A Big Curriculum Vitae Cannot Hide an Ass Forever

I usually don't get into the middle of topics like these.  Today, for some reason, this irked me in a way unlike other comments of its kind, probably because of the individual behind these statements:

Ben Carson is a renown neurosurgeon at Johns Hopkins, with an impressive range of publications and Chair appointments and whatnot.  I'm not going to go into what a big deal he is, because you can probably see that on his wikipedia page.  Or you can read one of his books and he'll tell you himself.  The man has power in the medical community, and he has a reputation of being a technically gifted surgeon, good enough that people would seek him out when they had a particularly awful or rare disease.  The man's 61 years old though, near retirement, and of late he has started to step from the medical world to the political realm as one of the republicans' alleged championed candidates for the next presidential election.  He's a Seventh-Day Adventist Christian, and he's not afraid to let the world know his religiously-guided views.

Here's where I find his comments upsetting and ironic (besides comparing gay marriage with NAMBLA and bestiality, because, well, I assume most rational people think that's fucked up):  In the clip, Carson describes the establishment of heterosexual marriage as a "well-established fundamental pillar of society" and says that gays, pedophiles, and zoophiles (had to look that one up) "don't get to change the definition [of marriage]."  He goes on to say that he's against anyone who "wants to come along and change the fundamental definitions of the pillars of society."

Let's take a look at those statements.  It seems to me that by "pillars of society" Dr. Carson is referring to the Seven Pillars of Society as defined by Christian followers.  The Seven Pillars are: Government, Family, Business, Media, Education, Religion, and Arts & Entertainment.  We could also take "pillars of society" to mean the American traditions that have been upheld for generations, which have become ingrained in our culture through the centuries.  Either way, his argument here doesn't make much sense to me.

In his books, Dr. Carson relates the many barriers he had growing up.  He was from a poor family, raised by a single mom, and he was an African American during a time that the vast majority of doctors were white.  Color barriers were possibly the strongest walls he had to break through to become a physician, and he describes holding fast to his religion, which got him through many of his darkest hours.  So what, you may ask?

Back in the day, slavery was defended with religion.  Proponents would cite Bible verses to justify keeping slaves, to justify their mistreatment, and to sometimes justify raping them:


"slaves, obey your earthly masters with fear and trembling" (Ephesians 6:5), or "tell slaves to be submissive to their masters and to give satisfaction in every respect" (Titus 2:9).

If you asked slaveholders, opponents of slavery could be described as wanting to "change the fundamental pillars of society", to destroy the masters' livelihood and to directly disobey the Word of God.  So what happened?  Why don't we have slaves anymore?  Those questions might anger some individuals, because the answer is so blatantly clear.  A morally good society toppled the senseless, racist, absolutely evil practice of servitude with a Civil War, though the war for true integration of African Americans continued into the 20th Century (and still continues to this day, to be honest).  Dr. Ben Carson was born (in 1951) at an interesting time, a time of intense racism, but a time where early integration was taking hold.  He reaped some of the benefits of the bloodshed during the 19th Century, where those "pillars of society" were shaken and eventually brought to the ground.  He could become a neurosurgeon because those pillars no longer existed and were ever-so-slowly being replaced by new ones.

Now Ben Carson is trying to reinforce other pillars, to prevent some individuals from achieving the same equality that he dreamed of as he went through school.  To continue his analogy, and to make my views perfectly clear if they weren't before, I think that some ugly, moldy, fading, crumbling pillars of society need to be hit with a wrecking ball so newer, stronger ones can be built in their place to support the modern architecture of society.  Interracial marriage and women's rights, as two examples, are other pillars recently constructed from the wreckage of age-old traditions.  Not many sane people would argue that women need to stay in the kitchen and tend to children at home forever, but that wasn't the case only a few generations ago.

Unfortunately for Dr. Ben, not everyone seems to share his opinions on gay marriage.  He was scheduled to speak at the commencement for Hopkins Medical School this year, but due to student protests over his comments, and the above statement by the dean of the school, he decided to step down from the job.  Here's a quote from his apology letter to Johns Hopkins:

"Although I do believe marriage is between a man and a woman, there are much less offensive ways to make that point. I hope all will look at a lifetime of service over some poorly chosen words."

And here I will make my last point.  The "poorly chosen words" that he describes refers to comparing homosexual individuals to pedophiles and zoophiles, not to his "pillars of society" comment.  Not only is he an ass for saying these demeaning comments, to me it appears that his moral compass has somehow lost its center, if it was ever even magnetized correctly in the first place.  For me, it is not these "poorly chosen words" that so angers me, it's his deep-rooted opinion of homosexuals within the recesses of his heart that truly upsets me.  It upsets me that this man is (was?) a highly respected neurosurgeon, representative of not only himself or Johns Hopkins, but in a way a representative for physicians and the medical community, whether he wants to be or not.  Even a lifetime of service, or a CV 60 pages long, doesn't change the fact that I no longer have a desire to shake his hand.

