What Bugs Me Today II

I couldn't believe it when I stumbled across this British medical student's shameless plea for donations. I'll give you the recap so that you don't need to click on it and drive up this loser's hit count-- he's a 4th year medical student in Manchester, U.K. (over there it's a 5 year program) and he's nearly 30,000 British pounds in debt. He's begging randomly to the internet community to send him donations because he doesn't want to 'graduate in debt'.

Please. Call the whaaaaa-mbulance. In Canada, since deregulation of medical school tuition in the mid-1990's a student would be unbelievably lucky to finish medical school with only 60K in debt (assuming the very rough conversion of 1:2 for British pounds to Canadian dollars). Not to mention the fact that we then have to make payments on this debt as we complete anywhere from 2-6 years of residency at which time our pay starts at $45K yearly. In fact, if you divide the weekly salary by the average number of hours a medical resident works in a week, we almost make minimum wage.

I admit, my debt is on the high end of normal. I didn't have a family to support, so I don't have that excuse, but I did put myself through a master's degree and a second undergraduate degree before medical school without outside assistance. And until the government student loan program wakes up and realizes that the max allowance of 10K a year is ridiculous for a medical student (whose yearly tuition and fees nearly doubles that and it's not like we have the flexibility in our schedules to work-part time through school), the bulk of my debt is with the bank. I could sell my first, second and third born to the bank and I'd still end up owing them in the end.

I don't usually feel sorry for myself when it comes to my financial situation. I don't begrudge the loan system-- without it, medical school wouldn't have been an option for me. I don't even resent the amount of tuition that we're expected to pay-- even my $16K yearly tuition is heavily subsidized by the Canadian taxpayers. But it's difficult to keep your head above water for the first few years making payments that eat up 50% of your take-home salary.

On one hand, I think it deters people from primary care (family medicine, pediatrics) where salaries are traditionally lower and overhead traditionally higher. But on the other hand, I wonder how my specialist colleagues in 5 and 6 year residencies can manage with the high debt and low salary for even longer than I have to.

I don't love being my age (i.e. not a spring chicken) still having to rent. There is so much travelling I want to do but unless it involves camping and is accessible by car it's unlikely to happen any time soon. Even having a baby may strain the finances more than I care to think about. But as long as I manage to make ends meet until I'm making real money, I know the debt will be manageable. It just means our first house will be small, we'll make due with our car until it dies a natural death, we won't be taking any vacations and we won't be contributing to RRSP's until we're in our late 30's. But that's not so bad, right? Um... right?

I guess that's why people like this guy irk me so much. What makes HIM so special that he deserves to graduate debt-free? Why shouldn't he have the same concerns as the rest of us who chose a life in medicine regardless of a distinct lack of rich relatives? I don't begrudge the people who had a hand in getting through school-- but I don't think I would have asked it of my parents even if they COULD afford it.

I just wish people would stop assuming that Mr. Couz and I are on easy street because of my title. Trust me... right now, it's no financial windfall.

(Thanks to Kevin, M.D. whose post brought this wing-nut to my attention)

Mmmm... Books.

I love books. I've always loved books. I admit it. My obsession started early, with Archie comics and Peanuts paperbacks. I was the kid who would be up at night with a flashlight under the covers trying to read one more page before being discovered by my mom. I eagerly anticipated the days my mom would bring us to the library, my sisters and I leaving with armfuls of hardcover books with crinkly covers. There was no feeling like cracking the spine of a brand new book. I've always loved bookstores-- from the tiniest hole-in-the-wall to the enormous Chapters/Indigo/Borders type-places, I can browse for hours.

I don't have much time to read for pleasure anymore, but I still get the same excitement out of books. Even the kind I 'have' to read. This has not always been a good thing. I don't know what on earth possessed me to buy our medical schools recommended pharmacology textbook-- I think I used it once in second year to look up some pharmacodynamics for a PBL session. I also have a nearly untouched Robbins Pathological Basis of Disease... I know that the American medical schools tend to regard this as a bible, but I managed to get through medicine with much more user-friendly texts. Other buys that made more sense at the time were a very good (and very large) textbook on rheumatology (on which my experience beyond the classroom has been non-existant) and a lovely (but somewhat heavy) textbook on infectious disease. That one I should probably crack open again-- I could use a refresher on bugs and drugs. But even now, I find browsing through a medical bookstore one of my favorite ways to spend a free hour.

These days, I'm a lot more careful about buying books. I don't buy books randomly at the start of every new rotation. In fact, since buying a subscription to up-to-date and installing the Lexi series on my PDA, I don't really use textbooks much at all anymore. And the ones I do buy I make sure will be a good investment-- a book that I'm likely to use and refer back to in the future. So most of those are relating to emergency medicine in some way.

Sometimes this works better in theory than in practice. My last major book purchase was one of the bibles of emergency medicine, Tintinalli. (When you're this well known in the world of emergency medicine, you're referred to by name) It was an exciting purchase to make... this text, together with Rosen, form the basis of resident preparation for the emergency medicine board exams. I eagerly dug in-- with each new rotation in my internship year, I'd read the corresponding section of Tintinalli. Great idea, right? Problem was, this textbook is about 5 inches thick. Not terribly portable, particularly for someone who does her best studying over non-fat vanilla lattes at Starbucks. On top of that, the weight of the book causes self-imposed time limits on studying. More than 45 minutes at a time causes painful ridges to form across the tops of my thighs where the book rests when I read. I think that Rosen had the right idea when they split their bible into three volumes.

So it's been a while since I've purchased any new medical books. Which is why I've been anxiously stalking the mailman for my package from Amazon. New medical books... yay!

First I got a family medicine text. It was less than $100 (a bargain for medical textbooks) and it much more complete than the Mosby text I'm using now. I wanted something beyond the review materials being passed around the internet when I'm studying for the CCFP licensing exam which is coming up in a little more than three months. This exam is freaking me out-- coming into family medicine from emerg and therefore knowing nothing about family medicine-oriented subjects like psychiatry, screening for disease and guidelines for management of primary health care issues, I still feel like I'm at a bit of a disadvantage. So over the next few months, I have some catching up to do. A friend brought this text to one of our academic days not too long ago and I really liked it-- complete, readable and relatively cheap. Add that to the shiny cover and pretty pictures and it's pretty much the perfect textbook. I was sold.

As long as I was ordering a book for exam prep, I decided to throw in another text that I've been eyeing for the better part of a year. The ICU book has been recommended by everyone I know who has read it. Seeing as how I'll be spending the month of June in the ICU here, another month of ICU next year during my emerg year, and will be using many of the procedures and protocols described in the emergency room. I had been waiting for the new edition to come out, so it's the perfect opportunity.

And speaking of perfect opportunities, Amazon.ca was offering The ICU Book in combination with another book I had my eye on, the Manual of Emergency Airway Management. This is another topic I'm a little insecure about, in spite of the month of anaesthesia that was intended to teach me these skills. All I've done in an emergency situation is fairly straightforward endotracheal intubation. The fancier stuff I've seen done in controlled situations, but I'd like to have more in my arsenal when some apneic 300lb guy with a Mallampati IV oropharynx rolls in the door. I'm hoping I get a lot more out of my next month of anaesthesia than I did in my first. I am perfectly aware that the techniques that will save my ass in a tight situation aren't the kind that can be taught in books, but I'm hoping it will be a good start.

