In Which Your Uncle Panda Rips Off the Lid, Rolls it in a Tube, and Places it (Politely) Where the Sun Doesn’t Shine

Why Don’t We Starve Them Too?

As my regular readers know, I am opposed to the use of sleep deprivation as an educational tool during residency training. The fact that residents are deprived of sleep as a requirement of their job is undeniable especially given the typical call schedules and the obvious fact that work never stops in the 24-hour-per-day patient processing facilities that most teaching hospitals have become. And yet despite my objections I have never made much of an argument against this practice, at least in terms to which the usual advocates of resident abuse will pay attention, because my distaste is more visceral than intellectual. People do need sleep after all. It’s a biological requirement and I have never felt it necessary to explicitely justify why we need sleep any more than I feel it necessary to explain why we need food and water. We just do.

Imagine if it was a regular practice to deprive residents of food. I have no doubt that there are some with a great deal invested in mistreating residents who would indeed deprive of us food if they could make a case that eating interfered with Patient Care. I also have no doubt that many residents, in full Patty Hearst mode, would come out in favor of the practice. It’s just the nature of the profession, to gain admission to which many would sell their grandmothers to white slavers.
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Fortunately, as residents can always cram a microwaved burrito into their mouths and suck down a luke-warm Dr. Pepper, the threat to patient safety is small and it hasn’t come to it yet. But imagine the outcry if it did…or perhaps the lack of outcry as the usual suspects opined that, back in the Good Old Days, they regularly went for weeks without food and the desire of the current generation of residents to eat is a sign of the impending medical apocalypse.

So why not starve residents? We deprive them of sleep every third or fourth day, why not make it a clean sweep and withold food and water as an additional character-building exercise, especially if we’re to operate under the theory that tired residents are as effective as well-rested ones?

Too Much Sun

The principle objection to allowing residents time to sleep is that limiting their hours interferes with continuity of care. It is correctly pointed out that the handoff, or the transfer of care of a patient from one resident to another, is a dangerous time from which all sorts of lethal misadventures can ensue. The new resident, after all, has not been following the patient and may not know the nuances of his condition or his plan. With this in mind, the theory is that by limiting the number of handoffs, the number of potential mistakes can be minimized. Limiting the number of handoffs means keeping the residents at the hospital longer.

Now, I am sure that there is a growing body of competing and contradictory studies comparing the risk to patient safety of the handoff versus sleep deprivation. Both probably result in mistakes but as to which is the worst I can only confess a profound indifference. I don’t care because the premise of the studies, that patients in teaching hospitals are at a significant risk, is so deeply flawed as to make the studies meaningless. This is not to say that there is no risk of mistakes but only that by the very nature of academic hospitals, the risk of mistakes is considerably less than it would be at a hospital without residents. This is obvious to anyone who has ever been in a non-academic hospital but maybe not so obvious to those who, like heat-stunned lizards laying on sunbaked rocks, may have been staring into the dazzling fire of academic medicine for just a little too long.

Consider the typical patient at a hospital which does not have residents. The patient is admitted either through the emergency room or directly from his own physician who most likely will not actually see the patient at the time of admission but only relay a few phone orders to the nurse. (This is especially true of a patient who comes through the Emergency Department.) The patient then languishes until the next morning, at which time his doctor will quickly rounds on his census of admitted patient, writing more orders as needed to solidfy the plan, before heading to an extremely busy day in his clinic. Once he leaves, barring a catastrophe, the patient is on autopilot until his doctor checks on him at the end of the day to write new orders or call for any consults which he has not previously anticipated. Many patients only see their doctor, if at all, for a few minutes during their stay while many others are fobbed off to hospitalists, the hired guns of primary care.
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Patients in teaching hospitals, by comparison, are positively coddled. Consider the typical service with its census of fifteen to twenty patients riding herd over which is a senior resident, a couple of junior residents, an intern or two, and often a gaggle of eager medical students. Not to mention an attending physician who, liberated from the exigencies of mundane bureaucratic tasks, is free to concentrate his entire intellect on diagnosis and treatment. Comes the night, the prelude to all manners of medical horrors, and there are several residents from the service actually living at the hospital ready to address any problems, from a request for a sleeping pill to cardiac arrest. Not the full complement of physicians to be sure but as doctors in private practice do not spend the night in the hospital, I fail to see how patients in a teaching hospital are worse off than those poor bastards starving for attention in private hospitals. As to the dangers of handoffs, I’m reasonably sure that I do a better job of signing out my patients to my fellow resident than the private practice physician does to his colleague who will be taking over his call duties, duties that they both can generally perform from home, especially as the standard advice to any patient inquiry, no matter how non-threatening, seems to be, “Go to the emergency room.”

