Hurricane Jill

Two more weeks, people ( or, more likely, person)

There’s a post I started writing 6 months ago, that I wanted to sleep on before publishing. And, well, the time got away from me. So I looked at it a couple days ago, and decided it needed some more … something. I don’t know what yet. And it’ll be around two more weeks before there’s any quality time to spend on it. In the meantime, hopefully some easier topics will present themselves.

Stay tuned for the Virtual Interview, in which I will be asking myself, and answering, the most popular interview questions. Also some questions that I’m anticipating on the basis of details within my application.

Readers, you are welcome to ask questions of your own, through the comments section.

Residents…mmm, tasty!

There are several topics that have been floating around in my head for the last few weeks, but none of them has coalesced into a post.

Probably the most appropriate to the season is the topic of forgiveness.  The capacity to forgive is a gift that benefits both parties, and it’s also essential to a stable society.  But it’s much easier to behave as though you’ve forgiven someone, than actually to do so.  And while society requires only the behavior, its gift of redemption is reserved for the genuine article.

One current cultural shift within medicine is in its response to errors.  I see this, in a way, as a rebellion against the tyranny of the lawyers.  In the past, when an error occurred, it was always considered an individual error, and the person responsible must be found and punished.   Then, possibly in defense against sophisticated arguments designed to assign the hospital (and its far deeper pockets) a portion of responsibility, systematic contributions to human error became a target of improvement.  Possibly that was not the reason, but I’ve seen enough of hospital management to know that in the end, it’s a business like any other.

Risk management is also behind the other major shift in dealing with errors, which is to approach the victims with candor and compassion rather than stonewalling.  Human beings want a human response.  They want what everyone wants from someone to whom they’ve entrusted their life: honesty, transparency and empathy.  Just as in any relationship, you know when any of them are missing.  You may not be able to identify exactly what it is, but you know that something’s not right, and that you’re not getting the whole story.  Most people don’t get mad when the mistake is made, no matter how awful the results.  They get mad when they see the wagons starting to circle, to deny fault or shift blame or whatever the lawyers are recommending as a legal defense.  All that most people really want is to know that you did your best, or that if an error was made, that you feel awful about it and want to keep it from happening to anyone else.

Supposedly there are people out there who are looking for a quick buck, and see your mistake as an opportunity to take you to the cleaners financially.  But I’ve worked in health care for around 25 years now (I started before I was in high school.  Not kidding.), and I’ve never met anyone who wanted anything more than compensatory free service.  Which I think is the least that you owe someone who’s been harmed while under your care.

At this point, these practices are fairly well-established with respect to patient care.  What’s disappointing is that those who advocate this approach in clinical medicine don’t seem able to make the connection to other aspects of their lives.   For example, education.  Residency is still very much about ascribing error to individuals rather than examining the process of teaching and learning.  To some extent, this has value in that one of things we must learn is to avoid mistakes, and to take responsibility, examine and remediate our weaknesses.  But so much of the time, we’re only doing what we’ve seen others do without rebuke or remediation, yet the program chooses one particular resident to castigate for it.  It might be you.  Or it might be a colleague who’s under some kind of unusual stress outside of residency, or perhaps comes to residency insufficiently prepared in some way by their medical school.  The program never has to defend that choice, because the only real record of the action is the fact that it was disciplined, or perhaps a report of it by someone with a malicious agenda, so it looks to any outside inquiry that only one resident was guilty of it.  When those of us on the inside, if we’re being honest, know that this is not the case.  How can the resident ever obtain justice?  And how can they ever find forgiveness, even if only for their own mental health, for the program and the people who treated them so?

I’ve been thinking about this lately with respect to Tulane.  I am still angry about what happened with my OB/GYN rotation, and I’m angry because people there behave as if they know they’ve done something wrong, but no one will admit it, and no one will apologize.  They made me sign a statement absolving them of blame before they would send the records the state board requires for my application for licensure.  Apparently they don’t know what duress means, or its significance with regard to any statement made under it.  They offered to send me my records, and then reneged when I took them up on the offer, saying that the board needed them directly.   Which makes me think there’s something in them that they’re afraid of me seeing, and they were betting that the offer would suffice to gain my trust.  I wasn’t looking for reasons to sue, but now I wonder what they’re hiding that’s so damning.  I would prefer to like and trust the school that granted my medical degree, and be proud to be an alumna, but they’re making it difficult.

And so I wonder: does forgiveness have to come first, for transparency to follow?  Or will it simply feed the monster?

Well, so much for WordPress’s iphone app

Apparently, even if you tell it to publish something privately, it publishes publicly.  So for all of you who got a short glimpse of my silly side, well there it is.  For those who missed it, trust me, that’s a good thing.

