Mandatory Clinical Reflection

I chose to take part in the gastrointestinal medicine service for our mandatory clinical week since I enjoyed the GI block greatly and heard it was a good mix of ruminating on problems and doing procedures. My assigned team was with Dr. Saloojee and his band of residents. On my first day, the first person I met with was Dr. Stephanie Collins, PGY-5, and we began patient rounds. The first patient I met on service was really medically complex: a middle-aged female that presented with chronic diarrhea that severely affected her quality of life, with a long-standing surgical history including small bowel resections, antrectomy due to a perforated ulcer, and a percutaneous endoscopic gastrostomy tube. She was in the hospital for five months at this

This was in the resident library and she asked me to look up stool osmolar gap (SOG) and causes of factitious chronic diarrhea while she went to grab lunch. I stayed and perused UpToDate and other sites, and when she returned she asked me to teach it to her. I recounted the cut-offs for the SOG that narrowed down our differential, how stool osmolarity reflects plasma osmolarity, the epidemiology, types of laxatives, stool electrolyte ranges, interpretation of results, and potential tests to order to confirm factitious diarrhea. This led to a discussion about the patient’s lab values and she had her stool tested 4 times, which gave us the osmolarity, sodium and potassium, and weight that changed over time. Some of the earlier values were confusing, like how the stool osmolarity was in the range of 400-600 in the absence of increased plasma osmolarity, but after some literature searching, I discovered that stool osmolarity >330 mOsm/kg in the absence of plasma osmolarity indicates improper storage, which was a relief for Stephanie. Furthermore, as the day went on I read about testing for magnesium and phosphate levels to check for laxative abuse, and testing stool pH to check for carbohydrate malabsorption. These were new ideas to her and she appreciated my suggestions, which made me feel valued as part of the team. It turns out

Saloojee, and this patient was to be discussed. Stephanie gave an update on the patient and gave me a lot of credit for ordering new tests to confirm our suspicion of factitious diarrhea. I really felt welcomed and appreciated for the week to come. Other concerning things on the differential were motility issues, even though she had gastric motility testing come back normal, and colonoscopy with biopsy, despite being previously negative. Now, it could have been an issue with dysmotility in the small bowel, but there are no good tests for that, so the team ordered a capsule-endoscopy to check the entire length of her alimentary canal and measure the time it took from mouth-to-anus, which would clue us in on motility issues. I got to discuss my ideas and hear theirs on the patient and I really enjoyed the team aspect of internal medicine. Unfortunately, my time ended with the service and I didn’t get to figure out if my suggestions proved if her diarrhea was factitious, or know the results of the capsule-endoscopy or colonoscopy, but I still appreciate the openness of the team to my ideas and that these ideas turned into action. One of the residents even chimed that this would be a great case report, so I should probably follow-up with them soon! In contemplating my experience, I recall stating my fear of things becoming too routine in my potential career in internal medicine or surgery,