ethics


Last year I got used to the idea that I was responsible for what the medical students did. I was supervising, so it was always my problem. If I hadn’t noticed what they did, that was my problem too.

“My problem” is getting bigger this year. Now I’m responsible for the interns too. If we’re on the phone, and I don’t ask them for some information, the fact that neither of us knows it is my problem because I should have asked, not theirs because they didn’t check in the first place. If I tell them to do something, and it doesn’t get done, it’s my problem, because I should have checked back on them. If they misorder something, it’s my problem, because I should look at their orders.

Human nature likes to blame other people. It’s really hard not to blame the interns; they’re so handy for it. But it’s not fair to them; they’ve only been doctors for three months. I’m the one who knows about all these details, and I’m the one who should be double-checking all of it. If anything gets missed or goes wrong, it’s my fault. Always.

I told myself that for three hours this morning. Now I believe it, and hence can feel appropriately guilty for the weekend’s errors. Every single mistake I make could change someone’s life. It’s starting to get to me. I don’t even need to bring the lawyers into the picture. After thinking about this for a couple more days or weeks, I’ll be so paranoid about hurting someone or missing something, lawsuits won’t even be part of my reasoning. That should make me a better doctor, but it’s no fun thinking about it.

(And nothing particularly bad happened this weekend; just details. I need to have a higher standard for myself than the attending does. I need to be more upset about what I miss than any attending or chief resident will be. Even when the attending agreed with my decision, if it didn’t turn out right, I can’t blame him; I have to blame myself. I should have known better.)

(And then some people call me ‘intense,’ with a connotation that means I should back off, let things go. I can’t. I make enough mistakes, without trying to let go too.)

I thought WhiteCoat’s story about medical professionals not having heard about Medicare’s new strategy to avoid paying healthcare professionals for services rendered (otherwise known as the “never” events) had to be an exaggeration.

Then I mentioned their upcoming enforcement (next Wednesday, Oct. 1) to a senior resident, and he gave me a blank stare. He seemed to think this was another piece of raving insanity, along with my defense of Palin (what can I say? when all the men in the room start attacking her, I morph into a Republican) and my objections to abortion. It took me quite a lengthy explanation to get him to think I might be right – this despite signs all over the medical records department warning physicians of the events that are now not permitted to occur, as well as notices popping up all over the charts, and random walls in the hospital. I had no idea that my time in the medical blogosphere was so well spent.

(For further information on the concept developed by some genius in Medicare (who really deserves a million dollar bonus – this scheme is going to save the government so much money – except didn’t they take it all from us in the first place? – until all the hospitals go bankrupt; do you think the government will bail out hospitals who fail because they tried to take care of patients, the way they’re bailing out the financial institutions that made foolish choices?) – excuse me. Back on track: for further information, see Buckeye Surgeon’s analysis, and this piece by Dr. WhiteCoat (as well as a good deal more on his site). Basically, the idea is that Medicare (and the private insurance companies will inevitably follow suit) picks several events which everyone would prefer not to happen, and unilaterally mandates that they will now not pay for these occurences; the goal being to promote “quality” healthcare. Which is fine for the “never” events like wrong-site surgeries and mismatched blood transfusions; those are rare and truly preventable. But then you come to things like urinary tract infections, central-line associated bacteremia, C difficile infection, wound infections, and on and on – things which we all deplore, but which there is no scientific evidence to suggest the possibility of completely eliminating. All the studies show ways to decrease their incidence, but not to prevent them from ever happening at all. I can quote you the statistics; that’s stuff I get pimped on. Anyway, basically, Medicare is going to penalize hospitals for existing in the real world. They’ll all go bankrupt. Somebody please help me figure out some alternative career options? I need to get out of this circus before the whole thing falls apart.)

(And in case you were wondering, I know that the goal of all this is to decrease costs to Medicare, not to improve patient care. Because if patient care were the point, hospitals could be held to evidence-based standards for acceptable rates of infections and other complications. But this whole rigmarole is being arranged by some accountants and their secretaries, who know nothing about taking care of sick people. . . . I’m looking for the exit, and that’s only partially rhetorical. I do not want to spend my life explaining myself to bureaucrats, and begging for permission to take care of the patients that I am morally and legally responsible for.)

