10.22.2007

The White Blue Coat...or better yet, avoid MRSA and wear *no* coat!!


I think physicians should wear long light blue coats (if any coat is worn at all). Where I work, the physicians are the *only* people without a white coat!! (I exaggerate, but only a little). It's unfortunate how obscure our various roles have become to the patients. Isn't it important for the patient to be able to identify their RN vs. housekeeping vs. LVN vs. pharmacist vs. physician? I have patients wandering about the ED, asking everyone from the janitor to the registration folks for pain medications and cups of ice water. When they are subsequently instructed to ask their nurse if it's okay to have food/water, they frequently express frustration in being unable to do so. "Which one is my nurse?" Who are the nurses? I'm not sure either...and I work here.

It's important for patients to know and remember that I am their doctor. That they were, in fact, seen by a doctor, and can ask the doctor questions and follow recommendations. If doctors were the only ones with white coats, this would be easy. I would walk in wearing my coat, and the patient would instantly know that they have been seen by a doctor. As it is, no one has a clue. I remember rounding on my patients one morning as a resident (rotating thru medicine) wearing the white coat, name badge displayed, and always introducing myself as "Dr. Backstage," not allowing others to call me by first name as to not interfere with my efforts to be seen as the doctor...and still, when rounds came with the attending, more than once I've had patients complain "I never see a doctor and I've been in here for 3 days." Of course all eyes turn to me...like, 'you haven't actually seen the patient in 3 days?' At these times I look at the patient and say, "Ma'am, I've been here the last 3 days, multiple times a day...had long conversations with you and your daughter..."

"Oh, you're my doctor? But you look so... young, pretty, nice...(I think the word you're looking for is *female.*)

*sigh*
As a patient, I was very confused laying there on the gurney wondering who's who. Who do I ask for help? Lots of people buzzing around busy, busy, busy...asking me questions and doing things to me. I couldn't remember all their names, and they probably did introduce themselves and stated their role...but...trying to curb my anxiety, cooperate, be well, and remember names/roles is difficult. If the nurses had on a certain color/style/pin it would have been easier to place them. If the doctors were the only ones wearing white coats, I would be able to pick them out. If everyone was proud to display *their* respective roles (instead of everyone pretending to be the physician), it would be easier for the patient, and easier for everyone involved.

This is why I think physicians should wear light blue coats. They are classy, don't look as dirty, complement figures and skin tones better than white, and will allow for easier identification. As more women become physicians, and more men enter nursing the typical gender roles are unreliable predictions of current positions on the healthcare team. Making it that much more important to distinguish who's who for the people we serve.
***

Otherwise, we should opt out of wearing coats altogether - afterall, they impede proper handwashing, are full of MRSA (drug resistant bacteria), and make people sick.

10.15.2007

Working at Kaiser as an Internal Medicine Hospitalist

...finally!!
So many of you have sent me emails asking for this post. Here it is, words of wisdom from Kaiser IM hospitalists...

I have a few friends who are IM hospitalists at Kaiser. This is what they had to say...

What is a hospitalist?
A hospitalist is the primary care physician who focuses on inpatient care. I chose to become a hospitalist because I grew weary of the day to day mad-house of ambulatory (clinic) work. Hospitalized patients tend to be "more interesting", and I feel more 'productive' (like I'm really helping sick people feel better) working in the hospital. Also, the business aspect is less cumbersome. I don't have to deal with managing people, a clinic, a business, etc. Also, since the hospital is open 24/7, the hours tend to be more flexible, and shift-like...which has it's perks.

Does a hospitalist have a patient panel? Do they see their patients once they are discharged? If not, what about continuity of care?
No (thankfully) I don't have a patient panel. I am apart of a group of docs that take turns admitting 'someone elses patients' and caring for them in the hospital. And even in that regard, I only manage their case for the time I'm physically in house, then the person I sign out to takes over. Just like all the other professionals in the hospital.

I do not see patients in the clinic...not even after they are discharged. They go back to their primary doctor. Continuity of care? Well, that's becoming evermore non-existent as it becomes more difficult to convince young adults to give up their lives and become the "small town doc" that's available for his/her patients whenever they need him/her. Just look at OB. Chances are, the doctor that cares for you for 10 months of pregnancy won't be the one who delivers the baby (unless it's surgical, and unless they happen to be on call that day). Medical students and residents are seeking a better lifestyle for themselves. I guess we're finally coming to realization as a group that medicine isn't worth your happiness and sanity. That it's hardly admirable to subject yourself to abuse (by CMS, by DHS, by joint commissions, by society, by medicine) and be absent in the lives of your loved ones. Maybe when doctors were respected, autonomous, and paid well...but now, not as much. When this happens, when docs start seeing themselves as employees with jobs, continuity of care sounds like crazy talk. Think how crazy it would sound if we suggested that nurses (or anyone else on the 'healthcare TEAM') were made to "feel guilty" about going home at night, or chastised for lack of their continued presence in the health management of a stranger/patient. Everyone has a job these days...which is what government created, and physicians (at least the professional societies) have allowed to happen.

