Tag Archives: Surgery

Allergies, Alerts, and Assessments: The Information Age of Medicine

If you have a pulse and have visited an American physician, you have surely experienced this bizarre situation. They have you show up early for your office visit to fill out a packet of paperwork on every medicine you have every taken and every orifice you have ever had examined, yet when the doctor shows up in the room he asks for all of the same information over again. MAYBE he glances at the packet, otherwise it gets scanned and filed and stored securely and uploaded “to the system”. Sometimes a nurse will even come in and confirm the info on the sheet, followed by the doctor who has no knowledge of any of this information gathering.

Or picture this. You visit a local hospital ER for some urgent thing that came up. You fill out another huge packet of info. They transfer you over to the local county hospital, where the process will surely be repeated. There’s also a good chance they forgot to send the disc with your CT scan on it, instead sending a sheet of paper with a report of what their radiologist thought it showed. I deal with these sorts of situations every single day, and the cost usually comes at the expense of the patient, with increased wait times, repeat scans, and extended hospital stays due to administrative headaches. “Transfer paperwork” is usually dozens of pages of worthless charting by nurses (patient does not have an ostomy, patient is not an Alaska native, patient does not drive a vehicle manufactured before 2004), with one short paragraph actually written by an ED doc on the patients problems, followed by another dozen pages of medical necessity for transfer and financial information.

Ambulance

This is the current culture of healthcare. There are two issues I want to discuss, but first some juicy secrets about how doctors interview and evaluate patients.

When I am talking to a patient, every question has a hidden purpose.  There are directions that I am leaning for a diagnosis and treatment, and I am looking for specific answers that guide me in the right direction. When I ask, “When was the last time you had anything to eat?”, I don’t actually care a lot about your food choices over the last 24 hours. I don’t care if you crushed a Chipotle burrito, I usually just want to know if you can or can not be operated on today. Please don’t walk me through each and every thing you’ve eaten. When I ask about your medications I am usually asking about your health problems in a roundabout way, asking you describe the problems you have that are severe enough to require medicines instead of saying “I’m actually a healthy guy doc. Little bit of the sugars is all!”. This also gets me around the incredibly confusing segment of the population that seems to think, “I don’t have high blood pressure because I take 3 medicines for it and it is treated.” So my questions are very directed to get me what I think is the sufficient amount of knowledge need to treat you effectively. I try to start with open ended stuff just to see what you say when I ask “What brings you in today?”, but when we get on a tangent I need to bring it back to the important stuff.

This is particularly true on morning rounds, I have to see 22 patients by 530am and I am ruthlessly efficient. Are you alive? Have you pooped? Is your pain being treated? Are you actively bleeding anywhere? I can sort out any number of issues during the day, but first I need to get a handle on the things that I need to know.

coffee

I always round with a horrible cup of coffee. It inspires me to get done in time to get an actual breakfast.

So that’s the first issue we have, and it plagues healthcare. We have all of this information about you, your meds, your vitals, you name it. We know so much about you, but not very many people know what to do with any of this information. As a surgeon, I am particularly concerned about certain vitals, labs, and physical exam findings to determine if you are going home, going back to the OR, cleared to eat, whatever. Medical doctors care about all sorts of other stuff that they order that doesn’t actually matter (looking at you, pro-calcitonin and activated protein C). Anesthesiologists care about the structure of your mouth and the ease with which you can be intubated. Since we have done a relatively poor job of identifying what we absolutely need to know about each patient, we have gone ahead and decided to record every single thing about each patient at all times, just in case it turns out to matter.

