So Thanksgiving has arrived and I have much to be thankful for. I have a beautiful family that I helped to build and an amazing wife who built it with me. I have a job I am passionate about and look forward to every day, even if my 2 year old's 6am wakeup makes me curse the gods of sleeplessness. I have a home that feels like home.
But I am also thankful for some other, less spoken things. I am Thankful for my attendings who have the grey hairs and years of knowledge and time and patience to have taught me everything I know about medicine. I am thankful for the patients who have done just as much teaching without trying. I am thankful for my health- something no one in my profession takes for granted.
I've been thinking, these days, about decisions and patience. A good decision can take years to pay off, but when it does there is no better feeling than the wait. Medicine feels like a good decision to me, and 9 years into the career, still in training but near the end of the tunnel, I know how grateful I will be for the decision to be on this crazy path. The truth is, I watch people every day suffer from bad decisions. Some of those decisions are made just beforehand- like not showing up to the ICU as a loved one dies, then feeling guilt in the final hour when the visit is finally made. But most of the decisions I see patients suffer from are ones made years before- like sleeping with a prostitute in Southeast Asia and contracting Hepatitis C, or using IV Heroin and ruining many lives along the way only to be left a shell of the person who once was, or not telling children about a cancer and watching their rage and helplessness as they find out with only weeks left to live. I have witnessed all of those scenarios and more.
We are a society fixating on instant gratification. It seems as though many people have lost sight of the patience our parents and grandparents exhibited when they worked long, hard hours at jobs that may not have "thrilled" them every day but in the end paved the roads and lit the lights of the 1950's American dream. My grandfather, for one, snuck out of Russia on a hay wagon, crossed the Atlantic and worked odd jobs for his entire life. He wasn't the dad of the year, but his son, my father, was a graduate-degree-educated success. My mother's parents worked odd jobs as well- her dad sold cigarettes door to door back in an age when such jobs were real. And out of the ghetto my mom came, and a successful career followed. The point is, my parents are a common 2nd generation story, which followed on the heels of long-term 1st generation thinking.
On this Thanksgiving I ask you all to be as thankful as I am for what is good and think equally hard about how to make decisions that are worth waiting for.
Wednesday, November 25, 2009
Tuesday, November 3, 2009
Wanted
So this week I'm attending a course on clinical investigation, something I am actively engaged in for the later 2 years of my fellowship. Lectures on medical ethics, statistics, study design and patient confidentiality are among the many topics I am engaging in. It is a course run by Harvard and the course is under the heading of a new umbrella called "The Catalyst" which is a new way of building the future of science and medicine.
In 2009, Harvard, and other academic institutions have recognized that the ideal product of their investment in training is a doctor or PhD who 1) stays at the institution 2) contributes more than their salary to the institution and 3) furthers the prestige of the institution. In order to carry this out, they are investing in fostering training across specialties and levels in fundamentals of research. The truth is, research drives the money boat for any academic medical center. The "ideal" faculty bring in NIH or other source grant money in much larger dollar values than his or her salary. He or she works for a salary of $125,000 a year at most for several years as the career builds. In the long-term, those lucky enough to develop a drug or get millions of dollars of NIH grant funds become department heads. But most flounder at low salaries for years in someone else's lab and eventually fail (there is less and less money) and go into private practice or industry). Of all of the small molecules investigated as possible drugs, only 15-20% ever make it to trial and far fewer become usable, and profitable.
So as I sit here I think: Why would anyone engage in this long endeavor? For one, there is the prestige factor. Harvard is better than most at relying on this factor. Who doesn't want to be among the "who's who" of Boston doctors. Who doesn't want to be the Chair of Cardiology (or any field) at a Harvard hospital? But those elder statesmen who have set up Catalyst have overlooked a few key items in 2009:
1) Cost of living. While $100,000 (the average starting salary for a Harvard investigator with an MD or PhD) may seem like a lot of money, in Boston or other large cities, this is not a big salary. Lawyers one year out of Harvard Law average $140,000. MBAs in their first year average the same salary. So why would a doctor, after 4 years of medical school, 2-4 years of residency and an additional 1-3 years of fellowship work for $100,000? It simply doesn't make financial sense unless you are independently wealthy. In fact, at the program where I complete my residency, I was asked by the Chair of GI how much loan debt I was in. At the time I thought nothing of it, and only now realize that my honest answer put me lower on the list: I am not rich enough to afford to be a clinical investigator in Boston without a struggle. My wife is a teacher. We need my income to support our family. $120,000 or so won't cut it if we want to buy a home, send the kids to camp- have a decent life.
2) Years of training. In 1965, residency was 2 years and fellowships were optional. To specialize, several of today's department chairs simply did a year or so of work in the field of their choice. Younger chairs (50+) in GI did a one year fellowship in the 70s. Then residency became 3 years. Then fellowships like GI and Cardiology became 2 years and finally 3. (There is now a push for 4!). The argument the grey hairs make is that the knowledge is too overwhelming to learn in 3 years. The truth: fellows at academic centers like myself are being asked to devote 80% of our time to research in our 2nd and 3rd years. They are grooming me to be a clinical investigator. And yes, I signed up willingly to an academic program, mostly for the training experience, knowing what I know now (and there are more clinical programs out there- not at Harvard.) Regardless, 3 and soon 4 years of post residency training puts the total number of post college years at 10 (14 including college). I am in year 9. That's a lot to ask of anyone at any age. Perhaps for someone who goes straight into med school from college, 32 isn't too old to launch. Perhaps that 32 year old can even afford the $100,000-$120,000 for 5+ years before they make it or fail ("making it" is $150,000, not $400,000 by the way- to make the big bucks there's an additional 20 years until you are professor at Harvard). But at 37, someone like myself will finish fellowship ready to have a career, not start one.
3) Grant money is disappearing: As we engage in a war a week, and fix our roads, and insure everyone (even immigrants), tax money is being allocated everywhere but to research. Bill Clinton expanded the National Institute of Health like no one else and remains a hero to many investigators. George Bush undid that, bankrupted our country with a one way ticket on the Halliburton express, and now science is struggling with anemic funds. The percent of new K awards applications, the grants awarded to young investigators like myself, funded in 1990 was 40 or so. Last year it was 18. There is no money to support people like myself even if we do everything right. And those with K awards then need to secure the R awards (million dollar plus grants from the NIH) for "job security" and the competition becomes every chairman in every division in America with 30+ years of experience. Even with ideas that seem cutting edge and important, there isn't money right now for growth in science.
So is the Catalyst doomed? Well, most investigators don't share my view. Many are spirited and engaged and buy into the "low salary, earn it yourself" mentality that this career requires. Many don't have my perspective on what used to be, and focus on what is (probably a healthier and happier way to live!) And many aren't as old as I am, with families to feed on their salaries. But I worry for these people when they turn 35. 5 or 10 years into this research career, will they be happy? I have grown accustomed to seeing people at Harvard with blinders on. Some are barely English speaking folks who are grateful to have work in the US on visas which require them to work at academic centers. Others are Americans who think that they will beat the odds. It's kind of like playing the stock market- no one knows where this will head, where funding will be in several years- and ideas are exciting and young investigators are invigorated.
Regardless, I see a propaganda machine, one that is spinning out joint MD/PhDs from medical schools (yes, many extra years of training and cheap research labor) and labeling them as "future department heads." In truth, there are only so many departments. I look forward to the data in 30 years from Catalyst. The idea is brilliant- getting us trained together, interacting with one another, cross specialty, calling us "translational researchers"- but in the end, how many people will live their lives in labs that other people benefit from. How many young brilliant doctors won't treat patients, but will inject mice instead with 80% of their time.
The academic institutions say we need them. And we do. But we also need our best minds in the clinic, where I am heading in a year, when I get out of this cage.
In 2009, Harvard, and other academic institutions have recognized that the ideal product of their investment in training is a doctor or PhD who 1) stays at the institution 2) contributes more than their salary to the institution and 3) furthers the prestige of the institution. In order to carry this out, they are investing in fostering training across specialties and levels in fundamentals of research. The truth is, research drives the money boat for any academic medical center. The "ideal" faculty bring in NIH or other source grant money in much larger dollar values than his or her salary. He or she works for a salary of $125,000 a year at most for several years as the career builds. In the long-term, those lucky enough to develop a drug or get millions of dollars of NIH grant funds become department heads. But most flounder at low salaries for years in someone else's lab and eventually fail (there is less and less money) and go into private practice or industry). Of all of the small molecules investigated as possible drugs, only 15-20% ever make it to trial and far fewer become usable, and profitable.
So as I sit here I think: Why would anyone engage in this long endeavor? For one, there is the prestige factor. Harvard is better than most at relying on this factor. Who doesn't want to be among the "who's who" of Boston doctors. Who doesn't want to be the Chair of Cardiology (or any field) at a Harvard hospital? But those elder statesmen who have set up Catalyst have overlooked a few key items in 2009:
1) Cost of living. While $100,000 (the average starting salary for a Harvard investigator with an MD or PhD) may seem like a lot of money, in Boston or other large cities, this is not a big salary. Lawyers one year out of Harvard Law average $140,000. MBAs in their first year average the same salary. So why would a doctor, after 4 years of medical school, 2-4 years of residency and an additional 1-3 years of fellowship work for $100,000? It simply doesn't make financial sense unless you are independently wealthy. In fact, at the program where I complete my residency, I was asked by the Chair of GI how much loan debt I was in. At the time I thought nothing of it, and only now realize that my honest answer put me lower on the list: I am not rich enough to afford to be a clinical investigator in Boston without a struggle. My wife is a teacher. We need my income to support our family. $120,000 or so won't cut it if we want to buy a home, send the kids to camp- have a decent life.
2) Years of training. In 1965, residency was 2 years and fellowships were optional. To specialize, several of today's department chairs simply did a year or so of work in the field of their choice. Younger chairs (50+) in GI did a one year fellowship in the 70s. Then residency became 3 years. Then fellowships like GI and Cardiology became 2 years and finally 3. (There is now a push for 4!). The argument the grey hairs make is that the knowledge is too overwhelming to learn in 3 years. The truth: fellows at academic centers like myself are being asked to devote 80% of our time to research in our 2nd and 3rd years. They are grooming me to be a clinical investigator. And yes, I signed up willingly to an academic program, mostly for the training experience, knowing what I know now (and there are more clinical programs out there- not at Harvard.) Regardless, 3 and soon 4 years of post residency training puts the total number of post college years at 10 (14 including college). I am in year 9. That's a lot to ask of anyone at any age. Perhaps for someone who goes straight into med school from college, 32 isn't too old to launch. Perhaps that 32 year old can even afford the $100,000-$120,000 for 5+ years before they make it or fail ("making it" is $150,000, not $400,000 by the way- to make the big bucks there's an additional 20 years until you are professor at Harvard). But at 37, someone like myself will finish fellowship ready to have a career, not start one.
3) Grant money is disappearing: As we engage in a war a week, and fix our roads, and insure everyone (even immigrants), tax money is being allocated everywhere but to research. Bill Clinton expanded the National Institute of Health like no one else and remains a hero to many investigators. George Bush undid that, bankrupted our country with a one way ticket on the Halliburton express, and now science is struggling with anemic funds. The percent of new K awards applications, the grants awarded to young investigators like myself, funded in 1990 was 40 or so. Last year it was 18. There is no money to support people like myself even if we do everything right. And those with K awards then need to secure the R awards (million dollar plus grants from the NIH) for "job security" and the competition becomes every chairman in every division in America with 30+ years of experience. Even with ideas that seem cutting edge and important, there isn't money right now for growth in science.
So is the Catalyst doomed? Well, most investigators don't share my view. Many are spirited and engaged and buy into the "low salary, earn it yourself" mentality that this career requires. Many don't have my perspective on what used to be, and focus on what is (probably a healthier and happier way to live!) And many aren't as old as I am, with families to feed on their salaries. But I worry for these people when they turn 35. 5 or 10 years into this research career, will they be happy? I have grown accustomed to seeing people at Harvard with blinders on. Some are barely English speaking folks who are grateful to have work in the US on visas which require them to work at academic centers. Others are Americans who think that they will beat the odds. It's kind of like playing the stock market- no one knows where this will head, where funding will be in several years- and ideas are exciting and young investigators are invigorated.
Regardless, I see a propaganda machine, one that is spinning out joint MD/PhDs from medical schools (yes, many extra years of training and cheap research labor) and labeling them as "future department heads." In truth, there are only so many departments. I look forward to the data in 30 years from Catalyst. The idea is brilliant- getting us trained together, interacting with one another, cross specialty, calling us "translational researchers"- but in the end, how many people will live their lives in labs that other people benefit from. How many young brilliant doctors won't treat patients, but will inject mice instead with 80% of their time.
The academic institutions say we need them. And we do. But we also need our best minds in the clinic, where I am heading in a year, when I get out of this cage.
Monday, October 5, 2009
The pulse
When I arrived at the hospital, it was already dark. October has a way of somehow creeping up on me every year and the end of dark purple twilight filled my rear view mirror as I pulled in for a shift. That was 8:30. In truth, I never know what I'll be walking in to. There are nights as calm as a pond without wind- and I treasure the ability to actually sleep for an hour or two. But then there are nights like the one I was about to have. Regardless, I paused that night as I locked the car and threw on my white coat- there was a waning moon rising from the east. There was something different in the air and I felt it and I knew it would be one of those crazier nights.
A college professor of mine, a famous one at Cornell, once gave a lecture on ESP. In the beginning of the class, he called a young woman up and asked if they had ever met or spoken and she swore no. He then proceeded to tell the 2100 of us in the class all about her. Every detail of her life was revealed to the astonishment of the class. At that moment I began to believe in the supernatural.
As I picked up the pager from the Saturday day float, he smiled and said, "It's been quiet, have a good one." I made my way to the hospitalist room and checked my email. I made a phone call to home to check on the kids. And then the overhead pager stated simply: "Rapid response to CCU." Since 2001, many hospitals have adopted some sort of systematic method for dealing with urgent medical issues. Whether it's a Code Blue (cardiac arrest) or other urgent issue, most hospitals have gotten better at dealing with such issues. In my residency, our hospital adopted such a system early on. Soon after a patient was in trouble, a "trigger" was called. Several parameters dictated whether a patient was sick enough to merit the attention of a trigger, but if all else failed, "nursing concern" was enough to send interns running, get a call placed to the resident and attending and have several people in a room within minutes. At my current hospital, a team of skilled nurses assemble to help facilitate next steps in such a situation. And most importantly, given that at night I am the only doctor in a 150 bed hospital besides a sleeping anesthesiologist and the ER doctors, the overhead page is really for me.
