30-hour day

I have not written much lately.  I have not done much of anything except work.

As part of my emergency medicine residency, I am required to complete two months of training at the University of Maryland Shock Trauma Center in Baltimore.  I enjoy being back in the city of my graduate school days, but the schedule at Shock is absurd: 80+ hours per week and call shifts in which I remain awake at the hospital–making critical life or death decisions about patient care–for 30 hours straight.  It is brutal.  It is unhealthy for residents.  It is unsafe for patients.  Yet, the culture is one of “It has always been this way.”  That doesn’t mean it should stay this way.

I tell every patient, and am now telling you, that I have often been awake for more than 24 hours when I am trying to figure out how to save a person’s life.  My brain is so tired, I frequently have trouble speaking clearly.  Patients are universally, and justifiably, appalled by this information.  I hope the reader need not require hospitalization, but if you do, ask your doctor for how long she or he has been working on shift.  The answer may not be a comforting one.

Upwards of 250,000 Americans die every year from medical errors.  The medieval, ridiculous, dangerous culture surrounding physician work hours surely is a part of the problem.  Physicians apparently refuse to heal themselves, so it’s up to readers and patients to demand change, to demand well-rested doctors, and to demand oversight and penalties for renegade providers and institutions that push physicians beyond all reason and margins of safety.

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Relay for Life

For those unfamiliar with Relay for Life, it is an American Cancer Society fundraising effort held annually by many cities, towns, and large institutions across the U.S. (and, indeed, the world).  Participants form teams and engage in an all-night walk-a-thon at a local track or gym to raise donations for biomedical cancer research; each team must keep at least one member walking at all times.  I’ve completed a couple of Relays in my life, and in trying to explain to others my reason for participating, I often shared the following experience from my third year of medical school:

I stood nearby as the attending surgeon opened the young man’s abdomen, peered inside, paused momentarily with his head bowed as though in prayer, and then let out a single, emphatic, forlorn, “Damn.”  I looked over the surgeon’s shoulder, and understood his reaction.

Thick, bloody, curd-like tumor encased the young man’s colon, and thousands of satellite lesions, like some morbid imitation of rhinestones, studded his entire abdominal cavity.  “He’s got six weeks, at best,” the surgeon muttered, as a gloom fell over the operating room.  The team resected the patient’s useless, toxic colon and as many of the tiny tumor outcroppings as possible, but the measures were only palliative.  Modern medicine and science had no miracles to offer.

In growing better acquainted with the patient during his post-surgical stay in the ICU, I began to appreciate fully the merciless, indiscriminate reach of cancer.  The young man was in his early 20s, tall and lanky, quiet and shy.  He liked basketball.  He added “sir” and “ma’am” to the few sentences he spoke to the nursing staff.  His family visited daily, wearing flat expressions of silent, stunned shock.  Every time I spoke with him, scenes from the operating room flashed across my mind, and I simply could not accept that the youthful countenance staring back at me had but six weeks to live.

“This isn’t right,” I thought, “Young people shouldn’t die like this.”  But, they do, because of cancer.

I think sometimes of this young man and the life wrested away from him, the future he will never experience.  In his memory, I walk in the Relay.

OB Baptism

My mother tells me I was baptized as an infant.  Sadly, I cannot recall the details of that particular occasion, but I do remember with clarity the baptismal event from my obstetrics (OB) rotation during the third year of medical school.

Together with a classmate and good friend of mine named Bryan, I had been assigned to a week-long stint on the nighttime OB service.  This nocturnal exposure serves purportedly to provide med students with additional opportunities for delivering babies and to teach the students to work with less supervisory oversight than during daytime rotations.  In reality, Bryan and I whiled away our overnight hours by surreptitiously swiping saltine crackers and peanut butter packages from the nursing station, consuming absurd quantities of caffeinated beverages, and trying to appear studious.  Every few hours, a delivery would commence, at which time one of us would accompany the residents to the patient room and “assist” with the birthing procedure; typically, the residents would deliver the baby, and the student would undertake the esteemed and vital task of delivering the placenta.  Crucial as this curricular exercise may seem for the training of physicians who probably will never practice obstetrics, even its scholastic value was eventually exhausted, and Bryan and I began to yearn for slightly more educational experiences during our remaining nights on the service.

