Wednesday, March 25, 2009

Sick Days

I have been sick this week. At first I just thought I had bad hay fever and was over tired from a long week at work and a weekend packed with social activities. But by Sunday night I realized that I just felt like crap. So I called in sick.

What's the big deal? I am in residency so calling in sick can be fraught with peril. My work has to be covered by someone else. In theory, if we miss too much time we could have to make up the days or the year might not count towards accreditation. Luckily for me we have an extra resident on service right now and I had covered some of his work when he was out last week. So I knew the coverage would not be a big issue. That doesn't mean I did not feel a sense of guilt about staying home for a day.

Overall, medicine as a profession does not take kindly to people calling in sick. Logically, this makes little sense. As physicians we should know that coming in to work with illness and exposing everyone around us, including patients, makes little sense from a public health perspective. We should know that we are not at our best when we are sick and that clouded thinking can lead to adverse outcomes for patients. And we do know that rest is essential to getting well. It is what we advise our patients to do. But somehow this all can get lost in our culture where work reigns supreme above all else and where we feel a sense of obligation to provide for our patients no matter what.

I doubt that any of this will change anytime soon. I know that I am guilty of participating in the culture myself. After spending a day at home sitting on the couch, I dragged myself in yesterday and worked a full day, despite people telling me to go home early and rest because I looked awful.

How can we make changes? We have to start by acknowledging that it is okay to take time off to get better if we truly are sick and convincing our colleagues to do the same. And systems that provide sick coverage need to be in place to allow people to take the time they need without feeling guilty and that they are burdening their colleagues. This can be especially difficult in residency where it is residents on "elective" and "call free" months who get pulled in to cover for sick colleagues. It will take a systemic shift in attitude, but a new perspective on sick days would be healthy for our profession.

Thursday, March 19, 2009

It's Match Day!!!

Congratulations to all who matched today! Match Day is a definite high point of the whole medical education process.

It is hard to believe that just one year ago I matched myself. Things change a lot in a year. A friend and I were reminiscing tonight about excited we were then to get started in residency. Now almost 9 months through this year, well, let's just say some of that shiny, excited feeling has worn off.

But, a nice thing abut being on this side of the Match is that it means that a new class of people is coming in. That means that I get to move up on the ladder. The end of the first year is now finely coming into view.

Wednesday, March 11, 2009

Playing With The Big Kids

Medicine is very hierarchical, especially during medical training. At the top are the attendings, then come the fellows, the upper level residents, the interns, and finally the medical students. The structure is more rigorously followed in some specialties and locations (ie Surgery, the East Coast) than in others. I have been lucky to train at places where things are a bit more relaxed in general, so as a medical student I could talk to an attending without going up the chain of command if needed.

However one feels about the structure and its nuances, it can be rather comforting to have in place. It starts from Day 1 of medical school. We were assigned a "big sib" from the 2nd year class who was there to answer our questions about what books to buy and how to study for tests. In those days the 3rd and 4th years seemed far removed and intimidating because they had "real clinical experience." Of course, the fact that they were on another campus most of the time probably added that perception.

Our "sibling" networks continued throughout medical school, and soon we were those "intimidating" students giving advice on how to schedule rotations to those below us, and asking our current interns about the different residency programs they had seen. There is something comforting about having someone who is essentially your peer available to answer all of your "dumb" questions and to calm your nerves about the next step when needed.

Then residency started and things changed. Don't get me wrong--I have great colleagues ahead of me in the program who have provided great guidance when needed. But one thing that is different about my field is that I have a lot of contact with attendings and fellows. They come to me to give them the answers on their patients. Let me tell you, it can be quite intimidating. Usually it starts okay because I have some idea of the case or the question at hand and can give them a basic answer. If I cannot, I will tell them upfront that I do not know, but will find out, and get back to them.

It gets harder when my basic answer is not enough and they begin the questioning, especially if it delves into more esoteric clinical realms. Let's think about this for a minute. I am not doing a traditional intern year, so my clinical knowledge is that of someone who graduated medical school. Actually, at this point some of that base has left my memory in favor of new knowledge, so I am on a decline. At that point of awkwardness someone higher on the totem pole than I will usually take over. It always amazes me how much my fellows and attendings know, and it seems impossible that I will ever be there also.

The whole experience reminds me a bit of being in kindergarten and riding the bus home with the 5th graders while I clutched my Care Bears lunch box and sat very quietly. I never thought I would ever be that big and that cool. But then one day I was, well maybe a bit shorter than they had been, but still I was there laughing and having fun on the bus home. So perhaps one day at the end of this I will make it to the top of the hierarchy and be able to show cases and answer esoteric questions with ease. Then it will be fun to play with the big kids. For now I think I'll just sit quietly, get my work done, learn via osmosis, and bide my time at the bottom of the trainee hierarchy.

Friday, March 6, 2009

Beware of Hospital Parking Facilities

What is it with hospital parking? Everyone complains--the patients, staff, physicians. Generally, it seems like a case of not enough spots for way too many people. In medical school I lived so close to the hospital that I never had to worry about parking. But that did not stop me from having my share of encounter with cars nearly running me over as I walked through parking areas, or near accidents caused by physicians racing out of the MD lot that was near the street I lived on.

Many of the patterns I observed there continue at my new institution. Only now I have to drive and am entitled to park in one of those "MD/staff only" parking areas. Being in the field that I am in where we do not do morning rounds, I get to arrive a bit later in the morning than many of my fellow residents. Thus, I get there around the time that tired people are leaving after working overnight and as many of the attendings are arriving.

Can I just say sleep deprivation, luxury cars with big engines, and arrogance are a really bad mixture? In the past week I have seen cars weaving towards the exit with the telltale open window of a sleepy driver, and been nearly read-ended multiple times by Lexus/Audi/BMW/Mercedes racing up behind me on the ramps in the mad dash for spots. In one case I looked in my rear view mirror and saw the driver making obscene gestures at me since I was apparently not driving fast enough in a narrow aisle with a 5 mph speed limit. I was very surprised he did not honk. But I was not surprised when I later caught a glimpse of his badge as we walked into the hospital. I'll leave his department to your imagination.

The moral of the story is drive very defensively when you go to a teaching hospital, especially if it is around shift change.

Tuesday, March 3, 2009

Work Hours Discussion

There are several articles in today's New York Times about work hours reform and some interesting discussion brewing on the comments section. It is the 25th anniversary of Libby Zion's death this week.

I have been wanting to write about work hours since there is a lot going on with the new IOM recommendations and the ACGME's response. But, ironically, I have been working too much to blog about it. So I'll let these articles wet your appetite and hopefully I can weigh in later this week on this rather controversial issue in medical education right now.