Growth

"Thinking always ahead, thinking always of trying to do more, brings a state of mind
in which nothing is impossible."- Henry Ford

It's been two weeks since I've been employed as a Medical House Officer. I won't comment on whether they were tough or not, rather I've decided to share some tips for persons who will be rotating through any Paediatric Hospital Clinic, however some things may be more specific for my setting but nonetheless they may hold helpful to others elsewhere.

I recently read a devotional entitled 'Growth' which I would like to share before I delve into the tips, so bare with me a while.

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Derek and Jordan were neighbours who agreed to plant a small vegetable garden together. They would each help care for it and share the produce with their families. The friends looked forward to spending time together on the project, but neither realised how involved the task would become. 

It took time digging up the soil and breaking up the hard clods. Planting the seeds required precision. Some had to be deeper than others; some were planted side by side; others were planted eight inches apart; and still others were planted three inches apart. As the seeds sprouted, a portion of the plants required stakes to support them. Watering, weeding, fertilising and cultivating took a lot of time, but the guys kept their end goal in mind. 

Finally, they began to see the fruits of their labor-tomatoes, squash, beans, cucumbers and other vegetables. As they harvested their crops, Derek remarked, "Aren't you glad we don't do this for a living? It's fun, but it takes a lot of work."

The time and energy it takes to grow a vegetable garden can be compared to the effort it takes to "grow" your life. You must fill your life with healthy, nourishing influences. Be careful of what you read, what you listen to, whom you talk with, where you go, and whom you choose for friends. Living a fulfilling life requires planning ahead and maintaining your "soil" daily. The value of your life will be measured by the positive impact you have on yourself and others. 

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These two weeks were all about growth. Being able to work alongside other physicians more seasoned than myself and to communicate as a colleague has shown me that in life, we're all given the opportunity to grow. Some of us require more soil and sunlight than others, but that's alright, the goal is to continue to grow.

I started off with nine other colleagues in the Department of Paediatrics. This department has several areas each house officer is required to rotate through during the three month period on the rotation. These areas are: 

1. Community Clinics (of which there are 2)

2. Team 1 (which is a hospital based team consisting of 3 consultants with various specialties in addition to General Paediatrics)

3. Team 2 (same as above)

4. Accident and Emergency Paediatric Department

5. Maternity Nursery 

6. Hospital Clinics (all previously discharged patients and patients with particular needs are seen here)

Today's post will shed light on the intricacies of the Hospital Clinics and what you can expect on each particular day and ways to ensure clinics run smoothly and on time. 

INTERN TIPS

1. BE ON TIME

This pretty much goes without saying. First impressions are lasting impressions and if you're known to be punctual believe you me, everyone will notice. If you're new to the hospital clinic setting and what all it entails, arriving early affords you the opportunity to speak with the nurses in charge, the Senior House Officer or the Physician overseeing the runnings of the clinic so that you can be informed of the functions of each person on the team and how each clinic is run if there are multiple clinics on the same day.

Arriving early also gives you the opportunity to ask the patients whether or not they are attending clinic solely to get results for tests that were done at their last visit since in our setting depending on the result, you would have to walk to or call the laboratory to retrieve them. Once this is done you can attach them to their notes for the day which will expedite their visit.

When you're new to an area, it takes some time to get acquainted with where things are located and where they belong. Being on time or earlier than scheduled particularly on the first day allows you the opportunity to get a tour of where things are stored, where the bathroom is (staff vs. patient), where the supplies are kept because you'll always be in need of an alcohol swab, tongue depressor or gauze as well as those infamous continuation sheets for the patients notes, growth charts (because every child is plotted) and referral forms.

There are other documents that are dedicated to certain things that you will also need to know-headache diary for instance for patients who present with a history of headaches in whom you're trying to rule out migraines.

At our clinic, all of the necessary documents for the various clinics excluding Infectious Diseases clinics are stored in a brown accordion folder which is placed on the desk in each examination room at the start of the day and stored by the nursing staff at the end of the day along with a cylindrical desktop container that houses all of the tongue depressors, alcohol swabs and gauze you'll ever need.

2. INTRODUCE YOURSELF

With changes being made to the schedule in terms of who goes where each month or every other week, it is important that everyone is aware that you are new to the team or service and it also allows you to familiarise yourself with the persons with whom you will be working over the next few days, weeks or month. 

By introducing yourself to everyone, you'll also have the opportunity based on the ranking to know to whom you are to report and who can actually review your consults and ensure your plan is in keeping with protocol and in the best interest of the patient. 

3. KNOW YOUR ROLE

In the Paediatric hospital setting your role as the medical house officer is to frankly, be on time, see patients, don't get on the nurses or any other team members' nerve and to ensure that you complete everything necessary for your patient. 