Yay Kim!

I want to take a minute to congratulate my friend (and college roommate) Kim on her prestigious and well-deserved award.  She makes it all look easy, but trust me, she had an incredibly tough road as an undergrad and then a grad student.  My memories are fuzzy, but I think we got to be friends while working a service project together.  At the time she was pre-med, and struggling with one of the early weed-out courses.  I was an economics major, but only on paper.

Her freshman chemistry professor told her point blank that she had no business being pre-med, or a science major.  She was obviously here for her MRS degree, and should stop wasting everyone’s time.  Or something to that effect.  Which was consistent with my own experience with that professor, and that of several friends.  I won’t mention his name, but that episode kept him from getting a very prestigious teaching award, with significant money attached.  Shame on him for thinking that anyone could be so insignificant as to be treated that way with impunity.   You just never know what the future holds for a freshman in college, and any college professor should know better than to judge like that.

I could go on with the examples of people who underestimated and misjudged her, because it was the story of her whole undergrad experience.  But really I just want to offer my sincere congratulations on the award.  She has excelled, from circumstances in which even an average career is a great accomplishment.

You, sir, are no sparkly vampire

You have to admit, a title like that demands a post, even if I had nothing apropos to discuss. But it turns out I do.

I’m still trying to wrap my head around the breakup. Not in an emotional sense–I’m actually totally fine in that respect. It’s just that nothing about his behavior made much sense, from an external perspective, nor could I imagine any scenario that would at least make it internally consistent. One week he would be all in, and the next he’d be talking about how he didn’t deserve me and how I deserved so much better and he wanted to break up. Seriously, WTF? In his defense, his mom had just been diagnosed with Alzheimer’s disease, and that would certainly be a heavy burden for anyone to bear. But if I were in his position, I’d want more support around me, not less. Frankly, it all sounded like an elaborate version of, “it’s not you, it’s me.” And it’s not my policy to argue with men who say they don’t deserve me, and that I’d be better off without them. My policy is to agree, and get out of there ASAP. But I hesitated because of the situation with his mom. Finally I told him that I didn’t care what he thought either of us deserved, or should do. I said to tell me what he wanted, and we’d go from there. And he said he didn’t want to be in a relationship, and that was that. Very self-destructive. It made me sad.

That was all well before I decided to move here, so if the move turns out to be a poor decision, I have no one to blame but myself. And correspondingly, the theme of these last few weeks seems to be, “what the hell was I thinking?”

Working at the county jail at first sounded like a novel and interesting experience. And before I started, I was toying with the idea of just staying there for the rest of the year. But now, I think not. I’m happy to get them caught up with their backlog of orders, but come January 1st, I hope to God there’s a better option for employment. Seriously, the pharmacy there is just a chain-link-fenced area of concrete sub-basement with mood lighting, no windows and no bathroom. And razor wire along the top, like frosting on a cake. I mean, we always joke about how the pharmacy is a dungeon. But this one really IS a dungeon.

The jail staff call the cavernous sub-basement where it’s located the “superdome.” I can’t decide whether that’s inappropriate-but-funny, or just totally inappropriate.

And a few weekends ago I got a random text from a guy friend, who somehow always manages to convey a more than casual interest, without saying anything that’s actually inappropriate. And I keep verbally pushing him away for extremely good reasons I won’t discuss here. Anyway, a few days later I realized it was CNS week. It’s just as well, because another conference-full of longing stares across a hotel lobby is really the last thing I need right now.

Run 2.0

Today, I am starting the Couch-to-5K running plan.  I tried it once before, but my right knee is very prone to injury.  To be honest, it feels a little unstable, like there may be a problem with one of the ligaments.  But I’m so out of shape, I can’t reliably distinguish the problem from inflammation.  Anyway, if it interferes again this time, I’m going to ask for some imaging instead of assuming it’s just the arthritis.

Last time, despite the injury, I felt great after just one week of walk/jogging.  I’d always wondered why people become such fanatics about running.  It looks boring and uncomfortable: hot, sweaty, altogether gross.  You’d think that if there really were any euphoria involved, then walking should produce at least a similar, albeit less intense, feeling.  And obviously, that isn’t the case.

But I think people must be meant to run, because it really is a self-reinforcing activity, in a way that other kinds of exercise are not.

Drought

My reasons to post right now are far outweighed by those not to post.  And I don’t have anything bad or scandalous to say, so the world isn’t missing much.

The guy and I broke up, probably for good, about a month ago, and I just ended the Facebook profile block I’d put in place for him.  Not that I was actually mad, or anything;  I just needed to re-establish some boundaries.  A temporary profile embargo is a nifty way to gain some space and privacy without actually de-friending.  Perfect for the civilized breakup.