I entered the room to find, to my surprise, only one nurse taking a blood pressure on a man who was mumbling incoherently. He had been admitted to the ICU with a gastrointestinal bleed and several studies had failed to localize the source. He had been very stable, per the nurse, until about 20 minutes prior when his blood pressure dropped precipitously. Luckily, I know as a GI fellow by day, that a drop in blood pressure in a patient like this almost always represents a big bleed. "But I haven't seen any blood" she told me. I didn't care. Within a few minutes I had 4 more nurses in the room frantically working. His blood pressure was 50/30. His one IV became 4 IVs for access for blood, saline, and medications to raise his blood pressure. The medications weren't working.
Then came the blood. Out his bottom it poured like molasses. And now he wasn't talking at all. His breathing became labored. At my request, soon after I arrived, his family had been called and arrived in time for me to confirm that they wished, for this 79 year old, for all possible measures. The timing was important, as he then went into a code and lost his pulse. I woke the anesthesiologist from his usual slumber to help me intubate him as we compressed his chest and administered medications- a hail Mary pass in a game long over. By 10pm he was dead.
I looked around the room. In about an hour a calm night in the ICU had led to 11 staff members, 5 covered in blood, in one room. A dead man lay before us with cracked ribs from 20 minutes of CPR, his arms were cluttered with IVs and medications and blood hung on a pole still dripping. A family of eight were crying in the waiting room expecting his death based on my candid discussion with them about his condition. 3 of the 4 consultants I had been in contact with throughout this ordeal were about to show up- and all would agree that he was too violently ill to move to an operating room or an angiography suite: in short, there was nothing we could do.
At the end of the psychology lecture on ESP, the professor called the girl back on stage. He confirmed again that they had never met or spoken. But then he revealed that his secretary had called her the night prior to obtain all of her information in preparation for the lecture. The secretary had then prepared a detailed document which the professor had memorized prior to the lecture. In summary, he concluded, ESP was a hoax. It was showmanship. There was no supernatural. What is, frankly, is.
But as I held my dead patient's wife of 41 years and she sobbed and repeated "He was fine today. He was completely fine," I wondered. Why did this all go down on my shift? Why was I chosen to shepherd him into death? Why was I the one to hold this woman? Why didn't he die days ago? Why did he wait for me? All doctors ask these questions. And perhaps the answer is what the majority think- that when your card is pulled, time's up. But perhaps the feeling I had as I looked up at the moon and watched a flock of late geese head southwest towards something warmer was one of connection. Perhaps in all of this science there lie things completely unaccountable and new.
What I can account for is how I felt, at 10pm that night. I felt a hollowness in my heart. I felt humbled by a wife beside her dead husband. I felt that I had failed him. I felt that I could have done more. I felt heavy. I felt alone. She must have seen it in my face because she gave me a gift so rarely given in those moments. "You did the best you could, doctor." At the end of the day, at least I knew that to be true.
A college professor of mine, a famous one at Cornell, once gave a lecture on ESP. In the beginning of the class, he called a young woman up and asked if they had ever met or spoken and she swore no. He then proceeded to tell the 2100 of us in the class all about her. Every detail of her life was revealed to the astonishment of the class. At that moment I began to believe in the supernatural.
As I picked up the pager from the Saturday day float, he smiled and said, "It's been quiet, have a good one." I made my way to the hospitalist room and checked my email. I made a phone call to home to check on the kids. And then the overhead pager stated simply: "Rapid response to CCU." Since 2001, many hospitals have adopted some sort of systematic method for dealing with urgent medical issues. Whether it's a Code Blue (cardiac arrest) or other urgent issue, most hospitals have gotten better at dealing with such issues. In my residency, our hospital adopted such a system early on. Soon after a patient was in trouble, a "trigger" was called. Several parameters dictated whether a patient was sick enough to merit the attention of a trigger, but if all else failed, "nursing concern" was enough to send interns running, get a call placed to the resident and attending and have several people in a room within minutes. At my current hospital, a team of skilled nurses assemble to help facilitate next steps in such a situation. And most importantly, given that at night I am the only doctor in a 150 bed hospital besides a sleeping anesthesiologist and the ER doctors, the overhead page is really for me.
I entered the room to find, to my surprise, only one nurse taking a blood pressure on a man who was mumbling incoherently. He had been admitted to the ICU with a gastrointestinal bleed and several studies had failed to localize the source. He had been very stable, per the nurse, until about 20 minutes prior when his blood pressure dropped precipitously. Luckily, I know as a GI fellow by day, that a drop in blood pressure in a patient like this almost always represents a big bleed. "But I haven't seen any blood" she told me. I didn't care. Within a few minutes I had 4 more nurses in the room frantically working. His blood pressure was 50/30. His one IV became 4 IVs for access for blood, saline, and medications to raise his blood pressure. The medications weren't working.
Then came the blood. Out his bottom it poured like molasses. And now he wasn't talking at all. His breathing became labored. At my request, soon after I arrived, his family had been called and arrived in time for me to confirm that they wished, for this 79 year old, for all possible measures. The timing was important, as he then went into a code and lost his pulse. I woke the anesthesiologist from his usual slumber to help me intubate him as we compressed his chest and administered medications- a hail Mary pass in a game long over. By 10pm he was dead.
I looked around the room. In about an hour a calm night in the ICU had led to 11 staff members, 5 covered in blood, in one room. A dead man lay before us with cracked ribs from 20 minutes of CPR, his arms were cluttered with IVs and medications and blood hung on a pole still dripping. A family of eight were crying in the waiting room expecting his death based on my candid discussion with them about his condition. 3 of the 4 consultants I had been in contact with throughout this ordeal were about to show up- and all would agree that he was too violently ill to move to an operating room or an angiography suite: in short, there was nothing we could do.
At the end of the psychology lecture on ESP, the professor called the girl back on stage. He confirmed again that they had never met or spoken. But then he revealed that his secretary had called her the night prior to obtain all of her information in preparation for the lecture. The secretary had then prepared a detailed document which the professor had memorized prior to the lecture. In summary, he concluded, ESP was a hoax. It was showmanship. There was no supernatural. What is, frankly, is.
But as I held my dead patient's wife of 41 years and she sobbed and repeated "He was fine today. He was completely fine," I wondered. Why did this all go down on my shift? Why was I chosen to shepherd him into death? Why was I the one to hold this woman? Why didn't he die days ago? Why did he wait for me? All doctors ask these questions. And perhaps the answer is what the majority think- that when your card is pulled, time's up. But perhaps the feeling I had as I looked up at the moon and watched a flock of late geese head southwest towards something warmer was one of connection. Perhaps in all of this science there lie things completely unaccountable and new.
What I can account for is how I felt, at 10pm that night. I felt a hollowness in my heart. I felt humbled by a wife beside her dead husband. I felt that I had failed him. I felt that I could have done more. I felt heavy. I felt alone. She must have seen it in my face because she gave me a gift so rarely given in those moments. "You did the best you could, doctor." At the end of the day, at least I knew that to be true.
Monday, September 7, 2009
Moonlight
The harvest full moon passed this week and I had to work a night shift, or "moonlight" that night. It was a bright, beautiful moon and I enjoyed it as my car rounded the windy bends of highway that connect my house to the community hospital where I bring home the money we need to feed the family and pay our mortgage. On that night, I did some soul searching about this whole system of training and near-poverty I've lived in for so long. Without much extra money, my wife and I have done very well. We are used to coupons, and we have family that is generous with us, takes us on vacations and has us for dinner or takes us out every now and then. In fact, we are thrifty and frugal without being cheap and bitter. We're happy people.
But as the clock turned to 8:20pm and I entered the garage of the hospital for a 10 hour shift, I had a darker thought and lamented, for a moment, something more valuable to me than money: sleep. You may or may not know this, folks, but your doctor has slept much less than you have in this lifetime. Really my troubles began in medical school. There I pulled an average of one all nighter every 2 weeks starting in my second year. I was no speed reader, and I was often awake just catching up with reading. In my third year, on rotations, the sleeplessness was officially job related. 3rd year medical students are on the same shift schedule as their interns, and a q3 (every 3) day call schedule meant no sleep every 3rd night. That's when I discovered the true goings on in a hospital at 2am and the meaning of fatigue.
2am is what I've always referred to as the "witching hour." A myriad of things go wrong at 2am. Blood pressures fall, chest pain gets worse, patients stumble out of bed, bleeding gets worse- somewhere in those early morning hours interns earn their stripes- and 3rd year medical students watch. 2am is also the strangest time of day in a hospital. Awkward characters are sometimes seen wandering around the halls- it's the hour when the computer system mysteriously goes down, when the cleaning people wash the floors and make them extra slippery. One patient of mine turned sheet green at 2am. My patient at the VA murdered his roommate with a pillow because he was convinced he was a German enemy soldier at 2am. I came to loathe 2am in medical school- and it has held its promise as the strangest hour of the day.
Suddenly it's daytime, and 2pm, for those who are up all night, is another sort of bizarre. Lunch is over, the morning coffee which gets you to lunch is long gone- and every inch of your body wishes to curl up and sleep. But as an intern, 2pm was lecture time, or time to round in the afternoon. 2pm is when you need to be bright, awake, alert, spirited- to get everyone through the afternoon. But 2pm is, for those who started the previous morning at 7am, 31 hours into the day. 31 hours is a long time to think. 31 hours is too long. Your thoughts are mush. Mistakes happen at 31 hours unless you carefully slow down- cool your own brain a bit and go delicately through each motion. I became an expert at this, moonlighting and working the day before and after, in residency. I needed the money to stay afloat. And slowly, those shifts took their toll. It was last year when my wife announced that the hair on the side of my head was turning grey. At first I was angry- defensive: "I'm in my 30s, that's what happens." But then I saw her look- one of compassion and sadness. We both knew it was the sleepless nights and nothing more.
That night, at my little community hospital, I admitted 10 patients. I answered over 15 calls from nurses on various floors about sick patients. I intubated a patient in the intensive care unit and kept him alive on blood pressure medications and antibiotics. At 2am I was walking down the 5th floor hallway when I caught a glimpse of the moon. It was high now, and brighter than any I had ever seen. It was smiling at me, and laughing at me, and somehow lighting my spirits. It was as full as I was of energy and it was as reliable as I was striving to be. I thought about that moon until 6:30am, when I finally handed the pager to my well-slept colleague, coming in for a normal, 10 hour day. I fought back jealously as I gave my signout- each patient summarized meticulously. I was amazed that I remembered them in that state of half slumber.
Then I slowly made my way down the stairs, out the long corridor towards the parking lot, got in my car, and drove to work.
But as the clock turned to 8:20pm and I entered the garage of the hospital for a 10 hour shift, I had a darker thought and lamented, for a moment, something more valuable to me than money: sleep. You may or may not know this, folks, but your doctor has slept much less than you have in this lifetime. Really my troubles began in medical school. There I pulled an average of one all nighter every 2 weeks starting in my second year. I was no speed reader, and I was often awake just catching up with reading. In my third year, on rotations, the sleeplessness was officially job related. 3rd year medical students are on the same shift schedule as their interns, and a q3 (every 3) day call schedule meant no sleep every 3rd night. That's when I discovered the true goings on in a hospital at 2am and the meaning of fatigue.
2am is what I've always referred to as the "witching hour." A myriad of things go wrong at 2am. Blood pressures fall, chest pain gets worse, patients stumble out of bed, bleeding gets worse- somewhere in those early morning hours interns earn their stripes- and 3rd year medical students watch. 2am is also the strangest time of day in a hospital. Awkward characters are sometimes seen wandering around the halls- it's the hour when the computer system mysteriously goes down, when the cleaning people wash the floors and make them extra slippery. One patient of mine turned sheet green at 2am. My patient at the VA murdered his roommate with a pillow because he was convinced he was a German enemy soldier at 2am. I came to loathe 2am in medical school- and it has held its promise as the strangest hour of the day.
Suddenly it's daytime, and 2pm, for those who are up all night, is another sort of bizarre. Lunch is over, the morning coffee which gets you to lunch is long gone- and every inch of your body wishes to curl up and sleep. But as an intern, 2pm was lecture time, or time to round in the afternoon. 2pm is when you need to be bright, awake, alert, spirited- to get everyone through the afternoon. But 2pm is, for those who started the previous morning at 7am, 31 hours into the day. 31 hours is a long time to think. 31 hours is too long. Your thoughts are mush. Mistakes happen at 31 hours unless you carefully slow down- cool your own brain a bit and go delicately through each motion. I became an expert at this, moonlighting and working the day before and after, in residency. I needed the money to stay afloat. And slowly, those shifts took their toll. It was last year when my wife announced that the hair on the side of my head was turning grey. At first I was angry- defensive: "I'm in my 30s, that's what happens." But then I saw her look- one of compassion and sadness. We both knew it was the sleepless nights and nothing more.
That night, at my little community hospital, I admitted 10 patients. I answered over 15 calls from nurses on various floors about sick patients. I intubated a patient in the intensive care unit and kept him alive on blood pressure medications and antibiotics. At 2am I was walking down the 5th floor hallway when I caught a glimpse of the moon. It was high now, and brighter than any I had ever seen. It was smiling at me, and laughing at me, and somehow lighting my spirits. It was as full as I was of energy and it was as reliable as I was striving to be. I thought about that moon until 6:30am, when I finally handed the pager to my well-slept colleague, coming in for a normal, 10 hour day. I fought back jealously as I gave my signout- each patient summarized meticulously. I was amazed that I remembered them in that state of half slumber.
Then I slowly made my way down the stairs, out the long corridor towards the parking lot, got in my car, and drove to work.
Monday, August 31, 2009
Supply and Demand
It was around 2pm when I finally finished with Mr. P. His was one of the more challenging upper endoscopies I've done thus far in my training, and the extra time (over 45 minutes to complete what is usually a 20 minute procedure) was well worth it as we had an excellent outcome.
Mr. P is 70, and I met him in the emergency room a few months ago with rapid bleeding from his esophagus leading to vomiting blood and a subsequent quick ambulance ride to the hospital. I was initially called at 1am by the emergency room for the dreaded "we have a bleeder." Within hours we had an endoscope in his stomach, and after removing blood clots, we identified that his esophagus was full of large veins, called varices, which often result from elevated blood pressure in the liver circulation, referred to as portal hypertension. The curious thing about Mr. P was that he had no risk factors for this bleeding. He was not a drinker, had no hepatitis history, no drug use, very few longstanding medications. That night I placed small rubber bands on the recently bleeding veins, a procedure called "banding." And I placed him on medications to help prevent further bleeding. Mr. P did well. We found a cirrhotic, small liver and elevated pressures in the portal veins, but we did not find a cause. He was discharged to home and planned to see me in clinic for further evaluation.
