* * Anonymous Doc

Tuesday, December 8, 2009

Yesterday was my latest night at the hospital since I've been on the day shift. I got there at 6:45 and didn't step out the door until 10:33 at night. (And back before 7 this morning.) I am so happy this rotation will be over this weekend. Not that there's any reason to think the next one will be any better-- and in fact I've heard it's worse-- but somehow the combination of this hospital and my patients and my team and these nurses has just made the whole thing so much harder than it should be.

What kept me so late was a patient with a fever, and an overworked nursing staff that is poorly synchronized with the doctor shifts. The nurses shouldn't have their shift handoffs an hour after the doctors do, it just shouldn't work that way. We're allowed to start handing patients over to the night team at 6, and the nurses change shifts at 7. In theory, I understand why this is supposed to work-- if the doctors are all ready to make their shift change at 6, then the night team is already set up with the patients by the time the nurses change, and there shouldn't be a lag. But, for the most part, the doctors are never really ready at 6. If nothing's going wrong, we're done at 6. But if anything's happening with any of our patients, we can't sign out, we have to do whatever we need to do to get the patient stable, run whatever tests, wait for whatever results, start whatever new medications.

So at 6:00, as I'm hoping to get to sign out, we realize my patient has a fever, and I need to order a urinalysis. I ask the nurse. She says she has other things she has to do before her shift is done, and she won't do it. I had an admission to deal with, so I figured I would just wait until 7 and grab the new nurse. By the time I find her at 7:15, she's already been given a list of half a dozen things to do, and says she'll get to the urinalysis when she can. At this point, I figured I'd just do it myself. Except we discovered the patient was incontinent and urinating all over herself. We needed to put in a catheter. I've never done this on my own. I waited for another intern to be free enough to help. We put in the catheter. I got the urine sample. It's 9:00 at this point. I bring it to the lab. And of course by 9:00 everything is working in slow-motion. I wait an hour for them to "rush" the results. And by the time I then do what I need to do and sign out, it's after 10.

I understand why we have to wait for test results, and can't just sign it over to the night team, I guess. I mean, I was on nights, I know what it's like to have 75 patients under your care and how annoying it is when a doctor leaves you someone who needs follow-up. It's enough that you have to deal with the emergencies that come up, but to have patients who you already know are going to take your attention, it makes it too much for the night person to have to deal with. But then there should be extra support at the transition period -- there should be an overlap so nurses can help get things done and help get the day doctors out at a normal time. Or the shift shouldn't end at that point, it should end two hours earlier, so the new nurses have time to get situated before the rush that needs to happen to get the day team out of there.

I don't know why I'm trying to explain this, and why I'm fixated on this systemic problem. I'm just grumpy that I had to be there so late, and I want to believe there's a way to fix it instead of being forced to admit that, hey, these are sick people and sometimes things happen, and for the next two and a half years there are going to be weeks like this, there are going to be nights I'm there for hours, trying to get someone's urine in a container so I can take it to the lab.

I ran into the attending from a previous rotation, and he told me one of my patients just died. Is it wrong that I don't feel too sad about it? This patient treated everyone poorly, treated his family poorly, and basically drank himself to death. Has this job made me so jaded that I feel nothing for him? That I'm not fazed in the least? I hope I'm still human. Gosh, this week sucks.


  1. I totally understand why you are fixated on it -- only highly intelligent, highly creative people notice systemic problems. The nursing track seems to be at cross purposes to the physican track, and I'm not sure anyone looks at the global system to see how it could work better. It's like two parallel universes that happen to intersect at the same physical place but have nothing to do with each other, really. The thing is, physicans today are really more like scientists; I don't think caring about patients is part of that, and may in fact interfere with the good practice of medicine. Sure, if a doctor and a patient hit it off, so much the better, but it's like when your car needs a mechanic, you want someone whose main skill is fixing your car at an expert level. I'm not anti-nurse, not exactly (though I have met very few nurses that I thought were worthy of the supposed prestige of the profession). Anyway, my point is that patients are also to blame, or our culture is to blame, for insisting that people who practice medicine be obligated to have a good relationship with every patient. No, I think one can be professional and do one's job and not have personal feelings about a patient. Our world is full of that sort of emotional distancing and it works well for all parties: people who are compassionate and who give to and help others greatly but who do so at a relative emotional distance: e.g., people who give to charities, therapists, clergy, teachers, soldiers, etc. Again, if they do develop a closeness/affection/regard for the person they are helping, fine, but it's not required. Nor should it be. One can strive to help *people* in general, and even dislike the individuals they help, and there's nothing wrong with that. The other thing too is that I think the hospital system is thoroughly broken, but it's also a case of the Emperor's New Clothes (and you're, unfortunately, the kid who see that the Emperor is naked). Hang in there! --Tina
    On Twitter: Miss__Tina

  2. If you didn't have some emotional distance from your patients, you wouldn't get too far in medicine...you're doing great I'm sure.

    If the resident/hospital/program culture is permissive, consider a quality improvement research project or study on the nursing and physician transition at your hospital. Might be fun! (Or very annoying).

  3. Caring enough to worry in print that you didn't care is a form of caring.

  4. If you told us that a little kid was run over by a truck and didn't make it, and you didn't care, then you'd be a heartless bastard.

    Considering that it was a "long-term suicide by alcohol", I think that more people agree with you than you realize.

    On another note, I believe you'd make a much better therapist than a GP... but that's just my two cents... you seem to be more about the relationship than about the disease/ailment/malady/problem to fix/whatever, so a line of work with more personal contact seems better for you

  5. It's good that despite the long unpredictable hours you have, you still find time to blog. I suppose it's where you can vent and release some pressure. Hang in there. If you've lasted this long as a first year resident, then you can probably finish the whole course. I'm just surprised that you expressed dislike in doing procedures and yet, you chose to join one of the most difficult areas--internal med.