As the remaining non-PAEA core rotation, I was not entirely sure what to expect coming into my Long-Term Care rotation. Completed at Gouverneur, a skilled nursing facility that is a part of the NYC Health and Hospitals, I was exposed to a large variety of patients that had vastly different goals of care. Because the facility is split as a subacute rehab and long-term nursing home, my days each week were split in an effort to understand how the providers plan has to change to tailor to patient goals.

On the subacute rehab floors, these patients were often transferred from local hospitals to for restorative therapy, which when completed, they could return home and assume the independent ADLs. My main preceptor on these days, was Dr. Polina Gilchyonok, the chief of subacute service. With her, we would attend morning report with the charge nurses of each floor to review any patient issues that had come up in the last 24 hours. These meetings were also attended by social work, physical therapy, wound care, and dietary to show the wholistic approach that the facility took to each patient. After receiving my assigned patients for the day, I would head to the floors to meet with nursing to see these patients together and address any issues that the patients felt needed discussion. These interim medical visits gave me the opportunity to work on my patient education and counseling for lifestyle changes once they left our facility. On these days, I could also work with the nursing staff directly to get hands-on skills training including inserting a straight catheter and performing blood draws. After seeing patients, I would write-up my interim visit notes to be reviewed along with reviewing the medications that the patient came in prescribed with from the hospital. Because I was given so much independence when it came to seeing patients, I used this rotation as an opportunity to refine some of my skills of completing a full physical exam as we learned during the didactic year. Coming from the emergency room where the physical exam is often tailored to the chief complaint, having this time proved most useful.

The remaining days each week were spent under the chief medical officer of the facility, Dr. Sherry Humphrey, a geriatric medicine specialist on the long-term floors. On these floors, patients, also called residents on these floors, are only required to be seen and have medications reviewed by a physician or NP once a month, unless otherwise needed. Because there are roughly 300 long-term beds in this facility, I received ample opportunity to learn and refine my geriatric assessment. One area of training that I had never received before came from CPAC, the Center to Advance Palliative Care. Because so many of the long-term residents had impaired cognition or an extensive list of comorbidities, it was imperative to have organized and updated advanced directives for each resident on file. One of the toughest aspects of this rotation, in my opinion, is starting the conversation with patients and their families as to what they would like to have happen in a worst-case scenario. For some, they were ready to have that conversation, but others found it very difficult to come to acceptance with some of the matters being discussed. With many years of experience in this field, Dr. Humphrey would coach me privately on how to address questions, comments, and concerns patients may have as well as how to properly respond when the conversation becomes difficult. While we talked a lot about advanced directives throughout our didactic coursework, it is challenging when that conversation is now with a real, ill patient and not a case scenario in a group discussion. Overall, I think this rotation, and site was a great learning experience with plenty of autonomy and a staff that was always willing to help. It was great to see the interdisciplinary approach that echoed the notion that healthcare takes a team.