Nothing seemed extraordinary about this story. More than 30% of all cirrhosis is "idiopathic" in nature, which means we don't know the cause. To label something idiopathic, we doctors will first do our best to make a diagnosis. But after enough testing, when we've reached the boundaries of what we know, we have to stop, and often where we stop is knowing the state of affairs (he had a cirrhotic liver and portal hypertension) but not knowing the root of the problem. This is often a huge source of frustration to patients who think we should know more, if not everything. And I don't blame them. Here is something wrong enough with Mr. P's body to hospitalize him. Something so drastic that he surely would have died if we had not intervened, yet the best we can do is describe what we see, with no explanation of how he got so sick. That, to me, presents a terrifying situation for the patient. Could this happen to his children? He asked. Will he bleed again? He wanted to know. Is this the result some strange virus? I wasn't sure.
But Mr. P interests me for reasons beyond his mysterious "idiopathy". After all, many people are told "we just don't know why" by doctors every day. The less arrogant doctors are more willing to put forth that sentence and not assure patients that we will find a cause every time.
In truth, what interested me most about Mr. P was his wife.
Ms. P is 72, from a Mediterranean country. She moved here at age 30 and shortly thereafter met her husband. She raised 3 children for him, and kept "the neatest home." She also was "the best cook in the world." Her specialty, he told me when we all met in my office the first time, "was lemon chicken with rice." I found it immediately interesting that in her presence, beyond these 2 compliments, Mr. P said nothing. In fact, I struggled in my interaction with him to focus on him, as she asked all of the questions, and looked skeptically at me when I told her that he would need two or three more endoscopic procedures to fully band his high grade varices. I explained that he remained a high risk for rebleeding. I explained that we were lucky last time, and that of the rebleeders, up to 25% die from bleeding to death. Her skepticism expanded: "No. No more. He's been through enough." I asked if her rationale was our uncertain diagnosis. She told me she didn't care what we said. When they left, I felt completely defeated. Here is a man I helped to save in the middle of the night just months before- who thanked us profusely when he was an inpatient- walking out of my office, muted by her anger, and possibly going to die if he didn't get additional medical attention.
So the question is: What was I to do next. In truth, what doctors are obligated to do by law, and obligated to do by oath are very different. The law states that we can do no harm, and need to do our best to do good. The oath I swore to (written by my medical school class- most med schools abandoned the not-so-politically-correct Hippocratic Oath 30 years ago) stated that my task was to have the "best interest of the patient in my heart and in my mind." There are few things I actually have to report to authorities. Child abuse is an obvious one. Elderly abuse is less obvious. Elderly Neglect starts to blur the line. And on and on the spectrum of what I observe vs. what I have the power to do continues. But when Mr. P, who clearly can make decisions for himself, decided to become a quiet lamb in the presence of a woman who had her own issues with the medical community and was willing to make him pay for those issues, my hands were tied. Still, I thought and thought. I had one of those dinners at home that night where my wife had to repeat a story because I was so deep in thought. I had one of those end of the day showers where she had to remind me to get out because I stood under the water for 1/2 hour pondering Mr. P- and how I might help him.
The next day I called- hoping to reach him. A lab result had returned normal and it was my excuse to call. But she answered instead, and refused to put him on the phone. She yelled at me for 10 minutes, telling me that no matter what I wouldn't "make money" on her husband. Little did she know that as fellow I make no money on endoscopies performed. So I did something else: I picked up the phone and called his primary care doctor. There I found a kind, caring man who clearly knew Mr. P and his wife well.
"She's beating you up!" he said laughing- "she does that to everyone except me."
"So what's your trick?" I asked.
"25 years of knowing them," he answered. And then I knew I had done the right thing. Within a week she had called to schedule his next endoscopy. And I arranged to be there. As the endoscope passed the first large vein that required banding, and I fired the band successfully onto the vein, I smiled.
I'll never know why Ms. P was so angry. Was it a brittle nurse who yelled at her husband one morning and reminded her of her sister when she was 13? Was it a lifetime of doctors making them pay co-pays and more and more expensive medications that didn't seem to provide all of the solutions she was seeking? Was it cultural differences- where American doctors ask completely different questions than those she is accustomed to? All of these and more probably. Regardless, I don't blame her. She did come to both appointments with him, standing by his side. She was there in the hospital to comfort him. Could I ask more of a wife? Even if her initial decisions weren't in his best interest, she was probably trying. And that is one of the toughest parts of my job- to look past blame and frustration and do what's best regardless of what I'm up against.
And believe me, there are more and more Ms. Ps out there- looking for a way to vent their frustrations with the state of medicine in America- and who better to yell at than the young man in the white coat?
Mr. P is 70, and I met him in the emergency room a few months ago with rapid bleeding from his esophagus leading to vomiting blood and a subsequent quick ambulance ride to the hospital. I was initially called at 1am by the emergency room for the dreaded "we have a bleeder." Within hours we had an endoscope in his stomach, and after removing blood clots, we identified that his esophagus was full of large veins, called varices, which often result from elevated blood pressure in the liver circulation, referred to as portal hypertension. The curious thing about Mr. P was that he had no risk factors for this bleeding. He was not a drinker, had no hepatitis history, no drug use, very few longstanding medications. That night I placed small rubber bands on the recently bleeding veins, a procedure called "banding." And I placed him on medications to help prevent further bleeding. Mr. P did well. We found a cirrhotic, small liver and elevated pressures in the portal veins, but we did not find a cause. He was discharged to home and planned to see me in clinic for further evaluation.
Nothing seemed extraordinary about this story. More than 30% of all cirrhosis is "idiopathic" in nature, which means we don't know the cause. To label something idiopathic, we doctors will first do our best to make a diagnosis. But after enough testing, when we've reached the boundaries of what we know, we have to stop, and often where we stop is knowing the state of affairs (he had a cirrhotic liver and portal hypertension) but not knowing the root of the problem. This is often a huge source of frustration to patients who think we should know more, if not everything. And I don't blame them. Here is something wrong enough with Mr. P's body to hospitalize him. Something so drastic that he surely would have died if we had not intervened, yet the best we can do is describe what we see, with no explanation of how he got so sick. That, to me, presents a terrifying situation for the patient. Could this happen to his children? He asked. Will he bleed again? He wanted to know. Is this the result some strange virus? I wasn't sure.
But Mr. P interests me for reasons beyond his mysterious "idiopathy". After all, many people are told "we just don't know why" by doctors every day. The less arrogant doctors are more willing to put forth that sentence and not assure patients that we will find a cause every time.
In truth, what interested me most about Mr. P was his wife.
Ms. P is 72, from a Mediterranean country. She moved here at age 30 and shortly thereafter met her husband. She raised 3 children for him, and kept "the neatest home." She also was "the best cook in the world." Her specialty, he told me when we all met in my office the first time, "was lemon chicken with rice." I found it immediately interesting that in her presence, beyond these 2 compliments, Mr. P said nothing. In fact, I struggled in my interaction with him to focus on him, as she asked all of the questions, and looked skeptically at me when I told her that he would need two or three more endoscopic procedures to fully band his high grade varices. I explained that he remained a high risk for rebleeding. I explained that we were lucky last time, and that of the rebleeders, up to 25% die from bleeding to death. Her skepticism expanded: "No. No more. He's been through enough." I asked if her rationale was our uncertain diagnosis. She told me she didn't care what we said. When they left, I felt completely defeated. Here is a man I helped to save in the middle of the night just months before- who thanked us profusely when he was an inpatient- walking out of my office, muted by her anger, and possibly going to die if he didn't get additional medical attention.
So the question is: What was I to do next. In truth, what doctors are obligated to do by law, and obligated to do by oath are very different. The law states that we can do no harm, and need to do our best to do good. The oath I swore to (written by my medical school class- most med schools abandoned the not-so-politically-correct Hippocratic Oath 30 years ago) stated that my task was to have the "best interest of the patient in my heart and in my mind." There are few things I actually have to report to authorities. Child abuse is an obvious one. Elderly abuse is less obvious. Elderly Neglect starts to blur the line. And on and on the spectrum of what I observe vs. what I have the power to do continues. But when Mr. P, who clearly can make decisions for himself, decided to become a quiet lamb in the presence of a woman who had her own issues with the medical community and was willing to make him pay for those issues, my hands were tied. Still, I thought and thought. I had one of those dinners at home that night where my wife had to repeat a story because I was so deep in thought. I had one of those end of the day showers where she had to remind me to get out because I stood under the water for 1/2 hour pondering Mr. P- and how I might help him.
The next day I called- hoping to reach him. A lab result had returned normal and it was my excuse to call. But she answered instead, and refused to put him on the phone. She yelled at me for 10 minutes, telling me that no matter what I wouldn't "make money" on her husband. Little did she know that as fellow I make no money on endoscopies performed. So I did something else: I picked up the phone and called his primary care doctor. There I found a kind, caring man who clearly knew Mr. P and his wife well.
"She's beating you up!" he said laughing- "she does that to everyone except me."
"So what's your trick?" I asked.
"25 years of knowing them," he answered. And then I knew I had done the right thing. Within a week she had called to schedule his next endoscopy. And I arranged to be there. As the endoscope passed the first large vein that required banding, and I fired the band successfully onto the vein, I smiled.
I'll never know why Ms. P was so angry. Was it a brittle nurse who yelled at her husband one morning and reminded her of her sister when she was 13? Was it a lifetime of doctors making them pay co-pays and more and more expensive medications that didn't seem to provide all of the solutions she was seeking? Was it cultural differences- where American doctors ask completely different questions than those she is accustomed to? All of these and more probably. Regardless, I don't blame her. She did come to both appointments with him, standing by his side. She was there in the hospital to comfort him. Could I ask more of a wife? Even if her initial decisions weren't in his best interest, she was probably trying. And that is one of the toughest parts of my job- to look past blame and frustration and do what's best regardless of what I'm up against.
And believe me, there are more and more Ms. Ps out there- looking for a way to vent their frustrations with the state of medicine in America- and who better to yell at than the young man in the white coat?
Tuesday, August 18, 2009
11th hour
Ms. P is 87 years old, on a ventilator and nodding to me to come closer. She points to her throat which is sore and I nod "I know, Ms. P- that machine isn't pleasant." Yesterday, on a pad she wrote to me that she is doing this for her children and her grandchildren. By "this" she means living. She has a terminal lung condition called pulmonary fibrosis and it has progressed to the point of difficulty breathing requiring transplant for which she is too old and frail or a ventilator or option C, hospice and death. She voluntarily chose the breathing machine even though it went against her own belief that life isn't worth living if you can't enjoy it. (She wrote that on her pad a few days ago as well.)
If you missed it, this week, one of the boldest, wisest, kindest and downright most intelligent things ever offered by a president was shot down by a nation in fear. Our president proposed that Medicare pay for end of life counseling visits with the elderly and, hopefully, their families. This reimbursed visit would set the guidelines for a living will and let the patient and their family discuss options for the last days of life. Studies (many of them) have shown that such conversations are not only well received, but makes for a better death both for the patient and their families. This article sums up one such study: http://www.msnbc.msn.com/id/32463644/ns/health-health_care/
Within days of the proposal, conservatives, insurance companies and the PR firms hired by both began a slur campaign against the end of life counseling visits. Ex-governor Sarah Palin dubbed the term "death panels" and within 2 weeks the proposal was stricken from the health care bill. Here, ex-insurance executive Wendell Potter speaks out in his commentary on the role of insurance companies in this PR nightmare: http://www.cnn.com/2009/POLITICS/08/17/potter.health.insurance/index.html
Now I'd like to give a doctor's perspective on this situation, and I dedicate this to Ms. P and her ventilator:
We are a nation terrified of death. We lose our parents at ages 85 and think it's a tragedy. We lose our great grandparents and think they should have lived longer. The truth is, people die. They die at age 1, 12, 31, 51, 72, 102. They die every day. They die in accidents, and from illness. They die good deaths and get to say goodbye and they die quickly and do not. I am quite sure that death is as ultimate as anything. I have seen corpses on a fairly regular basis in my career. And in doing so, something amazing happened: I got over my fear of death. Call it an understanding of nature, or just an appreciation that what makes life valuable is the absolute certainty of its end. But why are so many of us petrified of dying? Are our lives so important that we want to be immune from the inevitable? As a young man, this is so. It is unnatural and unexpected for the young to die. And it is indeed tragic as it rare for a young person to die and often others get left behind for a lifetime of grief. To argue that one should just "get over" the death of a young person would be silly.
But what about Ms. P? 87 years- is that enough? She thinks so. But she never had a Medicare sponsored visit to the doctor- who is trained in not only the facts and procedures, but HOW to discuss this issue. I took classes on the subject in medical school, worked with mock patients to sharpen every skill (and they were all criticized at one time or another) from tone to facial expressions to listening well. This is tough stuff- and we need professionals to deliver the meat of the conversation, and to listen and translate what people are feeling into a plan. A plan that, perhaps, would have saved Ms. P from her horrible, prolonged, painful death on a ventilator.
For what it's worth, her family only visited once in 3 weeks. And I was there when her daughter squeezed her hand and told her to "hang on." And to her I ask: What for?
If you missed it, this week, one of the boldest, wisest, kindest and downright most intelligent things ever offered by a president was shot down by a nation in fear. Our president proposed that Medicare pay for end of life counseling visits with the elderly and, hopefully, their families. This reimbursed visit would set the guidelines for a living will and let the patient and their family discuss options for the last days of life. Studies (many of them) have shown that such conversations are not only well received, but makes for a better death both for the patient and their families. This article sums up one such study: http://www.msnbc.msn.com/id/32463644/ns/health-health_care/
Within days of the proposal, conservatives, insurance companies and the PR firms hired by both began a slur campaign against the end of life counseling visits. Ex-governor Sarah Palin dubbed the term "death panels" and within 2 weeks the proposal was stricken from the health care bill. Here, ex-insurance executive Wendell Potter speaks out in his commentary on the role of insurance companies in this PR nightmare: http://www.cnn.com/2009/POLITICS/08/17/potter.health.insurance/index.html
Now I'd like to give a doctor's perspective on this situation, and I dedicate this to Ms. P and her ventilator:
We are a nation terrified of death. We lose our parents at ages 85 and think it's a tragedy. We lose our great grandparents and think they should have lived longer. The truth is, people die. They die at age 1, 12, 31, 51, 72, 102. They die every day. They die in accidents, and from illness. They die good deaths and get to say goodbye and they die quickly and do not. I am quite sure that death is as ultimate as anything. I have seen corpses on a fairly regular basis in my career. And in doing so, something amazing happened: I got over my fear of death. Call it an understanding of nature, or just an appreciation that what makes life valuable is the absolute certainty of its end. But why are so many of us petrified of dying? Are our lives so important that we want to be immune from the inevitable? As a young man, this is so. It is unnatural and unexpected for the young to die. And it is indeed tragic as it rare for a young person to die and often others get left behind for a lifetime of grief. To argue that one should just "get over" the death of a young person would be silly.