At this stage in your medical career, the goal is to gain knowledge, improve certain skills and to ensure that your history taking, physical examination, and overall patient communication is improving and you're asking for help when needed. 

It is imperative that following the review with the consultant, you document everything that was discussed in their presence in the patient's note, you complete all necessary referral forms and fill out any prescriptions they may need and ensure they understand what was discussed BEFORE they leave. In our system, the medical clerk is responsible for making the follow-up appointments, but as the house officer, it is our duty to ensure we inform the patient and/or the clerk of when we're wanting them to return for their next appointment. 

4. KNOW YOUR SCHEDULE

Knowing your schedule allows you to keep track not only of where you're meant to be at a particular time of the day, but also when you have some free time to get other things done. 

If you're like me, a new house officer with some things to follow up in the Human Resources Department then knowing how much free time you may have ahead of time can help you take care of other matters. 

In regards to the hospital clinics, there's usually a clinic every day of the week excluding holidays or during MBBS examination time which is around May/June each year. Here's an idea of our hospital clinic schedule: 

On Monday mornings as you can see, there are three clinics running simultaneously, so on those days it really is a gamble as to which patient you will see. Team 2 patients basically are kids who were admitted on a call when Team 2 was 'on take' or designated to receive the patients on that call. Once they are discharged by the service, they are then scheduled to return to clinic (all at the discretion of the Team) for a follow-up to ensure they haven't had any problems since, or if they did have any medical issues, what they were and whether or not they would need to be readmitted or watched closely before being completely discharged from the clinic. 

The consultants on Team 2 are General Paediatricians with Paediatric subspecialties such as Paediatric Neurology, Endocrinology, and Asthma. 

Like previously mentioned, Monday mornings are a toss-up. The patients needing to be seen in Paediatric Chest Clinic (patients with PTB for example) or the Diabetic Clinic is dependent mainly on the week as these two clinics alternate on a weekly basis. So if this Monday was the week for the Chest clinic then the next week would be the week for the Diabetes clinic. Following the morning clinics which can sometimes run a little late (all depending on the patients needing to be seen and the complexities of their case) is asthma clinic.  

In the asthma clinic, the main goal is to ensure that each patient is controlled on their medications and whether or not they are in need of being stepped up or stepped down based on the severity of their symptoms and their overall diagnosis and assessment. The main questions you must be familiar with asking are mainly based on the symptoms: 

• When were they first diagnosed with asthma?
• How did they initially present when first diagnosed?
• How many hospital admissions or visits to Asthma Bay did they have since being diagnosed? What treatment did they receive?
• What medications are they on?
• Do they take the medications as prescribed? If no, why not? Were they on any medication for asthma before? What was the dose? Please demonstrate how they take their medication and when. Do they use an aero chamber? Do they have an asthma action plan? Do they use a peak flow meter?
• Since their last clinic appointment did they have any asthma attacks? Any nighttime awakenings because they had problems breathing? Any decrease in their activity or exercise levels due to asthma? How often do they have symptoms of asthma such as wheezing or chest tightness? 
• How many times in the year, or since their last clinic visit have they had to use their reliever? 
• How many days of school have they missed due to asthma?
• What are their triggers (change in weather, cold, flu, illness, smoke, dust, pollen, etc)? 

Tuesday mornings there is no Paediatric clinic scheduled. However, all Paediatric interns and Residents have a teaching session at 8:30 a.m. At 12:30 on Tuesday afternoons, there is an Intern presentation session scheduled, from which you are excused by 1:30 in the event the session is running longer than normal so that you can make it to the clinic in time to see patients for Sickle Cell Clinic. 

Be prepared to leave the clinic around 4:30 or 5:00 on a Tuesday. Since there is only one Sickle Cell Clinic per week and one Paediatric Haematologist in The Bahamas, this clinic is one of the well-attended clinics (which translates to sometimes 10+ patients). Punctuality to this clinic is essential mainly because there are so many patients to be seen and sometimes plenty of pathologies to be exposed to which means the teaching opportunities are endless. 

When seeing patients in the Sickle Cell clinic it is vital to ask the following questions: 

• Since their last clinic visit have they ever had the following: fever? chest pain? dyspnea? cough? 
• Age of diagnosis? 
• Last date of crisis? 
• The number of hospitalizations and the reason (acute chest vs. vaso-occlusive crisis)? treatment while in hospital
• Number of transfusions if any
• Steady-state
• Immunization history
• Current medications their on and whether or not it was changed at any point
• Any symptoms of anemia (fatigue, lethargy, pallor, etc)?
• Abdominal distension or pain recently or in the past? Any surgeries in the past?
• Dehydration status (water intake)
• History of jaundice
• Any exercise intolerance or cold intolerance or history of swollen joints? hands or feet?

