Ambulatory Month

End of the rotation
I'm winding down my day here at 1 AM and thinking about how this month has gone. It's not quite over, but I have the evaluation notice e-mail in my inbox so the end-of-month or end-of-rotation can't be far away.  At the end of every rotation we are required to evaluate the rotation itself, the attending physicians, and supervising residents (if applicable).  I usually try to put down something meaningful.  It gives me an opportunity to reflect what I might want to do in the future to be a reasonably pleasant upper level resident someday.

The ambulatory itinerary 
All categorical Internal Medicine residents here at BCM spend a month in various outpatient clinics. I feel a bit like being a gypsy or traveler because there are so many different clinics.  For example, later today I will start at a VA infectious disease clinic in the morning before going to my regular primary care clinic in the afternoon.  Earlier this month I was at an outpatient neurology specialist clinic.  A couple of days ago, I was on call at St. Luke's admitting patients for a wide variety of conditions and writing orders for patients who needed adjustments to their therapy overnight ... this is probably why my sleep schedule is abnormal as I adjust from overnight back to day service.  Frequently this vagrant schedule means missing morning report sessions, noon conferences, and Grand Rounds because of the inevitable issue of closing out one's work at one site before moving to another clinic (or simply allowing time to travel across the medical center). Many attending physicians don't go to these teaching sessions and more or less seem to be unaware of them; they do have busy clinics to run, after all.

Benefits
The benefit of the above arrangement is that, as a resident, you see a variety of settings and probably learn a broader scope of outpatient care. Each specialty clinic has its own way of operating and unique set of patients from which to learn. For me it helps me remember diagnostic criteria and treatment options if I have seen at least one patient with a particular condition, whether liver failure or arthritis.  Another excellent benefit of the ambulatory rotation is that it allows time for life outside the residency program.  I spent a lot of time with my family this past month and that will change a bit on ward months.

Medical ICU at the Michael E. DeBakey VA Medical Center - Houston, Texas

I'm spending my first month of residency at the Michael E. DeBakey VA Medical Center in Houston, Texas. Starting out we have one or two patients usually and we order all the tests and medicines our patient needs as well as taking care of any problems that come up. An upper level resident and critical care fellow mostly supervise our work and we round twice a day with a critical care attending physician who teaches us various relevant material and reviews our patient assessments and plan. When we are on call, we work with an upper level to care for the patients in the Medical ICU and CCU. It's a great place to train with lots of teaching and interesting patients to work with. I like taking care of the veterans and talking to their families. In the ICU there isn't much conversation with the patients because they are very ill. However, the families are very appreciative and it's a good feeling when you do something that helps the patients recover an improve. Even if there is really nothing that can be done for a patient medically, there are sometimes good ways to help the family go through the process of dealing with death and grieving that seem to be helpful and appreciated. I'm looking forward to learning a lot and like the other physicians and nurses I work with.