So you see, “Medical Errors,” like “Patient Care,” is nothing more than another blunt weapon with which to bludgeon rebelious residents into submission. It is another despicable appeal to shame and an abuse of the resident’s sense of duty. The fact that most residents buy this argument is because they lack the conceptual tools to refute it. But if you think about it, if handoffs are so dangerous, we may as well never leave the hospital but instead live there, perpetually on tenterhooks, agonizing over every detail and jealously guarding our patients from interlopers like feral dogs over scraps of meat.

In Which Your Uncle Panda Rips Off the Lid, Rolls it in a Tube, and Places it (Politely) Where the Sun Doesn’t Shine

Moonlighting and Other Topics

Moonlighting

I have been doing a little bit of moonlighting lately and I have to say, it just feels different getting paid six times as much for doing the same work. Sorry, it just does. What’s a chore for twelve dollars an hour is decent work for eighty.
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As one of my readers pointed out, moonlighting in Emergency Departments for residents and non-Emergency Medicine board certified physicians is a controversial topic, primarily because of the supposed contradiction of non-qualified physicians working in a field for which the American College of Emergency Physicians believes that stringent qualifications are required. General Surgeons, for example, don’t moonlight as pediatricians so how can, say, a Family Physician or even an incompletely trained Emergency Medicine resident feel comfortable moonlighting in an Emergency Department? If anybody can do it, after all, why require board certification?

The point is not whether anybody can do it. Anybody can actually do it. Just like anybody can do internal medicine, family medicine, and any of the other specialties provided they have the training and the experience. There is nothing magical about Emergency Medicine. You put your head down, open your eyes and ears (uh, with your head down), and muscle through enough cases where you start to get a good handle on the knowledge and procedures that are typically required of an Emergency Physician. The best way to gain this experience however, and for most people the only practical way, is to complete a certain period of residency training where through a combination of formal didactics and supervised clinical training you gain the experience to handle the wide range of real, honest-to-Allah, potentially lethal patient presentations that you will likely encounter.

On the other hand, since there is a lot of overlap between medical specialties and also because Emergency Physicians have now become the closest thing we have to General Practioners (especially as the office-based primary care specialties start punting more and more of their complicated and thus unprofitable patients to the Emergency Department), there is a lot of basic doctoring going on in emergency rooms. Consequently, many physicians with minimal training can gain the illusion of comfort in that kind of environment. Most emergency departments also see a lot of urgent care where the stakes are low and a couple of vicodin or a prescription for amoxicillin covers a multitude of sins.

But that’s not really what Emergency Medicine is about. Those patients are fillers, people who we are happy to see and get the best care we can possibly give but who are dropped like a bad habit when something serious comes in the door. I work at a very busy, high acuity department but if you walked through the halls and didn’t know at what you were looking you’d think it was a just a busy community health clinic. That’s because the really sick people are in the trauma bays or behind curtains. The people in the halls are just hanging out while their work-up proceeds on autopilot, getting angrier and angrier as they mentally compose the scathing letter they are going to write to the hospital’s Patient Relations Department. We get to them when we can because time is money even in medicine. They are seen as quickly as possible given the regrettable fact that every patient does not get their own personal doctor and nurse to hold their hand and chit-chat while the labs cook.

At my program, we generally do in-house moonlighting, filling gaps in the schedule where we work more as physician extenders than regular doctors. In fact, most of our sanctioned moonlighting is in the urgent care side of our department where we pick up physician assistant shifts (and, it is my understanding, make the same hourly rate) working with the same attendings with whom we work during our regular shifts. The point is that even though I can work my way through most common gynecological, pediatric, or medical complaints and would feel comfortable doing it if I were moonlighting solo at an urgent care, at this stage of my training I would feel uncomfortable, almost suicidal, working on my own in an emergency department. Not to mention that it would be unfair to a critically injured or terrifically sick patient to have someone who was less than qualified in charge of his life. Now, sometimes this is unavoidable. If there are no physicians, emergency medicine trained of otherwise, willing or able to staff a sleepy one-horse emergency department in the fly-blown wastelands of Massachusettes they will have to take what they can get and an experienced ATLS-trained resident or Physician Assistant is better than nothing.

And yet, just because it can be done doesn’t mean it should be done or that it is an optimal solution. The optimal solution is to have formally trained Emergency Physicians staffing emergency departments. Allowances need to be made of course because nothing in this bad old world of ours is optimal. Not only is there a shortage of board-certified Emergency Physicians but many non-Emergency Medicine trained physicians practice emergency medicine and have a tremendous amount of talent and experience in it. (The American College of Emergency Physicians did, in fact, have an extensive period where the old hands who pioneered the specialty could become board certified without having done a residency) However, as money drives everything in this aforementioned bad old world of ours and many of the primary care specialties are not paying what they used to, many physicians see a segue to Emergency Medicine as an opportunity for better pay and better hours, both of which are excellent motivations but not things that should be achieved at the expense of patient safety.

