Well Blog

There's some good discussion/cathartic rambling going on at the NYT Well Blog. If you are a frequent reader of the Well Blog, you may be familiar with the links to Dr. Pauline Chen's columns and the responses. In a nutshell, she is an academic surgeon and will often write something about a current issue in medicine, particularly regarding medical education/training. She usually starts with an anecdote from her own training/teaching experiences, then finds a recent study that addresses the main point of said anecdote, and ends by interviewing the author of the study who offers his/her ideas about how we might change the system. Often, she addresses topics that are "taboo" to discuss in the hospital, like this week's topic: when physicians, especially stressed out residents, have "distress" in their lives, it impacts the care they provide to patients.

Now my first response, as it often is to these columns, is, "did we really need to conduct a study to reach this conclusion that seems so obvious?" But since the culture of medicine is not to address issues related to stress/being overworked/ balance in life/etc, I guess unfortunately the answer is yes. What I enjoy most about the Well Blog referencing her columns are the comments that soon appear. Several players dominate the discussion:
1. MDs - usually we hear from current residents/young physicians about the hell of residency currently, older generation MDs whining about how easy our generation has it or about how much medicine now sucks, a few voices from somewhere in between acknowledging the horror of training and the need for change, but reminding the young ones to remember why we entered this profession in the first place.
2. MD Haters - a few people will then start posting that MDs need to stop whining because our salaries are too high, we all have god complexes, we knew what we were getting into, we drive up health care costs, etc.
3. MD defenders - some people, often nurses, jump the aid of MDs and talk about the high debts we have when finishing, the awful hours in residency, the declining reimbursements, and the difficulty of seeing so many patients in limited time.
4. Lawyers/PhDs - then some other professionals, usually JDs/PhDs start posting about what they go through, how they work 80+ hour weeks/slave in labs and have debts/low wages, are underappreciated professionals too.
5. Some MDs then start to post again whining how the attorneys need to get off this blog because "we save lives" and being a lawyer is never that stressful. They then say the PhDs should go because they do not have the debts we do.
6. Repeat, around and around.

Will the problems ever get solved on the Well Blog? Probably not. But I do think the discussions are good because they give the public some idea of what goes on behind the scenes in health care. And they provide MDs/other health professionals with a virtually anonymous way to voice their feelings, which they often cannot do elsewhere. It can be a lot of negativity, but there has to be a place to let that out if it is not safe to do elsewhere. I think that is one reason why sites like SDN and medical school/resident blogs get traffic. Communal sharing of the pain is one way to deal with it.

Here were a few choice comments from anonymous MDs (not me, thankfully) on the current Well Blog discussion on the residency experience:

I’m currently in my internship and I would love for the next generation to be able to survive their training more healthily than I am.

1. Doctors from before the 80 hour work-week LOVE to hassle this generation for being weak because we don’t have to work more than 80 hours a week or 24 hours in a row. BUT:

It is just not HUMAN to work 24 hours in a row.

For anybody.
I don’t care if you are scooping ice-cream or folding socks, 24 hours is not do-able, the human mind can’t stay sharp, being awake for 24 hours does bad things to your muscles, your digestive tract, your mind, your circulation. As doctors shouldn’t We know this? For gods sake people, I come off a 12 hour shift with leg edema! After 24 hours I want to scream at people even when they are just being people and I’m pretty mild-mannered!

One of the arguments against changing shifts completely every 12 hours, for example, is that there are many details lost in translation between shifts. The ability to communicate succinctly, easily, comfortably are not skills that are valued in the application process to medical school. These skills are in fact underdeveloped in most applicants because we are still pushing those who are ‘good at science’ into this role of physician and unfortunately studying science can be a solitary and unsocial effort. Medical schools and residencies market themselves as looking for well-rounded individuals but they rarely consider anyone with poor scores or grades.

2. Psychology and therapy are not bad words. Why shouldn’t it be mandatory for anyone taking on the job of caring for others to spend time examining themselves, their motives, their influences. Cognitive Behavioral Therapy for example can help with depression, anxiety, perfectionism. If there is ever a group of people I have seen who ALL suffer from these and need some therapy it is medical students.

