• Today marks the end of my third year of residency. Tomorrow, I start work at the VA emergency department (ugh. I like the VA. I hate the ER) as a fourth year. Two more years to go.
• I told the director of the neurology critical care fellowship here that I’m planning on applying. I still vacillate about it, mostly because I dread putting together the application, asking for letters of recommendation, and somehow fitting a new, amazing, novel research project into my already busy-enough life. I hated the application process going in to medical school and into residency. The thought of doing it again makes me want to weep. But neuro critical care is really where I thrive the most. I still have tons to learn and I find it intimidating but… I think it’s where I should be.
• I finally made up with the attending that I was arguing with last week. He felt pretty bad about things, told my program director that I was really great, etc. Except that I kept getting confronted with all of the drama and it was this continuous awkward situation. But I apologized for for the emotional breakdown today, he apologized for being harsh and misjudging, we hugged, and hopefully it’s all good. I’ve got three months before I’m back anyway, enough time for it to be completely forgotten when I ask him for a letter of recommendation.
• Chris moved to Boston. I didn’t get to see him off. Three years ago, I cried for 2 days straight when he left for Asia, thinking that it was the end of our friendship. It wasn’t. This won’t be either. But I still miss him dreadfully.
• I heart Milwaukee. Especially the baseball games and tailgate parties. And I really heart my camera. Look for pictures later this week.
• TWO YEARS MORE!

Here’s a snapshot of what I’ve been doing at 0500 on my call nights:

1. Trying to figure out why my patient suddenly dropped his oxygen saturations, increased his intracranial pressures and became non-responsive. The respiratory therapist did a great job of bagging him until the anesthesiology resident came up an hour and a half later (!!!) and exchanged out his mucus plugged endotrachial tube.

2. Declaring a patient dead.

3. Admitting a transfer patient that nobody told me about. They always come in sicker when they are surprises.

4. Fixing electrolyte abnormalities, following up on blood gases, worrying about why the hemoglobin had gone down.

5. Answering pages from the answering service and arguing with patients that no, I’m NOT going to make a refer to a private hospital in NYC, just because you feel you can’t possibly walk into an ER there (that was a few weeks ago, I’m still beyond angry about the insufferable selfishness and lack of personal responsibility that some people possess)

6. Discussing with the ER why I’m not going to come down and see a patient, when the radiology resident over-called a head scan for a patient who had no new symptoms.

7. Napping. (I hesitate to call it sleep when the pager is going off every 15-20 minutes)

At 0500, I am tired. I am exhausted. At that point, I have worked 22 hours with another 6-8 to go. I lose the ability to multitask and can only concentrate on the thing right in front of me. Things have a tendency to crumble at 0500 in the morning. I have coded more patients than I can count at 0500. It can be utter chaos and like most things in the ICU, completely unpredictable! Two nights ago, I was balancing why another patient had suddenly increased ICPs and was trying to manage that, in between putting in a subclavian line at midnight (another rant that I’ll spare you) and adjusting another patient’s ventilation settings. It was a relative light night. I only had 6 patients of whom I was taking care, but I still didn’t get any sleep until 2 and that was punctuated by frequent calls from nursing.

It is because of that, because of all of the above reasons, that when the patient rolled in at 10:30 at night, and when we all decided that the patient wasn’t quick sick enough to warrant a middle of the night procedure, and when the attending asked me to page everybody under the sun at 0500 exactly for a procedure at 0600, I decided that it would be best that I inform the fellow of the changed plans (it was supposed to be an urgent in-the-middle-of-the-night case, but the patient was stable enough to wait a few hours) and have him page everybody instead. It is, after all, HIS responsibility and it was at 10:45 at night (plenty of forewarning) and he had to be up and here anyway to get everything going for the case and who knew how my night was going to go.

So when the fellow doesn’t page anybody and shows up 3 hours late, guess who’s fault it is. Or when the tech comes in and can’t find the order for the procedure, guess who’s fault it is. And when anesthesiology doesn’t take the patient until 8 in the morning, because the fellow isn’t there to get consent, guess who’s fault it is. Never mind that when I called the nurse at 0530 in the morning to check up on the patient, and found out that nobody had been by to see the patient, I had everybody paged to remind them (it was the first page received because “the fellow didn’t get my page” from the night before. Bull crap. The pages are trackable, moron.) Never mind that I had let the operating room know before the patient was even admitted. Never mind that I had orders done, the patient seen, examined, story straightened out, blood pressure controlled, and the attending notified within a half hour of coming from the outside hospital.

