One of the new initiatives in healthcare reform is called the Affordable Care Act (ACA) which requires that all participating hospitals and clinics be reimbursed by Medicare based on the quality of care they provide.
In the Emergency Department, we treat a wide variety of patients, so you must learn how to harmonize with everyone from CEOs and celebrities to blue-collar workers, alcoholics, drug dealers, criminals, feisty old folks, exhausted parents, defiant teenagers, babies, and everything in between.
As a first year resident in Emergency Medicine — I have had many colleagues ask me one simple question, “What about burnout?” To be honest, I never quite understood why so many non-Emergency Medicine colleagues seem to think burnout is more likely to occur in Emergency Medicine than in other specialties. Perhaps because Emergency Medicine is so appealing, that it must be too good to be true!?
But let’s be honest, working as an ER doc is probably more stressful than you imagine — but a career in Emergency Medicine is also vastly more rewarding than you likely realize. You will have some people wrap their arms around you and not want to let go, but you’ll also have other patients who will want to rip your spleen out and eat it. At the end of the day — saving lives is arguably the most important and rewarding job in the world. As an Emergency Physician, no other specialty will give you so many opportunities to help so many people in so many ways.
To the consternation of young physicians, the general public perception is that all medical practitioners are wealthy, which may be the reason why we hear so much grumbling over the cost of health care costs. What is largely lost on the public is that the vast majority of physicians begin their careers deep in a hole both in terms of money and time. It is difficult for the average person to fully gauge, let alone appreciate the monetary and time commitment that goes into preparing for the profession. Even before they confront the lifelong challenge of building personal wealth from a medical practice, new physicians are lined up well behind the starting line for a number of reasons..
If you’re finishing up residency or fellowship, you’ve spent the last 4, 5, 6, 7, maybe even 8 years being paid about 18 cents per hour. Now you’re out there looking for your first “real” job. So when someone comes along and offers you a 6-figure salary, it’s tempting to accept it, no matter how unfair the offer actually is. Unfortunately, some employers are anxious to take advantage of young physicians who are desperate to take any job that will help them begin to pay off their enormous student loans. So many times young physicians wind up accepting compensation under their physician employment agreement that is not up to par with market standards. After all, it’s hard to know what the market standard is when you don’t have access to national physician compensation benchmark data. Before you accept a physician employment contract offer, be sure someone is looking out for your financial and legal interests.
Many physicians, especially those fresh out of training, are hasty about accepting the first job offer that comes their way because they have enormous student loans to pay off, and they haven’t yet endured a horrific employment experience that has taught them to tread carefully into any given employment arrangement. After all, when you’re out there looking for your first job, the potential employers are great salespeople- reassuring you that your wants and needs will be met.
The temptation to quit is a traitor. It does not announce itself boldly during the peak of your work load, often you are too preoccupied to ponder on your lack of a life. Instead, it sneaks in during that silent minute in between surgeries, as you slump on the floor and wait for the next patient to be brought it; it sits in one corner as you wait for the elevator doors to open, you holding both stretcher bed and oxygen tank and it’s only an hour past midnight; it whispers in your ear, to wake you up from a nap on the first Sunday afternoon that you get to spend at home in a long time; it holds open your bedroom door, as you don your white coat, grab your stethoscope and keys, and rush to your morning rounds.
Only the patients whom you serve will keep you moving forward. Not pride. Not your family. Not even your ambition.
Please do not get sick in July. Why you ask? Well, you might die. No, we’re not suffering from heat strokes..
In a recent study published by the Journal of General Internal Medicine, there was a 10% spike in teaching hospital deaths during the month of July due to medical errors.
This spike, is referred to as “The July Effect” and it’s attributed to well, us — from the influx of all of us starting our residency training (internship).
The reason behind it? As a medical student, you typically graduate from medical school in June and end up beginning your first year of residency in July. To be honest, as eager as we are to invade the hospital, to care for our patients, and to make real medical decisions, there is just one problem. We don’t quite know what we’re doing all the time.
After at least four years of undergraduate education, another four years of medical school, and the letters M.D. after our name.. we arrive in the hospital (at our first job) with virtually no practical knowledge of medicine. At least we have our ‘peripheral brains’ made up of condensed medical manuals to make up for the lack of knowledge in our actual brains.
Everyone — even doctors, especially doctors — have to learn and train in order to become proficient. Interns start out as rookies, not seasoned veterans. Experience takes time.
So if you have to go to a hospital in July, please treat the interns with patience and respect — then perhaps check with your nurse to make sure we know what we’re doing.
“Two gun shot wounds,” the emergency medical technician says, breathing fast, the summer night pouring down his face. “One in the right flank, one in the right thigh.”
“I don’t want to die, doc,” pleads the victim, whom I will call Mr. Smith. His vital signs are stable.
“This is the trauma team,” I say. “We’re going to take good care of you, but we need to ask lots of questions.” I press my stethoscope to his chest. “Can you take some deep breaths?” I listen for the airy hollow of a punctured lung but am calmed by the hum of normal respiration, even as his alcoholic breath warms my cheek — or so I believe. He denies drinking, but this is one of those overnight shifts when everyone — motor vehicle crashes, chest pains, depressions, confused grandmas, even rashes — has thrown back one or two.
Once inside, we palpate Mr. Smith’s neck, chest, back, abdomen, and muscular extremities. “Does it hurt here, and here, and here?”
He doesn’t answer us. Now he acts annoyed and bothered. “Call my cousin,” he says.
