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Saturday, January 05, 2019
The General Medicine rotation that every single P4 goes through almost feels like a rite of passage. While its reputation for being difficult precedes it and may be exaggerated at times, the overall intensity is definitely a step up from most rotations. The patient care activities are not too different from other direct patient care rotations - you round with the rest of the healthcare team comprised of mostly doctors, and you take care of the anticoagulation and pharmacokinetic needs (read: vancomycin and aminoglycoside dosing and monitoring). However, what makes this rotation more challenging are the weekly projects, ranging from topic discussions to journal clubs. Nonetheless, I found the experience rewarding and had several interesting moments along the way that were quite memorable.
Diagnoses and ordering tests to confirm those diagnoses are usually under the physician's jurisdiction. We had a patient who had new complaints of mucosal ulcers. I patiently listened to the attending and medical students discussing potential causes. I then realized that I had been in a similar situation in my Surgical ICU rotation, and that patient had herpes simplex virus that was discovered using a HSV swab. So despite having no idea whether this would yield anything, I brought up the idea of getting a HSV swab on our patient. The attending and students seemed mildly surprised by my suggestion, but obliged. Turns out the patient did indeed have HSV, for which we started valacyclovir! The team gave me props for making this recommendation, and I have to say it is probably one of my proudest moments during rotations. It helped me realize that I was indeed progressing as a clinician, being able to take what I learned previously and apply it to a new setting. How exciting!
Another aspect of this rotation that I enjoyed was a MUE (medication use evaluation) on argatroban. Normally, this anticoagulant is used for patients with a documented heparin allergy or a positive HIT (heparin-induced thrombocytopenia) diagnosis. However, my preceptor suspected that we as an institution did not do a very good job of discontinuing argatroban upon negative HIT testing results. Sure enough, after combing through a year's worth of data, I found that we were spending tens of thousands of dollars on argatroban needlessly. It was towards the end of the rotation at this point, but we talked about setting up alerts in MiChart that would notify pharmacists whenever heparin antibody assay or serotonin-releasing assay results came back, so we can respond to such results in a timely fashion and avoid wasting more money. Perhaps getting trained in informatics could be useful...
All in all, I'm glad to be catching up on sleep this break. I won't miss waking up at 5 in the morning to get to the hospital so early, but I am glad we were put through the wringer. I have no doubt that these experiences will pay off when it comes time for residency interviews. I am also looking forward to my nontraditional rotation coming up next at the Michigan Oncology Quality Consortium. I'll be sure to update you on this in the near future!
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