I wish to say, from a lowly soon-to-be doctor with respect for every patient regardless of their race, gender, or sexual orientation, to a seasoned, respected, accomplished, world-renown neurosurgeon with a giant CV:

Fuck you, Dr. Carson.

The Ethics of CPR...and Slow Codes!

In light of recent events, I thought it would be appropriate to discuss some CPR-related material, while at the same time dabbling in medical ethics and the "slow code," which many people aren't aware of, even if they do work in a hospital.

I'd venture to guess that most everyone has heard of cardiopulmonary resuscitation, and most people would know that you perform the procedure when someone's heart has stopped beating.  I'm also fairly certain that a ton of people harbor some misconceptions about CPR, including when to start, when to stop, the traumatic nature of the procedure, and the possibility for saving the patient, among other things.  It's actually a pretty complicated (albeit very imperfect) procedure, wrought with inconsistencies between individuals performing it.  Let's talk about the procedure itself first, then we'll get to the ethics, which is a whole other sack of budding potatoes (shout out to TJ!)

Ok, so your 67-year-old uncle, Billybob, just collapsed on the dining room floor after a delicious meal of said potatoes.  He's definitely not responsive, not moving, and not doing much of anything, really.  However, your aunt Bettybob is active enough for the both of them, screaming at the top of her lungs and doing all sorts of unconscious panicky convulsions near his lifeless body.

What next?  After your "Oh **** (insert favorite explitive)" moment, you check Billybob's pulse, and there isn't one.  That instant, not 10 seconds later, not 20 seconds later, you HAVE to start CPR, and you HAVE to give it your full concentration. Tell Bettybob to call 911, and be confident whatever unintelligible utterances she gives to the dispatcher will summon the appropriate help.

Image from CNN

The whole purpose of CPR is to get blood to the patient's brain and, to a much lesser extent, all other vital organs.  That means you have to push hard enough to squeeze the heart ventricles between the sternum and the spine, which requires about 2 inches of sternal depression to accomplish.  This isn't a trivial fact.  Two inches is a big distance, especially for a chest cavity.  The rule is if you think you're pushing hard enough, push harder.  Notice how to hold your hands and where to put them with the above picture.  On top of that, you have to keep a fast rate, of at least 100 beats per minute.  Too slow, and you don't have adequate cardiac output.  Too fast, though, and you don't give the heart enough time to fill before the next beat.  As it turns out, the Bee Gees, despite their girly octaves, made a terrific contribution to medicine with their hit song "Stayin' Alive" (appropriately named, as well!).  Most anyone in the hospital has this song in their head while they're performing compressions, and it gets you a rate around 120-130, which, coupled with excellent, deep compressions, is about as good as you can get for the utility of CPR.  

Memorize that chorus.  It could save your Billybob's life.  

As you can imagine, our Billybob is in for a beating.  Most commonly patients suffer numerous broken ribs, bruises, and the occasional pneumothorax (due to a rib puncturing a lung) during CPR.  In 30 hypothetical minutes, to the Bee Gee's catchy beat (no doubt stuck in your head for the rest of the day, as it should be), a rotating team of 200lb men would pound on his chest 3,600 times.  It isn't pleasant, and I can certainly say I've had the unfortunate experiences of hearing the "snap" of few fragile ribs while performing CPR, especially on the elderly.  Just consider the train wreck equivalent you or someone you care about will be going through when "all resuscitative measures" are taken.  This isn't necessarily a bad thing, just something that isn't often taken into consideration especially when end-of-life decisions are being made in the geriatric population.

Just a few more points, then we'll get to the philosophical/ethical gobbledygook.  So now you're doing CPR on Billybob, pushing really hard on his chest, and you realize you haven't been giving him any breaths.  Its just you and Bettybob, still in her frenzied state, in the house waiting for the EMTs.  Here's another important point, one which has been slightly controversial in the past few years, but one which the American Heart Association has put to rest once and for all in March of 2012.  DON'T GIVE BILLYBOB ANY BREATHS.  I think we're all so put off by the mouth-to-mouth aspect of CPR, that a lot of people might not jump right away to help an unfortunate pulseless soul because they fear swapping spit with this (near) lifeless stranger.  Well fear no longer!  Even if your worst enemy, plagued with a variety of STDs and infected lip rings, manages to lose grasp of his pulse, you can effectively perform superb CPR without inflating his lungs.  Continuous, deep chest compressions are what matter.  The only situations in which you should stop compressions are when you are switching off with someone else, you are delivering a shock through a defibrillator, the patient gets a heartbeat back, or the patient is declared dead.  In our case with Billybob, the only thing we're really trying to do with CPR is to save him time until the medics get there to possibly deliver a shock.

