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Archive for the ‘Residency’ Category

Wednesday, September 5th 2012

Not Even All Physicians Understand Acuity Apparently

I’ve written about trying to communicate acuity to families. Maybe that needs to be expanded to encompass the same to other physicians.

To be fair I’m sure some of this, perhaps much of it, rests solely on my shoulders. Recognizing that I’m still going to make an accusation that talking life and death with families and patients is a skill not fostered in many providers. More accurately for this anecdote, and importantly for the care of patients, some physicians flat out fail to recognize the necessity of such discussions and decisions by families.

A while back I saw in consult a young man with a subdural hematoma who had been found down at home after days unseen. He was young but it was a serious injury that had, presumably, persisted unmitigated for some time, likely on the order of > 24 hours. It was not an unreasonable question about how the parents would want to proceed. And while I can’t offer quotation marks this is near verbatim from the consulting physician:

- I don’t think you can blame a parent for not wanting to make a life or death decision about their child on the spur of the moment
- I don’t think a family’s decision has any bearing on triage

These comments came as they got more and more frustrated with my lack of transfer orders while I had lengthy conversations with the family and awaited their decision on whether to proceed with surgery or not. The argument was that I should transfer the patient to the neurosurgical service and the family could then take their time deciding on whether to proceed with surgery or not. My argument was that if the family elected for end of life care there was no need for transfer.

To be fair I’ve changed the story considerably, for obvious reasons, but attest fully that those consulting physician comments are essentially synonymous with the actual quotes. I don’t feel comfortable adding the quotation marks lest I transcribed a word here or there. I’ve left out my own parts of the conversation that prompted those remarks, and thus considerable context. But I would argue there is no context you can give those comments where they are not incredibly naive. Everyday physicians throughout the hospital ask families to make spur of the moment life and death decisions. Everyday a family makes a decision for or against a laparotomy in an unstable trauma patient or a craniectomy in a patient with a head injury. And the decision is, often, to go now or not at all. This story doesn’t completely reflect that urgency but the principle remains. It was at that moment that the surgery offered maximal benefit. There’s no decision to wait until tomorrow or the next day, it is now or we discuss other options such as maximal medical care or end of life care.

The discussion with families obviously lacks that crassness but, as I’ve discussed previously, frankness is not always a bad thing. In a very empathetic way the family needs to be aware that they need to make a quick decision. And so for a consulting physician to hold it against me that I was awaiting a family’s life or death decision before proceeding seemed surreal and disconnected. It still does. It is hard to imagine a physician so removed from the reality of acute care in a large county hospital. It is hard to imagine a physician who would hold in so low regard a family’s wishes in determining the next step in care.

I think that this particular conversation was the most remarkable I’ve ever had with another physician concerning patient care. Maybe my incredulousness is misplaced. With admittedly only half of essentially a made up story, my side, at your disposal let me know in the comments if you think I’m way off base.

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Tuesday, September 4th 2012

Automating Healthcare

In 1982 Vinod Kholsa was one of the four founding fathers of Sun Microsystems. Since he’s been a major player in the Silicon Valley venture capital community. So, there was some noise made when a man of that stature, at the Health Innovation Summitt in San Francisco last week, said that “80% of doctors can be replaced by machines.”

Let me just say I’m an optimistic futurist and I think that no human endeavor is immune from automation. Whether we dismiss them I’m sure in my lifetime a computer written novel and song will, by any objective measure, be masterpieces. Economic and human capital issues and consumer comfort aside, cab drivers and airline pilots and even physicians are largely replaceable by machines. While his 80% figure might be high, or maybe not, I don’t think there is anything remarkable about Vinod Kholsa’s basic premise that in interpretation of tests, even radiographs, diagnosis and prescription of treatment computers will be better than man. I think surgeons and proceduralists are safer for a while.

But there’s more to health care than treatment. As Dr. David Liu points out over at The Health Care Blog,

Health and medical care is an incredible intersection of technology, science, emotions, and human imperfections in both providing care and comfort.

[...]

