You know it’s a problem when you walk into the room and the patient is reading a phone book of physicians in the Tri-State Area.
Behind the Green Baize Door
The NY Times has a great article about VIP floors in hospitals around the city. I’ve worked on one of them, and I can say that what is said in the comments is far truer than what is in the article. (This may be a first for the comments section of the NY Times.)
VIP floors, with their spacious single rooms — as large as my apartment — and their disaffected nursing staff, are the *worst* place to be if you are sick. I had a patient whose diagnosis was delayed for several days because his nurse refused to send stool samples as ordered. When the intern finally tracked her down and asked if the patient was still having diarrhea, she was like “diarrhea? wha?” It was obscene.
That being said, I’m wondering if VIP floors, and the money they bring in, isn’t worth it to keep the rest of the hospital afloat. We have a substantial uninsured population, and if it weren’t for the $1000 a day rooms, I’m sure the hospital would have gone under like St Vincent’s. My gut hates it, but my brain wonders if VIP suites are a necessary evil in modern medicine? It violates the principle of equality, but maybe it serves a greater principle, like doing the most good for the most people. And having now interviewed as places across the country, many with their own VIPs, I’m impressed at how down-to-earth my home program is about these things. At least here, no one tips the volunteers.
It’s a little like what we saw on Downton Abbey. No secret that Lord Grantham is what used to be called an enlightened despot, committed to the Good of his People. And now he has agreed to turn Downton in subacute rehab, but only on *his* terms. The more I watch of that show, the less I like the characters and the sloppy plagiaristic writing. And yet I keep watching!
Back in the City
So I’m back in the city now, for the last two weeks. It’s been fantastic. I’m on an ED rotation this month, while finishing up my interviews, and I’m loving being back in a clinical mode. Somehow or other, I’ve been getting a bunch of neuro cases: headache, stroke, etc. Still no seizures. They will come, I’m sure.
Yesterday I did an EMS ride-along, which was…interesting. Not the most educational day: I sat in the back of the ambulance and read a couple of articles, did a crossword puzzle. In 8 hours, we got just 4 calls, only one of which was legit. For another, when we arrived at the apartment, the doorman was like “They already left for the hospital in a cab.” ???
Wired
(12:18:54 AM) Me: i had post dinner coffee
(12:18:56 AM) Jessica: uh no
(12:18:59 AM) Jessica: nooooooooooo
(12:18:59 AM) Me: and am so freaking wired
(12:19:02 AM) Me: i know
(12:19:03 AM) Me: it was dumb
(12:19:07 AM) Jessica: poor life choice
I’ve now gone on six residency interviews, and have two more coming up this week. Luckily mine are spaced out enough that I’m not exhausted (yet), but my enthusiasm is starting to flag a little. There are only so many times you can hear “Do you have any questions for me?” before you collapse into the mental version of the fetal position, moaning incomprehensibly about research opportunities and career mentoring.
The best part, by far, has been the pre-interview dinner. That’s the real way to get a sense of the program — are the residents cool? Do I like hanging out with them? Because the interview day presentations are essentially the same — I’m not neurotic enough to get hung up on q4 vs q5 call. My favorite residents so far come from a less well known program, but I might have to do a second look there, just to be sure… more expense! Sure why not; four years is an awfully long time to live in the wrong place.
In semi-related news, I just finished Paul Harding’s Tinkers, which really deserves its own review post, but the spoiler alert is that you should go read it. I don’t care how you acquire it — Amazon, local bookstore, library, or theft (well, ok, I don’t really condone that last one) — but this is one of the few recent novels that actually exceeds the hype. And its only about 150 chapbook pages. No excuses. Go!
It begins…
Just got back from my first two residency interviews. Scheduling has been a nightmare — I once bought plane tickets for the wrong day — so it’s exciting and fun to actually get started at last. I get to see other parts of the country, other ways of doing things. The view from Ninth Avenue can be stifling at times,* so it’s good to get out and remind myself that there is life west of the Hudson.
I made the wise decision to base myself at my parents’ house in suburban Virginia for interview season. We live about twenty minutes from the airport, and down here I have access to a car, which just makes travel easier all around. It’s great to hang out with my parents more before I disappear into internship.
