The scripture yesterday in service was Matthew 25:31-46,

31 “When the Son of Man comes in his glory, and all the angels with him, he will sit on his throne in heavenly glory. 32 All the nations will be gathered before him, and he will separate the people one from another as a shepherd separates the sheep from the goats. 33He will put the sheep on his right and the goats on his left.

34 “Then the King will say to those on his right, ‘Come, you who are blessed by my Father; take your inheritance, the kingdom prepared for you since the creation of the world. 35 For I was hungry and you gave me something to eat, I was thirsty and you gave me something to drink, I was a stranger and you invited me in, 36 I needed clothes and you clothed me, I was sick and you looked after me, I was in prison and you came to visit me.’

37 “Then the righteous will answer him, ‘Lord, when did we see you hungry and feed you, or thirsty and give you something to drink? 38 When did we see you a stranger and invite you in, or needing clothes and clothe you? 39 When did we see you sick or in prison and go to visit you?’

40 “The King will reply, ‘I tell you the truth, whatever you did for one of the least of these brothers of mine, you did for me.’

41″Then he will say to those on his left, ‘Depart from me, you who are cursed, into the eternal fire prepared for the devil and his angels. 42 For I was hungry and you gave me nothing to eat, I was thirsty and you gave me nothing to drink, 43 I was a stranger and you did not invite me in, I needed clothes and you did not clothe me, I was sick and in prison and you did not look after me.’

44 “They also will answer, ‘Lord, when did we see you hungry or thirsty or a stranger or needing clothes or sick or in prison, and did not help you?’

45 “He will reply, ‘I tell you the truth, whatever you did not do for one of the least of these, you did not do for me.’

46 “Then they will go away to eternal punishment, but the righteous to eternal life.”

It was important for me to hear. Not the message of judgment necessarily, but the reminder of our obligation to serve.

Empathy is such an important part of medicine. It is favored in the medical school application process. And yet the decline in it as students and residents progress through training is well documented.

In part there’s a sense of inevitability with such. Familiarity weighs on such. Everything from callousing oneself to suffering to feelings that there is a lack of gratitude for your efforts to being tired to blaming patients for their illnesses. It all wears away the idealism and dedication to service that I think most medical students sincerely enter the profession with.

I’m guilty of it as most. And so it was good to be at church on Sunday.

I’m incredibly blessed. Not least because I am in a position to serve everyday. And I hate losing sight of that. I hate sitting in the call room at 2 am and getting a flood of pages from the ER. Those phone calls are a medical record number and some demographics and my annoyance at having more heaped onto my plate to do that night. All because some guy or gal got into their car after having too much to drink or fell off a bar stool or got into a fist fight.

There’s nothing to those judgments and my annoyance. These are people in the end who need my help. However they got to my care, here they are and I have the potential to do them great service and maybe affect their life for the better.

I want service to be central to me being a doctor. This isn’t just a job. These aren’t just hoops I have to jump through to complete training. These aren’t just operations.

These are chances to change lives; to serve.

Now just to take a deep breath late into my call nights and remember such.

There’s been a lot of dissatisfaction in surgical training with work hour restrictions. Perhaps I shouldn’t limit it to surgical residencies, merely to say, instead, that they’ve been the most vocal for my experience.

The 80 hour work week and the 30 hour work shift restrictions have been bemoaned by academic surgeons. Fears that resident’s hand offs of patients would harm continuity of care and thus patient outcomes were front and center, and voiced by all specialties. Fears that resident surgeons would get less hands on surgical experience were unique to surgery but no less concerning.

Talk that further restrictions on how much residents can work are coming brings the issue front and center again. A not too distant IOM report commissioned by the AHRQ recommended such further limitations on resident work hours. And decried by surgical specialists and others alike. I’ve heard prominent individuals from within organized surgery, of course being explicit that they’re voicing their opinions as individuals, decry any further attempt to limit the surgical resident experience.