The additional instruction we sought came one night in the form of an emergency Cesarean section due to fetal distress.  Because Bryan had already participated in three deliveries that night, I volunteered to take the case.  When the external heart monitors began to show dangerous decelerations of the fetus’s heart rate, the team decided to rush the pregnant woman to the OR for a “crash C-section.”  Imagining dramatic, cinematic shots of me running down the corridor while shouting commands and saving lives, I hurried after them.  After locating sterile gloves, protective shoe covers, hairnet, surgical gown, and goggles; after getting lost in search of the operating room; and after contaminating myself at least four times while scrubbing my hands, I finally entered the OR ready to assume the customary med student role of standing in awkward proximity to residents and retracting abdominal fat.  In a curious twist of fate, no residents were available to participate in the surgery, leaving only the surgeon, the OR nurse, and me in the room.  As such, I was in a prime position for the events that ensued.

“Stand over there, student,” the surgeon ordered, pointing emphatically with forceps to a position for me on the other side of the operating table.  He then made a lower abdominal incision on the patient to reveal her gravid uterus.  An enormous, tense, reddish balloon, the uterus seemed to fill the woman’s entire pelvis and abdomen, and I could appreciate that it was under extreme pressure from polyhydramnios, an abnormal buildup of the amniotic fluid that usually circulates within the uterus to provide a protective environment for the developing fetus.  As the surgeon placed his scalpel for a low transverse hysterotomy, the type of incision used to open the uterus in order to extract the fetus, I felt a premonition of doom and began to back slowly away from the table.  Too slowly, as it were.

Scarcely had the scalpel blade made its mark when, like a perverse version of Old Faithful, the woman’s uterus spewed forth a stream of amniotic fluid, with my chest as the direct target.  Staggering backwards under the force of the fluid, I cried out in shock as the deluge instantly soaked through my operating gown, my scrubs, and my undershirt, splashed up under my mask onto my face, saturated my underwear, and ran down my legs into my shoes.  The eruption ended as abruptly as it had begun, and for a few seconds, the only sounds in the room were the droplets falling off of me onto the floor and the cries of the newborn baby that had been handed over to the neonatology team.  Stunned and somewhat nauseated, I looked up at the surgeon and asked, “Sir, with due respect, may I go change clothes?”  He laid down his operating instruments, looked squarely into my eyes, flashed a malevolent and wicked smile, and replied, “Absolutely not.  You have been OB baptized.”

For the next ten minutes, my wet feet squelching in my shoes each time I shifted my weight and my body becoming increasingly hypothermic as the amniotic fluid evaporated from my skin, I stood next to the operating table as the surgeon closed the incision sites and completed the cesarean procedure.  Four-letter words probably not befitting a person so recently sanctified ran through my mind until the surgeon, with another morbid chuckle, finally permitted me to leave.  I fled to the locker room where, though nothing could be done for my soaked shoes, I quickly changed scrubs and dropped my saturated undergarments into a nearby biomedical waste container.

I then returned to the student quarters, where I found Bryan.  As I entered the room, he cheerfully asked, “So, how did it go? Did you learn anything?”  “My dear friend,” I replied, “It was a religious experience.”

Medical School: the curriculum

Patients rely on the knowledge and expertise of their doctors, yet they seem poorly informed regarding the process by which relatively normal human beings develop into the storied creatures known as physicians.  The following paragraphs describe the typical four year voyage through medical school–which, despite the striking similarities, should not be confused with a journey through Dante’s Inferno.

The first two years of medical school require students to learn the basic science concepts underlying clinical medicine.  Subjects necessary to master include anatomy, histology, physiology, caffeine consumption, biochemistry, pathology, pharmacology, prolonged sleep deprivation, behavioral science, neuroscience, immunology, disavowal of all social interactions, microbiology, and random advanced molecular theories related to professors’ research areas but unrelated in any respect to diagnosing and treating illnesses.  To complete this monumental task, students employ a number of time-tested learning strategies: watching prerecorded online lecture videos at home while wearing pajamas and eating Lucky Charms; rewatching said lectures online at Starbucks while wearing sweatpants and eating overpriced pastries; and, re-rewatching aforementioned lectures, on 2x speed, while wearing boxer briefs and softly sobbing one’s self to sleep.  Additional techniques include obtaining contraband copies of prior years’ examinations and shamelessly memorizing the answers; querying professors as to the exact lecture slides that contain likely test items; and largely avoiding any effort tantamount to genuine studying.

