Internal medicine wards

The goal of these articles are to depict what's the hospital system and the life of an intern/resident like in the US (more precisely in Dallas, at UTSW). I'll start with the wards (internal medicine) rotation at the Veterans hospital since this is the rotation I just finished.

Like all our rotations, it lasts 4 weeks. Each team is made of one intern (= first year resident, that's me), one resident (2nd or 3rd year), 2 medical students and 1 attending. Each person has a specific role in the team:
- The med students follow between 2 and 4 patients. They are the ones who will have most time to spend with them and get to know them. They alert us about anything concerning (for example, one of my former med students realized my patient was being abused at home and thanks to her we were able to gather resources to help her). They see their patients in the morning before rounds and present them on rounds. They're expected to have a broad differential about their patient's conditions and ask a lot of questions! They get one weekend day off a week.
- The intern carries all the patients in the team (max 10). He knows them all, adds anything missing in the med students' presentations, presents the others. He reviews plans with med students before rounds so they'll feel comfortable presenting. Writes notes everyday for every patient. Places orders, talks with consultants and families etc. His goal is to make the resident feel useless! If time allows, he can teach the med students (but that's not formally expected from him). He gets precall day off - Q4 day off.
- The resident leads the team. He helps the intern if needed, makes sure all orders are placed and everything needed is done for our patients. He teaches the med students. He does 28h call from 7am to 11am the next day, goes home at 11am and gets the next day off so one day off every four days.
- The attending rounds with us everyday, usually twice a day on call days to talk about the new admissions in the afternoon. He answers our questions, teaches us and makes sure we're doing the right things. He usually stays on for 2 weeks.

The main difference I see with French practice in the way we work is that everybody has its own important role to play within the team. We all listen to what the med students have to say (absolutely not the case in France, unfortunately) and interns/residents are the real care givers in the team. You'll rarely, if ever, hear "We'll do this because I like it/I've always done like this" but rather "I usually do this but there's no evidence, I'll let you decide what you want to do". We also have amazing staff for administrative stuff like making appointments, getting records, social matters etc. All those things are usually done by intern/residents in France and it is very time consuming. French residents if you read me, I don't even know where the fax machine is in the hospital!!

The other difference is going to be in the organization. Here "internal medicine" regroups cardiology, pulmonology, gastroenterology, endocrinology, rheumatology, infectious diseases, nephrology... The internal medicine team takes care of a lot of different diseases and will call consultants to help on a very specific question. In France, units are divided in all those different subspecialties. It helps that French patients are healthier and don't have so many different chronic conditions. When it happens, imagine that the cardiologist has to manage his patient's diabetes... What we call "Internal medicine" is usually closer to rheumatology, they'll see vasculitis and autoimmune conditions among other things.

Back to business, our wards rotation. We're on call every 4 days. Being on call means we admit new patients in our team, up to a total of 10. So if we start our call day with 4 patients we'll have 6 new ones during the day, either ED admissions or ICU transfers.  We start our day at 7am. I'll get to leave between 7 and 9 pm while the resident stays overnight and eventually admits other patients with the night intern if we haven't capped. On post-call day, we round at 7am - which means I have to see all patients before (usually starting at 5:00-30). The resident leaves by 11 am and I stay to finish what we have to do for our patients. On post-post-call day, the resident is off so it's just me taking care of our patients. Logically we have less than 10 since we've been discharging some on call or post-call day. We round at 10 so I start at 7 (can't start later than that as I have to relieve the night intern from its duties). The last day of our cycle is pre-call day: I'm off, and the resident takes care of our patients. Every day from Monday to Friday, we have morning report between 8 and 9 am: usually 30 min of teaching followed by a case presented by the pre-call resident - he presents the patient and we ask questions to solve the case. We also have a conference at noon with lunch provided by our program (and it's really good!). 

Seeing patients in the morning is probably not different from other countries' practice: we talk with our patient, examine him, update on the plan, hopefully answer his questions. On rounds, we present every patient to our attending - either sitting in our rounding room or walking in the hospital and presenting in front of the patient's room, depending on the attending's preference. Some of them will make you present in front of the patient - interesting challenge to give all the information you need and make it understandable by the patient! The Americans have this specific format of presentation (at least it doesn't exist in France): SOAP 

     - Subjective/24h events: how the patient feels, what happened since last rounds

     - Objective: vitals, physical exam, labs, imaging

     - Assessment and Plan: what are your patient's problems and how you're managing them

When medical students present, they're also expected to give their own assessment and plan (that they can review with the resident or the intern before rounds) and if possible bring up some articles about their patient's conditions - we aim to practice evidence-based medicine. After we go see some or all the patients as a team and update them on the final plan.

In the afternoon (after rounds and noon conference), we write notes for every patient using the SOAP format. We also answer pages from nurses, consultants, etc. and take care of things that need to be done. Once we're done, we hand off our patients to the intern on call: brief presentation of patients that might cause problem during the rest of the day/overnight and things to do (mainly check PM labs). At 7 pm, the intern on call will hand off all the patients to the night intern.

I also worked nights for one week. Basically as I said earlier I get there at 7 pm, get hand off from the on call intern and answer pages for about 30 patients during the night. I also admit patients with the resident on call if the team hasn't capped.

Obviously at a Veterans hospital I saw mainly males. They had lots of different diagnosis: chronic heart failure exacerbation, gastrointestinal bleed, new diagnosis of cirrhosis with ascites, metastatic prostate cancer, chronic kidney disease, pulmonary hypertension, stoke... We have these wards rotations in two other hospitals with the same logistics. The big difference is going to be the patient population we see:
- Parkland hospital is the county hospital and gets a lot of unfunded patients. It is medically very interesting as we see very advanced diseases and interesting cases, humanely very rewarding as our patient are very grateful for our care, and socially very sad to see some patients not able to afford care or not having the necessary education to understand their disease process and why it's so important to treat it. The spectrum of diseases we see is very broad: HIV/AIDS with opportunistic infections, heart failure, cancers, cirrhosis, kidney failure, diabetes... Most patients will have several chronic conditions.
- Clements University Hospital is the private hospital associated with UTSW. Over there patients are usually older than at Parkland - sadly cancers and dementia are more common. They are all funded and more demanding (one even requested wine with his dinner!). They also have an important transplant program so we see transplanted patients with their complications. Once more, very broad spectrum of cases.

That's all folks! Next rotation: Medical Intensive Care Unit!