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Imagine this….

A little thought experiment:

Suppose you are a guy, pushing the edge of middle age, and have been diagnosed with a reasonably aggressive brain cancer. You work in a menial job and can barely afford your rent, let alone health insurance. You travel 2 hours each way to see your neuro-oncologist, just about the only one in the state who sees people without insurance. You undergo a extensive surgery to take the cancer out — what they can see of it, anyway — and then rounds and rounds of radiation. A follow up MRI shows your disease is progressing despite all that. Your oncologist recommends chemotherapy in the form of a little pill every day for 5 days out of every month. Sounds good, you say, except you can’t afford it. Enter the bureaucracy of charity care, weeks and weeks of paperwork to convince the drug company to let you have a few pills for free.

In the meantime, you start getting headaches, right around where the cancer is growing. They respond to Tylenol, mostly, but you worry about taking too much at once. You call the oncologist’s office for advice, and a nurse tells you to go to the emergency room. So your brother drives you 2 hours to the emergency room at the hospital affiliated with the oncologist, where they can see all his records and the results of the brain MRI you had done 3 weeks ago.

Your headache goes away completely with a little tramadol. The emergency department doctor decides to get a CT scan of your head (“to look for bleeding”) even though you haven’t hit your head or anything. The CT scan shows there’s something abnormal — hardly a surprise in a patient with a brain tumor! — and the report recommends MRI to get a better look. So the ED doctor comes back to you and says, “maybe we should get another MRI.” And you say sure, you’re the doctor, you know what you’re doing. So back to the scanner you go, this time for an extensive scan which shows that your untreated tumor is, well, acting like an untreated tumor — a bit bigger than it was 3 weeks ago.

At this point, it’s 1 in the morning. You’ve been in the emergency department for over 12 hours. Your headache is still at bay. The emergency department doctor wants a neurologist to come evaluate you for possible admission to the hospital. You agree, because they are the doctors, they know what they are doing. Reason for the consultation: “I don’t feel comfortable sending this guy home because he might have a complication. I just want to do what’s best for the patient.”

Those are weaselly words, “I just want to do what’s best for the patient.” Because this is where I got involved, as the neurology resident on call. I was consulting on a man with a known tumor, with known tumor progression, now with … more tumor progression. The chemotherapy he needed could not be provided as if he were admitted to the hospital. The box with the charity pills was being delivered to his house in two days. The last thing he needed was to be admitted to the hospital. What’s best for this patient would have been some recommendations about headache management, and being sent back home from the ED in a timely fashion. Instead, he ends up having to pay several thousand dollars for unnecessary imaging, not to mention wasting hours of valuable sleep. (Realistically, he’s not going to be able to afford that ED visit, if he can’t afford his chemotherapy; to recoup the loss, the hospital will artificially inflate the cost of services to those who can pay their way.)

We failed this patient at nearly every step of the way. First, he should have been given headache recommendations in clinic or over the phone, instead of being sent to the emergency department for a non-emergent (though annoying/troubling) symptom. When he did show up in the ED, neurology should have been called early for recommendations — certainly before 6 hours into his ED course. (I do complain about bullshit headache consults, but if someone with an established neurologic problem develops a new neurologic problem, we’d like to know.) The imaging should never have happened at all — there was nothing clinical to suggest a bleed, and the CT and MRI told us nothing that we didn’t already know.

Moral of the story: think a little before you order a test. I know it’s fun sometimes to shotgun your way through medicine, and there is an academic curiosity in a lot of what we do. And be real careful about using the phrase “I want what’s best for the patient” — it makes you come across as a condescending asshole.

 
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Posted by on March 17, 2014 in PGY-1

 

I’m alive!!

Yes, my friends, I do exist. Somewhere deep in the depths of the hospital…

No but really. PGY-2, my first “real” year of neurology, has been unbelievable. In a good way. The hours are longer (hence the lack of keeping up with this blog) but so so very much better. Try as I might, by the end of intern year I really just did not care about cirrhosis.

I’m working an overnight in the neuro intensive care unit at the moment. I was admittedly terrified of the ICU — after my horrible month in the medical ICU as an intern, when I felt like the Angel of Death more days than not. I am not sure that I like it, exactly, but it’s much more manageable than the MICU. My tiny brain can only handle one organ system at a time, yo!

