Patient Note -- J. Doe

Patient has been here for 187 days and shows no signs of change. Building on the observation in note 184, it does in fact seem like patient believes that every day is Tuesday. Patient continues to complain that there is not enough variety in the hospital menu, but this complaint is unlikely to abate as he proceeds through his 13th rotation of the two-week menu cycle. Patient is continuing to recover from infection which developed on day 174, which was a result of the medication given to aid recovery from infection which developed on day 159, which was caused by the catheter needed while patient was being treated for infection which developed on day 132, which was caused by bedsores that developed while patient was in recovery from infection developed on day 119, which was caused by parasite that may or may not have been introduced to patient by his hospital roommate, who has also yet to be discharged. Patient was last intubated on day 104, extubated on day 105, intubated on day 106, extubated on 107, intubated on day 108, and may have swallowed the intubation equipment, resulting in a prolonged stay. Patient's first hundred days were marked by seventeen infections, fourteen procedures, and one new grandchild. These second hundred days have been less eventful. The third hundred days promise to be thrilling. Resident to write next note on this patient tomorrow, or when circumstances dictate.

This is probably not a story I should be sharing. I had a clinic patient yesterday who I knew-- I was his doctor three weeks ago when he was an inpatient. It was not a good couple of days when he was on my service. We were at capacity, there were rapid responses all over the place... in any case...

"Oh, I really like you, doctor. You really listen."

"Thank you so much. That means a lot."

"When I was in the hospital a few weeks ago, I had a doctor who didn't listen at all."

"Um..."

"Do you know Dr. [Me]? I would never want him as my doctor. I want you to be my doctor instead."

"I was your doctor in the hospital. I'm Dr. [Me]."

"No, it must have been someone else. I did not like Dr. [Me]."

"Dr. [Me] is me."

"Are you sure there isn't someone else with your name?"

"No, I remember you. You were my patient. And I'm glad you're feeling better, and sorry you don't feel like I was listening as well as I could have been. It's not an excuse, but it was a tough week when you were here."

"No, it definitely wasn't you. You should keep your eye out for Dr. [Me]. I hope you don't have to work with him."

"I hope I don't have to work with him either."

"So I put in the order for the CT-- now I can just sign out, right?" asked one of my interns.

"No. You have to wait for the results."

"Oh, come on. It's late."

"And what if it shows something?"

"The night team will deal with it."

"They have a million patients. We order a test, we have to wait for the results."

"That's ridiculous."

"I'm not leaving a sign-out that says, 'check his CT results, and if it shows something, do something about it.' How would you feel if you were on night float and that's the note you got?"

"I wouldn't do anything-- I'd save it for the day team tomorrow."

"And by then the patient will be...?"

"Fine. He'll be fine. What's going to happen in one night?"

"Have you worked nights yet?"

"No."

"Okay. You'll see after you work nights. There are some things it's okay to sign out. Emergency scans that may need to be acted on immediately-- not okay."

"You're the one who's always trying to leave as early as we can."

"I know. That's why when I say we can't leave yet, you should listen."

"But I don't want to be here anymore."

"I don't want to be here anymore either."

"So let's just go, and let the night team deal with it."

"We'll go after we get the results and see if we need to do anything."

"They shouldn't even do a CT this late. Then we could just leave."

"Did you finish writing all of your other notes?"

"No."

"Then you can't leave anyway."

"Come on, don't tell me we have to write notes on the weekend too."

Just got an e-mail from a friend who's a resident on the East Coast. With her permission, I'm excerpting:

They're making us sleep here. I'm not even supposed to be on this weekend, and they're making us work a 36 hour shift. Just in case. I understand they need doctors, but I'm not sure I realized this is what I was signing up for when I went to medical school. I didn't become a fireman or a police officer. I don't want to be involved in dangerous situations. I'm not in the Army. I'm an internal medicine resident doing an allergy fellowship next year. Dealing with the normal hospital population on a normal day is crazy and unpredictable enough. I didn't sign up to take the Hurricane Shift. I look forward to my fellowship, when they wouldn't even think to ask me to come in for this, because no one who doesn't belong in the psych ward is going to be wading through feet of water to come to the ER because they're itchy. If someone is hit with flying law chairs or blown out of their houses and drowning in the street, I understand they may need a doctor. That doctor will not be me. I was supposed to go to my dad's country house, in not-hurricane-land, and have a nice two-day weekend, my first two day weekend in four months. Instead, they're telling us they will "try to have enough empty hospital beds for us to sleep in" (!!) and we'll be getting hospital food for breakfast and dinner. I'd bring my own food, except they're saying probably a power outage, and the generators will only be used for essential equipment. If there's a power outage, all of our patients are going to die anyway, so why bother having us sleep there? I know I'm just annoyed because this stupid hurricane is ruining my weekend, but, really, why couldn't I have picked a normal job where they don't make you come in on the weekend when there's a hurricane? I am not that good of a doctor that anyone should really want me dealing with their emergency.