I moved away from Fellowship City.  We actually broke up before I moved, but my reasons for moving remained valid despite that. I’m sad, though, because I really liked living there.  It’s not nearly so scenic here, and I really hate the weather.  But it’s an airline hub, and a big city with lots of opportunity for work.  And despite the city’s size, I somehow managed to land an apartment within a 10-minute drive of just about everything, and easy back street access to the major hospitals.  Good workout equipment in the fitness center, too.

There was no exceptional planning on my part, I freely admit.  The things that have made it a good choice were not at all the things on which I based my decision to rent this place.  And the job I moved here for disappeared, so now I’m taking matters into my own hands and sending out applications instead of relying on my employment agency.  My recruiter seems a bit unfocused right now, and I can probably do a better job of selling my skills.

I’m still waiting on the state board to process my application.  But at least all the paperwork should be there by now.   A medical license would help immensely right now.

Question

This is a question I’ve been considering lately: if we have a particular talent or gift that would benefit mankind, and assuming adequate compensation etc, are we morally or ethically obligated to use it?

Readers (if I still have any), what do you think?

People are really going to pay me for this?

I finally have a minute to write again. At the same time I have a computer handy and am not at work.

Things have been a little crazy these last couple of weeks.  But it looks like I may have an actual doctor job for this year.  Stay tuned for further updates.

16 is the new 30

Back when I was an intern, we worked 30 hours at a time!  Sometimes every other day.  And we were happy our schedules were so humane!

Here is a summary of the proposed new work hour rules, taken from NEJM:

I’m probably one of few surgery-types who think this is an improvement for surgical education.  Yes, it means everyone will have to change to night float if they want to use interns for any kind of coverage.   But I think people forget how difficulty it is to work 30 hours straight when you are the one who gets paged first for every single thing on your service.  Over that initial year, your stamina builds, you get a better feel for when you need to really think through a problem versus when you can rely on rules of thumb, and what decisions you need to run up the chain versus what you can decide on your own.  Also, when you start out, there is a real aversion to calling someone who’s at home, possibly asleep, and asking them to wake up and/or come in to assist you with something.  Even if it’s clearly expected of you to do that.  So I think it’s appropriate to limit intern duty hours more severely than subsequent years, and to require in-house supervision.  Although for subspecialty residencies, I think that can be relaxed after your initial few months on the service.  The reason for the difference is that in the generalist fields, and in fields which require a generalist-type intern year, you usually rotate through an entirely different service each month, where the illnesses and treatments are very different, and you work with entirely different attendings, senior residents and fellows.  But if you are working several months in a row in your own subspecialty, by the end of 3 or 4 months you usually have a good enough grasp of basic medical management of those patients, and also feel comfortable enough with the idea of waking someone up at home at 3am to ask for help, that you can be relied upon to do so if necessary.

These new rules have also addressed the idea that, as the burden of paperwork and minutiae diminish, and attention is turned more toward the overall diagnostic and surgical decision-making and treatment for each patient, longer periods of duty are reasonable.  They also acknowledge that, on occasion, it makes sense to stay beyond official duty hours to care for an especially complicated patient, or to operate on an unusual or particularly educational case.

On the whole, I think it’s better for surgical training than the current rules.  The level of babysitting during intern year is a little excessive, but it’s hard to strike a good balance on a learning curve that steep, when the rules have to apply equally in every field from Day 1 to Day 365.

On second thought

Thanks to all who replied to my last post.  It was several months coming, and more of a last straw than a rational evaluation of the situation in which I find myself.  The problem is more my dislike of spine and the realization of just how big a part of neurosurgery it is, than anything else.  When you’re a student, you get to pick and choose (to some extent) the kinds of patients you follow and the kinds of surgeries you see.  And prior to this year, I was privileged to rotate only at large programs, where the faculty were highly specialized and could limit their practices.  As a result, I was able to avoid spine almost entirely.  And even when I couldn’t, I managed to scrub only with the cool people.

But it’s easily 60-70% of what you do. And it’s what pays the bills. So I think you have to like spine, at least on some level, in order to be a neurosurgeon.

And mostly I’ve just realized how miserable my life would be if I had to do that much spine in my practice.  In addition to dealing every day with the kind of personalities that neurosurgery seems to attract.

It’s been very difficult to sort out all the pieces of this puzzle–to figure out which of the things I dislike are situational and which are fundamental to the field.   To understand why I’ve enjoyed neurosurgery everywhere else I’ve been, but not here.  Put simply, I was sheltered elsewhere, and here I’m not.  Also, the omnipresent death and devastation does get to you after a while.  Even with a tolerance for disaster as high as mine.