Currently reading: 1493 (Charles C. Mann) as well as The Grass is Singing (Doris Lessing). Oh, and also Wolf Hall (Hilary Mantel). Only one organ system, but oh-so-many books!

 
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Posted by on February 28, 2014 in PGY-1

 

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Rain = baking!

I had a golden weekend, but because it’s been the wettest summer on record, the Gods of Rain once again ruined my plans to go hiking.

Not that I’m complaining, mind, because I used the opportunity to make some wondrous messes in the kitchen.

Read the rest of this entry »

 
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Posted by on August 18, 2013 in PGY-2

 

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Behind

I spent the week in subspecialty clinics, which was awesome. Except for one thing: the schedulers.

Patients are usually scheduled for follow-up appointments, in 30 minute slots. Occasionally there is an initial visit, which gets an hour. So today, I got to work at 7, spent an hour reading about the 6 follow-ups on my schedule, because even though they are well known to the clinic, they are not well known to me.

My first patient was scheduled for 8, but of course did not show up until 8:15. So by the time I’d seen her, staffed her with the attending, and written her refills, it was nearly 9. (And she was the easiest on my list.) And so it went for the rest of the day, as I slipped further and further behind. I had 2 extremely complicated patients, each of whom took over an hour even before I talked to the attending. Both of them actually need psychiatric care, which I am not qualified to provide — one does not think he needs a “shrink” and the other has limited resources. But when someone tells me they are actively suicidal with access to weapons, I’m not gonna be like “Well that’s not my problem, see ya later!”

Meanwhile, some lady showed up on the wrong day (her appointment is actually later this month) and the schedulers tried to guilt me into seeing her. “Look,” I said, “I’m nearly 1.5 hours behind as it is. She can wait if she wants, but I’m going to see the people who have appointments today first, since they’ve already been waiting.” (She didn’t wait, thank god).

I deferred all my notes, which I hate doing because I worry that patients and plans will blend together. As soon as a patient walked out my door, I went to the waiting room to get another. I felt like a revolving door, and I was rushing slightly toward the end, because I had to get to the Main Hospital, 2 miles away, for a conference.

I saw my last patient, scheduled at 10:30, at almost noon. Skipped grand rounds, disappointingly, because it was on prion disease, and who doesn’t like prion disease? Drove back to the Main Hospital for conference, then had an observed H&P scheduled for 2, then holed up in an empty room for 2.5 hours to write all those notes. Luckily I had no afternoon patients.

It was like this on Wednesday afternoon, too, when they scheduled me for 5 patients between 1:30 and 4, except between a late start and a rather ponderous attending, I didn’t finish seeing people until 6. I was teaching a class that night, so I couldn’t stay to write notes; instead I came back to work at 6:30 in the morning to write them all before Thursday clinic started.

This issue doesn’t happen in the Resident only clinic, I think because the schedulers take staffing-with-attending into account; it nearly doubles the visit time because you have to catch the attending (They are usually staffing 3 or 4 residents at a time), present, and have the attending at least eyeball the patient. But I suspect this is what clinic is like in the Real World of private practice — this revolving door mentality, never feeling caught up, which is frustrating to doctor and patient alike.

(The other frustrating thing: when I left clinic at a little after 5, the support staff, including the schedulers who pushed me into this, were all long gone. As a matter of fact, when I was waiting for the attending on Wednesday, I asked one of the staff if I could bring my next patient back and then staff two together — she said no because “I’ve already cleaned all the empty rooms.” It was 3:45 and she was ready to go home.)

So folks, next time you are pissed that your doctor is running late, remember that she is just as mad as you at a totally broken system that serves no one but the administrators.

 
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Posted by on August 9, 2013 in health policy, neuro, PGY-2, residency

 

Hello again!

Yeah, ok, I’ve been delinquent. Intern year, especially during the dark days of winter, slowly saps your ability to be a Real Person. (Newly minted MDs, are you excited?) It’s odd, because even though there is nothing specifically bad about internship/residency, the constant grind really wears you out. I can’t even imagine how the surgeons manage it.

But now, that summer’s coming, and it’s light out when I go to work and even when I leave, my spirits climb. A long-overdue haircut, a wedding, the summer series of outdoor concerts, and a new pair of hiking boots help. Plus, there was an unexpected success story last week at the hospital — I don’t want to go into details because they are too specific — but it made me think that maybe, just maybe, we can save some of the people, some of the time. Also, that Haldol is a wonder drug.