There are some things that may never be codified or driven into algorthims. Call it a doctor’s experience, intuition, and therapeutic touch and listening. If start-ups can clear the obstacles and restore the timeless doctor-patient relationship and human connection, then perhaps the future of health care is bright after all.

Consider the reversal of the trend of self checkouts at supermarkets.

“It’s just more interactive,” Wearne said during a recent shopping trip at Manchester’s Big Y Foods. “You get someone who says hello; you get a person to talk to if there’s a problem.”

It’s difficult to imagine a quick embrace, if ever, of a health care system devoid of the human touch. You might indeed someday soon have better care offered by a machine, but primarily the human element, the comfort of the patient, is going to prevent Vinod Kholsa’s dream from coming to fruition in any sort of timely fashion…even if the technology allows for it.

Thursday, July 19th 2012

I Love My Pager

As long as I’m a resident and I’m not serviced by a call center I will love my pager. I say this despite my love of all things tech.

And apparently I’m becoming slightly anachronistic.

Doctors don’t want to carry a pager anymore. They want to carry their iPhone or their Android device.

The quote above comes from Brian Edds, for Ancome Software, in an NPR story titled ‘Are Pagers Obsolete?’. So many I’m out in the minority, but I want my pager. I’ll be brutally honest about why but I don’t want people to be able to reach me on a whim. At least not while I’m a resident. I’ve written before about the abuse of communication with resident physicians. About how matters are triaged ineffectively at academic centers, partly I suspect, because it seems as less of a faux pas to call a resident, as say, a ‘real’ doctor out in the private world.

As such, I don’t want my phone ringing while on call. I return my pages timely but I want that barrier wherein I have to return the call. That barrier where I can triage the calls myself. A text page about a missing home medication can wait until I’m done with a procedure, a page from the ER may need more immediate scrutiny. A phone call takes away some of that discretion. And until the amount of frivolity goes down, until I’m out in the world practicing and deciding the systems in which I’ll practice, I want my pager.

Monday, May 28th 2012

Resident Physicians As Colleagues

I was half asleep typing a consult note as my last call creeped closer to finishing, about one in the eerie morning, when a string of pages awoke me. Amongst them was a consult for a patient who the neurosurgical service had recently discharged with a non-operative traumatic subdural and who had returned with an episode of vomiting. As the other resident talked and mentioned that the repeat head CT looked exactly the same I made an off handed remark, “Yeah, doesn’t sound like there is anything really to do.” But I take down the patient’s location and the call ends.

Less than 5 minutes later I get a page to the same number. On returning it it’s the resident’s in house attending who picks up to chastise me a little and make his expectations for this bounce back patient clear. Take the quotes with a grain of salt but the jist is there,

“You need to come lay eyes on this patient and examine him. And you need to drop a note. And if you think this patient can go home then you need to do that sooner rather than later, not three hours from now, so we can get him out. Is that understood?”

No yelling, nothing unprofessional but certainly putting me in my place.

Apparently my line above about not doing anything had drawn some concern from the resident that perhaps I wasn’t coming to see that patient, despite the fact I went on in the conversation to ask where the patient was located. That aside, what if I had truly thought the patient could go home without being seen?

It would’ve been a completely clinically appropriate decision that this patient did not need to be seen by a neurosurgeon again. One that plenty of neurosurgeons would have made. I can envision rare scenarios where the above lines of commands would’ve been given to a private neurosurgeon at 1 A.M. if he had decided he didn’t need to see this patient.

“You need to come into the hospital, examine this patient and drop a note. Yeah, he’s GCS 15, completely intact and his scans look exactly the same from the last time you saw him, but you need to get your ass in here,” just does not happen. And certainly not at 1 A.M. If it does, that’s maybe the end of neuro specialty coverage for that physician who called.

But there is something different about academics, and not for the better.

Resident coverage gets taken for granted. I’ve discussed this before as it relates to nurses. It appears okay to call at 2 A.M. about an incentive spirometer for a patient at an academic hospital because you’re only paging a resident and they’re already in house but it’s not okay to make that same call to a private physician at home. Something similar was going on here.

