June 29th, 2009 by Shadowfax in Better Health Network, Opinion
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Surgery Residency, Massachusetts General Hospital and Work Limits – Health Blog – WSJ
It’s not surprising that newly minted doctors at one of the most prestigious hospitals in the country, and in a specialty with a particularly demanding residency, have been violating national limits on work hours.
But the Boston Globe’s report that Massachusetts General Hospital must rein in surgical residents’ hours is a reminder that the work limits put in place several years ago remain unpopular with many residents and senior doctors.
Not surprising in the least. I’m actually astonished that there’s anybody with the chutzpah to defend extended work hours for residents. I did my residency largely in the pre-hour-restriction era — there were hour restrictions on months in the ER, but effectively none for the off-service rotations — and it was a terrible way to deliver care. I did my time of q3 call in the units and q2 call on surgical services. This includes a memorable time when I was the sole intern on the pediatric surgical service and was on duty for ten days straight without leaving the hospital. That gives a new meaning to being a “resident physician!” (Actually, that’s the original meaning, if you must get picky about it.)
The care provided was just scary. I prided myself on being a machine and able to get through 36 hours of uninterrupted work without cracking; I used to run marathons and endurance was my forte. And I did get through it better than most. But after 24 hours with no down time (and there was never meaningful down time), you get stupid, and you make mistakes. I remember once, in the medical ICU I was surprised in morning rounds to find that one of my patients had had a swann-ganz catheter placed overnight. Caught flat-footed by this in front of the attending, I asked the nurse who had put in a swann without telling me, only to be informed that I had done the procedure! Apparently I was too sleep-addled to recall that I had done it! Fortunately, I had apparently done it right, because a swann involves threading a catheter through the heart into the pulmonary vessels and can be Very Bad [tm] if you screw it up. But I apparently did it by reflex without actually achieving a state of full wakefulness. This sort of thing was fairly routine, and I also remember well the overnight residents being excoriated in morning rounds for the errors and misjudgments they had made overnight. Great training, but not so great for the patients who were the victims of the mistakes.
It seems to me that the defenders of the status quo have donned their rose-colored glasses. They fondly remember the camaraderie and the pride in accomplishment that their residencies evoked, while conveniently forgetting the mistakes and omissions, while neglecting the depression and divorces and other personal costs of such an abusive training environment. And there’s the faux toughness: “I got through it, they can, too if they’re not too weak.” And the old guard romanticize the qualities of the “true physician” in their dedication to their patients above all else: “These younger doctors just don’t care enough.”
What a load of crap.
Look, it’s with damn good cause that other professions in which errors can hurt people have work time restrictions (truck drivers, airline pilots, etc), and it’s stupid and arrogant to think that we physicians are so awesome that we are immune to the human factors of fatigue and circadian rhythms that contribute to errors. When it’s inexperienced trainees working the ridiculous hours with minimal supervision (in many cases), the potential for fatigue-related errors is compounded.
I also question the motivations of some of those who defend the status quo. It seems strangely self-serving that residency directors who would otherwise have to find attending physicians or PAs to perform the work that residents do on the government’s dime are the ones to insist that the situation is just fine, or that “the evidence of benefit is lacking.” How cool is it that they can ignore reams of research on human factors, take the a priori position that the system is fine as it is, and demand formal evidence on “efficacy, safety and cost” before making any changes? That’s balls! It’s also fairly blatant obstructionism and should not be given any credence.
Dr Bob of Medrants has some thoughtful comments on the matter, mostly pleading for flexibility in the new rules. I would mostly agree, excepting that flexibility is best given to those who have proven themselves trustworthy, and residency directors (especially but not exclusively of surgical training programs) have repeatedly and flagrantly flouted the rules thus far imposed. Flexibility is fine, but accountability should also be demanded.
