Thursday, June 30, 2016

intern year is over!

The most difficult year of my life is about to be over.

Intern Year, Generally Speaking

A whole year of stress, anxiety, being pushed around by senior residents and attendings, being ignored and not taught while being pushed to my physical and emotional limits.

Working under intense time constraints with unstable patients, giving bad news and poor prognoses, soothing crying family members and patients, seeing some patients actually make it off pressors and out of the ICU, being thanked by patients and family during rounds, patients and their family giving me blessing after blessing for just doing my daily job.

Calling the shots to initiate pressors and call the code when I had done neither before.  Being called to bedside to get ready to pronounce someone dead soon and watching the final changes in their vital signs.  Getting cornered and pressure to make decisions without time for help because I have "MD" after my name.

Seeing way too many people die uncomfortably and unresponsive on a ventilator on pressors and seeing far too few people take the option of comfort care.

I hardly saw my friends, even the ones I started residency together with.  A year further in my training, a year spent becoming more separated from the people I love.

It took me 3 months to renew my driver's license because I had no time to do it.  I've seen hundreds of patients over the course of this year but I haven't been to a doctor myself.

I've seen a lot of the people I started residency with gain 20 pounds or more.  I've seen one person quit and two people switch residencies.

This year's been a blur for me, but when I really look at it, it felt like a long march, often stressful and joyless.  I call it joyless because after a while, the amount of clerical things you need to do and time spent at the computer wears away at you.  So does having to study for your specialty while trying to pass Step 3 in one go (which I did!  that was awesome!).

Clerical Woes
Medicine reconciliation is one thing and absolutely good for the patient, but having to constantly tell administration why this central line is indicated is ridiculous and sends the message to us that doctors aren't to be trusted.   Yes the patient is in the ICU and they are unstable and/or need central TPN, why do you need me to tick these boxes?

The Burn Out
Being a doctor is something you're excited about since childhood, often times.  Then there comes the classic intern burn out you hear about all the time.  For most, it happens in January.  For me, it didn't hit until this June.  I didn't feel the same satisfaction I had at the beginning.  Mostly because so much of medicine is done through a computer clicking this box, and typing in this order, being rushed and gradually eroded by volleys of non-critical calls from nursing.  Often you're trying to stabilize a patient and then you get hammer get paged/called about the decision to start diet orders or maintenance IV fluids on someone.  Day in, day out.

Also, being made to do some activities like consent patients for things while your superiors play on facebook or do nothing wears on you because on top of that, you have to do all your internly duties of H&Ps, progress notes, and fielding all kinds of calls your superiors don't have to do.  You're taking care of something every minute of the day until sign out is over.

Futile care is something that you'll learn about and will erode you.  I've been so direct and compassionate with families and patients who end up not choosing comfort care and see their family member die unresponsive on a ventilator instead of choosing comfort care.  I know they're not doctors and they don't get how medicine works, but I'm constantly pushed to "do everything possible" even though I explain they're going to die unresponsive on a vent.

Hospice or comfort care is viewed too much as a defeat..but when you're not going to win the battle regardless, why not die comfortably surrounded by your loved ones instead of the middle of the night after undergoing a dozen procedures we recommend against including surgically placed equipment/devices?  I think aggressive family-led care in the moribund uses up a lot of resources, but most importantly, means less time a patient spends comfortable with their family before they die.

Break Time
A year of driving to work at 530AM or in the middle of the night to work 10-14 days in a row without a day off.  Telling myself my weekend was "6 hours long" so I could convince myself I actually did have some semblance of time for relaxation.

I've become more aggressive about my time off.   I'm disappointed I have to make a timetable for all my activities, but it helps me get to everything fun I want to do.  The earliest I've started drinking and enjoying my time off is 0841, lol.  Whisky in particular is my drink of choice.

