Higher Selves

As long as we are in touch with our higher selves our egos are not a threat, rather a tool in service of the spirit.

It's a rare thing in medicine, but when I find true professional, willing to talk openly about approach to problems in patient care...it can be magical. But it supposes for even an instant that all parties open their minds beyond "what's done here" and their own prejudices. I've learned so much that way. There are MANY ways to do almost everything in medicine. I can watch 5 people sew up the same wound 5 different ways. The knee has at least 8 approaches (if not more) for arthrocentesis.

Having such discussion usually happen late at night, in corners of intensive care units with like minded providers. They are insightful glimpses into the genius that is in most of us when others truly listen and open their minds to the possibilities. It's also about deferring such discussions from the presence of the patient and others so we don't feel the need to prove ourselves.

I am so surrounded by ego, and it's "my way or the highway" mentality that we often miss the point, and allow the patient to suffer in the process. But even during long, long days engulfed in 90 hour work weeks, there is still some possibility of finding our higher selves in spite of the attack of ego of others. It's better for the practitioner, better for the practice of medicine and better for the patient.

Bullshit Rules

I know the rules. The rule in surgery, your hands should never slip below your waist. Everything below the table level is considered "unsterile". Once your hands enter that area, they should never be brought back into the sterile field.

So when I lowered my hands to adjust my lead apron, hands at belly button level, technically I was in violation. I was careful to keep my hands in front and not below table level or my waist. One of my esteemed anal retentive, subversive, passive-aggressive colleagues (an oxymoron) pointed out to the entire OR my faux pas.

But in our world, it's a moot point, filled with inaccuracies and frank bullshit. We sit and stand regularly in the OR bringing our entire torsos to nipple level below the table and pop back up again...regularly, with impunity.

Some things are just bullshit. In this case, not sure if it's the rule without evidence or the colleague without discretion or sense. It's likely a commentary on more broad issues in the world of medicine, pseudo teamwork, inexplainable rule without evidence and ego than contamination.

I changed my gown and gloves without saying a word.

Surrender

"No retreat, no surrender; that is Spartan law. And by Spartan law we will stand and fight... and die." - Leonidas

But I wasn't willing to die. And I wasn't willing to give up my passion, compassion, sensibility, ethics, morality, optimism or sanity.  So I surrendered and did an absolutely unheard of act. I left residency.

I think the breaking point for me was the election of our new chief residents for next year who have been widely quoted that "the only thing I want in my medical career is lots of money". Money as a motivation for this pathway was never present for me.

Medicine is no fun by definition and had become less so under the direction of individuals with the sensitivity of granite and no sense of what adult education is all about. I've met very few people in my education and training that represented what I wanted to become and they have largely left medicine or are at their waning moments of practice. And the few role models I found were outside of my program, just an arm's length away, sequestered by "the match".

Truth is I don't know many happy people working in medicine, or maybe I just identify those folks more readily. I've almost resigned myself to unhappiness in my career myself. But one thing I wasn't willing to do is sacrifice another chunk of years to an end result that was so disappointing as the specialty I defaulted into, with people I didn't respect, in a place I didn't want to live in. I've left a residency spot open for someone else to fill (and fill it they will, easily) with someone who appreciates it much more and has the mentation to do it well.

For me, it was surrender and live.

P.S. Congratulations to my colleagues from medical school who matched in 2013. It's very exciting to see some bright young minds entering the field to hopefully make a difference.

Greatness Prescription

We all with for mentors in life that embody all of the characteristics of greatness to observe and emulate. Sure greatness is a perception of one's self, but it is a composite of learned skills and discipline that provides the pathway to, even private, greatness. I see those characteristics in the many medical professionals around me: colleagues, administrators, attending docs, nurses, physician assistants, pharmacists and other health care professionals. I've even seen it in the non clinical staff...campus security, maintenance, housekeeping folks. Some of those characteristics I've noticed:

1. Relaxed confidence - It's both in skill and emotional maturity that relaxed confidence exudes. More than a look or feel, it allows one to think logically, respond appropriately and overtly remained balanced in this unbalanced life.

2. Knowing what's really important - Se never learn this skill in school but some learn it on the street or at home. It's the ability to honestly follow one's heart, mesh it with education and experience, and figure out what's really important. More than anything, this allows releasing anger or frustration for those thing that aren't really important.

3. Focused activity - I've heard it indirectly referred to as "doing what's important" but it's really doing those things that feed what's important once you've identified that (see #2). When we become in "other" things we are distracted from the path to that success we seek.

4. Play - You've heard work hard, play harder? Well more than having the capacity and finding the time to play, it's also about seeing the fun in the everyday. It's easy to focus in the negative and what's wrong, but when we consciously understand that bad stuff happens, and deliberated search for the "present(s)", the good, the playful, the fun... our whole outlook improves and we become better at playing in the off time.

5. Positive expectations - A program director MD has never complained about what's not. But he constantly searches for ways to positively identify what's possible in the future. His expectations are verbalized in his statement of every problem that arises, offering solutions and positive outcomes as a probability.

