To be fair an average experience may be hard to articulate. Different rotations and different days yield different…adventures. Right now I’m on a service that could hardly be called grueling, but I cross cover the county hospital when on call. On the other hand I once had a 24 hour period where I took 28 consults. Which is something considering it is you and the chief resident and that is it.

But I thought I’d give a median weekend on call for me right now hour-by-hour. In reality I cover both a VA and a trauma heavy county hospital while on call over the weekend. But considering this is my last month at the VA and my census at the VA, with consults, runs between 2-7 patients I thought I’d condense it and just show a fairly reasonable work load solely at the county hospital.

I’m presenting this under the shadow of the 30 hour straight rule and the 80 hour work week. I know some older physicians will compare it to their training experience. I know some current or recent residents will point out that their program routinely flaunted the 80 hour rule. So be it.

7 a.m I meet with the post call junior resident and the chief at the county hospital. We table round, looking at images from last night and going over any new consults. The list has 60 patients on it. And that truly is a conservative number. Approximately half of them are our primary and half we are consults on.

8 a.m. The chief and post call resident run up to round on the unit and the approximate 5 primary patients up there and the 15 consults (let’s make the ICU players add up to 20 for simplicity, which is reasonable for our list).

I run down to see the 40 patients on multiple floors. I start at the top and work my way down.

9 a.m. My partner in crime is done rounding with the chief and is putting in basic orders and notes, without plans, on the patients in the ICU. I’m still seeing patients on the floor.

10 a.m. Our T9 fracture we added on for today gets an OR room. We were supposed to get to him on Friday, but coudn’t. Lukcily I’ve seen everyone on the floor, unfortunately there are three people waiting to get out of the hospital as I run down to the OR. My fellow junior resident manages to discharge two of the people.

11 a.m. I’m in the OR. My fellow resident is getting some of my floor work done but none of my notes.

12 p.m. In the OR I get a consult for a hypertensive bleed with intraventricular extension. I scrub out and run down and see her. My fellow junior resident meets me and checks out. The ICU attending wasn’t going to be available to round until the afternoon and so that task falls to me.

I run back upstairs and let my chief know I think this head bleed needs an EVD. I scrub back in and we close quickly.

1 p.m. While we’re putting in the EVD the intensivist calls me to see if I’m available to round.

2 p.m. I run upstairs and round with the ICU attending for 2 hours. Luckily I’m able to put in orders as we go on a computer on wheels. To give an issue of how many times I’m getting interrupted by other providers in the hospital my beeper goes off 15 times in those 2 hours including another consult for a C2 lateral mass fracture down in the ER.

I manage to put in admission orders for the head bleed downstairs on the computer on wheels while I’m rounding with the attending.

3 p.m. Still rounding in the ICU.

4 p.m. I run downstairs to see the cervical fracture. While I’m down there they have another consult with a small volume traumatic subarrachnoid bleed. I see him as well.

5 p.m. Then I run upstairs to see the post op on the floor and the EVD we placed, she has made it to the ICU. I sit down (it’s the first time I’ve sat down since 8 this morning) to add my last discharge and then write my consult notes and add the plans to the notes for the ICU patients. I follow up on a stat head CT the ICU attending had wanted while rounding, I call him with the results.

6 p.m. While starting my notes for the floor patients I get called about a patient in the ICU whose EVD has stopped working. I go downstairs and indeed it doesn’t flush or withdraw and the patient needs the ventric. I call my chief and prepare to replace the EVD.

7 p.m. EVD is in and go and see a guy I got called on with multiple parenchymal melanoma mets. I go upstairs and write that consult note, my procedure notes, dictate the op report from earlier in the day and then start on my notes for the floor patients.

8 p.m. I’m still writing my forty floor notes. I get called on a patient with some desaturations on a floor patient. I go and see him, check the CXR, see the atelectasis and with him doing okay go back to writing floor notes.

9 p.m. Still writing floor notes. Done I go downstairs and grab some chicken strips for dinner. I go upstairs and walk the ICU.

10 p.m. Another consult from the ER. A gentleman who fell from standing on Coumadin. There is 2 cm of shift from the subdural. His INR is supratheraputic. I call my chief, who calls my attending. They call me back and I call the OR. I order mannitol and more fresh frozen plasma. I go and talk to the family at length and consent for the procedure. I have to physically run and get the FFP myself.

11 p.m. I scrub into the decompressive crani.

12 a.m. Still in the crani and closing I get called about a teenager with some subarrachnoid and an apparent giant basilar aneurysm on an outside CTA.

1 a.m. I write my consult note on this emergency craniotomy and dictate the operative report and put in admission orders. I run up the PICU where this new consult has already been admitted. I try to track down the outside CTA; this’ll be an adventrue.

2 a.m. I finally get the CTA and indeed even I can identify the aneurysm. I call my vascular attending and email him some of the pictures from the CTA. I then go down and consent the family for a potential angio later that day.

3 a.m. As I’m writing my consult note I get a call about one of our ICU consults, actually on the trauma service, having a seizure. I go up there just to see if the trauma guys need anything. I then go back to writing my consult note on the pedi patient with the aneurysm.

4 a.m. I get called on a thoracic burst fracture down in the ED on some gentleman who jumped from a 2nd story window likely related to a positive drugs of abuse screen. I go downstairs and see him and as he’s intact I’ll just keep him in bed. I write my note.

5 a.m. I head back upstairs and start working on the list for the morning. Moving people around, taking the discharges off, adding the new patients and getting the labs for all the new patients and the 20 guys in the unit. I run and make copies for the chief and the junior resident coming on.

6 a.m. I pull up all the images from overnight on all the consults and on anyone who got uprights or repeat head CTs or MRIs.

7 a.m. The junior coming on and the chief show up. We table round going over all the images and everyone on the list. I’ll see the ICU patients today.

8 a.m. Me and the chief resident go up to the unit and round on the ICU patients including the consults up there. Let’s say we signed off on some of the consults yesterday and so even with the new admissions I still only have 20 ICU patients. There are the daily little things to do like drawing CSF.

9 a.m. I start writing my ICU notes.

10 a.m. The ICU attending wants to phone round today and so I take his call and run all the patients with him. It’s a little bit shorter over the phone. I’m able to sit at a computer and put in orders while we’re talking.

11 a.m. I finish up my notes in the ICU.

12 p.m. I check to see if my fellow resident needs any help and I get out with an hour to spare.

As with any service I’m taking innumerous pages and answering questions and doing the basics for my patients, 20+ on the floor and 5+ in the ICU, during this whole time. I’m also constantly reviewing results such as sodiums for hypertonic therapy and repeat head CTs at 6 and 24 hour intervals for head bleeds.

I’ve written more than 60 notes, rounded on 80 patients, done 2 EVDs, scrubbed 2 operations, seen 5 consults in 29 hours. Often fun and always rewarding hopefully but like any training program difficult at times. Even with the work hours.

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.

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.

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.

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.

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.

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.

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.

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.