So Why do I Stay in Medicine?

A friend called me the other day. He has been following my blog since I started, and asked me, "If it's such a pain in the ass, why do you stay in it?" This got me to thinking that very question. There are alot of smart ass answers I could give, at least as many dumb ass answers, and just a few really good answers. In the end, it comes down to this: I like to help people, to make a difference in their lives. I also just like people, which is sort of an oxymoron in surgeons, as we are notorious for not being people persons. I'm quite sure it costs me in the short run, since I don't mind spending a little more time with my patients, especially the ones with complex or difficult diagnoses. I'm always interested in what my patients do for a living, and have come across a few careers I've never heard of. Here in the midwest, it's mostly farming and agriculture, but I've also treated a rock star or two (just passin thru), college professors, engineers, soldiers, pilots, and train engineers. If you give a person a little time, just about everyone out there has a story, and all of them are interesting. Here today are a couple of tales from my past, reasons why I stay in this.

Mr Green was an elderly gentleman, approaching the end of his time here on earth, but still plugging. He and his wife, in much the same condition, lived comfortably in an assisted living center, and like so many elderly couples, stayed upright pretty much by leaning on each other. Tug either one out, and the other would probably just fall right over. They had been married for something close to 60 yrs, and when I met Mr. Green, Mrs. Green was admitted to the hospital across town with pneumonia, and in the ICU. I really met Mr. Green by accident. He developed severe abdominal pain, and went in to the ER at the other hospital. His CAT scan looked bad, but the hospital was full, and so he was transferred to our hospital, and I caught him. I did emergency surgery on him almost immediately, and then took him back in a couple more times to wash out the abdomen. Because of his bad lungs and heart, he soon had a tracheostomy, a tube in his neck into the windpipe to ventilate him through. Meantime, his family, bouncing between two hospitals, had transferred Mrs. Green over to our hospital. The two of them had rooms side by side in the ICU, and for about a week, the nurses would move one or the other over to the other's bedside for several hours each day. They would sit and hold hands, and it was obvious the love and devotion that existed there. Within a week, Mrs Green came off the ventilator (breathing machine), and was transferred out of the ICU. Mr. Green, while sicker, was slowly working his way off the vent as well. On Friday morning, however, Mr. Green took a nosedive, and it was necessary to ramp up the vent support. It quickly became clear that he was becoming septic, that an infection had set in somewhere. About noon, word came down from the floor on Mrs Green. Mrs. Green had passed away sometime between breakfast and lunch, probably from a heart attack or stroke. She had been DNR (Do Not Resuscitate), so, while the family mourned, they also rejoiced in her return home. That evening, I met with the family on Mr. Green, who had been deteriorating all day. They were thinking about withdraw support, but wanted to wait until after Mrs. Green's funeral, which would be within the next few days. They didn't want two funerals right on top of each other. I suggested they consider withdrawing support sooner, and having a joint funeral. I could see the idea quickly take hold, as they realized the meaning of this to their parents, as well as to all of the surviving family. They decided to wait until the following afternoon to withdraw support. Mr. Green had the last word. About 4am the following morning, he passed away peacefully. When I talked with the ICU nurse, she reported that his pulse had been slowing for several hours, and at almost exactly 4am, it simple stopped, the EKG went flatline. I didn't speak with the family again, as Mr. Green had already been picked up by the funeral home by the time I arrived at the hospital later that morning. One of my nurses was from the Greens' hometown, and attended the funeral, she said it was beautiful. I reflected that Saturday, as I made my rounds, on the Grace of living together for nearly 60 yrs, and going Home within 24 hrs of each other. Surely the Hand of God was present here.
I didn't think much about the Greens again, until 5 months later. I was heading out to a fall festival on a beautiful fall day, and stopped in a little town to grab a soda and stretch my legs. A gentleman in the convience store looked vaguely familar, and, obviously, he recognized me from somewhere. He quickly cleared the mystery, he was Mr. Green's son. He told me of the funeral, and how very grateful the family was for all I had done for them, and that they still talked of me, the hospital and staff, and those final weeks. While I had been feeling tired after a long week in the hospital, I left that store rejuvenated, and with a new feeling of accomplishment. It's been close to 5 yrs now, and I still reflect on the Greens and their family. I can only hope that when my time here ends, it will be with such a feeling of completeness and closure.

