they like me so much they don't want to confront me. But I have this sinking suspicion that my likability is preventing me from getting the reckoning I need. It's stressful to hear people say "Oh, you're an IMG? You must be pretty remarkable to match here." They're absolutely right. You typically do have to be remarkable academically to match into an IMG position in UBC. I am not being self-deprecating by suggesting I have the lowest test scores out of my entire class. They are woefully mediocre. I know people say that knowledge can be acquired over time and with practice, but social skills are harder to attain and that's why I matched. I have this wealth of what people want their family doc's personality to be, but I have this huge clinical ineptitude and it's really frustrating.
I recently worked a weekend shift at my family clinic in North Van. My preceptor had two unmatched IMGs working that morning (much like how I worked in Steveston last year). Their job was to alternate observing me interacting with patients because I'm apparently this "amazing" resident per my preceptor. And all they're picking up on is my casual confidence with the patients. They talk about it in a context that seems so odd to me. They say (in broken English) "She is able to meet a patient and be their friend and gather history at the same time. I am nowhere near being able to do that. I have a long ways to go." Hearing this breaks my heart because they're talking about my personality which wasn't something I had to put a lot of work into, but rather came naturally through life experiences/passions, not to mention that English is my first language. It seems unfair to expect an IMG to be able to speak and develop rapport like I do, but it's entirely fair to expect me to be able to know the level of clinical medicine they do and I know that's where I have a long ways to go. The idea of coming out of this residency riding on the coattails of my charm terrifies me. Sure it's great to have a personable doctor, but I'd think you'd want a competent one more.
Thankfully, I was strategic about booking my vacations and am now officially on vacation for 1.5 weeks before I start a 2 week Family Med-Oncology elective. I'm looking forward to sleeping, reading, and working on building up knowledge and breaking down the anxiety of incompetence.