I was yelled at, chewed apart by four different people that morning, for “slacking on my duties.” By the last one, when the attending was telling me that he’s not mad, but just disappointed in me, I was bawling, sobbing in the critical care unit. Control of my emotions is not one of my strong points post call.

The attending, one of my favorites which is why it hit me so hard, brought me up orange juice as an apology (although he really didn’t apologize – I think I just shocked him by the tears). And in the staff meeting today, apparently “things were clarified” and “it wasn’t [my] fault” and I am a “good resident.” So maybe a little vindication.

I’m still pissed off about it. (I moved beyond emotional once I got some sleep). I’m tired of being treated like a secretary. No, I’m tired of being treated like a lazy secretary, without any acknowledgment of the hard work that I’m doing.

I’m tired.

Two days ago, I had come to the decision that I was going to throw in the towel, and admit to myself what I’ve known for the last three years (but didn’t really want to admit because it’s going to be more hard work, and research projects and more CVs and applications and The Match all over again and did I really want that drama). I want to do critical care. I want to do neuro critical care (still trying to figure out the general part, but that’s even more complicated). And I kinda wanted to stay here, mostly because I’m not super competitive, I don’t believe in the nonsense that you have to go to the big name hospitals to get good training, and I rather like every body that I work with. I have a great rapport with most of the nurses, the nurse practitioners are fabulous, the attendings are good teachers, etc.

And now. This.

Hahahahahahahahaha. Ha.

The good news: the leak in my basement when it rains extremely hard does not seem to be coming from the toilet. Horray!

The bad news: I have no idea where it is coming from. Well, I fear that it is dripping down the inside of the bathroom walls, but I can’t seem to locate a source. It just seems to appear, like zombies rising from the ground. Or something like that.

For now, it’s trickling down the basement drain. I only flooded a year ago because the downpour was too much volume and speed for the drainage system to accommodate. I am sure tired of dealing with this issue.

I should have spent tonight finishing up clinic notes. Instead I spent it looking at neurological equipment that I’m not sure I’ll ever use and updating my WP blog to 2.8, importing LJ entries with their new import system. Somehow it messed it up, transferring everything in triplicate and when I attempted to delete it, it deleted the entry on the LJ side. Of course, Livejournal, in their infinite wisdom has decided that you can’t import blog entries to their database, so I had to repost, losing the comments (on LJ. It’s still there on the WP side). It’s going to take me forever to delete (correctly!) and merge everything.

The rain is really coming down now. Come on, little drains, keep up. I’m going to try to sleep.

ETA: Scratch that. It’s coming down the majority of my windows now. The drain that my church installed for me is not keeping up and I’ve got a large puddle puddle at my back door. My rug has already been taken up. It’s supposed to last for the next two hours before letting up. CRAP.

ETA #2: And the drains stopped working and I flooded my basement again. This time I had the sump pump, which I pumped into a sink and managed to keep from flooding every where. Sure am glad that I kept it all up on cinder blocks too. I’m going to be utterly useless at work tomorrow. What I really need to do is take the day off, get everything bleached and call a plumber to come look at my drains. And figure out how to waterproof windows

again

.

Of course, it’s starting to rain again.

Chris moves to Boston at the end of this month (I’m hoping for one more quick visit, but he’s booked solid with going away parties and moving companies). On July 1st, he’ll be working with my hero, who distills the health care reform arguments and gets down to the heart of the problem, and does so beautifully. Dr. Gawande’s latest article in the New Yorker is a must read. I’m sending a copy to my representatives, because nobody, nobody is addressing the real issues that affect medicine. I strongly disagree with Pres. Obama’s ideas of health care reform (and I’ve agreed or at least grudgingly understood why with all of his decisions so far–but I knew back in November that while I was supporting his election, it wasn’t on the platform of health care reform), but I loath every other politician’s idea as well. They aren’t in health care. They see health care from a business model, and the focus is on “saving money,” while insisting on continuing to provide care exactly how it is now.

“…We are witnessing a battle for the soul of American medicine. Somewhere in the United States at this moment, a patient with chest pain, or a tumor, or a cough is seeing a doctor. And the damning question we have to ask is whether the doctor is set up to meet the needs of the patient, first and foremost, or to maximize revenue.