Trauma revisited

It's hard not to come back to the trauma bay when you want great stories to entertain and impress. For many of us, if we could just do the trauma bay, and not have to deal with the riff-raff the next day, we, too would probably love trauma. In the "old days," ie, before lightening fast, very accurate CT scanners, the trauma bay was a lot more fun, too, because so much blunt trauma offered a chance to cut-- there was just no other way to see what was going on in that belly. Now, we can run the more or less stable patient through the Scanner, and rule out just about all of the operable trauma. Don't get me wrong, this is Great for the patient, it just sucks for the anxious, up and coming trauma surgeon who desperately wants to cut a hole in someone. And this is where penetrating trauma comes in, otherwise known as The Knife and Gun Club. While there are few outside sources of penetrating trauma, about 99% comes in the form of people trying to do away with other people, and the forementioned other people trying to prevent this. Predominantly, GangBangers. And this is where our tale takes us tonight. Now, keep in mind, GangBangers wear their surgical scars as badges of honor, and most of us who had any kind of KGC in their training have seen not just repeat, but 3peat customers. Their biggest fear, as they roll into the trauma bay, is, "Am I gonna get a bag?" referring to a colostomy, standard surgical treatment when someone rolls in with a hole in the colon.
Please let me insert a little disclaimer here. Gang violence, and the decay of the inner city, and urban violence, are all terrible blights upon the very fabric of our society. I do not make light of these serious problems. But, I can't fix these problems, and I don't think the government can fix these problems. The cure, when it comes, will come from within, very much like peace eventually came to Ireland when the civilians said, "enough is enough, STOP" In the meantime, those of us in the trauma bay can either cry or laugh. Since most of us have a pretty dark sense of humor, most of us laugh. And with that disclaimer, let's go live to the action:

Victim: "I'm shot! I'm shot! I'm shot!"
Doc: "Where? How many shots? Was the shooter in front or behind you?"
Vic: "My stomach! I don't know! I donno, I didn't see no one. I'm Shot! I'm Shot!"
Doc: "Slow down, take a deep breath. Let me see your belly. Do you hurt anywhere else?"
Vic: "I don't hurt no where else. Oh S**t, am I gonna get a bag, Doc?"
Doc: "I don't know yet. You're gonna feel a finger in your bottom, now" (to check for blood)
Vic: "YOU GONNA WHAT!!!???"
Doc: "OK, you've got some blood in your stools. We're gonna get some xrays, and then go
straight to the OR. We're gonna put a tube in your penis, now" (check for blood, and
monitor urine output)
Vic: "YOU GONNA WHAT!?!?!?!?!?"
Doc: "The xrays don't look good, you're shot pretty bad, we're going to the OR now"
Vic: "When you gonna take this tube out?" (referring to foley catheter in bladder)
Doc: "Sir, you've been shot, and are in rough shape, we're going to the OR now.
Vic: "When you gonna take this tube out?"
Doc: "Sir, we need to operate. You could die"
Vic: "When you gonna take this out?"

As you can see, the foley catheter pretty much ends any productive conversation. But, another member of the team has arrived, the police detective, who's job it is to arrest whoever did this. And so our discussion continues:

Officer: "Hey, Leon, didn't I just arrest you last week?"
Vic: "Yeah, but I got out again"
Off: "Leon, did you see the shooter?"
Vic: "Ahh, man, I didn't see nothing"
Off: "Well, did you even get a look at this guy?"
Vic: "Man, it was some dude. I ain't never seen him"
Off: "So just some dude. You sure you've never seen him? Maybe pick him out from some
mug shots?"
Vic: "Man, it was some dude. I ain't never seen him before."

About this time, we role Leon out, heading for the OR, and, if we're lucky, some really great surgery. And, if Leon is lucky, some really successful surgery.

All of us in the trauma bay know "Some Dude." He is, by all know accounts, the meanest, baddest, shooting-est character out there. If local law enforcement could remove just this single individual, the gun fire in the KGC would almost cease to exist. Of course, we all know we'll get to meet someone pretty close to his description within a day or so, when Leon's boys ask Some Dude to take out one of the rival gang's members. When he shows up in the trauma bay, yep, you guessed it: It was Some Dude. Damn, he is one bad asssed boy.

