Types of patients you found challenging in this rotation:

The most challenging patients I encountered on my ambulatory care rotation were those that I was unable to communicate with due to a language barrier. Being in Ozone Park, many of the patients were non-English speakers and only spoke Spanish. It is often difficult to connect with a patient when you are not speaking directly to them, and unfortunately things can get lost in translation. Often times an initial patient did not speak English, making the history that much more difficult to obtain because the question list is more extensive and more personal than that of an already established patient. I found that asking a patient about sexual history, and social history (i.e. drug/alcohol/tobacco use) was more difficult with these patients.

 

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

During my last week of this rotation, I had a 95 year old female who was recently signed out of the hospital against medical advice. She was diagnosed with community acquired pneumonia along with hyponatremia, and it was recommended that she be admitted to the hospital for further evaluation and treatment. However, due to COVID, the patient’s daughter would not be allowed to stay with her and the siblings jointly decided to sign her out against medical advice because they did not want to leave her alone. Instead, they brought her to our clinic because the patient was still not feeling well and they wanted us to help. It was a very difficult situation for me to witness, and I was emotional because the patient needed to be in the hospital for IV antibiotics and close monitoring, however she was refusing. I told the daughters that I understood where they were coming from but if they don’t take her back to the hospital her condition can worsen and she can ultimately die. Unfortunately, they decided to take her home and not have her admitted to the hospital despite our recommendation. I felt quite helpless in this situation, and was overwhelmed because this patient had an easily preventable condition that could have been taken care of at the hospital, yet there was nothing else I could personally do for her.

 

How was the way I did my work different from how other people did theirs?

It was interesting to note the differences in the way this office and its providers operated vs. what I would have done on my own. For instance, every initial patient (no matter the age or comorbidity) gets a chest x-ray to “have a baseline” on file for future visits. When I first heard of this practice I was confused and somewhat alarmed because I did not understand why we would expose patients, especially young and health ones, to unnecessary radiation. Later on I noticed that imaging studies would be ordered left and right even though it might not be indicated. For instance, a patient with an already diagnosed herniated disc would receive a repeat MRI in lieu of being referred to physical therapy. It might be that the providers wanted to make sure nothing had changed, but I viewed this action as easily billable and extra ways to make money. There were also times where the differential diagnoses did not seem to include an extensive enough range of possibilities. For instance, a patient presenting with pain on urination + associated flank pain that had CVA tenderness on physical exam, should have a workup done for pyelonephritis, nephrolithiasis etc.  and not necessarily be treated as acute uncomplicated cystitis without ruling out the more serious differentials. 

 

What did you learn about yourself during this rotation?

This rotation was the first one back after being away from clinicals for over 4 months due to the COVID-19 pandemic. On my first day back I was especially nervous because I was worried how rusty I would be having been away from actual “live” patients for so long. I was particularly worried because I knew this rotation entailed seeing patients on my own for extended periods of time (approximately 45 minutes-1 hour depending on if it was an initial or returning patient). However, once I did my first couple of patients I was back in the swing of things and realized that despite the time off I had never quite “lost” my ability to interact with patients. I was grateful for the opportunity to be with the patient on my own and to independently develop a diagnosis and plan which I then presented to my preceptor before he/she saw the patient. It was great being able to have this sense of autonomy, especially after such a long hiatus, and I quickly returned to my element and remembered why I had pursued this profession to begin with.