6. No excuses - "I couldn't because..." is not helpful. Identifying what needs to be done and understanding our limitations, expressing them to others, is conquering over ego and stubborn pride. Excuses are mental obstacles that keep us in the past.

7. Balance - Life at home, work, play, gym, eating etc...all in balance. If it's not "peaceful" than you are out of touch with what's the right reality for you (from a nurse who smiles all the time).

And so it is, I've got lots of work to do.

Viral something

Yep, you got the flu or that flu like thing or could be flu lite or viral this or that.

Yes, could be plague or burbonic or consumption, or rheumatiz. Sure could be the blight too. What? You saw the river "part" on your way to the hospital? Ya, amazing.

Nope. No antibiotics. Just lots of fluids, a hot water bottle, chicken soup, ibuprofen or tylenol for aches and fever, sleep and time in bed...time.

And throw away your toothbrush when you start feeling better.

I know. I got the vaccination too.
Bless you! Oh, that was a cough? I take back the blessing then.
Don't want to waste those.

Flu-like what?

Sick Kids

Pediatrics is a funny place. Mostly I have found we just humor the parents until the kid gets better. Expectant hand holding, saline mist, bulb suction, and lots of talk about poop, wet diapers, vomiting and breast feeding. Any people get paid for this?

But every once in awhile, a really sick kid comes in and the real art comes in. I'm blessed to have seen some really keen artists practice this craft, separating the patient from the ranting parent, and actually make a cool diagnosis and heal sick kids. I gain greater respect for pediatricians every single day.

God bless YOU!

A room full of doctors. One sneezes. Several say "God bless you". The sneezer says "thank you". All totally without thought, automatically. For those who claim to practice evidence based medicine, there is little evidence that saying "God bless you" provides any healthful benefits that we know of.

History says we have been saying "God bless You" since about AD 77. There are lots of theories where this came from and no real consensus on the origin. Could be from the lavish blessings Pope Gregory 1 in AD 590 ordered to fight the bubonic plague when sneezing was thought be an early sign.

Or it could be to bless a person to prevent the soul from being thrown from the body during a sneeze....a shield against evil. Another theory says that saying "God bless you" restarts the heart, thought to stop during a sneeze. Or maybe, it's just a reaction to feeling like you have to do something when you don't know what to do or say.

So next time I hear "God bless you", I'll know the plague is prevented, the soul is retained and the heart will continue to beat.

------------
**Level I: Scientific evidence is lacking, of poor quality, or conflicting, such that the risk versus benefit balance cannot be assessed. Clinicians should help patients understand the uncertainty surrounding the clinical service, and stop saying it around other clinicians.

Slavery, today?

It is hard to believe that it still exists. Millions of working "slaves" in farming, domestics, manufacturing, sex trade and other industries around the world today. All forced to work without basic rights, compensation, freedoms or care. All ages, all continents. Struggling to find a way out but feeling there is no help. But there is help.

January is National Slavery and Human Trafficking Prevention Month. It is our duty to identify and stop human trafficking in the world.

Distress

Studies have shown a higher lifetime prevalence of depression in those who go through medical training, perhaps as high as 30%. With propensity, family history, genetics, prior history or other precipitating factors, maybe higher. Choose the wrong specialty, location, or institution and the chances are good it will ensue.

Is it any wonder why I see so many unhappy people around me?

Learning to Fly

Imagine you are learning to fly a very large, passenger plane. You aspire to be the captain and make the daily decisions to fly and (hopefully) land the plane. You start with smaller planes and work your way up over time. But imagine after getting your private pilot license in small 2 seat small planes, your instructor, who has never seen you actually fly the plane, hands you the keys to a 747 and says "have a nice day". He assumes you know everything there is to know about flying because you finished entry level pilot school. And assumption that will likely be fatal to you and everyone on board.

I don't want to be dramatic, but that is essentially what often happens in residency training programs where the instructors are as lost as I am. Professional medical educator often make assumptions and are so lazy they can't begin to solve the problems at hand and truly mentoring and training future medical professionals. Now I know they are all not like that. And I know many who are extremely good, but I am dismayed at the number of inferior faculty members in medicine today.

On several occasions I've been "handed the keys" without a word of education, mentoring, direction or anything resembling teaching and told to "start the engines". Nothing quite 747ish, but certainly in a class I've never flown before. Assumptions of my skills, knowledge, education, morals, ethics, decision making, memory of clinical practice guidelines (checklists to the pilot) etc have been largely "assumed" inaccurately and brushed off with a "well you went to medical (flight) school, didn't you?" I've been careful, I've plodded through each situation with care, but not without error and certainly not without trauma (to me especially). The system, at least my part of it, is very broke.

If other industries worked as ours does, the country would be in shambles. Planes would fall out of the skies as pilots, who never practiced on a simulator or in an otherwise safe environment, muddle their way through piloting encounters. Vehicle accidents, caused by police/fire/EMS driving fast to calls, would be common as drivers muddled their way through it without the benefit of an emergency driving course or similar. You get the idea. We gain expertise by mentored practice and infusion of knowledge working first in safe environments with simulators, training courses, etc. Not on people.