Where the money goes

I talked a week or two ago about how doctors get paid by the insurance companies, but yesterday, someone started spouting off around me about "overpaid doctors," and how rediculous doctors' rates are, and so I'm back around the topic. Just a little rundown on the cost of doing business. We're gonna take out a gallbladder, and then follow the money. So get out your calculators, and follow the bouncing bill.



My charge: $2200

Medicaid pays: $1000 (-$1200)

Office costs: ~50% (-$500)

Malpractice: $100 (-$100)

My Income Tax: ~35% (-$140)



Total: $260

Hours/Pt: 4hrs



equals: $65/hr



Hell, I can make that working on the assembly line! And I didn't include in that the monthly payments on my student loans, which is equal to the mortgage on a nice 3-4 bedroom, 3 bath home.

It amazes me that Americans are willing to pay to watch somebody play baseball, football, basketball, etc, for millions of dollars per year, or shell out $10 a ticket for a movie with an actor/actress making$20 million dollars per movie, but they think that their doctor is overpaid, even though s/he has at least 7 yrs of education beyond college, at a cost of roughly $100,000, and is available 24 hrs a day, 7 days a week, 52 weeks a year.

There is a constant buzz in the hallowed halls of congress, and elsewhere, about the Right to Healthcare. Could someone please point out for me the specific text in the declaration of Independence, the Constitution, or some other founding document, where this is specified? I found, right up front in the first 10 amendments, the right to legal representation, but I don't see anyone working to control the cost of legal care --Hell, I sure can't afford a lawyer, not on my pay. I also see, in the Declaration of Independence, the Right to the Pursuit of Happiness. As I took my hippocratic oath, did I surrender this Right in exchange for the care of my patients?

Oh, well, it has become late, I was up early, and spent 10 hrs in the OR, I'm gonna hit the sack, tomorrow is another day.

Sex and Trauma, or, Love in the Fast lane

Ok, so a day or two ago, I promised tales of trauma from days old. So, I'm gonna dig deep into my repressed memories from my residency for a story of love (sorta) in the fast lane.