And now the bad news.

Billybob's chances aren't good.  The fact that he lost a pulse puts him in really bad shape, but the fact that you started CPR immediately gives him the best chance he can hope for.  When we talk about successes with CPR, we not only consider if the patient's heart started back up again eventually, but we also account for neurological function.  As an example, if CPR is administered less than 6 minutes after the onset of cardiac arrest, at 10 minutes of CPR time only about 50% of people who survive--we'll get to this in a moment--will have a satisfactory (i.e. awake and communicating) neurologic recovery.  At 30 minutes of CPR in the same patient, that percentage drops to about 2%.  If it takes more than 6 minutes to start CPR, the percentage of survivors with a satisfactory recovery plummets to 20% at 10 minutes of CPR, and is 0% at 15 minutes of CPR.  This is why you generally stop CPR after 30 minutes when resuscitation was started early ( less than 6 minutes), and 15 minutes after CPR was started late ( more than 6 minutes) after the initial arrest.  The reason the percentages are low, even for those with quick initiation of CPR, is because most individuals either do not provide adequate chest compressions or even adequate compressions are not providing necessary blood flow to the selfish brain.  And the final depressing stat about CPR:  The survival rate, at best, meaning the entire procedure is performed wonderfully with perfect chest compressions and the patient has minimal arrest time and relatively quick defibrillation, is about 10%.  This, combined with our previous stats, means that about 5%, at most, will have a satisfactory neurological outcome and survive their ordeal.  It sucks, but not if you or a loved one is the 1 out of 20 with this outcome. If you can administer a shock in the first 3-5 minutes, depending on the study, survival can reach an astonishingly underwhelming 30%, but still amazing compared to later shocks during the process.

The point of all this is that everyone, no matter what their education level or walk of life, could be in the position to save someone's life through proper administration of prompt CPR and good compressions, to the tune of a Bee Gees classic.  If you don't like the Bee Gees, learn the damn song anyway.

I now suggest you grab a beer (I'm sure as hell going to), listen to "Stayin' Alive" again, and put on the good ol' thinkin' caps in preparation for the second half of the longest blog entry I've ever written in my life.

The Ethics of CPR...and other things

At the beginning of the post, I linked to a trending news story in which (in very concise neanderthal-like sentences):  Old lady (87) in old lady living facility goes kerplat.  "Nurse" lady in said facility calls 911.  "Nurse" lady proceeds to tell 911 lady that it is the institution's policy to NOT perform CPR on their residents.  911 lady flips out.  No one else does CPR until the medics arrive like 7 minutes later.  Old lady dies.

This opens a whole kettle of worms, which are in turn infected with parasitic worms, in turn infected with more...well, you get the idea.  Point is, we have a shitload of worms and a nasty kettle that no one is going to eat from ever again.  Let me just preface this by saying that, if I were in "nurse" lady's shoes, and the old lady didn't have some kind of DNR order or advance directive that I was aware of, I would have done CPR on the old lady.  And I think the reason that this story is getting into the news in the first place is because it strikes a dissonant chord with the majority of people's morality eardrums.  It's great news to in fact see that humanity still has perky morality ears, but I think we have to look deeper into why this whole thing bothers us so much...or maybe it doesn't bother you at all, in which case we'd want to look into that too.

For me, this story is bothersome on a few levels.  First and foremost, the "nurse" lady says she is a nurse.  If anyone is going to do CPR for the old lady in this situation, it's her.  Knowing what we know now about CPR stats and outcomes, CPR has to be started immediately if there is to be any hope of recovery.  The old lady, undoubtedly, was starting with a worse projected outcome simply due to her age and whatever other comorbidities she had.  It's even more important, then, to start prompt CPR in this situation if we really want to have a chance of bringing her back from the purported "white light."