The surgical specialties are poorly represented in the decision making process. The IOM committee which so recently commented on resident work hours had a single surgical subspecialists on it. The current ACGME Board of Directors has two surgeons sitting on it (and I’m explicitly excluding the ophthalmologists serving on it, and for reason I believe considering their training experience as compared to say that of an orthopedic surgeon). That is two representatives out of thirty or 6% of the vote on the body that will ultimately, at present, determine any further resident work hour restrictions.

With relatively broad coverage in the media of the issue, a decided bent in the public for support of work hour restrictions, and significant public advocacy money in play to influence the decision the whispers from within the ACGME are that further restrictions are inevitable in the next 2 years.

But what if the decision was taken out of the hands of the ACGME, at least for surgical residencies?

There is a growing movement amongst rather prominent academic surgeons for an Accreditation Council for Graduate Surgical Education. Organizing such would be no small feat. Getting the state boards, with public pressure in favor of restrictions, to recognize it may be even more of a hurdle. And that presumes that the inevitability of all of this mess isn’t Congress legislating resident work hours as say the Patient and Physician Protection and Safety Act [PDF] tried to do early last decade.

It’s true, work hour restrictions have worked the rest of the world over. European registars are limited to 48 hours a week and it is hard to demonstrate a qualitative difference between a CABG here and over there. And while the design of their health care system necessitates that many of them will spend years as SHOs (or even lower on the training pole) before a consultant spot opens up.

Drawing the analogy with other other surgical training experiences across the world would require a reimagining of how health care is organized in America. A more tertiary experience with fewer surgeons and lengthier training with further graduation of responsibility during it. That’s not something I’m personally willing to accept. As much as residents still bemoan their hours in the hospital, if push came to shove, and an ACGSE could postpone further reductions in my operative experience I am all for it.

Intermittent, spotty posting is no way to run a blog. It has been a month since I posted anything; probably explains my Google Analytic numbers of recent. Luckily, I return with pretty incredible news.

Most incredibly, I’m engaged to a beautiful and wonderful girl. Off the market ladies, I apologize. I don’t know how I convinced her to marry me but she’s so far above and beyond what I deserve that I can’t ever imagine coming off this high.

In addition, about a year ago this time I did an interview with a Wall Street Journal blogger during which I was meandering and only at times coherent. I excuse myself for that, I had recently learned that I did not match after participating in the National Residency Matching Program. The interview was on the process of medical students become residents and physicians in the match and, in my case, the scramble.

I’ve spent nearly nine months serving in a general surgery preliminary residency spot and going through the residency match once again. This time with much better results. I’m going to be a neurosurgeon. Sure the path forward is rough and lengthy, but I’ve cleared a major hurdle.

The Sex Appeal Isn’t That He’s A Neurosurgeon, It’s That Hair

Anyway, I’m back to posting and I hope readers will return to reading.

It’s sacrilege to not want to be the OR if you’re a surgeon, or a wannabe.

I’m guilty of it this rotation. Not only am I not actively seeking out the OR, I’m attempting to avoid it. And today, spending the day in it against my wishes, I’m peeved.

My disdain is multifactorial. Some of the reasons for avoiding scrubbing in are personal and beyond discussion here. But, in part, the fact is I’m tired of general surgery. I want to be a neurosurgeon and if I never see the inside of an abdomen ever again I would be beyond comfortable with that. Even agreeing that any operating time is good learning experience I can’t shake that sentiment.

Toss me anything with a neurosurgical faculty, an osteoma or a shunt or a trauma crani, and I would be there with glee. But I just cannot shake my distaste for what I’ve been doing over the past seven months or for what I had to do today.

Despite my own misgivings about scrubbing in, I can’t understand future general surgeons refusing general surgery (or its subspecialties) cases. I faced such today.

There was a single OR running today with four cases.

There are five residents on my service. It is highly over staffed. Four of the residents want to be future general surgeons. I’m the lone outcast. One was on call, I understand him not wanting to drive across town to scrub in. That left three others, all of whom are seeking to impress the faculty, to garner a good evaluation from this rotation. I’m alone in having my evaluation bear no impact on my future. I’m alone in not wanting to be a general surgeon. And yet I was sent to scrub in.

