1/4 done!!!!

aah.
3 months of intern year (1/4) is DONE!!! It's hard to believe. I am soooooooooooooo excited to be on vacation! When I left the VA hospital today at 5 p.m., I was so pooped it was hard to be excited but, after a two-hour nap, some phone calls to friends, and being rested enough to comprehend the fact that I have more than 24 consecutive hours off, I'm ECSTATIC!!! It was therapeutic to be able to change my pager message to say, "I am NO LONGER at the VA; please page...." And maybe every thing is rosier in hindsight but, while there are certainly some things I WON'T miss (see below), I actually had a fairly good month and felt good about the medicine I practiced (and learned).

I will miss the patients and their families. When I told one family member today that it was my last day today, he said, "What? You mean we'll have a different doctor tomorrow?! No! We like you! Do you have to go on vacation?" (YES!!! For my mental health, I have to!) This is certainly more encouraging than poor Lesley hearing from her peds patients that they hate her (how could anyone hate Lesley?!). I've had some really wonderful interactions with some sick, but grateful, veterans and their family members.

I will not miss breaking bad news. Just this week, I have had three patients who were surprised with the diagnosis of cancer and seem to have my own personal oncology service. The first one was a spry 89 year old man who was walking 10 miles a day up until a month ago, when he started to get short of breath and noticed that his voice was hoarse. A chest xray in the ER showed white out of one lung-- he has a huge pleural effusion-- and CT/bronchoscopy showed a massive obstructing lung cancer, affecting his laryngeal nerve, as well as pain in his arm likely a result of brachial plexus (nerve) impingement from the tumor. We were awaiting the final pathology results-- it looked like small cell cancer, but it looks like he will probably go home on hospice care.

Another patient I cared for had been seen by his primary doctor for about 6 months complaining of neck pain, thought to be musculoskeletal. However, he also had weakness and weight loss; a CT done about three days ago also showed a large upper lobe lung mass with mets that was biopsied and will also probably come back as malignancy.

I admitted another man from the UrgiCenter last week, a previously healthy 68-year old on no medications, with a 1-month history of vague upper abdominal discomfort, diarrhea, and jaundice. On my exam, his liver was HUGE, with a large palpable epigastric mass, and CT showed that he has not only a gastric mass, but likely a lesion in the pancreatic head (causing the jaundice) and liver metastases. He was the second guy in a month to which I had to break the diagnosis of likely pancreatic cancer, which has a dismal prognosis.

Another one of my patients, a guy admitted after a fall but with a UTI, lower extremity ulcers and bad peripheral vascular disease, acute renal failure, and possible small bowel obstruction, got pretty sick overnight before I saw him Friday morning. I thought he looked much worse when I rounded--sweaty, hypotensive, and with some mental status changes, and rapidly started the transfer to the ICU, but he actually went into respiratory arrest on the floor before they could get him down there, ended up on pressors to keep his bp up, and died the next morning, which was a big shock to all of us. We had had him on broad-spectrum antibiotics, were hydrating him and cleaning his wounds, so it was a bit of a shocker and we are not sure what could/should have been done differently, but it was still very very sad. I will not miss having patients of mine die.

I will miss the learning environment. Although I was quite worn thin, I learned a lot about medical management that will help me in every other rotation (including when I have to cross-cover on those crazy sick gyn-onc post-op patients on OB!). I'm realizing that FP residency is very hard, because you are supposed to know a lot about a lot of different things-- OB, peds, internal medicine, etc. At times, the challenge seems really daunting, and it is frustrating to constantly be on a service where you don't spend as much time as the other (categorical) residents (i.e. I will never know as much about medicine as the medicine residents or as much about labor and delivery as the OB residents!) and where you constantly feel slightly incompetent at first, having to rotate through and juggle the info. from so many different fields. However, I do like the challenge and I do like learning about medicine and keeping up (like Les) with the physiology. I wish I had more time to do it systematically, rather than on the fly, but it is what it is.

I will not miss the hours I kept. On Friday night, I stayed at work until about 10:45 p.m. finishing up work and discharge summaries, which made for an almost-18-hour day. I was back Saturday morning at 6 a.m. for another 15-hour stint. This is my excuse for not being in touch. Sorry! The funny thing is that these hours were better than my previous month, on OB (which I actually think was more physically, mentally, and emotionally draining and to which I return after vacation and block time. I only cried TWICE on this medicine VA month! :))

I will not miss rounding until 1 p.m. We had a new attending last week who was, shall we say, very thorough and meticulous. Rounds would take us four to five hours, which made it so we could never get work done and consults in on time! I truly hate rounds, although feel like work rounds are much better than walking around for hours and hours.

I will miss the people I worked with. There were two medicine teams, and Brenden, my co-intern, was great in keeping me calm and in helping me figure out the VA system. My senior residents were good, and the people from the other teams and services-- medicine interns, fellows, and med students (which I wish we'd had on our team to scut out!)-- were very fun people to be around! We were always joking and chatting it up in the residents' room (when we were not working, that is).

I will not miss discharge summaries. AAAAAAARGH. These take SOOOOOOOOOOO long. While generally, discharging people is great b/c that means you don't have to round on them the next day, discharge summaries take forever. Especially when you try (trying to not violate work hours) to do them at home, on a laptop with a little rolly pad instead of a mouse, which makes cutting and pasting labs, radiology reports, etc. harder, and with a slow remote-access connection. One day I discharged four people within 2 hours and it was horrendous! This is an intern job which I will be GLAD to get rid of come next year.

I will not miss carrying my pager. While I finally got used to it going off constantly and stopped having baby seizures/panic attacks each time, I am so glad to be rid of that thing for a while :) It is so, so, so annyoing to constantly have to answer the phone while trying to get work done and seeing patients. I don't really like the phone that much anyway.

I will miss wearing scrubs every day. I don't know how I'm going to do with having to pick something (matching) to wear every day, it's been so long!

I will NOT miss getting up early. I am so looking forward to sleeping in tomorrow!

I leave for Colorado on Wednesday. I am soooooooooooooooooooooooooooooooo excited!!!!!!
I'm not sure what kind of mischief I will be up to these next few days, but it will NOT BE WORKING! :)