What really confuses me in this instance is the conflict between calling 911 and the refusal of care on "nurse" lady's part.  Her intent behind the 911 call was to obtain life-saving care for the old lady (at least I presume that's why you call 911 in this situation), but there was no attempt for bridging care from a medical professional between arrest time and EMT arrival.  If you're trying to save the old lady's life, then you call 911 and do everything you can to save her life.  If you're not attempting to save the old lady's life, as if she had a DNR, then you call the coroner.  You don't, however, half-ass resuscitation efforts when you commit to them, where quick action with CPR is the best (and really only) available treatment option at that point.  I don't claim to know the facility's policies on medical treatment for their residents other than what was said on the 911 transcript.  I have a hunch that their "rule" about not giving residents medical treatment was just stating that they don't dispense medications, provide nursing staff, etc. on the premises, and had nothing to do with whether emergency treatment was offered if needed.  Otherwise everyone in the facility would have to possess a DNR, much like a hospice facility.  So I think this case represents more of a lapse of judgment and moral compass from one or a few individuals involved in the early stages of the old lady's care.

But is CPR always necessarily started after every heart stops?  Of course not.  Let's put aside the cases where advanced directives and DNRs govern that no attempts at resuscitation be performed, and instead look at those cases where the patient has either expressed a desire for life-saving measures or has not made their desires known.  The first case appears easy; we would assume that anyone who wants CPR in the event their heart stops would get it, and for the vast majority this is absolutely true.  We'll save the exceptions (gasp!) for later.  The second case, where the patient has not voiced his or her desires, becomes a little more tricky.  Luckily, the American Heart Association again provides some guidance.  They recommend that resuscitation be performed on all patients unless:

1. The patient has a valid DNAR order.
2. The patient has signs of irreversible death: rigor mortis, decapitation, or dependent lividity.
3. No physiological benefit can be expected because the vital functions have deteriorated despite maximal therapy for such conditions as progressive septic or cardiogenic shock.
4. Withholding attempts to resuscitate in the delivery room is appropriate for newly born infants with —Confirmed gestation <23 weeks or birthweight <400 g —Anencephaly —Confirmed trisomy 13 or 18

So here we have only four instances where CPR can be withheld.  The first describes a DNR (DNAR = Do Not Attempt Resuscitation) situation.  The last describes newborns with devastating conditions.  The second is simply stating that you don't attempt to bring a cold, dead body back to life.   Also, if you are going to do CPR, make sure your patient's head is still attached to their body.  The third instance is where we will spend our time, as there is much room for interpretation.

In that third instance we're basically seeing that the AHA allows for the withholding of CPR based on a description of futility, and in fact their paper defines both qualitative (quality of life) futility and quantitative futility, the latter associated with factors such as arrest time, initial heart rhythm, comorbidities, and an ultimate "calculation" of chance of survival.  AHA recommendation is to take quantitative futility into account when withholding CPR, due to the wide physician-patient disagreement in terms of quality of life assessments.  This is all well-and-good, but we really don't have a way to give a great "calculation" for such an imperfect science, at least not yet.  As they point out in the paper, at what % chance of survival do we withhold resuscitation?  Do we have to wait until there is an absolutely 0% chance of survival?  Is the cutoff 1%, 5%?  In the end, a lot of this quantitative junk gets turned into a qualitative decision anyway, as we really don't have a good idea how to use the calculations we derive.  Basically if the doctor thinks CPR will be futile, that maximum treatment has been administered to no avail, resuscitation does not have to be started.

You're in for a treat now.  Get ready to have your mind fucked and your moral senses irked.  We're going to talk about slow codes.

During a regular Code Blue in a hospital, in which life-saving treatment is likely necessary, organized (and sometimes disorganized) chaos ensues.  Nurses are usually the first on the scene and the first to pull the code alarm.  The operator overhead pages a code blue with the location, and anyone on the code team usually gets a page or a call on their hospital phone to the same effect.  These are the times you see doctors running down the halls, because, as we've discussed, prompt resuscitation is key for improving the odds of survival.  Advanced Care Life Support (ACLS) is initiated, if required, and usually about 10-15 people gather in the patient's room, including nurses, physicians, med students, and sometimes a designated team to provide chest compressions.  This all happens within seconds of the original code being called.

Let's back up for a second and talk about an elderly patient named Mr. Z.  He's a grouchy old man, but he's also very sick.  He's had heart surgery in the past to repair a valve and unblock some coronary arteries, and he had a partial bowel resection for colonic perforation 6 months ago.  Since then, his health has declined, and he had a number of enteric fistulae develop (small openings in the skin tunneling down to the bowel, constantly leaking bowel contents), and he has required increasing amounts of oxygen.  Heart failure is creeping up, and he has not really gotten out of bed since his operation half a year ago.  He's currently the patient with the longest stay in the hospital.  Numerous attempts have been made to inform him of his ill-fated situation, but he insists that all resuscitative efforts be made in the event his heart stops, and his distant, ill-informed daughter agrees.  If his heart actually does stop, it is very likely that Mr. Z would not survive resuscitation due to his comorbidities.