Mmmm. Books. Love em. I can't wait. Now if only I could find the time to READ them, I'd be laughing.

The Scutmonkey Rules

Okay, I rarely do this-- post passages directly from another blogger. But rarely does another blog actually make me laugh out loud. Which isn't so great if I'm working on my laptop, say, in the middle of Starbucks. People think I'm crazy. But this recent exchange, ever-so-wonderfully captured by Michelle over at The Underwear Drawer, was worth risking a Form 1.

(That 'Form 1' comment was a medical joke. And jokes like that are why I will never be cool.)

So for context, Michelle is an anesthesiology resident in NYC. And this recent OR exchange illustrates what is wrong with the traditional medical mentality:

So of course Joe and I had to work this last week, but thankfully the OR schedule has been somewhat light, with the exception of the orthopedic rooms, because those orthopods just don't know when to stop. Yes, they love doing surgery, and I respect that, but at some point, don't you think that stopping the smell the roses or having outside pursuits is a sign of a fully realized life? Or am I just a lazy turd?

Apparently the latter, according to the neurosurgeons. I was in a neuro case just the other day when the following conversation transpired between the surgical team and myself. They were discussing interdepartmental rivalries between our institution and [Upper East Side Affiliate Hospital]. You know, the surgeons down there talking smack about the surgeons up here and vice versa. The attending surgeons then posed this question.


NEUROSURG ATTENDING
How about Anesthesia? Did the anesthesiologists down there have some sort of big rivalry with the group up here?

SCRUB NURSE
[Who has worked at both hospitals]
No, the anesthesiologists were pretty laid-back.

NEUROSURG RESIDENT
Anesthesia doesn't have rivalries because anesthesiologists have no ego.

MICHELLE
I'm trying to figure out if you said that as a compliment or an insult.

NEUROSURG RESIDENT
(Bitterly)
All Anesthesia wants to do is go home! You know they leave at 4pm some days? 4pm!

MICHELLE
Um, it's 7pm now, and I'm right here.

NEUROSURG RESIDENT
(Starting to froth)
I get into work at 4am and leave at 10pm! They get six extra hours in their day! Six hours! That's a whole life!

MICHELLE
That's exactly right. That is a whole life. My whole life outside of the hospital.

NEUROSURG ATTENDING
If all you want to do is go home, why be a doctor at all?

MICHELLE
I don't think that wanting regular hours means that you shouldn't be a doctor. I think that having regular hours enables me to be a doctor and something else too.

MICHELLE'S INNER MONOLOGUE
Like a human being.

NEUROSURG ATTENDING
Ignore us, we're just jealous.

NEUROSURG RESIDENT
(Mumbling angrily to self)


It's this strange attitude in medicine, this macho thing, that in order to be the best, most committed, most self-sacrificing, most punk rock doctor, you have to basically sell your soul to the hospital. LOOK AT ME IN AWE AND WONDER, FOR I HAVE NO OTHER LIFE. I just don't really get that attitude. I mean, I'm glad there are people like that out there, I suppose. I mean, when it comes down to it, most of us will do what we need to do to take care of a patient in trouble, regardless of what time of day it is. But on the other hand, doesn't it make you a better doctor to, I don't know, take a break once in a while? Or think of it another way--do you want to be operated on at 8pm, the fourth elective CABG of the day, after your surgeon has been awake for the past 30 hours?

("No" and "Hells, no" are both acceptable answers.)

Thank God I'm not the only one that thinks that medicine and having a life are not incompatible life goals.

If you want to read more of Michelle's wicked and warped sense of humour, check out her blog at The Underwear Drawer. I only recently discovered that she is also the force behind Scutmonkey, who was the originator of the Twelve Types of Med Students that circulated around my med school class way back when. Check her out. Seriously.

Lullabies and Lawsuits: How Sleep Deprived are Medical Residents?

Maybe the question is moot. Of course medical residents are sleep deprived. It's practically in the job description. We know it's not healthy. We know it's not a sustainable lifestyle. But it's the way it's always been done.

Stories of sleep deprivation are legendary among residents, who often share them as though they were badges of honour. One obstetrics resident spoke of falling asleep while driving home on a particularly straight stretch of highway. One of my medical school classmates confessed to driving off the road on the way home from a 36-hour shift. 'Post-call' wasn't just a description our work schedules, but a state of mind and an excuse of all sorts of mental dysfunction. It was part of the rite of passage.

In the States, this has been a much more heated topic of discussion. Since the Libby Zion case in 1984, where the death of a young woman in New York City was found to be at least in part related to extreme fatigue on the part of the residents responsible for her care. The woman's father has attacked the system responsible for the training of residents and has contended that the hospital was grossly negligent in allowing residents to practice medicine in a state of extreme fatigue. Between the Zion case and the subsequent Bell commission, the face of medical training in the US has changed dramatically in the past 20 years.

Medical residents have all worked with old-school physicians who are quick to recall the days of 'internship', where the interns were literally living in the hospital. Marriage was prohibited (at least unofficially) and the interns were paid peanuts-- occasionally out of the pockets of their supervisors. These doctors went on to become old-school doctors who never really left the hospital, and were always accessible to their patients. Admirable to some, but these are the same guys who had three wives by the age of 50 and often a brood of children to whom they were a virtual stranger. In my experience, these doctors (many of whom are now at or well past retirement age yet still hang on to hospital appointments, unable to imagine life without medicine) do not look fondly on the current crop of trainees. We're soft, our training was watered-down, and we have the audacity to feel entitled to a life outside of medicine. As I've said before, most of today's young doctors aren't willing to subject themselves to a life of 14-hour days and being on call 24 hours a day at the exclusion of family, friends and mental and physical health.

Now, residents in the US follow the 80-hour work week, as legislated by law. The rules limit residents to an 80-hour workweek; prohibit any single stretch on duty of more than 24 hours, which must be followed by a full 24 hours off; and require at least 10 hours between shifts and at least one full day off a week. To most other professions, this is still a hellish schedule. To a Canadian resident, this is a cakewalk. In Canada, the rules are less complicated-- 'in-house' call (meaning when you work overnight in the hospital, usually with little to no sleep) is limited to one every four days. So on this 'on-call' day, you start with your team (start time could be anywhere from 6am to 8am, depending on the rotation) and you work through the day and night. On your 'post-call' day you must be excused from your duties by noon. Ideally.

