The main stairwell in my hospital was very poorly designed. It is very narrow and accomodates about two average-sized people across its width. In the day and age of Americans of increasing body size, this type of design can be very problematic. One person moving slowly up or down the stairs can cause a massive back-up in both directions if no one can get around him. Around the floor that the cafeteria is on near lunchtime there are routinely traffic jams.
Additionally, at each floor the doors to the floor open outwards into the stairwell. Did I mention the door are heavy metal firedoors with no windows? And the landings are tiny? This means that as you are coming up or down you always have to be on the lookout not to get wacked in the face by someone swinging open a door.
So if you work at the hospital one would think that you get used to staying as close to the railing as possible, moving quickly, and swinging wide to avoid doors. One would think you would also learn that you have to walk single file behind your colleagues so as not to block traffic or have a collision with someone running up or down the stairs on the other side. But I guess that would be too much to ask for. Every trip on the stairs is an adventure, so I have started to categorize some of the staff stairwell behavior that never ceases to amaze me.
"The white herd" - this would be an entire team clad in white coats, usually Medicine, rounding in the stairwell. This involves standing around, often outside the radiology floor on the tiny landing, arguing some point of clinical minutiae and being incredulous when people are trying to squeeze by them.
"Best friends" - this involves a group of nurses and other hospital staff, usually female and on the way to lunch. They slowly move in a flock taking up the entire stairwell and preventing anyone from passing in either direction.
"Important people" - can usually be seen leaving the surgical floors and moving very rapidly. They tend to move in pairs and are never single file. Get out of their way, especially if they are headed for the cafeteria, because they might trample you.
"I hate my job" - these people move very, very slowly, especially if they are returning from break. Often they can be heard on their cells complaining about "that girl" or "that guy" on their floor or how unfair it is that they got their lunch at X time today instead of Y time. If you get stuck behind one and there is tons of traffic the other way, expect to be climbing stairs for awhile.
"Passive aggressive" - a subset of "important people" who run up behind you on the stairs even if it is clear things are moving slowly. They may even step on your heel not realizing that tailgating doesn't move traffic along.
"Door monsters" - usually late middle-aged folk who always swing the door open quickly and nearly take you out. "Oh, I'm sorry," they say sweetly as if after working here for 20+ years they do not realize the doors can take people out on the stairs all the time.
More to come, I am sure, as I continue to take the stairs.
Thursday, June 4, 2009
Tuesday, June 2, 2009
28 Days to Go
Now that I have made it to June, I am finally allowing myself to begin an official countdown to the end of this year. Unlike many of my friends, I do not get a week off at the end of "intern" year and will just roll from one service to the next to un-ceremoniously start my 2nd year.
Currently, I am doling out blood products for patients. Blood Banking is its own field within pathology and it is pretty complex. It goes way beyond ABO and criteria cut-offs for issuing products. There is a ton of medicine here, more than I have done most of the year. Some of the more difficult cases are actually fairly interesting. Most of my day is spent writing up transfusion reactions. Blood products are not benign and in some cases we all need to be sure that we have a good reason for giving products and are not just treating a number. Luckily, most of the reactions are the garden-variety allergic reactions which are unpleasant for the patient but not life-threatening. Then there are the badder actor--hemolytic reactions, TRALI, TACO. They do happen.
In other news, it looks like health care reford is coming to center stage in Washington. If you are interested in health policy, check out this piece by Atul Gawande.
Currently, I am doling out blood products for patients. Blood Banking is its own field within pathology and it is pretty complex. It goes way beyond ABO and criteria cut-offs for issuing products. There is a ton of medicine here, more than I have done most of the year. Some of the more difficult cases are actually fairly interesting. Most of my day is spent writing up transfusion reactions. Blood products are not benign and in some cases we all need to be sure that we have a good reason for giving products and are not just treating a number. Luckily, most of the reactions are the garden-variety allergic reactions which are unpleasant for the patient but not life-threatening. Then there are the badder actor--hemolytic reactions, TRALI, TACO. They do happen.
In other news, it looks like health care reford is coming to center stage in Washington. If you are interested in health policy, check out this piece by Atul Gawande.
Thursday, May 28, 2009
Wednesday, May 20, 2009
T - 6 Weeks and Counting
I am back from vacation. It was a lot of fun and SO great to be away from work. Once I get my pictures together I'll try to post a few. I came back to piles of work, as usual. But, I had an amazing revalation when I looked at my calendar this morning and realized that there is less than 6 weeks until July 1 and the end of this year!!! I read a collection of short stories awhile back that traced an internist's journey through residency. One of them was about checking boxes and counting down. She reflected on how her life had basically become a tasklist and a countdown: how many more things to check off before I can go home, how many more days on this service, how many more nights on call, how many more months until residency ends, and so on. How right she is.
Saturday, May 9, 2009
The Medical Home
I've been hearing a lot about the "medical home" model lately and I honestly have not been very clear on what it exactly is. It seems to have started to get more press about the time I hit my "senior slump" and stopped doing medical student rotations with much content other than leaving by noon. This video provides a good, short introduction to the concept, and Wikipedia also has a basic article.
