Finished With Internal Medicine

The VA hospital was an amazing way to end my internal medicine experience, mainly because of how extraordinary my team and attending were! As a parting gift, the VA graciously bestowed me with a nasty case of the common cold right before my shelf exam. I struggled to study on my “cram day” and was fighting a major headache/fever during the exam itself (Friday evening). Needless to say, the shelf nearly finished me off, but hopefully I’ll be back to normal come Monday when I start research at the BCM-TMH Neurosensory Center for a month. 🙂

In retrospect, I’m so glad I started my clinical experience with internal medicine. It was a great way to directly apply the basic sciences to actual patients without having to learn a whole new jargon (à la surgery). In particular, COPD exacerbations, heart disease (ischemic, congestive heart failure, hypertension), and cirrhosis were commonplace at the three hospitals I rotated through. Seeing these conditions in multiple patients also gave me a better idea of which etiologies are more likely for a given disease. For example, a patient comes in with plain old hypertension. What set it off? Based on the cases I’ve had, the etiology is far more likely to be from a poor diet/obesity than say… bilateral renal artery stenosis. Now one should consider all the possibilities, of course. I’m just remarking on a clinician’s ability to discern what’s “more likely” from “less likely.”

Internal medicine also provided me with a great understanding of how to manage chronic conditions. What kind of anti-hypertension drug regimen is best for a particular patient? How can we better control a patient’s diabetes? How do we get third parties (social services, wound care, etc.) involved to better facilitate this patient’s improvement? These skills will be invaluable as I progress through the rest of my rotations.

Main hallway, 4th floor, VA

My attending at the VA had two rules: 1.) When in doubt, ask the patient and 2.) If rule #1 fails, examine the patient. This may seem obvious, but in a world of electronic medical records, the “patient encounter” aspect of treatment has progressively taken more of a back seat. Regardless of whether or not the patient is a good historian, there’s no substitution for actually carrying out the full history and physical (H&P). Plus, there’s an indescribable satisfaction in seeing patients improve on a daily basis and being able to comfort their loved ones in times of uncertainty.

While I’m on the topic, I’d like to stress one thing – as a student, you’re at the bottom of the totem pole. If an attending, resident, or intern tells you to do something, DO IT! If you’re told to do a DRE to look for occult blood, don’t argue over the sensitivity/specificity of such a test. Suck it up, use it as a learning experience, and just do it.

In closing, I’d like to share an excerpt from the reflective writing assignment students are required to complete during each rotation. It deals with the advice given by one of my patients (we’ll call him “Mr. Smith”), a retired and distinguished physician, on my last day at St. Luke’s.

He took me by the hand, thanked me, and said, “the future of healthcare looks bright with people like you at the forefront.” As a student on my second month of rotations, this was perhaps the greatest compliment I could receive from a healer of such clout. Mr. Smith practiced for over forty years. He knew medicine – administratively, socially, scientifically, and therapeutically. He saw medicine change, and I’m sure he had expectations for the next generation of physicians (many of which I hopefully fulfilled).

He proceeded to talk about how modern medicine is grossly invested in the pursuit of money and power and how physicians will continue to face an up-hill battle against Washington. His last piece of advice  – “Take care of patients, and they’ll take care of you.”

I briefly considered the words while at his bedside, but had much more time to assess the magnitude of their meaning on my long commute home. As physicians, we have a tremendous deal of responsibilities to address with delayed gratification in return; however, placing patient care at the forefront of our duties provides an incredible and immediate form of reparation for our efforts.

That rather uneventful evening in the ER, the frailty of a physician’s body was made painfully clear to me, but the conversations I had with Mr. Smith during his course of treatment reassured me that I was on the right path towards mastering the art of patient care. In spite of being just a medical student, I truly felt like a “healer’s healer” during the two weeks I visited with him.

The Texas Heart Institute (THI) and St. Luke's Episcopal Hospital (SLEH)

Internal medicine was the perfect balance between learning and applying. I was fortunate to have a set of interns, residents, and attendings who tolerated my inadequacies as a new clinical student, and whatever progress I made I owe heavily to them. Hope the coming month of research continues to open new doors! 🙂

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  1. Great post Rishi! Stories like these really make me glad to know there are future physicians out there who are less concerned with money, power, and prestige and put their patients first. Don’t let them beat that out of you!

    As an aside, I just finished reading a book that you might enjoy. It’s called “Every Patient Tells A Story” by Lisa Sanders and it looks at the dying art of listening to the patient and doing the physical exam well. If I can keep half of what I’ve read close to heart when all is said and done, I think it’ll make me a better physician for it. Cheers buddy!


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