(On a side note, the history of medical advertising, as a reflection of medical sociology, is pretty wild. Psych stuff, in particular, seems to have undergone a sea change in the 60s and 70s, from the “quiet, docile white woman with schizophrenia” to the “angry black man with schizophrenia.” Jonathan Metzl writes about this, and other things, in Protest Psychosis; here is a pretty good review. Contextualizing illness is key, and I would say this holds for medical illness as well as psychiatric. Just look at the social history of cancer, treated wonderfully in Dr. Mukherjee’s Emperor of All Maladies.)

Alright, friends, time to do some Step 3 questions! (I’m trying not to treat this exam like a joke, if only because how embarrassing would it be do be in the 2% of people who fail?)

 
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Posted by on May 25, 2013 in PGY-1

 

The Forty-Nine(rs)

In the last three days of my ED rotation, I’ve seen 50 patients. One of whom had an actual emergency (new onset seizure). The other 49 were just chillin’.

The worst part of the medical bureaucracy is the feeling that it’s never going to change. Example: three of those 49 patients called their PCP or clinic and were told to come to the ED just in case, because everyone is afraid of being sued. One of the 49 was at a local health center, actually being seen for her non-emergent problem, the health center nurse called some ENT to try to get her an appointment, the ENT told her to come to the ED. Was my only order on that patient “ED Consult to Otolaryngology”? You betcha. Did I feel bad about calling that consult? Well…. maybe just a smidge.

I try to be very clear in my discharge instructions what constitutes an emergent condition. A good rule of thumb is, if you think you might need to come into the hospital overnight, the ED is a good place to be.

I would love to see more Urgent Care Centers, but I’m told over and over that they won’t solve the problem because you can’t ask people to triage themselves. To which I say “Why not?” We ask people to vote for president and contribute to the infrastructure of their country through taxes. We allow them to drive 2 ton vehicles, consume mind-altering substances, and purchase assault rifles. If they can behave like responsible adults with all of the above, why do we infantilize them medically by insisting that they can’t possibly know if they are sick or not sick. And if someone triages themselves to Urgent Care when they should have gone to the ED, the physician or nurse practitioner there should send them over straight away. 

Internship is making me cynical, and kind of a horrible person. Battle-weary. I am not tired or fatigued per se, but I do need a vacation, a change of scene. Really I just want to go hiking, which I can easily do here, but I suspect there is still snow on the mountains. So in two weeks, I’m turning off my pager and going to Sedona, AZ. I may not come back.

 
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Posted by on February 22, 2013 in PGY-1

 

What do you do when?

I seem to have the worst luck on call. Not that it’s oh so busy, but I seem to attract all the totally devastating cases. Of course, I also seem to only write when I am post-call and the tragedies are fresh.

I just wrote a long and literary description of a stroke code the other night, but then I realized the things that make it interesting also make it a HIPAA violation, try as I might to change the details. Damn you, HIPAA!

I suppose that, like most people, I hate it when crap things happen to young people. I mean, crap things happening to anyone is bad, but permanent disability as a result of sheer bad luck frustrates me. I’ve had a fair number of near misses myself over the years (including recently falling asleep while driving home from work) and sometimes it fucking terrifies me when I see myself or my family in my patients. It angers me, like Lear on the heath anger, to see how random death and disability can be. And it saddens me to realize how very little we can do in most of these cases. On balance we are probably better off than a hundred years ago, but it still feels like despite all the trappings of civilization and pharmaceuticals and Modern Medicine, there’s a hell of a lot of random violence in the world. Inflicted violence, of course, but also the arbitrary-ordinary violence of stroke and infection and cancer.

I’m reading A History of the World in 10 1/2 Chapters, by Julian Barnes, who is a pointy nosed genius. It’s a short story cycle, which I love best from a craft point of view — each tale stands alone, but reading in sequence you see threads and throwaway references that make you feel like the author is winking at you with a series of inside jokes. Anyway, one of the themes here is the caprice of selection. It starts on Noah’s Ark and continues all the way down the ages. That’s what I’m driving at, really, and Mr. Barnes puts it far better than I. 

 
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Posted by on February 16, 2013 in PGY-1

 
 
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