The Comrades

I've been able to make friends from different specialties.  The good part is I have so many friends going into surgery and surgical subspecialties that the OR environment as an anesthesiologist will be somewhat more familiar and less stressful.  I've become closer with the medicine interns most of all, but had the deepest bonds formed with the pediatrics interns.  A lot of off-service interns/prelims like ophtho, derm, and neurology bonded with me, mostly over the trying times we shared together and how badly we wanted to move onto our specialized training.




Monday, June 27, 2016

Thank you for helping my readership grow!

Hey readers, just wanted to thank all of you who are sharing my blog and telling others about it.  I feel like my blog has grown from a small whisper to an audible voice.  I'll keep writing about my adventures and trials in medicine and help make this blog a place where we can all get together and share our experiences.

So far I've been working 10 days straight without a day off and I'm so ready for my upcoming day off that will happen in just a few more days..it'll be a great break.

cheers and thank you

Tuesday, June 21, 2016

the nightmare parts of intern year

I'm not a public complainer.  I spend a lot of my days in the resident workroom typing notes and listening to my colleagues complain about their schedule or a certain service in the hospital day in, day out.

But I wanted to give people a glimpse into the bad parts of intern year and residency.  I nearly reached a breaking point a few months ago on an unspecified rotation.

The day started well.  I was dealing with the better part of a year of being an off-service rotator, farmed out to do all the work everyone thinks they're too good to do, with the best attitude I can put together.

The unit was weird.  Many people didn't understand how it worked.  There was no communication between services unless I called them.  I often had to call 3 times until someone answered or passed me onto someone else.

People started getting mad at me that I hadn't heard from Service X even though I was working like a dog to get a hold of them while getting pulled in 6 different directions.

I got about 15 calls about 2 patients alone in the span of 2 hours from confused nurses about what the plan for the patients were when I told them to talk to the primary service about them, I was just a consultant not in charge of primary-specific orders.  I started getting flak about how this patient wasn't getting discharged..WHEN I'M NOT THE ONE RESPONSIBLE FOR THEIR DISCHARGE ORDERS!  

I started to get closer and closer to exploding in a shower of splinters.   I kept getting paged about how this order isn't right and its not perfect WHEN PRIMARY SERVICE IS RESPONSIBLE FOR THOSE ORDERS!  They were either too dumb or too lazy to read the top of the EMR and figure out who the primary team was.

Then we got a really sick patient everyone was overreacting about.  I say "overreacting" because I've seen sicker patients and I don't overcall things and I don't overtreat.  I've covered the MICU and CCU by myself at night and these patients people are losing their minds about are rock stable compared to what I've seen in the MICU.

My team consisted of people who had to make it known they were "smarter" and "better" than you just because they were your seniors.  They overcalled things, they overtreated, they got into arguments with specialists about what should be done and they had to make me be the messenger while they didn't lift a finger.

I had to apologize to the specialists about my seniors' behavior and pushy nature.  I was doing damage control on the bridges between us and other services.  It was exhausting having to do that and manage patients.

I can't wait until I move onto better things and do what I actually want to do.  I'm still exhausted.  I just gotta keep moving.

good luck to the future interns

Sunday, June 19, 2016

tips for new medicine and surgery interns - part I

It's almost July and many med school graduates are getting ready to be interns.

They will be making a lot of decisions they haven't made before, and many decisions can hurt patients.

A lot of the time you'll be rushed and pressed for time in making critical decisions, and other times you'll be making a decision which has ramifications that might not be noticed for some time.

Basics:

1. Read up on things you're weak on.  A lot of people say you can't study for intern year, but you actually can.  The logistics of placing orders and the way the unit works is something you'll learn on the job, but there are essentials you need to carry with you into intern year.

2. Go see the patient.  Even if you get called for a fever, don't just say "Yea give some tylenol."  They could be tachycardic or hypotensive by the time you get to the room and you don't want to miss anything.

3. Always go talk to the patient or family when you're asked to unless you're managing an emergency.  A hospital is a strange and foreign place to many people other than you, they don't know how it works.  You might be the only sense of comfort and familiarity they have.