Do you miss the clinic?
I do sometimes. Ideally, I think I'd like to have a very small panel of patients, and manage both their inpatient and outpatient health situations. But, at Kaiser, we have panels in the thousands, and you just cannot be available for thousands of patients...and still be true to yourself. Most places it's easier to simply choose, outpatient or inpatient.

Does it require additional training to be a hospitalist?
No.

Do you take care of ICU patients?
I do, at least initially. We have 'intensivists' who take over the ICU patients shortly after they are admitted to the unit. And we pick them back up once they are d/c from the unit. This is good because the last thing you want to deal with while rounding on your patients, and getting hits from the ED (doing initial H&Ps), is a patient in the unit who's trying very hard to die that day.

What is it like at Kaiser, specifically?
Kaiser has it's pluses and minuses, of course.
The minuses first. Kaiser has lots of rules and protocols. Imagine someone telling you how to do everything. How to manage every problem. What paper to write on. As physicians, since they make you a "partner" you have no advocacy. It's like you sign away your ability to unionize, or otherwise advocate because you're vested. But, practically, you're an employee. Your chief gets orders from their boss, and usually s/he will agree to give their docs that 'one more task to complete', 'that one more piece of paper to fill out.' This is how chiefs get their jobs, keep their jobs, and get promoted. Not by saying 'no, I think my docs have enough paperwork to fill out...I think they jump thru enough hoops...why not hire another clerk to do that paperwork.' Can you imagine saying "no" to your boss...even if it's to benefit the people who work under you? And because of this hierarchy (which is necessary), and the lack of advocacy for the physicians within the group (which is not a morale boosting situation), lots of us are less than enthusiastic about our jobs. It's not about the physician-patient relationship, not to the doctor/employee. It's more akin to working at the DMV and with people who come to you for help. And that is unfortunate.

The hours can be very long, and there is no additional compensation for staying late - and with the amount of paperwork required, most docs stay late. Many docs 'volunteer' lots of their time...and that's just wrong, I think, since the corporation is making record "profits" with our sweat. Without the docs, Kaiser could not exist. The organization should reward those physicians who go the extra mile, stay late, come in early, and wrap things up. This results in better patient care...happier/healthier patients, more members/more money for the organization, and better reputation (=more money). But, the docs won't see these positive results. Any extra effort is simply absorbed into the organization...and this isn't good for morale, or dedication.

Minuses - Lack of advocacy. Too many unnecessary, non-physician tasks (scut), long hours/hard work, and no incentives (therefore waxing/waning motivation), low morale, and feeling like you're being used - all which affect patient care.

Pluses.
Flexibility. Kaiser permits you to work part time with benefits, which is nice. Also, flex-time, swing shifts, and longer/shorter shifts can be created to help individual physicians balance family and career. They have quite a few women in high places, and there is great recognition of the need to offer these things to keep (particularly female) physicians quiet enough to conduct business. The pay is comparable to the outside. As a plus I'll also add the long hours and hard work, since that's not only a bad thing. Afterall, having lots to do validates your job. If you stay long enough I hear the pension is one of the better plans. And hospitalists in general have set hours, no call, and flexible schedules.

Pluses - flexibility, benefits, accommodating of family/personal life without much ado.

Overall, would you recommend working for Kaiser as a hospitalist?
Overall, I would. Not all sites, not all groups have the same internal morale issues. I suggest that a person considering a job with Kaiser find someone in the group to give you the low down. The real deal. This isn't going to happen over email, because no one is going to write/document their discontent with their current employer. Be sure to be persistent with that one doctor that seems nice, and interested, but deflects your questions. Call him/her up and ask to meet. How many times have I seen interviewees, and thought to myself "I wonder what they think this is all about?" "I wonder if they knew the truth about this place, would they still want to come here." Just like residency...not every program is good for everybody. Even the great residencies may be horrible for certain personalities, or people in certain social situations, of a certain gender, ethnicity, etc. (parents, gay, married, Jewish, etc).

Kaiser is a nice place to work...but has very real drawbacks. It won't work for everyone. There are lots of rules, and basically you go to work, follow rules, do whatever 'new' thing they have you do (new sheet of paper to fill out, new box to check, new question to ask, new order form, new protocol to follow...always something else they squeeze into our day with no consideration for time/relevance). It's overwhelming at times, but if you don't think about it too much, aren't too passionate about that particular issue...you'll probably do just fine. Personally, it does get to me every so often, but I enjoy my flex time, and the money is comparable to what I feel I could make on the outside...so the benefits outweigh the drawbacks for me.