Happy to hear exciting medical-related hurricane stories in the comments. And if you run into my friend, tell her I say hi, and also you should probably find a different doctor.

Okay, clearly I've been on the floors for too long when I find myself jealous of residents working directly in the path of Hurricane Irene. Hospital evacuations? Sign me up. Getting to start over with a clean slate-- goodbye, malingerers! goodbye, people waiting for nursing home placement! goodbye, angry bipolar lady who threw her applesauce at me!-- would be like a dream come true.

I don't dream about normal things anymore. I wake up in a panic, because I've been dreaming about forgetting to put in an order, or having to yell at my interns, or watching a patient urinate on the floor. Three times in the past two weeks, I've had a dream that I am watching a patient urinate. I wake up and desperately have to use the bathroom.

I go back and forth between feeling like I'm a babysitter and feeling like I'm in over my head. One day it's three lumbar punctures and a central line, and, oh, wait, it's 7:00 and someone needs a paracentesis. The next day it's seven patients we can't find placement for, so they're just sticking around, taking up a bed, for no good reason. There are no good days on the floor. Because as soon as you think you're having a good day, you get paged about your brand new patient, who just threw up blood in the ER and you should really get down there and take his history before he loses consciousness.

"What would happen if someone stole drugs?" one of my interns asks me.

"Why are you asking me this?"

"Oh, I'm just curious."

Note to interns: not a good question to ask your resident.

Other bad questions for interns to ask their residents:

"What happens if you forget to put in an order?"
"Did you see where one of my patients went?"
"What number are you supposed to dial when a patient isn't breathing?"
"Do the pagers work if you take the batteries out?"
"I don't have to save my patient note on the system before signing out, do I?"
"Are drug interactions really a thing?"
"It's okay to skip a dose of chemotherapy, right?"
"What happens if someone who's supposed to be fasting eats lunch?"
"Who do you call for an MRI after business hours?"
"Can I just assume the patient wanted to be DNR?"
"Just one needle stick won't infect me with anything, right?"
"Remind me how to do CPR, okay?"
"Will it affect my evaluation if I strangle a patient to death?"

"If I was going to call in sick so I could fly to a wedding this weekend, but now I can't go because the wedding's in North Carolina and my flight is canceled, can I call in sick anyway and not show up?"

I'll be presenting at an M&M conference on Monday-- M&M referring to morbidity and mortality-- where we talk about recent patient situations that did not go entirely smoothly-- that's a gentle way of saying it-- and where there are potential lessons to learn.

The lesson from the case I'll be presenting is:

Patients should not stop breathing at night, because there aren't enough people in the hospital to notice.

There are more lessons to learn than that one, of course. But that's the big one. You show up in the morning to a patient doing far worse than when you left the night before and the first inclination, of course, is to blame the night team. But then you remember when you were on the night team, and it was you and 75 patients you'd never met, and your pager is going off every three minutes with something new, and the elevator isn't working, and the notes aren't clear, and you can't be in two places at once, and the nurses are changing shifts, and--

"How long has he been like this?"

"Doesn't say anything in the chart."

"I think we need to get him to the ICU."

"There aren't any beds."

"I think we need to get him to the ICU anyway."

"I'll call for transport."

"I think we need to get him to the ICU now."

"I'll page the attending."

"I think we need to get him to the ICU right now."

I think it's possibly a jinx to know you're scheduled to present a case at an M&M conference that week. Trouble comes looking for you. I thought I'd be able to skate by with a guy who choked on a bone in his hospital food, but ended up okay. A bone in the food. Served to a guy on a purees and liquids diet. That's an easy Powerpoint slide to make. All sorts of clip art available online. Very straightforward. But, no, instead I get to figure out what kind of graphics I can use to depict "not breathing" and "no one's watching."

Yesterday's post, continued.

"I don't want to confuse the patients."