These rules are haphazardly enforced. Particularly in surgical specialties, where the old-boys-club rules, leaving the hospital when you are post-call is often viewed as a sign of weakness. Many of the surgical residents don't feel that they should leave, for fear of missing an interesting case. So they work a usual 12-14 hour day after putting in a full 24-hour shift. Or, in the case of orthopedic surgery (the ultimate 'old-boys-club') they consider their call 'home call' (meaning they sleep at home and come in when needed) even though they end up spending the entire night in the OR more often than not. This allows them to be on call every three days, rather than every four days. In the province of Ontario, the Workplace and Contract Compliance Committee that is run by the resident's union is impotent in cracking down on abuses unless someone comes forward with concrete proof. And no one wants to be 'that guy'.

Ironically, the new laws aren't being implemented in the US without resistance from the very people the law is intended to protect. Residents resent being forced to restrict their work week to 80 hours, saying that their 5-year residency becomes a 3-year residency if they're forced to work 25% fewer hours. They worry that continuity of care is compromised, and that their learning is affected if they are unable to see anything through.

True, in theory. But in my experience, the stuff that residents stay post-call for has nothing to do with continuity of care. They stay to scrub in on that day's OR, or to attend clinic. Once rounds have been done and the day's plans set in motion, attention turns to the new cases. And a resident staying to scrub in isn't the one who will be called when a patient on the floor crashes anyway. That's why we have handover, so the new team will be fully informed regarding the active issues and unstable patients. Sure-- ideally, residents will always be available for 'their' patients. But that's not a realistic scenario. Maybe we should look at improving handover rather than extending resident shifts.

The other argument against the shorter work week is that patient care suffers from having less staff on. I'm not really going to argue with the fact that patients suffer when hospitals are understaffed. What I am going to disagree with is the fact that this is the responsibility of the residents to correct. Having been in the position of being responsible for two floors of very sick (and occasionally unstable) surgical patients, one half floor of pediatric surgical patients, overnight OR's and surgical consults for both adults and pediatrics through the ER during my general surgery rotation just a few months after graduating from medical school, I know all too well the feeling of panic as I put out fires and prayed that everyone would just stay alive until morning when the people who knew what they were doing would be back in the hospital. I still feel that it is totally inappropriate for such a junior resident to be faced with so much responsibility with nothing but 2-3 buddy calls with a senior resident to prepare them. If one of my parents had been a surgical patient in that hospital and had crashed with only a very junior resident to manage their care, you can bet I'd be pushing to change the system. Very loudly, and with a team of lawyers behind me. Sad that tragedy has to occur before the system is re-examined.

As for the staffing shortfall, maybe the Canadian government should look into expanding the roll of nurse practitioners, opening up more residency spots and hiring hospitalists to help shift the load from the shoulders of trainees. It can't be an impossible task-- in Europe, the average work week for residents and physicians hovers around 60 hours per week. In Scandinavia, an unheard-of 40 hours of work per week.

Just because something has 'always been done' a certain way, doesn't mean that changing it won't make it better. I don't think the American system is necessarily the solution. And I don't actually mind the way things are done here. But as recent studies have shown that sleepy residents are more likely to make medical errors than residents who aren't sleep deprived, it's clear that the system is in need of a tune-up.

LMCC-II

Every year at about this time, residents in their second year of training all unite in a common purpose-- to pass the LMCC-II. See, the Licensing Medical Council of Canada has devised a sadistic two-step test that we must pass in order to be licensed to practice medicine independently in Canada. The LMCC-I was written just weeks after graduating from medical school. It is the longest, most exhausting multiple-choice exam since the MCAT. For those of us in 'traditional' medical schools, the exam is just a formality. Very few people fail, and no one really feels the need to study-- after all, isn't that what we've been doing for the past four years? For the non-traditional medical schools that don't do much formal teaching and rely mostly on small group learning, this exam is often stressful and weeks, if not months, of time are dedicated to preparation.

For many of us, the LMCC-II is the first time we've done any formal studying since the LMCC-I. The LMCC-II is very different from the LMCC-I in that the formal is along the lines of an OSCE... they're all simulated patient stations. So in each room is a standardized patient (i.e. an actor) and an examiner. Each station is 10 minutes long, although in some of them the scenario stops after 5 minutes then you have 5 minutes to answer written questions on the station. Sound like fun yet?

I can't complain too much, though. Family medicine and emergency medicine residents definitely have the advantage here. All we do is manage 'the undifferentiated patient'. Our life, essentially, is the LMCC-II. Other specialties, on the other hand, aren't so lucky. Pediatrics residents haven't touched an adult since medical school. Psych residents... well, let's just say that 'the physical exam' isn't really part of their repertoire. Anaesthesia? Ninety percent of the time their patients are asleep. These are the specialties that crammed... some of them using valuable vacation time to prepare for this ridiculous waste of time.

Waste of time, you ask? How could an exam that makes sure that doctors graduate with a minimum level of competency be a waste of time? Well, consider the origins of the exam. In the olden days, as I've mentioned in previous posts, the first year of residency was a common 'rotating internship' year. After this first year, doctors in Canada were granted a general practice license allowing them to moonlight in walk-in clinics and hospitals while they did specialized residency training, a huge help in supplementing their income. Sometime about 20 years ago they abolished this rotating internship-- now, we can't practice independently until we pass the exams specific to our specialty. Either through the Canadian Council of Family Practice (for family medicine) or though the Royal College of Physicians and Surgeons (for other specialties)-- the exams we sit at the very end of residency. So the government of Ontario has managed to take away moonlighting, and whenever our union tries to raise the subject of getting it back we're told that we can't fight for better working conditions for residents if we're going to turn around and try to tell them that residents have enough free time to moonlight. Bastards.

So since the LMCC-II no longer certifies us for a general practice license, and we can't practice until we pass our specialty-specific exams anyway, this late October day amounts to nothing more than a $1400 cash grab.

Damn, I hope I passed.

A Dying Breed

This is what happens when I have too much time to think. In recent days, it's likely due to the amount of time I've spent travelling in planes, trains and automobiles (honest! all three!) to get to various emergency medicine fellowship interviews. Which are done now, thank God.

So I've been more than a little pre-occupied with thoughts of procreation lately. Partly because now that I'm married apparently everyone thinks it's the next logical step. And partly because I'm 32 years old and am starting to picture my ovaries shrivelling up like a pair of raisins from both age and neglect. And I do want kidlets... I just don't feel ready. But if I DO wait until I'm ready, we may be pulling the goalie shortly before I start getting pension cheques from the government. Which is not promising for fertility.

So here's my first observation. Medicine begats medicine. I remember reading a statistic somewhere that nearly a quarter of medical students in Canada today identify at least one parent as a physician. It's hard to say why. Maybe simply from being exposed to medicine as a career earlier than other kids? Maybe from parental pressure? Maybe it's a reflection of socio-economic status? Maybe from some weird genetic mutation that confers on them the desire to pick at scabs? Who knows? But the point is that the children of physicians are more likely to pursue a career in medicine than other children.