I need to expand on the trauma experience a little to make this a better story, first. Medical students LOVE trauma. It is exciting! There's blood, and violence, and fast past action -- all the making of a great hollywood movie. Nurses LOVE trauma. See above explanation. Residents..... HATE trauma. that's becuase after the med students go off rotation, and the nurses go home after shift, the resident is still stuck babysitting the trauma patient. And while, on occassion, a clean, wholesome, pleasant person comes through the doors of the trauma bay, the majority, at a ratio of about 20 to 1, are drunk, obnoxious, rude Assholes. They are uncooperative and belligerent in the trauma room, usually stink to high heaven with booze and tobacco, and, now a days with CAT scans and other imaging techniques, not even a good chance for an operation. Additionally, once they get to the floor, they tend to be demanding and rude, telling you about all that "they" are paying for the hospitalization (Oh, Ooops, you're on Medicaid, or, more likely, not even insured, so NO pay) and how they're going to "sue your ass" because they didn't get the breakfast of their choice. There was also the charmer who lay on the backboard bucking and thrashing and telling me he was "gonna get me. I got friends. We're gonna get you." This settled down when I leaned over real close and personal like, and explained that one more buck, or one more threat, and I was paralyzin' his ass and stuffin a tube down his throat. Amazin how nicely that worked. And on and on and on. Attending level surgeons either love or hate trauma, it just depends on whether they have residents or not. You can guess which group loves it. So, as a resident, a rotation on trauma is pretty much just a detour through hell, with all the unsavory characters and then some in Dante's Classic Road Trip Novel.
So enough ground work. Suffice to say, Trauma sucks. So here it was, a lovely spring morning, with morning rounds done, and settling into chasing down Xrays, CAT scans, and the various reports thereof from the previous nights customers, when the trauma pager went off. (On an aside, we kept all of the trauma pagers set to the same tone, and threatened other residents who used it for their personal pagers-- I still hate that tone. It causes flashbacks for me) It was a class 2 trauma from a motor vehicle accident. The patient was a direct flight from the scene, and, by report, was already intubated. There was a death at the scene, always a bad sign. When he hit the table, it was clear he had a pretty significant head injury, but really no other life threatening injuries. We drew blood, got in the appropriate lines and tubes, and prepared to get the whole body CAT scan to determine how bad the coconut was cracked, and see if anything else was damaged. 'Bout that time, the social worker came in. The social workers showed up for all the traumas, their job was to round up the family, friends, posse, whatever, and keep them informed what we were doing, and assist us with communications. Well, this one was a doozy. She let us know that his mother, along with his wife, girlfriend, and mother of his baby, were in the waiting room. "Ummm, how many people is that, exactly?" Yep. Four different people. "Oh, they all know each other? And get along?" OK. Needless to say, there was great wailing at the fall of the patriarch. We explained the plan of action, and promised to keep them updated.
Back in the trauma room, the State Police had arrived. It turned out that the death at the scene was actually the girlfriend's roommate. We, the collective trauma team quickly peppered the trooper for details of the accident, so as to better predict our patient's injuries. As it turns out, our patient was moving at a high rate of speed (in more than one way), when he drifted across the centerline to go head to head with a Semi. He had survived only because of an "airbag" Turns out, his pants were around his ankles (I don't recommend this when driving), and the girl was naked on his lap (I really don't recommend this while driving), when he became,,,, ummmm,, distracted, and lost control of the vehicle. The story, as it developed, was that apparently the girl was "auditioning," for a place in the family. Apparently, parking on a quiet street, or just renting a room, wasn't an option. Pity. As the story went on, after the initial show of great concern and caring, and as it became apparent that he was not going to snap out of the acute brain injury too quickly, all of these ladies disappeared. Patient X did come off the vent, and even woke up to some extent. He spent several months with us, as he had no home with out the ladies, and no extended care facility or nursing home would take him (did I mention, no insurance?) After about six months living in the hospital, as the nursing staff and residents became more and more aware he was faking a good deal of his deficit, he finally was sent home. The police dropped the vehicular homicide charges, since he was deemed incompetent to stand trial.
Makes for a kinda crappy ending, huh? Well there is a post script to the story. Around 3 years later, as I was finishing up my residency, one of the floor nurses who had cared for/put up with him showed me a newspaper clipping. It turned out that Patient X had continued to have "problems" after his return home, thereby avoiding the homicide charge. He had no memory of the event, couldn't comprehend the seriousness of the charges, and apparently even had significant problems with short term memory. This all collapsed one day when he was out walking his dog, who showed little respect for the neighbor's lawn, this let to a shouting match between the two men, followed by threats by Pt. X, who then went home to get a gun to carry out his threat. He returned, with said gun in pocket, to be met by a couple of the local law enforcement officers, and was promptly tossed in jail. The last I heard, this was the event the law had been looking for to prove competency, and he was headed to trial. And so too, ends my tale of Sex and Love in the fastlane.
Seein' as I'm on call tonight, I'm gonna hit the sack, as it's likely I will get woke up about once an hour for the rest of the night.

Sweet dreams, all.

Nursing: Old versus New

A couple of days ago, I promised to tell you the tale of the beaurocrats. The world of nursing is a great example of where the number crunchers and bean counters have overwhelmed the world of medicine and driven this noble, caring profession into a squirrel cage rat race doing more secretary work than patient care.



Let's take a look at "old nursing" vs "new nursing".



Old Nursing: Bring meds to patient, bring dinner, spend 10 min talking with patient and learning what they're scared of, a little about their family, spend time teaching about the next day's test. Pt's upset and nervous, you give a back rub to help them relax. Total time spent with patient: 50 min. Total time on paperwork: 10 min.



New Nursing: Run meds in, confirm patient ID with armband (because you really haven't had a chance to get to know them all. Spend 10 minutes on computer documenting you gave the meds, and did so with all of the appropriate safeguards. Nurse's aide brings in dinner. You run in to glance at tray to estimate how much they ate. Spend 10 more minutes documenting how much patient ate. Nurse's aide repostions patient. You spend 10 minutes documenting frequent repositioning of patient. Drop off a brochure with patient about tomorrow's procedure. Spend 10 minutes documenting you gave patient brochure. Nurse's aide lets you know the patient is anxious. You talk to patient for 2 minutes to confirm this. Call the doctor, get order for sedative, give to patient. Spend 20 minutes documenting anxiousness, call, and meds. Total time with patient: 10 min. Total time documenting: 50 min.



And on and on and on and on and on and on and on it gooooooooeeeeeeeesssssss.



How did we get here?