This is silly. This is dangerous. It was the best of time, it was the worst of times. And I have to go back to the planes tomorrow. I doubt I'll even be greeted by a hello, let alone meaningful teaching of any kind. But I'll do my best to park the 747 and not hurt anyone. Particularly me.

Public Violence

Another day, glued to CNN, watching a tragedy unfold. A small town. A small elementary school just weeks before Christmas and the New Year. There is not going to be any explanation that will make this event understandable on any level. Certainly not for the parents of one of the many children killed. The grief of the parents can't, won't be understood.

As time begins to reveal the true scope and causes much discussion will ensue about how to protect public buildings in the U.S. from this type of incident. Imagine a mentally unstable individual, dressed in camo or black fatigues, with a bullet proof vest on, armed with several weapons, gaining entry into any public building...determined to do harm. What really must we do to protect many from the one or two? This happens so quickly that even with armed officers on the premises, tragedies like this will happen.

I don't even pretend to have any prevention answers but the answer is not in gun control. We are well beyond that and this is more about people control. The real prevention must come at getting better at hearing and heeding the warning signals that may have preceded this and other tragedies. Threats, notes, comments, texts, tweets and other communications often precede such events and foretell that "something" is going to happen. Prevention is pro-active and requires investing time and resources. But it may be our best hope. Although I realize, there is no real way to totally prevent this from happening ever again. And likely it will. So, so sad.

My "parental" heart goes out to all those families who are grieving the very pre-mature loss of their children as well as those who have lost adult victims in this tragic event. CNN is reporting "closer to 30 killed at school" but it is still unfolding and the victims families are in the process of hearing for the first time that their child won't be coming home.

Brain Food

I wonder if brain food will help me get through this...

1. Fish: Herring, salmon, tuna, mackerel, halibut, anchovies, sardines & other cold-water fish

2. Soy: soy milk, tofu

3. Colorful and citrus fruits: avacado, cantaloupes, watermelon, tomatoes, plums, pineapples, oranges, apples, grapes, kiwi, peaches, cherries

4. Berries: Blueberries, Elderberries, blackberries and raspberries

5. Cruciferous and leafy green vegetables: broccoli, cabbages, kale, turnips, Brussels sprouts, broccoli, collard greens, cauliflowers, radishes, spinach, onions, red peppers, lettuce, carrots, asparagus, okra, mushrooms, broccoli and sprouts

6. Chocolate: Dark chocolate

7. Nuts

8. Whole grains: whole wheat, wheat germ and bran (folate), oatmeal, brown rice, whole-grain breads and cereals, barley and popcorn

9. Peas, lentils, green beans, lima beans, black beans, kidney beans, and a variety of legumes

10. Sage: oils and tablets

11. Spices: curry, tumeric, curcumin

12. Tea: Green and black

13. Eggs

14. Calcium-rich foods: Yogurt, cheese, milk

15. Iron-rich foods: Lean red meats

16. Complex Carbohydrate-rich foods: grains, nuts, sweet potatoes

17. Supplemental: Gingko biloba

18. Water, water, water

Here we go again. I  hope 2013 brings more sanity to this process of learning. That is of course if I survive the Mayan Mayhem and 12-21-12, 12:21:12 am and pm.

And, prayers for our country and the parents of the children killed in Connecticut. So sad.

And So It Begins, Again

I had hoped I awoke post 12-12-12 at 12:12:12 am or pm with the awareness that my world had died and I had been transported to a time and place where peace reigned through the kingdom. Nah! I'm back on a too-cramped airplane to a too-damn-small airport and taking care of patients in residency. I can't think of a more painful experience except maybe having my eyelids pealed back over my forehead. Oh wait, that happened too.

I'm not backward, ignorant or a naive trouble maker. I'm not psychotic, paranoid or anxious. I'm not angry and have no grudges. But the system I return to is broke, bad. And I hope at the end of the day, everyday, I don't hurt someone.

End of Days

End of days?? Yay!! 

The story of the end of the world is fascinating and goes something like this Cliff Note summary.  Apparently the Sumerians of days gone by discovered the planet Nibiru and they surmised it was heading toward Earth. It was supposed to make impact with earth and destroy everything, including the midnight grill at the hospital, back in May 2003 (remember that?). Obviously it never happened and I started medical school and residency. So the owners of that cosmic thought shifted the date to this month.

Why this month? Conveniently the end of days event was linked with the end of one of the cycles in the ancient Mayan calendar and the winter solstice on 12/21/12. And I for one, am thrilled about the possibility of total destruction of residency and the medical system that we know and love as well as obliteration of all past memory of failed relationships, bad meals, even worse instructors, lousy chief residents, lame exams, pimping, aging, passive weight gain, car troubles, parking tickets, famine, pestilence, war and terrible frozen yogurt flavors. We, or at least I, really need a do-over mulligan.

I have absolutely no clue about Nibiru or the end of days. NASA says the planet doesn't exist and I believe the guys who put a remote control vehicle on Mars. But I am very excited to know of the possibility of total destruction or anything that will prevent me from cleaning my bathroom one more time. Peace be with each of you time travelers. May your cosmic journey be a safe one; Because I know who's on call in the ER and it won't be pretty. 

Namaste.