This is probably the hardest on nursing staff and CNAs. At our hospital, nursing tasks are measured per hour, and an average of 42 minutes per hour is spent documenting on the computer, leaving a lousy 18 minutes for patient care (divided amongst their 3-6 patients each day). They document the patients bed position, what food is delivered to the room, visitors to the room, the temperature of the room, and the programming on television. This became an issue a few years ago at a hospital I worked at in undergrad, with nursing leadership complaining that documentation was hindering them from providing patient care. Instead of addressing concerns with workload and documentation needs, the hospital purchased 600 computers on wheels so that the nurses could wheel around the halls and do their charting. These computers initially were called COWS, but that term was deemed insensitive by the nurses who used them and they are now WOWs (workstations on wheels). I did not make any of this up.

charting

The result of this is a massive pile of poorly utilized, very sensitive information that we must not only keep protected at the risk of heavy fines and legal repercussions, but also pick out the important parts that could lead to poor patient outcomes.

The best example I see every day regards the allergy section of a patients chart. Actual allergic reactions are life threatening emergencies. The throat swells, you can’t breathe, and you die if you don’t get treated. Bad things that happen when you take medicines are not allergies, they are actually side effects (or sometimes intended effects). Morphine making you sleepy is NOT an allergy. Lisinopril making you cough is not an allergy. Taking a medicine while you also happened to have a viral respiratory infection is not an allergic reaction. Regardless, each thing gets dutifully logged by nursing as an allergy into the EHR. EVERY SINGLE TIME I try to place an order for medications for a patient I get that stupid chart blasted at my face to review allergic reactions. I am so used to clicking through and overriding (trust me, you really do want something for the pain after your open abdominal surgery), but I worry every day that I do miss a true allergy to sulfa or something.

The second issue revolves around documentation. Taking the critical amount of information for a patient and distilling it into a usable progress note or discharge summary is an incredibly difficult task. In the days of paper charts, notes from docs tended be brutally short. “Doing well, advance diet, monitor fevers”. Nowadays since so much is automatically generated our notes contain all vitals, labs, and a plan that (more often than not) is automatically carried over from the prior day. Again, we seem to be forgetting what the critical information really is, and instead just copying everything down.

Part of this is related to money. We get payed for what we do or do not document, and if the choice comes between losing money or writing more things into charts, you know which direction medicine will head. We have a weekly conference where one of our CDI (Clinical Documentation Integrity) docs goes over how we lose money by not writing the correct coding diagnosis in our notes. It is so ridiculous that it makes me angry to write about it on a rainy Saturday morning from my couch. We don’t get full reimbursement on a trauma patient if we don’t do a complete assessment of history on their intake. This means that if we don’t specifically ask our 90 year old patient with an intracranial bleed about diseases that run in their family, the goverment pays us less money. It doesn’t matter that it’s actually poor patient care, it is a box on the form that must be filled out so it must be done. In the trauma bay, with often critically ill patients, we end up asking about family history, mental health screens, and vaccination status (tetanus is important but others not so much in trauma) to get the boxes checked. It’s absurd.

The other part of this data is related to patient care. We need better tools to analyze big data to see what really matters for outcomes. We track re-admissions and complications because they are easy to measure, and it has made us defensive physicians. We need to measure outcomes in an efficient manner so that we become better physicians. This will be it’s own post down the road, for now I will just drop a quick link to a recent Wall Street Journal article that discusses an aspect of this idea.

If you have skills in data analytics, interface development, or programming of any kind, you could make an actual mountain of money in healthcare. Build us a system that lets us document efficiently and share our documentation with our colleagues across the street and across the country. Build us a system that allows us to study all of our data, our financial measures, our outcomes, and our complications. We need to see it often, not locked away in the medical records department. The last decade of medicine has been dominated by the Epics and Powercharts of the world, who have made it this long for being not as bad as their competitors, but my generation of physicians sees these systems as the dinosaurs that they already are, and we are ready for something better.

This is frustrating to me because I am still boots on the ground slogging through surgery residency. I lack the computing skills to even know where to start, but I know we absolutely need something better. This is the information age of medicine, but right now we aren’t using any of our info, it’s just weighing us down. Healthcare is still using a flip phone, it’s time we catch up and break new ground.

Thanks for reading!