Another thing I need to learn to be a real surgeon: When doing an open abdominal case on a patient who’s had practically any previous operations, there are bound to be adhesions to some extent (unless they’re on chronic steroids, in which case you get the prednisone effect – wonderfully smooth going in, and the near-certainty that they won’t heal afterwards). Depending on how many surgeries and where, and the patient’s genetic tendency toward scarring, there will be more or less adhesions, and it will be more or less difficult to get where you’re going.

When dissecting the adhesions apart in order to get to the underlying structures, you have to protect the bowel somehow. Touching the intestines with the bovie (electrocautery) is very much frowned upon, and can lead to all kinds of complications, ranging from post-op abscesses to enterocutaneous fistulas.

There’s a really simple maneuver to help avoid this. You slip your gloved finger under the band of adhesions, separating it from the bowel underneath. Then you bovie on your finger.

The bovie is hot.

This can really hurt.

If you don’t time it just right, you can go right through the glove into your finger.

The good surgeons 1) know how to time it, and 2) care more about protecting the patient than about how hot their fingers get.

I am still a source of frustration to my mentors for two reasons: If I ever have to put my hand under the bovie, I can’t take the heat, and I back off way too soon, which makes it take forever to get anything done (which is too bad, because it’s quite a privilege to be given the responsibility of putting your hand under and guiding where the incisions will be made, and I hate to mess up when an attending lets me do that). Or, when it’s their hand in there, I hit it. Either way, not popular.

I need to do some more surgeries.

My patient is dying (again), and I can’t do anything to stop him.

That’s such a horrible feeling. I can’t help him. I can’t stop the disease, I can’t change anything anymore. It’s too late.

At that point, the thought arises, if I can’t cure him, at least maybe I could make this quicker, easier for him and his family.

I never thought I’d understand (dare I say sympathize with) that idea.

I understood today, finally, how doctors, whose purpose is to heal, can end up wanting to kill (because that’s what euthanasia is, in the final analysis). I wanted to do something, anything, for this man; and if I couldn’t fix him, that left only one thing.

The problem is that I’m not God. There’s a very old joke about the difference between God and the surgeons; and I think death is his way of reminding us humans of our place in the world. Death is not under our control. It’s not a thing that we can order around, or organize, or turn off and on at our whim.

Life and death belong to God. He gives life, and he controls its end. The time of death does not belong to us. That’s our human arrogance talking, to think we can control every aspect of our lives, right down to death itself.

So I had to let go. That man was God’s creation. God let me care for him for a while; but ultimately I and my colleagues were never the ones in control. As the psalmist says, “Man returns to dust, and his spirit returns to his Maker.”

I’ve spent so much time in the hospital lately that coming out into the sunlight feels like culture shock: there is light like this around commonly?

I’ve figured out (belatedly, perhaps) that the hard part of call is only between midnight and 5am. That’s when the circadian rhythm really demands to slow down and go to sleep. Before, and even after, is not that bad. In fact, looking at the sunlight now makes me feel fairly wide awake, although I know i’ve missed so much sleep lately that if I don’t catch up on at least a fraction of it today, the rest of the week will be ruined.

Part of it, too, is the discipline we started learning back in grade school math: I don’t want to finish these problems, to pay attention and work all the way through, but I will anyway. At a certain point in the night, I really do not want to be there at all. It would be so delightful to simply walk away; not even out of the hospital, just into the callroom, and decide to ignore pages for an hour or two, or even just to ignore the jobs that ought to be done even though no one will page about it (checking labs and imaging ordered earlier, walking around to check on the critical patients, filling out some of the mountains of paperwork that have to be done at night because if saved for daylight they’ll overwhelm the team’s resources). But I won’t; I’ll keep going regardless of what I’d like to be doing.