At the conclusion of their second year, med students take the USMLE Step 1 Exam, which is a nationally standardized test that involves regurgitating in the span of eight hours the contents of every Powerpoint lecture slide ever observed during the students’ previous two years of coursework.  Though having little relevance to one’s ability to practice clinical medicine, Step 1 scores largely dictate where and into which specialties med students will match for residency training after medical school.  Faced with this stress, most med students prepare for the exam by closeting themselves for 6-12 weeks in a musty garret; studying intently for at least 3 hours per day; cruising Facebook and Insta while pretending to study for another 12-15 hours per day; and foregoing all sunlight, human speech, and vestiges of personal hygiene.  Immediately after completing the Step 1 exam, students invariably feel certain that they failed and elect to drown their sorrows by means of a several-day-long binge of alcohol, psychotropic illicit substances, and/or prior seasons of “House.”

During the third year of school, med students enter into the clinical realm of the hospital, where on a daily basis they face ridicule and condescension from attending physicians, residents, nurses, ancillary personnel, patients, janitorial staff, and reasonably perspicacious neonates.  Typically, med students take at least four hours to collect a history and perform a physical assessment of a patient, receive thirteen seconds to present this information to the resident or attending physician before being interrupted, and then stand by quietly as the patient proceeds to give the resident or attending an entirely different account of his or her symptoms.  This scenario repeats itself across a range of required clinical rotations that include pediatrics (also commonly known as “make funny faces” month), internal medicine (“whatever you do, do it pensively” month), obstetrics/gynecology (“wish I could forget seeing that” month), psychiatry (“you thought your Uncle Chuck was crazy” month), neurology (“finally get to use the reflex hammer” month), family medicine (“refer to a specialist” month), and surgery (Lasciate ogni speranza, voi ch’entrate).

Shortly after third year ends, med students take USMLE Step 2, which has two parts.  Step 2 CS requires the examinee to role-play as a doctor and to treat simulated patients.  Speaking rudimentary pidgin English and correctly identifying where in the body the lungs are located are the only skills necessary to pass the exam.  Step 2 CK evaluates students’ clinical knowledge much as Step 1 assessed their basic science knowledge–except that CK has less impact on residency options and therefore elicits only scant studying efforts from most students, unless the student has a pathological addiction to standardized exams and/or wishes to match into a highly competitive specialty such as neurosurgery.

The fourth and final year of medical school stands as a sort of Elysium.  The grueling, mandatory clinical rotations of third year have come, gone, and left their psychological scars.  Students in the fourth year take electives geared towards their specialty of interest; they rediscover the sky, trees, and their university gym; they engage in “research” months that involve reading one or two review articles and thereafter trying to abstain from any other scholastic activity; and, they apply for residency positions.  For those who do not know, residency begins after graduation from medical school and consists of three to seven years of additional training as a resident, or supervised doctor, in a particular clinical specialty.  In the dead of winter and during the year’s worst possible travel season, students receive interview invitations from residency programs that liked the students’ applications or that are desperate for the cheap labor these students will provide as residents.  Either way, students gladly brave snow and ice storms and spend $3,000-$10,000 on airline tickets, hotel rooms, and other travel expenses to attend the various program interviews.  Throughout the interview season, a mafia-like organization known as the NRMP, which claims to be an independent philanthropic entity but which in truth exercises monopolistic hegemony over med students’ lives, serves as the self-appointed intercessor between students and residency programs.  On a spring day known simply as “Match Day,” the NRMP matches students to their “optimal” residency positions based on a patented computer algorithm that a third-grader could have designed but that nonetheless earned the organization a Nobel Prize.

At last, with four arduous years behind them, $250000 of student loan debt, moderate to severe PTSD, and residency positions assigned per dicta of the NRMP, med students reach graduation.  In addition to congratulation cards from relatives whom they’ve never met but who nonetheless are “proud to have a doc in the family,” graduation provides students the opportunity to take their final licensing exam, USMLE Step 3, which as long as it is passed has absolutely no impact on students’ future careers and for which the maximum level of preparation consists of identifying the correct testing facility on the evening before the exam.  Beyond graduation lies the vast Unknown of residency, non-negative monthly incomes, freedom from grades, and being “a doctor.”  Godspeed.

