The following is my site evaluation summary:

During my site visit, I was with one other student. My preceptor asked us to each present a patient. She requested that we send our history and physicals to her the Sunday before we met, so she had a good idea of what we would be discussing. She emphasized the importance of placing specific orders before admitting patients to the floor, especially when in the ED. For example, during my presentation on the 4yo with the likely appendicitis, she reminded me to include that I would make him NPO. The preceptor than asked us about pharm cards and quizzed us on each other’s. She made it clear that she was available for any questions, and invited us to reach out if we had any questions or concerns. The site evaluation went very well.

The following is my reflection of this rotation:

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

I found it difficult to gauge how much information the resident or attending would want to hear from me after I had seen a patient. Many times, I could tell they were losing focus and not interested in the more trivial details; however, other times, physicians would be impressed by a specific question I asked and commend me for considering a wide differential. For example, if a patient came in with acute altered mental status, some physicians would appreciate that I asked them about prior infection in order to rule out meningitis whereas others would say that meningitis isn’t on the differential because the patient is well appearing. I began to try to change the way I presented patients based on how the physicians responded to them. Looking back, I’m not sure if this was the best method. As a clinician, I would want to keep my differential wide and encourage thoughts about diagnoses that are less likely. This ensures that we don’t one day forget to ask important questions that could reveal a lot about a patient’s diagnosis. As Mike said during Callback, at rotation 6, we need to start thinking as clinicians rather than students. It’s important to understand one’s audience, but to not change so much that you’re doing things you don’t necessarily agree with. 

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

A police officer was brought to the ED for chest pain. He was explaining classic signs of symptoms of panic disorder. The attending accompanied me during the history. Throughout the history, however, the patient started to become short of breath and was visibly becoming more anxious. The attending asked if he were okay, and he nervously said yes. She then had to urgently leave as a trauma had arrived. I stayed with the patient and did some counting exercises with him. Together we counted up to 10 3-4x. Each time he visibly became more relaxed and calmed down. He was amazed by how such a simple exercise helped him so much. I recommended that he began to start counting slowly and with deep breaths the next time he feels this chest pain and shortness of breath. He was very appreciative that I stayed and helped him. 

In the ED, it’s difficult to manage time well. The attending had to urgently leave. She was too busy to walk a patient through a breathing exercise. Nonetheless, the quick improvement and symptoms right before my eyes will likely motivate me to help do these exercises with patients as much as I can. 

How could the knowledge I’ve gained here be applicable in other rotations/disciplines?

It is important to not fall into a routine. Every decision regarding a patient should be deliberate. It can become easy to fall into the habit of ordering a CBC, BMP, CXR, and U/A without much thinking. This is a poor way of encountering patients. Even if it’s a gut reaction to order a CXR for chest pain, it is important to always ask why. Questioning one’s decisions often helps keep the mind sharp and deliberate. The physicians in the ED would always ask me to justify my orders. I am getting a CXR for chest pain to rule out a potential pneumonia, evaluate if there is a widening of the mediastinum, to see if there a rib fracture, etc. This helped me better understand disease processes and reiterate different diagnoses and how they can present. 

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

I want to think more like a clinician. Much of the orders that I present to my preceptor have an air of doubt. I am waiting for validation from the preceptor. From now on, I want to present with more confidence and truly believe in the decisions that I am making for my patients. I no longer want to seek validation for every small order and decision I make for the patient. If a patient falls, and I believe they need a CT head, I want to feel confident enough to be able to fight for that scan.