4.  Have a To Do list and write everything down.  You'll constantly be called and paged and interrupted while hungry, tired, and dehydrated and you'll lose track of things.

5.  Call consults on rounds, place orders early.  Inpatient medicine is incredibly slow so you need to get the wheels turning early.

6. Learn from your consultants.  If someone has a heart rate of 55 and they're sitting up talking to you, texting on their phone, walking around and have no symptoms and no cardiac history, and a normal EKG, it doesn't merit a cardiology consult unless there's something worrying you.  Feel free to ask them questions about management and make it a part of your practice.

7. Work for the interns next to you.  You are a unit and a team.  Build morale and the rotation will be better.

8.  Don't rock the boat..I hate having to say this but as an intern you have to follow orders and march.  People who oppose their superiors will often find themselves treated differently.  Maybe you'll have an attending or fellow who is open-minded, but especially early in your training, do what you're told unless it will harm the patient.  Don't argue on rounds and don't burn bridges.  Your contract isn't guaranteed to be renewed each year.

9.  Bring food from home, play music in the team room.  Residency can be a long, joyless and oppressive march.  Make it as good as you can.

Patient Care

1. Make the habit of finding the patient's first medical H&P and find out what problems they've had at that time.  As time passes, a lot of things don't get charted and you can potentially miss a lot of information.  Someone in 2016 might not have charted that the patient has a drinking problem, but maybe from 2010-2014 they had been drinking a liter of vodka a day, and so on.

2. Always compare prior imaging/EKGs to the new ones.  This ties into my next point.

3. Baseline, baseline, baseline.  I vomit every time I hear "What's the patient's baseline?" So now I give the baseline creatinine, exercise tolerance, hemoglobin, etc.

4. Know your hospital's antibiogram (what germs are resistant/susceptible to what antibiotics)

5. If you have someone in the ICU and you don't know if they'll be fluid responsive for resuscitation, you can lift their legs up and take their BP.  It'll take some help, but the fluid shift will tell you how some extra fluid will help.

6. Always know your patient's ejection fraction and renal status because this ties into fluid resuscitation.  You might kill someone if you bolus them with fluid when their EF is 15% and they've already gotten fluid.  Always ask the patient's cardiac status/renal status when you're getting sign out.

7. Don't copy-paste your physical exam in the EMR.  I've seen consultants/other teams keep on writing a patient was intubated when they were extubated for 3 days in another unit.  Don't embarrass yourself.

8.  Don't take criticism personally.  You will be criticized and corrected all the time.  You are a learner.  A lot of people have bristly personalities or will be rude, and that's their problem.

9. Take medical students under your wing.  Like you, they were used, disrespected, ignored, and bossed around.  Be an educator and mentor.

10.  Don't do maintenance fluids in sepsis.  The pathophysiology is that vessels have poor tone and leak in sepsis.  Bolus and pressors as indicated.

11.  Know everyone's drug allergies.  Ask them, even if there are already some that are documented. They might have tried a new medicine that gave them a new allergy.

12.  Bladder pressures if you think someone has abdominal compartment syndrome (trauma,bad ascites)

13.  Know side effects of what you're prescribing.  Iatrogenic harm is real

14.  Calcium channel blockers are contraindicated in patient's with afib-rvr in heart failure

15.  Don't forget to place patients on IV fluids if they're NPO for a procedure or imaging, preferably with dextrose in there.

16.  Update your nurses and treat them right.  Some will be difficult to work with no matter what, but if you make their lives easier and treat them like a team member, they will help you more.  They're at the patient's bedside more often than you, and they will often relay information from consult services to you.

17.  No potassium repletion for ESRD patients.  Renal should always be notified immediately when a dialysis patient comes in anyway and they'll give you a hand.

18.  Make sure all your patients on ventilators have orders for suctioning and n-acetylcysteine as needed.

19.  Don't miss the MI because you're so set on working up abdominal pain.

20.  Neutropenic fever patients need 2g of cefepime instead of lower doses.  Always get b-galactomannan as part of your work up.