There’s a point in the middle of an endless stream of traumas, one or two every fifteen minutes, where every single person in the ER looks at the others and says, “Why am I here, and why am I doing this?” And no one has much of an answer, so someone says something flippant, and we keep going. Or a patient threatens to leave AMA, and we all shrug: Sure, do us a favor, the door is that way.

Then there was the time I decided to put my head down on the desk for five minutes, and when the nurse came to ask me about something, I jumped so hard she was more startled than I was. I think I have too much of a startle reflex. I’d been half-awake the whole time, knowing it was a matter of minutes before someone needed something from me, and I still leaped to my feet. I’m usually a very solid sleeper, but I’ve trained myself to never really sleep in the hospital. I’m too worried about the consequences (to a patient, or to my career) if I sleep through a page. So I’m always half listening, and waking up every now and then to check the pager and make sure I didn’t miss anything. Which makes me rather unsympathetic to the new medical students and interns who do occasionally sleep through their pagers. I can have slept 4 hours in the last 48, and still jump up the second my pager goes off.

Those are bad numbers. Maybe I’d better go to sleep now. . .

I was fuming this evening, and the rest of the residents were tickled. They think it’s a joke, to see how much strong language I’ll use when I get upset. So far I only go in for colorful epithets; they’re waiting to catch some dirty words, which makes it dangerous to get angry around them.

One of the critical care consultants is driving me crazy. He interferes with my patients, and he shouldn’t, and I haven’t quite got up the nerve to tell off an attending from another specialty (and I rather doubt that it would do any good if I did; he strikes me as being very good at looking down his nose at anyone who tried it).

The last time I had to deal with medical consultants trying to manage critical surgical patients was in the burn unit last fall, and then at least I could tell myself that I knew nothing about critical care but what I was picking up from the nurses (if they reported something to me from overnight, I knew they considered that important, and I should pay attention), so I couldn’t possibly presume to criticize the medical folks. Now, admittedly, I am far behind a board-certified critical care specialist, but I do know more than I did then. I also think that spending a month learning to think like the most finicky doctor I have ever met, one of the trauma doctors who will spend an hour making sure that every single thing is perfect for one patient, has taught me something.

So, I (and my chief) object tremendously when this particular consultant (the rest of his group does it too, but he’s an egregious offender) tries to take over the entire management of a surgical patient whom he was consulted on either for vent management, or as a courtesy because the patient is in the ICU.

Today, without talking to anyone from the surgical service, he sat down with the family of a patient he’d met yesterday, and told them the patient was essentially brain-dead, and they ought to withdraw care, basically now. Then he ran into me inside the unit (I had just come up to have a similar, but perhaps more gradual and gentle, conversation), told me flatly that he’d told the family care was futile, and he expected “we will end up withdrawing before too long.” I was furious; I think there was smoke coming out of my ears. That’s my patient. I spent a month taking care of him, nursing him along, watching him slide out of my reach; I was heartbroken when I came back one morning and found him on death’s door in the ICU. I have talked to his daughter every day for a month. I know him; I know his family. He’s mine; or at least he’s my attending’s. This jerk met the whole group yesterday in the middle of a disaster; who does he think he is, to go telling them things like that, without talking to us? My attending or I should be the ones to say, We’re sorry, we failed, we couldn’t save him, he’s going to die, it’s best if you let him go. (And he’s not brain-dead; he’s not good, he’s not conscious, but he’s not brain-dead. I really hate it when consultants, usually critical care or neurology, try to call my patients brain-dead when they’re not.)

Grrr. I think next time I meet the guy doing things with my patients, I might say something; hopefully (in that grand British phrase) more in sorrow than in anger: “I’ve known this guy for a month, I’m really upset by his condition, and I feel like it would be more appropriate for someone like me or my attending, who have a rather longterm relationship with the family, to be the ones to break this news and discuss this situation with them. Now git!”

After work I stopped by the only farmer’s market in the city that doesn’t close before I get out of work, and was pleasantly surprised to find some good vegetable still around, and the farmers eager to dispose of the produce. I think I walked away with ten pounds of corn, zucchini, cucumbers, and tomatoes, for five dollars. I also acquired home-made sharp cheddar cheese, and fresh honey. It’s a good thing I waited to go shopping till I had the weekend off, to cook all of this.