Overall, it seems like the model has some potential to make the primary care experience better for patients and physicians alike. It was interesting to learn that the model seems to have originated out of pediatric practices caring for children with chronic illness. The experience I had in medical school that came the closest to the "medical home" model was the month I spent on outpatient pediatric heme-onc. Multiple people saw the patient and his/her at the visit: physician, infusion nurse, and social worker were key. Then others like physical therapists, speech therapists, nutritionists, other specialists were added based on the child's needs. Translators were always available, usually in person. They seemed to do such a good job of addressing everything that some parents said they felt no need to see the general pediatrician for routine visits.
So I wonder if this model could be a good way to go in the future. I have no doubt that the electronic medical record (EMR) can help dramatically in coordinating care. Having spent a good chunk of time this year at a hospital where most clinics still did paper charting, I came to see how frustrating it could be to have no way of finding out anything about a patient in a timely manner. I do not think that EMR is a magic bullet that will save the system; there are many problems with cost, implementation, and coordinating EMR across different health systems that will need to be addressed over time. But it does seem helpful at providing an accessible record for all that care for a patient within one system.
Bringing in nutritionists, PTs, psychologists might be a way to help chronically-ill patients make lifestyle changes, and could help to ease the burden on primary care physicians who do not have enough time to address these issues at routine visits. Group visits and classes could also help to shift to a more preventive focus. Kaiser offers a lot of classes for patients with chronic illness, who are going to undergo routine surgeries, for child-birth and parenting, and even preventive health classes for the "average" person. Feedback I've heard from people have attended these has been mixed, but overall positive. Of course, there is instructor variability to take into account. But Kaiser does seem to have made progress overall in reducing death from heart disease (it's in all of their ads, but if you want to know more, start on p. 20).
I'm not really sure what the medical home would mean for specialists. Would it make referrals easier? What about for hospital-based physicians? Could it improve care after discharge, which is said to often be a critical time for patients? For those of us in diagnostic specialties it seems it could help with coordinating procedures and getting results to patients in a timely manner. How helpful it is it turn around a biopsy rapidly if the patient, who is anxious and stressed that he/she may have cancer, cannot access anyone to give him/her the results?
I am sure we will hear more about the medical home in the coming months as health care reform takes center stage in Washington. It is clear that we need some drastic changes in our delivery of care in this country. Is this one of the answers? I'd be curious to hear your thoughts.
Overall, it seems like the model has some potential to make the primary care experience better for patients and physicians alike. It was interesting to learn that the model seems to have originated out of pediatric practices caring for children with chronic illness. The experience I had in medical school that came the closest to the "medical home" model was the month I spent on outpatient pediatric heme-onc. Multiple people saw the patient and his/her at the visit: physician, infusion nurse, and social worker were key. Then others like physical therapists, speech therapists, nutritionists, other specialists were added based on the child's needs. Translators were always available, usually in person. They seemed to do such a good job of addressing everything that some parents said they felt no need to see the general pediatrician for routine visits.
So I wonder if this model could be a good way to go in the future. I have no doubt that the electronic medical record (EMR) can help dramatically in coordinating care. Having spent a good chunk of time this year at a hospital where most clinics still did paper charting, I came to see how frustrating it could be to have no way of finding out anything about a patient in a timely manner. I do not think that EMR is a magic bullet that will save the system; there are many problems with cost, implementation, and coordinating EMR across different health systems that will need to be addressed over time. But it does seem helpful at providing an accessible record for all that care for a patient within one system.
Bringing in nutritionists, PTs, psychologists might be a way to help chronically-ill patients make lifestyle changes, and could help to ease the burden on primary care physicians who do not have enough time to address these issues at routine visits. Group visits and classes could also help to shift to a more preventive focus. Kaiser offers a lot of classes for patients with chronic illness, who are going to undergo routine surgeries, for child-birth and parenting, and even preventive health classes for the "average" person. Feedback I've heard from people have attended these has been mixed, but overall positive. Of course, there is instructor variability to take into account. But Kaiser does seem to have made progress overall in reducing death from heart disease (it's in all of their ads, but if you want to know more, start on p. 20).
I'm not really sure what the medical home would mean for specialists. Would it make referrals easier? What about for hospital-based physicians? Could it improve care after discharge, which is said to often be a critical time for patients? For those of us in diagnostic specialties it seems it could help with coordinating procedures and getting results to patients in a timely manner. How helpful it is it turn around a biopsy rapidly if the patient, who is anxious and stressed that he/she may have cancer, cannot access anyone to give him/her the results?
I am sure we will hear more about the medical home in the coming months as health care reform takes center stage in Washington. It is clear that we need some drastic changes in our delivery of care in this country. Is this one of the answers? I'd be curious to hear your thoughts.
Thursday, May 7, 2009
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.
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.
Sunday, May 3, 2009
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.
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.
Subscribe to:
Posts (Atom)
