Internal Medicine at Mount Vernon

Green book core
I was warned by a peer of mine beforehand that I should expect to be disappointed. Go in with low expectations he said, and everything will be fine. He was right.

When I first walked into Mount Vernon on that cold January morning all I saw was a run down hospital, with  30 beds. There are about 20+ internal medicine interns/residents and I had no idea how they could possibly split up so few patients between them. Turns out the first years (interns) are the ones who primarily care for those admitted in the hospital and the second and third years oversee and guide the interns in their management of the patients. As for medical school students... I spent a good many weeks trying to figure out what our role was in all this. This is what I walked away with:

Daily Schedule

Arrive by 7:30 a.m.- For those of you driving, med students get free parking in the garage. You have to ask the security guard at the front desk for a coin. For those taking the train, you've got to take the subway and then switch to the Metro North to get to the hospital.

7:30-8:00 a.m:  Listen to the head nurse discuss discharges for the day and then listen to the residents who were on night float discuss the new admits over night (usually anywhere from 2-5 patients). On Mondays and Fridays there may be a resident/med student presentation on an interesting case with Dr. R.

8:00~8:45 a.m.: Chase down an intern before they all disappear and ask to follow them for their morning rounds. Stand and listen silently as each intern does a quick interview of each of their patients. Each intern will have anywhere between 5-10 patients on any given day. If you're lucky the intern will voluntarily discuss the case with you, if not, it's fine to ask them questions since they are all friendly anyway. 

8:45-9:15/10:15: A number of things can happen during this time. If you know how to do blood draws and ABGs and the residents trust you, they will ask you to do the blood work for them. If you can't do either of those things then you probably just go back upstairs to the residents lounge on the 6 floor and hang out until cardio rounds.

9:15/10:15- an hour later: Depending on the day, cardio rounds with Dr. N will happen at either 9:15 or 10:15 on the 4th floor. This is the most useless hour of the day. Residents gather around Dr. N and they go through each patient in telemetry. As students you have to stand at the other side of the desk and you can neither hear nor understand what's going with each patient.This will take take 45 minutes and you just stand there silently. If time permits, Dr. N will pull up a couple of EKGs on a screen and teach the residents. You stand there still confused. You are never acknowledged. The session ends. 

10:15/11:15-Noon: Hang out or go get an early lunch. I usually go the cafeteria or the nearby Subway. The only things worth eating at the cafe is the soup and the chicken cutlet sandwich. People like getting food during this time because there's usually a noon conference. 

Noon-1:00 p.m.: Noon conference can be either a student presentation on a case/disease, an attending teaching the students/resident about something in their specific field, or a test prep/board review Q&A session with Dr. E.

1:00-Whenever: God knows what. You're probably safe to go home at this point, although officially we have to stay till 4 for no real reason. For the first few weeks I would go to clinic in the afternoons till about 3 and then head off. For some reason, I was the only one who would do this since there was an odd rumor going around that our malpractice insurance didn't cover the outpatient clinic, which literally makes no sense.
They have some interesting clinics at Mt. Vernon that are worth going to. In addition to the regular outpatient clinic, I've been to the HIV clinic and Methadone clinic, each providing its own unique experience on a very different patient population.
Also during this time, some people pick up a side project during the rotation so they may spend an hour or two in the afternoon to catch up on their work.
If you aren't going to the clinic or doing project work, there's really not much else to do. Every so often there might be "bedside rounds" where a student is selected to do a full interview of a patient as 15 residents and students look on, but that only happened 4-5 times out of the three months.

Overall, Mount Vernon was not a good place for patient interaction, but you are able to gain a few skills if you are willing to work for it. I walked away learning how to perfect ABGS (drawing arterial blood) and I'm somewhat proficient in blood draws. It's also great if you enjoy studying. You get ample time to study if you so choose.

Something I Learned Today

I never really considered this before, but this is as fundamental as you get when deciding how to manage your patient's health. When someone has uncontrolled diabetes, seizures, hypertension (or what have you) on the current drug they are on... what do you do?

a. Increase the dose of the current medication?

or

b. Add a second drug?


Today we had a couple pharmaceutical reps talking up ezetimibe, a drug that inhibits cholesterol absorption by the brush border of the small intestines, and how it's an excellent drug to add on to the first-line statins for those with hypercholesterolemia. They were questioning my attending if he ever used it as an add on or if he just increased the statin dose, to which he answered "add on".

There isn't a real correct answer to this question since doctors do both of of these things depending on the individual case, but my attending says he personally prefers to add a second drug if he's able to convince the patient. The problem with increasing doses is you increase the risk for side effects and many patients can't tolerate high doses because of this. So giving two low dose drugs not only synergistically combats whatever pathology you're dealing with, but you're also reducing the potential side effects that would be seen with upping a dose.

That being said, it is a hard sale convincing patients to take two pills when they can just take one, but with the proper communication and education, you can win them over because at the end of the day people want to live as unaltered a lifestyle as they've led up to that point. Nobody likes having to take a pill everyday (sometimes for the rest of their life) and it can be disconcerting to have to take something that causes daily discomfort. The patient is our number one priority and as physicians we want to make him/her as comfortable as possible and maintain a high quality of life. That includes limiting side effects.

Books for Clinicals - Internal Medicine/Family Medicine

I've been very very bad. I know and I apologize. I do plan on having a full update soon on my three months of Internal Medicine @ Mount Vernon, my move to NYC, finding housing in NYC, and the differences between clinicals and basic sciences. I hope to roll out these posts in the following days, as well as answer all the questions you guys have been asking, but first I'll start with this fairly easy, yet informative post about books you may want for the start of medicine.