But I think we deserve a little bit more respect.

Let’s imagine the attending who called me is both young and has spent his entire practice in academics. Let’s imagine that because it highlights the problem.

What if I was a fifth or sixth or seventh year resident? I would be getting these lines from an attending who essentially I had been an M.D. as long as he or she had. And these interactions certainly happen between residents in specialties with lengthy training and young attendings on other services.

The point is, while there was nothing unprofessional per se about what happened, it would’ve been far more appropriate for this attending to have a less teacher-pupil/parent-child conversation and more of a colleague-colleague one with me.

“Hey, I’m just giving you a call back to see if you’re gonna come see this guy, I guess it was unclear if you thought we could just send him out or not. I’d really appreciate it if you’d see him, I think it’s really important for him to talk to the neurosurgery team again because he has some questions and concerns.”

Thursday, April 19th 2012

Independence & Efficiency of Communication


Not That I’ve Ever Worked 40 Hours

It’s my opinion from limited, but not undiverse, observation that at public teaching hospitals resident physicians are burdened with an unnecessary number of mundane calls and often at inapropriate times. This compared to the private world.

I’m not sure why there needs to be a 11pm call for a potassium of 3.7 or a 2am call that there is no order for incentive spirometry. Not that such inappropriately timed communication is limited to nursing staff. I’m not sure why a resident (or staff) radiologist needs to call the ordering physician at midnight that an NG tube is in the esophagus. Nor am I excused here. I’m not sure I need to call the medicine consult service at 10pm for asymptomatic hypertension.

It seems sometimes that individuals within teaching facilities operate with very poor levels of discretion and independence and just plain commonsense.

My residency program rotates through my faculty’s private practice at a facility with no other residents. Similiarly my wife started at a community program where her residency was the only training program within the system. The norm in these private institutions is far fewer of such calls in my experience. Not that they don’t happen, just that they’re with much, much less frequency. Instead you arrive in the ICU for morning rounds and the nurse informs you, “The patient’s nausea was well controlled and she passed her bedside swallow last night so I pulled her NG tube and advanced her diet. Can you sign those orders in the chart?”

There is something in the culture or training of public teaching hospitals which apparently encourages everyone to run everything by everyone else. There is limited initiative and limited recognition of which issues need to be tertiarized to someone higher up.

I think the fact these institutions are places of training, and not just physicians but nurses and other providers, makes for more calls as people learn. I think the fact more providers take call in house at large public hospitals encourages calls as there is an attitude that the resident physicians are already working and so there is hassle to calling. I think the fact that these hospitals take care of sicker patients, who probably require more calls in general, encourages frivolous calls. And I do think that the fact it is residents, and not private physicians, who are being called also lowers the threshold at which calls are made somewhat.

Now to be fair my exposure to large public teahcing facilities outside my own is limited. I have some at rotations as a medical student and remember residents at those places getting plenty of inappropriately timed calls but perhaps my experience isn’t representative. I’d be interested in hearing from those who have been at other places.

This issue isn’t merely a matter of resident lifestyle; although it is such. This is a patient care matter. A call from a radiologist about a malpositioned Donhoff tube probably shouldn’t go from the radiologist to the ordering physician to the nurse, it should go from the radiologist to the nurse who understands the correct position and advances the tube of his own initiative. Increasing the relays of information is usually poor design, no less in health care. Nurses and RTs and other providers who can correctly tertiarize issues and provide appropriate care to patients on the spot obviously represents a better model and better patient care than waiting for a verbal order, from a scatterbrained resident in the middle of the night.

Tuesday, January 31st 2012

Impact of Admission Month & Hospital Teaching Status on Outcomes In Subarachnoid Hemorrhage

Background
It is common knowledge to avoid major teaching hospitals in July. Such is when new residents, fresh from medical school, begin as physicians. In some studies the month has been associated with more errors, including notably fatal medication errors. However, the effect continues to be questioned and debated. Even a short review of the surgical literature finds that a preponderence of studies show no worse outcomes with surgical procedures in July as compared to other months. The most notable of these studies is likely this large retrospective review of all Medicare patients undergoing CABG, CEA, AAA repair, colectomy, pnacreatectomy, esophagectomy or hip ORIF between 2003 and 2006. They found no increased mortality or reported morbidity in those three Julys as compared to the other 33 months of the study. Other studies looking just at patients undergoing CABG or patients undergoing emergent appendectomy back up those results.