Here's my second observation. Residents have trouble making babies. This isn't based on anything other than my own observations of the people around me. I don't know any female resident who has managed to get pregnant easily, stay pregnant to term and have an uncomplicated labour and delivery. Scary, isn't it? Male residents don't seem to suffer from the same curse, getting their wives and girlfriends knocked up at a dizzying rate. But female residents struggle. There are plenty of reasons why the cards are stacked against us. We delay childbearing later than the norm since we tend to spend our peak childbearing years studying. We work crazy hours that stress our body to the point that achieving a regular menstrual cycle is nothing short of a miracle. We work through pregnancy in conditions that expose us to a number of bacteria and viruses. We work though pregnancy in conditions that are often stressful. We eat erratically, often from vending machines. We spend one night out of four sleepless, and often compensate with higher-than-average caffiene intake.

It's scary. As a medical student, three of my female classmates had babies before graduation. There were miscarriages, early rupture of membranes (and I'm talking before 30 weeks gestation), preterm labour, multiples (although this one was through word-of-mouth since the mom in question left med school during pregnancy and didn't come back before the class graduated)... nothing simple or straightforward. Most recently, the resident that I did surgery with last year gave birth at 33 weeks. Her baby is still in the nursery, plagued with many of the problems common in premature infants. So it seems that women who get pregnant during residency not only have problems getting pregnant, but don't have much luck carrying their babies to term without problems or complications.

Add observation #1 and observation #2 together, and I'm forseeing a major physician shortage in the next 30 years or so. It's pure Darwin. Or IMpure Darwin, at least.

It's trains of thought like this one that are the reason why I need to be kept busy at all times.

My First Day of Pediatrics.

I learn a lot at my job. Here are the gems that came out of my first day of peds.

1. Don't ever, ever assume that just because you are a doctor, you are allowed to touch your patients. First, make sure to ask permission from the nurse, the peds staff, the senior resident, the child's parents, the baby herself, the cafeteria lady and the housekeeping staff.

2. If your patient is a newborn, you are not allowed to touch it while it is sleeping or after it has eaten. So if you need to do a physical exam, that leaves about 8 minutes in the early morning and another 4 minutes sometime in the afternoon. Nurses will enforce this rule with the ferocity of a rabid pit bull.

3. If there is a parent in the room, it is best to assume that they believe that you are there to do their child irreperable harm. Regardless of whether or not you actually intend to touch the child. In fact, the fastest way to befriend your patient's parents is to agree that everyone working at the children's hospital is horribly incompetent. Yourself included.

4. Many people in pediatrics have devoted their lives to children because they aren't that great at relating to adults.*

5. Every crib on the pediatrics floor will work slightly differently. Which means that you will look like an idiot trying to release the side of the damned thing for 10 minutes while the parents of your patient stand by, amused. It's hard to garner any respect after that.

6. Children are very different from adults. Don't ever think that anything you've learned in your previous 14 months of residency will prepare you for dealing with children.

7. Pediatricians and pediatric residents spend an inordinate amount of time discussing how no other physician in the medical universe knows the first thing about treating children.

8. Parents will describe every episode of vomiting as 'projectile' if it is coming out of their child. Even if it just dribbles down the front of their sleeper.

9. At some point in parenting school, parents learn that if they smoke outside their cigarette smoke cannot possibly have any effect on their child's asthma. This is a belief that they will defend and argue to the death.

10. Trying to get back into a regular schedule after two months of shift work requires copious quantities of caffiene.



* Vitamin K is, of course, the glaring exception to this rule. Cause she's just wonderful to everyone. Even when she's sleep deprived.

PGY-2

For the past week I've been brewing a long, meaningful post about my transition from first year residency to second. A lot has happened in a year-- I've changed programs. I've shifted priorities. I've learned stuff.

But really? It doesn't feel any different. Maybe if I were in one of those programs where I go from being the 'intern' to the 'resident' (and thus become the in-house representative for my specialty during my nights on call) like obs/gyn, internal medicine or orthopaedic surgery, but I'm not. And other than trying to get used to ending my signature with "R2" rather than "R1" (the latter being so ingrained in my subconscious that I have often caught myself signing cheques with a flourishing "R1" after my name) I don't feel that anything has changed.

Welcome to Medical Postgraduate Year II. Please keep your hands and feet inside the vehicle at all times and enjoy the ride.

Stick a Fork in Me...

It's funny. I used to think that the worst month to get get sick would be July. All of the new residents start on July 1st. But now, nearing the end of my first year of residency (or the end of my internship, for all you Americans out there) I no longer think that July is the scariest month to be in hospital... it's June.

In July, we KNOW we're new. We're scared. We feel like we've suddenly been given a massive amount of responsibility that we may or may not deserve. And for the love of God-- we don't want to screw it up. So we're meticulous. And careful. And probably more than a little paranoid. So the first few times the nurse calls for an order in the middle of the night, we'll drag our asses out to the floor to review the patient's chart first. And we'll double-check the dosage. And triple-check the med list and the allergies. And THEN we'll write the order. If a nurse calls and wakes me up because a patient is hypotensive, I'm on my way to assess them before she's hung up the phone. And it's not just the R1's that are like this-- as the R1's in internal medicine take up the lofty title of Senior Medical Resident, literally overnight they are ultimately responsible for the CCU, two wards of inpatient medicine, all consults from emerg, all consults from other services and every code called in the hospital. It's a lot. And rightfully, they're petrified as July 1st draws nearer.

But what a difference a year makes.

Want an order? Are they allergic? Any obvious contraindications? No? Sure, give them Ativan 0.5 mg po qhs prn. I barely even have to wake up anymore. Your patient is hypotensive-- are they stable? Any congestive heart failure? Give them a bolus of fluid and take the pressure again once it's run in. If it's still low, call me back. If a patient is stable I probably won't get out of bed for a systolic less than 85. Apathy? Maybe a little. But I can now do the bread and butter of my job with my eyes closed-- and sometimes, at 4:30am, I do.

Medical Urban Legends

As medical students, we whispered about it. Residency. We had read the books: The House of God, which chronicled one young intern's loss of everything that made him human as residency beat him down. The Intern Blues and Rotations, two books that followed peds residents through their first year of internship. We knew that they had no life outside of the hospital and that on the odd time they TRIED to socialize they would commit some horrible social blunder like falling asleep at a family wedding. We knew that would soon be us. We knew that clerkship was no measure of what residency would be like. As clerks, we got called to do consults in emerg... but when issues arose on the floor, the nurses would page the people whose signature meant something... the residents. So we would often get to sleep, at least for a few hours. We knew it would get worse.

But even though we had begun mentally preparing ourselves for the stresses of residency, there were still the whispered rumours that circulated among the medical students. One surgery program in the province was allegedly known for its 100% divorce rate among it's residents. Another was notorious for putting their residents on 1 in 2 call... and submitting dummy call schedules to the union so as not to get reprimanded. We knew the stories. They were repeated time and time again as a warning not to enjoy life too much-- if would soon get pulled out from under us.

There was one story, though, that made even the most naive medical student raise an incredulous eyebrow.

"Didja hear? An ortho resident at Big Name University Hospital had a STEMI."

"Yeah?"

"He was 31."

"No."

"Dude. Swear to God. I heard it from my senior, whose staff works with the nurse who knows the guy's clerk. He almost died. Stress. Lifestyle. It's crazy."

