Hurricane Jill

Grounded again.

Here we are, on lockdown eve once again. Everyone’s tired of wearing masks and staying home. So am I.

But, this time, there is actually daylight on the horizon, in the form of long-awaited vaccines that should finally become available in the next months. I say finally, because 10 months is a long time to hunker down without one. It’s certainly NOT because the vaccine has taken a long time in drug-development terms. This is practically overnight with regard to the normal speed of new drug development and approval.

With that in mind, can we not just endure a bit longer? Have your Thanksgiving dinner when you can be thankful your whole family is vaccinated and as safe as possible. Use grocery pickup instead of in-store shopping. And do you really need to do your christmas shopping now, or can you wait like you usually do until 24 hours ahead of time.

Also, Black Friday is only called that because it’s the day most retailers finally go in the black for the year. I guarantee that is not happening at most places on the Friday after Thanksgiving. So just stay home, or buy online. Or wear your mask to some local retail shop without a lot of customers, and support them instead.

I get it. It makes me feel a little more human to be around other people, even if they are total strangers in a supermarket. Or random people at the gym. And the community of worship doesn’t feel the same via zoom, or without the singing. And talking to family over the phone is just not a substitute for seeing them in person.

However, I speak from experience when I say that you can do anything for a month. You can put up with people you hate, do things that make you want to vomit, work a retail store from open to close every day, work a 30-hour shift every other day. Frankly, wearing a mask and socially isolating is among the easier things that life can ask of you. The job you do every day is probably harder than that.

Frankly, if we had all been socially responsible all along, we might have avoided this shutdown. But we weren’t, and now we’re grounded. At least we get to keep our phone and TV privileges.

Tiny Violins

This post was originally written in December of 2010, but I held off publishing it, even privately, for reasons that should be obvious.

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I’m about 6 weeks into this whole running experiment. Although officially I’m only done with week 3 of the couch to 5K program. I’m going super-slow because, in my estimation, my risk of injury is a lot higher than that of most people. I spent about 2 weeks on week 1 of the program, just because I was SO out of shape, and SO new to high-impact exercise. For those of you who don’t know, I’ve had rheumatoid arthritis since I was 17, and that’s approximately the last time both my feet ever left the ground at the same time during a workout. I’ve walked, and swam, used Stairmasters and elliptical machines, weight machines, balance balls, you name it. There’s not much in the low-impact category that I haven’t tried. But I’ve never been a runner.

Like 30 hour shifts in medicine, it was something I assumed was beyond my body’s capability to do, and so I didn’t try. I continued doing the kind of exercise I had done before developing RA. My doctor always said to rest instead of exercising, but my joints always felt dramatically better after exercising than they did after resting. I was a teenager at the time, so I did what made me feel better, instead of what the doctor said to do. There were days when my joints were so swollen and uncomfortable that they felt too unstable to use. But once the swelling went down enough to move the joint a reasonable amount, about half its normal range of motion, exercising at that point made the rest of the swelling go away faster, and kept it away longer. This was critical for me, because my RA was really bad.

Looking back, it was fortunate that I was in such excellent shape physically when I first got it. Joint inflammation produces a distinctly different kind of pain than that of muscle breakdown and repair. And I was familiar enough with the latter to know that the new pain was abnormal, and that something was really wrong with me. It usually takes anywhere from one to four years for a patient to get a diagnosis and start appropriate therapy for RA. For me, it took about six weeks from my initial development of symptoms until I was referred to a rheumatologist, and another two or three weeks till the actual appointment. That’s about two months from symptoms to diagnosis.

That’s also indicative of how rapidly progressive it was. I went from having one small inflamed joint to raging inflammation in nearly all of them in the space of 2-3 months. It was clearly either RA or lupus, and the early treatment was the same for both at the time.

Since then, it’s been a long battle between my immune system and the latest anti-inflammatory medications. Over the long haul, I’m winning, mainly because I have big guns in my corner, and an understanding of exactly how far it’s safe to push each of my joints over a whole range of levels of inflammation. I’d say the hardest part of college, for me, was simply learning how to function throughout the whole span of variation in limitation that I have, and simultaneously learning to manage the illness.  And what I’ve seen, over and over in my life, is that there are very few things I can’t do as well as someone without RA.  There are things people won’t let me do, because they don’t believe I can.  And there are things it took me a long time to try, because I didn’t believe I could.

