Internal Part 3/3: Ambulatory

14 01 2012

I’m nearing the end of my internal medicine rotation now.  Just two weeks, a quiz, a test, and a final exam to go before I go schlepping into vagina land (aka OB/GYN).  Internal has been a mixed experience, though it’s been more positive than negative.  Overall, I like it.

For the past two weeks I’ve been in the third and final chapter of the rotation: ambulatory.  I am assigned right now to a physician who works in a private office and specializes in diabetes management.  This means that the experience has been quite different from the other clinic experiences I’ve had.  First, I am the only student at the site, and working with only one physician (versus family med, where I was at a resident clinic and working with someone new ever half-day).  This means that the physician knows me, knows how I learn, and perhaps most importantly has seen me grow through the experience and will be able to accurately write an evaluation.  Family medicine was a different story, one which I’m still a little bitter about. 

Watching how a private primary care office operates has been a little bit of an eye-opener, too.  The doc is free not to take people with insurance, or even free to not see anyone with Medicare or Medicaid if he chooses.  Because he is an independent practitioner, he makes his own rules, chooses his own patients, hires his own staff, chooses his own system of record-keeping, and pays all of his own office expenses.  The entire office staff is 4 people (not counting me): two nurses who act mostly as secretaries, the office manager (who also happens to be the doctor’s wife), and the doc.  That’s it.  So you can imagine what happens if someone is sick!

It’s actually kind of cool to work there.  Everyone there is pretty chill, and because the physician really likes to have students, they know what students should be doing.  This alone counts for a lot, and since this cycle I’m the only student at the site, it means I get to do even more. Ask any teacher or student and they will tell you that fractured education is not nearly as effective as continuity.

When I say I do a lot, it basically means I do my own focused interview and physical, my own patient education, and my own treatment plan recommendation.  If I’m not sure, I’ll tell the patient that I will check with the doctor to make sure (This is a great approach because often if the doc recommends the same thing as I did, or explains things the same way, they will often say “oh, your student told me that” and I look good.  If I was wrong, they don’t say anything.  Who doesn’t like feeling smart around their superiors?).  If the doctor sees or hears or feels something on the physical exam that I missed—or didn’t think to do—he always asks the patient if I can check again.  Most docs I’ve worked with don’t do that because they are either too crunched for time or, more often, they assume that I know these things already. 

Important lesson learned in medical school: you don’t gain anything at all by pretending to know more than you actually do!

There are other perks to working in a private office.  Drug reps, for example, do still exist—I hadn’t encountered any at all since beginning clinicals.  They might not be allowed to hand out pens and calculators anymore, but this seems to have expanded their food budget.  When I used to shadow at private offices, the reps would bring in a pan of lasagna for the office and chat for half an hour about the drug.  Now what they do is give us a menu from a place like Ruby Tuesday’s, we choose what we want, one of the nurses calls it in, and the drug rep picks up the food and brings it to us.  It’s kind of awesome.  Sure, the reps still talk about their drug, but it’s only for like 2 minutes; they mostly just hang out and chat.

The hours are awesome also.  They work 8:30-5pm most days, get out at 12:30 on Wednesdays, and at 3:00 on Fridays.  No weekends, no holidays, no call.  Obviously the salary isn’t as high as a hospitalist, and the private practice guys are responsible for running their own offices.  They also all have to find their own health insurance, which from what I understand usually means ridiculous premiums on care that’s generally not all that great.  But overall the day-to-day seems much less stressful, and the doc is able to do things like clear out two hours in his schedule to go to his kid’s doctor’s appointment or soccer game.  Very family friendly.  And I thought it would be boring, but surprisingly, the patients are engaging and it’s kind of cool to manage multiple chronic conditions.  I like the continuity of care, and I like the idea of being a “home base” of sorts for my patients’ care. 

I think it would be cool to be someone’s “my doctor,” if that makes sense.

So what have I gathered from this experience so far?

I like outpatient care in the right setting.  Which means that, ultimately, I’m no closer to choosing a career path.  Awesomesauce. 

But that’s not keeping me from enjoying the extra time to sleep and study!

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