The beauracrats came along with "a better way"



"Healthcare is a disaster" "Our system is Failing" "Too many errors" "Systems will make it all better"



Beauracrates, with no knowledge of healthcare, nursing, medicine, or just simply caring for another human being decided they could do it better. And to acheive that, you must have DATA. So now, instead of caring for the patient, the nurses create data. This proves what good care they are giving. Of course, even as the beaurocrates were making healthcare better, they were already upsetting the balance of personel within the system. With all this DATA coming in, it was necessary to hire people to collect the DATA, and people to store the DATA, and people to analyze the DATA, and even more people to supervise the people who process the DATA, and pretty soon there were 5 and 6 people for every one person actually, physically, caring for the patient. Current estimates now are for 20+ people in healthcare who never actually provide care to the patient, either directly or indirectly, for every one person who provides actual, hands on care to patients. Recent estimates suggests that for every dollar the consumer spends on healthcare, about 17 cents reaches the doctor. Another 10 to 15 cents go to nurses and other allied health care salaries. More goes to administration, bean counters, and a host of others whose jobs is to file claims, check claims, scour the charts to make sure they are in compliance with a dozen different regulatory agencies, make sure everything is signed, dated, and complete. But, do you know where a little over half of your dollar goes? The insurance company. And is health care any better? I doubt it. Now that we document the living hell out of everything, our nurses spend less time than ever with the patients, leaving more and more of the patient care to "nurse extenders," aka, nurses' aides or "patient care technicians," basically someone who does all the hands on work like checking vital signs, feeding, bathing, bedding, bedpans, call lights, etc, leaving the nurse free to pass meds, run IV's, and, least we forget, DOCUMENT. Don't get me wrong, I work with a host of wonderful, caring, dedicated nurse extenders. But they lack the training to recognize subtle signs and changes in a patient headed for trouble, and so the call to the doctor warning of trouble is often that much more delayed. Too many times, I've rounded in the morning, looked at the flowsheet (the list of vitals, ins&outs, etc), asked the nurse why I wasn't notified of an obvious change or trend, and she had not even seen the flowsheet. This isn't evil people. It's good people, caring people, who've had their job defined and redefined, and redefined again, by people who've never provided patient care before. (The lawyers are part of this, but that's a whole other day. Gotta stay focused)
Ok, it's getting late, and I've rambled on again. Tomorrow, tales of trauma past, just for the fun of it.
Good night.

Well, we're back again. Getting late, so this is sort of a wrap up. That was, without question, the biggest abscess I have ever seen. It extended the length of the thigh, and had 1.5 liters of pus in it. And it was under pressure, shot 2ft when I cut into it. Don't try this at home kids, I'm a professional. I'll plan on taking him back to the OR for the next few days to try to get this thing really cleaned up, and then it will have to heal from the inside out, because any attempt to close it would simply lead to another abscess.



It was a busy day. I started rounds in hospital B, then office for about 5 hours, then to hospital A to do a quick case, which of course then took twice as long. I'm on call today, so by the time I had finished the case, I had three consults to see back at hospital B, so off I went. I saw this big abscess and got it routed towards the OR, then saw the other two cases, and lined up most of their management, then down to the OR, and finally back up to the floor to finish off the second two consults. I'm now home as it approaches 11p, and this is definately a short blog night. A while ago, I promised the expose' on the beauracracy, but I'm afraid it's going to have to wait a little longer.

I did notice, glancing at the last post, that I talked about abscesses as most surgeons' first case, as it was mine. Now, how is this so? Pretty simple. As I said earlier, abscess tend to come in at night. This is when staffs are lower, activity is minimal, and residents can take a little time to teach the enthusiastic student. So here ya are, on your second night of call on surgery service, already almost falling over because you were up at 0300 that morning to round on your patients, and it is now around midnight. The resident sent you down to the ER a couple hours ago to see this patient, and do the history and physical, and now the junior resident, and then the senior resident, has seen the patient, and the two of them have talked about you, and decided you really are bustin your chops, and they throw you a bone. Your first procedure. Sit here. Hold the scapel like this (Oh my God, they're letting me touch the scapel!) Cut here. Course, they forget to warn you about that pressure thing, so a half second after the, "cut here," you're falling off the stool backwards as you try to dodge the pus squirting out. But it doesn't matter. You've cut your teeth, you've drawn blood. You're hooked. Never again will treating the common cold be enough for you. You're A SURGEON now.

Good night,

It's Live, Tuesday night!!