My response was frank annoyance, hardly professional, but I figure hardly misplaced in full.

It’s true I’ve managed to avoid the OR but for a handful of times and left the responsibility (and may I opine, privilege) to the general surgery wannabes on the services. I imagine them figuring I needed to shoulder my share of the ‘scrub in burden’. But what a ridiculous notion. The fact general surgery residents figured scrubbing in as a burden; essentially refused several general surgery cases out of what I can’t help but call laziness is bizarre and worth criticism.

My own avoidance of operating experience is something of laziness although my reasons on this particular rotation, as I said, are complex. But if anyone could be afforded an excuse for such it’s myself; with nothing at stake on this rotation unlike all the others.

And while throwing ones fellow residents under the bus is something of a shameful act I have to ask about today, “What the hell?”

The one guy with the most legitimate (at least I feel so) excuses for not going into the OR is prodded in so everyone else can take a lazy breather?

I’m annoyed.

If I’m ever in an acute care setting I want to be the specialist. I want to be hidden behind the wall of a consult. I don’t want to be the front line guy.

As much as I love shift work, detective work, immediacy in medicine I was turned off of specialties like emergency medicine because of scenarios like this:

That is pretty much how it happens.

HT to reddit for linking to the OB&G in turn linking to the following appearance on Anderson Cooper and to Paul’s effort to prohibit a health insurance mandate and to his effort to give a 100% tax credit to all Americans for health care expenses and to his effort for national tort reform.

To call Dr. Paul’s ‘Comprehensive Health Care Reform Act’ reform, as the word has become common lexicon in Washington, would not be fair. The tax credit Dr. Paul proposes would probably do little to broaden health care access for those with current mediocre care. Even with the tax credit we probably don’t reach a place where most Americans can continue to fund an increasing percentage of their health care out of pocket. As well, as with most of Dr. Paul’s impressive proposals, it is a political non-starter. I think cutting government spending by dramatic levels is a noble goal, and such would be required to give all Americans 100% credits for every health care dollar they spent, but it certainly isn’t politically feasible. No matter how many Tea Parties are hosted.

It doesn’t mean that the proposal isn’t a good one. As I’ve said I’m not sure our goal should be increased coverage; that we should be so fascinated with these kind’ve global health care outcome measurements. That health care should be a social concern. Certainly it shouldn’t be one with a government vested interest.

Essentially reform, as it is thrown around in Washington, calls for a trade of liberty for some ill defined right to health care. I’m not comfortable with that. And I understand, and concede, that only government intervention will improve these utilitarian metrics used to grade ours and all health systems. I understand, and concede, that only government intervention will further health on a population scale. But what it is going to cost, in terms of a further broadening of the role of government and an erosion of the right to property, to get that ‘universal’ access and to improve these numbers is unacceptable.

So I’ll continue to cheer on proposals like Ron Paul’s.

It’s A Big One

There’s something gut wrenching about being an intern in July. You’re a ‘doctor’ in name but there’s nothing magical that happened when they handed you your degree.

To be fair, I would argue that the data leans heavily that patients receive no worse care at teaching hospitals in July, when new interns start, than any other month of the year. As well major teaching hospitals, where residents are involved intimately with patient care, consistently provide better care than non-teaching hospitals.

But that’s all a sidetrack. The fact remains that being a new doctor is not without some butterflies.

Every once in a while however you do something of effect. Opportunities to truly help patients often arise from the fact that as an intern I’m probably the physician who lays eyes on our patients the most.

I was two weeks into my intern year when I first ‘caught’ something with a patient. I was in the Surgical Intensive Care Unit. Late one day the ENT resident caught me to tell me about a post op patient they had put in SICU admission orders for. I can’t remember what he had had done but he had been a tough intubation and didn’t have an air leak when they were done with the procedure. So they kept him intubated and ventilated and dosed him with some steroids.