It’s a developmental task most other people are exempt from.

But as I get older, more and more of my friends are having similar problems as I did 20 years ago. Meanwhile mine haven’t progressed too much. So, friends, welcome to my world!

Brought to you by the letter J

I’m back! I was writing on another blog, but it’s been suggested, by those who know I’m the author here, that this one is better. It also has an associated Twitter account. Yeah, your guess is as good as mine on that one.

Of note, there has still been no hurricane with my name.

I’ll migrate my other posts and update my author information in due time. Since most of this writing is over 10 years old, hopefully it won’t ruin anyone’s life to make myself known. It’s much easier to write frankly when you are technically anonymous. So I need to make peace with my prior writing before owning it formally. Hopefully you understand. If anyone can identify themselves and would like me to tone something down or remove it, now’s your chance. Just contact me, and I’ll do so, while keeping your contact confidential.

Universal Healthcare (in prison)

For the last 3 years, I’ve been working in correctional medicine.  Yes.  Something I never even knew existed, back in medical school. But everyone needs health care, so there are niches of medicine everywhere you look, from the perspective of someone seeking to provide care. The question is, does everyone have a right to it?  And if it’s a right, then how can we charge different prices depending on who’s paying?  Isn’t that inherently discriminatory?

This job puts me smack in the middle of that debate. The funny thing is, the issue was decided way back in 1976, in a case called Estelle v Gamble. The Supreme Court ruled that failure to provide adequate healthcare to prisoners constitutes cruel and unusual punishment under the 8th Amendment. Yes, that’s right, prisoners are entitled to adequate medical care, for free.  Or at most, a week’s worth of loose change from your wallet.

So how do we justify our failure to provide adequate healthcare for all the people who haven’t committed a crime?  In the last 40 years, we’ve been on the declining slope of the Kuznets curve, if I can steal an economic principle and apply it to social justice. The problem is, we’re in a fight between those who’d have us climb back up the way we came, and those who’d have us press forward past this politically and socially incoherent period, toward a time where one doesn’t have to choose which basic rights to jeopardize in order to live a meaningful life.

Even in the face of Estelle v Gamble, the determination of what constitutes “adequate” health care is a controversial topic. The evidence says that x,y,z should be done, but what’s actually done is more like t, u, v, w, x, y, z.  And well, we didn’t check for a-s, and there IS a 0.01% that one of those things could be happening.

Is evidence the standard?  Or is it whatever is the usual practice of the community? Or do we conduct an exhaustive workup of everything? Because if it turns out to be c or d, well, we knew it could have been that, so how can we defend our failure to check?  Prisoners are among the most litigious patients in existence. They rarely sue outside specialists, but they will sue their in-house physicians like a cook throwing spaghetti at the wall. If nothing sticks, just wait a bit longer and try again.

There are many reasons for this. One is that prison is boring, and suing people occupies time and keeps the mind active.  Outside consultants nearly always find some nail to hammer, so we try to ensure that such a nail exists before we send a patient to them.  The patient experiences that as the in-house physician being the uncool parent, with the consultant as the cool parent.  Prisoners, in general, also do not grasp the concept of professional ethics, and tend to assign malicious intent to things that are a function of organizational limitations.

Prison health care is a balancing act between the health of an individual, and the safety of others. This creates many issues, both obvious and non-obvious. For example, it’s obvious that prisoners can’t just get in a car and drive to their cardiology appointment. They have to be accompanied by armed guards and taken in an adequately safeguarded vehicle. That means prisoners go individually on every trip, accompanied by two custody officers from the prison.  There is not an unlimited supply of custody officers to send, nor an unlimited number of cars to take.  So there is a hard limit on the number of prisoners who can go to see an outside consultant on any given day.

Prisoners also must wear 2-to-4 point restraints to prevent escape, anytime they are at an outside medical appointment. This can often prevent thorough evaluation of orthopedic and neurologic issues.  And what about the shoes they wear?  In prison, most prisoners wear the same brands of tennis shoes that you or I would. But they can’t wear them offsite, because it’s easy to hide things in them, and smuggle them into the prison.  So there has to be a really good reason for someone to need to wear them off site.