Well this isn't going to be a very long post, I'm waiting to go to the OR with a case of pus. As a matter of fact, my evening is awash in pus, seeing as, as soon as i finish opening an draining this huge collection of pus, I've got to more abscesses waiting for me up on the floor. AAAAhhhh, the joy of the general surgeon, Pus. The never ending call of the general surgeon is, "Don't let the sun go down on pus under pressure!" Unfortunately, a more appropopriate call would be, "Don't let the sun come up on pus under pressure!" since it seems I do 90% of these after dark. Tonight is a little bit of an exception to the rule, none of my 3 cases is in a really stinky, private place, like a butt crack, or next to the anus, which is usually where I find these pleasant little things. The perirectal abscess holds a special place in so many surgeons' memories, because, invariably, it seems this is the very first procedure any of us ever did in med school.


Well, I gotta run, they're calling for me from the OR.





More later.

Ya think your mechanic will go for it?

So I promised you yesterday I would tell you about how to pay your mechanic. So envision this: You take your car into the shop because it's got a funny noise coming out of the right front. The mechanic puts it up on the rack, uses the really fancy machine, you know, the one that goes "BING!" He then looks in a couple of big books in his office, and finally tells you the gloopa joint is bad and will need replacing. After you give him the go ahead, he pulls a new gloopa joint off one of his store shelves, replaces it, and finally presents you with the bill. It's a doozy, $2000. After he hands you the bill, and your keys, you tell him, "Great job. I'll get this money to you in about 3 or 4 months. About 3 months later, you finally pay him. But there's a hitch: In the interval, you've talked to all your friends who have ever even heard of a gloopa joint. All of you agree that $2000 seems pretty high, and so you send him a note with the payement: Dear Rusty, I have reviewed your charges for the gloopa joint, and, in keeping with the Usual and Customary Charges, for gloopa joints, I'm sending you $1000. Thanks for the work. HEY!!! Wait!! You can't do that!! Oh Yeah?? Welcome to my world. Wanta make it even better? OK, try this on. It's now 2am on a Sunday morning when your gloopa goes giddy. So you call your mechanic up, get him out of bed, and have him fix it, right then and there. Well, hell, that should be good for at least time and a half, right? Nope. Same half off discount. Hell of a racket, huh?
Let's sweeten it up again, and we'll take a little more off the ticket. In almost every state in the union (about 45 out of 50), in order to get a license to practice medicine, you must show proof of malpractice insurance. It's mandatory. What does this mean? There isn't much effort on the part of the malpractice carriers to give you a good deal. At this point in my career, with no claims against me, I am currently paying around $45,000/yr in malpractice coverage. And it gets better. Doctors have to deal with what is called "Tail Coverage." What this means is that if I go shopping around and find a better deal, or, for that matter, decide to move out of one state for another, maybe with better rates, I must either purchase a rider on my new insurance, increasing the price by several thousand dollars a month, or buy "tail coverage" from the previous carrier. This "tail coverage" is to cover any occurances that might be filed against me after I'm gone. I looked into this last summer when I moved from one state to another. My tail coverage, if I had purchased it, would have been about $135,000. One lump payment. OK, let's swing that back around to your car with the squeaky gloopa joint. You've been with Mexican Family for a few years, but just for the heck of it, you do a little shopping around, and you figure out that you can get the same insurance from State Barn. You go ahead to make the switch, and then get a bill from Mexican Family equal to about 5 yrs of insurance that you have to pay, in case some one files a claim against you for running over Rover 2 yrs ago. AND YOU MUST BUY IT. That's what tail coverage is.
About a year ago, United Healthcare was running an ad campaign that said, essentially, "we're doing all we can to keep the cost of medicine down." This coming from a company who's CEO's salary is in the 8 to 9 figure range. Have ya noticed who's building the biggest, fanciest buildings these days? I (and the entire medical field) are providing care for less than ever before. Gallbladder surgery, once a two week stay in the hospital, is now done as an outpatient. You can get your appendix out and go home the next day, where it used to be at least a week. Have a heart attack 25 yrs ago, and you'd be in the hospital for a month, now you're likely to be heading home within a week, depending on the severity. So, here I am, providing care more efficiently than ever before, your premiums are higher than ever before, and where is all the money? You tell me.

Next up: The beauracracy strikes.