It’s been a useful experience, though, and the skills and knowledge I’ve gained will likely serve me well in the future.  So no regrets.

Another year older and deeper in debt

Every once in a while I have a day that makes me want to quit, and leave everybody holding the bag for all my scheduled call days through the end of the month.  Today was a day like that for me.  We have this one attending who is constantly criticizing every single thing I do, as if I’m completely incompetent.  Even if it’s someone else’s mistake, I still get taken to task for it like it was my own.  Whereas if the person in question had presented it, it might not even have been noted.

I’ve put up with it for a solid year now, and as I stare down the barrel of joblessness in two weeks, I fail to see what I’ve gained by doing so, or what I stand to lose from walking away right now.

I really should have quit six months ago.

I’ve already decided I’m not going into neurosurgery, and it’s largely because I can’t stand the thought of dealing with this particular attending for 6 more years, and suspect that most places have people with similar personalities (as opposed to the mostly top tier places I rotated at as a student and intern).

Seriously, I don’t know what’s wrong with people in this field, but I am done with trying to please them.

Stay classy

You gotta love the break-up via text message.  Not that it was a surprise, seeing as I’m neither socially retarded nor in denial.   In fact, I was just telling someone this past weekend that I wasn’t sure how much longer the relationship would last.  We had a huge argument about a month ago, and it was obvious from that point on that he had mentally checked out of the relationship.  He kept trying to provoke me into breaking up with him–he’s never really the one at fault in any of his past relationships (and yes, I know the significance of that).  But it’s not like I was born yesterday, and I do have somewhat of a bitchy streak, so I waited for him to man up and do it himself.  And at least he finally did, although I have a feeling that when he tells this story he’ll be all noble and stuff trying to make it work, and I’ll be the inflexible one. {This is me rolling my eyes}

Anyway, it was fun while it lasted.  He wanted to keep the option open of getting back together in the future, should I change my mind about the subject of our argument (since there was no possibility of him doing so).  But as I said in reply, while it’s possible that my opinion might change, he will always be allergic to my cat.

And although I didn’t say this part, the fact is that if it came down to a choice, the cat was a prior commitment and would take precedence.  So here’s to my future as a crazy cat lady.

Third person singular

Last night I managed to get through an entire call without filling out a death packet.  Which by itself is not unusual.  The odd thing was that there were two patients we expected to progress to brain death, and neither of them did.  For some reason, those patients always die on my watch.  I am the queen of death-related paperwork.  So it’s always a surprise when they don’t.

I guess I should be grateful that the only patients who die on me are the ones we expect to die.  It would suck a whole lot more if these were patients whom we expected to recover.  Or at least to live.

Which reminds me of a story I’ve been meaning to tell for a while now.

Not too long ago, I was on call one weekend when this patient came in with–I forget exactly what– an aneurysm rupture, a huge hypertensive bleed, or some other nonsurvivable injury.  She was in bad shape: comatose, intubated, extensor posturing, but with intact brainstem reflexes at that point.  It was early in the morning, so everyone who was on call that weekend was there.

So far, this is all par for the course.  We looked at the scans, and decided to have a family conference to steer the family gently away from any kind of heroic measures and towards minimal intervention.  It all seemed to be going well until the very end.

Then one of the patient’s family members asked, “You all are Christians, yes?”

Stunned silence.  At some point in neurosurgery’s neverending exercise in giving bad news, you start to think you’ve heard it all, and have answers for anything anyone could possibly ask.  And then they ask that.

So then she says, “Who here is a Christian?”

The doctors all looked at each other: two Jews, one Indian, one Pakistani, and one member of an obscure sectarian religion.

After a long awkward pause, the patient’s nurse finally raises her hand.

And the relative says, “Oh I’m so glad she’s being cared for by Christians!”

They should make a TV show about this…oh wait

Even though I’ve been preoccupied with other things outside of work, work itself is still pretty interesting.  And my focus is much better, despite the fact that my life just got significantly more complicated.  Somehow it’s much easier to handle the uncertainty of finding a solution to a problem, than the uncertainty of defining the problem that needs solving.  But then again, that’s why I’m a surgeon and not an internist.

So my program just fired a mid-level resident.  The resident in question had excellent surgical skills, but was pretty deficient in basic doctoring skills like establishing rapport with patients and team members, handling criticism (which admittedly is more of a challenge when the purpose is not constructive), making training-level-appropriate decisions, and self-education.  There was definite improvement over the year, so clearly this resident is trainable, but I think there comes a point where people have just made up their minds, and they’re better off leaving voluntarily and finding another program.