I would also take issue with Dr Bob’s comment that this “training system that has served our profession well for many years.” I look at the statistics on physician burnout, substance abuse, divorce, depression and suicide. They are terribly concerning. I would not lay all of this at the feet of residency, but I would say that the abusive (I’m sorry, “rigorous”) environment of residency training sets the tone for the culture of machismo that harms physicians as much as it harms patients. Nobody is well-served by the current system.
It is true that change might be painful. Reducing hours might mean reducing patient contacts and reducing the training opportunities for physicians. This might require academic centers to revalue the time of physicians in training, by which I mean that residents might no longer be used as free menial laborers. Maybe it doesn’t make sense to have a surgical resident “running the book” — many surgical residents never see the inside of the OR till their second and third years. The universities might have to hire PAs or NPs for the “scut work” instead of using MDs in training as glorified secretaries (what a waste of time and money).
I’m glad the Institue of Medicine and the ACGME seem to be on the right path with the recommendations. The reactionary response from the change-resistant academic centers will take some time and political will to overcome. I remember when they first imposed the rules, they followed it up by decertifying the Internal Medicine program at Hopkins for violating the rules. That effected the desired change, I can tell you! Hopefully, as the restrictions evolve, there will be accountability and enforcement until the culture starts to shift.
*This blog post was originally published at Movin' Meat*
June 19th, 2009 by KerriSparling in Better Health Network, True Stories
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There’s stuff that’s bolus-worthy. New York style cheesecake. Chai tea on a snowy winter day. Wedding cake made out of red velvet with butter cream frosting. These indulgences are worth draining my pump reservoir for, and almost worth the spike I try to, but don’t always, avoid.
I’ve been very, very attentive to my diabetes lately. Logging all these numbers, sporting the Dexcom, trying to manage stress levels, exercising … whatever it takes to make me as healthy as I can be for the baby I want to have someday. But that wagon is hard to stay on all the time, and I have taken a risk or two in the last month. Like a trip on the Connecticut Wine Trail with some friends. And some pasta at Carmine’s last weekend with my sister-in-law.
And blueberry swirl cupcakes from Crumbs Bakery.
My diabetes control isn’t made or broken in one bite of a fluffy, delicious cupcake. Usually when I’m having a high sugar indulgence, I’m right on top of things, diabetes-wise. I bolus aggressively to avoid the high and I watch that Dexcom like a hawk for any subsequent lows. My management problems come more in the form of letting my numbers go untracked and pinging all over the place, letting highs creep up without corrections, then stacking boluses until I hit a nasty low, which I over-treat and rebound into a high … you know the cycle. It’s not the “one thing” but more my inability to care for more than an hour or two. The last few weeks of intensive management have been about keeping an eye on everything and not letting the cycle spin out of control.
And it’s hopefully working. My machine averages are down, I’m seeing many hours straight of flat-lines on the CGM, and knowing my Joslin appointment is at the end of July keeps my mind on task.
Besides, it’s not like I ate the whole cupcake. I split it with Chris and I asked for the estimated carb count before I took a bite.
But I did take the first, awkward bite.
And I did enjoy every other bite of it, too. Go ahead and judge! 🙂
*This blog post was originally published at Six Until Me.*
June 15th, 2009 by DrRob in Better Health Network
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I am a flaming moderate. Yes, I know that is an oxymoron but the fact remains that I am both passionate and moderate in my political opinions.
And I am in the mood to rant, so beware.
Living in the deep south, I often seem like a radical communist to those I see. I frequently get patients asking questions like “So what do you think about Obama’s plans to socialize medicine?”, or “I wanted to get in here before Obama-care comes and messes things up.” I usually smile and nod, but find myself getting increasingly frustrated by this.
The house is burning down, folks. Healthcare is a mess and desperately needs fixing. How in the world can someone cling to old political yada-yaya-yada when people are dying? I am not just talking about the conservatives here because to actually fix this problem we all have to somehow come together. A solution that comes from a single political ideology will polarize the country and guarantee the “fix” to healthcare will be one constructed based on politics rather than common sense.
