The Medical Apprentice

The start of a new month brings about another new rotation.  Just as Toledo seems to be a battleground in the Michigan/Ohio State rivalry, my away rotations are equally split.  After a month at the University of Michigan I am heading down to Ohio State.  For November I will be completing an elective in Pediatric Emergency Medicine at Nationwide Children’s Hospital in Columbus.  I really enjoyed my time in the ED at UTMC during my third year clerkship, so I’m looking forward to this upcoming month.  I have heard that Nationwide Children’s is always quite busy, and with H1N1 there will certainly be no shortage of patients. 

I enjoyed last month’s rotation in Pediatric GI at Michigan.  Even though it was a subspecialty month, I saw a great deal of general pediatrics.  I think being able to manage the common complaints is just as important as caring for the rare “zebras” that are found at large tertiary care centers.  I gained a lot of experience in evaluating the “bread and butter” of pediatrics, from growth and nutrition to constipation and vomiting.    

Stories from the pediatric ED coming soon!

Hot chocolate made with butter and heavy cream

A bowl of cereal with whole milk

Mayonnaise as a dip for raw vegetables

Extra eggs and powdered milk for pancake batter

Gravy for just about any dish

No, these aren’t tidbits from Paula Deen’s latest cookbook.  Nor were they used by the child-devouring witch to fatten up Hansel and Gretel.  They’re actually some of the suggestions given by nutritionists for children who need to increase their caloric intake.  While a high calorie diet is the last thing the average American might need, I’ve encountered many children on my GI rotation that are benefiting from this change in diet.  Our body digests food and absorbs nutrients through the GI tract.  Therefore any disorder disrupting the function of this system has the potential to cause malnutrition.  Adequate nutrition is crucial for child growth and development, so early intervention in this area is extremely important. 

During this month I’ve had the opportunity to rotate through a number of interdisciplinary clinics.  These bring together healthcare workers from a variety of fields that work together to care for patients with complex medical issues (such as the Intestinal Rehabilitation or Liver Transplant clinic).  Instead of making appointments and tromping around the hospital to see multiple people, patients and their families come to one clinic.  Families set up shop in a single exam room to be seen by multiple healthcare professionals.  In addition to the physician, a nurse might assess medication compliance or recent health issues.  A dietician will monitor weight gain and ensure the child is receiving adequate carbohydrates, fats, and protein.   A PharmD looks at medication dosages, efficacy and monitors for side effects.  A social worker helps families adjust to caring for a sick child and advocates for whatever help they might need (financial assistance, medical leave, or special accommodations at school).

As a student in these clinics I often get assigned to one family.  I then go in with each member of the team for their assessments.  It’s been interesting to witness each person’s role.  The teaching has been great too (i.e. calorie counts or updating TPN orders with a nutritionist).  It’s nice to see folks from many different fields taking an active role in clinical education.  After all, there are many people in the hospital that med students can learn from, other than physicians.  Interdisciplinary clinics have plenty to teach students (including the decadent new places to add butter on the menu!)

The physical exam is an important part of any clinical evaluation. For a child, getting poked and prodded by a complete stranger can be quite scary. Throughout my rotations I have discovered that pediatricians have quite the arsenal of games and tricks to help get what they require from an exam while keeping the child as comfortable as possible. Ears can be examined while the child is in their parent’s arms.  A fun sticker or penlight can keep an infant quiet long enough to listen to their heart and lungs. Having a child talk about this year’s Halloween costume helps them relax their tummy and allow for an abdominal exam.

Fun games and distractions can help disguise a physical exam. In a similar way, sometimes a disease can present appearing to be something else. For example, in the Peds GI clinic they commonly evaluate children who have symptoms of gastroesophageal reflux but have not found relief with diet changes and commonly used medications. Luckily there are plenty of tests available to help clinicians sort through all the potential causes. In this case, one such test in an esophagogastroduodenoscopy (EGD). It looks down the throat with a tiny camera to visualize the esophagus, stomach, and first part of the small intestine. Biopsies can be taken, and these little pieces of tissue can provide clues that point to the underlying cause of a patient’s symptoms.

Each week the Pediatric GI team at U of M has a pathology conference. The team meets with a pathologist to look at biopsies from the previous week. We gather around an elaborate microscope that allows everyone to look at the same slide. In this way the team is able to correlate a patient’s clinical presentation to findings on the histologic (tissue) and cellular level. These conferences are a great refresher of classes from my pre-clinical years, and we’ve seen some interesting cases. It is pretty amazing how quickly the pathologists can pick out seemingly subtle changes under a microscope.

Though more invasive means are required to obtain them, biopsies can provide a more definitive idea of what process is causing a patient’s symptoms. That case of gastroesophageal reflux actually turned out to be eosinophillic esophagitis, a disorder that can present the same way but require different treatment.  It seems that it can sometimes take months to find the true cause of a little guy’s discomfort, so it’s a big relief to families to finally get the right diagnosis.

“Hi, my name is Pat Clements, and I’m a medical student.  I know we just met, but I’m going to take a seat and ask you thirty questions or so about your bowel habits.”

This month I am doing an “away” elective.  Fourth-year med students can apply for electives at other medical schools, adding to their clinical experiences and allowing them to visit residency programs in their field of interest.  I’m up at Mott Children’s Hospital at the University of Michigan.  I am rotating in Pediatric Gastroenterology, the specialty that deals with the digestive system.  Disorders of these organs impair the ability to eat, digest food, absorb nutrients, and excrete waste.

U of M has a pretty big pediatric referral base, so plenty of interesting cases come their way.  I’ve already seen a couple of “mythical” diseases (ones that I thought existed only in textbooks).  At the same time, the majority of my days in clinic I see the “bread and butter” of Pediatric Gastroenterology.  These are patients referred for evaluation of constipation/diarrhea, vomiting, and failure to adequately grow.

When interviewing a patient and their family, particular questions are asked during the review of systems.  For GI, the questions are focused heavily on diet and bowel habits.  As you can imagine, these areas are sometimes a bit strange to talk about.  There’s even a standardized scale to help move the conversation along.  The little guys look back with wide eyes to their parents.  Does he really want me to talk about my poop?  On the other end of the spectrum are the young adults, often mortified to have to talk about their sometimes embarrassing problems.  Issues with the GI system can cause a lot of frustration and discomfort for children and parents alike.  Hopefully in the end the solution makes the child healthier and gives them a better quality of life, making the awkward “GI interrogation” well worth it.

This month will hopefully give me a good exposure to patients with the spectrum of gastrointestinal illnesses, plus increase my experience in evaluating growth and nutrition.  I’ll try not to mention bowel movements in every blog, but no guarantees!