So what if Mr. Z's heart stops beating?  On the one hand, he aggressively stated that he wanted all attempts at resuscitation.  On the other, the man is extremely sick, and the CPR probably wouldn't help much, if at all.  There's no 100% guarantee that it wouldn't work, however, and we may be able to bring the man back to life, albeit at best in the same condition he's in now, probably worse due to all the trauma induced from the procedure itself.  So, pretend for a minute that you're the attending surgeon coming on the general surgery service for the week.  You have to tell your residents what you want done if Mr. Z's heart poops ou in the middle of the night.  What will it be?  Resuscitation or no resuscitation?

Before you answer the question in your own mind, there is one more option.  Hardly discussed outside of the hospital setting, your third option is to perform a slow code on Mr. Z.  At this point in the discussion, all ethicists familiar with this topic start to get sweaty palms and their anal sphincters start puckering.  A slow code is an attempt to clear up a situation like Mr. Z's, to provide him with the requested resuscitation while at the same time allowing nature to take its course, so to speak.  Here's how it works:

When Mr. Z collapses on the floor or wherever, a Code Blue is called just as any other code.  The decision to perform a slow code lies with the physicians, and often times the nurses will be performing their duties as they would during any other code.  However, when the residents and attending physician get their pages about the code, everyone will take their time getting to the room, in hopes that Mr. Z peacefully passes before they start running the code in the room.  Instead of seconds, sometimes it will take the physicians a few minutes to get to the room.  Once there, CPR is continued, but compressions are not as deep, not as frequent, and the goal is to not cause trauma to the chest.  CPR is also not maintained as long as it would be in a full code.  Pretty much no one is brought back from slow codes, as the half-assed effort does not truly circulate any blood to the individual's brain.   It's an elaborate show, good enough to say a code was run but not quite satisfactory to win a tug-of-war game with death.  Of important note, no mention of the words "slow code" or similar jargon appear anywhere on the patient's chart.  It also stirs some pretty strong feelings in a vast array of fields, including ethics, nursing, sociology, anthropology, and law.  It really pulls on some moral heartstrings (ha!), and causes everyone involved to spend some time in reflection about their own values and the field of medicine as a whole.

So now you have three options for Mr. Z:  Full resuscitation, no resuscitation, and a slow code.  Remember, you're in charge of a life here, so choose carefully!

I have to admit that I'm very uncomfortable with the idea of slow codes.  They're deceitful, and they parallel the case of the  "nurse" lady not providing CPR to the old lady at the living facility, where a half-assed resuscitation was attempted as well.  But I'm not convinced that they are entirely evil either, and though I would hope that I am never in the situation of making a decision about running a slow code, I can't say that it would be absent from my repertoire of options.  It's a slippery slope, I wholeheartedly agree.

My last bit of advice for nurses, medical students, and anyone else who finds themselves with a coding patient on their hands without a physician in the room, regardless of a discussion about slow coding the patient was brought up, is to perform a code aligned with the patient's wishes.  If his or her wishes aren't known, I would still give every ounce of my effort into appropriate resuscitation, and wait for a physician to make the final call about the course of the code.  Mr. Z's case resembles that of a patient encountered on my surgical service, and though the patient never coded, the decision was made by the attending to perform a slow code if the situation presented itself.  As an aside, nursing got wind of the plan, and made a formal statement saying that they would not be participating in a slow code if physicians were not present, which, as I mentioned, I find to be perfectly appropriate.

I have much more that I would like to discuss on all of the topics I've covered in this novel of a post, but I'll save everyone's eyes and possibly put up a few smaller posts in the coming weeks.  I'd love to hear other opinions on the "nurse" lady and her actions, as well as the morality of slow codes, as I'm trying to master my moral compass on the matter as we speak.

Meaningful research and the "antibiotic apocalypse"

I wanted to share a recent article at BBC news that caught my eye, especially considering a conversation Mike, Jim, and I had just the other day regarding the argument that any kind of public health service in the U.S. would hurt medical research, which is currently funded in large part by American pharmaceutical companies.  It seems to me, at least, that the general assumption behind that argument is that nobody else in the world is making real, significant contributions to medical discovery and that if the U.S. offers a public option, which could hinder pharmaceutical profits, then research will suffer.