Even on site, there are limitations that you would not consider obvious.  You or I could go and buy a knee brace or a wrist brace and wear it wherever we want.  But most braces contain a piece of hard plastic or metal serving as a stabilizer.  That’s a potential shank.  Even a simple ACE wrap can be a problem.  It can be a noose, or it can shield a small metal object from a metal detector or a manual pat-down. Same with abdominal binders, knee and elbow sleeves, leg immobilizers, arm slings, etc.

Each decision about care has to be considered from many more perspectives than in a normal practice. To think otherwise is to compromise the safety of everyone working at the prison.

And yet, even within these restrictions, many prisoners are provided better care than they ever received on the outside. Not because prison medical providers are better clinicians, or more thoughtful diagnosticians, but because care is a right, and is provided without regard for ability to pay. But it would be a lie to expect that providing a minimum level of care for all does not compromise the ability to provide all the care that everyone needs. And that’s the struggle we have not solved, either in prison, or for the rest of society.

It’s hot out, and this looks remarkably like a handbasket

I’m finally almost out of the pharmacist business entirely. I have a medical job right now doing Medicare H&Ps. It’s fun, and interesting in that I like talking to people, and you never know what kind of person you’re going to meet. The downside is that it’s all house calls, and you never know what their house is going to be like, either. Though what bothers me most is the indoor temperature, far more than the dirt/cleanliness factor.

Old people seem uniformly to like their houses around 80 degrees, which is about 6 degrees hotter than I can bear when I’m sitting around doing nothing, and 10-15 degrees hotter then I can stand when examining patients. And it’s generally >100 degrees here in the daytime, with my air-conditioned car as the only refuge. So lately I’ve been dressing in sandals and flowy skirts and T-shirts, which is 10x cooler than the pants and thin cotton sweaters that made up my professional attire up to now. I look like a hippie, but no one seems to mind. People are happy to have a real doctor COME TO THEIR HOUSE and spend AN ENTIRE HOUR with them, and aren’t going to quibble about style in the face of such substance.

They routinely tell me that I’ve spent more time with them than their regular doctor ever has, even cumulatively over the course of all their visits. Which is a sad commentary on how thoroughly our current payment structure has impeded good medical care with its payment for documentation as a proxy for time and complexity.

Anyway, this assignment ends soon. Hopefully there will be another afterward, or else my residency search will finally yield results.

Names (updated repost)

Whenever I look at my list of Facebook friends, it irritates me how many of them have the same name. Approximately 5% of them are Chris/Christines, another 5% are Davids, 4% are Eric/k, 4% John, 3% Jennifer, 3% Kim, 3% some version of Laura, and 3% are Marc/k. That’s 30% of my friends whose parents are lemmings. And I have three friends who named their boys Ryan. So clearly the apple didn’t fall far from the tree. It bothers me to scroll down and see Chris This, Chris That, Chris Theother, Chris Somethingelse. Particularly when I think of how very different they all are from each other. It seems a little insulting for them all to have the same name.

I was named after my great-grandmother, who supposedly was the great-granddaughter of a notable indian chief. And I like that it has a story, that there’s a reason it was given to me, even though it was at the nadir of its popularity at the time. My parents also gave me a nickname, and both are useful, depending on the situation. But when I was younger, people would always ask, “how do you get X nickname from Z given name?” My answer was factual, that it’s a less common diminutive, but still correct. Now I just say, “How do you get Jack from John, or Peg from Margaret? So STFU.” Although the STFU part is just in my head.

My point is, if you’re having a kid this year, please do not call your son Jacob (#1 boys name, 2009) or your daughter Isabella (#1 girls name, 2009). Or Katniss, or Gale, or Peeta. You think you’re being wonderfully creative, naming them after characters in a book you like. But think about what it will be like for them in 6th grade to have at least three girls in every class with the exact same name. On the rare occasion that some other girl had the same name as me, it felt like a) I couldn’t be friends with her, and b) she was stealing my identity. Of course, it can also go the other way, for example the packs of Ashleys and Jessicas of years past. But that was really an exceptional situation.