"By calling yourself a doctor when you're not, you're confusing the patients."

"I'm wearing a white coat. They think I'm a doctor. I don't know what the big deal is."

"The big deal is that you're not a doctor. And you're not the person who they should think is in charge of their care. You're absolutely an important part of the team. But you're still learning."

"You know I'm smarter than [the intern]."

"You have a very high opinion of yourself. That can be good, but it can also be dangerous."

"I don't think I should have to apologize for knowing things. I feel like the surgeons told me this would be how it is in medicine. It's why I'm not going into medicine. In surgery they make decisions. They do things."

"It's important to do the right thing for the patient, to figure out the problem and not just jump to conclusions."

"I guess we just do things differently."

"And on my team, you need to do things my way. Which means not telling patients you're a doctor, and not trying to be in charge. I told you on the first day-- you can all get a good evaluation from me. I'm not judging you against each other. Medicine is not a competition."

"Another thing I like better about surgery."

"I don't think surgery is supposed to be a competition either."

"It is."

"Well, whatever it is over there, over here we need to work as a team. I don't want you seeing patients on your own anymore. Shadow [the intern] for a few days and she can assign you which notes to write. I don't want to have this conversation again. We have seven more days on this rotation, and I think we can get through them without any problems."

"I actually only have five more days."

"What?"

"I'm going to a wedding this weekend. I was going to tell you."

"We're scheduled to be on both days this weekend."

"Yeah, I'm not going to be here."

"Okay. You know what, that's fine."

"You want me to take on some extra responsibilities to make up for it?"

"Nope. It's fine."

"Great. Can I leave early today?"

"You can leave early every day."

"Awesome."

Thanks for all of the comments on Friday's post. Will come up with some posts based on them soon. In the meantime-- I need to figure out how to stop a medical student who's gone rogue. I go into a patient's room:

"...so we're thinking we're not going to be able to discharge you today like we planned."

"Oh, yes, Dr. Jones already told me."

"Dr. Jones?"

"Yes, the young-looking one. Dr. Jones."

"Oh, you mean Bill. The third-year medical student. He's not a doctor yet."

"He said to call him Dr. Jones. And he told me he thinks I have cancer."

"That's not necessarily correct. We're still running tests-- like we talked about yesterday. We don't know what's causing your symptoms. Cancer is certainly on the list of possibilities, but we have no reason to conclude that yet-- there are a lot of other things it could be."

"Dr. Jones said it was cancer."

"Dr. Jones is still a student. And let's call him Bill."

"Why would Dr. Jones tell me it was cancer?"

"I don't know why Bill would tell you it was cancer."

"Does he know something you don't?"

"No."

"Maybe he does."

"I promise you, he doesn't. We are still running tests. And he should not have been speculating as far as your diagnosis, because, honestly, we still don't know."

"He also said I should be on a liquid diet."

"That's not at all necessary."

"He said it would be better for my condition. Am I going to be okay?"

"You're on a normal diet. We may have you skip breakfast so we can run some tests in the morning, but tonight you'll have a normal dinner, tomorrow you'll have a normal lunch. There's nothing about the food that should be causing any alarm."

"It's not very good."

"I'm sorry that the food is not very good. I know, unfortunately, it's not very good. But from a medical standpoint, you are not on a restricted diet."

"So Dr. Jones--"

"Bill--"

"Bill was wrong?"

"Bill may have been misinformed. I'm going to take care of the miscommunication on our end, but I want you to know you can have me paged if you're told any information that seems new or confusing. I will keep you absolutely informed about what we find out. Bill is just a medical student. He's smart and absolutely means well, but he should not be the one giving you information."

"Dr. Jones also said I did this to myself from smoking."

"We don't even know what your diagnosis is, and whatever it is, what caused it is not our concern-- our concern is figuring out a treatment plan that's going to address it as best as we can."

"Dr. Jones said he would make sure I have the best nurse in the hospital assigned to my room."

"Our nurses are excellent, and unfortunately Bill does not have any control over which nurses are assigned to which room. But I will speak to your nurse and make sure he or she is fully informed as to what you may need, and what to keep an eye on."

"Dr. Jones also gave me his cell phone number in case I had any questions."

"I think it would be better if you gave me that slip of paper, and if you have any questions, ask the nurse to have me or whichever resident is on call paged. We can answer your questions, and are in a better position to do so than Bill."

"Okay. And you're an actual doctor, right?"

"Yes."

