I chose my MS4 electives based on the skills I anticipate needing during my residency and future career. Since I’m going into Internal Medicine and Heme/Onc, the list of potentially-beneficial electives is long. One, however, stands out: Infectious Disease. My future patients will have multiple risk factors for infection. First, malignancies inherently alter the immune system, diverting its focus from foreign pathogens to internal ones. Second, leukemias invade areas of blood cell development, thereby destroying the bone marrow and lymphoid tissues where infection-fighting cells are produced. Finally, cancer treatments directly promote infection by depleting neutrophils (chemotherapy), seeding the body with bacteria (surgery), or outright destroying cellular immunity (bone marrow transplant). Clearly, I’ll be depending a lot on ID docs later in my career, and I sought to ingratiate myself with them as early as possible.
I worked on the Infectious Disease team at University Hospital. With one staff physician, a fellow, two residents, an intern, and a pharmacist, I was initially worried that I’d not have a meaningful role on the team. To my delight, I learned that I would be acting as an intern. While the residents would assist me in forming my plans, I alone would see my patients before rounds and my notes were the ones signed by staff. This had a profound impact. I found that the degree to which I understood a case was directly proportional to my level of responsibility. The more I worked to explain and justify the management of my patients the more literature I reviewed and the deeper level of understanding I reached. *
It was also a challenge to adjust to the role of a consultant; to focus my attention on the specific question in hand. Consider, a comorbid patient is admitted with spiking fevers. The presumed etiology is alcoholic hepatitis, and steroids may limit damage to the liver. But if the cause of the fevers is bacterial, then steroid-induced immune suppression would be deleterious. So, the primary team consults ID to assess the risk of giving steroids and the likelihood of an infection. It felt disingenuous to sideline the patient’s comorbidities and instead sign off the case by parodying Jay-Z: ‘the patient’s got 99 problems but ID aint one.’
In truth, diving deep into a single problem is a rewarding educational exercise and my staff were remarkable in highlighting the nuances of each case. Rather, the greatest challenge of a consult service is communication. First, you need to ensure you understand the reason for the consult. Is primary really unsure how to treat a diabetic foot, or do they simply want your help to find placement for the patient? Next, you need to verbally relay your daily recommendations to the referring team and hold a stiff upper lip if they choose to ignore them. Further, remember that the primary team will make the final decisions. Therefore, do not confuse the patient by providing conflicting information; you must feel comfortable referring them to their primary team for most questions (eg: ‘when can I go home?’) Finally, communication regarding follow-up is paramount. A typical University patient already has 3-4 physicians (surgeon, oncologist, palliative care, cardiologist, etc). Should they start following with an ID doc for their abscess or will one of the others feel confident deciding when to stop antibiotics? Does the follow-up plan change if they live 2-3 hours away? There are no easy answers here.
Fortunately, the ID service is an incredible pleasure to work on. The staff uniformly have a passion for teaching and gave daily lectures on topics chosen by trainees. Further, they have a remarkable memory and use it to both reference literature and to tell wonderful anecdotes from their own training. Since I anticipate working very closely with ID teams in the future as a Heme/Onc doc, I am tremendously reassured to know that these physicians possess an encyclopedic knowledge and a gregarious attitude that will make consulting them fun and productive. Needless to say, I strongly urge you to consider an ID rotation as an MS4.
* Whereas my ID staff encouraged this level of MS4 autonomy, I do not think it is unique to the ID clerkship. Rather, as of March 2018, CMS has permitted attendings to bill for encounters by verifying medical student notes without re-documenting them. In July 2018, this policy went live at IUSM.