21.  No DREs on neutropenic patients.  Don't introduce GI germs into their bloodstream

22.  Do everything you can to prevent intubation on an asthmatic patient.  If it absolutely has to happen, make sure there's a fluid bolus and pressure bag ready, that people have atropine and epinephrine at bedside.

23.  Don't hesitate to call the code.  You'll be inexperienced but the nurses and residents will come in quickly and run the code and help.

24.  Get the lactate and VBG in patients who roll in tachycardic and hypotensive.  Draw blood cultures before antibiotics

25.  People post-PCI or cardiac surgery will have elevated cardiac troponins and a scary looking EKG with ST elevations that take some time to die down.  If you get called about an EKG with ST elevations, go see their previous EKGs and see the patient first.

26.  When you get called with a set of abnormal vitals, tell nursing you'll be there and for them to have a repeat set as you walk over there and any necessary labs.

27.  If someone comes in with chest pain, ask what their exercise tolerance is and how it has changed, their pillow orthopnoea, if they have enough energy and strength to do their ADLs without getting short of breath, and if they've missed any doses of their medicines, including aspirin/plavix for people with stents.

28.  Know your GI prophylaxis indications.  Examples are steroids, coagulopathy, intubated on a vent, etc.  The typical patient just hanging out in the hospital doesn't need it.

29.  If someone's platelets have tanked in the ICU, it could be due to sepsis, antibiotics like vancomycin, or heparin-induced thrombocytopenia.

30. Expect hypoglycemia if someone's getting steroids.  Manage it accordingly

31.  Expect transient bacteremias after ERCP

more to come

Thursday, June 16, 2016

public shaming in medicine

part of what ruins my desire to stay in medicine is episodes like this.

to keep things anonymous, I'm changing the details some.

It was the last patient to talk about on rounds, and the team we consulted was outside the patient room too.  The resident who is a friend of mine ordered a therapy they thought was indicated.  I could see why they thought it was indicated but they had put in the order without me knowing and they hadn't asked anyone if it was safe.

The consultant heard about their ordered therapy and proceeded to absolutely roast this resident in front of the consult team, our team including the attending, and the patient's family member who was there.  Our supervising doctors didn't know about it until then and they failed to supervise.

It was brutal.  I felt demoralized with the collateral damage.  It's so unprofessional to act like that around so many people.  Who are you trying to impress with that kind of power trip?  Why not treat your colleagues like actual colleagues?

I get disappointed with medicine and the hierarchy and the "it's okay to disrespect other people because I'm higher than you" mentality.  sigh.


Wednesday, June 15, 2016

How to tell someone they're dying

Welcome to the Intensive Care Unit, where end of life conversations will happen almost daily.

The ICU is stressful for so many reasons, and you deal with a lot of scared and grieving patients and families.  One thing I've done really well during intern year helping people cope with death and dying.

Here's what you do:

1.  Ask the patient or family what they understand about their illness and current state of health.  Some people might think they're going to die from a GI bleed that just needs close monitoring, and some family members might not have had anything explained to them about why their family member is so sick after chemotherapy.

If you're sure the patient's dying from sepsis on 4 pressors despite all efforts, you need to communicate it at the earliest moment possible to give the family time to grieve and get ready for death.

2.  If someone has failing/failed organs, tell them their organs are failing or have failed.

Be realistic and honest, but not callous.  Many people don't fully understand their diagnoses or what's going on in the hospital and it's your job to inform them.  Inform them each time an organ fails.

Some people might not know they can choose comfort care and that they don't have to spend the rest of their life in an ICU getting dialysis dying slowly and uncomfortably.

I'll paraphrase conversations.  Mechanical support doesn't "cure" anyone the way antibiotics might.

In a case of ESRD from hypotension/shock/long code:

--
"..What is that..the dialysis, doctor?"