10.09.2007

The worms.




Horrible case of neurocysticerosis!! We counted the number of active cysts in this patient to be about 65!!! (On these two cuts alone you can see 33!)

Neurocysticerosis is caused by the tape worm taenia solium found in improperly cooked pork that, when ingested, hatch in the stomach, and the larvae crawl thru your intestine, and find a home in your muscles and brain. The resulting inflammation, and possible mass effect/obstruction of the flow of CSF commonly causes headaches and seizures.

We see this quite a bit in Southern California, so when traveling here, don't eat the pork...or drink the water.


Family: Doctor, what's wrong with her?
Me: There are worm cysts in her brain.
Family: oohhhh...the worms!!! She got the worms....



No further explanation was needed, they understood.


10.01.2007

Choosing a Specialty - AAA (All About Anesthesia)

Today, ER doctor asked me to write an entry about anesthesiology. I am an anesthesiologist with a subspecialization in pain management. I work both in the operating room, take trauma call, and in my pain management clinic. I'm a few years out of fellowship...and today, will shed some insight into my professional world.
I decided to become a physician sometime in high-school. There was no magical 'calling', or parental influence. I just had to make a decision. I thought for awhile about my favorite subjects, those I learned with the most ease, and narrowed it down to a few applicable careers. Although nursing crossed my mind, as I learned more about the differences between what nurses did, and what doctors did...I decided I didn't really want to 'nurse' people. I considered PA, but thought to myself...I'll never regret going for the top rung, but I may one day (as a PA) regret not going full-speed to the top, and "settling" for PA. So, physician it was.

With regard to specialty choice, that came later. As a premed (and my first year or two of medical school) I thought family practice was for me. Back in those days there was a big "push" for medical students to pursue careers in primary care. Family practice is "the doctor" I visualized when I thought of "doctor." I liked the idea of treating the entire family, establishing a long-term relationship with my patients, etc.

As I progressed to my clinical years and gained exposure to the 'real practice of medicine.' After having candid discussions with primary care docs...I 'realized' that family practice isn't what many people/students expected it to be. It's very stressful, and doesn't pay well. The physicians didn't seem to enjoy what they were doing...and that bothered me. Haunted me, actually. So I had to consider (for the first time) that family practice wasn't for me.

Anesthesia isn't one of those specialties that students get much exposure to in medical school...unless they actively seek out the experience. So, it's no wonder appreciation for what we do isn't fully realized. For many students, the only exposure they have is via their surgery rotation....or OB with epidurals.

The process of - Passing the Gas
Anesthesiology requires a medical student to complete their degree, their USMLEs, and a preliminary internship (either surgery, medicine, or transitional). After that, you move on to your CA-1 year as a first year anesthesia resident. Training is 3 years after the internship. The first year of training (the CA-1 year), you mostly get acquainted to the anesthesia machine, and do relatively simple cases such as ortho (usually young healthy men), and ophthamologic cases (with sedation). Most cases are short (unless a new surgical resident is learning to do an appy). The CA-2 year consists of more advanced cases, longer cases, and children. OB/epidurals, c-sections, trauma calls. There were more outside rotations for more specialized experience...such as children's hospital, and transplant centers. You do ICU/critical care coverage. CA-2 year is the nitty-gritty of training. The CA-3 year you do advanced cases, such as long transplant cases, long cases in general, complicated cases (like patients undergoing major surgery that are likely to die). Heart transplants, burn cases, brain and spinal cord surgery, etc. The best part is you have more administrative tasks, like running the OR board (deciding if/when the various operative cases go to the OR). You get to choose your electives, and have exposure to those areas that interest you. Subspecialty areas include pain management, hospice/palliative, critical care - officially. There's also areas that aren't "officially" subspecialties but requires experience/training, some offer an exam and may become 'specialty' soon - such as pediatrics, OB, and neuro.

Why I chose anesthesiology.
During my 3rd year of medical school, I was quite convinced that I'd pursue internal medicine, and subsequently subspecialize in....say cardiology. I knew general internal medicine wasn't for me, but with the numerous subspecialty choices in the field, I figured I'd find something I enjoyed. Then, honestly, as a 'easy rotation' to break the monotony I decided to schedule an elective anesthesia rotation near the end of my 3rd year. That is when I learned what anesthesiologists do all day.

I went to medical school, and subsequently trained at a major trauma center. To me, trauma were the most exciting cases. It was during the traumas that 2-4 anesthesiologists were present. One intubating. One doing an a-line. One doing central line. One getting blood/saline and putting it thru the level 1. All working quickly, carrying out their various tasks of stabilization and resuscitation. I fell in love...
Typical OR day. Arrive between 5:30 and 6:00am to pre-op on the day's patients. Introductions. Acquisition of information. Reassurance. Then off to set up the OR. Pulling drugs into syringes. Getting various equipment set up. And above all, checking the anesthesia machine. There's an intimate relationship between the anesthesiologist and the anesthesia machine.