I have a bad habit of flipping through the Living section of the newspaper when I go to the medical library, and there’ve been all these articles lately about the joys and virtues of cooking and eating fresh, local produce (the Slow Food movement, or something like that). Apparently it is only virtuous to eat fresh food if it has been produced within a twenty-mile radius of your abode.

I personally like this honey because it tastes good, not because it was made by bees flying over fields a couple of miles from here. (In fact, given the level of pollution, perhaps it would be better if it originated farther away.)

I’m not sure whether to label as puritanical or hedonistic the fallacy that it is right to eat good food simply because the good food was grown nearby. Somehow epicureanism is now the new virtue, because it is supposed to “help the planet” if you promote local horticulture.

I’ll be going back to this farmer’s market because the food is good, it’s close, and it’s cheap. Not because I think I’m saving the panda bears, improving the ozone layer, decreasing the rate of decline of the polar ice caps (which actually aren’t declining, by latest reports). Invisible hand, anyone? (Adam Smith, 1776, Wealth of Nations)

One more day of internship left. It’s a little hard to believe.

I’m making a couple of notes for myself about what I most admired in the junior residents I worked with over the last year, because I know that within a month, if not less, I’ll have completely forgotten what it was like to be an intern. (The same way that I’ve forgotten what it was like to be a medical student. For the med students out there wondering, “How can the residents treat us like this? Don’t they remember what it was like?” the answer is, no, we don’t remember, because things change so fast in just a few years. I remember third year of medical school about as much as I remember college, unless I concentrate. Even my own blog from back then seems foreign. I’m a different person now, immeasurably more cynical, skeptical, overbearing, determined, confident – hardened. For instance, when people ask for pain medicine, I have no problem saying flatly to the nurse, “That patient has been told that they will have no more iv pain medication. Tell them those are the rules that the attending discussed with them, and please try not to have to call me about it again.” The other day, as we were setting up the trauma bay for a gunshot victim, one of the residents told me, “You can put in the chest tube, but you have to really throw it in. No time for lidocaine, no dissection – cut and push. It doesn’t matter if the patient feels it. In fact, if he feels it, that’s good [because it would mean he was alive enough to care].” I told him, “It doesn’t matter to me what the patient thinks. You watch, I’ll throw it in.” And I did, because by this time I care a lot more about the technical affair of getting the tube in fast, and the overall implications of getting it in fast enough to prevent a tension pneumothorax or overwhelming hemothorax from killing the patient, than I do about whether it hurts him for a short time.)

Getting back to the stated topic: There were some residents I worked with for whom I would do absolutely anything, from something I simply could barely get up the willpower to do, like calling family members with bad news, to pure scut errands, like running to the other end of the hospital to get a paper they should have remembered to bring with them in the first place. Other residents (the minority) could make me silently furious simply by reminding me to do a job which was clearly my responsibility, and which I had been planning to do.

I think the biggest difference between these two groups was that the first kind of resident acted as though we were on a team, together; working toward the same goal, taking care of the same patients; they knew as much or more than I did about our patients, and didn’t have to have the whole story told to them fresh when I came to ask question. They routinely helped get all the work done, no matter whether it was “intern-level” or not; and if they didn’t help, I knew it was because they were overwhelmed with their own work. They cared about whether I got to sit down or eat, what time I came in and left. (Speaking of which, all year, all the seniors seemed to work at getting the interns home at a very decent time, no matter what that meant for themselves. I think now that I’m ready to commit to the longer hours the seniors worked; I need to remember to think about the interns’ hours.) Since I knew they cared about me and my patients, I would do pretty much anything for them, and still will, as we both advance in seniority. The second kind of resident clearly regarded me as a working machine, who existed to save them from having to do any work, and preferably from having to know much about my patients. That is purely bad leadership, and bad medicine.

So my primary resolution is, not to enjoy having an intern to do the scut work so much that I stop caring about the intern’s patients, or stop sharing in the general work of the team. (Although after these last two weeks, desperately short-staffed, without even medical students to help out, having someone junior to me, to do work, when I haven’t even had a senior to help out, will be an unbelievable luxury. I’m not sure what I’ll do with it.)