The BBC news article discusses a new project examining life from isolated areas of deep oceanic trenches for fresh ideas on antibiotics.  The two things I wanted to sort of highlight from the article are: 1) the research is being led by scientists from Aberdeen University in Scotland, a country that coincidentally has a public health service; and 2) the last sentence of this quote - the bold font is mine:

"Project leader Marcel Jaspars, professor of chemistry at the University of Aberdeen, said: "If nothing's done to combat this problem, we're going to be back to a 'pre-antibiotic era' in around 10 or 20 years, where bugs and infections that are currently quite simple to treat could be fatal."
He said there had not been a "completely new" antibiotic registered since 2003 - "partially because of a lack of interest by drugs companies as antibiotics are not particularly profitable"."

It's cherry-picking, I know, but I wanted to share because we were just talking about the idea.  Money is absolutely important when it comes to research. But maybe the approach and general philosophy behind research can and should sometimes be of greater importance than who can dump the most money into a problem (and the foreseeable profit that can be made from a discovery).

Work Hour Restrictions--Resident Opinions

How convenient!  In the latest issue of the New England Journal of Medicine, there is a follow up study on the new resident work hour restrictions, last updated in June of 2011.   The researchers decided to send a survey out to current resident physicians, asking how they liked the new 80 hour work week and how their medical training and lifestyles have been altered due to these restrictions.  I thought there were quite a few interesting results of the survey, and I'll talk a little about what I've noticed in the hospital as a result of all these changes.

In 2003, the 80-hour work week restrictions were put into place, stating that residents could not work more than 80 hours per week, averaged over a month.  Shifts were limited to 24 hours + 4 hours for educational purposes (i.e. lectures), and call was limited to every third night.  In 2011, shifts were cut for interns to 16 hours + 4 hours, but higher level residents were still held to the 24 + 4 limitation.  (Here is a table comparing the 2003 and 2011 regulations) As would be expected, there was a slight outcry in the medical community that duty would be shifted from interns to higher level residents, since they worked longer shifts.  People complained that continuity of care would be lost for interns and that they wouldn't be as prepared for subsequent years in residency.  People on the other side of the argument said that more medical mistakes were being made because residents were so tired and overworked.

Let's see how the residents felt about all of this.

First off, 123 of the 682 ACGME-accredited residency programs participated in the survey, and the researchers received a 23.3% response rate from residents at these programs (6202 individuals).  All specialties and subspecialties seemed to be well-represented, with internal medicine the largest group, composing 28% of the total responses.  The responses to the questions were based on a simple, 3 point scale:  worse, unchanged, or better.  If you take a look at table 2 in the article, you can see what the doctors thought of the new changes.  In summary, it seems that residents thought that the safety of patient care, the amount of rest they get, the availability of supervision, and the total number of hours worked this year as compared to last year remained unchanged after the new 2011 regulations.  The only thing that was remarkably better, according to the survey, were the quality of life for interns.  About 30% of those polled felt that they get more rest after the restrictions, and about 30% feel that their work schedules are better.  The things that were remarkably worse after the new restrictions were quality of life for senior residents, work schedules (43% felt they got worse), and preparation for a more senior resident role.  The quality of resident education overall was either unchanged or worse after the 2011 restrictions.  As feared, the number or frequency of handoffs in patient care was thought to have increased, as was the frequency of senior residents taking on work of more junior residents.  I would have liked to see a better breakdown of the responses, especially by specialty and by year of residency.  I'm sure they have this data, it just wasn't presented in the article.

In conclusion, 48.4% of residents disapprove of the 2011 regulations, 28.8% are neutral, and 22.9% approve of them.

Wow!  I bet the ACGME isn't too happy about the results of this study.  Unfortunately, I haven't been working in hospitals enough to really confirm for myself whether these 2011 changes, coupled with the 2003 restrictions, have or haven't been beneficial.  I do see a lot of work getting dumped on senior residents because the interns have to go home, so as not to go over their hours.  I have also noticed a TON of handoffs occurring, and I have noticed that many things often get lost in the mix.  Imagine the "telephone game," where one person whispers something into someone's ear, then they whisper something to the next person, and so on until the original message returns very distorted from how it started.  In a milder sense, this is what is happening with increasing handoffs in medicine.  The more whispers, the more can get distorted or misunderstood.  I actually have seen some pretty important information missed during a handoff that made for a poorer outcome for a patient.  If residents were at the hospital for longer periods of time, the argument would be made that they retain the continuity of care, know the patient's story, and are less likely to miss a small detail as compared to a resident who just acquired the patient 2 hours ago during a handoff.  The resident who has known the patient for 2 hours is obviously less invested in the patient, as opposed to someone who was paying close attention to that patient for a continuous 20 hours.