But what about Ms. P? 87 years- is that enough? She thinks so. But she never had a Medicare sponsored visit to the doctor- who is trained in not only the facts and procedures, but HOW to discuss this issue. I took classes on the subject in medical school, worked with mock patients to sharpen every skill (and they were all criticized at one time or another) from tone to facial expressions to listening well. This is tough stuff- and we need professionals to deliver the meat of the conversation, and to listen and translate what people are feeling into a plan. A plan that, perhaps, would have saved Ms. P from her horrible, prolonged, painful death on a ventilator.
For what it's worth, her family only visited once in 3 weeks. And I was there when her daughter squeezed her hand and told her to "hang on." And to her I ask: What for?
Thursday, August 13, 2009
Do you care?
I start tonight by stating that I sat for a total of 30 minutes today, on my couch, and it felt great to rest. I never had much of a chance to sit today, and given that a friend of mine is studying sitting time, and has concluded in her work that time on one's derriere is directly linked to earlier death, I am not unhappy about that.
This may represent a slight change of tone, but I need to know who out there is really paying attention to what is going on right now. This op-ed is important, and summarizes many of my own thoughts. http://www.nytimes.com/2009/08/13/opinion/13gawande.html?_r=1&pagewanted=2 I heard Atul Gawande speak last night at my hospital and I was impressed that he is a man who truly understands the issues at hand and what needs to be done to begin to fix this mess.
This is so important, this issue of health care reform. Everyone deserves to be able to be insured. And everyone deserves a fair system with a common goal of doing good by the people.
But I need to ask Dr. Gawande, our president and all of you- do the 50 million or so people without insurance deserve this benefit without doing anything for it? Yes, the emergency room has become the new primary care physician-but why is no one talking about welfare reform? What about a national job bank and a six month limit on handout money for unemployment? How about a bill for those non emergent emergency room visits sent to the patient who has chosen not to be insured? And if collection agencies collect the money, people will have to come up with it, and if 25% of them did, we'd begin to chip away at this mess.
As a physician, I am thrilled by the thought of everyone being treated equally, but I am also worried that in America, we are so fixed on fair coverage, and not thinking rationally about ownership. Do we really need to pay for folks who are capable of work but unemployed? At what point do people need to have some onus for their well-being?
I was shocked this week to find out that a man won a lawsuit for the "damage" done to his wife by the Tobacco industry after she smoked 2 packs a day. I am no fan of big tobacco, but it's so very American to reward the smoker for damages! I liken the smoker to many of the uninsured in America. Of course the exceptions are those who are truly disabled mentally or physically and uninsured. (And yes, the smoker was 72, and lived through an era of lies and false advertising which despicably continues in 2009). Still, I cannot tell you how many patients walk into my office with 2 working arms, 2 working legs, often a college education and have been "out of work" for 2 years. I have been alive in prosperous and awful financial times. I have never gone a day without work when I wanted a job since I was 14 years old. I know that we have 9 plus percent unemployment and that some of that is layoffs. But somewhere in the past 80 years, the spirit of the 1930's New Deal was lost in a lazy haze. What happened to "Ask not what your country can do for you..."?
I am not turning a blind eye to those in need- I just want everyone involved in owning the problem. Everyone wants Big Insurance to fork over their secret stash of billions to fix this. And they do owe America more than record profits in these times. But the papers are also full of ideas of how to cut my salary. I'll gladly do so when I know that I am not in the only profession penalized for other people's circumstances. Where is the talk about tort reform? Where, in these discussions, are those snake lawyers making millions off my decisions which they later deem "mistakes?" And where are the millions awarded to people for bad lawyers? People behind bars because they weren't defended properly. People who got little or no money (myself included) when they suffered accidents. One multimillion dollar lawsuit against a lawyer would change the entire health care system in America. Put the lawyers under this microscope, give them checklists and pay them for performance. Embarrass them publicly in the papers for their "mistakes." And if you argue that health is more serious than prison time, or justice served, think through that one for a minute.
(As an aside, I work in a prison several months a year- and the health care delivery there is unique: Everyone behind bars is "insured" and not one prisoner pays the bill.)
So if you care, form strong opinions of your own. Disagree with all of this? I welcome that. Please, just make informed decisions about this crisis. Think about what's important to you. And if you're a hard worker, and always have been, I applaud you and believe wholeheartedly that we need to make insurance cheaper for you. Millions more people who are resting on their laurels can pitch in to help pay for that. They can work hard, even in non-profit government run jobs which help society- perhaps jobs in health care delivery, and accessibility, jobs aimed at keeping them out of the emergency room- and from sitting around.
This may represent a slight change of tone, but I need to know who out there is really paying attention to what is going on right now. This op-ed is important, and summarizes many of my own thoughts. http://www.nytimes.com/2009/08/13/opinion/13gawande.html?_r=1&pagewanted=2 I heard Atul Gawande speak last night at my hospital and I was impressed that he is a man who truly understands the issues at hand and what needs to be done to begin to fix this mess.
This is so important, this issue of health care reform. Everyone deserves to be able to be insured. And everyone deserves a fair system with a common goal of doing good by the people.
But I need to ask Dr. Gawande, our president and all of you- do the 50 million or so people without insurance deserve this benefit without doing anything for it? Yes, the emergency room has become the new primary care physician-but why is no one talking about welfare reform? What about a national job bank and a six month limit on handout money for unemployment? How about a bill for those non emergent emergency room visits sent to the patient who has chosen not to be insured? And if collection agencies collect the money, people will have to come up with it, and if 25% of them did, we'd begin to chip away at this mess.
As a physician, I am thrilled by the thought of everyone being treated equally, but I am also worried that in America, we are so fixed on fair coverage, and not thinking rationally about ownership. Do we really need to pay for folks who are capable of work but unemployed? At what point do people need to have some onus for their well-being?
I was shocked this week to find out that a man won a lawsuit for the "damage" done to his wife by the Tobacco industry after she smoked 2 packs a day. I am no fan of big tobacco, but it's so very American to reward the smoker for damages! I liken the smoker to many of the uninsured in America. Of course the exceptions are those who are truly disabled mentally or physically and uninsured. (And yes, the smoker was 72, and lived through an era of lies and false advertising which despicably continues in 2009). Still, I cannot tell you how many patients walk into my office with 2 working arms, 2 working legs, often a college education and have been "out of work" for 2 years. I have been alive in prosperous and awful financial times. I have never gone a day without work when I wanted a job since I was 14 years old. I know that we have 9 plus percent unemployment and that some of that is layoffs. But somewhere in the past 80 years, the spirit of the 1930's New Deal was lost in a lazy haze. What happened to "Ask not what your country can do for you..."?
I am not turning a blind eye to those in need- I just want everyone involved in owning the problem. Everyone wants Big Insurance to fork over their secret stash of billions to fix this. And they do owe America more than record profits in these times. But the papers are also full of ideas of how to cut my salary. I'll gladly do so when I know that I am not in the only profession penalized for other people's circumstances. Where is the talk about tort reform? Where, in these discussions, are those snake lawyers making millions off my decisions which they later deem "mistakes?" And where are the millions awarded to people for bad lawyers? People behind bars because they weren't defended properly. People who got little or no money (myself included) when they suffered accidents. One multimillion dollar lawsuit against a lawyer would change the entire health care system in America. Put the lawyers under this microscope, give them checklists and pay them for performance. Embarrass them publicly in the papers for their "mistakes." And if you argue that health is more serious than prison time, or justice served, think through that one for a minute.
(As an aside, I work in a prison several months a year- and the health care delivery there is unique: Everyone behind bars is "insured" and not one prisoner pays the bill.)
So if you care, form strong opinions of your own. Disagree with all of this? I welcome that. Please, just make informed decisions about this crisis. Think about what's important to you. And if you're a hard worker, and always have been, I applaud you and believe wholeheartedly that we need to make insurance cheaper for you. Millions more people who are resting on their laurels can pitch in to help pay for that. They can work hard, even in non-profit government run jobs which help society- perhaps jobs in health care delivery, and accessibility, jobs aimed at keeping them out of the emergency room- and from sitting around.
Monday, August 10, 2009
Training Wheels Part 2
So I am going to continue where I left off a few weeks ago (sorry for the delay- I need to find time to write this every day, especially now that I saw the film Julie and Julia yesterday and I am convinced that blogs can make a difference in this world if written well and with a purpose).
Let me start with intern year. Now here is a secret about the first week of training that is rarely disclosed: Interns are terrified. Let's face it, 3 weeks ago they were medical students. Then, off come the training wheels and on comes one of the most grueling years in our training. It isn't the work hours that make the transition from medical school to internship so difficult, it's the sheer weight and responsibility of actually being responsible for human lives. OK, so there are attendings who ultimately are legally responsible, and fellows and residents who know more and can help- but at 2am, in those tiny rooms, when the blood pressure is rising and you don't know why- or the chest pain is getting worse- or breathing looks more labored- it's just you and the patient, and occasionally a nurse waiting for what to do next (and another secret is that he or she often knows the answer which the smart interns figure out early on). Let me share a few of these tense moments from my first 3 weeks of intern year to set the tone:
One morning in my second week as a doctor I was told that Mr. S was bleeding out his bottom. I ran to the bedside and indeed, there was a small pool of fresh red blood on the bed. I lifted the sheet and found that the catheter in his penis was gushing blood. Knowing that a balloon inflates to hold this catheter (called a Foley) in place, I asked the nurse to deflate the balloon, push the catheter in further and reinflate it. The gushing continued. I asked another nurse to call my resident and to call urology. But then I was stuck with 5 minutes alone with the patient and the nurse to try to make this better. "Do you want a 3 way?" She asked me. I had no idea what this meant other than the obvious bad joke. She must have seen me look perplexed because then she explained that a 3 way catheter had a larger lumen and could be used to flush the urethra and bladder. Within a few minutes she got this in, and with some irrigation we dulled the bleeding and allowed for the Urology team to come and evaluate my poor patient.
A week later I arrived to check on my patients at the usual 6am start time to find that one of my patients had shallow breathing and wasn't responding to me. I asked the nurse to call my resident and then stood petrified for a moment next to my patient. I froze. I did not know what to do next. I did not know where I was. I was panicking. Then, I remembered some basics and started to tell the 3 nurses who had gathered to help what to do. Someone needed to get a blood pressure. Someone needed to get an oxygen level. I needed to do an arterial blood gas which I had only seen done once and now was in the unfortunate position of NEEDING to do immediately. Minutes later, as I slowly poked around for the radial artery with a needle I remember thinking to myself, "You can do this. You HAVE to do this." And I will never forget how it felt to watch the blood fill that syringe, my heart pounding, sweat beading down my forehead.
Then, during my first night call in my second month of being a doctor, I was told that a patient had died and to come declare the patient dead. I had done this in medical school and knew the routine- listen to the heart, check some reflexes and for a pain response. What I did not prepare for what came next. As I entered the room, a woman sat at the end of the bed holding the patient's cold hand. On her lap was a four year old, crying. He had lost his father. She had lost her husband. And just like that I knew for the first time what being a doctor really meant. I chocked up. I fought back tears of my own as I placed my stethoscope delicately on the chest of the dead man. I fought back tears as I said "I'm so sorry for your loss" to this woman and her boy. I did feel sorry for them. I felt vacant, alone, afraid. I felt unworthy to be there. I felt that the world was not a fair place at that moment. And finally I felt privileged to have been a part of comforting them in any way. That was my role. Confirming his death confirmed something. There was no doubt. She knew that the hand she was holding wasn't just cold, it was dead. And that provided something for a woman who had sat by a man's side for 6 months as he died of cancer. He was gone and I was the person who told her so. And as hard as that was to hear, and to deliver, that was the beginning of mourning, and the end of dying, and that was a gift.
The stories go on and on. There was the time my patient peed on his roommate because he thought he was a urinal. We laughed for 15 minutes in the lounge after that. We had to laugh. There was the man who called me to his bedside to thank me before his breathing machine was discontinued. He requested my presence when he died and that was the biggest honor I ever received. There was the woman who claimed that her quadriplegic husband on a breathing machine who could not communicate with anyone could speak with her through his eyes. And no one believed her at first but slowly some of us began to wonder and finally I was convinced that they were having dialogues without words. And no matter what the story, I was learning. I was learning how to administer medications, do procedures, determine who was really sick and who wasn't from the doorway. And I was learning how to handle someone screaming in your face, and lying about prescriptions being lost, and how to comfort someone who was beaten by a person or by an illness. I was finally living up to the MD that came after my name.
Then, in a blink that takes forever, it's June- and the intern class sniffs emotional smelling salts and suddenly realizes that they are about to be residents. Many say that the transition in July after intern year is complete is the scariest moment of training. It was for me. Suddenly we were sitting through training sessions on how to teach, and floods of emails began to circulate on what to do when and how to manage 2 interns at once. Suddenly I needed to know the rules of the hospital as far as how admitting worked. The things I was protected from as an intern made themselves unbearably clear to me on the cusp of the transition and then, in a blur, in came new interns. This time I was the one being called for the scary situations. My backup was often my colleagues. Attendings weren't always on the floors. They weren't always easy to reach even by phone. Now the real challenge began: Did I know enough? Was I competent to keep people alive? Was I teaching the real lessons of being a doctor or just medial minutia?
The first time I saw feedback from my interns was one of the best days of my training. One July intern described being on my service as a "safe place. " That was my goal. That made me smile. But those late night calls made my heart race as I walked into a room. Now not only was nature playing its role in what had transpired, now the intern had something to do with it, too. On good days, good things were done. On bad days, anything was possible. And as many times as the interns heard: Don't act alone, get help- there wasn't always time. Once, in the ICU, an intern of mine let a patient slowly drop his blood pressure all night until he was critically low in the morning. No one had noticed because the incremental drops were so small. It took new eyes to see what had taken place. That was the day I realized my role as resident. I was to see, and to have others act based on what I was seeing. I was to teach based on those experiences. I was to be a guide, but to let interns make mistakes as long as they didn't do harm and learn from them. It was the toughest job I ever had and the most rewarding. To see the look on an intern's face when she made a diagnosis correctly and helped someone- that made my day. To hug an intern after he had to tell a family that their young father was dying- that was hard, and necessary.