"Heh. Does ortho let you leave at noon post-call if you have a STEMI?"

"Doubtful."

Ortho is the ironman of residency programs. Only for the hardest of the hard-core. Big men (for the most part) wielding saws, hammers and drills in the OR. Long hours, long patient lists... short marriages, and apparently, according to recent lore, short lives. An ortho resident (as is the case with most residents) simply cannot maintain a healthy lifestyle. The work week lasts 120 hours. Call is 1 in 3, and is usually without sleep. Rounds start at 6am so that they're done in time for the OR at 8am. The OR ends at 6pm, when it's back to the ward to deal with the scut. Then, if you're one of the few lucky enough to be going home that day, you're out by 8pm. Usually. Exercise? Please. Eating right? Eating at all is an impressive feat, and it's usually cafeteria fare shoved unceremoniously down the orthopod's throat while the OR is being turned over between patients. Downtime? Stress relief? You've got to be kidding me.

I was a disbeliever. I thought that residency was only as bad as you make it. I brushed aside tales such as that of the 31-year-old orthopod with the STEMI as urban legend, passed on to strike fear in the hearts of medical students everywhere.

Fast forward to the present day.

I'm sitting at the nursing station on the internal medicine floor writing in a chart. Sitting next to me is a fellow junior resident, whom I'll call Steve in a half-hearted attempt at anonymity. Steve was post-call, and was dressed in the shapeless green pyjamas that residents have been trying to pass of as real clothes since the dawn of medicine. This is significant because scrubs have short sleeves. Usually, on internal medicine, guys wear dress shirts. Long sleeves. While chatting with Steve, I happen to glance down at his exposed forearm. A prominant scar marked his inner arm, extending from his elbow to his wrist. Steve caught me staring.

"Impressive, eh?"

"Bar fight?" I asked, jokingly.

"CABG."

"Pardon you?"

"Yeah. I had a STEMI in my second year of residency." He said it nonchalantly, as though he told the story on a daily basis.

"Oh! I thought you were first year internal." Obviously, I was at a loss as to the appropriate response when someone catches you staring at their deeply scarred forearm. Because what year his was in was OBVIOUSLY the important thing, here. Sigh.

"I am. But I used to be ortho. I had the STEMI in my second year, when I was 31. I had to take a leave of absence, and I transferred to internal medicine. I probably wouldn't have survived ortho if I'd gone back to it."

"Um, wow."

Less-than-brilliant response aside, I am now a believer.


P.S. A STEMI, by the way, is an ST-elevation myocardial infarction. For the purposes of this story just think of it as a VERY bad heart attack. CABG is a coronary artery bypass graft (pronounced "cabbage").

The Best Intentions...

I had them. Really. And I have a whole bunch of topics that I've wanted to write about here over the past two weeks. But there was Easter, a trip to visit old friends, a trip to visit family, and this...

The latest addition to our family. Needless to say, now that furkid #1 is pretty self-sufficient (at a whopping 18 months old), furkid #2 was a quick reminder of how damn much work puppies can be.

So that's where I've been.

In addition to this, I'm still planning a wedding. Most recent things accomplished were ordering of bridesmaids dresses, purchasing of wedding rings and confirmation of floristy stuff.

I've also been trying to clean up my last 5 years of taxes, which were all inexplicably re-assessed in the past few months. This involved many meetings with accountants.

I am also trying to nail down the details of my schedule for next year. Life as a PGY-2. Sweet.

I am also trying to tie up the ends of my ill-fated involvement with my provincial union. It taught me a lot about administration and politics, but I can't WAIT to not be involved in this stuff anymore.

I have started running again, as I have come to accept the fact that as long as I am working one hour away from where I am living, I am lucky to make it to the gym twice a week. And that just isn't enough. Then I got plantar faciitis. So I stopped running. Then I felt better. So I started running. Then I got that stabbing pain in my heel for two days again. So I stopped. Well, you see where this is going.

And in the midst of all this, I am still a medical resident.

No wonder I'm so tired.

More from me soon. I promise.

Back in the Saddle Again

So I've been spending some time (quite a bit of time) back where I belong. Or at least, where I thought I belonged. Not in an academic centre, but in a community emergency room-- the same community where I have been practicing family medicine for three months. A surprisingly busy community emergency room.

My first shift was less than stellar, however. My preceptor had nicely written the emerg docs a letter of introduction. I would like to introduce my resident, blah, blah, very competent, blah, blah, good technical skills, suturing in particular, blah, blah, please be nice to her. And the morning that I was to start in the emerg, he was even nice enough to go over and remind the doctor on dury that I was coming by to work that day. Apparently, the emerg doc wasn't really listening.

When I got there he nodded curtly and gestured for me to follow him into the patient's room. So I did. And listened patiently while he assessed her. When we emerged, he started the inevitable pimping.

"How do you diagnose the patient?"

I HATE the 'guess what I'm thinking' game. What is he asking me? Does he want me to explain what I'm looking for? What tests I should order? What my differential diagnosis is? What I had for breakfast this morning?

"What do you mean?" I ask.

"Through the HISTORY and PHYSICAL, of course!!!"

Um, sure. I thought he was referring to some revolutionary test he had recently invented to decipher 'weak and dizzy old lady' into a concrete diagnosis and treatment plan. Apparently not. So then he proceded to sit me down and write out exactly what the components of a good history and physical were. I had been pretty quiet until now, but I decided to speak up.

"Sir? I *have* done this before." I said jokingly.

Apparently, the wrong thing to say. He looked up at me, clearly offended.

"I am TRYING to teach you something here. This is the sort of thing that will be on your EXAMS."

Alrighty then. So I sat, quietly and patiently, while he explained how to take a history and physical. Then, how to palpate an abdomen. Then he decided to teach me an approach to reading ECG's. He told me how to assess a headache. He asked me what the ABC's of trauma were. He also continued to pimp me, asking me random questions about appendicits, long Q-T syndrome and the administration of TPA in stroke. So I answered his questions. For six hours, I followed the attending around like a big dumb sheep.

Finally, just before shift change, he was assessing a woman with abdominal pain and asked me what was the first thing I needed to know. Easy one.

"I'd want to know whether or not she was pregnant."

"Right," he replied, "and why is that?"

"Because I'd need to rule out an ectopic."

He stopped. And eyed me suspiciously.

"Have you done much emerg yet?"

Confused by his question, I started to babble. "Well, not since I was a clerk. See, I started off in the FRCP program, but then I switched to family medicine, but I never actually DID any emerg shifts as a resident, but I..."

He cut me off. "You're a first year RESIDENT?" he asked, incredulously. "I thought you were a first year MEDICAL STUDENT."

Um, thanks. You don't think it's odd that I know about long Q-T syndrome as a first year medical student, but knowing about freaking ectopic pregnancy tips you off? Not to mention the nametag I'm wearing that clearly identifies me as DR. Couz, Medical Resident? Or the fact that my preceptor introduced me to you TWICE??? Apparently, I am clearly the world's brightest and most knowledgeable first year medical student.

