Rules and Regulations: Is Cover-Your-Ass Medicine Devaluing Healthcare?

Today was the day I realized I will have to go into family medicine. Not because I loathe internal medicine (quite the opposite--I have loved almost every day of this clerkship) but because I cannot work inside a hospital. There are many terrible things about hospitals. They are full of sick people. And because they are full of sick people they are always full of the things that accompany sick people in societies both full of resources and those that reside in the third world: the smell of disinfectant mixed with the odor of bodily excrement--almost unavoidable if you spend a day walking around on the floors; the screams... the tortured moans of patient's suffering either from a psychiatric issue (although who wouldn't be driven insane by being locked up in a hospital room for days?) or a pressing physical complaint? (I don't imagine a leg ulcer infested with maggots* can be purified without any amount of pain).

But, unfortunately... well, unfortunate for those people who find themselves confined to hospitals, and also for those people like me who have the option of working in one... the worst thing about hospitals isn't the patients or their illnesses. The worst thing about hospitals are their dumb-@$% rules.

I have a patient. He is my only patient. He is my favorite patient. He is super old and he has borderline dementia.... he reminds me of my father and so I try to be super nice to him because he, like my father in about a decade, deserves the best.

One of the things that is really hard to deal with while working as a pretend internist is how old and close to death so many of our patients are. In surgery, all of our patients had to be surgical candidates, and to be a surgical candidate you have to be able to withstand general anesthesia and someone poking around your insides. This is not so with internal medicine. Hell... one of our team's patients died the other day.

SIDE NOTE: I think surgeon's fear death way more than other physicians. While m&m's (morbidity and mortality) presentations for internal medicine (IM) are relatively tame and emotionally controlled, surgery m&m's seem to be intensely discussed, with the accusations of "who-to-blame" are hotly debated. I think this is a result of surgeon's wanting to, one some level, think of themselves as able to prevent death in their patients. I think this also makes much more timid, surprisingly, when it comes to patient care. I called both of my parents today (remember: both of my parents are surgeons) to ask them what they would have done with one of our patients: patient is an 84 year old man, with a past medical history significant for hypertension, diabetes, and two previous strokes, who was admitted to the hospital 7 days ago with slurred speech and left sided facial weakness suggestive of acute, focal cerebral ischemia, with brain CT and MRI also suggesting stroke, who know, the day before being cleared for discharge, has spiked a WBC count. Both of my parents said he should stay in the hospital. True, you should find the source of his infection. But we could almost be sure what the infection was... couldn't we just treat him for that and send him on his way? The extra care my parents seemed willing to offer might have simply been an artifact from how much more surgeons have to pay in medical malpractice. OR, they could simply hate seeing patients die from something so insidious and so simple as an infection. 

Where was I...? Yes, the incredibly stupid rules. And I'm not complaining about stupid seeming rules that are set up for the purpose of patient safety. For example, this patient, with his borderline dementia, was put on high fall precautions... essentially, he was strapped to his bed by soft handcuffs, which are called "soft restraints" in medical jargon. I understand this rule--if he falls out of bed he could easily die--although it is terrifying to think of fading in and out of orientation to a world in which you are permanently tied up against your will. No. I hate rules like the one that requires the next of kin to physically enter the hospital to sign cover-your-ass paperwork when the patient isn't at full decisional capacity. And even though a lot of terrible malpractice cases, a lot of morbidity, and a lot of mortality have arisen from the fact that things weren't explained well enough to the patient, there are some procedures that are so non-lethal it really doesn't make sense to require the patient's family member(s) to come in. Some people are busy. Most people are busy. Even I never get a weekday off work... if I was told I had to go to the hospital on a Wednesday to fill something out so that my parents could get discharged... I'd probably still take until the weekend to scrounge up enough time to liberate my parents. Doctors know what's best for the patient. We shouldn't have to explain to the patient how the procedure is done, what risks are involved... if the risks are minimal enough.

I know, I know: that wreaks of paternalism. But in all honesty, what we do now is highly inefficient. If I become an internal medicine resident, I'm going to spend my intern year writing down all the times money and/or time was wasted because we had to get paperwork down before patients could get what they needed and leave the hospital as soon as possible. Some patients love staying in the hospital... most patients don't. All doctors want to see their patients get back to baseline so that they can be discharged. But I don't think enough doctors want to put in the time necessary for analyzing why these rules and regulations are often detrimental.

Or maybe we just don't have the time. After all, I rarely see doctors taking off weekdays.

*yes. there were actual maggots in this patient's room. there were actual maggots under her skin. however, when they were finally discovered and the wound care nurse and her assistants were telling everyone outside the room about their findings within, I did not--in that moment--have enough courage to walk inside and look that hollering woman in her face while examining her wounds. I was not brave enough to examine and deduce what exact parts of her scabbed up wounds were flesh and blood and what were maggots.

