Abusive, Arrogant Doctors

This is an interesting article. It talks about how arrogant and abusive doctors can (not surprisingly) really affect the health care of a patient, not to mention affect the workplace and those around them. I've definitely run into plenty of them myself and experienced it firsthand, not to mention heard of other abuses plenty of times. It's a very unfortunate and inappropriate problem. As the article points out, I think the good thing is that there is awareness of the problem and steps are being taken at every hospital to minimize and eliminate it. Interestingly, many of these doctors happen to be surgeons - go figure.

I just also wanted to mention that I've been on the receiving end of this from not just doctors but also nurses, physicians' assistants, nurse practitioners, you name it. So although I will agree that it's much more prevalent in doctors than other medical staff, it is definitely not phenomena limited to MDs alone.

Difficult Decisions

Sometimes people have so many different diseases that it's difficult to decide which one to treat. For example, one common conflict is between the heart and the kidney. If you have too much fluid in your blood vessels, and if your heart is weak already from other processes, that can make your heart even weaker and it can't pump all that fluid around. As a result, the fluid can build up in your legs and arms, and in your lungs, making you short of breath. The treatment for that is to "diurese" a patient - that is, use medications to make people urinate and decrease the amount of fluid in their veins. However, if your kidneys are sick, you need a higher dose of these medications, which can actually harm your kidneys even more. However, the higher doses may be a necessity to keep your heart healthy. It is not uncommon for there to be a natural conflict between the cardiologists (heart doctors) and the nephrologists (kidney doctors) over this very situation. In the end, often the cardiologists win out because while we can treat kidney failure (at least temporarily) with dialysis, if your heart fails, we don't have any sort of substitute for that.

There are many such decisions that clinicians often have to make. I tend to think that usually things work out ok - if we see signs that we made the wrong decision, we can always change and go the other way the next day. Unfortunately, some people are on such a fine balance that choosing the wrong path for even a few hours can sometimes be hugely detrimental. Hopefully through collaboration and talking together with many specialists, we can make the right decision the majority of the time.

Little Fish

We just went to Little Fish for dinner tonight. It was excellent - enough so that I have to blog about it. :D

For appetizers, we had diver scallops with orange, almond and serrano ham as well as peekey toe crab with red beet, tarragon butter and shaved fennel. The crab was very flaky with an excellent texture - a little plain, but still good. However, the diver scallops were excellent - cooked to perfection with a wonderful flavor, and surprisingly good with the almonds and mandarin orange slices.

For entrees, I had the skate (a type of ray) with truffled spaetzle and shredded leeks. I think this is their most praised entree. This was absolutely amazing! The skate was fried lightly so that it was crispy on the outside but very soft and moist on the outside. The sauce was a salty parmesan broth that complemented it very well. The leeks were also tasty and complemented the strong-tasting fish very well. Pete had mahi mahi with a sweet potato puree which I believe was also very good, but not nearly as good as the skate. I would go back to eat skate at this restaurant any time.

Transfer of Care

At almost all hospitals, interns and residents go through rotations that last about 4 weeks at a time. That means at the end of the four weeks, you transfer care to another team. Like I mentioned in the previous post, at Pennsylvania Hospital, we use a night float system. So what happens at the end of a rotation, one team signs out to night float with a paper signout describing all their patients (like a normal night) and the next morning, the new team picks up the paper signout with news about whatever happened overnight from the night float person. As the night float intern takes care of about 100 patients (or more) a night, they don't know any of these patients in detail unless they're pretty sick, so they don't really have any details to hand off to the new team in the morning. There is really no verbal communication between the new intern and the old intern regarding the patients. The best continuity comes from the resident of the team, who is on for about 4 days before the interns switch, so they know the patients at least to some small degree, although they often do not know the small details, or the really complex patients well.

As a result, the new intern is really dependent on the paper signout for active issues and things to do for the patients. In addition, if a patient has been admitted for a relatively long time (on the order of weeks to months), there should be an end-of-service note written by the previous intern for the new intern. Usually if all these things are done well, there are no problems.

However, I cannot believe how angry I was at the start of one of my months. I had 4 long-term patients, none of which had an end-of-service note. The paper signout I received from night float, who had been given this signout by the previous intern, was horrendous - it was lacking in detail, disorganized, and did not point out what the active issues were. It didn't feel appropriate to me to approach the other intern personally, but I did contact the chief resident and hopefully the importance of these notes will be emphasized. I also think instituting a verbal signout, in which one intern calls the other intern to verbally tell them about the patients and what's going on would be a great idea. It wouldn't take that long and I think it would go a long ways towards improving continuity of care.

Night Coverage

Clearly, doctors can't be at the hospital 24 hours a day, 7 days a week, so for at least some of the time, their patients have to be cared for by somebody else. Different hospitals handle this in different ways. At Pennsylvania Hospital, there is a night float system. Most of the interns leave the hospital at night and sign their patients out to a single night float intern who works from about 5pm to 7am. The good thing is that most interns actually get to leave the hospital at night and are refreshed the next day to do work. The bad thing is that the night float intern is taking care of probably about 80-100 patients a night, and since you get signout on so many patients, it's not that detailed and you really only remember the really sick patients or make a note of specific things you have to do for certain patients. That means that night float doesn't know most of the patients very well at all - they just handle critical issues at night. Most patients are sleeping at night, and there's not much going on, so it's manageable, but if there are quite a few sick patients that night, it can get very busy and complicated. The good thing is that there is a resident or two for backup if things do get ridiculously busy.

Some other hospitals do it differently. They have teams that round together, and at night, 3 interns will sign out to one other intern for the night. The good thing is that that since they all round together, that intern staying overnight is supposed to know all the patients relatively well. The bad thing is that one out of every 4th intern stays overnight, making 25% of the interns extremely tired and miserable the next day (since usually they get very little to no sleep) and also decreasing the work force by 25% the next day since they have to leave by noon.

It's hard to say which is the better option. It's bad to have so many interns tired working the next day as studies show that the more tired doctors are, the more mistakes can be made (not that they are common by any means). This is an argument for the first system, like at Pennsylvania Hospital. However, newer studies are starting to show that the more times care is transferred between different doctors, especially doctors who are not super familiar with the patients to begin with, the more mistakes can be made (again, not that they are common). This would be an argument for the second system.

In fact, there are rumors of new legislation in the works that forces interns to take a nap (!) in the middle of call for at least 3-4 hours. During this time, they would have to somehow sign off their patients to someone else, and then get them back at the end of their nap. This is all part of ongoing legislation reform about duty work hours (a whole other post). However, the problems with transfer of care may be an argument against doing this sort of thing. Until hospitals have more money to hire more helpers (e.g. RN's, NP's, etc) that can at least do part of the work of interns, I guess we'll have to make do.