Breaking the intern

Well, here it is, 8:00p, and I'm home for the day. I'm on call today and through the weekend, I've already cleared my pager twice, about 40 calls so far. I started the day with rounding at one hospital, removing a gallbladder (a "lap chole"), several scattered patients in my office, and rounds and a couple of consults at the other hospital. All in all, a moderate day, hopefully the pager will settle down and I'll get a decent night's sleep. Lately, when on call, my pager has managed to wake me about once an hour throughout the night. Really smart doctors, one's who go into fields where they don't take call, have studied this. They took healthy volunteers (read: poor college students), hooked them up to monitors, and everytime they started to fall into dream sleep, they'd wake them up. Within a few days, they were pretty much fried, bleary eyed, drooling, unable to concentrate, mean and crabby. Call is pretty much the same thing. In residency, where they take medical school graduates and teach them to be real doctors, call was traditionally 1 in 3, or if you really had it bad, 1 in 2. This led to the dunkin donuts man syndrome, where you eventually run into yourself going out the door as you're coming in. It was perpetuated by the same logic that has killed freshman and rookies for a hundred years-- I survived, you can survive, get over it. What this means in real terms is that starry eyed dreamers who were going to save the world and make it a better place for mankind had this attitude beaten out of them, until they simple look to morning's light as a sign they are still alive. I entered my training in the days of old. I reported for duty July 1 at 0600. I got home around 1000p that night. This went on for 3 days, and then, glory to God, my chief told me I could have the 4th off. I fell asleep at 1030p that night, about 15 minutes after I walked through the door. My pager went off at midnight after just an hour and a half of sleep. As I looked at my pager and the clock showing midnight (exactly), I thought, what kind of rotten trick is this to play on the intern? It wasn't. I wound up covering a trauma for back up while the regular trauma team took care of other patients. I finally had that patient tucked in to a bed in the SICU (Surgical Intensive Care Unit) around 400am, and was back in my bed by 5a. so much for the 4th, I slept through half the day. When I returned to work the following day, I launched into what would turn out to be two and a half months without a day off, working 16 to 18 hr days, with call (ie, up all night) every third day. I completed the rest of my training on pretty much this schedule, though there were the occasional rotations where call dropped to one in four or, rarely, one in five.
My senior year dawned a new light. There was change in the air. The government, acting in the best interest of the people, were enacting tough new standards for resident education. These new rules limited residents to an 80 hr workweek, and forbid working more than 30 hr straight. Being in a very forward looking residency, we started working by these rules in January of my last year. It made for a rather nice year, and I wound up my residency taking call about once a week. These rules were enacted after a couple of highly publicized deaths involving residents that were severely sleep deprived and trying to care for patients. There was a great deal of debate involved in these changes being made, much of involving "continuity of care," meaning decisions on your care are made by someone who knows every detail about you, what's been done, what hasn't, the drugs you're on, your allergies, your spouse's name. It was finally decided that continuity wasn't as important as being bright eyed and bushy tailed, and so the new hours were instated. So what's the post script? Several studies done since the change have shown no improvement in deaths or complication rates, or an actual worsening.
More fun for those of us who made it through, we take comfort in knowing that, having been there, we can do it again when we are faced with no options in our private practice, which is still pretty common in much of the country. While there have been plenty of times in the few years since entering practice I would have really loved to have quoted those resident hour rules back to the ER doctor calling me, the simple truth was, if I didn't stay up, or get out of bed, to take care of little Tommy's appendix, it wasn't going to get done. "Sorry folks, I know little Tommy's hurting pretty bad, but, hey, I just hit the 24 hr mark, and I won't be able to operate for the next 10 hrs. I sure hope his appendix doesn't rupture before I'm allowed to operate again. People reading this in big cities may not appreciate this, but in the rural communities which make up pretty much all of the midwest, one or two surgeons covering everything within a hundred miles is not unusual. And this shortage is only going to get worse, as fewer and fewer young doctors chose this lifestyle. In most fields, as the number of trained individuals available to fill a position decreases, the pay for those individuals goes up. Not so in medicine. For the last 5 or so years, every year dawns with the theat of huge medicare cuts. There have been reprieves every year, but this reflect more just that there was no cut in funding, not that an appropriate cost of living increase took place. If the government is so short on cash, why aren't they cutting congressional salaries, perks, and pensions?
OK, my pager is going off again, so I think I'll wrap this up here. Next up: Paying your mechanic the way your insurance company pays me. And other dirty tricks you don't know about.