Board-certification in any specialty is just a marker, however imperfect, of qualification. By nature it is exclusionary and a little unfair to the minority of otherwise qualified but non-certified individuals who can do the job. But that’s life. As a guy who has had to suck up a lot to both go to medical school and match into Emergency Medicine, while I don’t think it is unreasonable for a residency-trained physician in other specialties to be able to gain board certification in Emergency Medicine after a reasonable period of training, a one year fellowship with minimal hours and scant didactics structured for the fast track to certification isn’t going to cut it.

Emergency Department Crowding

Let’s face it, many of the patients in the Emergency Department at any given time are not really that sick. Many people show up with complaints that seem fairly promising but turn out to be nothing. I can’t tell you the number of chest pains I have seen that have turned out to be dry holes. Even the patients with serious diseases and dozens of frightening comorbidities aren’t usually so sick that they are in imminent danger of death. They’ve been sick for years and their occasional visits are merely opportunities for the rapidly approaching grim reaper to take his government mandated coffee breaks. But people still come and the conventional wisdom is that these patients use the emergency department because they lack health insurance.

Many of these patients, however, do have health insurance and many have their own doctors. So why, I once asked a patient, did he come in and wait three hours to be seen and then six hours in the department when he had excellent health insurance and is a patient of one of the finest physicians in town?

The answer was surprising because it is so obvious. So obvious that I am almost afraid to mention it for fear that you, my wise and long-indulgent readers, will roll your eyes and accuse me of being a simpleton. As my patient related to me, in order to see his doctor he has to make an appointment which is often weeks to months in the future. On the day of his appointment, even if he shows up on time he will usually have to wait an hour or two because the doctor is always running late. Then he will spend a brief ten to fifteen minutes with his doctor who will order a slew of tests and imaging studies, many of which will have to be completed at a different location. He may, for example, have to drive across town for a CT scan and it is usually scheduled for a different day, often weeks in the future.

Then, as my patient explained, he must wait several weeks for his next appointment where his physician will explain the results and finally initiate either definitive treatment or, as is often the case, referral to another specialist who will repeat the time consuming process.

I know this is true on a personal level. I recently had a colonoscopy (everything is fine, by the way and they can still write “no significant past medical history” on my chart) and from my inital visit to my internist to finally getting the results of a post-procedure CT scan from the gastroenterologist took close to six weeks and four separate trips each of which sucked up a big chunk of my infrequent days off.

My patient also confided to me that even getting the results of studies and imaging was not guaranteed. Although we are all quick to relay bad news, apparently follow-up is not that pressing to many physicians if the results are normal. (I still have not actually been infomed of the results of my CT scan and only know it was normal because I walked across the hall and asked the radiologist to look at it for me.)

Consider now a visit to the Emergency Department. First, my patient did not need an appointment. While it is true that he was triaged to a low acuity and had to wait a while, at certain times of the day the waiting times are not that much longer than the typical wait for his delayed primary care physician. Second, the lab tests he needed were drawn on the spot and the results reported within an hour even though he was a low acuity patient. Our goal, you understand, is to discharge or admit as fast as possible. Likewise his imaging studies were obtained, read, and reported quickly. Finally, if anything serious has been discovered he would have been admitted within hours. More importantly to my patient, since everything was all right he knew fairly quickly instead of biting his nails for a couple of months.

As to the cost, even though the same complaint in the Emergency Department costs four times as much as it does at his primary care physician’s office, my patient has insurance and the cost of the work-up is of little concern to him because it costs him roughly the same either way, especially considering that he only has to make one visit versus three or four.

So you see, Emergency Medicine is a victim of it’s own success and, as Emergency Departments begin to look more and more like self-contained hospitals-within-hospitals complete with admitted patients (waiting for rooms, you understand) and even critical care patients being managed for most of the initial five or six hours in which everything important is usually done, the problem of overcrowding is only likely to get worse. Add to this the growing reluctance of office-based practices to handle really complicated patients when it is ridiculously easy to divert them to the Emergency Department and a steadily worsening shortage of primary care physicians, while the situation is no doubt great for my personal job security it is hardly the best way to do business.

Or maybe it is. Maybe what people want is the speed of the Emergency Department, or at least some semblance of it. The problem is that maintaining the infrastructure that lets us move patients quickly is also horrifically expensive.
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Pandictionary

Come on now. Surely someone has some original slang. I repeat, to be included the word has to be truly original or at least funny enough where it doesn’t matter. Again, I want to give proper credit. I believe I invented “polybabydadic,” “dependocracy,” and “homo polycomorbidus.” The rest are unattributed because I truly do not know form whence they came.

Moonlighting and Other Topics

On Vacation

I’ll be taking a blogcation until the the end of this month.  Keep checking back and as always, don’t forget to look back at my extensive archives.

On another note, I’m looking for new and unique medical slang to put into the Pandictionary. I will give proper credit and remember, it has to be original.  “GOMER,” “CTD,” and the like are well-known and done to death so we’ll skip those.

Feel free to email me at [email protected] if you have a particular topic or question you would like to see discussed.

On Vacation