Goodbye Community Practice, hello Internal Medicine

Community Practice is done, which is somewhat bittersweet. Sure, there were a lot of things about CP that I didn't like or that got old after a whole month, but overall it was an enjoyable rotation (which is good, since I think that my career goal after vet school is basically CP-type employment).

My first two days on Small Animal Internal Medicine (SAIM) have provided an interesting compare-and-contrast to Community Practice (CP). Here are a few of the variations:

CP clients are, overall, pretty nice but usually come with a financial limit. There's plenty of haggling over which heartworm medication to prescribe ($35 for 6 months versus $45 for 6 months), whether diagnostics like cytology of a skin mass (~$35) fit into the budget today, that sort of thing. CP clients are to always be advised of the cost of everything before we do any procedures or diagnostics -- even things as simple as vaccines or a nail trim.

SAIM clients arrive at the VTH having already been informed of the ~$90 exam fee. That means that they are aware that, just by walking in the door to see a specialist, they will be spending roughly a hundred dollars before we get to any bloodwork, urinalysis, xrays, ultrasounds, CT, MRI, anesthesia, surgery, endoscopy, cytology, biopsies, or myriad treatments. Most SAIM clients have already had their pet's problem(s) worked up by their referring DVM (rDVM), meaning they've likely already shelled out quite a bit of money before arriving at the VTH.

CP clients tend to be intelligent people who are not overly familiar with veterinary medicine, wellness care such as vaccine schedules, and the benefits of screening tests such as annual bloodwork and fecal exams. Their level of compliance with such recommendations is quite variable.

SAIM clients have typically done a lot of research into their pet's suspected illness, whether through the Internet, their rDVM, or multiple other consults before they came to us. They tend to be familiar with causes, complications, and treatments for their pet's disease, and are often quite comfortable with medical terminology.

CP sets a time limit for appointments: a goal of getting the client from the front desk checking to the client service desk checking out in under an hour. This goal is not always met, if CP is very busy or if the pet has complicated medical problems requiring diagnostics, but it is a goal just the same. CP clients tend to keep one eye on the clock throughout the entire visit and will readily inform you if you took 25 minutes instead of the 20 minutes you told them they would have to wait.

SAIM clients often spend an entire morning or afternoon in the waiting area or exam room while their pet is seen by one or more students and one or more doctors, in addition to diagnostics such as bloodwork and imaging. They tend not to bat an eye when they've already been at the VTH for 2 hours and you tell them you'll need to borrow their pet for yet another 30 minutes so you can take radiographs.

CP students can see quite a few patients in one day. On our very busiest CP days, we probably saw 35-40 appointments with 7-9 students sharing the case load.

SAIM students see generally 1 or 2 new cases per day, plus maybe some rechecks in the afternoon for ongoing cases. They may also have 1 or 2 hospitalized animals that are housed at the VTH overnight and on weekends to manage an illness or for owners' convenience the night before a procedure.

CP students have "topic rounds" in the morning, lasting about an hour and covering such themes as "new puppy visit," "new kitten visit," "heartworm disease," and "feline upper respiratory infections." CP students have "case rounds" in the afternoon, lasting 20-60 minutes and briefly discussing all of the appointments from the day.

SAIM students have topic/case rounds in the morning, lasting 60-90 minutes and including updates on all of the inpatients from the previous night, as well as often discussing one or two internal medicine topics (like diabetes or renal failure). SAIM students have afternoon/evening case rounds, lasting 1-2 hours and discussing most of the day's cases, especially any patients staying in the hospital overnight.

Two of the most stressful things about SAIM are (1) presenting cases to clinicians and (2) discussing cases in rounds.

Presenting a case to a clinician goes something like this: The SAIM student retrieves the paperwork, client, and pet from the waiting area, escorts them to an exam room, and spends 20-30 minutes (less if a recheck) getting a history and physical exam completed. The student then leaves the client and pet in the room, pages the clinician to the rounds room, then tells them about the case. You start with the signalment (pet's name, species/breed, sex, reproductive status, and age), then the presenting complaint, then the history, and finally your physical exam findings. Next the clinician asks for your problem list -- the list of each thing that is wrong with the animal (e.g. vomiting, coughing, lethargy, elevated liver enzymes on bloodwork from rDVM, etc.). Then you go through each problem one at a time and tell the clinician your "differential diagnoses" (what possible diseases could be causing the problem), rank your differential diagnoses from most to least likely based on the other findings, and discuss what further diagnostic steps you would need to take to prove or disprove each differential diagnosis.

Presenting cases to clinicians is somewhat harrowing because, for some reason, your brain tends to completely shut off when you are sitting down one-on-one with somebody with much more education and experience than you. It's something that I'm sure gets easier with practice, but at this point in our senior year we find that it's altogether too easy to misspeak, second guess ourselves, and overthink even simple problems.

Discussing cases in rounds is probably even more stressful. This means you're sitting in the cramped rounds room with 8 other senior students, the head faculty clinician, and 4 other doctors (interns and residents). The head clinician basically grills you, in front of everyone else, on the nitty gritty details of your case, the pathophysiology of the pet's disease, the pharmacological actions of the drugs you've chosen, the possible causes for all the abnormalities on the labwork, and anything else they can think of. There is lots of awkward silence while everyone avoids eye contact to minimize the chance of being asked about someone else's case -- and lots of empathy toward the poor individual stuck in the spotlight until their case has been thoroughly dissected.

Overall SAIM is a lot less physically exhausting than CP, because, for one thing, the rounds room and treatment area are right next to the lobby rather than at the farthest end of the hospital where CP is located. Second, seeing only 1-2 new patients a day means a lot less animal handling. Third, there is a group of 4-5 technicians who are dedicated to SAIM and extremely capable of obtaining blood and urine samples or restraining for procedures while you go off to research your case or discuss it with the clinician. So it's nice not to be on my feet quite as much, not to be racing around the hospital all the time, and not to be wrestling large dogs everywhere I turn.

However, SAIM is undoubtedly a much greater mental challenge than CP. It's a struggle sometimes to recall all of the important yet very detailed information I've learned about anatomy and physiology and disease processes over 3 intense years of classroom teaching, and to put it into practice when much of our previous style of exams has been more about regurgitation of facts than about decision making with real life case examples. And I just want to point out that many of the cases that we've seen in the last 2 days are referrals from rDVMs who had already tried and failed to diagnose the pet's illness. So it's not like they're just run-of-the-mill cases.

In any case, it's definitely going to be a fantastic learning experience and a challenge to my brain -- and I think I'll feel like it's been a rewarding experience at the end of my 2 weeks when (hopefully) I've become a little better at planning my case work-ups and thinking of logical differentials and diagnostics to pursue.