Random and Random-er

Not Even a Reach-Around

Residency programs should protect their residents. I’ll grant you that the long hours and low pay hard-wired into the system are not likely to be modified in my lifetime but a good program, one that is resident friendly, operates under the well-known prison rule that while I may be a bitch, I am your bitch and nobody messes with your bitch.

Unfortunately, you tend to get “passed around” a lot as a resident to services who have no regard for you whatsoever, don’t know you, will never see you again, and thus feel free to extract as much cheap labor out of you as they can.

Here’s how one scam goes down. Suppose you are a physician with no residents of your own with admitting privileges to a hospital that has residents and you have a patient who you want to admit. Traditionally, you would either send the patient to the hospital from your office with admission orders and at least a brief note or, if it was after office hours, you would come to the hospital, assess the patient, and do the usual honors. If you know there are residents however, you can get away with sending your patient to the hospital without seeing him at all and your single phone order is “Consult Medicine Service (or Pulmonary or Cardiology) for medical management.” This forces the already over-worked resident to see the patient (because his attending certainly isn’t coming in to do the consult at 10PM) and materially contributes to his work load and his sleep deprivation. The physician calling the consult can come in at his leisure the next morning and “gun deck” his note off of the usually fairly detailed consult note written by the resident. He bills for his time, the consulted service is happy because they bill for their time, and the only one with nothing to show for it is the resident who knows he’s being hosed.

I’ve been called at night by frantic nurses who have a patient directly admitted with no orders, no notes, and often only a vague idea why he is there except that the admitting doctor has asked for a consult for medical management. We generally don’t do consults until after we are finished with admissions but in some cases because it seems like a fairly dangerous enterprise to leave a potentially unstable patient in a hospital room with no orders or direction, even though the patient is not technically my responsibility I often drop what I’m doing to take care of him. And I know I’m being hosed because the admitting physician knows good and well that somebody is going to cover him.

This is different, of course, from doing a direct admission for your own service. In this case you are actually working for the attending who admits the patient and you will always get a phone call from him giving you a little guidance.

“But, Panda,” you say, “Isn’t this how you learn?”

Well, frankly, no.

You see, not every admission or consult is a wonderful learning experience. The first couple of chest pain work-ups are pretty exciting, for example, but after a while you notice that you are writing the same orders over and over with only minor variations. Everybody gets cardiac enzymes, everybody gets an EKG (which is usually normal) and everybody gets a stress test in the morning. I might as well get myself a big rubber stamp. Why my hospital doesn’t not have a standard order set for this is beyond me. This kind of thing, if nothing else, is check-box medicine at it’s finest.

But here’s the real problem. As I have mentioned before, the current system of residency training was devised almost a hundred years ago at a time when fairly little was known about physiology and treatments and studies were scarce. Hospitals were little more than boarding hotels and they remained this way until the early seventies when technology and geometrically expanding medical knowledge began to transform them into the high output patient processing units they are today. Even though the residents physicians of the early twentieth century literally lived in the hospital, it wasn’t until the early seventies when sleep deprivation became a routine part of medical training making it very difficult for a resident to both keep up with his clinical duties and study the rapidly increasing body of medical knowledge.

It is the sleep deprivation which allows the current system to function, taken as a whole, that detracts from your education. To say that going without sleep and being as sick as a dog because of it (as I often am) enhances learning is to buy into the propaganda that perpetuates the current system.

You try reading at 3AM between pages from the floor and admissions. And then see how enthusiastic you are post call to crack open Harrison’s.

Praemonitus Praemunitus

I would invite all of you, again, to visit Brother Hoover’s highly subversive little blog “MedschoolHell.” It is an entirely truthful, entertaining, and informative look at medical school of a type that you will simply not find anywhere else. Any rational person reading it would have second thoughts about medicine as a career…and yet I don’t think anyone who is serious about medical training will be deterred because you almost have to be a little insane to put yourself through this.

Hoover has also added a lot of features. The zealots among you may actually find a lot of useful information about medical school and selecting a specialty if you can contain your impulses to burn him at the stake.

If you don’t read it and find yourself in medical school regretting your decision, don’t say we didn’t warn you. I like this job. He didn’t. Doesn’t mean he has nothing to say on the subject. In fact, since you need to know the good and the bad before you make any decision in life, I don’t know why people get so irate when the less than savory aspects of medical training are discussed.

My Apologies

I have been neglecting the blog for the last month. Sorry. I had Q3 call for most of it and I’ve been tired. Please keep reading. I have a few interesting articles in the works including the first in a series of play-at-home games that will allow those of you just thinking about medical school to “kick the tires” of your potential lifestyle.

Watch for them.

Also, as always if you want to suggest a topic or just ask a question my email address can be found on the right.

4 thoughts on “Random and Random-er

  1. i am going back and reading previous blogs.

    being trained on the surgery end, we tended to laugh at the fleas. “look at them rounding for hours. complaining about how much time they spend here. boohoo”

    as for most things we really have no idea what other services do. it brings to light some of the dumping that occurs. and why medicine gets cranky when ortho tries to get them to admit the 80y/o hip fracture (although i do believe these should not be on the orthopaedic service. these patients can go south quick). i do peds so we rarely admit to the pediatricians.

  2. The ironic thing is that when I was on my last Trauma Surgery rotation, we had patients on our census with no medical problems, nothing but an isolated orthopaedic injury (tibial fracture with an ORIF for example) being followed by ortho but they still languished on our serivce.

    My trauma attending never consulted medicine except the most dire or complicated patients on the assumption that surgeons should be able to manage their patients pre- and post-op.

  3. that is why trauma surgeons are so cranky :). truth is we could probably manage medical problems, just like the medical doctors can manage simple casts, arthritis, and back pain. if it was your mother, as your self this, who would you rather manage he blood pressure, diabetes, and cardiac risks?

    my answer would be not my local orthopaedist. gen surgeons always like to show what they can do. i can run the ICU, a trauma, and operate with my hands behind my back. we (gen surgeons) work so hard. look i am here late again.

    i got enough of that when i was an intern, prior to the 80hr/week restrictions. when my wife came to our new home for the first time (she is from the UK), i was on call. she came friday night, i didn’t she her until tuesday. well i did for a minute on saturday, but i fell right asleep.

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