3. Hospitals are unfortunately extremely unhealthy places. The food for both the staff and the patients is generally low-quality. There is no respect for the act of eating and taking breaks. The only breaks universally accepted are smoking breaks. Wearing scrubs while it is comfortable, I believe, contributes to the normalization of obesity among the staff.
It smells bad. The lighting is depressing. The facilities in community hospitals where much of my training has taken place are deplorable. Why not have intelligent and sensitive and HUMANE architects design the next generations hospitals? With a little aromatherapy, more break areas and areas designed for quiet reflection (who hasn’t hid in the clean utility room to cry when things get overwhelming) hospitals can be less hostile toward those working there and therefore also the patients.

4. The bullying. The elephant in the room in the hospital is the overwhelmingly negative behavior between staff members. It is considered wimpish (and maybe un-American?) to complain about bullying as an adult, but there is an attitude of pouring the negativity that is poured on you onto those below you in the hierarchy. This happens within residency programs, between nurses and doctors, toward the medical students, the aids, the social workers, it is everywhere. How can people who supposedly want to help people treat each other with so much hostility? I think this daily. The culture of negativity and complaining and talking behind people’s backs and criticism without encouragement, etc, etc, creates such a malignant environment that any doctors with a shred of sanity and humanity left opt out leaving behind those who create and harbor the caustic attitudes.

5. I could go on and on but I have another 24 hour shift tomorrow…

---------------------------

Residency turned me from an upbeat, happy, optimistic person into a crabby, ultrasensitive, irritable, depressed and angry person. There are the “80″ hour (my record was 107 hours) work weeks, the “24″ hour shifts (my record was 37 hours straight - without sleep) up to 3 days a week, the condescending and power-hungry attendings who belittle residents and tell them “how easy they have it nowadays”, the average 12-14 hour work-days full of nonstop beeping beepers/paperwork/inability to scarf down a snack or even go to the bathroom without 23 interruptions/and legitimately sick patients, the four days off a month (to pay bills, buy groceries, change the oil, call your parents, and “do all that reading” so you don’t feel like a complete idiot when you’re being pimped at 6 AM the next day in front of 10 other people), the friends who leave you because they “don’t understand why you never call them”, the sheer constant exhaustion that never goes away…

…and you do that for 3-6 years of residency! Of course you get depressed and distressed and hate yourself and the world and that damn patient who comes in in the middle of the night requiring emergency surgery. Of course you very seriously consider dropping out of residency… or life altogether, as a woman in my class attempted to do.

This is NOT a pity party. This is the reality on how doctors are trained.

Until serious and considerable changes are implemented, the smart people will be doing their homework and will take a different career path.

I wish I had.

Home Call, Take 2

So I tempted fate blogging about home call while I was on call. It has been a really busy week. We've just been swamped. And I am really ready for a day off after working for days and days in a row. Luckily, I get my last week of vacation next week. I am SO excited.

Anyway, back to home call. Basically, you're sitting around waiting for the pager to go off. Depending on how heavy your home call tends to be, it can be a quiet night at home answering a couple of random pages here and there, or a total nightmare where you are basically working non-stop from home or going back into the hospital. When you have the heavy nights where you are up all night, there is no "post-call" day to recover. You go into work and work another full day. And if your program does long blocks of home call, you might be on call again that night and the next and the next.

Another thing I have discovered about call from home is that it makes it harder to get things done. There's something about paging someone back to a number outside of the hospital that seems to make it take longer for your pages to get answered, if they ever are. Computer access can be a nightmare depending on your hospital's system. You have no back-up nearby. If you do not know what to do, or just want to run a plan by someone, you have to call someone else, most likely your attendings. At 3 am you may not want to call them because as much as they say they are there anytime, they will not be happy to hear from you then.

Call From Home

Since I am on call right now, I thought this might be a good time to discuss taking call from home. On one hand, I am really not complaining that I picked a field where I do not have to do q4 overnight call in the hospital. I am thankful for that on a daily basis when I interact with exhausted interns and residents.

But on the other hand, call from home is really not what it is cracked up to be. It sounds benign enough--you sit at home and get to answer calls from the comfort of your couch. If something is urgent, you go in. Or at some programs being on call "from home" also has some set time that you spend in the hospital each day. So you might work basically a full day and then go home and take call. However, you were technically on call "from home" all day, so none of the work you do counts towards duty hours. Pretty sneaky, huh?

Being on call from home has its drawbacks. You are basically stuck at home because you cannot go too far away in case you have to go to the hospital. Access to a phone and computer are needed at all times, so that eliminates things like going out to dinner. I guess if you had an I-Phone you could pull it off, but then you have HIPAA to think about when discussing cases in public. So you sit at home and wait for the pager to go off. And there goes my pager. How ironic. More on this later.

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.