Inversely Proportional

I didn't discover the connection, but seem to be living it now.  On a daily basis I can't believe how much emphasis is placed on memorization in medicine. It's rewarded, encouraged and even used to flagellate others in person. It is clear to me though that the relationship is present. As the need for memorization increases, understanding decreases proportionally.

There really is no need to memorize the genus and species of microbes, or the pharmacological reactions and actions that can be easily looked up. Portable technologies and the references they provide have changed the game in clinical practice. The world of information is at our finger tips and accessible. I don't need to know the Krebs Cycle. I need to know how to use it in taking care of my critical patients though. When will medical education move from memorization to that of focus on understanding with the user end point in mind....medical practice.

The use of information is much more important that memorizing it. Yet that is the emphasis found on exams in medical school and on national boards.  The emphasis on memorization in many ways determines our future by selecting out memorizers from users of information for residency based on test scores.

The reality is that medicine is controlled by memorization and performance on exams, guided by results on Step USMLE. Performance on that exam is, for the most part, the determining factor in residency selection. And that system isn't going away easily with the multi-millions that system makes.  Exam, boards and pimping performance (hallway pop quizzes perpetrated on unsuspecting learners) is the core of how medicine teaches and expect learning. But is it really learning at all? Is it really providing insight and apprenticeship to the insight of knowing how to apply the knowledge memorized?

We need more formative and summative assessment that is "application" based and less memorization based exams in medicine. We need a return to a real apprenticeship system that values moving knowledge from teacher to student in clinical practice with application in mind. As a colleague recently wrote, "medical education is failing us" all, both practitioners and patients. It has certainly failed me and gutted my passion on so many fronts.

Terror : Part of Public Health

Imagine riding a bus in Atlanta, Miami or Denver. You are going to the mall to meet your mates and hang out. About 10 minutes into your ride a "blast" rips through the bus throwing you backward. You cut your face on glass, the back of your head on the post behind you. You can't hear clearly due to the blast "ring" in your ears and you are bleeding profusely all over yourself. Your new boots are ruined. You can't find your smashed cell phone on the floor 10 feet back. The man sitting in front of you is more injured and unconscious.

That's sort of what happened in Tel Aviv today. I don't have a dog in this fight. I have no family or political ties to Israel or the Gaza Strip. But it's difficult to imagine living that way; living the reality that rockets are falling from the sky and buses can blow up at any time. This is the reality in Israel today.

And that made me wonder why my Syrian born colleague (a foreign/international medical graduate or FMG/IMG), gaining a great future in medicine training in the U.S., pondered out loud about the "villain and murdering Israelis". Why is it that some believe there should be equal mayhem and death on both sides for there to be a fair fight. That's what he explained.

So I asked our campus police, an officer at a nearby table at lunch..."Does engagement with a terrorist require that the police lose as many officers, killed, as the terrorist they confront on the street?" He laughed. And I already knew the answer. Defense of freedom, justice, democracy and rule of law does not require fair. It requires "superior force" to stop the aggressor. Center mass stops. That is what the hospital police officer said.

It is regrettable that modern terrorist organizations use civilians as shields to deploy arms. As careful as any protective force can be, injuries and death to civilians will then happen. I hate that part about modern warfare viz. a vie, Iraq, Vietnam, Afghanistan etc etc. It's the reality of urban combat and there are no easy answers. But let's not confuse who the aggressor and who the protectors are in any such conflict.

My Syrian colleague and I will remain colleagues and I trust him not to blow up the hospital. I'm not sure my colleagues in Tel Aviv today feel the same confidence in their neighbors. I pray this Thanksgiving for peace and rational clarity at what is really happening in the Middle East and in many corners of the world. I'm thankful for many things, but in this day, I'm very thankful for "superior force", a center mass mentality and safe bus rides to the mall.

Public Health: Terror

Some Stuff I Learned & Read

1. Take a 10-30 minute walk every day. And while you walk, smile; the ultimate anti-depressant.

2. Sit silent for at least 10 minutes each day. Talk to whatever God is for you. Buy a door lock.

3. When you wake up complete, 'My purpose is to____ today. I am thankful for____'

4. Eat more foods that grow on trees & plants and eat less food that is manufactured in plants.

5. Drink green tea and plenty of water. 

5a. Eat blueberries, wild Alaskan salmon, broccoli , almonds & walnuts.

6. Try to make at least three people smile each day.

7. Don't waste energy on gossip, the past, negative thoughts or things you cannot control.

7a. Invest energy in the positive present moment.

8. Eat breakfast like a king, lunch like a prince and dinner like a college kid on a budget.

9. Life isn't fair, but it's still good.

10. Life is too short to waste time hating anyone.

11. Don't take yourself so seriously. No one else does.

12. You are not so important that you have to win every argument. Agree to disagree.

13. Make peace with your past so it won't spoil the present.

14. Don't compare your life to others. You have no idea what their journey is all about.

15. No one is in charge of your happiness except you.

16. Frame every so-called disaster with these words: 'In five years, will this matter?'

17. Forgive everyone for everything.

18. What other people think of you is none of your business.

19. GOD heals everything - but you have to ask Him.

20. However good or bad a situation is, it will change.

21. Your job won't take care of you when you are sick. Your friends will. Stay in touch!!!

22. Envy is a waste of time. You already have all you need.

23. Each night, complete "I am thankful for______. Today I accomplished_____."

24. Remember that you are too blessed to be stressed. 

25. When you are feeling down, start listing your blessings. You'll smile.

26. When in doubt, start with #1 again. Repeat often.

27. Listen more to your heart, gut and less to your head.

Professional Education

There is a science called education.

