Thursday, June 14, 2007

the hypocritical oath

So I probably overreacted with the petichiae thing, but dude, PETICHIAE. It was right to bring him in to the doctor's office (my first walk-in visit ever), and it was right to have the scary things on the differential, though perhaps not constructive to freak out that we were on the road to Waterhouse-Friderichsen syndrome or some such thing.

What this whole episode has emphasized to me, actually, completely unrelated to petichiae, is how hypocritical we in the academic medical community can be. Well, maybe I shouldn't generalize. It has made me realize how hypocritical I am about being a member of academic medicine. Look, I'm a resident. I may be a doctor, but I'm still in training, and still on the steep part of the learning curve. When it comes down to it, I am learning on my patients. I am practicing my skills on my patients. I don't have the experience of my senior attendings, and undoubtedly I make more mistakes than these attendings. But this is how the system works. This is how the system perpetuates. My patients come to [University Hospital] for the higher level of care that an academic hospital provides, but implicit in that is an agreement that they will be participating in the education of medical students, residents, and fellows. We need our patients to buy into this system, and for the most part, it works out well.

But then when it comes time for my family to come into the hospital, or if my child gets sick, I don't want to buy into the system of which I myself am a part. I want to skip to the top. I want the attending. And not even just any attending, I want the senior attending. I want the one with the grey hair and the 30 years of experience who trained in the days of the giants and who has seen everything at least 600 times before. I will let med students in the room and I will chat with the intern and I will let the residents do whatever scut needs to be done, but when that needle's coming at my back, or when (god forbid) it's my child going under the mask, I want the very best, most experienced person to be involved.

I realize that this probably makes me not only a total hypocrite, but an asshole as well.

I know I'm not the only one that feel this way, though. Every day on the anesthesia schedule, there are cases labeled "ATTENDING REQUEST," wherein the skills of specific anesthesia attendings are solicited for particular patients. Sometimes it is the surgeon doing the requesting, but much of the time, the patient making the request is actually an employee of the hospital--a nurse, an doctor from another department, someone from the billing office--or a relative of a hospital employee. People who work in the hospital get to know who they want taking care of them. I myself already have a list in mind for who I will go to if anyone in my family needs cardiac surgery or what have you, and who would be doing the anesthesia for those cases.

I've had patients, giddily floating out of the ether cloud, tell me that the next time they're in for surgery, they want me and no other to do their anesthesia. That's very nice of them to say, but I can tell you, there are very few, if any, "resident requests" on the schedule.

So the question is, is it fair for those of us on the inside to be able to pick and choose who we want to manage our care, while we expect our patients to put up with what's doled out to them because they're at a teaching hospital? Is it moral to use our pull and access to the system to get what we feel is the best possible care for those that we love, and yet expect everyone else to play by the rules?

Last week, I was with a medical student on a day of doing straightforward cases on basically healthy patients under general anesthesia. That day, I wanted to give the medical student a chance to put in an IV. It was the end of third year, she said she had put in an IV successfully just the day before, I selected a nice young, skinny patient for her to try on, and I gave her a 20 gauge, which (for you non-medical types) is a small needle. Basically, I wanted to maximize the med student's chances of success, because then it's a feel-good experience for everyone. The med student had introduced herself to the patient out in the pre-op area, and then we all walked back to the OR, where I got the patient up on the table and set up all her monitoring. I set up all the IV stuff, put the tourniquet on the patient's arm, swabbed with alcohol, silently indicated a couple of good veins to aim for, and then discreetly stepped aside to let the med student start the IV. I didn't make a big deal of it. I didn't say to the patient, "Now I'm going to let our med student start an IV." I just stepped aside and let her try.

What happened was this: the med student hit the vein, got a flash, but probably her approach was a little too steep and the needle went through and through, leaving her unable to advance the catheter. I must have done this many, many times myself when I was learning to start IVs, but after you screw up a couple of times you modify your technique and you eventually get it right. I tried to help her adjust position, but the vein was already blown, and it became clear that we would have to try again.

"What are you doing?" the patient started asking. "Why is she doing the IV? What is she, an intern?" She looked at me. "I want you to do it! You put it in!" I didn't say anything about the "intern" remark (figuring that it would only make things worse to remind the patient that the "intern" in question was in fact two years junior to an actual intern) but just quickly stepped up, slipped in an 18 gauge, and said in a cheerful voice, "Absolutely. Done. Now, what do you say we get you off to sleep?"

The patient calmed down and we induced general anesthesia without incident. After the tube was in and taped, I turned to the med student, who looked like she felt bad. "Don't worry about it," I told her, "you'll get the IV next time." We talked about her approach, how she could take a shallower angle next time, how to advance the catheter using just one hand instead of two, and that was that. As one attending told me early last year as I was berating myself for screwing up something or other, "You're supposed to make mistakes. If you could do everything perfectly already, you wouldn't need residency."

Obviously, this is true. Also, it deserves to be said that attendings can make mistakes, and resident can perform at incredibly high levels. But it does make me uncomfortable sometimes, thinking how much less I knew when I was an intern, or even as a first-year anesthesia resident, and how much responsibility I had at that time anyway. And it also makes me uncomfortable to know that if Cal had been the patient that day, surely there is no way that I would have let a needle-wielding medical student anywhere near him.

(And don't call me Shirley.)

Currently reading: "Incidental Findings." Did you know that Danielle Ofri wrote a second book? Neither did I, until today. Her first book, "Singular Intimacies," is about her medical training at Bellevue (and not, despite the title, about masturbation).