"Because Dr. Jones said some of the med students like to pretend they're doctors."

"Okay. I'm going to go have a talk with Dr. Jones. I'll come back and check on you a little later."

It's Free Diagnosis Friday. Put your symptoms in the comments and I'll tell you what you have.

I'm kidding.

But tell me what makes you most angry about doctors-- your doctor, any doctor-- because I'm curious, and maybe it'll inspire a post or two.

"The patient's completely unresponsive. She looks awake, but I've got the translator phone pressed up to her ear and she's not following any of my commands."

"So you think she's had a stroke?"

"I had the translator tell her to move her left arm-- nothing. Right arm-- nothing. Tell me her name-- nothing. Blink her eyes-- nothing. She doesn't even seem to be reacting to the words."

"So you want to get a neuro consult?"

"I think we have to. I already called up there. I'm just trying to decide if it makes sense to keep the translator on the line and keep trying, or just give it a rest until later. I'm not sure how easy it is to get a Mandarin translator on the phone after business hours."

"She speaks Cantonese."

"What?"

"Yeah, she doesn't speak Mandarin."

"So maybe that's why she isn't responding to commands?"

"I think it might be."

"Oh. Okay then."

Crazy Patient Newsflash:

Threatening to hurt yourself is not an effective strategy to get your doctor to do what you want.

"You get me that x-ray today, or I am going to leave this hospital. Right now. And there's nothing you can do to stop me."

"You give me methadone, or I am going to go back to drugs. And I am going to use more of them than I have ever used before."

"You write me a note excusing me from work, or I am going to stand in the middle of the street until a truck runs me down."

I consistently fail to understand the logic behind this tactic.

I don't care if you leave the hospital. In fact, I prefer you leave the hospital, because it means I have one less patient to worry about. I don't care if you use drugs. You shouldn't use drugs. But you're hurting yourself, not me. I don't even like you. If you want to stand in the middle of the street and let a truck run you down, go for it. Your choice.

Why do people think I am required to stop them from being stupid? Why do they think threatening to harm themselves is going to get me to break rules for them? The only thing that threatening to harm yourself can get you is a psych consult.

You're asking for things I can't do anyway. I don't control the CT schedule. I don't cook the hospital food. I don't give away narcotics to the highest bidder. I'm not going to lie to your boss for you. I'm not going to let you stay an extra day just for fun. I don't care if you sneak out the window and run far away-- and I have no idea why you think I do.

Some people seem to believe that they're doing us a favor by being in the hospital. That we grateful to have them there, and will bend over backwards to get them to stay. "I am not going to let you poke me with that needle anymore" is not an invitation for a discussion where I attempt to bribe you with non-diabetic meals in order to get you to consent. I will explain to you why I need to poke you with the needle. And if you still say no, guess what? I'm not going to poke you with the needle. We are not going to debate. You are not going to scream at me while I hold you down. It seems like that's what you want-- and I don't know why-- but it's not going to happen. You have the freedom to leave. I will not fight you, as much as you want to provoke me.

Is it that the hospital turns everyone into a child? I think that's part of it. Patients are scared. Often poorly informed about their own condition. Often upset and irritable. But I don't know the difference between the "no!" that means I will not consent to the biopsy and the "no!" that means I want you to explain to me again why I need it. I'll try, but it can't be my job to read your mind. It can't be my job to be your parent. It can't be my job to twist your arm to let me help you.

"You get me a charger for my cell phone or I'm going to rip this IV out of my arm and walk right out of here."

Bye!

"I just have to ask a few standard questions. Have you been tested for HIV?"

"I'm a priest!"

"I know. But it's not just about being sexually active. HIV can be spread through shared needles, bodily fluids... I have to ask."

"I have been tested for HIV."

"You're saying you have been tested--"

"Yes. It was negative."

"And you were tested because you've been... sexually active?"

"Shhhh. Yes."

"With men? Women? Both?"

"Both."

"Okay. Would you like us to test you again?"

"Yeah, sure, that's fine."

"Have you had any new partners recently?"

"Yes."

"Okay. And you came to the clinic for what reason today?"

"I was hoping to get some pain relievers."

"Is there a specific medicine you've been taking?"

"Morphine. But I ran out, so I've been buying it from other sources."

"You've been buying morphine?"

"Well, I've been buying heroin. But they're basically the same, right?"

"Sir, you really shouldn't be using heroin. Or having unprotected sex."