Welcome to Doc's Page

Aaaahhhhh, the end of the workday. I hope. My day started with rounds 12 hrs ago, and, if all goes well, is now done for the day. I've poured a glass of my favorite adult beverage, and am going to sit and relax for a little while before attacking the mail and a dozen other chores around the house.
But let me introduce myself. I am a General Surgeon, living and working in a small community in the Midwest. While that may seem a little vague, so it must be if I am to do with this blog what I intend, which is to tell the tales of my life and work (mostly work), some sad, some maddening, some comical, I must maintain a certain degree of anonymity so as to avoid a dredded breach of confidentiality and a certain HIPPA violation. (More about HIPPA later) I'm quite certainly going to wind up on some political soapboxes along the way. The opinions expressed here are quite certainly my own, please feel free to disagree at any time. It's a well known fact in the medical community that if you want two opinions, ask two doctors. You'll get them.
More importantly, though, is a desire to journal the life of a surgeon, and the factors that shape us and our work, the issues that drive us nuts, the things that we really want to say, but don't, because you'll get pissed off at us and walk out of our office. I certainly want to highlight some of the absurdities that the lawyers, politicians, beaurocrats, and insurance companies have propagated upon the unknowing public, much to the expense of the public, both in money and in health. I also want to try to show you all just what is involved in being a doctor today--for instance, the fact that my pager just went off, even though I'm not on call tonight. Most people today have an impression of medicine derived from one part Marcus Welby, 3 parts "ER", 4 parts "Grey's Anatomy," and 5 parts "House". Second page in 5 min. Hang on a second.
OK, I'm back. Well let's see. I vaguely remember Ol Doc Welby, saintly, always there, all knowing. What a great age that was. Oh, and that was also before Medicaid and lawyers. Truly a golden age, but alas, now gone.
ER. ER hit the airways the year I started Med School. Every Friday morning, my classmates and I would sit around and analyze the previous night's adventures, compare them to our cases and studies, and unaminously assign last night's disease du jour to one of our patients. It was haled as "gritty," and "realistic", and in those early days, I guess it was. But I haven't watched it in years, and what little I've heard of it certainly doesn't impress me as real.
Grey's Anatomy. Have never seen it, haven't ever seen anything that suggested it was worth wasting an hour of my time. What little I have heard and seen of it, screams "soap opera!" And, hey, hospitals make for great soap operas.
House. Another show I've never seen a full episode of, and what I have seen was probably sitting in a surgeon's lounge, waiting to start a late evening Appendectomy. Pertinent observations-- Ooops, hang on, another page. OK, observations. 1) House is an arrogant, pushy ass, and would be kicked out of any current day hospital as a "disruptive physician," a label that would just about end his medical career, no matter how good he is. 2) House has managed to get miracle, just developed cures from drawing board to patient in a single episode. That's damn good, considering it takes the standard pharmaceutical company a company several million dollars and several years to do the same thing.
What does this all mean? That people really have no clue about what a doctor's life really is. And that's what I'm going to try to show. OK, I'm back just took another page, and a phone call from another doctor, to discuss a patient with no good answers. As a matter of fact, this is a great case to open a discussion of a doctor's life.
Ms. Green (no, not her real name), is a 90 year old lady. She's pleasantly demented, which medically savvy people will recognize as meaning, "she's clueless, but she doesn't cuss, spit, or try to hurt you." She was admitted several days ago with nausea and abdominal pain. The cat scan done at the time suggested that she has some intestines that are not getting enough blood, and are almost dead, or are getting no blood, and are dead. From a clinical perspective, she certainly doesn't look that sick. But by the book, she probably should be operated on, to determine if this really is the case, and, if so, to remove the dead gut. But here's the glich. She won't survive the operation. Oh, sure, I'll get her off the table, and into the ICU, but she won't leave the hospital alive. Now, she's just had another cat scan, and it shows a slightly less pretty picture. So the question is, what should I do when the family says, "save her. do everything. spare nothing." Am I doing Ms. Green any favors? I certainly don't think so. Am I practicing "responsible" medicine, trying to make the most effective use of your taxpayer's dollar? I don't think so, either. I know what I'm going to do, I can only pray that the family agrees with that course, and I don't wind up doing CPR on a 90 yr old lady who will not leave the hospital alive.
OK, I'm going to get to those chores and mail I mentioned about an hour ago. Next installment (if I remember): How I got here, or, the breaking of a starry eyed intern.