Somehow, this misunderstanding was my fault.

"If I had KNOWN you were a resident... well, you should have been writing ORDERS! You should be formulating TREATMENT PLANS!"

No kidding. Sigh.

Thankfully, I don't think I'm working with this bonehead again.

I AM a Specialist, for God's Sake!

In the old days, after medical school everyone did what was called a 'rotating internship'. After a year of rotating through various specialties, doctors were awarded a general license. They could either practice as a General Practitioner, or they could return to residency to specialize. Since everyone had a GP license after one year of residency, they could also moonlight for extra money through the rest of their residency.

Things are different today. They did away with the rotating internship years ago, and along with it went the concept of the General Practitioner. All areas of medicine required a unique residency-- two for family medicine, four for internal medicine and pediatrics, and five for most other areas of medicine.

Having recently switched from a five year program to a two year program, I've been on the receiving end of a special brand of elitism. Many doctors have the mistaken impression that family medicine is something that anyone can do. Many feel that they are somehow better clinicians than family doctors because they have specialized training. I didn't think I felt like this before I changed programs, but it still surprised me how much about family medicine I didn't know when I started. Most specialites know a lot about a narrow range of topics... family doctors are expected to know a little bit about everything. Sure, if you're working in a mid-to-large sized centre you can refer anything that you're not comfortable that you can manage effectively, but in many cases you're expected to know as much about prostate cancer as you do about chronic sinusitis.

So it's no surprise that I find it irritating when people declare themselves specialists as though it's something more impressive than family medicine. Family docs are more likely to really be making a difference in people's lives than the surgeon who took out your gallbladder, the dermatologist that fixed your rash or the radiologist who read your CT scan but has never actually seen your face. Not to bash any of these specialties, I just don't understand why family docs are seen as the generic version of the physician. Of course, the ability of your family doctor to actually make a difference in your life depends entirely on whether or not you've lucked into a good one. And at a time when over 4 million Canadians don't have ANY family doctor, even having a bad one is sometimes the lesser of two evils.

I do honestly believe that family doctors are underappreciated and underpaid. But that's another post.

Paging Dr. Hypocrite...

As a family doctor (or in my case, a reasonable facimile) a big part of my job is preventive medicine. The idea behind this is that by taking care of the 'big picture' of our patient's health, we'll prevent larger problems down the road. The fee schedule that my preceptor works under actually encourages this... in place of a fee-for-service model that encourages assembly-line medicine and rewards procedures over counselling, under this new model a family physician is paid a monthly fee for every patient enrolled under his care. Regardless of how many times or for what reason each patient actually comes into the office. This isn't quite as wacky as it sounds. The monthly fee for an elderly woman, for instance, is substantially higher than a young adult. Young adult males, who traditionally are the lowest users of the medical system, are worth the lowest monthly fee... unless they have a serious mental illness, which makes the fee higher. Get the idea?

So anyway, this alternative funding system lets us spend time doing things like helping patients stop smoking, improve their diet, cope with their stress and other things often deemed 'touchy-feely' but that pay off in the long run. The problem is, the medical system makes it pretty damn hard to practice what you preach.

Before medical school, had a pretty healthy lifestyle. I ate well, I managed stress in a constructive manner, and I was pretty active. I hit the gym 4-5 times a week, and picked up a new sport every year-- most recently I had learned to row, play touch football and golf. And I maintained a weight, which although I was always unhappy with, translated to a healthy BMI. All in all, I was doing okay. Then came clerkship.

The hours got longer and the gym visits got fewer and further between. Healthy meals gave way to take-out on more evenings than I care to admit. Sleep became a valuable commodity, and I wasn't getting nearly enough of it. And the stress grew. Some people coped... some didn't cope so well. I did okay, mostly thanks to a kick-ass support system in the form of two close friends and an amazing significant other. But many of my healthy habits went right out the window.

So here I am, 25 lbs heavier than I was before I started medical school. Before this week, I haven't seen the inside of my gym more than once in the past month. I'm relying less on take-out thanks to the joint efforts of myself, my fiance and our slow-cooker, but diet alone isn't enough to undo the damage. And that makes me a hypocrite. What are people thinking as this overweight, overtired doctor advises them on improving their diet and finding time to exercise? How can they take me seriously when I can't take me seriously?

Quick Update

Remember my run-in with the surgery chief resident? The one when he put me on call on my vacation and threatened me when I protested?

(If you don't, here's a refresher... http://drcouz.blogspot.com/2005/12/perfect-example-of-why-im-getting-hell.html )

Well, this morning I met with the program director for general surgery. I had a member of the union's contract compliance team as my escort. I told him what had happened with the resident. He said that he had heard about it from the resident, but had been informed simply that 'the matter had been resolved'. He apologized for what had happened on behalf of the chief. As expected, the director stuck up for the chief, saying that "this behaviour is very our of character for him" and that he's usually "a really nice guy". Um, sure dude... wanna check with the nurses on that one? They refer to him as The Pompous Ass.

Anyway, as I told the director, although I don't stand to gain anything by complaining now, I just want to ensure that this won't happen again to the next off-service scut-monkey. The union guy made it clear before we left that they had intended to take this to formal grievance, but that I was happy just making my concerns known. So I looked good.

Not entirely satisfying (I doubt the chief will get so much as a slap on the wrist) but at least I did the right thing.

Just in case anyone was curious how that all worked out.

An Interesting Conversation

Well, interesting in my opinion, anyway. As I've mentioned before, I am a union representative. This basically means I attend a meeting every 6 weeks or so. Running for the position was a last-ditch attempt to drum up some enthusiasm for the aspect of academic emergency medicine that interested me the least... administration. It was an attempt that failed miserably. So now, every six weeks, I attend meetings that are largely spent listening to the same few people talk (the ones who are obviously loving the sound of their own voices, mostly) while the rest of us try to pay attention. This month's meeting was actually pretty interesting. Partly because it was the 'road trip' meeting and wasn't in Toronto like all the others, and partly because the bulk of it was spent debating what stance we should take as a union on the privatization of the health care system in Canada. But more on that later.

After each meeting we go for dinner. I was sitting with a second-year peds resident and a second-year obs/gyn resident, the latter I knew fairly well. We were talking about which obstetrician at our academic centre we would want to deliver our own children. There was some gossip, some banter, and then I mentioned that if I was a low risk pregnancy, I'd likely opt to be delivered by a midwife.

Well, you'd think I had announced my intention to give birth in a hot tub in the middle of the next union meeting. Both the budding obs/gyn and the budding pediatrician looked horrified. Immediately, they felt the need to share stories where an 'obvious' complication arose and the midwife failed to call for help. I explained my reasoning-- I honestly feel that midwives give more complete care than obstetricans do, particularly in the post-natal period. In an academic centre, the obstetrician walks in to supervise the resident for the last few minutes of the delivery unless something goes wrong. The labour & delivery nurse is the one guiding you through the process, and it's not like you get to pick your nurse. If you get a good one, it's a great experience. If not, tough titties. By delivering with a midwife in the hospital, you have the best of both worlds. You have the low-intervention, attentive, one-on-one, continuous care of a midwife but if something goes wrong and help is needed, the obstetrician is just steps away.