No, this doesn’t frustrate me; it infuriates me. The healthcare system is going to be handed over to the political ideologues so they can use it as a canvas for their particular slant. In the mean-time, people are going to be denied care, go bankrupt, and die. Yes, my own livelihood is at stake, but I sit in the exam room with people all day and care for them. I don’t want to be part of a system that puts ideology above their survival.
So here is what this radical moderate sees in our system:
- The payment system we have favors no one. Every single patient I see is unhappy with their health insurance to varying degrees.
- Stupid and wasteful procedures shouldn’t be reimbursed. This is business 101; if you don’t control spending, you will not be able to sustain your system. This means that we have to stop paying for procedures that don’t do any good. Some will scream “rationing” at this, but why should someone have the right to have a coronary stent placed when this has never been shown to help? Why should we allow people to gouge the system for personal gain in the name of “free market”? I got a CT angiogram report on patient today who has fairly advanced Alzheimer’s disease. I twittered it and the Twitter mob was not at all surprised. These things happen all the time. The procedures do no good and cost a bundle. The procedure done today probably cost more than all of the care I have given this patient over the past 5 years combined!
- The government has to stop being stupid. Why can’t I give discount cards to Medicare patients? Why can’t I post my charges, accept what Medicare pays me, and then bill the difference? The absurdity within the system is probably the best argument against increased government involvement. Who invented the “welcome to Medicare physical??” I never do it because the rules are utterly complex and convoluted. If the rules can be this crazy now, how much worse will it be when the government takes over? If my medicare patients are confused now, how much more will we all be if the government grabs all of the strings?
- The money is going somewhere. In the past 10 years, my reimbursement has dropped while insurance premiums have skyrocketed. There are more generic drugs than ever and I am no longer able to prescribe a bunch of things that didn’t get a second-thought 10 years ago. Hospitals stays were longer and procedures were easier to get authorize. So where is the money going?? We do know the answer to this question – there is no single culprit. Drug companies were to blame for a while, but now they are going to the dogs; and yet the rates aren’t dropping. The real problem is that there are far too many people trying to capitalize on the busload of money in healthcare. Shareholders, CEO’s, and simple corporate greed has bled money out of the system like a cut to the jugular.
- Docs have to stop being idiots. We like our soap boxes to rant against EMR, malpractice lawyers, drug companies, and insurance companies. We stand on different sides yelling our opinions but don’t come up with solutions. Instead of doing what is right for our patients, we join the punching match of politics. Is EMR implementation important? Duh! There is no way to fix healthcare without it. But the systems out there are designed by engineers and administrators and don’t work in the real life. So why can’t we computerize ourselves? Every other industry did. Why must we cling to the archaic paper chart because we don’t like the EMR’s out there? Aren’t we smart people? Aren’t we paid to solve problems? Stop throwing darts and start finding solutions. Med bloggers are terrible in this – they rant constantly against EMR, but don’t ever say what would work. It’s fun to criticize, but nobody wants to propose an alternative.
- We need to get our priorities right. Healthcare is about the health of the patient. Yes, it is a job for a lot of people. Yes, it is an investment opportunity. Yes, it is a good thing to argue about – whether it is a “right” or not. Yes, it is a major political battleground. But in the end, these things need to be put behind what is most important. As it stands, we are more passionate about these other things than we are about the people who get the care. In the end it is about making people well or keeping them that way. It is about saving lives and letting people die when it is time. If we were all half as passionate about what is good for patients (and we are all patients) as we are about these other issues, we wouldn’t have half of the problems we have.
As a flaming moderate I get to offend people on all sides. We need to fix our system. It is broken. It is not a playground for those who like to argue. It is not a place to be liberal or conservative. This is our care we are talking about, not someone else’s. The solution will only come when we all come to the table as potential patients and fix the system for ourselves.
Is it easy? Heck no. This rant is not meant to show I am smarter than the rest of you; it is meant to get all of us away from the other issues that make any hope of actually fixing our problem remote. Given the fact that we all are eventually patients, our political posturing and plain stupidity may come back to haunt us. No, it may come back to kill us.