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Surgery, Metaphors, and the Story of Your Life

Most of us have a very limited understanding of the world in general. It’s not really our fault. Our perspective is pretty well limited to our immediate circle of family and friends, and of course you have only your direct sensory perception of the world to actually create the framework of your consciousness. There’s a big world out there, surrounded by an incomprehensibly huge universe, and we’re pretty much blips. Because our own experience through our lives is very limited, humans have traditionally told stories about their lives and the experiences of others. So many ancient texts and myths have been passed down to us today as oral tradition, or essentially campfire stories that were told for generations before we finally started writing stuff down, which turned out to be a pretty big deal. Nowadays we have the entirety of the internet to connect and share (and in some cases overshare) our life stories. We have even managed to make obscure stories from long ago available widely online, expanding our collective knowledge an incredible amount in a relatively short amount of time. My story on this blog is technically contributing to that collection of knowledge, though it is admittedly drastically limited by my unwillingness to proofread and the limited sphere of influence of both of my readers (hi Mom!).

I think stories are important. I should mention here that I have read an incredible number of books over the years, mostly because I am a huge nerd. I continue to read (at a much slower pace) even during surgical residency. I love the structure of a story, the ebbs and flows, climaxes, and suspense. I like to view my life as a story, as it gives me a framework to look at my family, friends, and goals in a larger setting that may be difficult for me to grasp otherwise.

Stories work especially well when discussing shared experiences. Laughter, fear, embarrassment, stress, relief, and grief are all common across mankind, and sharing stories about how those feelings have affected our lives draw us closer to each other. People generally like to tell stories because they usually like to talk about themselves, but listening to stories is almost as good. I like telling stories so much that I take time to write them down to people on the internet.

Some stories are difficult to share effectively if the experience is relatively unique to you personally. You can communicate the facts and the sequence of events, but you won’t be able to really convey the meaning of the story unless the person listening has had a similar enough experience. I have found this particularly true when it comes to incredibly stressful events such as natural disasters, traumatic events, and surgical residency.

It’s hard to tell stories about residency to people that aren’t residents. Most people don’t have any similar experiences to relate with, and so it’s tough to get that understanding across. This is why many residents only hang out with other residents (also no money, shockingly little spare time, and poor social skills). I recently had the opportunity to catch up with some old friends and this was made very clear as we shared about our lives. I worked more than double the amount that my friends (who have full time jobs) work each week, with far less compensation, WAY fewer benefits, and a much more hostile work environment. It was actually a little depressing as I realized how sad my life was. I found myself saying things like “I can usually do my laundry” and “I’ve been sleeping in until 5am or so lately”. I can still tell funny stories about crazy people, or gross stories about traumas, but it’s tough to actually relate with how I get through my life. I don’t get off at 5, take a lunch break, or even have my own chair. I do have a small locker all to myself, which I think is pretty great.

I really like metaphors. I think they are useful both for teaching and for communicating with others who may have some things in common with you, but not necessarily the experience you are discussing. I have an attending surgeon who overuses metaphors. He will start teaching with a sports metaphor, switch to fishing, then make a pop culture reference from 30 years ago to end it, and I can’t keep up with all that. Medical students definitely don’t, but they will laugh at his jokes, which are terrible. His metaphors are even worse, there needs to be some similarities in your metaphors for them to work.

I like to compare anatomy to cities. Surgeons love anatomy. Every little thing in the body has a name, a function, and variants to know. Then add in the insertions, origins, innervation, vascular supply….it really adds up. Anatomy is often the first traumatic experience medical students have in their schooling. Though it may cause PTSD in medicine residents, it’s a working language and constant learning challenge in surgery residents.

Learning surgical anatomy is like learning to drive around a new city. You can look at maps and get a good idea of the layout of the city, but once you get there you need to start driving and see signs to confirm that Main Street is actually Main Street. Experienced surgeons are essentially the cabbies of the city, having spent years making their living driving on every single block, watching accidents happen (and causing a few), taking alternate routes for traffic, and knowing how time of day affects traffic flow. Medical students don’t know simple things because they are still getting their bearings, they still need to drive down Main Street and see the big attractions.

