Anonymous Doctor

I wouldn't want to be an inpatient here.

It's interesting how hospitals get their reputations off the purported quality of their attendings, but the attendings aren't the ones actually doing the moment-to-moment patient care. One of the patients on my floor coded while I was on call yesterday and as soon as the bells sounded, the second-year resident goes running-- "I'm supposed to run the code," he said. "Good luck," whispered the attending, just when the resident was out of earshot. This is a guy who two weeks ago was an intern, just like me. I don't want him running my code if I'm the one in the bed.

But it's not just that. It's that you could have world-class attendings, specialists in their fields, but they're not internists, they haven't practiced general medicine in twenty years. So when an incidental problem comes up-- not necessarily incidental to the patient but I just mean something that doesn't have to do directly with that world-class treatment they're getting for Big Fancy Disease that Big Fancy Attending specializes in. Say, elevated blood sugar. Or pain. Or delirium. Or sleeplessness. Problems sick people have. There's no expert in general medicine around to order the right treatment. We've got interns like me, who don't have a clue. And we've got specialist attending (if the problem happens to come up between 9 and 12 or 4 and 6, when he's here doing rounds), who only has a clue in his very small specialty bubble. And so no one knows that the 93-year-old who's suffering from some nighttime confusion probably shouldn't get drugged up with Haldol as a first-line treatment. Especially not the night float intern. So when someone like me rolls in at 7AM and finds his patient hallucinating and practically comatose, it's a little too late.

In more than a couple of cases, I feel like my patients' biggest mistakes have been coming to the hospital at all. We've taken one sick but relatively stable patient and drugged her to the brink of death. We've taken another sick but relatively stable patient and given her a battery of unnecessary tests-- I say unnecessary because even if they all came back positive, she's likely not going to live long enough from Big Fancy Disease for Little Thing We Biopsied to ever make an impact-- and caused a pretty painful Something-Itis in the process (oops!) that seems like it's very quickly hastening her demise. Are any of these actual malpractice, as in standard-of-negligence, court-finds-the-doctor guilty malpractice? Probably not. Are they unfortunate complications that could have been avoided if we at least had some hospitalists or some general medicine attendings roaming around? Absolutely.

What's completely bizarre to me is that no one trains us. We're dropped in on day one expected to be able to apply our med school knowledge to patient care, but the chain of command is such that the only people we're able to ask for help aren't much more knowledgeable than we are, and the only people they're able to ask for help are people they're afraid to talk to. So even if I remember that Drug X is first-line hypertension, I don't know if there's a better drug to use in this case, or whether my textbook was outdated, or whether there's going to be interactions between Drug X and everything else going on with the patient. And even if I try my best to find out, I don't have the clinical experience to be confident about my decision. And the attending doesn't necessarily have the wherewithal to realize he has to be triple-checking, or to assume we know as little as we do, and so he signs off without giving it due diligence, and patient ends up suffering for it.

Has anyone on my service died? No, not yet. Have any of these mistakes been mine? No, not yet. But I can see how easy it would be for something bad to happen-- how few checks and balances are in the system, how much people like me are being relied on, far beyond our experience and capabilities at this stage-- and it terrifies me every time I write an order. It terrifies me. Because I know, without question, that I would not want to be one of those patients. And, maybe just as bad, I know that not everyone is as terrified as I am, and that's the scariest part-- because there are no consequences, short of something truly, truly egregious happening. But hastening a sick person's death doesn't seem to rise to that level. And that's crazy.

In other words, if I am your doctor... run away.