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LTC Rotation Reflection

  I had my Long Term Care rotation in the Internal Medicine department. During my 4 weeks there I got to work with two different attendings with an entirely different approach to patient care, so it was very interesting to participate in both. This was my 4th rotation, so I was definitely feeling more confident and was not afraid to speak up to ask questions or ask to do procedures, so I did not really note any interpersonal challenges. QHC staff is very friendly and willing to teach, and I got clear guidelines on what were the expectations of me which was very helpful.

    One of my biggest challenges on this rotation was working with terminally ill patients. We had many “goals of care” and other difficult conversations. There were many discussions on how to approach the terminal DNR patients in terms of breaking the stigma that they do not need treatment.

    A memorable patient experience that I will carry with me was with a stage 4 pancreatic cancer patient who was with us the entire month of my rotation and was deteriorating on our eyes. His family wanted a full code and insisted on every intervention possible so there were many educational conversations with the family on what makes sense and what does not. I checked on him every day. He seemed in good spirits and definitely was not ready to die but his labs looked worse and worse with every day. I have learned the importance of staying with the patient and keeping seeing them even if there’s nothing more we can do for them medically.

    Another patient I will never forget was a 22-year-old girl with stage 4 endometrial cancer. We spoke about her unfinished college education and her dreams that will never come true and it made me feel so grateful to be alive and well and to be able to pursue mine. I was amazed watching palliative care team handle these situations, it definitely takes a special type of person to be able to do this job. Sometimes I could not say a word because I knew I would cry if I tried to speak (Thank God for the masks!).

    I made sure to attend all lectures and meetings – the ones for the residents and the ones for the med students, the morning report and the Grand Rounds, even though they were not mandatory. All of the above were extremely useful for development of clinical reasoning and forging connections with the team. Showing up to all these meetings helped put me on the map with the head of the Internal Medicine department who offered to write me a recommendation letter which I will definitely be taking him up on later. Meanwhile some medical students who did not attend these meetings asked him for the rec and he denied them. Therefore, I learned that participating in extracurricular activities can yield some extracurricular benefits. Our rotation time is so short that it is imperative that we make the best of every minute we have a privilege to be there.

    On my last day the residents noted my improvement throughout these past 4 weeks and congratulated me on it, which I was very surprised with as I personally did not feel any shifts.

    Things I want to improve on my following rotations are a thorough physical exam since I am still missing things and have to go back almost every time. For example, if my patient has chest pain, I would generally do a complete heart, lung and neuro exam but will often neglect peripheral vascular and thyroid. I would like to have my presentations to become more organized. I need to work on listing my pertinent positives and negatives in a way that they tell a story of my differential diagnosis. I also need to work on my skills of breaking the bad news and having “goals of care” conversations. For my future rotations I will try to come in earlier so I can see the patient I am presenting sooner and have more time to organize my presentation. I am planning on shadowing the palliative care team and being present in the room where difficult conversations are held, even though it is sometimes extremely uncomfortable.

    During this rotation I have learned that I really enjoy internal medicine, which I did not expect. It feels a lot like being a detective. We get to really look at a broad picture of patient’s condition and identify connections in order to provide optimal clinical care and sometimes the findings can be pretty surprising and interesting.

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