Ambulatory Medicine Rotation Reflection

      Urgent Care was a perfect specialty for a first rotation. At Centers, I was allowed to do everything the providers did and eventually saw patients on my own, as well as came up with Diagnosis and Treatment plan. What was different from the didactic year is documenting and the way we actually performed the visits. My Center was seeing between 200 and 300 patients a day so visits had to be brief, focused, but still deliver the optimal patient care and customer service. Documentation had to also cover medicolegal issues such as patient education to seek emergent medical help in case if they experience certain symptoms.

      The part I struggled the most with at first was actually guiding patients to focus their history on the most relevant findings and establishing the main complaint. Many patients felt like sharing their life story or answered yes to the majority to the review or systems which made the visits and diagnosis challenging.

Another thing was presentation: mine were scattered and unorganized because I was sexcited to run and report to my preceptor, especially when I already had treatment in mind. Taking a minute to organize the story in order to be able to deliver it in effective fashion was a new habit I formed. One of my preceptors said, and I think it is a perfect way to put it: “Imagine you woke me up in the middle of the night and I am very grumpy. You need to tell me everything I need to know to treat this patient emergently in 2-3 sentences but be ready to have more information if I ask to elaborate”. Looking at the presentation from that perspective really helped me to function more efficiently in the Urgent Care setting and in my week 4 I had no problem presenting at all.

   The way I have learned to format my presentations is going to be very useful for my next rotation – ER. I think my ER preceptors will appreciate my ability to summarize the case in two-three sentences.

  Interpersonal challenges I encountered were with Medical Assistants. Often I was asked to do things that were not my job – printing, swabbing asymptomatic patients for Covid for job clearance, taking vitals…Some of them would boss me around and demand me do their job. I am a team player so my first week I just did everything they asked, exhausting myself working with no breaks 12 hours straight but that actually  took away from my learning rather than adding to it.. While I was taking vitals for someone who came in for Covid testing before their flight (asymptomatic, no real history to take), I often missed really interesting cases of actual clinical patients. Luckily, my preceptors caught up to it and told me to only see clinical patients and real pathology as that’s where the real learning is. Since then, my learning experience has improved dramatically as I was able to see and discuss complicated cases and broadened by differential tremendously.

  I changed my opinion on Orthopedics. I found ortho cases being very interesting and became more comfortable with my Physical Exam for different injuries and now I really wish we had an ortho rotation.          

   A memorable patient experience I had was with a 72 y/o cancer patient who came in for an IV hydration drip. He had Raynaud’s. When I came in to check on him, He showed me his hands and said “Here, Tess wanted you to see this. I have Raynaud’s”. The room was very cold. I touched his hand without the glove and realized his fingers were freezing. I asked if it hurt, he said yes with a sad smile. My heart broke for a second. That man has encountered so much pain with his cancer and chemo and did not complain a single time and was very grateful for the help he was receiving, even though we were overwhelmed with patient volume and could not really give him the attention he deserved. I recently lost my grandfather and this man’s sad smile reminded me of him. I went outside and grabbed a cup of warm water. I gave it to him to hold on to with his both hands. He was surprised. “Wow, this actually feels nice” – he said with so much gratitude. Since then I take a personal vested interest in as many patients as I can since I was again reminded they are all someone’s mothers, fathers, and sisters.

        I have noticed some providers being less thorough since it’s an Urgent Care setting and some taking a pause and doing a full workup for patients they thought could be complicated, like vertigo. One provider straight up prescribed Meclizine after 2 minutes talking to the patient, another did a full neuro exam, asked countless questions and spent time educating the patient in the reasons of their vertigo, especially if it was central, and the concerning signs to look out for. Interestingly enough, the provider that was thorough had years of experience in Emergency Room. She said seeing people die because of our mistakes taught her a lot. I resonate with the thorough approach. No matter how much pressure we are under and no matter how rushed we are, we need to exercise medicine consciously in order to know we did our absolute best – it’s the only way I would be able to sleep at night.

   The areas that need improvement are countless. Full neurological exam and effective patient presentations are the main areas of weakness I have discovered so my plan is to practice them as much as I can until they become second nature.

   I learned I am much more resilient than I thought (at first working 3 12 hour shifts back to back was physically difficult but now I miss coming to work when I am off) and how much practicing medicine inspires me. Helping patients, educating them and seeing an expression of gratitude on their faces must have been one of the most fulfilling things I have experienced so far.

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