People seem to have realized how ridiculous that was, and so this decade there’s been much more variety in what people name their girls.  IMHO, the best gift you can give a girl is her own identity, whether that’s a less than common name, or simply a meaningful story behind a more common one. The next best gift is also to give her an option that allows her to blend in, when that’s what she needs instead. Tweens are mean, so give your kids some armor.

The enemy of good

Long time, no see, compadres. I put my writing here aside for a while out of concern that it was part of the reason for my difficulty finding further training. But on reflection it cost me something valuable to give it up, and I’ve gained nothing of value in return. I often regret not saying what I’m thinking, but only rarely have I regretted speaking my mind. Although those occasions are pretty spectacularly destructive. Still, when you have nothing to lose, there’s little incentive to shut up and keep your head down. More later.

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?

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.

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.

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.

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.

Meh, happy new year everyone.

For once, I’m neither happy nor sad to see the year end.   2009 was kind of blah.  Which I guess is not so bad in a life like mine, where the boring and conventional are in short supply.

It really hasn’t been a good year, although there have been far worse.  It was much closer to the middle of the scale than to either end, really.  I’ve learned a lot of new things, and met a lot of new people.  I even managed to meet a few who didn’t remind me of someone else I’d met before.  But it hasn’t gotten me closer to any of my major goals in life.  I feel like I’m just treading water, waiting for the arrival of that epiphany I can sense just over the horizon.

I don’t have any new year’s resolutions.  The things I need to do require substantially more dedication than the average new year’s resolution, so the whole idea that changing one particular detail of my life will make all the difference is kind of a joke.  Plus, new year’s resolutions imply that there’s something you dislike about yourself and want to change.  And I don’t actually want to change myself, I just want to be the best version of myself that’s humanly possible. Which involves a multitude of small choices, every day, rather than any single big poor decision.

Yeah, I try to set the bar low like that.

Things they didn’t talk about in my medical ethics class

Recently we had a patient come in brain dead after a severe injury.  (There have been lots of these admissions, so I’m not really giving away much, HIPAA-wise.)  To be honest, there was zero chance of survival, so I’m not really sure why the patient needed a level 1 trauma center.  Certainly the organs would have a better chance of viability, however it was obvious that the patient would not be needing them himself.

But we couldn’t declare him brain dead yet because he’d been sedated and paralyzed for intubation, and had other drugs on board from before the injury.  In addition, he was hemodynamically unstable on arrival, so I found myself in the very cognitively dissonant position of trying to save him so that we could declare him dead.

It seemed like a very slippery ethical slope, since it was clearly a non-survivable injury, and no intervention of ours was going to change that.  But he was a potential organ donor, and so I felt obligated to do what I could to preserve that status until he was officially brain dead and organ services could talk to the family about donation.  I just couldn’t bring myself to say that to the family in so many words.  It felt like a betrayal of their trust.  Looking back now, I think I should have.  It would have been better for them to know that our efforts were not really to save their relative, but rather in the hope that they would allow his death to save several others’ lives.  But we’re always told that we shouldn’t be the ones to broach the subject, that there should be a bright line between our role of trying to save the patient’s life and that of donor services.

Even though most of the time, there isn’t, the situation is usually muddy enough that we can cling to that fiction without too much intrusion of reality.  This time it was quite clear.

I went home that day feeling a little tarnished, ethically.

Paying the piper

The unfortunate thing about taking two weeks of vacation is that the payback is two weeks of q2 call.  Because it’s not the actual schedule that matters, it’s the average over your time on that service.  Fortunately due to some internal program politics not involving me, one of my days got reassigned to someone else and I had an unexpected weekend day off.  I have to admit it was nice.

But overall, q2 call – at least the kind where you really do work 30 hours or less – is not that bad.  Basically you work 30, go home for 18, and come back for another 30.  And repeat.  And repeat. And repeat.  It’s more sustainable than I would have guessed.  Of course, you can’t have much of a life outside of work.  However, I find q3-4 call just as disruptive socially and yet less of an excuse for not having a life.

In fact, if we’d been working with anyone other than the person actually assigned to be our critical care attending these last couple of weeks, it might have been truly enjoyable.  I do my best not to be obvious about the fact that I prefer to work with some of our critical care attendings more than others.   But I’m human, and I’m sure it shows.