Somewhere in there, between those long nights, crazy days, tears of joy and tears of sorrow- I earned my degree, awarded too soon in my opinion, before I knew what being a doctor meant and what being a doctor took. It took, after all, from my life at home and my life outside of home. It took my tan skin and turned it pale. It took good eating habits. It took well controlled acid reflux and made it out of control. It took all of the patience I could muster and then some. It took my happiness on many winter days. It took my positive outlook on everything on some days and squashed it. But what being a doctor gave back made up for all of it. And I knew it even though I suffered through it. And that dichotomy is medical training summed up. And that's what people need to know before signing up for it.
Let me start with intern year. Now here is a secret about the first week of training that is rarely disclosed: Interns are terrified. Let's face it, 3 weeks ago they were medical students. Then, off come the training wheels and on comes one of the most grueling years in our training. It isn't the work hours that make the transition from medical school to internship so difficult, it's the sheer weight and responsibility of actually being responsible for human lives. OK, so there are attendings who ultimately are legally responsible, and fellows and residents who know more and can help- but at 2am, in those tiny rooms, when the blood pressure is rising and you don't know why- or the chest pain is getting worse- or breathing looks more labored- it's just you and the patient, and occasionally a nurse waiting for what to do next (and another secret is that he or she often knows the answer which the smart interns figure out early on). Let me share a few of these tense moments from my first 3 weeks of intern year to set the tone:
One morning in my second week as a doctor I was told that Mr. S was bleeding out his bottom. I ran to the bedside and indeed, there was a small pool of fresh red blood on the bed. I lifted the sheet and found that the catheter in his penis was gushing blood. Knowing that a balloon inflates to hold this catheter (called a Foley) in place, I asked the nurse to deflate the balloon, push the catheter in further and reinflate it. The gushing continued. I asked another nurse to call my resident and to call urology. But then I was stuck with 5 minutes alone with the patient and the nurse to try to make this better. "Do you want a 3 way?" She asked me. I had no idea what this meant other than the obvious bad joke. She must have seen me look perplexed because then she explained that a 3 way catheter had a larger lumen and could be used to flush the urethra and bladder. Within a few minutes she got this in, and with some irrigation we dulled the bleeding and allowed for the Urology team to come and evaluate my poor patient.
A week later I arrived to check on my patients at the usual 6am start time to find that one of my patients had shallow breathing and wasn't responding to me. I asked the nurse to call my resident and then stood petrified for a moment next to my patient. I froze. I did not know what to do next. I did not know where I was. I was panicking. Then, I remembered some basics and started to tell the 3 nurses who had gathered to help what to do. Someone needed to get a blood pressure. Someone needed to get an oxygen level. I needed to do an arterial blood gas which I had only seen done once and now was in the unfortunate position of NEEDING to do immediately. Minutes later, as I slowly poked around for the radial artery with a needle I remember thinking to myself, "You can do this. You HAVE to do this." And I will never forget how it felt to watch the blood fill that syringe, my heart pounding, sweat beading down my forehead.
Then, during my first night call in my second month of being a doctor, I was told that a patient had died and to come declare the patient dead. I had done this in medical school and knew the routine- listen to the heart, check some reflexes and for a pain response. What I did not prepare for what came next. As I entered the room, a woman sat at the end of the bed holding the patient's cold hand. On her lap was a four year old, crying. He had lost his father. She had lost her husband. And just like that I knew for the first time what being a doctor really meant. I chocked up. I fought back tears of my own as I placed my stethoscope delicately on the chest of the dead man. I fought back tears as I said "I'm so sorry for your loss" to this woman and her boy. I did feel sorry for them. I felt vacant, alone, afraid. I felt unworthy to be there. I felt that the world was not a fair place at that moment. And finally I felt privileged to have been a part of comforting them in any way. That was my role. Confirming his death confirmed something. There was no doubt. She knew that the hand she was holding wasn't just cold, it was dead. And that provided something for a woman who had sat by a man's side for 6 months as he died of cancer. He was gone and I was the person who told her so. And as hard as that was to hear, and to deliver, that was the beginning of mourning, and the end of dying, and that was a gift.
The stories go on and on. There was the time my patient peed on his roommate because he thought he was a urinal. We laughed for 15 minutes in the lounge after that. We had to laugh. There was the man who called me to his bedside to thank me before his breathing machine was discontinued. He requested my presence when he died and that was the biggest honor I ever received. There was the woman who claimed that her quadriplegic husband on a breathing machine who could not communicate with anyone could speak with her through his eyes. And no one believed her at first but slowly some of us began to wonder and finally I was convinced that they were having dialogues without words. And no matter what the story, I was learning. I was learning how to administer medications, do procedures, determine who was really sick and who wasn't from the doorway. And I was learning how to handle someone screaming in your face, and lying about prescriptions being lost, and how to comfort someone who was beaten by a person or by an illness. I was finally living up to the MD that came after my name.
Then, in a blink that takes forever, it's June- and the intern class sniffs emotional smelling salts and suddenly realizes that they are about to be residents. Many say that the transition in July after intern year is complete is the scariest moment of training. It was for me. Suddenly we were sitting through training sessions on how to teach, and floods of emails began to circulate on what to do when and how to manage 2 interns at once. Suddenly I needed to know the rules of the hospital as far as how admitting worked. The things I was protected from as an intern made themselves unbearably clear to me on the cusp of the transition and then, in a blur, in came new interns. This time I was the one being called for the scary situations. My backup was often my colleagues. Attendings weren't always on the floors. They weren't always easy to reach even by phone. Now the real challenge began: Did I know enough? Was I competent to keep people alive? Was I teaching the real lessons of being a doctor or just medial minutia?
The first time I saw feedback from my interns was one of the best days of my training. One July intern described being on my service as a "safe place. " That was my goal. That made me smile. But those late night calls made my heart race as I walked into a room. Now not only was nature playing its role in what had transpired, now the intern had something to do with it, too. On good days, good things were done. On bad days, anything was possible. And as many times as the interns heard: Don't act alone, get help- there wasn't always time. Once, in the ICU, an intern of mine let a patient slowly drop his blood pressure all night until he was critically low in the morning. No one had noticed because the incremental drops were so small. It took new eyes to see what had taken place. That was the day I realized my role as resident. I was to see, and to have others act based on what I was seeing. I was to teach based on those experiences. I was to be a guide, but to let interns make mistakes as long as they didn't do harm and learn from them. It was the toughest job I ever had and the most rewarding. To see the look on an intern's face when she made a diagnosis correctly and helped someone- that made my day. To hug an intern after he had to tell a family that their young father was dying- that was hard, and necessary.
Somewhere in there, between those long nights, crazy days, tears of joy and tears of sorrow- I earned my degree, awarded too soon in my opinion, before I knew what being a doctor meant and what being a doctor took. It took, after all, from my life at home and my life outside of home. It took my tan skin and turned it pale. It took good eating habits. It took well controlled acid reflux and made it out of control. It took all of the patience I could muster and then some. It took my happiness on many winter days. It took my positive outlook on everything on some days and squashed it. But what being a doctor gave back made up for all of it. And I knew it even though I suffered through it. And that dichotomy is medical training summed up. And that's what people need to know before signing up for it.
Sunday, June 21, 2009
Training wheels
So tonight's blog is the first of a two part series dedicated to how I got here and what doctors, in 2009, go through to get trained. I find this an opportune time to write about the subject as our president is currently considering the ever expanding topic of "Healthcare Reform" which most people do not know how to define. In Obama's efforts to reform, much has been speculated about who is to blame and who should pay. Someone, after all, is going to have to give up something or nothing will change. In light of this, Atul Gawanda's recent piece in the New Yorker caught my wife's attention, and then mine:
http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande?currentPage=all
My patient wife has now been with me for seven years, that's seven out of the eight I've been in medical training. My average salary, including the negative $34,000/year in loan debt I was in during medical school and then the $48,000-$54000 salaries I've had in internship, residency and now fellowship comes to an astonishing $8000/year average net in those 8 years. We have squeaked by with moonlighting, and very good money management (by her, thank god!) But needless to say, articles about blaming doctors scare both of us- sitting where we sit- having put in everything to make virtually nothing yet. Especially given how much money insurance companies made last year.
So I'll start at the beginning which is how to get into medical school. Basically, medical school is a daunting task from the moment a young high school student or college student begins to read on what getting in requires. There is the traditional pre-med track which, as of 2009, still includes very unnecessary coursework (physics, organic chemistry, calculus) and a few vital topics including biology, chemistry. At most schools these are the more popular classes and majors. At most schools these are also the toughest to get As in. And you need As. The average GPA for enrollment in a US medical school in 2008 was a 3.76 on a 4 point scale. You also need superb extracurricular activities, letters from multiple professors, and more and more, hands on experience in the form of volunteer work or real work. An increasing number of applicants are graduating and becoming EMTs or paramedics or nurses prior to applying to medical school. They are well ahead of the traditional track college grads in terms of real life experience (something I think vital to becoming a well-rounded young doctor).
As for the odds: According to the American Association of Medical Colleges, in 2008, there were 558,053 applications from 42,231 applicants, (an average of 13 applications per applicant) to US medical schools. Of these 42,231, there are 18,036 spots to fill. So approximately 1 out of 3 applicants lands a coveted spot. An approximately 2 out of 3 do not. That's 2/3 of people going through all of the same training, coursework, letters, applications (13!) and interviews as their more fortunate peers who are told "maybe next year." That's right, interviews. One needs to travel at his or hr expense to the medical schools for rigorous interviews where everything is asked from, "How much money do you expect to pay on your own and how much are your parents going to pay?" (which one of my friends whose parents were dead was asked at a certain southern state school) to "Who is your favorite American Idol?" Most of the questions are geared towards seeing how you do under pressure. And many of these quizzes have no right answer. One famous admissions director was known for theatrics, often leaving the room during his interviews for an uncomfortable amount of time. I interviewed at 9 medical schools in 2000-2001, and I left 9 interviews feeling odd, and somehow wronged.
So if you are in the lucky third, you're in! And then comes the biggest reality check of your life: Medical school is hard. It's really, really hard. For two years you memorize the equivalent of the New York City phone book. I counted tests one semester in my second year: 37. I was tested 37 times in 21 weeks. Almost two tests a week. After a while the multiple choice bubbles all look the same, and the books all sound the same. And then comes the first of 4 huge national tests, the United States Medical Licensing Examination (USMLE) step one. This is notoriously the worst experience of everyone's life. It's a testament to minutia, a dedication to memory and unimportant tidbits. The stuff written at the side margin of page 238: That's tested. The stuff mumbled once by a professor who barely spoke English: On the test. And it's 8 hours long, at a computer testing center, usually somewhere you've never been before. Most students set aside approximately one month in order to prepare for Step 1. Most medical schools build this study period into their curriculum as a "vacation" period between the second and third years. While text books from classes and review books are a large part of preparation, commercial test-prep services and software are extensively used. This represents an additional $500-$1500 out of pocket expense.
If all goes well, you pass. by report, 7 out of 100 in my medical school class did not and repeated the test. Once complete, you move on to the third year of medical school and things really heat up. Third year is sort of like playing pro-football with no pads and no experience. You are rounding daily with medical teams, always judged by your smile and apparent willingness to learn, a tough thing to keep up as the days grow longer and the tasks grow more mundane. For instance, on my surgery rotation, I stood for 11 hours once holding a retractor in place. I did not ask to go to the bathroom (that is unheard of). I did not eat. I just stood, in place, holding for 11 hours. On my medicine rotation, I was once asked to "support" a patient's testicles while someone scraped the skin beneath them into a vial. And on and on the stories go. The good news is that, luckily, you're learning the whole time, and hopefully you have not decided yet that this profession is for fools but rather it is a privilege to be there (which was a tough sell on testicle night!) In truth, in the first two years you learn the words and alphabet of medicine. In the third year you get dropped off in the foreign country for immersion. The experiences are unforgettable, and often difficult. I had never actually witnessed someone breathe their last breath. I had never seen an ulcer so deep that the bones and muscles were exposed all the way down. I had never seen a husband lose a wife, or an old person dying alone, or someone on the brink of dying walk out of the hospital a week later.
Meanwhile, the grades pour in. I was evaluated for my six rotations an average of 14 times per rotation. Most of these evaluations are subjective. The surgery resident who cheated on his girlfriend in front of me at a bar one night evaluated me poorly. There was nothing I could say. By and large, having now been on the flip side as the evaluator, I think it entirely (with a few exceptions) the fault of the residents and attending physicians if a student under their tutelage does not excel. Everyone has passed the brightness test, some just needs constructive feedback early on to help shape behavior and learning. One of the more detested med students I encountered got a much needed sit down by an attending 2 weeks into his medicine rotation on my service and ended up a superstar. It turned out that she was terrified, and overcompensated by coming across arrogant. And that emotional roller coaster, mixed with terrifying immersion is the third year of medical school.
And the truth is, med school could and probably should end there. By the end of third year, students have rotated through Medicine, Surgery, OBGYN, Psychiatry, Family Medicine (in some places), Pediatrics and occasionally Neurology and are prepared to chose their paths. So then you wait another year, taking electives and as much time as you can to your family and friends before Internship. First, of course, two more step exams for the USMLE. One (Step 2 CS) requires travel to one of six US cities where fake patients are arranged with fake ailments and grade you according to your diagnostic skill, physical exam prowess, and generally, how not creepy you are. This costs $1000 plus travel. The other is Step 2 CK. For most people, this is easier than Step 1. And most do better (as did I) on this exam. But for me, I found it a more terrifying task. Partly, perhaps, because it is 9 hours long. But mostly because I felt a strong sense of responsibility to pass- a voice inside me begging: "You can't screw this up, or you're a shitty doctor." I've never felt pressure like that. And that was only the first of so many times that I felt that way.
My next entry will focus on Internships and Residency. But before I part I will say this for medical school, and pre-med as well: Only fools go so far as to get into medical school these days without a clue of what is to come. There is a reason, in times of economic prosperity, that the number applications for enrollment to US medical schools plummet and then peak in times of trouble: Other jobs represent easier earned money. But the day I graduated from medical school, not yet knowing that I knew nothing still, I felt a sense of joy that I had chosen a path that asked everything of me. It was a humbling experience, really, to take the diploma from the Dean of Students' hand. I knew now that there was no turning back, and that I was truly a step closer to my dream. I just didn't know yet what that dream really encompassed.
http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande?currentPage=all
My patient wife has now been with me for seven years, that's seven out of the eight I've been in medical training. My average salary, including the negative $34,000/year in loan debt I was in during medical school and then the $48,000-$54000 salaries I've had in internship, residency and now fellowship comes to an astonishing $8000/year average net in those 8 years. We have squeaked by with moonlighting, and very good money management (by her, thank god!) But needless to say, articles about blaming doctors scare both of us- sitting where we sit- having put in everything to make virtually nothing yet. Especially given how much money insurance companies made last year.