The two other participants in this conversation were horrified at how irresponsible I was being with my future baby's care. The obstetrics resident didn't understand how I could trust my midwife to know when something was wrong. Um, dude? That's what they're trained to do. And moreover, I told him that it was awfully pompous of him to assume that a midwife with 15 years of experience delivering babies would be less qualified to detect a potential problem than him, with a year and a half of obstetrics under his belt. In fact, as a second year resident, his total time in obstetrics was likely less than six months, all told. But somehow, he figured that he had been magically granted the ability to detect impending problems in labour and delivery and fix them in such a timely manner that he could single-handedly assure a good outcome.

Maybe I'm exaggerating slightly, but all but that last sentence was completely true. What is it about medicine that often refuses to acknowledge the contributions of other members of the health care team. Why would this guy be so threatened by the idea of a midwife offering comperable care in low-risk pregnancies? It's not like there will ever be a shortage of patients requiring obstetric care. It's not like midwives will ever be allowed to perform c-sections. It's not like this guy even intends to spend his life delivering babies... he intends to focus on gynecology as a career. But yet, the idea of a midwife being able to detect late decels in a rhythm strip as well as he could put him immediately on the defensive.

Why can't we all just get along?

The Year in Review...

Good-bye, 2005. It's been interesting. Here's a look back at the highs and lows of the past 12 months.

January

The year started off with winter fun up north with my soon-to-be in-laws. From there, the CaRMS tour. I hit Sudbury, Montreal, Ottawa, Kingston, Hamilton, Toronto, Winnipeg, Edmonton and Vancouver in the space of 10 days. Craziness. It was a blast. I was snowed in three times (January is NOT the best month for air travel in Canada), spent an unscheduled second night in Winnipeg and narrowly missed having to sleep a night at the Edmonton airport. I was hosted in the 'Peg by a fantastic friend whom I was meeting face-to-face for the first time, and had a blast chatting over wine well into the evening. I met lots of great people, and realized that part of what drew me to emergency medicine to begin with is the amazing people. I also realized that Vancouver is an absolutely beautiful city, and I'm eager to return there soon to spend some time exploring.

Honestly. How could you NOT love this city? If it weren't for the exorbitant cost-of-living, I'd be there in a shot.

February

I had the first two weeks of this month off, and then dove into 4 weeks of Hematology clinics. Hardly taxing. I used the time to discover my inner Martha Stewart. My significant other got to come home to lovely meals and enjoy a clean apartment every day. A definite departure from my usual.

March

March 1st was Match Day. I'm not going to re-hash.

http://drcouz.blogspot.com/2005/09/match-day-results.html

That and three weeks of gastroenterology rounded out my month. Good times.

April

I got engaged. Hee hee. I'm sure other stuff happened that month, but it's kind of overshadowed by the engagement. I still think the boy is crazy to want to put up with me and my crazy job for the rest of his life but hey... HE asked ME. In fact, my response to his sweet, heartfelt proposal was to throw my arms around him and tell him he was crazy. I did, of course, eventually accept.

May

I finished medical school. Granted I finished with a hideous rotation on general internal medicine where I got a shitty review (I was told that my knowledge base was lacking and I wasn't 'engaged' with my patients) but I was redeemed by getting honours on my internal medicine exams. Screw you, Dr. W.

Then, I wrote the LMCC's-- a glorified day-long multiple choice exam that you need to practice medicine in Canada. Really, just an excuse to squeeze another $1200 out of the already-impovrished medical student. Thanks. I passed. Very anticlimactic.

Then I graduated. Eleven years of university education come to a close. I can feel the student loan collectors breathing down my neck already.

June

I don't even remember what I did for most of this month. Met equally bored friends for coffee, went for long walks with my dog in the bush, went to the gym, met other friends for patio drinks and generally enjoyed the last of my freedom.

Went north. Got bit by a mosquito. Got lymphadenopathy, flu-like symptoms and neck stiffness, followed by weakness of my right arm. Became convinced I had West Nile Virus. Serology proved me wrong. Apparently leaving medical school doesn't cure the med student hypochondria.

Moved to a new town on the first day of a brutal heat wave. Thank God for large, muscular male brothers-in-law. I didn't lift anything heavier than a houseplant. Which was DOA thanks to making the trip in the 40 degree heat. Next time, I'm going to try to move in January.

July

I was lucky to draw a pretty easy start to residency. I started off with a one month rotation in emergency psychiatry. It was slow, but kind of fun. Now, in retrospect, I really wish I had started blogging back then. So many stories...

August-December

At this point, the months just started blending into each other. I worked a lot, this month on obsetrics and gynecology. I started blogging. I started to think about changing programs. Anyone who has read my blog knows what happened for most of the rest of the year. I did two months of obs-gyn... loved it. I did a month of anaesthesia... hated it. Did two months of surgery... well, you know the story. Tried to keep my sanity and my non-medical life while surviving residency. Sometimes I managed to do this, sometimes I failed. Life is a learning process.

The intern year... six months down, six to go.

Please Allow Me to Apologize on Behalf of the Entire Medical System...

It started as soon as I was accepted into medical school. People would feel inexplicably compelled, upon learning of my career path, to tell me their medical horror stories. It was never in relation to a bona fide medical error, but usually in reference to some asshat physician who was insensitive. I've heard stories about how someone's aunt was told that she had cancer by a physician over the phone while he was chewing loudly in her ear. I've heard about family doctors who have erroneously diagnosed people flippantly with everything from 'probably herpes' to 'possibly leukemia' until tests showed that they were fine.

In these cases I often expressed the appropriate amount of horror and sympathy, thinking that was likely the best I could do under the circumstances. Inside, of course, I was wondering if the doctor would have told a much different version of the story. But defense of the doctor was obviously not what these people were looking for. I'm not sure exactly what they WERE looking for (anyone feel free to enlighten me?) but they seemed satisfied with my response at the time.

Now it's a whole new ball game. Now I'm considered part of the giant enemy. I'm one of them. Now, apparently, my sympathies and apologies aren't going to cut it. Now I get all kinds of complaints-- my room is too cold, my nurse doesn't come fast enough, I want to see a real doctor... it never ends. In fact, I am often paged at odd hours because a patient, facing discharge, does not feel that he or she has had a chance to adequately air their grievances. So the nurse does what I'd certainly do in his or her situation... passes the buck. Page the intern.

I'm the first to admit that our medical system is far from perfect. That being said, it worries me when people talk as though our only alternative is a system modeled after our neighbours to the south. In my opinion, our system is the lesser of two evils (in spite of the fact that a nice cushy job in a private hospital is looking like heaven to me right now). But plenty of other countries have managed to do a better job at providing health care than any of the ones on our continent. In France, where I did a month-long elective in general surgery after my second year of medical school, the country has managed to make a two-tiered system both sustainable and satisfying to the people who use it. But I digress...