There is a psychology of communication and information.

There are well tried adult learning tenets.

Medical educators, for the most part, don't know them & don't practice them.

Happy Diwali Fall Festival

Happy Diwali to all of my Hindu colleague brothers and sisters!
सभी मेरी कत्थई भाइयों और बहनों के लिए हैप्पी दीवाली!
For Hindus, Diwali is one of the most important festivals of the year and is celebrated in families by performing traditional activities together in their homes. Diwali marks the attainment of moksha or nirvana by Mahavira in 527 BCE.
Studying and working with many Hindus these past years, Diwali has become part of my Fall Thanksgiving celebration. We should all attain Nirvana and celebrate life and "colors and many sparkles" around us.
Happy Diwali - हैप्पी दीवाली

Gender Regrets

I don't have many regrets in life. I don't regret things I've done that have failed; Still learned. I regret not doing medical school earlier in life. But I don't regret the decision to go late in life. But today I have a new regret.

Where I am, medicine is a man's world. It's dominated by male attendings and women who think they are men or have to make pretend they are periodically. So when a female joins the ranks, you tend to notice. Such was the case recently when a new medical student joined rounds with us boys.

There she was, 5 foot something, with curves from her pony tail to her painted toes all reddish-blonde with a cute Southern accent. All the boys made sure they mentored, led, guided and pimped her. She got more attention than the last Krispy Kreme donut in the nurses break room. She remembered kool little factoids about medicine from her recent reading and studying for Step 2 and was sure to walk briskly with the attending so everyone behind could see her, uh, ya...see her. The boys loved it. I didn't get spoken to, pimped or looked at the whole day. I got no new patients and didn't have to present the few I had. There wasn't time. She was there.

So my regret? I regret not being born reddish blonde, 5 foot something, with curvaceous curves, a cute Southern accent and a decent memory for medical text factoids. Maybe my next life?

Uncertain Certainty

"The problem in medicine is, the body is complex and our knowledge is incomplete. People who want certainty – physicians or patients – are kidding themselves"

The patient perspective is sometimes sobering.

E-patient Dave deBronkart, writing online from the patient's perspective, grabbed my attention with "Expecting Doctors to be Perfect is a Setup for Dysfunction"

And the corollary from the e-doctor perspective is "Expecting ourselves to be perfect is dysfunctional", yet it is the core of performance in post-doctoral training. And with so any being intellectually perfect, the stakes are higher and more significant.

Mr. deBronkart quotes a study involving after death autopsies stating that 10-15% of "cause of death" and "final diagnoses" are actually incorrect. I'm not surprised. We have so much technology but so little real insight into disease particularly when it involves multiple systems. It's not that we don't care, or don't want to do good...we do. But..."the body is so complex and our knowledge so incomplete" that we can't be certain at all.

But the system deals regularly in absolutes, teaches great certainty, extolls the virtues of greater insight into our belief system. It's a mismatch with the true reality of what is. And it's what makes learning in this bad system even worse. I'll go out and do my best today, with the limited knowledge I have, about the complex systems we deal with, and try to make sense of the environment that creates uncertain certainty. At least, I'll certainly try to be as certain as uncertainly possible. Of that, I'm certain.

A Year Inside a Medical Residency

In a recent Atlantic opinion piece, Dr. John Schumann speaks of the sometimes cavalier nature of medical practice and education among new physicians. In  the article

http://www.theatlantic.com/health/archive/2012/11/a-year-inside-medical-residency-part-2/264523/

Dr. Schumann notes talks about overconfidence and the confidence-knowledge gap present in the early phases of learning.

"This confidence-knowledge gap is normal in medical trainees. Coping with stressful environments like residency necessitates that learners find some element of near-mastery in the early phases, or else the ego can be severely bruised."

My ego was thrashed long ago. I have none left. But the bruising continues.

Morphed Discussion, From Here to There

We did it! Moved in one conversation from a city in Texas to Mongo, of Blazing Saddles fame.  I think this is how it happened.

Patient has a fungal infection of some type the requires special testing to determine it's species.

There is a great lab in Tyler, TX that apparently is quite good and known for genotyping and/or categorizing such infections for ultimate prediction of best antimicrobial to use on the patient.

Know what else Tyler TX is famous for? Earl Campbell, great football player.

Football players have short "sport" lives. Earl had about 8 years. Most, particularly linemen, get about 3-5 on average.

Know what a linemen made playing football way back when? Under $50,000. Many had to work extra jobs in the off season to maximize year round income.

Alex Karras was a football player who had to work in the off season. He chose acting.

What character did Alex play in Blazing Saddles? Mongo!

http://www.imdb.com/name/nm0440090/

So from Tyler TX to Mongo....No wonder rounds take so long to finish.

