The REAL reason there’s a helipad on the roof

January 19, 2010 at 11:45 pm | Posted in Uncategorized | Leave a comment

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.