Exposure to new techniques or treatment strategies – how did that go?

• During this rotation, I was not able to perform [only observe] blood draws or EKGs due to the agreement I was told was made with the institution. However, I was able to perform breast exams after EKGs were completed. I had begun with the linear/grid pattern learned in Physical Diagnosis. However, the attending showed me another technique whereby one hand was placed at the base of the breast while the other hand was used to palpate with the pads of the fingers in small step-like strokes from the periphery of each quadrant of the breast toward the center of the breast. He stressed the importance of placing the pads of the fingers flat on the patient on the breast as well as on the abdomen during the abdominal exam in order to apply gentle pressure on patients, as the tips would elicit more pain in the elderly. This was a skill I was able to more deliberately practice and improve upon throughout the rotation and believe it is important to note in the elderly population, as patients may be more sensitive to pressure and pain.

Skills or situations that are difficult for you (e.g. presentations, focused H&Ps, performing specific types of procedures or specialized interview/pt. education situations) and how you can get better at them.

• Presentations are particularly difficult for me, as I had been intimidated listening to residents present patients with an ease that felt very foreign to me. Nevertheless, it was a skill I know I needed not to shy away from and ultimately attempt despite my lack of confidence. After seeing a patient on my own and presenting to the attending, I directly asked him for feedback on my presentation because  I did not feel great about it. He assured me not to worry, as no one, including him, presents patients perfectly, and the most important step in learning to present, is the first step – so it was great that I took it. Afterwards, we went over what is considered the systematic approach to presentations. Of note, a separate geriatric assessment is completed during patient visits where I was rotating, and completing this assessment was also a skill I was able to incorporate and become accustomed to throughout the rotation. This was also part of the presentation. Going forward, my focus is on gaining more confidence during presentations by doing them as often as I can and learning from each to build on for future experiences. I will also continue to ask for feedback and constructive criticism to help me improve. This will help me become more comfortable and up for the challenge as I progress through each rotation and beyond.

Types of patients you found challenging in this rotation and what you learned about dealing with them.

• During this rotation, I found that patients in the elderly population often present with some degree of cognitive impairment, most notably dementia. This would become challenging when trying to complete screening tests to assess cognitive status, such as the Mini-Cog, Mini-Mental State Exam, and St. Louis University Mental Status Exam. Patients who were unable to perform long-term recall, or other components of the exams, would often become embarrassed and sometimes emotional due to their inability to repeat the words mentioned to them previously. Family members would also become emotional, as it became difficult for them to watch their loved ones struggle and simultaneously accept a possible decline in cognition. From such experiences, I learned the importance of providing empathy and reassurance to both patients and their families through the example of the attending I had the privilege of following. During each encounter, he empathetically explained to families that their family member, even if they did not remember who they were, was still the same human being with the same soul they know – just that their brain is not allowing them to function as effectively as that full version of themselves. These experiences also taught me to manage my own emotions in those moments, as they were often sad to witness. Moreover, for patients who presented with moderate to severe dementia, the conversation of advance directives was also one that often needed to be had. While it can be difficult for patients and their families to think about end-of-life scenarios, it was important to begin such discussions so that patients’ wishes were understood and respected in the decision-making process – before things became too stressful in the moment. This taught me the importance of starting and having difficult conversations and the sensitivity needed in doing so.

Managing new types of patients and the challenges that arise from that.

• Though this was my first rotation and I do not have other experiences to compare it to, I found that managing elderly patients is challenging in that many older patients present with multiple co-morbidities, and in turn, present with an extensive list of medications. This is particularly noteworthy, as polypharmacy is a primary concern in geriatric patients. In addition, the inability to reconcile medications, due to patients not bringing their medications or having a list of their medications with them, can make it difficult to make necessary changes in patient management. Therefore, it is important to stress the need to bring medications to patients at each visit. Their compliance helps to identify possible drug side effects or interactions and thus the need to discontinue a medication. Being able to reconcile medications  in this way benefits the patient and leads to optimal treatment plans.

How your perspective may have changed as a result of this rotation (e.g. elderly patients, kids, IV drug users, etc).

• As a result of this rotation, my perspective has broadened in many ways with respect to caring for elderly patients. For instance, there can be many people involved in a patient’s care, as some patients require home services with one or multiple home attendants based on their need for assistance. This may also be in addition to the help already provided to them by those they live with. Social workers are a vital part of the patient’s care team in this aspect of patient care, and their work cannot be understated. Additionally, in some instances where family members would care for their loved ones, I have learned that it may come to a point where it no longer becomes an option to do so due to the worsening progression of conditions, such as dementia, as patients may become aggressive with other behavioral changes over time, deeming the situation unsafe. With respect to such instances, and also in general, I have learned more and more that it is no one’s place to judge a patient or their care takers in how they proceed with such difficult circumstances, even when it may be difficult to understand. On a different note, in the management of some patients, I have also learned that if it is within reason in terms of their health, it is OK for them to enjoy a certain food once in a while rather than taking it away from them. As highlighted by the attending I rotated with, elderly patients have very worked hard throughout their lives, and they deserve to enjoy the little things that bring them joy even if those things may not be of ideal nutritional value. If their clinical picture allows for it, it will not cause them much harm.  Lastly, I have also learned that elderly patients, perhaps due to the stress of the pandemic, are pretty forthright about their depression when they are asked. Therefore, it is important to always screen patients with the PHQ-2 and potentially the PHQ-9 because I have found that they can also be receptive to talking to a social worker for help to manage their depression.

What did you learn about yourself during this 4-week rotation?

• During this rotation, I have learned that I need to be more patient when it comes to my learning. Initially, I had been trying to absorb everything and worried about not knowing enough. However, there was a lot of information to take in – too much to fully absorb at once despite my efforts. Therefore, I am learning to be more comfortable with being uncomfortable. I believe this will also help me build more confidence, as I do not want any doubt to get in the way of me reaching my full potential, especially that of my own.