Models Abound Elsewhere

We spend way more, and get way less. And worse, we train future doctor to behave the same way. There is no end in sight to this madness called U.S. medicine in my very humble opinion. I don't have the answers but I believe that only through regulation and strong oversight can we make it succeed. Leave it to the local entities (hospitals, etc) and they'll make improvements with profit in mind. Because in the end, medicine is a business guided by legal and clinical experience and guidelines developed over many years of trial and error.

The real bottom line is providing the best care, with the best outcomes to everyone while not spending ourselves, nationally, to disaster. I get that this is not easy, because it's really not. But I see clearly that much of it emanates from antiquated institutional policy providing misguided medical education to poorly chosen future physicians. The system is thick with politics (no matter what you call it) and won't change easily if at all, without strong outside intervention....outside of academics, medical associations, politics and the pharma/insurance mega beast.

What do all the countries who do better have in common? Centralized, one payer medical systems funded by national health taxes or equivalents. They also free institutions and individual physicians from "trying to figure it out daily" and provide a framework for both clinicians and patients to flow into. We need strong reforms in this area in the U.S. and the models in other civilized countries is clear. Not easy, but certainly clear. And they have been doing it for much, much longer than we. Why can't we fast forward, and take back medicine to it's rightful place in society?

Breast Feeding Public Service Announcement

Apparently breastfeeding rocks for yungins. I got a 20 minute corridor speech from one of the pediatric residents about this the other day. The benefits she enumerated were extensive. I was almost convinced that world peace would be easy if everyone breast fed.

Pose and Strut

It absolutely makes me sick sometimes. There is so much posing, showing off, attempts to out do the other guy. There's absolutely no chance that a young, anal retentive 20 something who's been in competition his/her whole pre-med and medical school career can turn it off. Worse, it continues to create some of the most self-serving, judgmental, non-team playing individuals I have ever seen. It's nauseating, and worse, it's counterproductive to effective patient care.

Back to studying. I'm sure I'll get pimped about some useless topic on rounds.
Oh hell, I'll just let the overachiever answer it.

Bad Rules

Head surgeon sees medical student running around at a local restaurant in green scrubs and is totally incensed that someone would "steal" scrubs from his hospital.

He returns to work and tells everyone about the "stolen" scrubs he saw everywhere (We have a anti-stealing scrub device that checks out scrubs to each person by their ID badge)

Decides to forbid all scrubs outside the hospital due to possible infection spread and how would it look to outsiders who get surgery and have seen the scrubs in the outside dirty world (they are mostly unconscious or can't remember who they saw, let alone what they were wearing)

So another dumb rule. Particularly when you see surgeons wearing their horse dung covered boots with no covers into the OR for surgery. It's shocking how retarded this system can be sometimes.

Just do it!

I am only one, But still I am one.
I cannot do everything, But still I can do something;
And because I cannot do everything,
I will not refuse to do the something that I can do.

- Edward Hale

Godly Healing

The Catholic Church canonized its first ever Native American today. Kateri Tekakwitha, a Mohawk woman born in 1656 in what is now New York state, died over 300 years ago, but the church attributes miracles to her influence even in the 21st century. She's also famous for many self punishing rituals when she was alive like barefoot walking in the snow, lying on beds of thorns and other such painful proofs of faith.

The commitment to her faith during her life and the miracles attributed to her are one thing, but the way to sainthood is proof of a modern, post death miracle. And most of these historically are medical in nature. Such was the case with Saint Kateri.

In 2006, a boy in Washington touched a piece of Tekakwitha's wrist bone and made a miraculous recovery from a flesh-eating bacteria. How the wrist bone made it out to the boy is one looming question to me, but it was the miracle that pushed the Vatican committee on canonization to recommend sainthood.

In this modern age of science in medicine and evidence based medical practice, it's difficult for many to believe in faith as a way to healing, let alone touching a carpal bone from the wrist of a 17th century woman. I'll leave miracles to the experts in the church who have expertise in this area, among other social permutations, but it's worth rejuvenating regularly the effect of personal faith on individual healing processes and it's possible effect on the bodies ability to heal from illness.

Dr. Christina Puchalski of Baylor University Medical Center wrote an article about this "The role of spirituality in health care" in October 2001 that stimulated my interest in the practice of spiritual connection with patients, irregardless of my own personal spiritual beliefs. You can read the entire article at:  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1305900/ . Dr. Puchalski sensitized me to the need of the patient to connect spiritually with their illness and their ultimate healing, whether they know it or not. She summarized what is involved in serving patients and providing compassionate care - 

• Practicing compassionate presence—i.e., being fully present and attentive to their patients and being supportive to them in all of their suffering: physical, emotional, and spiritual
• Listening to patients' fears, hopes, pain, and dreams
• Obtaining a spiritual history
• Being attentive to all dimensions of patients and their families: body, mind, and spirit
• Incorporating spiritual practices as appropriate
• Involving chaplains as members of the interdisciplinary health care team

I don't think we have yet explored the potential of patient recruitment into the process of healing. At least in an academic medical center, beyond the visit from the hospital chaplain, it is rare to become a part of the process let alone institutionally incorporated into what we do (although chaplains do write progress notes in our electronic medical record). I don't hope to carry the wrist bone of a passed Native American saint in my lab coat pocket, but it's worth exploring recruiting spirituality into the process of health and healing. Certainly better than fungus infected joint injections isn't it?

