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May 08, 2007

Time is my enemy; time is my friend.

As everyone knows, time passes. Sometimes it's your enemy, and sometimes your friend. Lately I've been saying to myself, "Time is my enemy; time is my friend." I repeat over and over again with a singsong cadence, as in "She loves me; she loves me not."

Now that I'm doing a month on trauma service, I can't seem to get this out of my head. Everyone who knows me knows that I love my free time and I love my sleep -- these months spent in the hospital all the time and not sleeping really crimp my style. Even though there are good enough reasons to do this (I did sign up for it after all), I go through these months like a little kid running through a cold sprinkler, with his face all scrunched up and running like hell, hoping to come out on the other end quickly.

From the time I wake up in the morning until I leave the hospital, time is my friend. Time passes, after all. Every second that goes by is one less second until I get to go home and post on my blog. Of course, when I'm home and indulging in the time I have for myself, time continues to pass. But now, it's my enemy. Every second that goes by brings me that much closer to the time when I'll have to go back to the hospital. See? Time is fickle. Or it seems that way, when I'm post-call and blogging on only two hours of sleep. :)

April 10, 2007

What medical problems do you have?

When I ask this question of patients in the ER, it's amazing how often they forget to tell me about serious diseases that completely change the way I want to treat them. It happens so often, in fact, that I'm tempted to say this to all my patients when I first walk in the room:

"Tell me what medical problems you have. And tell me everything. I'd better not go out there and look you up on the computer and find all sorts of shit that you haven't told me about. I want you to come clean with me now. If you have diabetes, you'd better just tell me now and get it over with. Because I'm going to find out, one way or the other. And if I find out that you're a diabetic or that you have lupus or some shit like that and you haven't told me, I'm also going to assume that you also have dementia, or that you've been sniffing glue."

Of course, all of this is (somewhat) in jest. I'm lucky enough to be a healthy person; I can tell you all the medical problems I've ever had since I was born, mostly because there's been so few of them. I had ear infections. I had an effusion in my knee once. I've had intractable vomiting from eating bad refried beans at a disreputable mexican restaurant in Sedona. I remember all of these things because they're so unusual.

But I suppose that if I had diabetes, or lupus, and I'd been living with it for years and years, I might forget to mention it when I went to the ER. Maybe. Assuming, of course, that I was also hypoxic or hypoglycemic or high from breathing the fumes from a tube of Krylon spray paint.

Sheesh.

March 30, 2007

More on resident work hours

Assuming for the moment that excessive resident work hours is a problem, it would seem to be one of those problems that isn't likely to be solved by either professional self-regulation or by the market.

Daniel Goldberg's nice post about resident work hours reminds me that even if residents weren't as accepting of their brutal schedules as they seem to be, they probably wouldn't be able to do very much about it. As Goldberg points out, medical students and residents don't have a lot of bargaining power compared with their hospital employers, who benefit economically from low-cost resident labor. Moreover, there aren't a lot of other players in the current health care market who should be expected to argue forcefully for reduced work hours. Insurers and employers in our fragmented system would find it hard to capture the economic benefits of fewer medical errors made by overworked residents.

Professional self-regulation shouldn't be expected to solve the problem either. The medical professional societies and hospital groups that comprise the ACGME (the organization that regulates work hours) are all served nicely by the current system. The professional societies benefit because the total number of residents is kept small. Residents in training may suffer, but after graduation they benefit from larger salaries. Hospitals of course like cheap resident labor paid for mostly by the government. Although each additional resident usually means more money for the hospital, in the face of restrictions on the number of residents Medicare will pay for and the relatively higher costs of PAs, NPs, and attending MDs, the hospitals are not going to support limiting resident work hours. Residents are the cheapest hospital laborers available.

So if the market won't fix things, and professional self-regulation won't fix things either, who's left? Yep, the government. What's the likelihood that the government will step in to limit resident work hours? Almost nil, because "patients" as a group aren't as focused a lobbying group as are the hospitals and the professional societies. So absent another high-profile case like Libby Zion's, nothing is going to happen.