* I’m being sarcastic. Sort of. New York and me, it’s complicated.
Second-rate
Since starting med school, I’ve always made it a point to read fiction before going to bed. Even though my own productivity has gone down significantly — nearly zero through third year, only slightly better now — I think I’ve read more extensively than ever before. Certainly many more contemporary authors.
Right now, I’m reading Monica Ali’s In the Kitchen. I read Brick Lane in college and liked it, though there were occasional moments when I was baffled by her stylistic choices, one time jump in particular. Reading In the Kitchen, I’m not so much baffled as frustrated. The characters are flat, unidimensional tropes: the Silent Russian, the Tart with a Heart, the Laid-Back Jamaican. The eponymous kitchen (if that’s the word I’m looking for) employs one of each nationality, because it is MULTICULTURAL. That clang you hear is Monica Ali’s anvil hitting your head.
Just when the narrative was starting to pick up momentum, she up and moved her protagonist away to be with Dying Dad. That segment was almost painful to read, because the dad lives in a small village now “overrun” by immigrants (let’s ignore the plothole of why immigrants would come open curry houses in a dying factory town where there are no jobs for anyone), and therefore every single conversation (seriously! every single one!) is about how England is losing its character because of the influx of the furriners. Rural people are nostalgic and racist! We get it! This is a FOIL to the MULTICULTURAL London restaurant! Bonus: a whole new set of stock characters, including the Wise Pubkeeper, the Demented Granny, and the Straight-Talking Sister. Plus, the dialogue here is wooden and speechy.
There were a blackbird on the lawn and I was stood there watching, the way he’s trying to pull up this worm, and there’s a fascination to it, if you’ve a mind to notice. Well, we never really look. You see the colours in the feathers, like a slick of oil on water, you see the beauty in it when you take the time.
The sentiment is banal, the language hokey, and the outcome non-existent. Gabe’s father doesn’t take his Life Lesson ™ on slowing down and noticing beauty to heart. He’s too busy bemoaning the loss of the British Character.
So why do I keep reading? Well, as a writer, I learn a lot from second-rate books. I learn a lot of what not to do. For instance, during a meeting between the protagonist, his Mafia-inspired boss, and the boss’ pathetic henchman, we read the following gem:
“Gabe watched the deputy manager clenching and unclenching his buttocks, a glaze of pious suffering over his face.”
I laughed out loud at that one, then found a pencil and replaced “buttocks” with “jaw.”
(Apologies for the lack of medical content this time. Um, maybe it’s an analogy? I learn medicine from other people’s mistakes? Or something.)
Goldilocks
In the past three weeks or so, one of my interns has been on my case about:
-doing too much for my patients
-doing too little for my patients
-asking too few questions
-asking too many questions
-my notes are too detailed
-my notes are too short
-writing on team to-do list
-not respecting the hierarchy
It’s not the hierarchy. It’s her. The fact of the matter is, I can’t respect someone who thinks it is ok to pimp their student — that is, quiz them on medical algorithms or workup or pathophys or whatever — by reading off the Redbook/Greenbook or UpToDate. If you don’t know the workup cold, you have no right to be pimping me on it. These aren’t even obscure or complex topics either. Interpreting iron studies. The definitions in the sepsis continuum. When I do ask her questions, she gives me one word answers that totally shut down my desire to engage in a conversation.
She also tends to scoop my admissions, by being the one who talks to family (I previously got my head chewed off for daring to talk to family), and then not updating me fully when I ask, and then jumping in during rounds to look like a superstar.
Also, she reassigns patients daily, and when we the sub-i’s say “I think So-and-so was following that person” she says we should just know everything about all the patients. She also once assigned me a new patient saying it was a good medical student case because “we need to obtain records from an outside hospital.” It’s a mixed message — you are a sub-intern and should be functioning semi-independently, and you are just a medical student, do this scut.
Granted, I’m grumpy today because I only got a half-hour of sleep yesterday and my admission crashed about an hour before rounds.
Refuge
Whenever New York City starts to get to me — as it does about every two weeks these days* — I hightail it up to the very tip of the island, to Inwood Hill Park, and walk into the woods.