Confused

Every month of internship bring a change in venue, a new rotation to content with. New attendings, new clinic, new rules, new dress codes, new procedures and new confusions. No less so this coming month. No less than 4 emails from players on the new service. Each with completely contradictory information to the next.

I have no clue where to go on the first day, who to report to or what to wear. Sadly, this isn't the first time and more likely the result of a real problem of too many chiefs, too little communication between them and individual "kingdoms" of power, rules and processes that are not easily given up.

Uniform rules? Appropriate training and instruction? Clear failure and success paths? Adult educational theory integration? Humility? Compassion? Recognition of....? Oh never mind. This has been broken for way to long and those in charge don't know it's broke, have no motivation to fix it, and are way to ego inflated to even care.

So we just do what we have to do to survive it, and make sense of it long after we leave with our dysfunctions into the real world. Is it any wonder that the average physician leaves his first job within five years? When you leave residency this messed up about organizations, it's no wonder at all.

So I'll go to wherever the wind takes me on the first day, and I'll likely have to apologize to someone for my error, confusion and hysteria. Better to ask for forgiveness later than ask for help now. And besides the former is way more fun.

Shame! Self-stigmatisation as an obstacle to sick doctors returning to work

I have sick days given to me as part of my physician package of compensation and benefits at work. But I've been warned on a few occasions that using them is tantamount to gross negligence and professional misconduct. Really?

But I see it everyday. Sick, sick clinicians coming to work out of pressure to do so...to man-up (or woman-up) and come no matter what. I'm sure at least one patient has been affected directly or indirectly by a "sick" physician in training.

A small study that looked at doctors returning to work after grappling with physical or mental illness found that those physicians perceived a lack of support from their colleagues in a recent BMJ publication: http://bmjopen.bmj.com/content/2/5/e001776 . The study completely confirms my gut feelings that this phenomenon exists and is a real problem in U.S. medical training programs today.

But even those providers that practice evidence based medicine are unlikely to follow evidence based evidence as to themselves. It's one of those paradoxes in the way we practice and teach the practice of medicine to others.

I guess for the moment I'll man-up and despite my fever, sinus infection, recent outbreak of cavitary pneumonia and pustular rash...I'll go back to work in the AM. Wouldn't want to be seen the weakling among my strong, virile colleagues would I? No worries, I'll wash my hands.

Residency Causes Insulin Resistance

In a small study published Monday in the Annals of Internal Medicine, researchers found that not getting enough sleep hurts the ability of fat cells to respond to insulin efficiently. So sleep isn't only about restoration (real "rest") but also abut cellular function and the processing and utilization of glucose.

We just don't get enough sleep in training. There is no time to actually get restorative sleep when you work 80-100 hours per week. The hospital acknowledges that burnout among nurses is directly correlated with working more than 40 hours per week and monitors that closely. While I thought it was all about quality time with significant others, nutrition, and quality of life, turns out it's also about good sleep.

Fact is, any system of training that includes the hazing phenomenon of decreased sleep and lower quality of life  only produces tired clinicians with a propensity to glucose intolerance. It hasn't worked so far to produce great physicians and more importantly may be the prime cause for physicians leaving the profession in record numbers with many remaining very unhappy. 

To what extent it is about sleep, quality of life, and other restorative processes is largely unstudied, but I know now that all the fatigue I see around me isn't good for the person, let alone patient care. It's really time to stop the madness that is post graduate medical education in this country. Who knows; With some real effort to reform the system, maybe we'll actually improve the system. 

Nah. I hallucinated there for a moment.

A Good Dementia

I've got a good kind of slowly progressive dementia. 15 minutes after I walk out a really nice drug company marketing lunch or dinner, I totally forget what the product was. That's not comforting to those who run the multimillion dollar marketing divisions of major pharma.

But I have noticed an "imprint" that happens after attending one of these functions for a drug in which I know not other in the class. When I go to prescribe a drug in that class, I can smell the food that was brought, and immediately think of (at least a photo) of the drug or label. So at some level, as hard as I might try to forget or ignore the hype, I may be more prone to wrote for that drug. That's not good.

My Escape Fire is likely to be, no more free lunches or dinners. I might actually lose a few pounds and stave off this metabolic syndrome I'm working toward. Maybe I'll even reverse my low grade dementia.

Awareness of Breast Cancer

2,748,000 live woman have breast cancer.
Almost 40,000 deaths from breast cancer this year.
There are 1600 clinical trials going on in the U.S. for treatments.
5 year survival for localized (no spread) breast CA: 98%
5 year survival for metastatic breast CA: 24%
There are 229,000 new cases of breast cancer each year.

Men get it too...
1 in every 1,000 men will get breast cancer.
2200 new cases of male breast cancer each year.
400 men will die from breast cancer this year.

Too Late

We hardly think about our aging bodies. When they work well, we pay it little mind usually. In fact we often push the limits of our healthy state and operate on the fringe of over stress, high demands and overt body abuse. 