I have also seen work hours being violated in certain departments, especially surgery.  One of the main problems with how this system is set up revolves around the reporting of work hour violations.  Residents who want to file a work hour violation complaint are NOT protected by whistleblower laws.  This isn't anonymous reporting.  Also, why would any resident want to report work hour violations, when the penalty to their program is loss of accreditation if these violations pile up?  If the program dissolves because of the violations, residents are left out of a job, and it becomes infinitely harder to get licensed.  Anyone with common sense sees that you're just shooting yourself in the foot by reporting work hour violations.  That's why resident work hours are believed to be vastly understated, especially in specialties such as surgery and OB where very long days are the norm.  We clearly need a better reporting system.

There are a few studies out there that disagree whether morbidity and mortality is actually increased or not when residents stay up for long periods of time.  It really seems like these arguments for or against work hour restrictions are based more on anecdotal and theoretical evidence than hard facts.  One thing is clear from this study, however...residents aren't too happy with the 2011 regulations.  It seems to me that, if there really isn't a difference in patient outcomes with longer hours and residents aren't a fan of the current system, maybe some further adjustments have to be made with these regulations.  As it stands, I find myself leaning more towards having longer hours for residents.  I like continuity of care, and I personally hate handing off patients every 12 hours or so.  I feel less responsible for my patients, less connected to them, and ultimately less interested if I know that the next team will be handling the brunt of my patients' problems during their shift.

I'd be interested in seeing if Stanek has run into anything regarding this stuff during policy-making discussions.  I don't know much about the financial aspect of these regulations, or the implications on federal/state/hospital policy.

I'd also be interested to hear whether nurses and other staff have noticed a difference in patient care now that the new regulations are in place, or if things have remained about the same for the past 10 years.  What does everyone think?

Jim

Be Nice to Residents

So it's 5 am and I'm on my 2 week internal medicine night rotation, sitting here in the resident's lounge on the top floor of a huge hospital. We haven't seen a patient in 7 hours because the day team already "capped", meaning we can't accept any more patients tonight unless they are bouncebacks to our team. My two residents went to the call rooms to sleep (I certainly don't blame them!), leaving me to watch old reruns of sportscenter and the history channel. It's actually a nice time to reflect on topics that I haven't thought about in a long time, just because I've been so busy studying. One of the things I've been meaning to discuss on the Speakeasy pertains to residents, the docs that actually take care of you when you're an inpatient at the hospital.

Let me preface this by saying what I'm going to talk about applies mostly to large teaching hospitals, not the smaller community hospitals that do not accept resident physicians. A lot of people don't realize that, when they are admitted to a large hospital, most of their care is not managed by seasoned physicians like House. Usually a team of doctors, who aren't that far out from med school, are the ones really taking care of you. This team includes interns (first-year residents right out of med school) all the way to 5th year senior residents in some specialties. It's a hierarchy of power and decision-making capacity, designed to deliver the best care while providing the most education for these new doctors.

I want to run through what usually happens if you come into the ER at 2pm with a simple complaint like a skin infection (I'm going to pretend you're one of the patients that we saw tonight). You'll probably spend a few hours in the waiting room, depending how busy the day/night is. Unfortunately for you, your ailment isn't nearly as urgent as the 40 pack-year smoker having chest pain, that guy on a motorcycle who was just hit by a semi, or the little old lady with dementia who fell on her hip. You could be waiting for a couple hours just for an ER room. Once you get one, you'll probably spend another hour answering questions from a nurse, having vitals taken, and answering questions from another nurse. Then, if there haven't been a ton of other admissions to the ER more urgent than you, you'll get to be seen by an ER intern. He/she will ask you a bunch of questions, going over all of your past medical history and the history of your current illness. Then you'll wait as the intern eventually meets up with the chief resident or attending (depending on who is at the hospital at the time and how serious your complaint is) to present your case. The attending will eventually get to see you, popping his or her head into your room to eyeball you. They make a decision on whether to consult with the intention to admit or "treat and street", meaning they take care of you in the ER and send you home right from there. If they suspect that you will be admitted, the whole cycle starts again. In your case, they consult internal medicine, and the intern (with a medical student) comes down to the ER to see you. They ask you all of the same questions that the other resident asked, but because they're a different service, they have to ask you everything again so they can put it in their history and physical on the Electronic Medical Record (EMR). Once they are done, the intern presents you to their chief, and the chief comes down to see you (and often asks the same questions again, filling in any gaps the intern missed). The chief resident decides whether to admit you or not, in most instances. Not the attending. The attending is probably asleep, because by the time that decision has to be made, it's 11:30pm. regardless, it takes about a half hour to put in orders into the computer to admit you, and you find yourself in a room around midnight, finally ready to sleep.