Of course, I've ignored the serious argument that shorter work hours do not directly correlate with increased patient safety. There is evidence that medical errors are more likely with an increasing number of handoffs and signouts -- the happy medium between overworked residents and too many handoffs hasn't been identified yet. Add to the fact that this happy medium is likely to be different depending on the specialty, the severity of illness, the number of patients, and the stability of the resident's schedule, even if the government did want to do something, it wouldn't be clear what exactly it should do.

This uncertainty about how to solve the work-hour problem doesn't mean that I dislike excessive hours any less. It doesn't make me any more sympathetic to the simplistic non-arguments advanced by traditionalists that amount to "more time in the hospital = better training." It just means that I'm glad to be going into a specialty where I can limit my own hours if I want. And I think we ought to spend more time and money gathering information about what kind of training systems work best.

March 21, 2007

On-call hours

Via Gruntdoc, this post from former infantryman in the United States Marines (a group who aren't generally known to be weak whiners) and now emergency medicine resident Panda Bear M.D. about on-call hours in medicine:

....The fact that your program has bitten off more than it can chew and cannot maintain it's commitments is not your problem. You are the low guy on the totem pole and are not getting paid to solve the program's problems. It is actually a leadership problem on the part of the program who are committing the cardinal sin of leadership: Not standing up for their subordinates.

Read the post, and read the comments. Everyone who knows me knows that I hate call -- give me the power to change one thing in medical training and it would be this. Residents are on-duty without sleep for far many hours in a row. The threat of federal legislation a few years back led the ACGME to implement an 80-hour work week rule, but this rule is often violated, and the rule itself isn't strong enough. Believe me, you can be worked beyond physiological reason under the current 80-hour rule.

The most fascinating thing to me about the whole thing is the seeming complicity of the residents. Panda Bear describes it thusly: "their thinking is cluttered with duckspeak from the medical establishment which not only hides the reality of the situation but sets the conditions of any potential debate to preclude anything but the party orthodoxy." Even if you don't agree that the residents are brainwashed, it's clear that they aren't the ones pushing for a more rational and physiologically sound schedule.

Consider this study performed at the University of Chicago by Dr. Vineet Arora and her colleagues. Despite finding that a nap period significantly reduced overall fatigue for on-call medicine interns, "use of coverage by interns on the nap schedule was impaired by their desire to care for their patients and concerns about discontinuity of care." In other words, when given the opportunity to sign over their pagers in the small hours of the night and sleep, medicine interns chose not to do it (although they did sign over their cross-cover patients).

These residents gave different reasons for not signing out their pagers, including a concern for patient care and a desire to stay informed about what was happening with "their" patients. Is this reluctance to just go to bed the result of brainwashing? The study can't tell us. There's really no way to know. The question is whether the reluctance of interns to sleep is something we ought to encourage, defer to, or override. I tend to think the latter, because I don't think sleep-deprived interns deliver good patient care. But, as Panda Bear's post points out, there's no definitive study out there that tells us how many hours are too much.

Given the economic incentives of hospitals, the absence of such a study means that the problem will probably get worse before it gets better. And we should be asking: what kind of evidence must we have before we take action to solve the problem?

March 08, 2007

How to be a considerate ER physician

Spending time on off-service rotations gives you a good view of the ER from the outside. Here's something that I used to know in my head, and that I now know in every organ of my body:

If an ER doc calls a trauma consult for a patient with abdominal pain from trauma eight hours after the patient first came to the ER, that doc should have done a rectal exam already. It's just considerate, not to mention good patient care.

I'll try to remember this when I'm back in the ER.

February 26, 2007

Returning to my blog

Hey again, all of you out there in blogland...

I'm back from my dead-of-winter sojourn through internship. It's still cold and snowy here in Chicago, but somehow I feel like the coldest, darkest, and loneliest parts of the year are behind me. Maybe seeing an inch-tall bundle of new crocus leaves poking out of the ground along 57th street yesterday (!!) has something to do with it. Maybe the emergency medicine inservice exam that I'm taking on Wednesday has me thinking about how soon residency will be over with, and about how soon I'll have to take the specialty boards for real. Maybe it's just that the days really are longer, even if they're still cold. For whatever reason, I see a big light at the end of a tunnel that I'm almost all the way through.