*This blog post was originally published at Musings of a Distractible Mind*
June 8th, 2009 by KerriSparling in Better Health Network, Patient Interviews
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Even though I do not like the disease, there are some diabetes-related simple pleasures that make me smile:
- I like when I change the battery and the insulin reservoir at the same time. Having my Medtronic 522 “full” on both sides makes me happy.
- I like when the carb count on something is exactly 10 grams of carbs because it matches my insulin to carb ration precisely. One snack, one unit, one oddly happy Kerri.
- I like the sound of the pump counting up a bolus. Boop boop beep!
- I like when the sound of the bolus is caught by Chris and he ends up whistling it back to me, almost without thinking. It’s a little soundtrack snippet of our life.
- I like when the cats wait patiently for me to remove the pump tubing from my body before they lunge for it.
- I like when new boxes of diabetes supplies show up and I can organize them in my little OCD supply closet.
- I like when the number on my meter is two digits, but higher than 89 mg/dl. It’s a tight range, I’m not usually in it, but it brings me weird joy.
- I like when the Dexcom beeps and my coworker (who works a wall away from me) IMs me quietly to check, “Low?” because she’s ready to get juice if necessary.
- I like not having to wear a watch.
- I like when I get to dump all the used test strips that have piled up throughout the day. Knowing I’ve tested a bunch makes me feel like I really stayed tuned in.
- I like the smell of white glucose tabs.
- I like when the new infusion set doesn’t sting at all.
- I like having someone in my life who is willing to get their hands covered in SkinTac in an attempt to stick a Dexcom sensor to random places on my body.
- I like that the hope of the parents of kids with diabetes rubs off on me, and makes me feel good for even just a few minutes.
- I like that diabetes gives two people, who wouldn’t otherwise have a thing to say to one another, a whole dinner’s worth of conversation.
- I like having coworkers who understand but don’t push.
- I like when my best friend clinks her beer to mine and says, “Bolus, baby.”
- I like when the cat licks my hand after I test.
- I like “free shower:” a shower without a pump site or a CGM sensor attached.
- I like having a whole network of people who understand – and do not judge – my diabetes life.
I like when I can focus on the silly, simple things when I feel a little overwhelmed by the tough stuff.
*This blog post was originally published at Six Until Me.*
June 4th, 2009 by Jerome Ecker, M.D. in Better Health Network, Health Tips
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Aspirin? – Yes, I should take that to prevent heart attack and stroke, right??
Well……perhaps. A new study (called a meta-analysis), the largest comparative trial of its kind, shows that being overzealous about aspirin use for prevention of initial heart attack and stroke may be unsubstantiated.
Specifically 95,000 subjects were evaluated, producing 1671 vascular events in the aspirin group and 1883 in the control group. Aspirin was associated with an absolute reduction of 0.06% heart-related events per year. Correspondingly, aspirin did not significantly reduce ischemic stroke risk, but researchers noted a borderline-significant increase in hemorrhagic stroke. Aspirin also increased the incidence of bleeding outside the brain. Overall, aspirin was not associated with a significant reduction in vascular death.
What does it mean? The advantages of aspirin in low risk patients are scant. As cardiovascular risk factors (like smoking, high cholesterol, high blood pressure, diabetes, family history of early stroke/heart attack) pile up, aspirin gains a bit more support, though there is a modest associated bleeding risk.
We will be following this data and it’s analysis further. In the meantime, it may be reasonable to discuss things with your doctor, or perhaps cut aspirin dosing to the appropriate lowest dose (81mg in most patients).
Want the original?
See Collins R et al. for the Antithrombotic Trialists’ (ATT) Collaboration. Aspirin in the primary and secondary prevention of vascular disease: Collaborative meta-analysis of individual participant data from randomised trials. Lancet 2009 May 30; 373:1849. We will post the appropriate links after publication to make it easier.
*This blog post was originally published at eDocAmerica*
