How did it go? What have you learned? What can you improve? How do you plan to improve these new skills?

My internal medicine rotation was a dramatically new and different experience. Most of the patients I saw were admitted, and I’ve only had previous experience in the ER and outpatient settings, with my last rotation being in a family medicine office. In the inpatient setting, the cases were much more complex, with each patient having multiple issues and chronic conditions that needed to be managed. Although most patients had specialists following their case, I often felt slightly overwhelmed when thinking of all the bases the internal medicine team had to cover and manage. I believe going through this experience and learning about the roles of physician assistants in the challenging inpatient setting was very eye-opening and important! I was lucky enough to observe interesting procedures as well, such as cardiac catheterization and transcatheter aortic valve replacements.

In terms of areas of improvement, I believe case presentations were difficult for me because I’ve never had experience in the inpatient setting. When admitted, the patient goes through so much during their hospitalization, and it was hard to encompass that in a 2-minute presentation. I was not confident in the order of my presentation, in terms of where to insert the interval hospitalization history, and which events/diagnostic tests to include (especially when the patient had been admitted for an extended period of time and had extensive workup done). I noticed this was an issue for me to I continued to practice presenting patients to my preceptor, and I paid close attention during rounds. I listened to how other providers presented their patients and took note of what they thought was important to point out in order to keep rounds concise/efficient. I plan to continue doing this and picking up on how experienced clinicians give patient presentations. I also plan to start asking whoever I’m presenting to if they can provide constructive feedback on my presentations.

Types of patients you found challenging in this rotation and what you learned about dealing with them

The group of patients I found to be challenging were the patients that could not communicate with me. This includes those that are nonverbal, altered, with dementia, and those with decrease level of consciousness that cannot communicate at all. I felt this group was challenging because they could not express how they felt, and almost all history/information came from family, aides, or from the facility they came from. With these patients, even if they could not see or hear me, I made sure to still introduce myself and explain everything that I’m doing. Before every step of the physical exam, I would explain to the patient what I was doing. With this group of patients, I learned the importance of doing a THOROUGH physical exam. Because these patients cannot communicate where they may be feeling symptoms, it is important to check all systems thoroughly, especially when looking for pressure ulcers in patients that are bedbound. I also learned the importance of communicating with the family and keeping them in the loop with all steps.

Skills or situations that are difficult for you and how you can get better at them

Compared to my last family medicine rotation, the patients in my internal medicine experience were overall much more acutely ill. This is somewhat obvious because the patients are all admitted, however, I did not expect the cases to take such an emotional toll on me. I’ve always had difficulty with maintaining a healthy balance of empathy; I can provide compassionate care, but it often takes a heavy toll on me when I see patients in pain or seeing family members watch their loved one suffer or pass away. During this rotation, I was following a particular patient for 4 consecutive shifts. On the 4^th shift, he passed away, and I left the hospital that evening feeling mournful. Situations like this that come with the profession are still difficult for me, but I plan to get better with time and seeing more difficult cases. I plan to ask my preceptors and other colleagues on their advice, and I’ll consider using their tips to get stronger in this aspect so that I can still provide compassionate care without getting emotionally burned out.  

What was a memorable patient or experience that I’ll carry with me?

A patient that I recently saw was on day 9 of her admission. I was seeing her for the first time, interviewing her, and performing a physical exam as I did with all my patients every morning. Before I entered, I went through the patient’s chart and read that she had initially come to the ER for altered mental status. Her head CT was negative, and she was having neurologic workup done to find the reason behind her AMS. While speaking with the patient, she seemed very alert, oriented, and her affect was appropriate. Once I started asking her questions to see if she was oriented to name, date, time, and location, is when I realized the patient was confused. She was oriented to name and location, but thought she had only been in the hospital for 2 days. This is when I learned how important it is to ask those 4 questions to assess the patient’s orientation because someone may seem alert and oriented conversationally, but they may be good at hiding their confusion/disorientation. When I told the patient she had actually been admitted for 9 days, she started to become very worried as she came to the realization of the state of her confusion. She became distraught as she realized how disoriented she was. I realized how scary this situation must have been for her, so I stayed with her to listen to her worries. I recognized her emotions and assured her that I understood why she was feeling this way. As I was leaving the room after the patient had calmed down, she thanked me for my “kind care.” I could tell that she really appreciated the time I spent with her to listen to her concerns, and I will carry that with me throughout my future PA experiences.