I also want to start posting on my blog again. And I think I want to post about my job. Most of my readers (at least the ones I had before I stopped posting) are not in medicine, and I think it would be fun to tell them about what it's like to be a resident in the Queen of the Medical Specialties -- emergency medicine. After all, it can be fun as hell, and I see some of the strangest shit almost every day. It would be a shame not to blog about it.

The only thing is, I need to find a way to do it that ensures that my patients won't recognize themselves on my blog. As I've said before, I think it'd be pretty shitty for one of my patients to see me in the hospital, go home, google my name, and be able to recognize themselves in one of my blog posts. It's not a matter of the privacy of my patients-- it'd be easy to blog about them in a way that no one other than the patient in question could identify themselves. It's more a matter of my own privacy. If I think the guy with the gunshot wound to the left buttock was acting like a little shit, I don't want him to find out about it on my blog. I'd rather keep it to myself, or if I'm going to tell him, I'd want to do it in a professional way, face-to-face. If the old lady with the rapid heartbeat that I saw the other night had me convinced that she was about to die, she shouldn't find out about it after the fact on my blog. The same thing goes for my co-workers. I don't want them to recognize themselves in my blog posts, either.

In law school it was easy to blog about cases and issues without mentioning what was said in class by particular professors or students. I never really blogged much about law school anyway, because I never wanted to, and I always had so much free time that I could write about non-law subjects pretty easily. Residency is different. I don't have enough free time (damn!) to spend two or three hours a day reading random articles and blogs and responding to them. These days, I want to post about what I'm doing in the hospital. I'm still thinking about how to do it.

November 15, 2006

The light dims, the bears sleep, there's Christmas music on the radio again...

Here in Chicago, the bright sunny days of summer have gone away -- as they should -- and another season of darkness, cold, wind, and (any day now!) snow has arrived. Also as it should. It's been this way every year for, I don't know, longer than any of us have been around.

And yet I dread it. There's something about your alarm clock going off in the dark, about dressing in the morning under the same lamplight that you read your book by last night before reluctantly giving up the day and going to bed, about heading to the hospital through the cold dark, about glimpsing the gray dawn on your hurried way past a rare hospital window, about not being able to leave the hospital before the daylight is gone. The joys of winter -- fluffy snow, brightly lit coffee shops, curling up with a hot cocoa and a good book -- are tough to arrange on an intern's schedule. Not that the joys of summer weren't also elusive on this schedule, but somehow it wasn't as consequential. Q4 call in July isn't as depressing as q4 in January.

To pass the time these next few months with quick wit and style rather than with dull grunts and vacant stares, I've decided that I need a new project. Since I'm not driving the bus when it comes to my residency schedule, I need to be when it comes to the time that's all mine.

So what should I do? Learn to read Latin? Write a persuasive defense of agrarianism against the common charge that it's illiberal and regressive?

Any thoughts?

October 29, 2006

In the ICU, and thinking about Huckleberry

I'm in the ICU this month. It's a great place (the only place?) to learn what I need to be a competent ER physician -- but it's no less draining for knowing that.

The medical ICU is a joyless place. It's a place where very sick people stay, usually at the end of their lives, to absorb all the high-tech medicine that we can possibly throw at them, in order to live a few more weeks than they would have otherwise. Yes, there are important exceptions, where we save a patient's life in the ICU and he or she leaves to spend time with their families and go for walks on sunny days in their favorite park -- but this is still an exception.

Add to this the horrendous hours, which makes it impossible or at least very difficult for residents to get to know each other as anything other than tired, overworked, cogs in a machine. Throw in the intern's inevitable lack of knowledge and gross inefficiency, and it shouldn't be surprising that there's not much joy for them in the ICU. Speaking for myself at least, there isn't.