On the one hand, there’s a palpable sense of relief that the situation has finally been resolved.  Even though it means we all have to work that much harder, and take that much more call, we were all so tired of the drama that it almost doesn’t matter.  I say almost because q2 call does indeed suck, and the juniors take the brunt of it. And now one of the other juniors is having an extended family emergency and is out for an unknown duration of time. So we’re down two people right now. But I don’t mind the first situation, and we’re all sympathetic to the second, so everyone’s pitching in to cover as needed.

However, the program is now without a scapegoat, and there’s a fascinating dynamic at work these days.  Everyone is jockeying not to become the new scapegoat, and actively trying to ensure that the role falls on someone else.  As the most junior person here, I am of course in the running.  But it seems like everyone’s getting their turn in the hot seat, which is how it works in a generally functional group.  Or at least one that’s not totally dysfunctional.  Of course, the dysfunctional portion of this dynamic is the jockeying among the residents.  In my view, we should present a unified front  and contain the squabbling amongst ourselves.  But that’s got to come from the chief down, not the other way around.

Come on, universe, help me out a little here

I promise this blog is not defunct!  It’s just that what’s going on in my head right now is neither surgical nor medical, and certainly not catastrophic.  Although in a few weeks I may be on here talking again if there’s not a solution to the conundrum of the moment.

Basically, this whole long-distance thing has turned out to be 10 times more painful than anticipated.  Most long-distance relationships at least start out in the same city, and then the two people get separated by circumstance and either power through until they can be together again, or fail.  We, on the other hand, are in two different cities, and not within driving distance of each other.  Which would be tough enough if I were settled in residency where I am, but which is made even worse by the fact that I don’t know where I’ll be in 2 months.  And he doesn’t want me moving there just for him at this stage of things (qualified very emphatically), a statement which despite the qualification still has a strong eau de bagages about it.  But it’s not my plan either, since there clearly is neither a neurosurgical nor an integrated vascular residency position available there, and it represents a huge compromise on my part, and one that neither of us wants me to make.

So, having underestimated the crappiness of Plan A, the search now is for a viable Plan B.  Ideally, that would be a residency position where he lives.  Or elsewhere, combined with the retirement or catastrophic death of his colleague in charge of that region.  Or a promotion and transfer to headquarters combined with a residency position in that city.  These would all be tricky to finesse at best, and they represent the extent of his options within the company.  And we both agree that he’ll never find another job with the kind of flexibility he has now.  I mean, he basically works from the golf course via email and text message.  Can you think of any better complement for the kind of job I have? I can’t.

Onward to Plan C: close enough to drive.  A realistic driving distance is about 300 miles in any direction.  There are several programs in that radius, so that may be a good place to start.

Well, I guess with 6 billion people on the planet, it was inevitable

Sorry about the unintended blog hiatus. I met this great guy who is smart, attractive, supportive, employed, not in any significant debt, age-appropriate and neither a neurosurgeon nor even a physician. And who apparently likes me, in spite of the hundred reasons I’ve given him why he shouldn’t. Including the all-encompassing lifestyle of neurosurgery, and particularly neurosurgery residency, and even more particularly, the capricious nature of opportunities to train in the field, and the fact that they might not be anywhere convenient for him and his life and career, or for us to be together. I mean, I pretty much laid out all the grim details, and it didn’t faze him a bit. Perhaps he’s insane? I don’t know.

Anyway, I’m feeling a bit like I won the lottery, even though it’s really far too early to tell how things will go. But I’m a little distracted by the whole thing. Hopefully people will understand.

Sunday subtlety

First of all, congratulations to everyone who matched!  The match is definitely the worst form of residency placement in existence.  You know, except for all the other ways that have been tried in the past.

Still, there’s got to be a less expensive, equally effective way of sorting it all out.  I mean, that’s a LOT of money to ask our already poor and indebted medical students to shell out.  Literally thousands and thousands of dollars.  And with no guarantee of even finding a spot.  And then to have to do it again the following year if they don’t match.  It’s like being mugged.

–Just hand over your wallet.  Oh, and I may still shoot you if I think you didn’t genuinely enjoy the mugging.

It’s one of several things about medical education in the U.S. that really, truly pisses me off.  So I try to avoid talking about it, so as not to go off on a huge rant.  But it’s not cool, and something really needs to be done about it.

Gimme that sharp thingy over with the string attached…

Yesterday I got to do an entire case nearly solo.  It wasn’t anything big, but I’ve just never had the experience of having the attending go sit in a chair, entirely out of the field for the whole case.  Very unusual for this particular attending.  In fact, it was so disconcerting that I made him come over a couple times and look to make sure I was in the right place for what I was doing.  Plus there was no warning ahead of time that this was going to happen, so I went into this momentary panic:  oh crap oh crap oh crap I don’t know what I’m doing I’ve never done this before I didn’t read enough.  The kind of panic that makes you forget things you know like the back of your hand.