Add a recent study in the Journal of Neurosurgery to the pile of evidence that new resident physicians in July don’t endanger patients.

McDonald, Robert J., Harry J. Cloft, and David F. Kallmes. “Impact of Admission Month and Hospital Teaching Status on Outcomes in Subarrachnoid Hemorrhage: Evidence against the July Effect.” Journal of Neurosurgery 116 (2012): 157-63.

Design
The study by a group out of the Mayo Clinic is a retrospective analysis of a huge proportion of all hospital admissions between 2001-2008 for non-traumatic subarachnoid hemorrhage. The study pulled all admissions with ICD codes associated with SAH from the National Inpatient Sample. This is an AHRQ national database contributed to by all hospitals in 44 states.

The admissions and their outcomes were studied with two linear regression models for both teaching and non-teaching hospitals. One looked solely at inpatient mortality. The other looked at “unfavorable” discharged; those patients with SAH being discharged to skill care.

Results
There were 52,879 admissions for non-traumatic SAH in the NIS database between 2001-2008. 36,914 were admitted to teaching hospitals and 15,965 were admitted to non-teaching hospitals. There was no monthly variation, in either teaching or non-teaching hospitals, in either model. The authors failed to find any evidence of a “July effect.”

Of note however, there was a discrepancy in outcomes in terms of hospital teaching status. The probability of in-hospital mortality for patients presenting to a teaching hospital with non-traumatic SAH was 11% lower than that or patients presenting to a non-teaching hospital. The probability of “unfavorable” discharge, likewise, was 12% lower.

Discussion

The results of this retrospective review of SAH hos -pital admissions within the 2001–2008 NIS failed to demonstrate significant month-to-month variation among outcomes including in-hospital deaths and/or discharges requiring skilled care. This pattern was observed in both teaching and nonteaching hospitals and suggests that a July effect is absent among SAH hospitalizations.

Also, for life threatening problems, such as subarachnoid hemorrhage, tertiary centers (more often than not teaching facilities) appear to be the place to go for care. At least in terms of outcome.

Tuesday, January 17th 2012

It Is Cheating But Should It Be?

This has been up and around. I’m sure within the radiology community the CNN “exclusive” was hardly news at all.

The gist of the accusation is that,

For years, doctors around the country taking an exam to become board certified in radiology have cheated by memorizing test questions, creating sophisticated banks of what are known as “recalls,” a CNN investigation has found.

No doubt what was going on constituted cheating. There were specific prohibitions against reproducing questions that test takers agreed to before the privilege of being able to take the written portions of the radiology boards.

But, I guess controversially, should it be that way?

True, it would be hardly a point of confidence if the board self published the questions on their tests and then told the resident candidates to memorize all the answers before they showed up. But the recalls are hardly that. I imagine them more as a study tool. I also imagine that studying them and getting the questions right on the board exam means the radiology residents have learned the material. And that seems the whole point of standardized testing as a method for certifying physicians for various specialties; to make sure they have a baseline, basic set of knowledge. In once sense, how does it matter how that knowledge is memorized?

Thursday, November 10th 2011

Video Anatomy

The American Association of Neurological Surgeons has a great new YouTube channel hosting videos on surgical anatomy, including some Rhoton lectures. Even some videos in 3D if you have a computer capable of playing such. I hope they keep updating it but it’s a great resource as is.

Tuesday, September 27th 2011

More On Work Hours

Currently non-intern physician residents are limited to working 320 hours in any four week period, 24 hours of patient care in any one continuous setting and most have 4 days off in any four week period amongst other rules.

The history of medicine’s self governing bodies limiting resident physician work hours in a patient protection bid has a long history, as do my complaints about such.

