Every Internal Medicine resident is required to do a number of blocks called "CTU" (Clinical Teaching Unit), also known as General Internal Medicine, as part of the residency curriculum. The spicy nugget for internationally graduated physicians such as myself is we are required to complete two of these blocks, back-to-back, to start off the year.
Block 3 was therefore my first subspecialty block, and it was Gastroenterology. The rotation was further divided into two 2-week periods. The first was in luminal gastroenterology, which is concerned with pathologies of the esophagus, stomach, and intestines. Most patients admitted to these services are suffering a gastrointestinal (GI) bleed, or have inflammatory bowel disease (IBD).The second 2-week block was hepatology; in other words, disease of the liver.
Mr. J - 23 years old, admitted for a Crohn's disease flare. Awaiting surgery.
There is something inherently different about treating a patient who is young. For better or worse, there is less comfort with the notion of being sick. There is also less tolerance from younger generations for paternalistic medicine practices. The overall experience is more of what modern medicine likes to call "shared decision-making." To be honest, it's refreshing. That is not to say I don't enjoy treating older patients, or feel rewarded in giving them care. However, sometimes you have to convince them their opinion matters and that they can have a say in their own medical journey.
Mr. J was a relative newcomer to the sphere of "I have a chronic disease." He had only been diagnosed with Crohn's disease one year earlier, and still had a deer-in-the-headlights look about him. I don't blame him; he had been shitting his brains out, on and off, for three months, and his first treatment given to him by his gastroenterologist was not working. He was in hospital to get control of this flare, which is code for "eat nothing and take this tub of steroids." He took it like a champ, considering his was one of the worst CT scans I had ever seen. Crohn's disease is known as a stricturing (fuck) and fistulizing (fuuuuuuuuuck) inflammatory bowel disease. He had bad cases of both; he was about one millimeter away from his bowels burrowing a hole into his bladder and causing him to piss chocolate milk. This man was headed for surgery.
Unfortunately, Crohn's can create fistulas from your rectum, through your butt cheek, and out your back-end in very unexpected places. It is the literal version of "tearing you a new one." So when J told me it really hurt to defecate, I had to at least consider he had one of these perianal fistulas. Another lovely side effect of going to the toilet 20-30 times per day is getting hemorrhoids. Either way, I had to take a look, and probably a feel. Luckily, he had neither of these. His pain was simply due to shitting blood double-digit-times per day. The worst part of it all for him was perhaps me looking him in the eye and telling him I needed to put a finger in his rectum. For science.
Ms. K - 32 years old, admitted for an ulcerative colitis (UC) flare. Or so we thought.
Ms. K was actually admitted to the hospital at the same time as Mr. J; I often rounded on them sequentially, which provided starkly different doctoring experiences. Ms. K was by all accounts, a goddamn boss. This was at least partially due to the fact she was supremely comfortable with her disease process. She'd look me in the eye and go "Today I only went eight times, and there wasn't that much blood. Want to see a picture?"
She was in a flare, or so we thought. Prior to her hospital visit, she sat on the toilet 10-20 times per day, as is normal for UC, and passed a lot of blood each time, also kind of normal for UC. She knew it; we knew it; easy diagnosis. Except we stuck a camera into her colon to confirm the diagnosis and saw a perfectly healthy bowel. Not a flare.
It turns out she had taken some penicillin a couple of weeks prior at the dentist's office, which can throw off your bowel bacteria and lead to a c. difficile infection (hence the frequent toilet visits). And the blood? A sneaky artery just on the inside of her rectum, invisible to all scopes, exposed because of her long history of bowel inflammation, that just could not withstand the stress of 20 bowel movements per day. Lesson learned: do not underestimate all the creative ways your body can learn to shoot blood out ya butt.
A tale of two fellows
The second half of this rotation was Hepatology, a vastly different beast to the first. Luminal gastroenterology, at least in the acute phase of treatment, is often focused on whether to stick a camera into someone to find out what's wrong with them. The battle, most commonly against bleeding or inflammation, is simple, but the enemy is sometimes inexorable.
Hepatology often felt like a chess match. The team sits around a computer and studies lab results; diagnostic uncertainty abounds; gestalt and finesse reign supreme. In luminal gastroenterology, I at least felt like my assessment and proposed plan for our patients was plausible. Hepatology made me feel like a puppy treading water out at sea. Pile on fatigue, unfamiliar environments, and a computer operating system you don't recognize, and you just start to feel dumb.
This part of the rotation wasn't memorable so much for the patients as the colleagues I worked with. Subspecialty rotations always place you with a fellow specializing in that field; the attending physician steps back and oversees operations, but it is the clinical fellow who coordinates, sees all patients, teaches, and manages the team. As a first year resident, they are your greatest source of support, and your most likely teachers.
My first clinical fellow on hepatology, we'll call him Prof X, was..... an angel? There always seemed to be a free moment for him to pull me aside and teach around the cases we had seen; he always managed to make me look good in front of attending physicians; he always made sure my clinical decision making was thoughtful and evidence-based. The greatest treasure he gave me was making me comfortable "getting it wrong," of which I was doing plenty.
My second clinical fellow (Magneto?) on this rotation was... not any of that. He was the type of person who managed to get frustrated by tough patients and rickety desk chairs, by a busy schedule as well as a pen that ran out. There did not seem to be a moment in his day available for a positive thought, and that in turn made my days with him very not-positive.
It is not the most groundbreaking thought to say that being a good colleague, boss, or subordinate can make a big difference in someone's day. It is just incredible that my experience on Hepatology had nothing to do with the patients, learning, or my schedule, and everything to do with the individual occupying this one role on the team.
I am slightly terrified by the notion that the locus of control for my enjoyment of a rotation rests so far outside of me. However, it is also liberating. A bad day, a mistake made, or a displeased superior, may not alway be my fault! Sure, this feels obvious in retrospect and is easy to type with some perspective. But I challenge you to tell a resident or medical student "not to worry." It's about as helpful as telling someone who is depressed to "cheer up" or a raccoon to "stop eating my garbage."