On a ventilator, of course, he was going to require an ICU bed.

I went down and visited him in the Post-Anesthesia Care Unit. There was a good chance he was going to spend the entire night down there as there were no ICU beds open. At that time he was hanging out. I put in some standard ICU orders, talked briefly with his wife, wrote a note and headed back up to the ICU.

About two hours later I get a call from the nurse in the PACU that the patient is agitated.

Something made the experienced nurse caring for him sit up and take notice when this patient began to pull at his restraints, rather than just turning up his Versed drip. As such I probably shouldn’t be calling this ‘my’ catch.

In anycase, I get down there and the guy is tachycardic on the telemetry monitor. I’m an intern so my modus operandi is to order every test in the book for every little thing and I’m already thinking about a PE protocol CT scan with this guy. But first things first, the nurse and I get an EKG. I’m admittedly surprised at how classic it looks.

The EKG Looked Something Obvious Like This

I remember MONA, call the cardiology fellow, fax over the EKG, call my upper level, call the ENT resident and the patient ends up in the cath lab with a clot pulled from his LAD.

The patient ended up in the MICU and I’ll be honest I don’t know how he ended up. Hopefully well. For me, this patient taught me some valuable lessons; he taught me to respect what the nurses have to say about patients, to lay eyes on patients whenever there’s any change. Things I need to keep in mind as I get along in my residency.

I’ve been working some hours of late as my fellow intern is taking vacation and there really wasn’t afforded anything in the schedule to mitigate that. Not to get all ‘I walked uphill in the snow both ways to get to school each day’. I know residency used to be something tougher. Maybe.

While I haven’t gotten into the operating room I’ve gotten some cool procedure, gotten pretty proficient at chest tubes and pigtails and generally had a pretty good weight towards actual patient care this rotation considering the bureaucracy of medicine that falls to residents at academic centers. So don’t number the above as a complaint.

But the amount of time I’ve spent at the hospital has got me thinking about the way the ACGME polices residency rules. So much centers on self reporting. And there’s huge pressure to not report violations. When residency programs get in trouble with the ACGME there are consequences for the residents. A residency program shutting down can be disaster for residents. You could be searching for a new program, leaving a program you love, maybe even switching specialties or moving across the country.

The medical community does some to help in situations when programs are lost. In many specialties other programs traditionally give preference to those residents who have lost their spots. And the ACGME and most RRCs are helpful in giving residency programs exceptions for extra residency spots when programs shut down. In reality those concessions and that assistance are small potatoes.

Scrambling for a new spot that has funding for you, moving, acclimating to a new environment is major trauma. That is assuming you even get ahold of a new position.

There are major incentives for residents to keep their programs in good standing, including to lie about their hours worked.

Some research indicates almost half of residents lie about their duty hours. And you have to believe that is a remarkable under reporting of the situation.

Now I’ve never lied about my duty hours. And I can’t say I know directly of anecdotal episodes of categorical residents lying about their duty hours to protect their programs but you have to believe it happens. It is just not something that will ever be spoken to. If the ACGME wants residents and others to self report violations; if truthful reporting is going to be the centerpiece of review then it needs to give residents more protections. I’m talking about an extreme shift. I’m talking about emergency funding for residency spots when programs run into trouble, about guaranteed spots for residents whose programs fail including about requiring all programs to agree to participate in helping to take on displaced residents, about relocation expenses.

I’m thinking program violations for all sorts of things must be vastly, vastly, vastly under reported. ACGME policies don’t have a lot of teeth when weighed against the future of your training.

A traumatic subdural with a pretty good shift deteriorates on his transfer from some rural area, gets to your hospital as a GCS of 7 and needs to go to the operating room emergently. His next of kin rode on the transport to your hospital. Other family members are en route by car but are some distance out.

You try to consent his next of kin using phrases like ‘emergency,’ ‘right now,’ ‘life and death’. The response is a lot of waffling, a request to wait until the rest of the family gets to the hospital, and calls to those same family members seeking advice.