But I thought it worth reiterating one of the major problems with these work hours. They can only be policed by individuals who are largely negatively impacted by their violation.

Say you’re a obstetrics/gynecology resident at a program that has some rotations that regularly violate the 80 hours/week (averaged). Let’s say you, and all the other residents in your program, report those violations. That is the only way that programs (and thus medical schools and the ACGME) learn about violations…they ask their residents to report them. Mix in some other things and before you know it your program is on probation from the ACGME and then, a few years later as the work hour violations continue despite best efforts, your program is shut down.

All in the name of patient safety. Only there is evidence, despite our best intentions, that restricting resident work hours has done nothing for patient safety.

And so now you are an out of work ob/gyn resident who can only blame yourself for self reporting those duty hour violations. Now you have to go out interviewing across the country to find another residency program, costing you potentially tens of thousands of dollars. It’s true that your funding for your resident position (your salary) can travel with you as you look for a new residency program and that the ACGME will almost universally provide a waiver to any program that accepts you to increase the size of their residency program and so your odds of finding another residency program to accept you are high, even if you’re in a competitive specialty. However, that isn’t guaranteed and there’s a small chance you may not find another ob/gyn residency to accept you. Even if you do it means packing up your family and your belongings, leaving your friends and moving cross country.

There’s some evidence that the majority of residents continue to routinely violate duty hour rules, largely without complaint. For one, I’m not sure they see the adverse effects of doing such. For two, knowing the light at the end of the tunnel they swallow the long work hours. And, for three, reporting those violations most negatively impacts the resident physicians themselves.

This isn’t a call for some dramatic shift in how we track resident physician work hours or for mitigating the effects of program violations on residents. This is a call for some return to sensibility and some loosening of the work hour restrictions in the first place.

A pipe dream but I’ll dream it.

Wednesday, September 21st 2011

Establishing Immediate Trust

I’ve written before about a sense of urgency sometimes lacking amongst patients and family and friends when asking permission for surgery. The majority of the time that appears to come from being overwhelmed, rarely it comes from a lack of trust.

I was thinking about situations in which physicians need to establish trust in very short order. I suppose that’s always the case in the patient-physician relationship. But there’s something to be said for the acuity of a hospital visit and what things like resident work hours, increased physician hand offs, co-management of patients between different physicians have done for the inpatient-physician relationship and what it means for establishing trust during a scary period for most people – when they’re in the hospital.

Last night, for example, I was cross covering at the county hospital. Basically I’m on rotation at another hospital, but because the county hospital, with its high level of neurotrauma, is the only participating facility in my residency that we take in house call at they need residents at the other facilities to come take call there some nights.

Not quite inevitably but often there are inpatients at the county hospital who are going to the operating room the next day and who have not been consented for surgery. And so that responsibility falls to me overnight.

This is a situation where I’ve never met this patient before, haven’t participated to this point in his care and in our first encounter I’m going to go over, amongst other things, what potentially horrific sounding things could happen to him during brain surgery.

It’s not easy presenting it with some confidence, humility, frankness to someone you’ve just met and leaving the situation with them feeling confident in the major step they’re taking tomorrow. I’ve certainly bungled it, and seen many another physician bungle it, even when they have a good pre-existing relationship with the patient.

I think the key is being confident, friendly but professional and dedicating some time to explaining the situation.

That may seem obvious, but sometimes the response on a busy cross cover night is to rush the situation. The patient usually knows they’re going to surgery tomorrow and has a general idea why and what for. Sometimes amidst the ICU and the consults the idea is to do the consent as quickly as possible and move on.

Being frank about who you are, your role in the introduction, describing the surgery and then being frank and honest but apologetic and realistic in the risks are good strategies for making patients as comfortable as possible as they contemplate surgery the next day. Doing it earlier, rather than later in the evening is also a good move.

And then poof, after such an important life discussion you’re gone. As for that patient I consented last night there is a good chance I may never see him again. That probably says something about physician coverage, work hours and the like but I’m not sure what in full.