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.

They Do Get Better

As wrong as things feel sometimes as a working medical professional, the patient care seems to plug right along and, in most cases, do what it needs to do to get people better. I'm sometimes amazed at that fact but grateful when it happens. For the most part, people don't get better in the hospital when they stay long periods of time. I'm shocked when they do get better and don't catch something alien like a blah blah resistant blah or something just as bad. Patients do get better in spite of it all.

The most gratifying experience for me is to see someone progress from completely debilitated, totally dependent on medical care professionals for life and function, to walking out of the hospital better when they came. Having just experienced that, I'm elated to know that for the patient, the system often works just fine. And that is the saving grace of working in this often chaotic field. It's stressful, emotionally draining, taxing on the mind body and spirit at times for those that work in it...but in the end, if the patient benefits and walks out with greater healing than if he'd stayed at home, it's very gratifying.

And so was Ms. H. Mind and body totally dependent on us when we first met almost 3 months ago. And then yesterday, hugged me goodbye and thanked me for my little part in the process called medical care. Then I watched intently as she exhibited the improved function we had sought and worked so hard for.

People really do get better after devastating insults to the body. And that hug...the best feeling I've had in a long, long, long time.

Abs Suffer

It's just not enough hours left in the week at the end of an 80-90 hours work week to do the things you need to do. I spend most of my days off doing wash, shopping and the like. I get to the gym infrequently and wonder why I can only aspire to the abs I dream of. Residency makes the abs suffer, no doubt.

P.S. Not the abs I aspire to get, but since she won Olympia 2012 Bikini, they are worth admiring. And I don't have a belly button ring either. Not yet anyway.

Smoking

It's time to just make the evaluation of diseases related to smoking no less or no more than drug abuse. Everyone should be tested and held to the same standard as addicts of any other kind of drug abuse. Our response in medicine should not be predicated on legal or illegal but mass net effect on the body and on the system of care we provide.

And while we are at it, stop all government subsidy of any substance that causes lung cancer, COPD, asthma, stunts growth and makes you smell so badly.

Sleep

I slept in today for the first time in ages. I feel guilty for getting solid 7 hrs, and I shouldn't.

Sleep is an active process where the brain works to heal the body by producing hormones beneficial for repair and growth. 

This is also the time for the brain to consolidate memories of what we studied and learned that day. Rapid Eye Movement Sleep (REM Sleep), which happens in the last part of the night, appears to be associated with learning and memory. 

This all just reinforces the mantra that you should be getting eight hours of shut-eye if you want the full benefits of sleep. But those of us who are sleep deprived regularly and take care of patients know this full well and welcome days like today.

Residency doesn't appreciate, acknowledge or care about sleep. Imagine how efficient the system would run if academic medical institutions were filled with NON-sleep deprived people?

Behold, La Differance'

Ok, I admit it. I have a surgical personality and mid-set. It's what I enjoy most in my practice of medicine. I like the doing and the immediate gratification. I like the personalities better. So I have a bias. But I think I've figured out the difference between Surgery and Medicine in academia.

Surgeons do it.

Medicine thinks about it, pre-rounds on it, rounds long hours about it, provides a conference about it, makes a medical student research it and present it on those long rounds or at morning conference, runs the list later and discusses it....then consults surgery to do it. 

Lovely

It doesn't catch you. You catch it!

Dear Healthcare Professional;

This is to inform you that during the period blah to blah, blah you may have been exposed to at least one case of active tuberculosis. A case that you were [closely and intimately, crawling all inside his orifices and fluids] has been recently been diagnosed by the country health department and may have not been showing clinical signs and symptoms when you were involved in his/her care. This information is provided to you as a Public Health Service and we would recommend contacting your primary care provider for immediate testing, evaluation and treatment if necessary. If you have any further questions please contact this office immediately at the above number and refer to case #blahblahblah. Thanks very much for the work you do.

[Love] Sincerely,
[Your director of county health department extraordinaire]

LOVELY! How unique to my profession to advised of exposure to the little elongated yellow beast. Let's review. Mycobacterium tuberculosis is a nonmotile (meaning they do not move) rod-shaped bacteria. The common site of infection is the lungs because the bacteria are obligate aerobes, meaning that they require oxygen. The cell wall of Mycobacterium tuberculosis is mostly lipid which contributes to difficulties in staining and dyeing the bacteria for identification. The bacterium is difficult to kill because it is resistant to antibiotics and other treatments. And it loves to dig large caverns of space from normal lung tissue (cavitary) and fill them with gobs and blobs of fluide, semi fluids, pus, sputum and other hairballs.

Lovely. So not only do I work unimaginable hours working for mostly children supervisors with little or know knowledge of adult education or supervision, but I also have been exposed to a bacteria with a passion for my lungs. Poetic.

I'm off today for the first day in over two weeks. I think I'll just focus on the things neglected (besides my health) and go to the gym, shop for food to fill my empty fridge and wash sheets. If I think too much about this bacteria crawling around in my lungs, I'm sure I'll quit and go back to my drive thru job at the donut place. But then I could be exposed to flour or chocolate sprinkle inhalation. Lovely.

Unpredictable variability

There is nothing more predictable than variability in learning in medicine. Largely perpetrated by the type of patient rolling through the door, the learning is based on the patients, their presentations and how those patients are utilized in learning. That variability is expected, understood and often the excitement that is learning in medicine.

But then there is the variability that is nothing but stress, created by the leaders of learning. That stress is caused by unpredictable, variable and ghostly expectations. The ones that largely live n the minds of those guiding the learning. Would it be so damaging to create success paths instead of failure paths at all?

Predictable variability is a God-send.
Unpredictable variability is a night mare