"There are a lot of things I shouldn't be doing. Are you going to give me the morphine, or do I have to go to a different clinic?"

"I think I need to talk to my attending."

Suddenly panicked in the middle of the night, woke up from a dream. Realized I forgot something. Called the resident covering my team overnight.

"Hey, sorry it's so late-- I just wanted to give you a call and let you know-- I forgot to put in the order for Mr. Jones to get a diabetic meal. Just figured I'd catch it before breakfast."

"Uh, Mr. Jones is dead."

"What? It had nothing to do with his diabetic meal, right?"

"Yeah, he choked to death."

"What??"

"Oh, I'm just kidding. Mr. Jones is fine. Go back to sleep, I'll put in the order."

"You sure he's fine?"

"No. I have no idea who he is. But that probably means he's fine, since I haven't been paged about it."

"Okay. Put in the order?"

"Yeah, no problem. See you in the morning."

"Yeah, have a good night."

[conversations with a germophobic intern]


"Oh my god! Does this patient have HIV? His blood is on my shoe!"

"You know you're not going to get HIV from blood on your shoe, right?"

"I just want to be extra safe."

"Then why are you working in a hospital?"

* * *

"Oh no-- I think the patient's peritoneal fluid got on my scrubs--"

"Okay, so get new scrubs from the machine."

"But what if it makes me sick?"

"Are you licking your scrubs?"

* * *

"That patient touched my arm."

"So?"

"She might have something."

"Everybody has something. Calm yourself."

* * *

"I should wear gloves, right?"

"You're writing in a chart."

"Yeah, but the patient is filthy and contagious."

"But his chart isn't."

* * *

"Did you take the HIV prophylactic drugs?"

"No-- I haven't had a needle stick."

"But just in case you do."

"Do you understand how medicine works?"

* * *

"You think I'm going to get this guy's cold?"

"Probably."

"How do I avoid it?"

"Drop out of residency."

* * *

"You think our attending wears gloves, right?"

"I assume so."

"Because he just touched my pen."

"Please stop."

* * *

"I can't believe you're eating that bagel."

"I bought it downstairs."

"But it's been in the hospital air."

"So have we."

* * *

"Can [the other intern] and I switch patients?"

"Why?"

"My guy looks extra contagious."

"Can we pretend we didn't just have this conversation?"

* * *

"Do you know where I can get a paper mask?"

"Why do you need a mask?"

"I was going to use the bathroom."

"I have no words."

Someone named Batman Light left a comment on a recent post:

I am currently a pre med student and I've spent some time shadowing and doing rounds as a volunteer in hospitals and all that. I think my biggest problem is going to be my patients. One of my shortcomings is that I am very impatient, especially with ignorant stupidity. How am I supposed to handle a situation like this? when I see patients like this I want to laugh and shake them until they realize how ridiculous they are being and actually doing themselves harm while I am just trying desperately to help them. ... Also from your other post- how are you supposed to help and advise someone who is hellbent on still taking cocaine if he had just suffered from a heart attack? I'm afraid that everything I think of doing/saying to these "wonderful" people will one day get me fired lol...

Mr. Batman,

One answer:

You have to remember that, in most cases, these are people who are scared, who may not be terribly well-educated, and who are trying their best. The lack of knowledge can be frustrating, absolutely. The difficulty of getting someone to understand that you're trying your best too, and that modern medicine may have ways to help them, and that they're only hurting themselves-- absolutely maddening. Balanced with the fact that no one has endless time or endless patience-- of course you want to scream. You do what you can do. In the end, it's up to them*. You explain things as best as you can, you tell them what you want to try and do for them, or what you think they need to do for themselves, at whatever level of detail you can get them to understand, you document everything, and you move on. You can get family members involved, explain things to them and let them take on some of the burden of convincing their father not to use cocaine if he doesn't want to kill himself. And then when the patient comes back three months later, in worse shape, you do your best again.

*Unless the attending decides it isn't, and you're going to biopsy that thing anyway, without consent. Yay!


Another answer:

Who's going to believe a crazy patient who says you shook them? Come on, you're a doctor, so think like one. Doctors are credible witnesses. Crazy patients who don't want to give you a urine sample because they're afraid they'll run out of urine are not credible witnesses. Do whatever you want, just don't do it in a room with a camera.