 

Hong_Kong_Cedric009-1500x792

This is Hong Kong, by the way.

Surgery residency is a strange beast, but I think it has a lot of similarities with baseball. Both are long seasons or careers that require endurance and daily performance. In baseball you can strike out with the bases loaded in one inning, then hit a game winning home run the next at bat. You can play extremely well and the team will lose, then vice versa the next day. No matter how well or poorly you are playing, there is always your next at bat, the next inning, the next game, and you have to continually prepare yourself to perform at your best when that time comes.

Baseball Infield Chalk Line

In the same way, surgery is tough business. Patients live and patients die. The hours are long, and the stress is real. The stress comes in different intensities, like a fire. Each morning there is the distant, soft, constant burn on the way to work. “I don’t want to hurt anyone today. I hope I can help at least one of my patients. How can I be my best?” Then there’s the anxiety when you aren’t at the hospital, but you know have a huge case the next day, or a sick patient back in the ICU. There’s the intense heat and focus in critical situations, when everything is beeping and you are the first to respond to a code, or have the MAC blade in hand to intubate a patient. Everything is on the line, and you’re up to bat. No games to win or lose, but the lives of others are at stake. Finally, there’s the huge weight of fatigue when you walk into the hospital for your 18th shift in a row, or walking out late at night knowing you’ll be back early the next morning.  Batter up.

The story of general surgery is not good. 20% attrition in residency. Huge egos competing for operating room time and influence, each person convinced in their own skill and decision making. A long, antiquated tradition of training surgeons by breaking down medical school graduates and molding the pieces into surgeons. That story is changing very, very slowly, but is still the reality for surgery residents all over the country today, tomorrow, and the next day for the remainder of our training.

If our lives are stories, each of our stories is made up of layers. Starting broadly, there are the events of our lives, or the circumstances that we either create of find ourselves in without our doing. Next, there is our conscious interpretation of those events and their effect on our lives. Separate from that are the actions we take and the decisions we make.

Finally, and most importantly, there is the internal story that you tell yourself about what is happening in your life and how you are going to respond to it. We all have inner voices, or an inner dialogue, and I think that voice is the single most important factor that drives who you are as a person. That inner voice is you, or at least as close as anything can be to you as a person. Whatever you are doing, or whoever you want to be, that voice is going to get you there. It’s remarkable how much I can affect my own day and my own well being despite the circumstances of the day, and that is the single most important thing I have learned in residency.

Intern year has been ROUGH, and there have been life circumstances that have made it more difficult as well, but it hasn’t changed who I am.  The challenge will be to maintain this for the next few years of training without burning out. I’ll probably write about that if it happens, but I hope to just keep telling you all funny stories and letting you know what’s on my mind instead.

Thanks for reading!

 

 

 

 

 

My Life is Very Glamorous Now

For anyone keeping score, I have not written a single blog post in almost two years. In that amount of time I have passed a whole bunch of tests, finished medical school, moved partway around the country, and become a for real, honest-to-God surgical resident. Impressive, I know. I return now to divulge all the juicy secrets about doctors and describe all the ways that my life is exactly like Grey’s Anatomy.

glamor

Actually, I’m back because I got an email that someone might have hacked my page and been posting malicious content. The security threat was neutralized (unknown source, but it could have been either of my regular readers) and once I remembered my password I realized what a gold mine of ridiculous stories I am sitting on and how much I miss writing. Shockingly, this blog is visited routinely despite not logging in for over two years. There are comments from 2014 that will still be awaiting moderation when the world ends. If I had monetized this thing two years ago I could probably get a York peppermint patty at the gas station, but as I mentioned, I have been busy living a very glamorous life, which I will detail below.

