Update on sign out

OK, now that I've got some more experience on my belt. I gotta say that sign outs really aren't that bad. First, every morning the entire team rounds on every patient on the service, so even though I'm not managing every patient, the fact that I may be responsible for the patient at some other time gives me incentive to pay close attention. The fact that I have that incentive to pay attention has the added benefit of learning about a patients condition without doing all the busy work. The second reason why sign outs aren't that bad is that we're all getting better at effectively presenting patients to each other and writing effective notes. This is a skill that takes some time, but each week it gets better and better. So, now I'm willing to say that shorter hours and more sign outs (in the long run) is better for patients and residents than an overtired resident managing patients. Numerous studies have shown that sleep deprivation severely affects cognitive performance. So, I'd rather have fresh residents who need to spend some time getting to know patients versus an overtired, cognitively impaired one that knows their patient really well.

Signing Out

With the new work-hour rules for medical interns, the ICU is no longer a place where every 4 days an intern spends 30+ hours in the hospital. I'm glad for the rules. 12-18 hour days are bad enough. However, what it leads to is a lot of passing patients from one resident to another, which, in turn, leads to a general lack of ownership of a patient. It used to be that you admitted your patient to the ICU and for the next 20-30 hours, stabilized them and figured out what was wrong with them. You knew their history inside-out and knew how to manage them and what to look out for. Now, you may admit a patient, but 6 hours later, you've signed the patient out to the next intern. The sign-out is a five minute conversation relating the patients history, status and what to anticipate. The receiving intern know very little about the details of the patient and has to essentially start over. This leads to lots of information falling through the cracks. I recently got handed a patient that had been in the ICU for several days. He was stable enough to be transferred, which meant, I write out the discharge paperwork. Since I didn't know the patient, all of it is based on previous notes. I have to trust that those notes are completely accurate and thorough enough or something important about the patient could be missed. Unfortunately, many notes are neither completely accurate nor completely thorough.

It's a choice between having overtired residents who are prone to make mistakes or this. I'm not sure which is better.

The ICU

So, I finally get a day off from the ICU today. It's not bad, but there have been a few situations where I felt like I was biting more than I could chew. This is the place where the sickest patients go. It's pretty scary to be playing doctor with people who are just barely hanging on to life. Just a few hours ago, a patient of mine passed away. He crashed in front of my eyes and I can't help but look back at every order I made (or didn't make) to see if it could have been prevented. What's worse is that I can find things that really could have caused him to crash. I suppose this is the reason why the learning curve is so steep. If you don't pick it up quick, lives will be lost.

The fact that I, as someone who hasn't had any meaningful responsibility in a hospital, suddenly am seen by others (patients, nurses, family members) as an expert whose every wish will be carried out (if it's correctly entered in the computer) is terrifying. What's worse is that there never has to be a backup. Yes, there are other interns, residents and attendings, but there is a lot of on-the-spot decision-making that falls on me. Most of it is harmless, but there are times (especially at night) that it can irreversibly affect a patient's health. There are many orders I've put in that I am not confident of (or as a fellow intern said about an order a nurse suggested to her, "I don't know what it was, but I ordered it"). Things go very quickly, there's high patient turnover, and people die (signing your first death certificate is a pretty strange feeling).

I've only worked in the ICU for 7 days, but it's felt like a month. It's an experience where you learn a lot, but it wears you down. I'm glad I'm getting the experience, but I know it's not for me.

Lost in the ICU

Talk about getting slammed! Working in the ICU doesn't leave much time for anything else. I should have known that when a fellow intern said that I should take care of all my bills before starting the rotation. I will try to have an update sometime soon.

Frustrating Patients

My attending and I have a pretty good relationship. Good enough that we can have a back and forth about politics (typically a no-no in the world of medical education and "professionalism"). He tends to point out my leftist tendencies and I point out his right-winged nuttiness. After 3 weeks of working in his clinic, which serves a rather impoverished part of the state, I can see his point of view.

Nearly half his patients have their healthcare covered by the state. This is great, but it seems like those same patients tend to do the worst at taking care of themselves. I don't mean eating right and exercising. I could understand if they didn't have the resources to do that. I mean they ignore doctor recommendations, then get an exacerbation of their disease, get admitted and have a hospital work-up that costs tens of thousands of dollars, get better, then go back and ignore every recommendation made to them. It's frustrating for a physician when a patient who is unemployed (and has no trouble with transport or any responsibilities at home) misses important appointments repeatedly or a patient who has all their medications paid for not taking them. Yes, some patients with good insurance also fall into this pattern, but from my admittedly short experience so far, it's a nearly universal pattern with those that are under the public health plan (and my attending agrees). One assumption I could make is that they have trouble following recommendations because they have a lot of other problems in their lives, but it's hard to tell if that's the case.

No, fear not dear readers (both of you), I'm not becoming a Republican (though my attending keeps on telling me that it's a matter of time). Rather, I think that there needs to be a shift in healthcare resources. Covering expensive medications and procedures is great, but I'd rather give those up for increased education of patients and more access to social workers. Preventative care looks great on paper, but in the real world, it only goes as far as patients know to take it.

Refill on the Vics

So two weeks into a non-academic community setting, I've learned what the real world is like. I'm not so surprised by fact that there are a lot of patients who are addicted to narcotics. I'm more surprised by how there are so many doctors that are feeding their addiction. It's so easy for a patient to find a doctor that will prescribe them some heavy-duty narcotics without too many questions that things that I learned in med school like counseling, pain contracts and limiting refills just plain doesn't work. If legitimate doctors to try to manage their patients' chronic pain without overly relying on narcotics they risk losing the patient and likely the patient's other chronic medical conditions won't be taken care of. Or, they can just write the refill to bring them back and make sure that they have their diabetes, high cholesterol, heart disease, asthma, etc. under control. It's a hard decision to make, but many of the patients in this area just won't see a doctor unless they need their pain meds refilled.

Slow Start

So, I'm officially a doctor. July 1st was supposed to be a mind-numbing experience where I get thrown into the medical system, overwhelmed with things to do and actually get to feel like I'm making a difference in people's lives. Unfortunately, I feel like I've gone back a few years. I start with a primary care rotation. Primary care is not my thing, but I can appreciate the value of health maintenance and getting to know patients and I was looking forward to actually acting like a primary care doctor. To my surprise, I find out that all I do is shadow a physician while he sees his patients. It's worse than 3rd year. At least then I got to see patients beforehand. The clinic I'm at doesn't have electronic records, so I can't even read about the patients. I go in not knowing what's going on and about 30 seconds later come out not knowing what happened. The physician knows his patients and doesn't really need to go into the details that I would have needed in order to diagnose and treat (actually, I'm a little wary of how quickly he goes through patients). It's a complete waste of time. All I can say is that at least I get paid for it.