1. Mass General Pocket Medicine
You see this little green book on every single residents on the floor. I love it because it's so concise and clinically oriented. It focuses on how a patient will present with a disease,  abnormal labs, diagnoses, and how to TREAT him/her. When I first started Internal, I had bought the Oxford Handbook of Clinical Medicine and was disappointed because of it's sparse treatment information, which I find is the most important thing to be learning at this stage in our education. Sure we've learned about many diseases, the pathogenesis, how it may present, what abnormal labs we may see, but what do we DO about it? That's what 3rd and 4th year is all about.



2. The Practitioner's Pocket Pal
This handy little book is about 90 pages and gives you the essentials on what you would need to know in the wards. It discusses lab values, what to ask for when taking a history, how to write SOAP notes, progress notes, differential diagnoses for common complaints, a rundown of the most commonly used drugs, ALCS emergency algorithms, and even gives you helpful Spanish-English medical words.... this book has a little bit of everything and I love it. You'll see most students with the Maxwell's Quick Medical Reference book, but I find this one more useful.




3. Download the Epocrates App for Android/iPhone
When it comes to knowing your drugs- mechanism of action, indications, contraindications, dosing, side effects, black box warnings, pregnancy class, pricing (which I find most interesting... no idea how expensive drugs are) this app has everything and you'll be using it fairly often. Another drug app that I've seen students use is the Micromedex... I still like epocrates better because for whatever reason it loads faster on my phone.






Great Books for the Medicine Shelf!!
At the end of each of the 5 cores- internal medicine, psychiatry, pediatrics, surgery, and OB/GYN, AUC students have to take a 2.5 hour, 100 question shelf exam at a nearby prometric center. I took my Medicine one last Friday and feel that I did pretty well on it. Here are the two books I heavily leaned on:

1. Conrad Fischer's Master the Boards for USMLE Step 2 CK

This book really distills the material to clinical presentation, best initial test/ most accurate test for diagnoses, and the step-wise approach for treatment. There is NO in-depth discussion of the pathophys and whatnot of certain diseases because this book basically assumes you know all that information already from basic sciences... so some people may not like this because it is so sparse on that particular material. If you want something to supplement this book, people absolutely love using Step-Up to Medicine, which I've thumbed through and it's actually pretty good. It reminds me a little bit of Goljan since it is in outline form but it does provide more information on diagnoses/treatment options.


2. MKSAP for Students 5
Everyone can agree that doing practice questions is a great way to study for any exam, so most students turn to UWorld. Of the possible 1400 internal questions on UWorld, I probably did around 400 questions and found them to be their usual u-worldy type selves. Then I went on to amazon and one of the "recommended books" on my page was this MKSAP question book. I figured why not buy it and give it a shot and oh my god, I am so glad I did! Not only does it give you amazing explanations and beautiful salient points on the clinical aspect of medicine, but these questions were a perfect match for the shelf. I probably had 5 or so questions that were almost identical. There are 11 sections divided by organ system and I did 5 of them before taking my exam. Had I gone through the whole book...

I should be getting my shelf score tomorrow so I'll let you guys know how I did.
FYI: You need a 53 to pass and a 77 to honor.

update: ended up with a 71... a bit short for honoring, but still pretty good for my first shelf

Rotations Schedule

I received a schedule a couple weeks back (Dec 21 to be exact) but wasn't too happy. Not only did I just find out that I was starting in 16 days but that I had to travel between 4 different hospitals including a psychiatry site that's 2 hours away from where I'll be living. NYC is not a cheap city and I really don't know if I was ever going to find someone to sublet my apartment for two months while I go away and rent another place in Rockaway.

I called my clinical advisor that very day. I'm sorry to say that she is terrible. AUC really ought to look into fixing its clinical department. Not only did I have to call 8-10 times to finally get a hold of her, but when she promised me she would send me a revised schedule on a specific day of the next week, she didn't do it. So the following week I called her 5 more times, left a message, and still didn't hear back from her. I called her the next day, got a hold of her and she said that I just needed to wait till she emailed me back my schedule. She never did and I'm supposed to start my first rotation next Monday.

People who took their Step exams a week or two after me got their schedules today and when I saw that some of them got the psychiatry rotation at Bronx that I wanted (and was told there was NONE AVAILABLE) I went absolutely insane. Enraged. Dear readers, I flipped out and I'm actually surprised at how angry I was, but there it is. The poor woman who picked up the phone got my bitchiness and aside from her exclaiming "EXCUSE ME!" after I demanded that she MUST fit me somewhere in the Bronx for psychiatry, she was actually very well composed and that settled me down. 10-15 minutes later, I got the schedule you see just above.

What does it all mean? In one 15 minute phone call, a capable young woman who isn't even my advisor fixed my qualms and gave me a schedule that I'm happy with. I don't understand why my own advisor couldn't do it for me. I'm not one to call for someone to be fired, but honestly something needs to be done to improve this whether it be more training or... I don't know. Anyway, I'm happy to be starting clinicals and can't wait to share my experiences (good and bad) with all of you!

Onwards!

I just received my score back today and I'm happy to report that I passed with a 224! A little lower than what I was hoping for but at least I hit the average for US med students (silver lining much?). Now it's time to start the next chapter of my medical school education by sorting out where I want to do my clinical rotations. All I know is I want to do all my cores in New York City and I want to do as many as I can at the same hospital site. I also want to find a place to live that is (somehow) centrally located... in the event that I am scattered throughout the boroughs. Below are the sites of the seven NYC hospitals AUC students go to.

Looks like Upper East Side would be an excellent place to live