"Dialysis is a treatment that uses a machine to help get rid of extra fluid in the body and helps remove toxins in the body, which the kidneys do on their own.  The kidneys help filter the blood.

The reason your dad needs dialysis is because many times, when someone's heart stops, many organs in their body don't get enough blood, and they don't work the same as before.  Since your father has been here, we've been doing everything we can to help his kidneys, heart, and blood pressure, but his kidneys won't be able to recover on their own.  The dialysis machine is doing the work for his kidneys right now."

Or in the case of an AKI being managed with dialysis:

"The job of the kidneys is to help the body get rid of extra fluid and help clean the blood.  We've found that your father is very sick and needs help cleaning his blood and help getting rid of the extra fluid.  We've been able to use this dialysis machine to help take off some of the work from your father's kidneys.  We hope it can help him get through this stage of his illness.  It's too early to tell if he will keep needing dialysis while he's in the hospital or for the rest of his life.  So far we've been able to control his fluid well and have seen him responding well to the filtering of his blood with the dialysis machine."

===

Ventilators:

"Many patients get so sick that they can't breathe well on their own and they need help with a ventilator.  Right now, the ventilator is doing the breathing for your mother because she's too sick and weak to breathe on her own.  We watch her everyday and check the ventilator to see if she's recovering.  We'll be making small changes day by day and see how she does."
==
"Will she be able to come off that machine..?"

"Your mother is very sick right now and needs help breathing right now.  I know you're worried and the machine might look scary.  I can't promise you that she'll come off the ventilator at this point, but we'll keep doing everything we can to take care of her."

3.  Go back to the symptoms.  Families and patients are scared and don't interpret signs and symptoms the same way we do.  They're not as familiar with death as we are.

"Doctor, he's not feeling any better.  He keeps getting more and more short of breath.  Is the medicine not working?  Is he going to die soon?  How is his heart now?"

"I know it's hard for you to see him like this.  I know you have been going through a lot seeing your father so sick.  We've been supporting him with medicine as much as we can but his heart has become so weak.  In a heart like yours or mine, it's strong enough that it keeps fluid from building up in our lungs.  His heart isn't as strong as it used to be, so we're using medicine to help keep the extra fluid off, and using medicine to help boost his heart function."  

4.   Preparing for the end.  Show your human side while spelling things out so you don't give false hope.  Here's a paraphrased conversation of mine.

"So how long does he have left, doctor?"

"It's hard for me to say exactly how long your husband has left.  We know he's been very sick for a very long time, and his health has gotten worse since he came into the hospital.  He requires dialysis because his kidneys have stopped working.  The ventilator is doing the work for his lungs now because has become too weak and too sick to breathe on his own.  We've been taking the best care of him night and day."


=
Giving short, direct sentences minimizes confusion and helps get everyone to understand what's happening.  When you read what I wrote, it might sound pretty callous and maybe condescending, but I actually have a great bedside manner and everything is in my body language and voice.

If you're "good" at giving bad news, you will project warmth, concern, and comfort.   It's easy to tell who is genuine and who isn't.

Always have tissues ready for people, listen closely, don't interrupt, and communicate your understanding.  

How do doctors get depressed, out of all people? And how do I help a co-worker?

Wow.  I am amazed by how many views and comments my entries on depression and burn out have received.  I wasn't expecting it.  I thank you from the bottom of my heart for reading my entries and recording your thoughts on here.

I'm writing posts like these a little more because it's been a hard year and also, because I've already seen people quit residency in different programs since I've started intern year.

Since I was a student, I've seen about 4 surgery residents switch into neurology or anesthesiology. I've seen one person quit pediatrics residency.  There were 4 suicides of medical students when I was a medical student.  I know of a resident who switched from a surgical specialty into something else, then quit that residency.

It's a scary pattern that you start noticing in your training, but as a student you just are so naive and optimistic, and you continue your training.

I'm writing this post partially exorcise my own demons but also let people know they're not alone.