My brother just lost his cat, Huckleberry. He was the greatest cat. Friendly, intelligent, and always hungry! He had some klnd of cancer that deformed his jaw, and he had to have it taken off. For a cat who loved to eat, that must have been a particularly large loss. My brother, because he loved this cat, did the best thing for him in the end, and had him "put down" by the vet. Huck, RIP.

If Huckleberry had been a person, he would almost surely have been laid up in the ICU for the last few weeks of his life. He'd have been unconscious, with a feeding tube down his throat to substitute for the eating he'd loved before the cancer. The people "caring" for him would have been overworked and unfamiliar with him as anything other than a reason for more chores. They'd have been more concerned with writing down all the numbers that the machines hooked to his body were spewing out 24 hours a day than with "caring" for him in any sense that could have mattered.

I'm not saying that we should euthanize people. I'm saying that the end of Huckleberry's long life was probably better, being my brother's cat, than it would have been as a human being.

***

Here's a poem I've posted before that means more to me now that I'm spending so many hours in the ICU.

Three Elegaic Poems
Wendell Berry

I
Let him escape hospital and doctor
the manners and odors of strange places
the dispassionate skill of experts

Let him go free of tubes and needles
public corridors, the surgical white
of life dwindled to poor pain

Foreseeing the possibility of life without
possibility of joy, let him give it up.

Let him die in one of the old rooms
of his living, no stranger near him.

Let him go in peace out of the bodies
of his life --
flesh and marriage and household.

From the wide vision of his own windows
Let him go out of sight; and the final

time and light of his life's place be
last seen before his eyes' slow
opening in the earth.

Let him go like one familiar with the way
into the wooded and tracked and
furrowed hill, his body.

II
I stand at the cistern in front of the old barn
in the darkness, in the dead of winter,
the night strangely warm, the wind blowing,
rattling an unlatched door.
I draw the cold water up out of the ground, and drink.

At the house the light is still waiting.
An old man I've loved all my life is dying
In his bed there. He is going
slowly down from himself.
In final obedience to his life, he follows
his body out of our knowing.
Only his hands, quiet on the sheet, keep
a painful resemblance to what they no longer are.

III
He goes free of the earth.
The sun of his last day sets
clear in the sweetness of his liberty.

The earth recovers from his dying,
the hallow of his life remaining
in all his death leaves.

Radiances know him. Grown lighter
than breath, he is set free
in our remembering. Grown brighter

than vision, he grows dark
into the life of the hill
that holds his peace.

He's hidden among all that is,
and cannot be lost.

August 27, 2006

Two months of small patients

Tomorrow is my last shift in the pediatric ER. I'll miss it; it's been a fun month.

But I'm also looking forward to finally seeing some adults. The kids are great, but there's only so many fevers and rashes and sore throats and crying and ear infections that I can take before I go stark raving mad.

August 21, 2006

Blogging about patients

Here's another reason I haven't been posting much recently: I haven't quite gotten comfortable with blogging about patients.

It's not a HIPAA thing. I'm not tempted to post anything on my blog that would identify a specific patient, and that shouldn't be surprising. Plenty of great medical bloggers put up interesting posts all the time about the patients they see, and HIPAA's never an issue. See, for example, Dr. Bard-Parker's post about this stabbing victim. I'm hesitating not because of patient confidentiality, but because of my knowledge that the patient himself or herself might sometimes be able to identify themselves if they read my blog. And even though I'm fairly certain that they aren't reading my blog (famous last words, those), I'm still a bit wary of the whole thing. I ask myself: if I were a patient and I read about myself some evening on a doc's blog, what would I think? Well, I personally wouldn't feel upset if I wasn't being mocked in the post, and provided that no one else could tell it was me. But I can imagine that other patients might feel differently.

And that's why I'm not rushing to blog about my shifts in the pediatric ER, or my days and nights in the PICU (yes, my schedule has been peds-heavy so far this year).

Eventually, I'll find the approach that works for me -- the right level of detail, the right amount of historical separation between when I've seen a patient and when I've blogged about what I've seen. But for the time being, I'm not posting a lot about what I've spent most of my time doing. Draining abscesses, stiching up lacs, getting LPs (my first successful one two weeks ago!). I suppose I could blog about the single most time-consuming activity of my residency so far: filling out paperwork. But that'd be boring.