So I'll start at the beginning which is how to get into medical school. Basically, medical school is a daunting task from the moment a young high school student or college student begins to read on what getting in requires. There is the traditional pre-med track which, as of 2009, still includes very unnecessary coursework (physics, organic chemistry, calculus) and a few vital topics including biology, chemistry. At most schools these are the more popular classes and majors. At most schools these are also the toughest to get As in. And you need As. The average GPA for enrollment in a US medical school in 2008 was a 3.76 on a 4 point scale. You also need superb extracurricular activities, letters from multiple professors, and more and more, hands on experience in the form of volunteer work or real work. An increasing number of applicants are graduating and becoming EMTs or paramedics or nurses prior to applying to medical school. They are well ahead of the traditional track college grads in terms of real life experience (something I think vital to becoming a well-rounded young doctor).
As for the odds: According to the American Association of Medical Colleges, in 2008, there were 558,053 applications from 42,231 applicants, (an average of 13 applications per applicant) to US medical schools. Of these 42,231, there are 18,036 spots to fill. So approximately 1 out of 3 applicants lands a coveted spot. An approximately 2 out of 3 do not. That's 2/3 of people going through all of the same training, coursework, letters, applications (13!) and interviews as their more fortunate peers who are told "maybe next year." That's right, interviews. One needs to travel at his or hr expense to the medical schools for rigorous interviews where everything is asked from, "How much money do you expect to pay on your own and how much are your parents going to pay?" (which one of my friends whose parents were dead was asked at a certain southern state school) to "Who is your favorite American Idol?" Most of the questions are geared towards seeing how you do under pressure. And many of these quizzes have no right answer. One famous admissions director was known for theatrics, often leaving the room during his interviews for an uncomfortable amount of time. I interviewed at 9 medical schools in 2000-2001, and I left 9 interviews feeling odd, and somehow wronged.
So if you are in the lucky third, you're in! And then comes the biggest reality check of your life: Medical school is hard. It's really, really hard. For two years you memorize the equivalent of the New York City phone book. I counted tests one semester in my second year: 37. I was tested 37 times in 21 weeks. Almost two tests a week. After a while the multiple choice bubbles all look the same, and the books all sound the same. And then comes the first of 4 huge national tests, the United States Medical Licensing Examination (USMLE) step one. This is notoriously the worst experience of everyone's life. It's a testament to minutia, a dedication to memory and unimportant tidbits. The stuff written at the side margin of page 238: That's tested. The stuff mumbled once by a professor who barely spoke English: On the test. And it's 8 hours long, at a computer testing center, usually somewhere you've never been before. Most students set aside approximately one month in order to prepare for Step 1. Most medical schools build this study period into their curriculum as a "vacation" period between the second and third years. While text books from classes and review books are a large part of preparation, commercial test-prep services and software are extensively used. This represents an additional $500-$1500 out of pocket expense.
If all goes well, you pass. by report, 7 out of 100 in my medical school class did not and repeated the test. Once complete, you move on to the third year of medical school and things really heat up. Third year is sort of like playing pro-football with no pads and no experience. You are rounding daily with medical teams, always judged by your smile and apparent willingness to learn, a tough thing to keep up as the days grow longer and the tasks grow more mundane. For instance, on my surgery rotation, I stood for 11 hours once holding a retractor in place. I did not ask to go to the bathroom (that is unheard of). I did not eat. I just stood, in place, holding for 11 hours. On my medicine rotation, I was once asked to "support" a patient's testicles while someone scraped the skin beneath them into a vial. And on and on the stories go. The good news is that, luckily, you're learning the whole time, and hopefully you have not decided yet that this profession is for fools but rather it is a privilege to be there (which was a tough sell on testicle night!) In truth, in the first two years you learn the words and alphabet of medicine. In the third year you get dropped off in the foreign country for immersion. The experiences are unforgettable, and often difficult. I had never actually witnessed someone breathe their last breath. I had never seen an ulcer so deep that the bones and muscles were exposed all the way down. I had never seen a husband lose a wife, or an old person dying alone, or someone on the brink of dying walk out of the hospital a week later.
Meanwhile, the grades pour in. I was evaluated for my six rotations an average of 14 times per rotation. Most of these evaluations are subjective. The surgery resident who cheated on his girlfriend in front of me at a bar one night evaluated me poorly. There was nothing I could say. By and large, having now been on the flip side as the evaluator, I think it entirely (with a few exceptions) the fault of the residents and attending physicians if a student under their tutelage does not excel. Everyone has passed the brightness test, some just needs constructive feedback early on to help shape behavior and learning. One of the more detested med students I encountered got a much needed sit down by an attending 2 weeks into his medicine rotation on my service and ended up a superstar. It turned out that she was terrified, and overcompensated by coming across arrogant. And that emotional roller coaster, mixed with terrifying immersion is the third year of medical school.
And the truth is, med school could and probably should end there. By the end of third year, students have rotated through Medicine, Surgery, OBGYN, Psychiatry, Family Medicine (in some places), Pediatrics and occasionally Neurology and are prepared to chose their paths. So then you wait another year, taking electives and as much time as you can to your family and friends before Internship. First, of course, two more step exams for the USMLE. One (Step 2 CS) requires travel to one of six US cities where fake patients are arranged with fake ailments and grade you according to your diagnostic skill, physical exam prowess, and generally, how not creepy you are. This costs $1000 plus travel. The other is Step 2 CK. For most people, this is easier than Step 1. And most do better (as did I) on this exam. But for me, I found it a more terrifying task. Partly, perhaps, because it is 9 hours long. But mostly because I felt a strong sense of responsibility to pass- a voice inside me begging: "You can't screw this up, or you're a shitty doctor." I've never felt pressure like that. And that was only the first of so many times that I felt that way.
My next entry will focus on Internships and Residency. But before I part I will say this for medical school, and pre-med as well: Only fools go so far as to get into medical school these days without a clue of what is to come. There is a reason, in times of economic prosperity, that the number applications for enrollment to US medical schools plummet and then peak in times of trouble: Other jobs represent easier earned money. But the day I graduated from medical school, not yet knowing that I knew nothing still, I felt a sense of joy that I had chosen a path that asked everything of me. It was a humbling experience, really, to take the diploma from the Dean of Students' hand. I knew now that there was no turning back, and that I was truly a step closer to my dream. I just didn't know yet what that dream really encompassed.
Wednesday, June 17, 2009
Breath by breath
At 9am this morning I sat on a pleasant 40 something year old woman's bed. The sun was dancing off the buildings out her 14th floor windows, splashing Boston with the energetic glow of late spring. I took a breath and thought about that breath. Once, when I was an inpatient, I counted breaths for hours. I listened to the ins and outs, and pondered day after day about how much I had taken for granted, like the invisible air around me, or brushing my own teeth, or taking a shower, or walking. The woman on whose bed I sat has a limited number of breaths left in her lungs. But hopefully she was not partaking in my maddening count. She has more important things on her mind, like the fact that she is scheduled for a bilateral lung transplant in a month or so. That means, in English, that she is going to have both of someone else's lungs replace her own- an absolutely mind blowing feat of modern technology, medicine, thinking and reasoning. But the back story, and what has transpired in the past week which lead me to her bedside this morning is more amazing than the surgery itself.
6 years ago, this pleasant mother and wife developed a cough. She thought nothing of it for about a half of a year, and then, at the suggestion of a friend, she sought advice from her doctor. She was prescribed cough medicines and after another month an X-ray was done which was fairly unremarkable. But as the cough persisted, she underwent a CT scan and that revealed pulmonary fibrosis, or scarring of the lungs. At the time the scarring was minimal, and she was followed closely by a pulmonologist who measured her lung function and noted, throughout the next year that this steadily declined. At the time she also had hoarseness and saw a gastroenterologist who prescribed an antacid. The gastroenterologist also performed an endoscopy, looking into her stomach and small bowel. All seemed fairly normal and life went on.
Over the next 5 years, her lungs steadily declined. The working diagnosis was "Idiopathic Pulmonary Fibrosis" which means "Fibrosis for god knows why." In fact, the word "Idiopathic" scares me as a doctor for that is when we reach the boundary between what we know and what we do not know and admit defeat. Almost every organ has its idiopathic conditions. Strictly speaking, the word is defined as: Arising spontaneously or from an obscure or unknown cause. It hails originally from the Greek ἴδιος, idios (one's own) + πάθος, pathos (suffering), and translates more appropriately to something like "a disease of its own kind." All in all, if you get sick, you don't want the word idiopathic thrown in- because usually "there is very little we can do" soon follows. Eventually, as many who suffer from debilitating lung disease come to learn, the pressures in her pulmonary artery increased leading to pulmonary hypertension and subsequent heart disease as well. In those same 5 years, she had 2 additional endoscopies performed by her gastroenterologist for progressive food sticking. Swallowing became a nuisance for her, and while she got most foods down, it often took water to "rinse" down a meal before she felt like it was out of her chest.
I met her last week, when the team caring for her called a gastroenterology consult on the supposed last day of her admission. She was in the hospital for a pre-transplant evaluation, when a series of tests are performed to evaluate how someone is doing from a lung perspective and how they will do post-operatively. She happened to mention the swallowing issue and an astute intern thought it was worth mentioning to an equally astute surgeon who called our team to see her. Luckily for me, I was on call that day, which meant that I was answering pages (38 that morning). I eventually made my way to her chart, and then to her and listened to the whole story. I asked her about her swallowing, and found out an amazing amount of detail about the sensation of food sticking, about what brought it on, and when. I found out that cold foods sometimes triggered her symptoms. I found out that she often felt yesterday's meal still "sitting there" and pointed to her chest.
The next day I was staring in awe at the film I had asked her surgeons to obtain. A film of her esophagus after she swallowed barium contrast. And the esophagus narrowed to a point, or the so-called "bird's beak" which is hallmark for a disease called Achalasia. A day later I had a tube placed from her nose into her stomach with pressure readings taken over an hour including when she swallowed. The manometric readings from that esophageal motility study confirmed the diagnosis.
Achalasia isn't so incredibly uncommon. I've diagnosed this 4 times this year and will see it again many times in my career. The treatments vary but involve opening the dysfunctional muscular sphincter at the bottom of the esophagus to allow the equally dysfunctional pipe-like esophagus to pass food by gravity, for the normal waves of contraction that aid food into the stomach are absent. But perhaps the most under appreciated side effect of achalasia, and one which makes this a sad story, is that of aspiration. Food stuck in the esophagus, and acidified liquids can reflux backwards, spill over the epiglottis into the trachea (the windpipe) and then move downward by gravity into the lungs. While the food itself usually doesn't present the biggest problem, the chemicals and acids which spill cause a condition called pneumonitis which, over time, can ruin perfectly good lungs.
This woman didn't have idiopathic anything. She had a longstanding condition in her esophagus which ruined her lungs. Three times a gastroenterologist performed an investigation with a camera (as I did the day after the diagnosis was confirmed), and three times he found nothing (as did I). In fact, Achalasia is not diagnosed by endoscopy. The tissue looks perfectly normal. The damage is at the level of nerves, and the dysfunction is best captured by imaging and manometry.
It is so easy, in medicine, to point a finger. We doctors love to talk about 20/20 hindsight. Coming in later in the game is always an advantage. Someone else's negative workup allows you not the stumble down the same pathway. But 3 tests? All the same test? This seemed quite odd.
What astounded me more, as I sat on her bed and watched a plane gain altitude over the city, was that she called her gastroenterologist yesterday and told him what had transpired- that this was Achalasia after all of these years, and that she was angry with him. He said that there was nothing we would be able to do. He told her this was something she would have to live with, and that ours was a wasted effort. When she told me this we both smiled. Because yesterday, after I was finished with the investigatory portion of my endoscopy, I injected botulinum toxin (botox) into the sphincter at the base of her esophagus through a special needle that fits into the channel of the scope. As a result, she enjoyed dinner last night for the first time in 5 years.
She will get a lung transplant. And before then she'll have a definitive esophageal surgery to cut the muscle holding that sphincter (botox only lasts a few months). And she will have new lungs that are spared the acid that ate her current ones. And then she can watch her kids grow up, and share a pizza with them, and share their laughter.
On her bed today, I had questions: What if this had been diagnosed 5 years ago? Who is that arrogant doctor (and in my field no less!)? Will she beat the odds and actually live more than 6-10 years after her operation? Is she better off knowing the diagnosis now? And knowing it was missed? Did I do her a service after all? Is there bliss in "idiopathic?" In ignorance? But I just sat there and shared a laugh with her as she enjoyed a pancake- neither of us taking a bite of it for granted.
6 years ago, this pleasant mother and wife developed a cough. She thought nothing of it for about a half of a year, and then, at the suggestion of a friend, she sought advice from her doctor. She was prescribed cough medicines and after another month an X-ray was done which was fairly unremarkable. But as the cough persisted, she underwent a CT scan and that revealed pulmonary fibrosis, or scarring of the lungs. At the time the scarring was minimal, and she was followed closely by a pulmonologist who measured her lung function and noted, throughout the next year that this steadily declined. At the time she also had hoarseness and saw a gastroenterologist who prescribed an antacid. The gastroenterologist also performed an endoscopy, looking into her stomach and small bowel. All seemed fairly normal and life went on.
Over the next 5 years, her lungs steadily declined. The working diagnosis was "Idiopathic Pulmonary Fibrosis" which means "Fibrosis for god knows why." In fact, the word "Idiopathic" scares me as a doctor for that is when we reach the boundary between what we know and what we do not know and admit defeat. Almost every organ has its idiopathic conditions. Strictly speaking, the word is defined as: Arising spontaneously or from an obscure or unknown cause. It hails originally from the Greek ἴδιος, idios (one's own) + πάθος, pathos (suffering), and translates more appropriately to something like "a disease of its own kind." All in all, if you get sick, you don't want the word idiopathic thrown in- because usually "there is very little we can do" soon follows. Eventually, as many who suffer from debilitating lung disease come to learn, the pressures in her pulmonary artery increased leading to pulmonary hypertension and subsequent heart disease as well. In those same 5 years, she had 2 additional endoscopies performed by her gastroenterologist for progressive food sticking. Swallowing became a nuisance for her, and while she got most foods down, it often took water to "rinse" down a meal before she felt like it was out of her chest.