“Sure,” I say, “after we make certain you don’t have an injury that needs immediate attention.”
“And you are?” he says.
I’d already introduced myself, but I know what he means: Who am I in the hierarchy? “I’m the doctor in charge,” I tell him.
“Good,” he says. “Go call my cousin.”
“First things first,” I say.
“Hey, douchebag,” he says, his voice hardening. “Call my cousin.”
I pretend the comment was what he might, on reflection, consider a regrettable slip of the tongue. But his head arches off the stretcher and his eyes meet mine. “Now, douchebag.”
I feel the heat of the trauma team’s averted gazes. I say nothing, but inside, I grasp at explanations. He’s been popped with two bullets. Maybe he’s scared, anxious, emotionally shocked. Or he’s a thug, a power-fiend, and now he’s vulnerable. He distrusts authority. Perhaps he is drunk, his tongue greased.
He refuses intravenous fluids, blood draws, x-rays. “Let us take care of you,” I say, proffering shared control, thinking he’ll soften up and participate. “You don’t want to die, do you?”
“I’m not afraid of dying,” he says, despite his plea on arrival. “Listen up, douchebag. Are you calling my cousin or what?”
I swallow hard. The ache in my stomach will ease somewhat when I find time to eat my tuna sandwich. But the frustration feels bottomless — untouchable and undeniable. “What gives you the right to talk to us this way?” I finally say.
He stares me down. I tear the blood pressure cuff from his right bicep.
“I’m not fighting you. Many patients are waiting to be seen. You’re free to go if you want.”
He stares at me. “I’m calling my lawyer!”
“Good luck. We’ll dress those wounds before you leave.”
It’s an old joke: a long line of people waits at the Pearly Gates as St. Peter slowly checks them in, taking an eternity. Little guy in a white coat shows up, carrying a leather bag, stethoscope around his neck. St. Peter waves him through. “What the hell was that?” someone asks. “Why does that doctor get cuts?” “Oh, that wasn’t a doctor,” Pete says. “It was God. He just likes to play doctor once in a while.”
But it’s no joke. Whereas I don’t buy the “playing God” aphorism, I’ve had to make life-and-death decisions on occasion, and I don’t like it. I mean “life and death” literally: this person lives. That one dies. Saving a life is nice, and part of the job; failing to save one is horrible, yet inevitable. But deciding in advance — looking at a situation and concluding it best to let things go, or choosing to render help when the outcome might be regrettable — is a responsibility beyond understanding. Maybe it also comes with the territory, but who has the roadmap?
Bowel infarction is a good example. Dead bowel happens for a lot of reasons. Untreated, of course, it’s fatal. In operating, one may find — depending on the cause and the anatomy — a small segment of intestine the removal of which is not only life-saving but free of side effects; or you might find essentially the entire gastrointestinal tract dead and black. Removal in that case is possible, too, leaving the person entirely dependent upon permanent intravenous feedings. Or there might be enough small and large intestine remaining to handle oral intake with or without intractable diarrhea, with or without the need for complicated supplemental nutritional support.
And there you are, in the operating room at three in the morning, looking into a belly. No crystal ball, no outcome-prediction software; no moral counseling or ethics committee with two-cents worth of advice. What resources do you marshall; how do you decide whether to close up and deliver the bad news to the family, or to go ahead? Can you make a decision without interjecting your own moral values? Should you? Surely it’s conceivable that two people might make different decisions; ergo, it’s subjective. Who, then, has the right? Rarely, you may know enough about the patient to have an idea of what he/she would want. But how can you apply that when you’re not sure what kind of life will result from going ahead? Wrongful death? Wrongful life?
The use of mobile tablet computers was associated with improvements in perceived and actual efficiency among residents, according to the findings of a single-institution study.
Bhakti K. Patel, MD, from the Department of Pulmonary/Critical Care, University of Chicago, Illinois, and colleagues published their findings in a research letter published in the March 12 issue of the Archives of Internal Medicine.
The authors note that medical residents spend much of their time working on indirect care tasks such as updating patient medical charts. “Unfortunately, the implementation of electronic health records actually increases time in indirect care and the need for available computer workstations to advance care,” the authors write. “These trends, coupled with the growing information needs for patient care, have led to more time spent locating a computer or working on the computer at the expense of time at the bedside or at conference.”
More than three quarters (78%) of the surveyed residents reported that the use of iPads (Apple) improved their workflow efficiency, with an average savings of approximately an hour a day. In addition, 68% of the house staff reported that delays in patient care were avoided because of iPad usage.
A simple technique dramatically improved the memory recall of Harvard Medical School students. Try it for yourself!
Turning a medical student into a doctor takes a whole lot of knowledge. B. Price Kerfoot, an associate professor of surgery at Harvard Medical School, was frustrated at how much knowledge his students seemed to forget over the course of their education. He suspected this was because they engaged in what he calls “binge and purge” learning: They stuffed themselves full of facts and then spewed them out at test time. Research in cognitive science shows that this is a very poor way to retain information, as Kerfoot discovered when he went looking in the academic literature for answers. But he also stumbled upon a method that really is effective, called spaced repetition. Kerfoot devised a simple digital tool to make engaging in spaced repetition almost effortless. In more than two dozen studies published over the past five years, he has demonstrated that spaced repetition works, increasing knowledge retention by up to 50 percent. And Kerfoot’s method is easily adapted by anyone who needs to learn and remember, not just those pursuing MDs.