Like how to drape a patient sterilely.

But the patient survived.  I even managed not to cut any major nerves in the process.  That’s always good, right?

George Dacy

Yesterday a great man died. His name was George Dacy, and I owe him a debt I could never even begin to repay. For many years he served as an advisor to a student organization that was a large part of my life in college. It was a small role, and largely ceremonial except in organizational crises. But crisis or not, he was there at the meeting every single week, without fail.

I had the privilege of working with him during perhaps the largest crisis the organization had ever seen. The organization’s treasurer the previous semester–an accounting major, ironically enough–had through negligence, fraud or some other sort of malfeasance drained the organization accounts to nearly zero. When this was discovered, he disappeared from town, leaving his apartment littered with papers and garbage, which we waded through to try and find what financial records we could. He was of course thrown out of office immediately and a special election was held to fill his place. I was elected on a platform of, essentially, “1. I’m the bitchiest person running, and you know you can count on me to fix this.” Of course, no one in that room ever asked me out on a date again.  But at the end of the semester we were solvent, and I really don’t think anyone else there had the balls for that task.

But even I couldn’t have done it without George Dacy.  Because when we gave him all the cash for safekeeping after our new member ceremony at the beginning of the semester, I got the envelope that following Monday with substantially more money than he’d been given.  I didn’t know this until long afterward, because I had not been elected yet, and so had not been the one to collect the money.  And it made all the difference.  And then he and his fellow advisor, David Rainey, had my back on every single decision I made that semester, whether the president of the organization liked it or not.

I owe him a personal debt as well.  He wrote recommendation letters for me, both for pharmacy and for medical school.  I never saw the one he wrote for medical school.  But when he filled out the evaluation form for pharmacy school, he rated me “outstanding” across the board.  I begged him to change one of them to something less superlative, because, I told him, no one would take his recommendation seriously if he wasn’t critical of something about me.  And he replied, “but that’s what I really think, and I’m not going to lie just so someone will believe me.  So if you want me to fill out this form, you’ll have to live with being outstanding.”

That’s the kind of guy he was.  He always saw the best in people, and I have no doubt that I was only one of many whom he supported so unconditionally in all their endeavors.  We’ve lost a very bright light with his death, and I am sad to hear of it.

The box of pain

It takes a special talent to earn a collective facepalm from all of your attendings, but apparently I have it.   While I can’t go into too much detail without violating HIPAA rules, what I can say is that it was entirely an error of my presentation, and not an actual medical error, or an error in judgment.  There was a very important detail of the patient’s past medical history that I had actually considered in formulating my plan, but had neglected to present until well after the films had been shown and discussion was underway regarding what diagnosis they indicated.  And with that one detail, a ~30% pretest probability turned into a nearly 95% probability.

So you know, it was like, important and all.  And it didn’t help that the chief resident, not being privy to this detail, disagreed with my assessment and was arguing vehemently (not that he ever argues any other way) against it.  All in all, a pretty spectacular FAIL on my part.

But there was plenty of FAIL to go around this morning.  Not as entertaining in most other instances, but certainly more revealing.

We had a particularly bad outcome, which again I can’t discuss in detail, but it was the kind of outcome where no surgeon would ever choose to operate if it were more than a very unlikely possibility.  And yet statistically it happens, and this patient was the one to whom it happened.

We all feel remorse on a professional level over outcomes like this. It’s the horrible and inescapable fact of being a surgeon: despite your best efforts, there will be some people you harm instead of helping.  There are really only two ways to deal with that fact: to personalize or depersonalize.  And the attending of record is someone whom I’d expect to be upset on a personal level as well.  I have an immense amount of respect for that attending, for that very reason.  And he clearly was upset.

But then I looked around the room, and noticed something that surprised me.  Our supposedly “malignant” attending was actually wiping his eyes with a Kleenex.  I use quotes because I disagree with that assessment, and not just because of today.  Although this particular attending is uncomfortably direct with criticism, it is rarely misdirected and never personal.  And on the one occasion that he actually sat me down for some extended constructive criticism, I think he was almost as distressed as I was over the process.  Personally, I think that’s empathy and character rather than malignancy.  But your mileage may vary.

OMGWTFbiochem?!!!

Nothing like preparing a review of a MR spectroscopy article to make your head explode.

Listen all you first year med students, biochemistry is like a zombie.  No matter how many times you demolish it, it just keeps coming back.  Goddamn glycolysis.  Citric acid cycle.   Gluconeogenesis.  I hate you all.