I met her last week, when the team caring for her called a gastroenterology consult on the supposed last day of her admission. She was in the hospital for a pre-transplant evaluation, when a series of tests are performed to evaluate how someone is doing from a lung perspective and how they will do post-operatively. She happened to mention the swallowing issue and an astute intern thought it was worth mentioning to an equally astute surgeon who called our team to see her. Luckily for me, I was on call that day, which meant that I was answering pages (38 that morning). I eventually made my way to her chart, and then to her and listened to the whole story. I asked her about her swallowing, and found out an amazing amount of detail about the sensation of food sticking, about what brought it on, and when. I found out that cold foods sometimes triggered her symptoms. I found out that she often felt yesterday's meal still "sitting there" and pointed to her chest.
The next day I was staring in awe at the film I had asked her surgeons to obtain. A film of her esophagus after she swallowed barium contrast. And the esophagus narrowed to a point, or the so-called "bird's beak" which is hallmark for a disease called Achalasia. A day later I had a tube placed from her nose into her stomach with pressure readings taken over an hour including when she swallowed. The manometric readings from that esophageal motility study confirmed the diagnosis.
Achalasia isn't so incredibly uncommon. I've diagnosed this 4 times this year and will see it again many times in my career. The treatments vary but involve opening the dysfunctional muscular sphincter at the bottom of the esophagus to allow the equally dysfunctional pipe-like esophagus to pass food by gravity, for the normal waves of contraction that aid food into the stomach are absent. But perhaps the most under appreciated side effect of achalasia, and one which makes this a sad story, is that of aspiration. Food stuck in the esophagus, and acidified liquids can reflux backwards, spill over the epiglottis into the trachea (the windpipe) and then move downward by gravity into the lungs. While the food itself usually doesn't present the biggest problem, the chemicals and acids which spill cause a condition called pneumonitis which, over time, can ruin perfectly good lungs.
This woman didn't have idiopathic anything. She had a longstanding condition in her esophagus which ruined her lungs. Three times a gastroenterologist performed an investigation with a camera (as I did the day after the diagnosis was confirmed), and three times he found nothing (as did I). In fact, Achalasia is not diagnosed by endoscopy. The tissue looks perfectly normal. The damage is at the level of nerves, and the dysfunction is best captured by imaging and manometry.
It is so easy, in medicine, to point a finger. We doctors love to talk about 20/20 hindsight. Coming in later in the game is always an advantage. Someone else's negative workup allows you not the stumble down the same pathway. But 3 tests? All the same test? This seemed quite odd.
What astounded me more, as I sat on her bed and watched a plane gain altitude over the city, was that she called her gastroenterologist yesterday and told him what had transpired- that this was Achalasia after all of these years, and that she was angry with him. He said that there was nothing we would be able to do. He told her this was something she would have to live with, and that ours was a wasted effort. When she told me this we both smiled. Because yesterday, after I was finished with the investigatory portion of my endoscopy, I injected botulinum toxin (botox) into the sphincter at the base of her esophagus through a special needle that fits into the channel of the scope. As a result, she enjoyed dinner last night for the first time in 5 years.
She will get a lung transplant. And before then she'll have a definitive esophageal surgery to cut the muscle holding that sphincter (botox only lasts a few months). And she will have new lungs that are spared the acid that ate her current ones. And then she can watch her kids grow up, and share a pizza with them, and share their laughter.
On her bed today, I had questions: What if this had been diagnosed 5 years ago? Who is that arrogant doctor (and in my field no less!)? Will she beat the odds and actually live more than 6-10 years after her operation? Is she better off knowing the diagnosis now? And knowing it was missed? Did I do her a service after all? Is there bliss in "idiopathic?" In ignorance? But I just sat there and shared a laugh with her as she enjoyed a pancake- neither of us taking a bite of it for granted.
Saturday, June 13, 2009
Our fault
I am in a unique place, as a budding gastroenterologist. For one, I am a subspecialist. I am board certified (after several one or two day multiple choice examinations and 7 years of post college training) in internal medicine. Now, like many of my peers, I have chosen years 8-10, to learn in depth about one organ system. In my case, it is a love of all things digestive, or, as I joke with my friends: "everything from the mouth to the bum including the liver and the pancreas." One thing that I like particularly about my field is the fact that I can help people with many of their ailments. And when I cannot, I can either turn the patients over to doctors who can (for instance in the case of cancers, where oncologists or surgeons become part of the care team), or I can provide support in other ways (like sending my patient with intractable nausea to an acupuncturist last month- yes, it worked!) Sharing in care is one of the great joys of being a doctor. Each time I call or email a specialist in a different field I am astounded by what there is to learn, and eager to hear their perspective which is often grounded in how they see the body or have been trained to see. But last month, in sharing a patient with a particular cancer specialist, I learned a harrowing lesson about how medical doctors may be contributing to the problems I have alluded to in earlier posts with end-of-life care. Tonight I share this experience:
My patient is a sad story. At 17 she had her first of 3 children all by different men, two of whom are alcoholics who she kicked out of her home years ago. At 28 she lost her job and shortly thereafter got into a car accident and was on disability for years. At 39 she saw a physician for constipation who discovered that she had anemia as well and she underwent a colonoscopy and was found to have stage 4 colon cancer with metastases to her liver. So now, at 40 she has a 23 year old, a 19 year old and an 11 year old. She could not afford college for the older kids so they did not attend. She had trouble motivating them without a father figure in their lives. So this is hard: A 40 year old mother of 3 who will be dead in a year or two. As it turns out, her mother died of colon cancer in her 50s. She never told anyone that until it was too late.
It is here where the branch point begins. There are probably a thousand different paths we doctors could take at this stage. Here are 3 such paths:
1) There are new drugs out there, and protocols for drugs yet to be tested in the human body. The consent forms for enrollment into these studies are long and tedious due to the liability which needs to be carefully explained to the patient. Hours are spent on education and most of the education is in what can go awry. Complete understanding needs to be demonstrated by the patient (which requires a fair amount of intelligence that many lack) in order to enroll. Once enrolled, the patient needs to be compliant with the protocol, often involving stopping other medications, or eating certain foods. Protocols are strict about getting scheduled blood draws, showing up to doctor's appointments, returning screening phone calls. As one patient smartly put it once, "this miracle pill thing is a full time job." And the truth is, of all of the drugs out there in protocols, the vast majority will not cure the illness. In many cancers, a "success" is an additional 2 months of life. And at what cost? The side effects of these agents can be horrific. I watched a patient turn green and lose her hair in 3 days once on a new medication that was supposed to extend her life. On the flip side- think for a moment about that 11 year old. Isn't every moment with a mother a moment worth living? Before I had my daughter I might have flippantly judged a patient willing to sacrifice quality of life over days on Earth- now I have to think twice.
2) You are dying and I am going to help you have a wonderful death. Yes, I wrote "wonderful death." There is such a thing. We talk about good and bad deaths all of the time in the hospital but we don't always know what we're trying to say. Here's a good death: A 72 year old composer died last year in the ICU when I was rotating there with his 4 children and wife by his side and his favorite cello concerto playing on a CD player. He had not a single IV in his arm when he died. The room was quiet and they cried and laughed and spent 2 extra hours with him even after he passed. It was the most peaceful, beautiful death I've ever seen. And I felt honored to be a part of that. Now here's a bad death I witnessed: A 59 year old grandmother of 4 died slowly after months of inoperable gallbladder cancer and a total of 14 procedures including surgeries to relieve bowel obstructions. She died in an ICU over 11 days as the medical team pleaded with the family to reverse her code status should she go into respiratory of cardiac failure. 3 family members did not want her resuscitated but her official health care proxy was her eldest daughter who kept her code status as "full" and she then underwent 2 separate cardiac arrests requiring CPR and shocks in the final week of her life. After she died, the family members who wished for her to not receive the resuscitations did not speak to the daughter or the doctors out of anger.
3) You are going to die, but you can fight fight fight and I will fight with you. This is perhaps the most common scenario. The drugs that exist do delay death, and despite their side effects, patients often chose hair loss, nausea, weight loss over an early exit. In this case, the doctor is the mediator and the bulldog. This is often the oncologic stance.
In each scenario the doctor has a role- we are salesmen, biased by our own ethics and morals and religious beliefs and backgrounds and sometimes even by money (this one makes me sick). And in those moments of utter helplessness, patients turn to us as if we had divine insights- which we do not (although this scene from Malice is worth a much needed laugh right now! http://www.youtube.com/watch?v=LqeC3BPYTmE). At the end of the day, we bias our patients left and right, whether we admit it or not.
My unfortunate 40 year old patient was told, by her oncologist, "We can prolong your life." She was told, "We can give you time." The doctor that day never said "We can give you quality life and quality time." She bought it. She is now hairless, upset, in the hospital, and beginning to die a bad death. In the end this is her choice. But I am not at all convinced that she had the tools to begin with to understand her choices despite her clear thinking and ability to demonstrate some basic knowledge of her decision. Perhaps an ethics board should convene for each and every dying patient, early in their disease if possible, to discuss their options for them. These could be explained to the patient carefully and meticulously and a truly informed decision could be rendered. But this would cost money and time, neither of which is readily available in today's world.
At the end of the day, she will live a month or two longer in and out of the hospital than she would have staying at home, with her 11 year old by her side- a boy who had a chance to learn a vital lesson in what constitutes a good death- albeit at a much too early age.
My patient is a sad story. At 17 she had her first of 3 children all by different men, two of whom are alcoholics who she kicked out of her home years ago. At 28 she lost her job and shortly thereafter got into a car accident and was on disability for years. At 39 she saw a physician for constipation who discovered that she had anemia as well and she underwent a colonoscopy and was found to have stage 4 colon cancer with metastases to her liver. So now, at 40 she has a 23 year old, a 19 year old and an 11 year old. She could not afford college for the older kids so they did not attend. She had trouble motivating them without a father figure in their lives. So this is hard: A 40 year old mother of 3 who will be dead in a year or two. As it turns out, her mother died of colon cancer in her 50s. She never told anyone that until it was too late.
It is here where the branch point begins. There are probably a thousand different paths we doctors could take at this stage. Here are 3 such paths:
1) There are new drugs out there, and protocols for drugs yet to be tested in the human body. The consent forms for enrollment into these studies are long and tedious due to the liability which needs to be carefully explained to the patient. Hours are spent on education and most of the education is in what can go awry. Complete understanding needs to be demonstrated by the patient (which requires a fair amount of intelligence that many lack) in order to enroll. Once enrolled, the patient needs to be compliant with the protocol, often involving stopping other medications, or eating certain foods. Protocols are strict about getting scheduled blood draws, showing up to doctor's appointments, returning screening phone calls. As one patient smartly put it once, "this miracle pill thing is a full time job." And the truth is, of all of the drugs out there in protocols, the vast majority will not cure the illness. In many cancers, a "success" is an additional 2 months of life. And at what cost? The side effects of these agents can be horrific. I watched a patient turn green and lose her hair in 3 days once on a new medication that was supposed to extend her life. On the flip side- think for a moment about that 11 year old. Isn't every moment with a mother a moment worth living? Before I had my daughter I might have flippantly judged a patient willing to sacrifice quality of life over days on Earth- now I have to think twice.
2) You are dying and I am going to help you have a wonderful death. Yes, I wrote "wonderful death." There is such a thing. We talk about good and bad deaths all of the time in the hospital but we don't always know what we're trying to say. Here's a good death: A 72 year old composer died last year in the ICU when I was rotating there with his 4 children and wife by his side and his favorite cello concerto playing on a CD player. He had not a single IV in his arm when he died. The room was quiet and they cried and laughed and spent 2 extra hours with him even after he passed. It was the most peaceful, beautiful death I've ever seen. And I felt honored to be a part of that. Now here's a bad death I witnessed: A 59 year old grandmother of 4 died slowly after months of inoperable gallbladder cancer and a total of 14 procedures including surgeries to relieve bowel obstructions. She died in an ICU over 11 days as the medical team pleaded with the family to reverse her code status should she go into respiratory of cardiac failure. 3 family members did not want her resuscitated but her official health care proxy was her eldest daughter who kept her code status as "full" and she then underwent 2 separate cardiac arrests requiring CPR and shocks in the final week of her life. After she died, the family members who wished for her to not receive the resuscitations did not speak to the daughter or the doctors out of anger.
3) You are going to die, but you can fight fight fight and I will fight with you. This is perhaps the most common scenario. The drugs that exist do delay death, and despite their side effects, patients often chose hair loss, nausea, weight loss over an early exit. In this case, the doctor is the mediator and the bulldog. This is often the oncologic stance.
In each scenario the doctor has a role- we are salesmen, biased by our own ethics and morals and religious beliefs and backgrounds and sometimes even by money (this one makes me sick). And in those moments of utter helplessness, patients turn to us as if we had divine insights- which we do not (although this scene from Malice is worth a much needed laugh right now! http://www.youtube.com/watch?v=LqeC3BPYTmE). At the end of the day, we bias our patients left and right, whether we admit it or not.
My unfortunate 40 year old patient was told, by her oncologist, "We can prolong your life." She was told, "We can give you time." The doctor that day never said "We can give you quality life and quality time." She bought it. She is now hairless, upset, in the hospital, and beginning to die a bad death. In the end this is her choice. But I am not at all convinced that she had the tools to begin with to understand her choices despite her clear thinking and ability to demonstrate some basic knowledge of her decision. Perhaps an ethics board should convene for each and every dying patient, early in their disease if possible, to discuss their options for them. These could be explained to the patient carefully and meticulously and a truly informed decision could be rendered. But this would cost money and time, neither of which is readily available in today's world.
At the end of the day, she will live a month or two longer in and out of the hospital than she would have staying at home, with her 11 year old by her side- a boy who had a chance to learn a vital lesson in what constitutes a good death- albeit at a much too early age.
Sunday, June 7, 2009
Time's up
Last evening at 3am during a moonlighting shift, (translation: extra work as an in-hospital overnight doctor for the money I need to sustain my family), I got a call from the ICU that every doctor dreads. The conversation went something like this:
Nurse: "Doctor, patient X has no traceable blood pressure, is on multiple pressors [medications to maintain his blood pressure] and has blue hands now. His wife is in the room and would like to speak with you."
Me (half asleep in between admitting 7 patients in the emergency room): "Why is he on multiple pressors? Why is he in the ICU?"
Nurse: "He coded 3 times today and underwent CPR for an hour with multiple defibrillations (shocks) and then had a full pulseless arrest and then finally came back with multiple resuscitation attempts and is now intubated [on a breathing tube] in our unit."
Me: "And the family knows his outlook and wants our aggressive care?"
Nurse: "Well- I'm not sure...."
Me (now much more awake): "I'm on my way."