Not many people actually know how much is decided for you by the resident when you go to the hospital. Let's start with your skin infection. They have to decide whether it looks bad enough to get surgery involved in your case, or whether it can be managed medically. You'll need IV antibiotics, labs, and an x-ray if a bone infection is possible. You also need IV fluids, depending on the labs drawn in the ER. If you were taking medications at home, those have to be reviewed and either continued or discontinued in the hospital. You have to be put on a diet, you have to be given bathroom privileges, and orders for tomorrow morning have to be put in (especially for labs). Contact precautions, because the last time you were in the hospital you had a MRSA infection, have to be initiated. You will need cultures of your skin infection, as well as nasal cultures, to prove that you are a MRSA carrier during this hospitalization. These are just some of the dozens of decisions and orders that have to be made for you, the easy patient with a simple skin infection. Imagine a patient with 12 current medical problems, with crazy abnormal labs, needing a slurry of decisions and orders to be made for each of these problems. Even though only one of those problems may have brought them to the hospital, they all have to be managed appropriately for the duration of their stay. The point of this is that residents do a shitload of decision-making and are really in control of over 95% of your treatment while in the hospital.

Ok, back to your skin infection. In the morning, you'll be bombarded by questions from the new nursing staff, medical students, and a whole new day team of residents. They will all have a meeting with the attending during or before morning rounds, talking about you and how to manage your problem. The attending will probably make only a few adjustments with the orders, everything else being taken care of by the night intern who admitted you or the day intern that you saw very early in the morning. Around 11am, the entire student/resident/attending team will show up in your room, the attending will say a few words to you and wish you luck in your recovery. Depending on their schedule, the attending will probably leave in the early afternoon to take care of other business, or more complicated patients. But to bill for the entire hospital stay, the attending must "lay eyes on you" at least once per day. That's it! He or she really needs to only see you for ten seconds. The attending will sign off on the resident's progress note, and the next time you will see the attending will be around 11am on the next day. Every question that the nurses have about you will go to the intern first, the up the food chain of residents until it gets to the chief, if it needs to go that far. Usually everything is taken care of by the intern. Unless something very serious happens, the attending will only find out about the previous day during the next morning rounds. Things can get much more complicated if multiple consults are made, or if you have procedures done to treat your illness. But for the sake of argument, we'll say that you didn't need any consults and you didn't need to have that skin infection drained.

Because you're such a healthy patient otherwise, your IV antibiotics do a good job taking care of that skin infection, and in a few days you're ready to go home. Before you can go, the attending must again "lay eyes" on you that day...then you're free to go! The residents handle most of the paperwork, including the discharge summary that goes to your primary care doc (and any other pertinent healthcare providers) summarizing your hospital visit. Oh, and they are most likely handling about 7 more patients more complicated than you at the same time they are taking care of you and your skin infection.

So the point of all this, if you made it this far in the post, is to demonstrate how much residents actually do for you while you're in the hospital. A lot of people immediately ask for the attending when they get here, not understanding how the system really works. In fact, consider yourself lucky that you're in a hospital with residents in the first place. A lot of smaller hospitals don't have this resident backbone, and in my opinion this can cause your healthcare to suffer. A lot of double-checks and discussion about your case takes place in these larger hospitals, both between residents and students, residents and residents, and residents and attendings. All this communication can only help when it comes to improving a treatment plan...the more minds, the better. However, you'll be sacrificing in time what you gain in brainpower, a concept that many patients don't understand when they come to very large hospitals. They assume that care will be faster because there are more resources, more staff, and more collective experience in the bigger hospitals. That's definitely not the case, and you may be waiting a very long time if you have a relatively minor complaint (minor in the eyes of the healthcare providers--I understand that even minor things can seem really scary and bad to patients).

One moral of this post is that everyone should get a primary care doc and go to them when they have smaller issues (or call them when you're not sure). I should practice what I preach, since I don't have a primary care doc while in med school, as don't many med students and residents--a topic for another post!

The real moral of this post is to be nice to your residents when you go to the hosptial. I'll try to talk a little more about resident work hours in yet another post, because this is one of the hottest topics when it comes to resident education in the US. Just remember that you are lucky to have them, as they are also lucky to have you as their patients and to learn from you. Consider that extra time you spend in large teaching hospitals to be a good investment in your health, since so many problems and mistakes get caught by people other than the lone attending watching over you from a distance, especially by residents and students (and nurses--another post topic!)

I'm really setting myself up for failure by suggesting all these future post topics...but hopefully I'll have some time on nights to address all these things. Let me know if there's something that strikes your fancy that I might be able to talk about more in depth. I want to get some quality stuff on here in the next two weeks.

Jim