In the meantime, I'll post a part of a poem relevant to hospitals and sickness by one of my favorite authors:

Let him escape hospital and doctor,
the manners and odors of strange places,
the dispassionate skills of experts.

Let him go free of tubes and needles,
public corridors, the surgical white
of life dwindled to poor pain.

Foreseeing the possibility of life without
possibility of joy, let him give it up.

Let him die in one of the old rooms
of his living, no stranger near him.

Let him go in peace out of the bodies
of his life--
flesh and marriage and household.

From the wide vision of his own windows
let him go out of sight; and the final

time and light of his life's place be
last seen before his eyes' slow
opening in the earth.

Let him go like one familiar with the way
into the wooded and tracked and
furrowed hill, his body.
. . . .

--Wendell Berry

June 29, 2006

Chicago EMS triage

In Denver (unless things have changed), the paramedics decide on scene where to transport a patient, and then they call their chosen hospital to let them know they're enroute.

In Chicago, the paramedics don't determine their own destination. Instead, they call their "resource hospital" (U of C, Illinois Masonic, or Northwestern) and the nurse or doc at that hospital decides where the ambulance will take the patient.

Which system is better? One complaint that's been made about the Chicago system is that the resource hospital appears to have a conflict of interest. The resource hospital doc may often have to decide whether to send a patient to her own hospital when she's stressing because her ED is so busy.

As a colleague of mine put it: "I don't see that it adds anything when the doc, and not the paramedic, makes the destination decision."

June 26, 2006

Moving back to Hyde Park

One of the side effects of being a resident at the University of Chicago is being able to live in Hyde Park again.

Now, it's true that many of my fellow first-year residents (great people, all of them) have not chosen to take advantage of this opportunity. With a few exceptions, they've all rented apartments within a two block radius of each other near Clark and Diversey. Ok, I'm exaggerating. But not by much.

Anyway, Hyde Park: it has its good and bad sides. On the bad side, it's not anything like Clark and Diversey. Not as many restaurants, nowhere near as many bars, and there's no Bed, Bath & Beyond within a ten mile radius. On the good side, it's nothing like the north side. It's not as yuppified, and it's not as homogenous. People other than late-20-something professionals live here, and you'll see some of them walking home from the grocery store. Unfortunately, some of them will be carrying guns and will stick you up for your wallet, cell phone, and Dogfish Head 60 minute IPA -- but I don't think those guys actually live in the neighborhood.

Besides, Hyde Park has the best bookstores in the city of Chicago, and some of the best in the country.

How does it compare with Ann Arbor? You can read this great blog post (including all the comments), which gets it almost entirely right. The most insightful comment: "Not sure if this goes for the over or under side, but Hyde Park’s flocks of feral parakeets give it a certain flair that AA’s pigeons can’t attempt."

June 23, 2006

Getting processed

I've spent the last few days at the hospital getting processed by the hospital bureaucracy. They need to transform me from an ordinary civilian into a first-year resident so I can start seeing patients on July 1.

It's been boring and exciting both. The boring part: hours of talks and PowerPoint presentations about the computer system, the benefits packages, the infection-control programs, etc. All accompanied by an avalanche of handouts: flyers, brochures, booklets, pamphlets, and laminated cards. Where I'll put them all I don't know yet. The amazing thing is how much of this orientation material is mandated by various federal laws or agency regulations. I was handed an evaluation form and told that my opinions were really important, but I don't see how that can be true when the hospital doesn't have the option of getting rid of the HIPAA compliance presentations or the OSHA-mandated demonstrations of how to use a fire extinguisher.

But I'm glad I sat through all of that, because some parts of the hospital orientation have been pretty damned exciting. It's cool to get my hospital name badge : University of Chicago Hospitals, baby. Then there's my printed prescription pads. Carey Cuprisin, MD. Yep, I guess if I'm gonna be a resident, people are gonna start calling me a doc and expecting me to write them some scripts for generic Zocor. I'd better start getting used to it.