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July – It’s That Time of Year Again

It’s July.

It’s that time of year again.

Those involved in medical education — or just those that work at academic medical centers — know that this is the time of the year when brand new interns step into their roles as doctors.

Cue all the jokes about July being the worst time to be sick in a hospital.

During my chief resident year I was in charge of the first Journal Club session of the academic year. I assigned the residents an article about the July effect. You can find that article by here: Annals of Internal Medicine.

Jokes aside, I think the month of July is an exciting month to be involved in medical education. It’s a time of very new beginnings. As an attending physician supervising learners it is a time of heightened stress. However, I think it’s also a time of when you get to see new baby doc spread their wings for the very first time. This is the first time they are addressed as “Doctor.” These are the first orders they will write as a physician. This is the beginning of the rest of their professional careers.

The transition is defintely not always smooth-sailing. But it is definitely worth the trip.

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Doctor, Please Explain…

Recently I have been thinking about communication.

In my short career so far, I have realized that there is often a huge chasm between what we (physicians) think we have explained and what patients understand.

As a general rule, I try to take the time needed to talk to patients and answer all their questions. Sometimes I think I do an adequate job. And patients have voice appreciation for it before. I have been thanked for actually taking the time to explain my thought process and my plan. But I’m sure there are other times when I my question-answering leaves something to be desired.

Unfortunately, time is a luxury. Sometimes things get rushed. Sometimes there are patients who need more attention because of their condition so we spend a shorter amount of time talking to the more stable patient.

I’ve also had nurses tell me that they care for patients who ask them all sorts of questions about their medical care but when the physician comes in to see them, the patient either forgets or chooses not to pose the question to the physician. Sometimes they get overwhelmed. Sometimes they are intimidated. Nurses tell me that sometimes after the doctor leaves the room, the patients will ask their questions to the nurses.
Most of my work caring for patients involves residents/interns and medical students. I try to emphasize the need for clear and accurate information each time I work with a new group. Nevertheless, miscommunication happens. We aren’t perfect. We operate in a flawed and broken system that expects perfection and efficiency from medical providers.

If you’re reading this post, I’d love to hear about your experience as a patient. Are there still things that confuse you about that experience? Are there things that you wish your doctor had taken more time to explain? Are their topics or diseases that they sped through while talking to you? Do you wish they’d have slowed down and spoken in plain English? I want to know what the confusing topics are! I want to know where we, as a profession, fall short!

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Parenthood Thus Far

It’s now December. I went back to work in mid October after approximately 6 weeks without a shift. During those six weeks I had the occasional meeting to attend and other administrative responsibilities. But I had no 12 hour shift to fulfill. After feeling like I’ve been going non-stop throughout medical school and residency, it felt weird not to have any clinical duties for so long. At the same time, however, it wasn’t a vacation.

Prior to my 6 weeks off, I thought I would be able to stay at home, take care of the baby, and take time to read. I had hoped to have this time to catch up on much-needed reading. I soon learned that a newborn takes a lot of time. Despite both me and the wife being off work, we frequently found ourselves getting behind on things we had to do because, well, we were trying to keep this new creature alive.

During residency I had my share of on-call shifts that lasted over 24 hours. The newborn period soon came to feel like a prolonged call shift lasting days. Our nights were split into shifts where we would take turns taking the baby and making sure she was clean, dry, and fed.

We were lucky that Faith, our baby, was quick to take the breast or bottle. She wasn’t fussy and she didn’t need much coaxing to eat. But let me tell you, this little one can go from 0 to ‘hangry’ in no time at all. It’s as if she finally has the realization that, “Oh, I actually AM hungry.” This is usually followed by immediate wailing and crying.

They say that parenthood changes you. They say that having a child shifts your own priorities. I wonder how she shifts mine. I suppose only time will tell.

Oh well. It’s December. It’s baby’s first Christmas. And I will try to enjoy it while it lasts. In a few days the baby turns 4 months. I can’t believe it’s been 4 months already. It’s been crazy watching her grow so much in such a short period of time.

 

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Back To Work

I go back to work this week. It’s the first time I have been on a shift since mid August. My wife and I recently celebrated the birth of our first child, a baby girl. I was fortunate to be able to arrange my schedule in order to accomodate this time off.

It’s odd going back to work after a long time. Part of me welcomes going back. Part of me wants to hang out with this brand new, little human being.

They say that having children changes your priorities and perspectives.

Personally, I think its’ too early for me to say what, if anything, has changed.

Sure, I wish I could spend a ton of time with the little one. But I also have gotten antsy and wanted to get out of the house.

If it were an option or possiblity, I wonder how I would do being a stay-at-home dad/husband. I would probably have to be intentional about being active and doing things out in the community with the baby. Needless to say, I’ve got tons of respect for men and women who are full-time caregivers with their children at home.

We’ll see how it goes.

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About 3 Months Left

There’s about 3 months to go in this academic year.

That means I will be a Chief Resident for only another 3 months. My contract is coming to an end. The incoming Chief Residents have already been chosen and announced.

It some ways I feel like I know what a lame duck president must feel like.

The year has gone by faster than I could have anticipated. It’s been a period of satisfaction, personal & professional growth, and frustration. There have been ups and downs. Joys and disappointments.

My fellow residents who graduated from residency last year — well those who went on to work “real” jobs — have pulled in so much more money than I have this year. I’m sure they are enjoying the dough. Sure it is not has high as those surgical specialties. But it sure is a lot more than what I’ve been paid this year.

Still, I don’t regret it. Knowing what I do now, I would do it again.