So this is emergent care?

My teammate and I were sitting on the plethora of abandoned chairs in the emergency room. It was an odd time of the day for people to show up--right around lunch time--and it wasn't the right weather: too cold to be outside and accidentally or intentionally get hurt. Yet there were still patients in about half of the rooms, and because we were on call, all those patients who could be deemed fit for admission had to be processed by us. While we had been interviewing a man with suprapubic pain suspicious for bladder cancer, nearly continuous screams were emanating from a female patient nearby, drowning out the sounds of televisions, beeping monitors, and phone calls. I've been getting better and better at ignoring people screaming in hospitals. But this woman was loud and persistent and every once in a while I could hear the crashing of equipment or cheap furniture, and I'd wonder why a code hadn't been called yet or why nobody had tried to administer drugs.

I was incredibly saddened that the screaming had stopped--it is secretly my dream to rush in to help with a "Paging Dr. Strong" or "Code Grey" (combative patient/person). Alas, today was not going to be that day. Our intern had disappeared again so we had little to do except periodically check up on our patients through their electronic medical records. And then... an Emergency Medicine resident swept by and without hardly stopping asked: "You medical students?" "Yea," we both answered. "I need one of you to follow me." I started asking why as my friend was already standing up to follow him--she is way more instinctively helpful than I am. "To chaperone." Only as they were entering one of the private rooms did I kind of understand. Female patient. Delicate issues. Male doctors needed a female in the room. How obnoxious and unnecessary. So this is where politically correctness was taking us, that male doctors were no longer trusted enough to perform gyne check-ups without female supervision. 

Shortly thereafter, I was pulled away by one of the resident's on my internal medicine team to help out with ABG draws and paper work and phone calls. Eventually my teammate pages me.

"Hi Elora. It's Rebecca. Where are you?"

"The residence room. Why?"

"Okay. I need to tell you something. Will you be in the residence room for long?"

I looked at my computer screen, at the list of patients who were awaiting results of labs and imaging.

"Yea I'll be here."

to be continued. 

Internal Medicine Clerkship (Entry 1: First Impression)

So now I'm starting the third week of my internal medicine rotation, and I am loving it. These residents are significantly nicer than the surgery ones (although most of the surgery residents were definitely good human beings), and because of that, I feel like I'm getting more out of the rotation. Basically, I feel forced to learn and study on my own because not looking something up would make my residents disappointed in me and that would break my heart.
Speaking of hearts, and as an example of the previous statement made above, I finally understand EKGs. It's still very difficult for me to determine what the exact diagnosis is, but considering before I could only get rate, I think it's a step in the right direction. Maybe by the end of this rotation I'll feel and sound intelligent! The only drawback--but it's not that bad--is there's a lot of scut work. A lot of using pagers and calling people and talking to nurses, or social workers, or consultation services.
Speaking of scut work, today I was trying to decipher a note, but it was using an abbreviation I didn't know so I sent an e-mail to my surgeon dad to see if he knew what it was (I could of more easily used dr. google, but I like to keep my dad informed of my learning).

ELORA: "Hey dad! Does PCI stand for percutaneous catheter intervention? Thanks!"
FATHER: "I am not sure. That is why acronyms are not welcome in medical practice. It does make sense that PCI stands for percutaneous catheter insertion. It could also stand for pulmonary catheter insertion or pulsatile cardiac imaging. The message is TRY NOT TO USE ACRONYMS unless you are with friends, who cannot judge you. Dad."

Virtues in Medicine

It was a dark gray day in late summer. No rain. Just cold, northern air that had brushed across my face as I walked from the "L" train stop to the hospital. It was 5 in the morning. This was surgery. You had to come early so you could pre-round, and pre-rounding was something I didn't enjoy. But I did it anyway because talking to patients about frivolous matters was better than getting yelled at for incomplete notes. "Have you been going to the bathroom?" "Are you eating alright?" "Have you been walking?" Waking up anyone else to ask questions like this would be insane. But after you've been operated on, you hand over your rights to interesting conversations and get to be awoken at any time for a barrage of inconsequentiality. My reasoning was simple: the surgeons seem to think these questions matter a lot, so I asked them.