#notarealmemo

To: Residents
Re: Financial Crisis

Due to the recent turmoil in the financial markets, we would like to ask you to follow a few simple guidelines to ensure that we retain the flexibility to continue to pay your salaries:

1. If a patient needs one test, you may as well give him two. We're not saying you should wheel patients to CT unnecessarily, but if they're there anyway, you may as well stop on the way back for an MRI. Never hurts (us) to have more images.

2. We will be changing the standard blood protocol to once every twenty minutes. If you can't find a vein, keep trying.

3. "Oops, how did that sharp object get on the bed?" We will be distributing objects to place in the path of your patients. Should one of these objects accidentally become lodged inside a patient, of course we will have no choice but to perform a surgical procedure to remove it.

4. Automatic nightly discharges. Let's get everyone out of their beds and back in the ER each night, so we can readmit them by the morning. Shorter stays, but full beds. That's the game.

5. "Is he really dead?" Let's be completely sure. Don't be afraid to perform procedures when the patient is still in that transitional phase between life and death. We never really know what can happen, right?

6. Is someone still here because he has nowhere to go? Effective immediately, the parking lot in the back is going to serve as intermediate storage for patients awaiting placement. We already know they don't need a bed. Now, they don't need a roof either. Let's keep it moving.

7. There are worse things than a new-onset infection from contaminated medical supplies. Just keep that in the back of your mind.

8. We will be raising the television rate to $50/day. Inform your patients all television will be turned off unless they prepay by 5PM. Cash only. And, at this point, preferably foreign currency.

See you at tomorrow's morning meeting. Invisible doughnuts will be served.

"Hey, did you follow up on the patient's blood work?"

"Oh, I thought it was a lab error," said my intern.

"Um... what?"

"The numbers were crazy. I'd never seen numbers like that. I figured it was a mistake. That's why I didn't want to bother you."

"Did you re-run it?"

"No."

"Then how do you know it was a lab error?"

"Because he seems okay."

"And what if it's not a lab error?"

"I don't know. Then he's screwed."

"Exactly. So we need to act like it's possible the blood work wasn't a mistake. Which means re-running it, quickly, to check. And coming up with a plan in case it's not an error."

"But I don't know what to do if it's not a mistake."

"And that's why you're supposed to tell me instead of ignoring it and waiting for me to ask about it three hours later."

"Oh. So I should re-do the blood work?"

"Yes."

"And I should do that right away?"

"Yes."

"Before I eat lunch?"

"Yes."

"OK, sir, are you on any drugs?"

"Shhhh!"

"What?"

"I don't want anyone in here knowing any of my business."

"Sir, you're in the emergency room-- you had a heart attack. It's important for me to know what's been going on in your body. Do you use drugs?"

"Shhhh. What if the police hear me?"

"We are doctors, we're not policemen. I'm not asking you so I can arrest you. I'm asking because I want to help you."

"Okay, you can name drugs, and I'll stop you if you get to one I use."

"Sure... cocaine..."

"Stop."

"How much cocaine did you use?"

"Shhhh! Don't keep saying that."

"You're in the emergency room. No one's listening."

"I don't want these kinds of people knowing about my business."

"What kinds of people?"

"Sick people."

"You had a heart attack. If you keep using cocaine, you're going to die."

"Shhhh!"

"How much cocaine did you use?"

"Stop saying that word! Call it something else."

"Fine. How much turkey did you use?"

"Fifty dollars."

"How much cocaine?"

"You don't know how much is 50 dollars worth?"

"I have an idea, from other patients."

"How much are they paying?"

"It doesn't matter."

"No, tell me."

"You used one gram of... turkey?"

"No, I used two grams. See, I'm a businessman. I got a deal."

"Great. You need to stop using cocaine... uh, turkey."

"Sure. Just give me a prescription for something even better."

There's an article in this weekend's New York Times Magazine (link is here) about sleep-deprived residents and work hour limits. They've changed the rules for interns this year-- we used to be able to work 30 hours in a row-- now it's just 16 hours. (Of course, they've kept it at 30 for everyone who's not an intern-- so those of us supervising interns, who supposedly know a little bit more about what to do, and are actually the ones making the medical decisions-- we can still be just as exhausted as before.)

The article basically says that while it's probably good to limit work hours and not have exhausted, sleep-deprived doctors, it's only part of the problem, and just as important are making sure patient handoffs are done in a smart way, and care is coordinated between hospitals and outpatient providers so that everyone knows everything that is going on.

Can't really argue with any of that.