Interesting, yes. Fun? I’ll have to get back to you on that in about 6 years.

The worst thing about being somewhere in the maze of knowledge between complete ignorance and expertise, is that every little success, every patient care decision that turns out well, every correct answer I manage to pull out my nether regions when pimped, feels like I’m just postponing the inevitable exposure of my complete incompetence.  I mean, obviously fear of exposure is a strong motivator to keep reading and learning, and that’s exactly how I’m using it.  But that doesn’t make it any less uncomfortable a sensation.

In fact, it makes it worse.  It seems that with every gain in knowledge, I become aware of how exponentially much more there is to know about a subject than the mere surface that I’ve skimmed.  Looked at from the outside, neurosurgery looks like a fairly defined and manageable subset of medical knowledge.  But in fact the ratio of what’s unknown about the brain to what we actually know is frighteningly large, and current practice is right on that scary edge where we think we’re doing the right thing, but we’re not entirely sure.

Geaux Saints!

Well, that was awesome.  Superbowl XLIV brought tears to my eyes.  Although it did NOT make me want to move back to NOLA, even if they did just elect Mitch Landreiu.  Which they should have done four years ago.  But I’m happy the Saints won, and happy for all my friends who still live there.

As for me, somehow I managed to contract food poisoning last night, and couldn’t keep anything down until about 4pm today.  Things are still pretty iffy, even now.  So I didn’t get to go to any superbowl parties.  Oh well.  At least the Saints won.

Weapons of mass destruction

Every neurosurgery service needs at least one blue-eyed, blond-haired female among its residents and attendings.  I am probably going to be tarred and feathered by my female colleagues for making this point, and yet I doubt anyone could truly deny it with a straight face: most males 15-50 who are in any way conscious and processing visual information are going to have a better neuro exam for someone they find attractive.  Which by conventional standards in our society is the blue-eyed blond girl.  If they’re capable of regarding and tracking, they’ll do so.  If they can follow commands and talk, they will.

The same can be said of female patients and male doctors.  But the fact is that most trauma patients are males 18-35.

I’d always considered looks more of a liability than an asset for women in this field.  You know, the whole, “why do you feel it necessary to do this kind of grueling, depressing work when you could easily have married well, and be off having smart, good-looking children while your husband earns a living instead?”  Nobody really gets it, and frankly I ask myself that question as well.  There’s no rational answer.  Other than that I like to work, and no guy has yet convinced me it’s a good idea to have kids with him.

I’m not against the idea of kids in principle, but I’m not having any unless I also have the resources to raise them well.   End of subject.

Anyway, I’ve noticed that with certain patients, the nurses and I routinely get better exams than the male residents do.  And not just that, I’ve noticed that I get better exams when I wear my hair down than when I wear it in a ponytail or up in a bun or twist.  It’s actually kind of funny, and on a couple of occasions recently I’ve been sent in to see patients in that demographic who won’t respond to any of the residents.  But I can get an exam.  I don’t fool myself that I’m any better at examining patients than they are–it has absolutely nothing to do with skills or knowledge.  But at least I’ve finally found an acceptable use for the blond hair and blue eyes.

The REAL reason there’s a helipad on the roof

My last call was… how shall I say it?… interesting.  We very nearly won the game, at least with respect to the floor patients.  And the ICU portion of the service was relatively small and stable. But contrary to what you might think, it is actually not at all desirable to be going into a call night with a small service.  You see, the limiting factor on the size of our service is not the supply of patients who need a neurosurgeon, but rather the availability of ORs and nursing staff for the ICU.  So all that a small service means is that the on-call resident can get that many more hits before the on-call attending has to stop accepting transfers from the remote corners of our catchment area.

And then, of course, there are always the patients who come in through our own ER and need to be evaluated.  The yield is somewhat lower for these, with respect to problems that might actually be operative and interesting.  But they still have to be seen and recommendations made for treatment or follow up, or potentially admitted for observation.

And for whatever reason, that night we also had several old-school pre-op admissions, where they come in the night before surgery without any labs, studies or even the H&P, and all those things need to be done and reviewed by morning.  These days all of that is usually done at a clinic visit beforehand.  The patient shows up the morning of their surgery, and comes to the floor or ICU postoperatively.  It involves a great deal more cat-herding, in terms of handoffs, coordination of care and paperwork to do it the way we do now, but it minimizes hospital room charges, which by the usual accounting practices is more cost-effective.  If we could somehow quantify those intangibles, as well as resident learning and an overall less frantic pace and fragmentation of planning and preparation for surgery, I think that might not be the case.  But the last 20-30 years’ focus on cost-effectiveness and patient safety in hospitals has come at the expense of medical education and training. Residents are cheap labor, and one role of a good residency program is to keep the service component of residency subservient to the learning and teaching components.   An unintended consequence of all this concern over money has been a significant decrease in resident autonomy. You can’t bill for services if the attending wasn’t directly supervising.  Not to mention the public outcry over the idea that a resident may actually be directing Grandma’s care over at the county hospital, without significant attending supervision. This kind of fearful overprotection has paralleled the trend in parenting over the same period: how can kids learn to make good decisions when their parents are constantly hovering, ready to rescue them and fix all their mistakes?  Helicopter attendings are the new reality in medical training, and current rules encourage them to be that way.  They literally can’t let the residents make their own decisions, even if they want to.