There is a fraternity of sorts with former chief residents. And I’m proud to have joined those ranks.

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Attending Status

What’s in a title?

My ID badge now says “Attending Physician.”

I guess that’s my title now.

Last month I worked two hospitalist shifts. A week later I followed it up with 7 MOD shifts.

As a hospitalist I was responsible for my entire set of patients. I did get to work with one resident who was spending the month doing a hospitalist elective.

During the MOD shifts, I was the attending on one of our Internal Medicine teaching teams. I had a senior resident and two interns.

It is definitely a new feeling to have “the last say.” All my previous experiences on inpatient medicine had been as a resident. There were always things that I deferred to the attending. Like discharges home, for example.

As the attending, I had the final say. And it was a very different experience.

Serving as the attending on the teaching service was interesting as well. I remember frequently paging my senior residents to check in and make sure they did certain things. And as I did that, a light in my head turned on. I realized why I used to get several pages from attendings as they wanted to make sure I followed through on certain things.

When you have other people taking care of patients under your license and supervision, you start to pay attention.

Part of my job as a Chief Resident is doing a cetain number of MOD shifts. Seven shifts down. Looking forward this upcoming year. I have a lot to learn about medicine still. I have a lot to learn about teaching residents and students. I also have a lot of fun in store.

Stick around, dear reader. This should be a fun year.

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An “A” for Effort

We’ve all heard of getting an “A” for effort. At least it was an “A,” right?

But how meaningful is that grade if you still fail?

I remember a patient I shall refer to as David.

I didn’t know David very well at all. He was a patient in the Medical Intenstive Care Unit (MICU). He was not on my team. In fact, I didn’t really have a team. I was cross-covering the patients who were already admitted for a strech of 6 nights.

At the start of each shift, the primary team would hand me a list and “sign out” their patients to me. They would tell me about pertinent, active issues. They would also try and anticpate what could go wrong and let me know what to expect. Also, if there were any studies that were pending they would let me know if I had to check on the results.

David was one such patient. What I knew about him could be written down on just a portion of a full letter-sized paper. He had previously been diagnosed with cancer a little over a year ago. He had underwent treatment with surgeries and chemotherapy. During this visit to the hospital he came because of pain. As the ED completed their workup for the cause of the pain, they discovered he had a clot in his leg and multiple clots in his lungs. They also saw a large mass in his abdomen that appeared to be malignant.

In the ICU, the primary team was treating his multiple blood clots with a heparin infusion. Heparin is frequently referred to as a “blood-thinner.” It’s purpose, in this case was to prevent further clots from developing and to prevent the current clot from growing.

When patient’s have blood clots in their lungs (usually called a pulmonary embolism or PE) this is usually the treatment. However, if a patient becomes unstable (blood pressure or oxygen levels drop) there are more drastic treatments that can be attempted. One such treatment is thrombolytics. A thrombolytic is a medication whose purpose is to break down a clot. It is reserved for the unstable patients because they are quite risky. There is a risk for bleeding and one must always consider if a patient has any contraindications for this therapy.

On this particular night, David’s nurse called me. While he had been fine for the last day or so, he was now appearing very uncomfortable. His respiratory rate was increasing. His blood pressure was trending down. His oxygen levels were also trending down.

After spending a few minutes watching him, I made the call to Anesthesiology. I explained the situation and told them that I thought David would need to be intubated as he was in respiratory distress. Within minutes they were at the bedside and preparing to intubate.

Contacting the family was my next order of business. There was a daugther listed as the next of kin in his chart. My first call went to voicemail. I left a brief message asking for her to call me back.

Within a few minutes David’s daugther returned my call. She was understandably concerned. I had to explain what had happened. I then began asking some detailed questions about David’s medical history. I needed to know if he had any contraindications to thrombolytic therapy. The answers I got were reassuring. David was stable, though, after intubation and initiation of one vasopressor. We would wait until she arrived and we had a chance to speak in person before going forward with thrombolytic therapy.

In the meantime I would have to place a central venous line and an arterial line in order to continue administering medications and monitor his hemodynamics. In between these two procedures I found out that his hemoglobin was dropping. I had no obvious source of bleeding. My heart sank as I knew I could no longer use any thrombolytics. There was enough evidence to presume he had a bleed and I had no way to rule it out at that time.

An hour later, Tonya, her mother, and two other siblings arrived. They were ushered into the conference room. I gathered what little notes I had about David, took a breath, and walked into the room. I made sure to hand off my hospital handset to the Charge Nurse so that we wouldn’t be interrupted unless absolutely necessary. She would screen the calls.

The family took in the grave prognosis with great composure. I explained that I could only support him temporarily. I could not treat the clots with thrombolytics. I could no longer treat his clots with heparin either. I could only place a band-aids. But considering the clinical picture, I expressed my doubts that David would survive into the following day.

David’s wife, though, seemed to persist on telling me what happened throughout his battle with cancer. I tried to politely tell her that we needed to address the issues at hand — not his constipation or abdominal pain that he experienced a year ago after the initial diagnosis and treatment. I couldn’t tell if this was her way of coping. As I allowed her to continue re-telling the events of last year, I looked at each of David’s grown children. They knew what was happening. They seemed to just want to let their mother go through this in her own way, though.

By the end of my shift David would eventually need 5 different vasopressors concurrently. He was maxed out on the ventilator. He had received over 3 liters of fluids and 4 units of blood. I knew it was only a matter of time. I had done everything I could. David died before I came in for my next shift 10 hours later.

There are times in the hospital when doing everything you can — when doing your best — is just not enough.

And those times suck.

Period.