But here's my problem. There's already enough ammunition for doctors to accuse residents of having it too easy-- why give them more? This is the only topic of conversation any doctor out of residency can come up with when meeting a resident. "You guys have it so easy. Back in my day, we worked 168 hours a week and if we fell asleep, they shot us in the face! We also weren't allowed to wear gloves, and had to clean the hospital floor with our tongues."

I understand this happens in every industry-- the people from the past will always say they had it tougher. But at some point that can't be true. It didn't start out as 24 hour a day / 7 day a week shifts and just get easier and easier.

And-- I would argue that the problem isn't really the 30 hour shifts as much as it is the alternation between day schedule and night schedule. Sure, you can limit shifts to 16 hours-- but if you're coming in Monday morning at 7 and working until 11 at night-- then coming in for your next shift on Tuesday night at 7 and working until 11 Wednesday morning-- then back Thursday morning at 7 to do your 16 hours again-- you will be exhausted, confused, and no better than if you did 30 and then got 20 hours off to recuperate. The weekly max is still 80. Hospitals are going to get that 80 in however they can. You end up with more days off if you're working 27 hour shifts than if you can only work 16 at a time. You end up having to introduce a night float system if you didn't already have one. So you end up messing people's sleep up just as much, if not more. And where did they come up with 16? You work a 16 hour shift, you're not well-rested if you have to be back 8 hours later (and I think less than 10 hours between shifts is against the rules anyway).

I looked at a couple of the comments on the Times piece-- there were only 3 or 4 comments when I read the piece, there may be more now-- and it was doctors saying the limits are stupid because working so many hours as residents trained them to work those kinds of hours as attendings. Now, those are surgeons and specialists who do work those hours, and I suppose I can make the argument that they should be trained in how to do so-- although I'm not convinced that you can't ease people into long hours once they have expertise and knowledge, as opposed to forcing endless shifts on interns who don't know what they're doing yet-- but for the rest of us, who want to have normal lives and normal schedules when we're practicing, what's the justification for shifts that are more than 8 hours long, right?

The patient handoff argument never really made sense to me as a reason to have longer shifts, because you're just delaying the inevitable. Handoffs have to happen. They happen all the time. Patients are here for days and days and days. Whether there are 3 handoffs or 4 handoffs-- does that really make a difference?

Not to mention that if they really wanted to address the problem of doctors not knowing anything about their patients, they would ban the trading of shifts (which happens all the time, so people are subbing for people and have no idea who the patients are or what they need to be watching for) and they wouldn't allow hospitals to hire moonlighters to cover overnight.

"Hey, I was hoping to go to a lecture they're having tomorrow morning about intern responsibilities," said my intern.

"It should be fine, but I'd rather play it by ear, in case it's busy, or we're still doing rounds with the attending, and I need you on the floor."

"But I was really hoping to go to the lecture."

"Your first responsibility as an intern is to make sure your patients are being taken care of. I think the lecture should be fine, if nothing crazy is going on-- but I just want you to be prepared to skip it if you're needed here."

"They told us we should try and make the lecture."

"I'm not saying you can't go."

"I feel like we're still going to be rounding, or something's going to come up, unless you say I can absolutely go."

"I don't know why they're putting a lecture about intern responsibilities in the middle of attending rounds-- which are the intern's biggest responsibility of the day. I can give you a lecture about intern responsibilities whenever you want. I don't know what they're going to tell you that's more important than actually dealing with your patients."

"But I heard they're having sushi."

The comment thread on the previous post is more interesting than anything I can write today. I'll try again tomorrow.

(Or I can just quietly mention that I hear some people think psychiatrists might over-prescribe medication, and see if that gets a whole different debate started...)

"So I just checked on the test, and, sure enough... you're pregnant."

"Terrific."

"Great. I'm going to refer you to the OB service, and you can set up an appointment--"

"Oh, I'm not going to do that."

"Why not?"

"I don't want any doctors involved in this."

"In your pregnancy?"

"Yeah. I've heard stories."

"About doctors?"

"About people being injected with poison, people being cut open, babies being pulled out. I want to do everything like nature intended. I am not interested in a doctor being part of this. No offense to you."

"No offense taken, don't worry. But I think it's important to see an OB, even if you don't want to have an OB deliver the baby. They can take blood, monitor you to make sure everything is going okay--"

"No one's taking any blood from me, or from my baby. You people push this agenda to turn pregnancy into something medical."