When you're assessing them, be sure to look in their mouth and refer if needed to a dentist if you happen to see a number of dental caries or poor dentition. Also, be sure to review the tanner staging and comment on the Tanner stage. The consultant in our clinics loves to ask about the tanner staging as well as the surgical history and the conditions sicklers are prone to which would result in them needing to undergo surgery. 

Wednesday morning clinics are dedicated to Infectious Disease clinics. Be sure to speak to the Senior Registrar or the head nurse in charge of this clinic as this clinic runs differently compared to the others. They will be the ones to advise you on which patient they would prefer you see and how to go about conducting your consultation. This clinic runs fairly smoothly because the nurses are so efficient.  Once this clinic is done, be sure to get a bite to eat in between. Technically afternoon clinics are scheduled to begin at 12:00 p.m. however, the team may decide to work through a break so clinics can end a few minutes earlier. 

Neurology clinics can be long as well but they are filled with learning opportunities so be sure to make the most of your time there. Wednesday afternoons are usually for follow-up patients so reviewing their drug levels and reading EEGs to determine if medications are to be adjusted. Sometimes though, you may have one or two new patients who were referred to the Neurology clinic that is seen on a Wednesday afternoon as opposed to a Thursday. One main tip for the Neurology clinic in addition to a detailed CNS and MSK examination, be sure to complete a mini-mental status examination where needed. For example, if the patient has some developmental delays and during the exam appears to be cognitively impaired. It will help in your assessment when you're presenting to the consultant.

Thursday- all day- you'll be stationed in the Neurology clinic. Team, 1 clinic patients are usually seen by the senior house officers and more seasoned members of the Paediatrics department. The physicians in charge of the Neurology clinic will be the ones with whom you are to report and who will be responsible for dismissing you from the clinic. 

Friday's are usually interesting clinic days where you don't really know what to expect. The neonatology clinic sees patients who were admitted to the Neonatal Intensive Care Unit at the hospital and discharged. Some patients may be in the clinic for results of a karyotyping study that was done or just to know whether or not they will be discharged from the clinic altogether.  Fridays can be an early day depending on what needs to be done for a patient and how many patients the Consultant has to see. 

Although our schedule says Cardiology clinic and consults, since there is no Paediatric Cardiologist in the public setting of the hospital this clinic, unfortunately, doesn't exist. 

5. BE PREPARED

Nothing beats preparation. 

That said, prepare yourself each day for the worse. Pack your bag with snacks, water, lotion, hand sanitizers, extra gauze, alcohol swabs and don't forget your diagnostic kit (since clinics aren't furnished with them). By preparing yourself for anything you'll ensure that you aren't loosing anytime from your consultation with a patient because you're either looking for something or dying for a bite to eat. 

I forgot a few times to pack my bag the night before with snacks that I eat and had to wait until the clinic was over to get something. Let me tell you, the last thing I wanted to eat was peanuts. 

By knowing what clinic you're to attend the following day, you're able to read up on common topics so that you can take advantage of having a consultant present to discuss topics with and why certain things were suggested for a patient's management. 

6. BE WILLING TO LEARN AND TO TEACH

It's all up to you to make the most out of this year of internship. Although you've successfully completed all requirements of medical school and attained a degree in Medicine, it is important to remember that learning is lifelong. 

The clinic settings afford you the time and opportunity to learn. You are in a setting with persons at different levels in a particular specialty who are still learning themselves. Most times they're excited to discuss something with you and to guide your thinking. 

Once you've been taught, it's important to pass that knowledge on to the medical students who may be present in the clinic as well. Remember you were literally months ago a student, continue to be kind and willing to teach. After a while you'll realize you won't need to ask all the time the dosage of certain medications and why you're checking the levels of Tegretol in a month as oppose to a couple of weeks (remember autoinduction?) and you'll be now able to store new information. 

7. BE WILLING TO HELP

Regardless of your position on the medical totem pole, you always find that you're in a position to help. A colleague may be in with a difficult patient and in need of a radiological report but they're unable to move at the moment if you're free to, why not offer to run and retrieve it? 

What I've found over the last two weeks in clinics is that a little goes a long way, especially if persons were on call the night before and weren't able to get a night's rest. 

8. COMPLEMENT SOMEONE EVERY DAY

Compliments go a long way! 

From a simple "you look nice today" to "the way you handled that situation was impressive, you did a great job with that" can create an environment that is comfortable to work in and to grow in. Once people realize that you're teachable, genuinely nice and have great work ethics, your daily experiences -despite the unforeseen circumstances that may arise (i..e that close call with explosive diarrhea or having kids pee on your lap) will be so rewarding. They may even have a ripple effect that changes the culture. 

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My very good friend Dr. M was so kind as to send a video of his tips based on his two weeks in the Hospital in Scarborough Tobago. I've posted it below. 

If you're a new House Officer or an experienced one please share in the comments section your tips and tricks on how you survived your initial weeks of internship. 

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