“There is no insurance system that will make the two aims match perfectly. But having a system that does so much to misalign them has proved disastrous. As economists have often pointed out, we pay doctors for quantity, not quality. As they point out less often, we also pay them as individuals, rather than as members of a team working together for their patients. Both practices have made for serious problems.

“Providing health care is like building a house. The task requires experts, expensive equipment and materials, and a huge amount of cordination. Imagine that, instead of paying a contractor to pull a team together and keep them on track, you paid an electrician for every outlet he recommends, a plumber for every faucet, and a carpenter for every cabinet. Would you be surprised if you got a house with a thousand outlets, faucets, and cabinets, at three times the cost you expected, and the whole thing fell apart a couple of years later? Getting the countrys best electrician on the job (he trained at Harvard, somebody tells you) isnt going to solve this problem. Nor will changing the person who writes him the check.

“This last point is vital. Activists and policymakers spend an inordinate amount of time arguing about whether the solution to high medical costs is to have government or private insurance companies write the checks. Heres how this whole debate goes. Advocates of a public option say government financing would save the most money by having leaner administrative costs and forcing doctors and hospitals to take lower payments than they get from private insurance. Opponents say doctors would skimp, quit, or game the system, and make us wait in line for our care; they maintain that private insurers are better at policing doctors. No, the skeptics say: all insurance companies do is reject applicants who need health care and stall on paying their bills. Then we have the economists who say that the people who should pay the doctors are the ones who use them. Have consumers pay with their own dollars, make sure that they have some skin in the game, and then theyll get the care they deserve. These arguments miss the main issue. When it comes to making care better and cheaper, changing who pays the doctor will make no more difference than changing who pays the electrician. The lesson of the high-quality, low-cost communities is that someone has to be accountable for the totality of care. Otherwise, you get a system that has no brakes.”

From The Cost Conundrum, The New Yorker, June 1, 2009.

A few short months after I started residency, the neurology department switched from paying their physicians a salary that was based on experience and tenure to a “relative value unit” compensation system, meaning that patient visits or procedures were reimbursed based on a calculated fee. A basic office visit would be 2 RVU, doing injections for headaches would make it worth 10 or performing an EMG would give you 30. You had to make a certain number of RVUs in order to get a base salary, anything else you do is “gravy”. Things changed overnight. Attendings who used to lecture at noon time suddenly were squeezing in more clinic patients or doing another procedure. My program director is the only one who lectures any more. When on service (meaning they’re in charge of the patients who are admitted to the service and over the residents), attendings leave for a few hours to see clinic patients, cutting into the time that they spent teaching. My neurology clinic was a disaster. Instead of learning how to diagnose and treat migraines, seizures, Parkinson’s, etc, I had lectures on how to document my notes, so that they would generate the most income.

Contrast that to the internal medicine side, who pay their physicians a set salary. The attendings work their two weeks on service every three to six months. They staff the residents clinics and I never hear anything about how I need to see more patients or finish my notes in X amount of time so they can get all of the billing. The focus is instead on my learning: making sure that i understand thoroughly what the cholesterol panel on my diabetic should be for heart attack and stroke prevention. I just learned that that the internal medicine doctors will be getting a 15-30% pay cut next year because of the economy (and some piss poor economic decisions by higher management–but that’s a rant for another day). So far, I haven’t seen it affect the care that they are providing their patients or the education that they are providing me – a vastly different and much more preferable. I understand that unfortunately in this capitalistic* society, medicine is a business as much as anything and that I will have to face monetary decisions once I graduate, but I strongly disagree that it should be influencing my medical education or the care I provide my patients, to this degree.

Also check out his other article Getting There From Here that has a fascinating history lesson in how health care coverage and insurance evolved over the past century, as well as an examination of why idealism should not prevail in our quest for a better medical system. It’s a beauty as well.

Now if we could only get good tort reform as well…

*I support capitalism, but I don’t support endless greed (such as CEOs of private insurance companies or hospitals making billions of dollars a year), which is what our current system seems to be based on. We seem to be learning lessons very slowly.

(Sorry if I lost your comments. I was transferring all of my entries to my other blog, which for some reason copied everything 3 times, and then I clicked delete on the wrong entry. Argh)