Wednesday, April 20, 2011

Another Pet Peeve: the Finger-Pointing

People blame anesthesia personnel for EVERYTHING. You name it, they blame us for it. They call us by the umbrella name "Anesthesia" and if there's a problem, it's always "Anesthesia's" fault.

Got into the room late? Blame Anesthesia. (Even though the anesthetist's been sitting at the bedside for twenty minutes waiting for the surgeon or the nurses to be ready.)

Patient craving ice cream when she woke up? Must be Anesthesia's fault.

No more coffee in the break room? It's because of Anesthesia.

Think I'm exaggerating? Spend a day in any O.R. in the country and count how many times someone says, "It's because of Anesthesia."

Why? Because it's easy to point the finger at the people / work / department you understand the least. The practice of anesthesia is poorly understood by people outside the specialty, so it makes the perfect scapegoat for EVERYTHING.

I recently heard about a conversation that exemplifies exactly what I'm talking about. My chief was explaining to some of the O.R. nurses what happened to a patient who experienced a known but uncommon complication from one of the materials used by the surgeon during the procedure.

"Yeah," my chief said, "X event happened after the surgeon put in Substance Y for that part of Operation Z."

One of the nurses replied, "Really? How did you [anesthesia] guys cause that?!"

The attitude is so ingrained people can't even detect the nonsensical nature of their own illogical utterances. *Sigh*

The practice of anesthesia looks easy but if people were to try it for a day I think they'd come away pretty spent. When the endpoint is a smooth course, with "nothing unusual happening," the expertise, planning, and careful execution are easy to take for granted. For the record: we prevent or correct many more problems than we cause. When you hear someone say, "It's because of Anesthesia," think twice. You're probably not getting the whole picture.

Friday, April 15, 2011

Sometimes It's Easier Not to Write

I've been neglecting this blog because I've had some recurrent feelings of annoyance lately, and I like to keep my unsolicited invective to a minimum. After all, when I see whiny complaints or bitter criticisms on other blogs sometimes all I want to do is roll my eyes and say, "Who died and made you queen?"

Still, I can't deny that I have some of those thoughts and feelings too. I got a lot of heat when I disclosed the behind-the-scenes frustration that sometimes gets vented "around the water cooler" about certain less conscientious members of the anesthesia and/or nursing staff at my workplace. Lately the same people have exhibited the same lack of professionalism, not around calling in "sick," but avoiding work while at work (disappearing between cases, not checking in with the person in charge before leaving, refusing to see a patient on rounds twenty minutes prior to the appointed departure time because "it's almost time to go," etc.). And the same loud, obnoxious people who have often pontificated about things they don't know enough to pontificate about have continued to be loud and obnoxious and under-informed.

Then there are the surgeons with narcissistic priorities. Some examples:

Dr. Narcissus: "Can you bring the patient to the recovery room without extubating him, please, so we can get the next case in faster?"
Our team: "No, that's not the safest way to conclude the anesthetic for this patient."
Dr. Narcissus: "What difference does it make, extubating there versus extubating in the O.R. with me having to wait around for turn-over?"
Us: "Extubation is safest in the controlled environment of the O.R. We'd still have to watch over and extubate the patient in recovery. It wouldn't save any time and we'd have less available anesthesia equipment outside the O.R."
Dr. Narcissus: "Bring it with you."
Us: "Huh? You don't seem to be understanding the relevant issues..."


Me: "I did something a little different for the anesthetic based on some studies in the British Journal of Anesthesia."
Dr. Contemptuus (looking at patient in recovery room and not understanding that he's actually doing better than expected): "Well, I don't think the patient read that study."
Me: "His pain score is already less than expected considering you cut him open from stem to stern."
Dr. Contemptuus: (shrugs)
Patient: (chatting comfortably with family, laughing, and telling jokes)


Me (through the nurse-in-charge): "I'm sorry, tell Dr. P I have to delay his case because I have a hemorrhaging pregnant woman who needs an immediate C-section to attend to."
Dr. Puerilus: "I'm going to call the administration." He proceeds to do so AND to call my chief at home to LIE and say I asked him to come immediately to help with the C-section (only because the surgeon actually wanted to avoid the delay of his own, NON-emergency case).
Chief (to me, on the phone): "Hey, Dr. P said you really need me there. I'm on my way."
Me: "I don't. I never said that. In fact, I never actually spoke to him because I had to run up to O.B."
Chief: "Oh. You mean he made that up?"
Me: "Yup."
Pencil-pushing administrative nurse calling me to ask about delay of Dr. P's case: "I guess I shouldn't be distracting you with this while -"
Me: "While our patient's about to bleed to death and lose her child? NO, I guess you shouldn't."
Pencil pusher: "Well, he's just wondering when-"
Me: "We'll be able to start Dr. P's case once THIS LIFE-THREATENING EMERGENCY is stable."


It's not the clinical medicine that's the most stressful part of this job, though that can be demanding enough. It's the short-sighted PEOPLE.

I've cut back my hours and elected to spend more time enjoying life with my family. Life requires balance, and medicine tips the scales pretty forcefully. So we try as a family to keep the equilibrium. I recently took my daughter to her first Shakespeare play (The Merchant of Venice, with F. Murray Abraham as Shylock), a feminist theater festival highlighting women's rights abuses across cultures, and a wonderful performance of The Fantasticks in New York. My husband and I have had lunch a couple of times, been to the movies, spent some lovely quiet time talking. My son and I have had some time to ourselves. I wouldn't trade any of this to make more money; it's just not worth it. My family's love keeps me going and helps me remember why I need to keep looking past the little frustrations at work and focus on taking really good care of patients and those who love them.