Medical School: the cast

MED STUDENT

Generally considered a semi-sentient creature ranking just below newts and precocious fungi on the evolutionary tree, the medical student is able to process crude emotions and to withdraw from painful stimuli, but has rarely been observed performing higher-level cognitive functions.  Masochistic at best, and likely suffering from pathological psychosis, the med student chooses to undergo four years of studying 100+ hours per week while suffering routine ridicule from clinical instructors who treat him or her with approximately the same level of respect as one treats the sock lint that accumulates at the tips of one’s shoes.  Med students are easily recognizable by their shuffling, dejected gait; by the patronizingly short, white coats they wear; and by the ease with which they create awkward situations, such as turning red-faced and stuttering during the clinical breast exam or gleefully offering to manually disimpact a 90-year-old constipated elderly man.  Being unlicensed, the med student cannot provide any substantive assistance to the medical team but does serve as a convenient scapegoat for any failings of the US medical system–whether medication errors, missing documentation, rising healthcare costs, the collapse of Medicare, or unpalatable cafeteria food.  In a process that still baffles leading scientists and that should terrify the general public, the med student on the July 1st following his or her graduation from medical school ceases to be a lowly bottom feeder and metamorphoses into a resident physician who is expected to knowledgeably manage patients.


RESIDENT

The resident.  A med student in heart; a doctor in theory; a peon in reality.  Residents are the curious hybrids of the clinical world.  They have graduated from medical school and, having earned a medical degree, enjoy the esteemed title of “Doctor,” without any of the privileges: they cannot yet practice medicine independently, they don’t have vacation homes in Monaco, and they don’t drive vintage German automobiles.  Instead, they labor at the hospital under the auspices of attending physicians (see below) in a sort of medieval apprenticeship called “residency,” in which they obtain further medical training in a specific specialty such as emergency medicine or dermatology or orthopedics.  The length of this purgatorial residency varies from three years for primary care fields such as pediatrics to seven years for surgical disciplines such as neurosurgery.  The cushy schedule during residency involves a mere 80-100 hours of work per week.  The resident typically arrives at the hospital at the hearty hour of 3 or 4 AM, visits all of the patients on his or her attending’s list, and then writes notes and places orders for each patient–knowing that the well-rested attending will arrive after a morning tennis match around 11 AM and will berate the resident’s medical decisions while issuing directives that exactly match the resident’s original orders.  The resident then remains at the hospital until 8 or 9 PM to complete the day’s activities and to polish the attending’s golf clubs for tomorrow’s early morning tee time.  Residents are easily spotted as the sleep-deprived zombies in wrinkled scrubs and dingy white lab coats running frenetically around the hospital and answering a constant stream of ringing pagers strapped to their waists.  Raking in an average gross salary of ~$50000, they enjoy a competitive hourly wage of just over $10/hr, an ample return on their investment of 8+ years of higher education and only slightly less than they could make stocking shelves at the local department store or selling their nonvital organs on Craigslist.

 


ATTENDING

The word “attending” operates in everyday speech largely as a participle or gerund (e.g., “Attending church was a Sunday morning tradition…”), but in medicine, it serves as a noun for the doctor in charge of the medical team caring for a patient.  It translates roughly as “Boss Man,” “Divine Being,” or “Your Majesty.”  Technically, the word is only the first half of the phrase “attending physician,” but the full title is rarely necessary; the mere utterance of “attending” generates immediate genuflection–if not prostration–on the parts of all sentient beings in the vicinity.  Having usually studied alongside, and perhaps even tutored, lesser healers such as Hippocrates and Jesus, the attending possesses unassailable authority.  He or she dictates the diagnosis and therapy for each patient under the team’s care and makes certain to criticize, refute, and ridicule any and all aspects of the team’s clinical decision-making.  It is customary for God to seek the attending’s permission prior to intervening in the outcome of any given patient.  For mortal humans, receipt of no fewer than twenty-six Nobel prizes is required before one may speak directly to an attending.  Residents and medical students must not meet the attending’s gaze, and students in particular must take caution not to step within the attending’s shadow, lest they risk immediate corporeal combustion for transgressing the sanctified boundaries of Holiness.  Attendings earn prodigious salaries, take solemn oaths to drive only Porsche and Audi vehicles, and live in resplendent luxury while their resident underlings work 12x harder than they do but can scarcely afford the crumbs of the imported French brioche that the attending has for breakfast every morning.  Lastly, attendings do not die; they answer Death’s page, at their own leisure.