So I arrived in the ICU, room 12, to find a kind woman sitting calmly at the end of my intubated patient's bed. His hands were indeed blue. That was secondary to our medications. His breathing was 100% automated by our machine. How much brain function he had remained unclear, but he was 85 years old and had undergone over an hour of intense resuscitation requiring the cracking of several ribs during CPR, placement of invasive lines, strangers hands everywhere- in every orifice- in an ignorant attempt to cheat the inevitable.
Of course, at 3am, standing before his wife of 58 years, who was I to judge or divulge? Will I not, one day, faced with the exquisitely painful moment of my own spouse's death, ask for anything and everything possible to relieve me of all of that? Believe it or not, I don't think so. The truth is, in these years, seeing so many bodies take their last breaths (as every doctor does over time), I understand clearly that life ends, and that it is not up to us to decide when. I've seen wonderful 30 year old mothers die with their husband and toddlers at her side. And I've seen miserly old women die friendless and alone. And in both cases, the body could no longer sustain itself. As clear as it could be in these instances, it was time, even if the death itself seemed untimely.
In the next 10 minutes, I discovered everything. I found out that they met in high school. That he smoked and that she loved that about him. "It made him seem so cool" she told me. "And he was cool." Certainly it sounded that way to me. This man, who had worked construction before becoming a successful building inspector- had started a business with his own hands and become a complete success. And his daughter, weeping quietly in the corner, proved that he was leaving a compassionate legacy that will carry his name and his DNA forward.
Then I laid out the prognosis: that he would surely be dead in a matter of hours. I am not cavalier about divulging such statements. In fact, I, like most of my peers, hate to prognosticate as we doctors take the huge risk, when doing so, that we will face anger from families and our own guilt if we are wrong. But in this case it was inevitable that he was dying. So I asked his wife what he would want, in his final hours.
"Not this," she said, "god not this."
Within an hour the tubes were removed, and the lights dimmed, and a quiet room was established where his 3 daughters now sat with their mother beside him. A final family moment before, like the cobalt sky of pre-dawn, he was gone.
Nurse: "Doctor, patient X has no traceable blood pressure, is on multiple pressors [medications to maintain his blood pressure] and has blue hands now. His wife is in the room and would like to speak with you."
Me (half asleep in between admitting 7 patients in the emergency room): "Why is he on multiple pressors? Why is he in the ICU?"
Nurse: "He coded 3 times today and underwent CPR for an hour with multiple defibrillations (shocks) and then had a full pulseless arrest and then finally came back with multiple resuscitation attempts and is now intubated [on a breathing tube] in our unit."
Me: "And the family knows his outlook and wants our aggressive care?"
Nurse: "Well- I'm not sure...."
Me (now much more awake): "I'm on my way."
So I arrived in the ICU, room 12, to find a kind woman sitting calmly at the end of my intubated patient's bed. His hands were indeed blue. That was secondary to our medications. His breathing was 100% automated by our machine. How much brain function he had remained unclear, but he was 85 years old and had undergone over an hour of intense resuscitation requiring the cracking of several ribs during CPR, placement of invasive lines, strangers hands everywhere- in every orifice- in an ignorant attempt to cheat the inevitable.
Of course, at 3am, standing before his wife of 58 years, who was I to judge or divulge? Will I not, one day, faced with the exquisitely painful moment of my own spouse's death, ask for anything and everything possible to relieve me of all of that? Believe it or not, I don't think so. The truth is, in these years, seeing so many bodies take their last breaths (as every doctor does over time), I understand clearly that life ends, and that it is not up to us to decide when. I've seen wonderful 30 year old mothers die with their husband and toddlers at her side. And I've seen miserly old women die friendless and alone. And in both cases, the body could no longer sustain itself. As clear as it could be in these instances, it was time, even if the death itself seemed untimely.
In the next 10 minutes, I discovered everything. I found out that they met in high school. That he smoked and that she loved that about him. "It made him seem so cool" she told me. "And he was cool." Certainly it sounded that way to me. This man, who had worked construction before becoming a successful building inspector- had started a business with his own hands and become a complete success. And his daughter, weeping quietly in the corner, proved that he was leaving a compassionate legacy that will carry his name and his DNA forward.
Then I laid out the prognosis: that he would surely be dead in a matter of hours. I am not cavalier about divulging such statements. In fact, I, like most of my peers, hate to prognosticate as we doctors take the huge risk, when doing so, that we will face anger from families and our own guilt if we are wrong. But in this case it was inevitable that he was dying. So I asked his wife what he would want, in his final hours.
"Not this," she said, "god not this."
Within an hour the tubes were removed, and the lights dimmed, and a quiet room was established where his 3 daughters now sat with their mother beside him. A final family moment before, like the cobalt sky of pre-dawn, he was gone.
Tuesday, March 31, 2009
Hotel Hospital-ity
Tonight I write about the needs of people. Not people whose needs are filled on a daily basis by their spouses, or families, or jobs, or hobbies, or friends. But there are a host of people out there in need of something- otherwise unfulfilled in their lives- but unaware of what that something is. Some of these people are mentally ill. Some are addicted to substances. But this entry is about another category of person-one that I have been fascinated by since I was in medical school: Lonely, sane people.
On a given Saturday night in the Emergency Room, the crazy people and drunks are abound- but also tucked away, in corner bays, are 22 year old college kids, far away from home with stomach aches. There are 82 year old women with children on the other coast with chest pain. There are 50 year old divorcees with headaches. And after $1000 of tests show "nothing serious," more often than expected these people will ask a simple question: "Please, doctor, can I stay the night?"
When I was 23, I fell almost 3 stories. I broke bones, and had a concussion, and came inches from my death. And I was hospitalized for almost 3 weeks. And at the end of this ordeal, on my last day, I found myself terrified to leave. The nurture that the hospital provided went beyond my broken body. And despite all of the needle sticks, the mistakes, the frustration- call buttons pressed with no answer- catheters left in too long- I derived something in those 3 weeks that I needed for months before the accident: An emotional hug.
A hospital overnight stay costs $1500, even for an uncomplicated patient. This cost takes into account nursing, supplies, a percentage even pays the janitors, keeps the lights on. But the cost doesn't take into account human need. Yes, the homeless man who needs a roof over his head and a cup of soup- it's easier to wrap the brain around giving him a bed. But that 22 year old? Who is to say she won't derive as much, or more from a night of hospital loving? Maybe that night will inspire her in some way to find that feeling of nurturing in a more appropriate place, like a relationship, or in work that she loves, or in giving to her community. And the 82 year old- maybe this is the first, and only human touch she's had in months. Maybe she just needs a reminder in kindness, to make it through another year of arthritis and television.
In an ideal world, perhaps we'd have a special floor in every hospital for these folks. Perhaps funded by those of us with more love in our lives. In reality, 9 times out of 10, our answer to the question is unfortunately no. We don't have the funds for admissions for no good reason. That isn't the point of a hospital. Mental health can be provided in an outpatient setting. Lonely isn't a diagnosis. The arguments I've heard go on and on.
And as I watch these folks walk out, I send them virtual hugs from afar, and hope that they find what they need out there, in a world that is tough on those without.
On a given Saturday night in the Emergency Room, the crazy people and drunks are abound- but also tucked away, in corner bays, are 22 year old college kids, far away from home with stomach aches. There are 82 year old women with children on the other coast with chest pain. There are 50 year old divorcees with headaches. And after $1000 of tests show "nothing serious," more often than expected these people will ask a simple question: "Please, doctor, can I stay the night?"
When I was 23, I fell almost 3 stories. I broke bones, and had a concussion, and came inches from my death. And I was hospitalized for almost 3 weeks. And at the end of this ordeal, on my last day, I found myself terrified to leave. The nurture that the hospital provided went beyond my broken body. And despite all of the needle sticks, the mistakes, the frustration- call buttons pressed with no answer- catheters left in too long- I derived something in those 3 weeks that I needed for months before the accident: An emotional hug.
A hospital overnight stay costs $1500, even for an uncomplicated patient. This cost takes into account nursing, supplies, a percentage even pays the janitors, keeps the lights on. But the cost doesn't take into account human need. Yes, the homeless man who needs a roof over his head and a cup of soup- it's easier to wrap the brain around giving him a bed. But that 22 year old? Who is to say she won't derive as much, or more from a night of hospital loving? Maybe that night will inspire her in some way to find that feeling of nurturing in a more appropriate place, like a relationship, or in work that she loves, or in giving to her community. And the 82 year old- maybe this is the first, and only human touch she's had in months. Maybe she just needs a reminder in kindness, to make it through another year of arthritis and television.
In an ideal world, perhaps we'd have a special floor in every hospital for these folks. Perhaps funded by those of us with more love in our lives. In reality, 9 times out of 10, our answer to the question is unfortunately no. We don't have the funds for admissions for no good reason. That isn't the point of a hospital. Mental health can be provided in an outpatient setting. Lonely isn't a diagnosis. The arguments I've heard go on and on.
And as I watch these folks walk out, I send them virtual hugs from afar, and hope that they find what they need out there, in a world that is tough on those without.
Tuesday, March 17, 2009
9 pm Negligence
My readers, however many of you there are out there. I have spent the last few months in work purgatory, so many apologies for not writing for a while. I will get back to work now on a more consistent basis.
Someone I know died this week. And I was especially touched by her death in many ways. For one, it was a preventable death brought on, at least in part, by negligent health care provided by doctors and nurses (both responsible in this case- but mostly the doctors). I was also touched by how the various members of her family coped with this death.
For starters, the recently deceased was 89 years old, lived independently with her 90 plus year old husband, and in almost every way defied the odds and the norm of what the lay person thinks of "elderly" in that, despite her dementia and quirks that was assuredly due to her age, she was one of the most spirited, self-sufficient and remarkable people I have ever met. She always wore a smile, and despite a memory that failed her, she knew her family well and remembered what they meant to her. Last week she had hip pain and was found to have a small hip fracture which was supposed to be an easy repair but ended up being a larger repair once the orthopedic doctors took a look inside. The surgery went quite well and she was walking, talking, complaining, and acting very much herself by a few days after the operation.
One of the more common post-operative conditions, especially in elderly patients, is one of ileus. Here, the motility of the bowel slows to a halt, and the result is one of what we docs refer to as pseudo-obstruction (pseudo in that the bowel is not actually blocked or twisted, but instead is so slowed or dilated that the end result is the same). And that result is nausea, vomiting, abdominal pain, and a general state of misery. The standard of care for such a state is to give medications for nausea, and place a nasogastric tube from the nose to the stomach which decompresses the stomach of food and air refluxing backwards up the bowel. This tube is placed for comfort, but more importantly to prevent vomiting which inevitably comes with ileus and obstructions after enough time. In all patients, and especially the elderly, vomit can easily pass the epiglottis and travel down the bronchus into the lungs- an event called aspiration. There the acid mixed with food causes a burn called chemical pneumonitis as well as bacterial pneumonias. The end result can be very bad for the lungs.
So on the third day after her hip repair, the beloved great-grandmother, grandmother, mother, and wife developed an ileus and vomited 3 times. Sometime that day her son, who luckily was there visiting, began to advocate on her behalf for something to be done. An IV bag ran out. The bed was not cleaned. And the vomiting continued. Despite promises from doctors, trained, board certified MDs, to place the tube, one was never placed. At 7pm, she vomited and aspirated into her lung a good deal of her vomitus. She was intubated in an intensive care unit an hour later when I found out what had happened, and then died of complications stemming from this by midnight. Just like that- a woman who successfully underwent a big operation, carefully performed by watchful, skilled physicians died from medical neglect just days later.
Now the question is what her family is to do with that anger. Do they bottle it? Do they sue the hospital? I will devote my next blog to lawsuits and medical malpractice, every doctor's nightmare. For now I'd ask you to think about how enraging it is when a life is on the line, and you trust people to cherish that life, and not treat it like a nuisance in a workday- and mistakes happen and the life is lost. There's no making up for that mistake. Money, apology- maybe they help, but they do not heal.
Someone I know died this week. And I was especially touched by her death in many ways. For one, it was a preventable death brought on, at least in part, by negligent health care provided by doctors and nurses (both responsible in this case- but mostly the doctors). I was also touched by how the various members of her family coped with this death.
For starters, the recently deceased was 89 years old, lived independently with her 90 plus year old husband, and in almost every way defied the odds and the norm of what the lay person thinks of "elderly" in that, despite her dementia and quirks that was assuredly due to her age, she was one of the most spirited, self-sufficient and remarkable people I have ever met. She always wore a smile, and despite a memory that failed her, she knew her family well and remembered what they meant to her. Last week she had hip pain and was found to have a small hip fracture which was supposed to be an easy repair but ended up being a larger repair once the orthopedic doctors took a look inside. The surgery went quite well and she was walking, talking, complaining, and acting very much herself by a few days after the operation.
One of the more common post-operative conditions, especially in elderly patients, is one of ileus. Here, the motility of the bowel slows to a halt, and the result is one of what we docs refer to as pseudo-obstruction (pseudo in that the bowel is not actually blocked or twisted, but instead is so slowed or dilated that the end result is the same). And that result is nausea, vomiting, abdominal pain, and a general state of misery. The standard of care for such a state is to give medications for nausea, and place a nasogastric tube from the nose to the stomach which decompresses the stomach of food and air refluxing backwards up the bowel. This tube is placed for comfort, but more importantly to prevent vomiting which inevitably comes with ileus and obstructions after enough time. In all patients, and especially the elderly, vomit can easily pass the epiglottis and travel down the bronchus into the lungs- an event called aspiration. There the acid mixed with food causes a burn called chemical pneumonitis as well as bacterial pneumonias. The end result can be very bad for the lungs.
So on the third day after her hip repair, the beloved great-grandmother, grandmother, mother, and wife developed an ileus and vomited 3 times. Sometime that day her son, who luckily was there visiting, began to advocate on her behalf for something to be done. An IV bag ran out. The bed was not cleaned. And the vomiting continued. Despite promises from doctors, trained, board certified MDs, to place the tube, one was never placed. At 7pm, she vomited and aspirated into her lung a good deal of her vomitus. She was intubated in an intensive care unit an hour later when I found out what had happened, and then died of complications stemming from this by midnight. Just like that- a woman who successfully underwent a big operation, carefully performed by watchful, skilled physicians died from medical neglect just days later.
Now the question is what her family is to do with that anger. Do they bottle it? Do they sue the hospital? I will devote my next blog to lawsuits and medical malpractice, every doctor's nightmare. For now I'd ask you to think about how enraging it is when a life is on the line, and you trust people to cherish that life, and not treat it like a nuisance in a workday- and mistakes happen and the life is lost. There's no making up for that mistake. Money, apology- maybe they help, but they do not heal.
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