I seem to have run into the above, or the equivalent, several times over my still young intern year. Not every night or every week, but a few times. Too many times.

I understand such situations are incredibly stressful for those presented with a decision for an emergent procedure (or not) for a loved one. I understand a lot of information is presented to them in a short period and they’re asked to digest it under stress and make one of the most important decisions of their lives.

I’m not sure it excuses trying to skirt the responsibility.

The most frustrating instances involve those legally responsible asking you as the provider to seek the opinion of other family members and to have them decide.

“Oh, I just don’t know! Can you call his sister and have her decide?”
“I’m happy to talk to her and anyone else in the family, but this is something I really need consent from you for.”

Admittedly it could be me. I don’t think so however. I think I present the situation generally with the proper sense of urgency and yet lay out the decision to be made and the options and the consequences of each option in a pretty down to earth and understandable way. The few times I’ve run into this, others – my residents, fellows, faculty – who have come along to talk to the family after me have had the same problem.

True, maybe as the first to attempt consent I’ve spoiled the whole pot for all who follow. More likely the commitment and responsibility owed to a loved one breaks down under the spotlight of the situation for some.

Decisions under time pressure, with limited information, with a loved one at stake are incredibly difficult and I try to check my frustration. However, a sense of responsibility is just sometimes lacking from those asked to choose to either put the pen to the consent form or to refuse to put the pen to the consent form.

Life as a healthcare provider is privileged. You get to see a lot of humanity. The good, the sad, the humorous.

Probably two weeks into being a physician I had to push neostigmine on a patient. Neostigmine is a powerful cholinesterase inhibitor that among other things causes…significant bowel contraction. Which is why I was using it. My patient had come into the trauma ICU following, literally, a nose bleed. Early onset dementia had left the patient in a nursing home and following a fall at that nursing home no one had been able to stop his epistaxis. Down in the ER they had literally stuck foley catheters deep into his nostrils and inflated them to apply pressure and stop the bleeding.

Typically Doesn’t Go In The Nose

He had a lost a lot of blood and had a lot of comorbidities and was at high risk for rebleed and so he ended up in the ICU. Easily, supposedly the least sick patient in the trauma ICU.

He had significant deconditioning on presentation and likely had some generalized ileus. Being in the ICU and further bedridden didn’t make his condition better and his belly started to grow. A KUB sometime into his stay showed a pretty significant generalized ileus without evidence of obstruction. Enemas and other efforts didn’t do a lot to decompress him. So my resident sent me in to give the patient neostigmine.

Neuostigmine isn’t always a benign drug. ‘Side effects’ include bradycardia and, that persisting, arrest. So my resident had me go into the room to administer the neostigmine with a syringe of atropine should I require it. The rest of the team, in a telling move, stood outside peeking into the room; they feared the consequences of rapid bowel contraction.

I slowly push the neostigmine and I stand there, vigilant, grim waiting to have to urgently give the atropine if needed. I’m tense. I’m a two week old doctor and my resident has made this out to be a serious medication.

Suddently my patient starts with, “I have to go. I have to go. I have to go.”

“Okay, sir, we’re getting you a bed pan,” I say. It does nothing to temper my poor demented patient, “I have to go. I have to go. I have to go.”

The nurse runs out of the room to get a bed pan; an admitted oversight for everyone involved in this endeavor. “I have to go number two!”

“It’s okay, sir,” as we slide a bed pan into position. “You can go if you need to.”

I’m watching his heart rate on the monitor and then the patient starts throwing in a new phrase. At first I think he’s saying, “I hate you.” But as I strain to listen it’s clear, “I hate poo. I hate poo. I hate poo.”

I almost lose it. Sitting there with atropine in hand should this patient have a crisis and brady down, I have to turn around and walk to the corner trying to stop myself from laughing.

I refuse to call it unempathetic; there was something endearing and worth a non-condescending chuckle about what we were putting this man through to treat him and help him. It’s the humanity of practicing medicine.

“I hate poo. I hate poo. I hate poo.” Me too.