I have 3-4 scheduled cases that ideally end at 3pm or so. I get a couple of short breaks, either between cases, but usually during cases when a colleague comes in to relieve me. I also get bathroom breaks and lunch break if they are unable to be scheduled in between cases. There are times when I'll break the OR for lunch, depending on our staffing levels. There are intermittent emergency cases that supersede scheduled cases, but we usually have someone available specifically to cover those instances. One of us anesthesiologists runs the OR board, and it is up to us to decide who gets surgery that day, and when - despite what the surgeons believe or say. It is our prerogative to cancel cases, close OR rooms, and manage the operative suite.

When there's an airway emergency anywhere in the hospital (excluding the ED), we respond and assist with airway control. We respond to all code blue arrests. We backup the ED...if they have a problem airway, they call us. We also assist with intravenous access and spinal fluid access (for lumbar punctures, or anesthesia administration). We cover OB, do epidurals, and are available for crash c-sections. There is a pediatric 'fellowship' in which we work at Children's hospitals doing typical anesthesiology tasks.

In addition to airway, and emergencies, we do regional blocks to prevent or treat painful conditions. In pain management, we treat patients with chronic pain syndromes. We deal with end of life care, and palliative pain issues via hospice and ICU. And of course, speaking of ICU, we manage critical patients in the ICU - usually surgical, and usually post-op.

What I don't like. What I like.
The lifestyle isn't always great. 6am is a very early start to your day. And 3pm easily and frequently turns into 4 or 5 pm....which makes for a very long day. There isn't a lot of down time because an empty OR is costing everyone money. Eventhough you only have 1 patient at a time, there's a sense of hurry to get cases started, and to leave patients in the PAR (post anesthesia recovery) even if you're not quite convinced you should leave them just yet. Dealing with some surgeon types makes for a very stressful, or negative atmosphere in the OR. There is little exchange between you and your patients (practically speaking) since they're sleeping the entire time. The OR is the same everyday, and somewhat boring. They say it's 90% boring, and 10% "oh shit!!" I think that's true. The solitude behind the blue curtain is nice, mostly, but it can get lonely.

There are a few specialties in medicine known for their "problems". Stereotypes don't apply to individuals, but rumor has it that anesthesiologist tend to have drug addiction issues. I guess passing all that gas, and administering all those drugs, makes access easy. This is a problem that is made clear on day one of anesthesia training. This is a problem on the radar of every anesthesia department. Not unlike radiologists getting blood cell cancers, psychiatrists committing more suicide, or surgeons having more broken families/marriages.

Also, patients (and people in general) frequently are unappreciative of the work we do. It's difficult keeping a patient comatose, paralyzed, with adequate blood pressure; breathe for them, protect their eyes, monitor the blood loss, and then....wake them up *intact* after hours of a human digging around in their abdominal cavity (or brain, or back...). When things go wrong, they go wrong FAST. You need to be aware of many drug actions, interactions, indications for use, and how to deal with pretty much any foreseeable (and unforeseeable) catastrophe. You have to be exquisitely more familiar with the workings (on a mechanical level) of the anesthesia machine than you ever imagined possible. You have to have a grip of physics, and understand the differences in gas pressure and turbulent flow of air thru tubes depending on the atmospheric pressure, type of tubing material, diameter and length of the tubing, and the viscosity of the gas. You have to be familiar with all the different procedures the surgeons are doing...and read up on the procedure beforehand to be sure you can anticipate/prepare for complications of that procedure, and anticipate when significant changes in vitals signs are expected to occur. Some drugs are so potent, that mere drops of it makes a huge difference. There are reactions to blood products, failure of equipment...and surgical complications that affect the well-being of the patient. And when things go wrong, everyone is very quick to blame the anesthesiologist. These factors result in a very difficult board exam - amoung the most difficult of any specialty, and many of us do not pass them on the first 1 or 2 attempts.

The job's both exciting, and frightening. The compensation is great. By working with residents I'm not tied to an OR all day. I get to be present at the start of a case, and at the end of a case. I am not tied to one room, therefore I don't feel the boredom or loneliness. I work at a trauma center, so that's exciting. I also have a pain management practice...so I have more 'patient contact' and continuity than almost any other type of doctor. And, I get paid to see my patients in pain management -unlike primary care docs.

More and more students are choosing anesthesiology, and the specialty is becoming more competitive. For years students were told anesthesia was oversaturated...and that created a shortage that was subsequently filled with FMGs. As more American students choose the specialty, and competitiveness increases....our profile will elevate, and that's a good thing for gaining respect and prestige for the profession.