So why do these ultra-intelligent, super-hardworking people burn out, quit, or commit suicide?

1.  The hierarchy.

Great!  You're a doctor!  Everyone respects you now!

Yea, right..You're new, know so little medicine compared to your bosses, you don't know the system and are constantly asking questions or being corrected and nurses think to themselves if you really know what you're doing.

Your upper level will push all the work they don't want to do on you.  Your fellow might laugh at your assessment and plan.  Your attending will call you out in front of your team and patients for not knowing some mechanism or bit of medical knowledge not relevant to patient care.

The more senior members of the team will either be really hands-off and let you make mistakes and then yell at you (Even though they should be supervising you), or micromanage you and make you think you're not good enough to do patient care.

2. The hours.

Get ready for irregular hours and being treated like an underappreciated factory worker tasked with unrealistic expectations of endurance.  We're talking 30+ hours of constantly being awake and working, probably 5+ times a month, every month, until you graduate.  For some people, that's 6+ years.  There are work hour "limits" but you're going to lie on your duty hours because your program can't save you from the ACGME (governing board for American residencies in a way, they accredit programs).  Get used to being cheap labor and being exploited, basically.

3.  Emergencies.

So many emergencies.  When you'd least expect them.  You'll get better at managing them, but many times that one patient who was almost going home develops a pneumonia, PE, a ridiculously resistant infection and only gets worse...

4.  Being told what to do by people who aren't doctors.

Frustrating.  Being told family members of patients what to do or what not to do when they don't have a medical degree (especially this happens in pediatrics).  Care managers, etc, everyone has an opinion and they don't respect how hard you've worked and what you know.

I can't tell you how much agony I've gone through when patients with aggressive stage 4 metastatic cancer who also have cirrhosis and an EF of 15% and ESRD tell me they want to be full code and I have to do "everything" for them despite me telling them all their organs are failing and it might be slightly more dignified and comfortable to go to hospice and have a better quality of life with their family.  I just do what they say because its law and we end up breaking ribs during CPR which causes a pneumothorax and they end up intubated and get a chest tube and die sedated on a ventilator surrounded by family they don't even know are there.  Day in, day out, one patient and the next.

5.  Difficult co-workers.

I wish I had a dime every time a consultant was rude to me over the phone, or even the primary team.  Everyone is just oh so busy and important and complete royalty and forget they're getting paid to do their work and see the completely reasonable consult you ask for.  I've never gotten over it.  I've known so many specialists who think you're some kind of mentally incompetent fool for consulting them.  Absolutely terrible.

6.  People don't respect each other.

I saw this on a Humans of New York post and I absolutely agree.  It might not just be stress your fellow doctors are affected by, many have terrible personalities by default.  I thought that medicine would be a world where everyone is nice to each other and helps their fellow man out, but there's so much competition and just blatant disrespect.  A lot of doctors talk about each other behind their backs.  It's ugly.

7.  Being owned by big pharma and also being told to cut costs.  Being ruled by the ignorant.

I've worked in hospital systems where they ran out of enough money for generic chemo drugs.  I've seen this totally non-superior drug get constantly prescribed by other doctors "because reasons," essentially.  I've been depressed that I can't prescribe this one great drug or that this patient can't get this therapy because it's way too expensive.  I hate having to argue with an insurance company about a CT scan my patient needs because they have cancer and need to get re-staged.


So what can you do?

Ask people how their day is.  Ask if they need any help admitting this new patient or with orders.  Stay later with them and help them.  Build comraderie.  Bring in food, buy lunch for your team, do kind deeds.  Go have drinks with the team.  So many people in medicine are too proud to say they're unhappy or that they're struggling.  People who say they enjoy notoriously terrible rotations likely are showing you their coping mechanism.

Residency especially is a long, dark, uncomfortable voyage through a tunnel that insulates you from the outside world and sunlight.  Many people won't be able to handle it well.

More entries on this to come