Yesterday marked the end of my three-week internal medicine ward rotation, and I started my week in the outpatient clinic. As an intern on the ward, I was often so busy handling assigned tasks that I didn’t have much time to understand the actual patient care process. The need to thoroughly document progress notes in the U.S. took up much of my attention, which might have prevented me from grasping the real treatment process. Some decision-making processes also bypassed interns, making it hard to follow along. However, as a second-year resident now, I became more deeply involved in the decision-making during patient care and could follow the process more easily. Although there were likely many shortcomings during my first ward rotation, I expect to improve in the future.

Internal medicine residents essentially manage the ward, including tasks like organizing progress notes and checking consultation requests. They are responsible for everything from admitting patients, providing appropriate treatment based on the admission reason, gauging treatment progress and discharge viability, and even preparing discharge plans, with final decisions made in consultation with the attending hospitalist. It is also crucial to ensure that necessary interventions, tests, and treatments are performed timely.

U.S. hospitals have well-established social support systems for patients. For those being discharged, there are professionals who assess whether a patient can go home, needs assistance, or requires rehabilitation. They coordinate with these professionals to arrange discharge destinations, an important part of a resident’s duties (although specifics may vary by hospital).

At our hospital, a ward team generally includes one attending hospitalist, one resident, and one intern, responsible for up to 14 patients. If the number exceeds this, the attending takes on the excess patients. Most admitted patients receive short-term treatment (2-3 days) and are discharged, though sometimes social factors (like insurance not covering post-discharge rehab facilities) can extend the stay. Typically, 3-4 new patients are admitted and a similar number discharged daily, requiring constant evaluation of patient readiness for discharge and necessary steps for safe discharge. This process finely hones clinical knowledge, revealing gaps that need addressing for better patient care.

Accidentally, I ended up broadly summarizing internal medicine ward duties, but that wasn’t my initial intent for this post. During these past three weeks, I had the task of delivering bad news multiple times, which prompted me to share my thoughts.

Two tasks never get easier as an internal medicine resident. One is the “goals of care discussion.” I’m not sure how to translate this precisely into Korean, but it involves discussing prognosis and appropriate future care — such as when aggressive treatment no longer seems beneficial — with the patient and their proxy. In these discussions, families (and the patient, if they can participate) might decide to refuse life-prolonging treatment and opt for hospice care, or continue aggressive treatment. With diverse lives and goals, a doctor’s role is providing objective medical information (like prognosis), leaving decisions in the hands of the patient and their family.

Obviously, such discussions aren’t easy. Conveying poor prognosis is challenging. Although medical school teaches how to break bad news, real-life scenarios differ from practice drills. While adhering to basic principles, various approaches might be employed. For instance, outside of the ward, I had to tell a family that a patient, found unresponsive with suspected anoxic brain injury following cardiac arrest and showing no responses for over a week, might not recover and that hospice care should be considered. Miraculously, the patient began responding the next day, regained consciousness, and was eventually discharged. Meeting the patient and their family in the outpatient clinic weeks later was both joyful and deeply moving.

Besides goals of care discussions, many other instances require delivering bad news, ranging from diagnosing chronic conditions like diabetes, hypertension, and hyperlipidemia needing lifelong medication, to life-threatening diseases like immunodeficiency disorders or cancers. Determining how to communicate these truths empathetically and effectively is an ongoing challenge. During this ward rotation, I repeatedly had to relay such news, often feeling that I could have communicated better. Will it ever become easier? I’m not sure. It’s an area demanding extensive practice.