"It's a medical event. I would just be concerned about making sure you're not taking on any additional risks for you or your baby, that's all. Unfortunately, not every pregnancy ends up as easy as we wish they all were. I'm not an expert, but we have some OBs who are very well-trained."

"People gave birth for thousands of years without doctors or ultrasounds."

"That's true. But, unfortunately, a lot of women and babies died in childbirth, and luckily we have the ability to identify risks now, and intervene where appropriate to save lives and provide for healthy babies."

"My baby is perfectly healthy."

"Odds are that's true. But a checkup and someone being able to monitor you along the way can help provide peace of mind and catch problems before they become dangerous."

"Doctors cause more problems than they solve."

"I know it may seem that way, but I don't believe that's true. I wouldn't have chosen this profession if I thought it was true."

"You don't deliver babies."

"That's right, I don't. But the people who do are very well-trained to do so."

"I don't want anyone touching me or my baby."

"I'm going to give you a referral to the OB clinic, and I hope you'll decide to make an appointment. No one's going to do anything, to you or your baby, without your permission."

"I want to have a water birth so my baby will grow up knowing how to swim."

"Please make an appointment with the clinic."

A commenter asked in the comments on the previous post about my reference to the lackluster state of medical education. I wasn't necessarily intending to make a serious point in the post, but, sure, I'll try. It's superficial. There are big topic areas that patients, especially in an outpatient clinic setting, expect their doctor to know something about, and medical school just doesn't touch them. Ophthalmology, dermatology, allergies, smaller specialties like that. There's elective time, but you still can't cover them all. And even the ones you do cover-- two weeks shadowing an ophthalmologist, who's mostly performing plastic surgery on the bags under rich people's eyes, doesn't really accomplish anything as far as adding useful knowledge. I don't necessarily have a solution-- more time learning one thing means less time learning something else-- and I know it's expected that interns (and residents) can't do things entirely on their own, and that's why there are attendings, and there's supervision, and checks in the system... and of course you get better over time and with more exposure to patients... but that doesn't mean you don't start out lost and mostly unprepared for the situations you're forced to deal with.

Hi [Intern],

Just wanted to send you a quick e-mail to say hello and introduce myself, and gain some goodwill before your life becomes far more depressing than you could ever imagine it would be and you lose all ability to interpret anything that happens in a positive way, including a friendly gesture from someone who's been there already.

I'll be your resident starting next Monday, as you embark on a month of eighty-hour weeks taking care of people who are hell-bent on making your job as difficult as possible and wish you would go away and die only slightly less than you wish the same for them.

I'm looking forward to meeting you, unless you're going to make my life even more difficult by showing up late, failing to pre-round, and ignoring simple commands that you should be more than qualified to execute but given what I've realized is the terrible state of medical education in this country-- including my own-- I know there's no guarantee you even know the difference between a live patient and a dead one, so as long as you're good at pretending to listen, that's probably as much as I can expect.

A few quick pieces of useful info to let you know how I like to run my teams, and how you should prepare for the start of the rotation:

1. I've never had a three-intern team before, so you're going to have to bear with me if I call you all by one name. Just assume I'm talking to you if I'm looking at you.

2. I will arrive at 7AM, which means 7:15. You should arrive to pre-round at 6:30, which means 5:45.

3. When pre-rounding, please remember to check if the patient is (a) still in the hospital, (b) alive, and (c) bleeding profusely from the head. I have had issues on previous rotations where the interns did not check these three things. They are important.

4. If you see a nurse giving your patient medication, please make sure it is actually that patient's medication and not gummy bears or Gobstoppers. The non-diabetics may have a limited number of gummy bears and Gobstoppers, but those are in addition to medication, not instead of.

5. Feel free to make evening plans as long as you know you will have to cancel them.

6. Let me put an end to any rumors you may have heard that the residents bring the interns breakfast after your overnight shifts. I don't care what kind of bagel you like. It will not be relevant.

7. Speaking from experience with a previous intern, please do not try and imitate the native language of a patient when they are within earshot. They know what you are doing.

8. Patient food is for patients, not interns.

9. Pain medication is for patients, not interns.

10. Sleeping is for patients, not interns.

I think we'll have an amazing month, full of tons of action-- if when I say action, you think of the kinds of things that happen in an action movie, like death and dismemberment.

Looking forward to greeting you next week with a pile of disorganized patient records that may or may not relate to the people in the hospital beds.

Best,
Your Resident (and Friend, sort of, maybe, probably not)