Inwood Hill Park is one of the last remaining (the last remaining?) old growth forest in the city, and as you climb up and around the side of the hill, the city drops away to just a dull roar. My usual MO is to enter near Payson Avenue, and just keep walking and walking until the cars on the Henry Hudson Parkway are replaced by crickets and the crunch of my own footsteps.
I’ve hiked this in all weather, in snowboots and in sneakers. On a sunny weekend, like yesterday, there were plenty of people out and about. I passed about 6 groups, more than I’ve ever seen. Most of the paths are paved, which makes it pretty family-friendly (so easy even a grandma can do it!) but occasionally I come across real trails, leading off to Narnia.
The whole point of hiking is to be away from noise and chatter. I suppose I am something of an introvert, stranded in the world’s most extroverted city. So having this refuge, for days when even the Cloisters is abuzz, is key for me. The goal, if there is a goal, is to get lost. (But not too lost. Safety matters. Phone++.) Of course, sometimes you do some across signs of life.
After two hours of hiking on Sunday, I reemerged just off Broadway, feeling full of goodwill, the way people are supposed to feel in Christmas movies. And as I made my way back home, passing young families (Inwood: the new Park Slope?) and people walking their dogs, I suddenly realized, “What the hell am I thinking? I don’t want to leave New York.”
This feeling lasted just about till the George Washington Bridge, before I started feeling stressed again just trying to cross the street without getting run over by a gypsy cab or a MetroBus or a little old lady with a walker (true story!). Ah, well, it was nice while it lasted.
* There are only so many times you can squeeze yourself onto a crowded subway carrying groceries in both hands and just hoping that your eggs make it home unsmashed, before you start pining for a car with air conditioning and some space of your own. The current rotation, where I “take care” of 90 year olds by causing them a great deal of pain for little clinical benefit, doesn’t help. (But that’s a story for a whole nother post.)
Shitshow Call
I just came off what I hope is the worst call in my career.
In terms of patients, it wasn’t too bad. I did four admissions, but they were mostly very early; only one came in after the resident had gone home for the evening. I even got a few hours sleep (sitting up in a chair, because you do what you gotta do).
Then the next morning, I got a worrisome personal text just before rounds, and didn’t have a chance to follow up. So I was admittedly distracted as I was trying to present the single complicated case to the attendings. We have two attendings on service at once, which is usually excellent for teaching purposes, but sometimes contributes to the shitshow, see below.
Frequent interruptions, which made me lose my mental place repeatedly, at one point confused patient A with patient B, failed the pimping questions… it just got worse and worse and worse. Meanwhile, my mind is running to all kinds of crazy-bad scenarios re personal crap.
So by the time I got to the assessment and plan, I had tears running down my cheeks which I was trying to pretend weren’t happening. I started off addressing the chief complaint, at which point one attending said to start with the “main medical problem” so I switched systems, then he was like “no, as you were,” and then the two attendings started duking it out as to which problem was the “main” one, meanwhile I’m sitting there totally confused, and sleep-deprived, hypoglycemic and watching the table rise toward me. My team is mouthing all kinds of encouragement and thumbs up, you’re doing great, etc. And then one of the attendings turns to me, acknowledges my distress, and whatever little bit of internal reserve I had came crumbling down at the kindness, and turned into full-blown sobbing, blowing my nose, apologizing to everyone, until my resident sent me out for some water. At which point I stole an apple juice from the morning report room and ran and hid in the bathroom, which is actually the worst possible place to cry because the tiles just magnify all sounds. Which is where my intern finally found me, twenty minutes later, reassured me, and sent me home.
So basically. Yeah. Shitshow call. Never ever ever want to go back to the unit ever again.
Confessions of a Clinical Ethics Weakling
I’ve been looking around from some decent readings on medical ethics. I took a course in college, which was taught by a lawyer and therefore had a totally non-clinical spin. It’s dry and academic and abstract, completely ignores any discussion of the relationship between patient and physician, which grounds any ethical discussion. Was flipping through the text the other day, to help me think through a challenging case we have on service, and I realized how utterly inadequate my understanding and ability to reason through ethics is.
So how ’bout it? Any suggestions for clinically-oriented, practical ethics* readings?
*An oxymoron?
