As we were in the ER evaluating a patient, we came across an EKG which was rather interesting for its complete normality (in a patient with a list of medical issues as long as your arm). So I started quizzing the student (yet another one of these bright-faced, eager fellows who plans to do surgery) and making him read it in order. I like to force students to go through EKGs neatly (rate, rhythm, P waves, QRS complex, ST segment and T waves) because I had a hard time learning EKGs, and I was halfway through fourth year before some cardiologists impressed on me the importance of reading EKGs in an organized way. By now, I can glance at them and get a gestalt (no afib, no ST/T wave changes suggestive of an MI), but I still have to go through carefully and make sure I’m not missing an AV block or a bundle branch block or something else with zebra-stripes. Anyway, in addition to the overall plan to make medical students not fear surgeons, and to impress on them the five causes of postoperative fever, I hope to make EKGs a little less fearsome by teaching an organized approach.
So then I offered the student to leave and get some food while I waited for Brad to get down there, and he said, “I want to stay around as long as possible, because people say you’re a good teacher, and I don’t want to miss anything.” You could have knocked me over with a feather. Me, a good teacher? I’m almost afraid to meet the medical student on call for the night, because depending on how enthusiastic they are, it’s only a matter of time till they come up with some (fairly basic) question I don’t know the answer to. So for the next five minutes I was almost stammering, re-evaluating every statement that came to mind in light of my new persona, and then I turned around and paid him for the compliment with a pretty lengthy pimping session (nicely, of course!). I hope he feels educated now! (The ER interns were laughing at me, standing in the middle of the ER on a Friday night, discussing the treatment of afib, and guidelines for blood transfusion, and the clotting cascade, etc.)
Work hours: The other night one of the chiefs chased an intern out of the hospital, saying, “You have no idea how much trouble you’re going to get us in if you stay around like this.” Which just struck me as funny, because the chief himself clearly wasn’t going to leave for another couple hours. At least at this program, the 80hr rule works out to, interns and second years are carefully protected, and then as you pick up more responsibility, you’re expected to get the job done, no matter how long it takes – and just make sure the records look pretty. Which is ok with me, at least on the protected end of the list, because that’s how it works in practice. You can’t dump work on your partners all the time; you have to make sure your patients are taken care of. (Although I’m rather insulted by the assumption, when the chiefs warn me about hours, that I don’t know how to keep the records neat as well as they do. Four months is plenty of time to pick up on how that works. If I want to stay and watch a case, I know better than to let those hours count.)
Continuity of care: With a night float system, continuity largely depends on how conscientious the day folks feel about signing out. Some of the interns are very good; they’ll print a list for me, write a brief summary of what procedure the patient has had, how much progress they’ve made towards a normal diet, and any other issues that might crop up over night. Other interns just barely tell me when they want a post-op check done, and forget about advance warning on who’s been short of breath, tachycardic, febrile, or anuric. This far into the month, I know most of the big players, and have admitted nearly half of the lists, so I don’t need signout as much now as I did at the beginning. Still, if you ordered a CT to rule out PE, it helps to let me know to look for the results. (This is one thing I think medicine is better at: they seem to have a more official, engraved-in-stone approach to signout responsibilities.)