Tuesday, April 5, 2011

Life in Medicine: A Reality Check

This was posted on a discussion forum for physicians. It's a draft of an e-mail from an anesthesiologist to a medical school applicant who has not been accepted to medical school and has subsequently written to him/her for advice. I've changed the name of the student in question to just "Student."

Many physicians on the forum commented, "I'll sign it too" or "Put it up for all of us to sign" or "You could almost certainly get every doc [here] to sign this" or "It's the truth. She should know the whole story."

The e-mail draft is reposted here by kind permission of its author. I think it's extremely thought-provoking and worth reflecting on, especially by any students contemplating applying or reapplying to medical school.


Sorry to hear things didn't go as well as you would have liked this cycle. It is a difficult process and I too had a tough time getting into school. That being said the road is long, hard, filled with debt and financial uncertainty. The federal government and a series of large multi-billion dollar companies provide their CEO's 10's of million dollar bonuses on taking payments and distributing a small fraction of them for your services. This is typically deemed as "efficiency in medicine" but Ii can't exactly see any efficiency out of a $22.2 million dollar bonus to the CEO of AETNA. Everyone says "I can work hard" or "I can get through it", but when it comes down to it you get 8 years into it and you start to see for the first time and question why nurses are running the show at the majority of hospitals, why the lawyers are so "involved" at work, and how no one with an MD after their name ever gets educated about expense, cost, and reimbursement.

The interesting thing about medicine is that by the time you see what it really is you are already committed to it. The paperwork, insurance, and contract negotiations don't show up until you are already in your 30's. Insurance companies establish a team of individuals dedicated to finding reasons not to reimburse your services, fortunately residency and academic medicine protects you from a lot of this, but that soon changes. By this point most people find themselves >$100k in debt and feel that there isn't any other job they are qualified to do which provides some significant barriers to exiting. As a physician you are expected to be the first one in the door, the last one out it, and the ultimate individual responsible yet a body of administrators / insurance companies tell you what drugs you can and can't give as well as what studies you can perform.

To this a lot of people say "but I want to be a doctor and help people" but which type of people do you want to help? When some entitled patient walks in your door and complains about a $20 copay do you want to help them? Is your time not worth $20 after a decade of your life, $200k in medical school, $50-100k into college, and 3-7years of earning less than a first year nurse (out of a 2 year school) while you were in residency? How about when you are anesthetizing a 60yr old HIV positive heroine addict with no veins who thrashes when you attempt to put an IV in? Most people want to run away from that one, but someone has to help her and you happen to be the person on call.

Truth be told, [Student], there are lots of great jobs out there. Jobs where you can come out of college and earn a decent living with less sacrifice of your time, effort, and finances. Dental school is an excellent option. Dentists make anywhere from 150-300k/yr as a 3 day/wk General Practicioner (+/-call). The training involved is 4 years of dental school and 1 year of residency. Endontists make $500-700k/yr working 4 days a wk with 4 years of dental school and 2 years of residency (no call). Now why do they make more pulling/drilling teeth than you do prolonguing lives? You can thank the federal government for medicaid/medicare and the hippocratic oath for your moral imperative. There is nothing like a patient walking into the ER with a tattoo on their arm (tattoos are expensive ranging from $300-800 typically) complaining that they want a prescription for motrin because they can't pay for a bottle at the store (medicaid covers prescriptions written even for diapers). A dentist seeing the same financial complaint for a dental extraction would tell the patient to reschedule.

For a physician to make anywhere near 300k they would have to enter a top-competitve residency at a minimum of 4 years length with what is typically a significant call burden. The only specialties avoiding this are radiation oncology, dermatology, and radiology which have a lessened call burden. The time sacrifice also has social implications as a woman, most people don't like hearing this, but most physicians don't have more than 2 kids. By the time they have time to have children they are typically approaching advanced maternal age (AMA is age 35, residency typically ends at age 30 if no breaks were taken) and the risks start to outweigh the benefits.

Now do I hate medicine? No, actually I am fairly satisfied with my job. I get to take people who just met me then poison them with drugs to slip them into a coma so that they don't feel the lacerations, saws, and needles that we poke into them to raise their overall quality of life. Not only do i spare them the trauma of the experience, I off set my poisons with other drugs to keep the patient alive, well resuscitated, and from going off the physiological deep end. The job itself is amazing, unfortunately it is surrounded with lawyers, politicians, and white haired physicians pronouncing a "follow what i've said not what i've done" mantra while lining their pockets. This is then wrapped around the recent scandals of states equating an anesthesiologist to a CRNA, because 4.5 years of school is just as good as 12. I am actually quite fortunate to have no debt outside of what I plan on marrying into, but have friends with easily $500-600k in debt with the juice running (rates are currently 6.8% on loans). If i could spend all day in the OR and not have to hear administrators tell me about "hospital compliance training" or "annual compensation reviews" or "drug shortages" it would be heaven.

[Student], from what I know about you there were top grades at a good school but your boards were a little weak. You should look at this as a blessing and really review why you are drawn into this and investigate alternatives if you find those reasons wanting. One universal constant in medicine is that people applying to medical school and subsequent people applying to residency don't know a thing about what they are getting into. The only exceptions possibly family of a physician who is open about the experience. Be careful of blind leaps.

Friday, April 1, 2011

Celebrate Poetry Month!

It's National Poetry Month. I'd like to open the celebration with my favorite recitation. Ladies and Gentlemen, "Litany" by Billy Collins, recited by a three-year-old boy.

Poetry Month Challenge: learn a poem (or two, or three) by heart and recite it (them) to someone you love. If on Facebook: upload a favorite poem or stanza each day as part of a Poetry Month album. Celebrate the mystery, beauty, and power of well-wrought language!