I find it ironic that the people who expect me to act instantly to fix what's bothering them are the same people who, just minutes after introducing myself as doctor Couz, ask when they're going to be seen by the doctor. So I'm medically impotent, but when it comes to making your nurse respond to your call bell immediately or the fact that your dinner was cold I'm expected to produce immediate results.

Just call me Couz: Medical Ombudsman.

A Perfect Example of Why I'm Getting the Hell Out Of Academic Centres

Warning: Gratuitous vent ahead.

When the December call schedule came out at the end of November, I was surprised to see myself put on call on December 28th. According to our union contract, every resident is entitled to 5 consecutive days of vacation, either over Christmas or over New Year's. Now, since I'm related to many people with crazy schedules I opted to apply for New Year's over Christmas... I figured I'd be more likely to get what I wanted and could arrange two different celebrations. One with my family the week before Christmas (this week) by taking a week of vacation, and one with my in-laws the week after Christmas (the New Year's block). Everyone would be happy.

So when I applied for my New Year's block and didn't get any response (all vacation requests need to be denied within two weeks, or they're considered approved), I made my holiday plans for that period... my five days were December 29th, 30th and 31st and January 1st and 2nd. Then the December schedule came out and I was on call the 28th. That means that I'm actually working until at least 10am on my first day of "vacation". Totally not allowed by union contract. So I'm only getting four days of vacation instead of the five I'm supposed to get.

I e-mailed the chief resident as soon as the schedule came out, thinking it was just a mistake. I was told that 'someone has to take that day', and told that I wasn't going to get an additional day elsewhere to make up for it. Basically, I was brushed off. I mentioned it to our program secretary who sent an e-mail stating in no uncertain terms that they had no right to take a day off my holiday, and to please change it. No response. I mentioned it at a recent union meeting, and another e-mail was sent. No response. Finally, the contract compliance guy got the big guns (i.e. union lawyer) to draft a letter threatening grievance if the contract was not honoured.

Finally, a response. I was pulled aside yesterday by the chief resident who expressed his anger at being contacted by the union lawyer in no uncertain terms. He said that I took him by surprise... apparently no one has EVER complained about having their vacation shortened after being previously approved before. Right. I'm sure.

He said that if I was 'determined' to follow our union contract 'to the letter', he'd start following other rules to the letter as well. He threatened, for starters, to make me work every day over holidays as though it were a normal day (due to OR shutdowns and cancelled clinics over holidays we usually just treat each day as a weekend day and the person on call covers both that day and night). I asked if he'd be expecting this of everybody, and he responded that this would be enforced on 'a case-by-case basis'. Meaning, obviously, that I'd be doing this alone. He then pointed out that I only have 5 call in December and therefore have no right to complain. I pointed out that 5 is the maximum number of call that anyone on the schedule is doing in December, and that I have the same number of call as everyone else in spite of having a week of vacation. His response was that he could legally (according to the contract) have given me more, particularly on the weekends flanking my week of vacation. Hint, hint, eh? Sigh.

So I'm being forced to suck it up. It's apparently not enough that I work my ass off for enough hours every week to be equivalent to two and a half NORMAL jobs, but now the minute I try to stick up for the time off that I'm entitled to by my contract, I get threatened by my senior. I can't freaking believe this shit.

An Hour in the Life of a Pager

I read an interesting fact the other day-- as many as 25% of all beeper pages were unimportant or unnecessary and actually interrupted patient care (citation below, if you care that much). That makes one heck of a lot of wasted time answering pages and trying to find a free phone.

What immediately came to mind was an incidence of pager-abuse not too long ago, when I was paged *1 (meaning STAT, or emergency) out of a patient assessment to the emergency room. As I had three patients in emergency at that time that were admitted and waiting for beds to become available upstairs, I rushed out of my assessment and ran to the nearest phone. The emergency? I had forgotten to sign a radiology requisition, and the patient was on their way to x-ray. Nice.

So I decided to conduct an experiment. Today I actually wrote down what I was being paged for every time my electronic leash went off. This lasted for little more than an hour before I couldn't keep up with it, but it was interesting while it lasted. Now keep in mind that during this hour I am trying to see three surgery consults in the emergency room with the help of two clinical clerks.

10:02am: The floor pages me to tell me that Mrs. W's urine output was low. I ordered a bolus of fluid over the phone.

10:04am: The emerg (two feet from where I was currently sitting) pages me to let me know my patient is waiting for me in emerg. Um, thanks. I know.

10:04am: Senior resident pages me to remind me that Mr. D's CT scan needs to be set up before lunch. Thanks, I know. I've done it already.

10:09am: Radiology pages me with results of an ultrasound on one of my patients.

10:12am: The floor pages me to tell me that Mr. P's PICC line fell out. I inform her that it didn't fall out, we ordered it removed last night because it was infected. She is satisfied with that.

10:12am: One of the clerks pages me from the other end of the emergency room to tell me he's finished assessing his patient.

10:12am: Who knows who this was? I tried to call it back three times and the line was busy. Don't page me and then get on the freaking phone!

10:19am: The floor pages me to ask if I'm sure that I want Mr. H's heparin stopped. Yes, I do. That's why I wrote the order "discontinue heparin".

10:21am: The floor pages me to tell me that Mr. Y has spiked a fever of 40.2. The nurse has given him Tylenol, but she just wanted to make me aware. Um, thanks.

10:34am: The floor pages me to tell me that Mr. L's nurse thinks that his abdomen is becoming more distended. I tell her I'll be up to look at it when I get a chance.

10:34am: Senior resident calls me from the OR to let me know that we'll be running the list with the staff (i.e. discussing the patients) after their next case. I agree to meet them. I wonder how the heck I'm going to get these consults done before then when my pager keeps going off.

10:40am: Hematology resident pages me to tell me about another consult on one of their patients. This day is not looking any better.

10:52am: Nurse from the floor pages me to ask me if Mrs. M's additional bloodwork can be done tomorrow morning when the tech comes back because she's a difficult stick. The bloodwork isn't urgent, so I tell her it's fine.

10:54am: Nurse from the floor pages me to tell me that Mrs. W's bloodwork showed that her INR (measure of how easily blood will clot) is too high. I change her dose of coumadin (drug that makes blood less clotty) for that evening.

10:57am: Another page from the ER (this time, 10 feet from where I am sitting) to ask if we're going to be sending one of our consults home. If I had time to deal with the consult between pages I'd be happy to answer the question.

That made 15 pages in the space of one hour. A page every four minutes, on average. Of these, maybe 6 were useful or necessary. This hour might not have been representative (I don't usually get THAT many useless pages in such a short period of time) but I'm now starting to understand why I can get through a 12-hour day without having time to eat or sit down and yet still feel like I've accomplished nothing.

There is good news, though. As of today at 6pm when I finally left the hospital, I am on vacation. For a whole week. Thank God.



Blum NJ, Lieu TA: The effects of paging on pediatric resident activities. American Journal of Diseases of Children 1992; 146(7):806-808.