Then we round. I enjoy rounding because I get to cross my arms behind my back and walk around the hospital quickly and quietly with my fellow medical students, a flock of baby ducks following behind residents. It is generally peaceful. Today it wasn't. Today we went to see a patient who has some form of nasty infection in her leg. How nasty? Well, surgery residents are highly sarcastic. But if they weren't flat out lying in the residents' room during sign-out, well then... this patient could possibly die from this infection. The solution? She needed her leg amputated. Late last night, during her admission, she had signed a consent form okay-ing the procedure. Now as we saw her, she was resisting. She wasn't going to lose her leg. A soft-spoken but snarky, sixty-something year old woman--this patient was refusing the operation for some reason. As a human being I could see the resistance in her face. I knew there was more to the story.

But the resident just asked the same old, stupid, inconsequential questions. And the wall separating us, hidden underneath white coats, and the patient, sickly and exposed behind a cheap hospital gown, shot right up. The rounding team left. Notes for the intern: send the patient over to internal medicine. Get them to deal with her.

After rounding, everyone disappears into operating suites. I stayed behind on the floors. And I went back to that old lady's room. I left my white coat at the nursing station, and I went and reintroduced myself to this woman. I broke the silence with some silly, history taking questions: "What brings you in?" "Where does it hurt?" Then I asked the question that nobody had asked because nobody took the time to connect with this patient. "Why don't you want to lose your leg?" Followed shortly by, to get around the wall, "Why don't you want to lose your leg, really?"

And everything spilled out. This patient's history of present illness, but what it really was, not with transformative language but with a story anybody but these surgeons could understand: Recently widowed, fifty pack year smoking history, mismanaged diabetes, shame at being in the hospital again, too embarrassed to call her only living relative, her son, to tell him that she might be dying, because what would he say, "Mom, why didn't you listen to me? You've got to take your medicine. You've got to stop smoking."

It's regrettable nobody took the time to figure out why this woman was refusing treatment. It only took a smile, friendliness, and fifteen minutes of my time.

"You should call your son. Tell him what's going on. And you should get this surgery." I had told her. And she did both of those things. The next time I saw her she was missing a leg. But she smiled when I walked into her room to pre-round on her.

Clerkship

I hate my life.

But first, let's focus on the positives:

• During my last entry, I had decided (although not revealed) that I was going to push my step one test date back 10 days to June 11th. Good news, I passed. 
• I am now almost entirely moved into my downtown apartment. My room is still full of random stuff and I still don't have a well stocked fridge, but I know the area pretty well now and every weekend I go to the beach (within walking distance) with my friends. 

Okay, now on to clerkships.

I started with Surgery. At Lutheran. Widely rumored to be the toughest place to do a surgery rotation. Results are in: I hate it even though I love how much I'm learning and how much I'm doing everyday. In the last two-and-a-half weeks I have cried six times, every single time because of surgery. I am a mess. And I finally know exactly why so I'll tell you:

Being a third year medical student on rotations is like being a middle child: no one likes you and no one pays attention to you so you might as well die. 

If we were to compare the classical hierarchy of teaching hospitals to a nuclear American family circa 1950, the Attendings would be your parents, your older sibling is the residents, medical students are the middle child, and depending on group dynamics, the role of younger sibling is played by either medical students who are great at sucking up and being professional or interns. 

Attendings are the people you want to be like. They are your role models. Sometimes you hate them, but most of the time you love/respect them. They may make you upset because they yell at you and occasionally call you dumb, but eventually you realize they are right about almost everything. 

Residents are your older sibling. But there are a lot of different ways older siblings can act:

-We're in this together: Life is hard. But with any luck, your older sibling likes you and wants you to succeed. This sibling gets extra points if they know how to succeed. Residents can be good role models, just like attendings, but they can also be terrible influences. And as a young med student, you can't really know what's right or what's wrong yet. So you just pray these people are good influences.

-Too cool for you: Okay, you can't really blame someone for this, and to be honest, medical students are dorks. So...

-Constantly antagonistic: For some unknown reason, most likely being they are still bitter about that you took attention away from them (i.e., your birth), they hate you. They would never say that. But if they can, they will make you look bad. For fun. Because, to sum it all up, the world is cruel and if seeing someone else suffers helps you get through your shift, then someone's going to suffer. 

Essentially, residents will determine how you feel about yourself day after day. Your parents may be important to you, but sometimes, they just don't understand. If a resident physician tells you that you did something well, then you feel pretty cool and competent. Otherwise you're just a useless person who know one pays any attention to.

Finally, there are the suck-up med students, the little sibling who really just makes you feel worthless. Everyone is so much nicer to them for reasons you cannot completely elucidate. They are even nice to you--but only some times. At other times they are totally working the angle so they get more assignments. Everyone wants to be around them... nobody wants to be around you. 

Anyway, I'll probably post up something less... emotional, more analytical later. But right now, an hour past my bedtime, I'm genuinely shocked that I haven't quit yet. 

More good news I guess.