And our bodies live in a symptom based medical world. We don't see people in the hospital until it's too late, after the symptoms appear and the ravages of disease have already begun. For those enlightened to prevention, they may be able to stave off disease to some extend, but in the end, our cellular "aging" will determine the health of our cells and our bodies made up of those cells. Only when our bodies stop working the way we expect do we really pay attention.

And then it happens. You wake up one morning and wonder how you got to this point. The arthritis hurts more often. The back ache is more common than not. Workouts are abbreviated by fatigue. The hair is grayer. The skin more saggy. They heartbeat more irregular or even painful. The skin reflects the over use of sun or other products. The wrinkles betray the age our mind thinks we are. The young treat us differently. The old treat us better.

And as the telomerase doesn't work as good and the chromosome shorten, and cells die off into oblivion of youth and health of the past, we start to pay more attention to our aging bodies and begin to try to figure out what we should have tried to figure while we were young.

Dress Code Blue

These ridiculous dress codes with no rhyme or reason have to go. We can't wear scrubs on certain days and in certain venues? Ties are mandatory in certain locations on certain days? Where is the sanity of the rules that have no basis in evidence.

Just the tip of the evidence iceberg: Scrubs were considered most hygienic by patient in a recent study of patient perception. Ties were found to be the most filthy and unrestrained ties increase transmission of infection causing bacteria.

We practice evidence based medicine (mostly). 

How about some evidence based dress coding?

Night Nurses

Night nurses, those who stalk the hallways from late night until early morning, are definitely a different breed. The thrive on quiet. They relish in waking patients intermittently for medications. They love not having so many baby docs around to bother them and nary a medical student. They form strong bonds with families and patients. They don't mess with formality and, except for the new ones, don't both you much with frivolous phone calls or pages. They don't miss not seeing much day administration around and love having lunch at 2 AM. They are clearly a different breed, and I for one, love knowing they are there.

Days, Weeks like this

Some days, I just feel fetal! Complete with all the signs of regression you might expect. Babbling, drooling and wanting ice cream. It's the end of the pathway of a day usually, when I've been surrounded by savants who have memorized page 167 of Sabiston's or Harrison's in it's entirety...complete with details about the color palette for the diagram on the bottom of the page. I hate those guys. They are such automatrons of medical knowledge. So willing to share great knowledge about this and that study. So able to offer suggestions for care. They just make me feel....fetal.

An Apple a day? Easy!

Any apple a day keeps the doctor(s) away?
I'm starting to eat them by the barrel!!

Git 'er dun!

I've had a bunch of moments over the past 5 years that seemed impossible. And once I get through it once or twice, seems to be nothing impossible at all. But the missing link in medical education is often the path from there to here...how one is instructed, guided or led from impossible to accomplished.

And that my friends is the difference between a good education and a bad one; a good program and a bad one; a healthy training scenario and one filled with anxiety. Because in the end, we all want to do good and git er dun right. It's never a matter of someone wanting to screw up on purpose that I've seen.

With gentle guidance, direction, understandable objectives with failure and success paths understood and compassion nothing is impossible. With overbearing, angry, frustrated, information hoarding direction to "just do it" there is nothing but anxiety, and often, error. It's simple to see, very hard to change a culture that has "done it this way" forever. But then, that's why medicine is in the mess it is, filled with burnt out providers.

Pink Awareness

There are lots of activities going on around the country, totally unrelated to the elections or the debates. It's about "pink awareness" and a month dedicated to breast cancer and finding a cure. It's also about celebrating life and those who have survived.

In my life, you know who you are (don't want to violate federal privacy laws), and I love you. Fight the good fight!!...for the duck!

Mi Vida Loca Dots

I'm covering trauma. The call is gunshot wound or a knife stabbing. He is awake, alert but bleeding from entry points. Your turn. What's the story?

I don't know what happened, you know. There was this dude. And I just got shot. Ya, I got a job you know. I buy and sell wholesale electronics from the west coast. Need a nice GPS doc? I got one for you later if you fix me up. Drink? Ya, a 40 a night. Hungry? No, I'm good. My old lady is bringing me some drive thru.

Crazy life? It's freekin insane.
If this is the crazy life, give me peace, cool, calm, and collected anytime.

Bowties, cool?

They say it's cool. But it looks like total goof ball to me. Bowties, white coats and sneakers on doctors. I really don't care how people look for comfort. I'm all for that. But this is a goofy look extraordinaire. It doesn't inspire confidence. It inspires flashback to Pee Wee Herman; And that's not a good flash back for many given his last visit to a X rated movie theater. I suspect it's an outgrowth of the many attendings grounded in some old Southern tradition based on who knows what. But it still look stupid.

But then, it is a wonderful form of infection control. I can't even imagine what would culture out of one of my clinical long ties that's never been washed. Like the stethoscope, the tie is a wholly neglected item physicians wear that is a cesspool carrier of bacteria, viruses and assorted parasites. So the answer? Ban ties completely. No ties in a clinical setting, ever. Not necessary. Frankly dangerous.

Culturing ties....I think I have my research project for residency.