The main perk of being a surgical intern is that you get do everything. Actually, mostly everything. All of the cool stuff gets done by people above you, BUT you get to do everything else, so pretty much lots of pushing buttons of the computer, taking papers from one place in the hospital to another, and keeping tabs on dozens of patients doing their best to leave the hospital to overdose on drugs or make poor decisions as soon as they can. Also, everything is your fault unless you have proof of being in a different location, being on a different service, or an iPhone video of the attending surgeon telling you explicitly to do that specific thing. The basic procedures that are “intern level” are bestowed on you as though they were gifted from God himself, but really it’s just a chief resident with a healthy opinion of himself “letting” you do a gallbladder. But trust me, you are very busy and definitely not with busy work.

Perfect resident

A second perk of being a surgical resident is the ease of managing your life outside of work. See, a “resident” describes someone who lives at a certain place. To “intern” someone also means to confine them to a certain location. The ACGME had to create new rules specifically so that we worked less than 80 hours a week. Simply put, your life outside of the hospital becomes pretty well simplified into brief periods of lucidity shortly before or after going to sleep. Starting residency, I was shocked at how little cleaning I needed to do, since I was never actually in my apartment long enough to make a mess. I have since managed to surreptitiously move into and live in an upstairs call room at the hospital, and I use the neighboring anesthesia call room to store all of my boxes.

A third perk of surgical residency, which I consider to be a defining perk of surgery in general, is the ability to wear scrubs every day of your life. I love my scrubs. My sweatpants at home aren’t as comfortable as my scrubs. I can change them whenever I want, add or subtract layers above or below them, and they are so comfortable I could wear them as pajamas. Acceptable all days of the week, on the floor, most of the time in clinic, they simplify your life and wardrobe into a nice dull shade of green. Gain a few pounds and no one will ever know. They are impossible to wear inside out once the logo and tag get washed off in the scalding hot bleachy hospital wash water. Depending on the situation it is possible to layer your scrubs for maximum efficiency, allowing you to remove and dispose of the top layer on the go (while seeing isolation patients, for example).

Finally, one of the key factors that made me choose to be a surgeon in the first place, I actually feel like I help people. Surgery, as an act, can directly fix problems. Gallbladders come out, mesh goes in, wounds are repaired, infections drained….whatever that individual needs, we can often help them in a tangible way. Of course some people have chronic issues no surgery can fix, but that’s a common theme in all areas of medicine now and a bigger problem than choosing your specialty.

Honestly, surgical residency is nothing like Grey’s Anatomy. The one episode my wife showed me started with the surgeons going to the hospital after the sun had risen, which immediately tipped me off that it was going to be incredibly wrong. Ironically, surgery residency is more similar to Scrubs than to any other show. The ridiculous “cast” of hospital staff you work with every day, the unbelievable patients and family members under your care, and the combined drama of having all of your patients experiencing their worst day ever weave together to form a story so impossible to communicate effectively that you end up just seeing the pieces.

I wish I could tell you about the stress, the anxiety, the soul crushing nights of trauma, delivering bad news to cancer patients, and grasping for ways to explain to families how their loved one has died. I wish I could share the combined experience of every sleepless night, running around the hospital while three pagers ring incessantly, worried that my action or inaction would cause harm to a patient. Conversely, I wish I could tell you about the bond I have with my co-residents, the thrill of mastering difficult technical skills, of doing work well, and the peaceful content after a job well done. There is a deep satisfaction to working as a surgeon so impossible to convey that it’s easier to just show the “skits”, the short stories that are relatable and funny, easy to tell at dinner on the weekend.

On this blog, however, I can do something different. My writing over the years builds on itself. My story, my perspective, and my experience can create a narrative that is greater than the sum of its parts. The lessons and experience I am currently gaining are coming at a dear personal cost and are worth sharing. It’s worth it to me personally to take the time to sort out my thoughts and articulate them here, and I hope that over the years this story has a meaningful impact on someone else in the world too, wherever or whenever that may be.

That’s why I’m back writing here.

Thanks for reading.