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

Many of the patients admitted to the internal medicine floor first came to the ER, expecting to go home shortly after they were treated. However, depending on their condition, they were sometimes admitted for ongoing care. Some patients were reluctant to stay or would ask to be discharged after a day or two, believing they were stable enough to go home because they felt better. However, we needed to make sure all consults were completed and that all their bloodwork and imaging results were stable. The patients might not understand that all this is happening in the background. For example, one patient wanted to leave because her chest pain had stopped. But, just before discharge, we found she had developed afib without her feeling anything. She was disappointed and eager to go home, but the PA took the time to explain her condition and outline the new steps necessary before discharge. They made an effort to understand her perspective as well and showed empathy.

I learned that each day, when the PAs rounded they provided a brief update on what the patient was waiting for and when discharge might be possible, depending on pending results. This helped the patient feel involved in their care and assured that we were working to help them recover, even if it sometimes seemed like they were waiting without any reason.

2) What do you want to improve on for the following rotations? What is your action plan to accomplish that?

During this rotation, all the patients were admitted for several days, so they had a lot of documentation, including consults, nurse’s notes and PA notes. When I needed to read up on a patient before seeing them, I found myself overwhelmed by the number of charts for each patient. I didn’t know where to start to gather the most essential information without spending excessive time on each patient. After seeing each patient, I had to present the case to the PA, highlighting why they were admitted, any pending tests or consults and how they were doing.

I decided to ask for help and asked one of the PAs for guidance on navigating the charts since they do the same when they first see the patients. They advised me to always start by reading the attending’s admission H&P, check labs and imaging and then review the most recent chart entries. The assessment and plan section was especially helpful since it summarized what was pending for the patient. In my next rotation, I want to become good at going through multiple charts for each patient. In surgery, I will need to review charts on each patient’s status, including surgical and post-surgical notes. I plan to ask the PAs there for tips on how they approach chart review and use similar methods. With continued practice, I’ll become more efficient and improve my case presentations.

3) Skills or situations that are difficult for you (e.g. presentations, focused H&Ps, performing specific types of procedures or specialized interview/pt. education situations) and how you can get better at them

In future rotations, I want to improve my skills in educating patients’ families. Although we don’t do this often as students, I think it’s an important skill to develop as a future PA by watching how the other providers do it. Many patients in internal medicine are older, so the PAs I worked with frequently needed to update families on the patient’s care. I learned that it’s important to first establish the family member’s connection to the patient and ensure privacy. Then, we should communicate in a way that’s easy to understand, avoiding medical terms, or explaining them if necessary. Being empathetic and honest about the patient’s health, including whether they are improving or declining, is also critical.

To improve in this area, I plan to prepare everything I want to say beforehand and anticipate questions the family might ask. If I am telling them an imaging result I should know why it was done and what is the treatment for it. I’ll also continue observing how PAs and attendings handle these conversations and take notes. Being well-informed about the patient and their care plan will help me feel more confident when speaking with both the patient and their family.

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

On my last day of the rotation, I had a 95 y/o cancer patient who was not improving despite the team’s efforts. Each time we saw the patient, she refused any labs we requested and declined any assisted breathing devices. She expressed her desire to go home and spend her remaining time with her family. But, her family did not want to stop interventions and move to comfort care. They wanted us to keep doing everything we could. Due to the patient’s limited capacity, we were required to prioritize the decisions of her health proxy over her personal preferences.

This was a memorable experience for me because I haven’t encountered a situation like this in my previous rotations. I was able to see the process of advocating for a patient and using our knowledge as providers to help the family make the most informed decision possible. The PA spoke with the family, explaining that the patient’s health was declining despite all available treatments. She shared that during rounds or attempts to draw blood for an ABG, the patient would beg her to not be poked with a needle anymore. Medically, it seemed in the patient’s best interest to transition to comfort care. The PA did not force this option on the family and emphasized that the family had the final say in their grandmother’s care. The family expressed that they couldn’t simply “give up” on her, but ultimately agreed to meet with the healthcare team to review all available options moving forward.