Frankly, I like the old-school system better, as painful as it makes a modern-day call night.  I felt like I knew those patients better in the morning, because all their clinical information was coming at me when it was immediately relevant, and I could link all the parts together into a coherent whole of what we were doing and why, rather than getting the information weeks ahead of time when I’m just checking off boxes to be diligent, and may or may not be the one who actually needs it.  The way we do it now is not conducive to adult learning.  And no matter how young some of us are when we start medical school, by the time we graduate we are all adult learners.

Anyway, we have a few attendings who seem quite good at letting us drive the bus overnight and then pointing out the cliff we were dangerously close to (or on occasion drove over) the following morning, all without compromising patient care in any significant or permanent way.  It’s amazing how much more you learn when all you have is a cushion to prevent serious injury, rather than a net to keep you from hitting the ground at all.

Don’t tell me this thought hasn’t crossed your mind at least once

Today’s fortune: Often, the definition of success is just hanging on after all others have let go.

I’ve found this to be very true, and why success is often not as satisfying as we expect it to be.  It makes you wonder whether you’re just the idiot who was too stupid or stubborn to reconsider, and is now left holding the bag.

First post from the new computer.  It went fairly smoothly, with the exception of transferring my iTunes files.   I still can’t figure out how to do that, and I think the main problem is that my old computer was just too old to run the latest few versions of iTunes well.  And you have to be able to set up the transfer correctly on the old computer in order to move all your files to the new one.

The only annoying thing is that all my old photos are now distorted in that particular way that HD displays distort regular definition TV.  I wonder how to fix that?

Ditching it for a newer, flashier model

This computer is over 10 years old now.  Although I replaced the hard drive about 6 years ago, so maybe it’s officially only 6. Who knows?  I bought the exact same hard drive configuration, so I say 10.

Either way, it’s served me remarkably well, and for far longer than I expected.  I did a lot of research into the various kinds of hardware components available at the time, and bought it from one of those places that will let you select each component separately, and totally customize your computer.  So I was able to get something that would stay current–at least for my anticipated uses–a bit longer than the average 3 year lifespan.  After that, it was just a matter of not minding too much if it ran a little slow, and could only run two or three applications at a time without freezing up.

But when I can’t run Firefox and iTunes at the same time, that’s where I draw the line.  And it’s been like that for about 6 months or so now.  At first I was waiting for Windows 7 to come out.  I’ve been running XP for a decade now and would like to continue the pretense that there’s no such thing as Vista.  Then I couldn’t find a computer I liked.

It’s pure commitment-phobia.  I would go to Costco, and see a whole host of affordable, up-to-date, perfectly good computers.  And I’d stand there dithering around, comparing them all, liking one thing about one of them, and something else about another, but not finding any with everything I want except ones that are overpriced and cluttered with all sorts of other gadgets and gizmos and programs I don’t want.

It’s quite the metaphor, now that I think about it.

I hadn’t even been able to decide between a desktop and a laptop.  My laptop is totally dead, but I really want to replace it with a netbook instead of another laptop.  And I can’t justify buying a netbook when what I really need is MORE power and functionality, not less.  So, I finally decided, desktop first.  Then when Google comes out with their OS next fall, if it’s any good, I’ll buy a netbook at that time.

So having made that decision, I was surfing around yesterday looking at what’s out there.  Still not entirely liking anything I saw.  You know, lots of memory but a low-end processor, or good memory and processing speed but still running Vista, or a crappy graphics card, or a high-end graphics card but a stingy hard drive.  Yes, I’m picky.  When I buy something, I want to be happy with it, and not wonder if maybe that other one would have been a better choice.

Fortunately there are several companies that will still let you customize your computer, so I ended up going to one of them and just building what I wanted from scratch.  It was much cheaper this time around, thankfully.  And I got everything I wanted–or at least, as much of what I wanted as I was willing to pay for–and just as importantly, nothing that I didn’t want.

Sadly, this only works with computers.  But at least my computer and I will live happily ever after.