The other thing that I know I loved about seniors was when they let me do procedures, or enabled me to scrub in on cases. That may be a little more challenging, since I know I’ll be grasping to do every case that comes my way, now that I’m finally allowed/expected to do more, and as for procedures, I’ll still be gaining confidence at doing them on my own – let alone supervising someone else. Many juniors, who seem to have ice in their veins, taught me how to place lines in coding patients, by standing back and forcing me to try myself, before they would take over. I don’t know if I can be that cool.

Correction to the last post: I guess there was one attending in the group whom I didn’t totally antagonize. If we were playing a game of “pick one attending you’d like to be on the good side of,” I’d have chosen him, since he’s powerful, and has a very sharp tongue when he’s displeased. Actually, I don’t know how, I seem to have impressed him well enough that as I spent the morning stumbling through rounds, he remarked a couple of times: “I know Dr. Alice is a very good resident. In fact, she’s one of the best we’ve had all year. I don’t know what’s happened to her this morning, but I guess we can excuse her for one day.” Mmm, thanks; I suppose there’s a limit to how many days I can work straight, no time off, pushed to the limit, pulled in a dozen different directions for critically ill patients every ten minutes, without starting to crack a little bit. So I picked a good attending to stay friendly with.

In other ways, this day has to have been one of the worst of the year. More than one patient with seriously bad outcomes, which are maybe somehow someone’s fault. I can’t honestly tell whether it’s truly my fault, but I keep getting caught in this whirlpool: I should have done something different, I really should have; could I have changed this? was it physically possible for me to be in enough places to have caught this? I should have known; I should have, I should have. Some of the more senior residents saw me standing still, I guess looking as miserable as I felt, and made some remarks that I shouldn’t get too personally involved with the patients. I told them briefly what had happened, and they backed up. “Well, as bad as that, ok.”

All year, when I breezed through things, the seniors and chiefs have told me, “We’re paranoid, and after you have enough patients get hurt around you, you’ll be paranoid too.” The last month I think does it for me, and especially the last few days. Now I know why the best doctors here are obsessive about every single detail – because you never know which detail is going to come back to bite you, maybe to kill or maim your patient.

The best junior residents I’ve watched all year were the ones who came in early and stayed late, even when they were working night shift, or post-call, to double-check on things, and watch over patients till the oncoming team had thoroughly grasped the situation. Now I know what drives them, and I resolve to simply stop caring what time of day it is. I’ll mark my hours how I please, but I’ll stay, every single time, till I know all the details, till the next team knows all the details. Nothing outside of the hospital matters compared to making sure I’ve done the best possible for every person I’m responsible for. I am sick of seeing what can happen when things slip through signout; perhaps more precisely, I’m sick of worrying about whether something slipped.

On the other hand, as I contemplate being on call the Fourth of July (I was expecting that; given the small number of junior residents, and the surgical attitude of “throw them in the deep end and see if anyone figures out how to swim,” I knew I was going to be on call very early in the month), I realize that this month, as nightmarish as it’s been, has made me feel very comfortable with handling all kinds of calls about ICU patients, and semi-comfortable with the prospect of juggling admissions, consults, and disasters by myself. I guess there’s an element of familiarity about it too: I’ve been looking ahead to this kind of responsibility for a year, and I think I know better what’s expected of me (if not what I should expect) than I did heading into internship. (Now if various seniors would just stop making rueful remarks about me being a junior in three days. I can’t tell if they’re serious or not, or how concerned they are.)

Tell you what this year has done to me, I’ve developed such an insanely strong work ethic, that my response to being betrayed by the hospital administration, and overworked by the program, is to decide to go in to work even earlier, in order to take care of things properly. How crazy is that? They’re abusing me, ridiculously so, and all I can think of doing is how to do my best to take care of the patients, in spite of all this craziness. . . Why should I keep caring, since it doesn’t matter to anyone else?

All right, time to go to bed so I can get up extra early.

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