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Thursday, April 16, 2015

"Hippocratic Oaf"

I can come up with pretty good, snarky ("clickbait"?) blog post headlines, but this one can't be improved upon.
Hippocratic Oaf: My First Day as a Doctor
I was technically a real physician the moment I walked through the hospital doors, but I quickly realized that medical school had left me woefully unprepared.


...In medical school, I had moved through  rotations in surgery, neurology, psychiatry, radiology, internal medicine, pediatrics, and finally, obstetrics, where a young Jamaican woman let me deliver her child on my first day. She insisted on giving birth on her hands and knees, her back arched like that of a cat as the baby slowly emerged. An amused midwife later said that I had looked like a nervous quarterback, receiving a snap in slow motion.

As graduation approached, choosing a specialty had proved to be difficult. Ultimately I had settled on internal medicine because it was the broadest field, the one that might allow me to feel like a jack-of-all-trades. But tonight was my debut in the big show, a 30-hour shift taking care of critically ill patients and responding effectively to anyone who might roll through the door...

Until a few days ago, I had never set foot in a cardiac-care unit. Nothing about the setup looked terribly familiar. I continued to study the room, trying to decode the symphony of incessant beeps and alarms and wondering what each of them meant. It felt like I was sitting in the middle of a giant equation with infinite variables...

Baio wiped off the bagel crumbs on his scrubs and leaned in close to me. “We have to work as a team. Everything is teamwork. So I need to know what you’re able to do. The more you can do, the more time I have to think about the patients. So rather than listing the shit you can’t do, tell me what you can do.”

My mind went blank. Or more accurately, I searched it and found it was blank. “Well …” I glanced at the sedated patient before us. He was on a ventilator and had a half-dozen tubes in his neck, arms, and groin, almost all of which pulsed with medications I’d never heard of. As a medical student, I had been exposed to all sorts of patients. But all of those encounters had involved walking, talking, reasonably well-functioning individuals. Lying there, inert and blanched of all color, the patient before me seemed well beyond the reach of my limited powers. If he needed his appendix out or his face stitched together, I was his man. But intensive cardiac care? The learning curve in medicine was so unforgivably steep.

Finally Baio broke the silence. “All right,” he said, “I’ll start. Can you draw blood?”


“Can you put in an IV?”


“Can you put in a nasogastric tube?”

“I can try.”

“Ha. That’s a no. Ever done a paracentesis?”

“I’d love to learn.”

He smiled. “Did you actually go to medical school?” Even I had to wonder. If Baio had been asking me to recite pages from a journal article on kidney chemistry or coagulation cascades, I could’ve put on quite a show. But I hadn’t learned much of the practical business of keeping people alive. In fact, I had been allowed to skip the CCU month of my med-school training at Massachusetts General Hospital so I could learn tropical medicine in Indonesia. Who had talked me into that?

“I graduated from Harvard earlier this month.”

“Oh, I know you went to Haaahvaahd,” Baio said with exaggerated fake reverence. “But do you know how to order medications?”

A bright spot. “Some!” I practically beamed.

“Do you know how to write a note?”

“Yes.” The moment I said it I realized just how paltry a contribution it would seem to him. Baio must have seen my face drop.

“That will actually be a big help,” he said. “Examine every patient and write a note on them for the chart. That will save me time. You need to be concise yet precise.”

I grabbed my small notebook and scribbled examine everyone/write notes...
Matt McCarthy, MD, is the author of this new self-effacing book, which has been on my get-and-read list since I first learned it was coming out. Just downloaded the Kindle edition.

Sometimes I read linearly, cover-to-cover. Sometimes I read a ways in, and then cut to the concluding chapter(s) prior to going back and finishing all of them. Sometimes I scan the table of contents, looking for specific topics.

In this case, I first used the keyword search function: "health IT"? "health information technology"? "EHR?" "EMR"? "digital"? "interoperability"?

Nothing. Nada. Nyet. Zip. Zilch. "0 matches found"

OK... "chart"?

"23 matches found"


I logged in to the computer and found my patient panel. I was scheduled to see patients in thirty-minute increments from 1: 00 P.M. until 4: 30 P.M. Opening the medical record of my first patient, I felt a small thrill as I prepared to jot down notes about him, a fifty-three-year-old man who had been coming to the clinic for several years. I opened the last note from the previous primary care provider. But as I read, my eyes almost instantly went crossed.

The note began: Problem List
1. HTN
2. CKD
3. CAD
4. TIA
7. PVD
8. Migraines
9. ED 1
0. DM2
11. BPH
12. Active tobacco use
13. Depression
14. HLD
15. OSA on BiPAP
16. Afib on Coumadin
17. Glaucoma?
18. HCM: needs c-scope
What kind of patient had eighteen different problems to deal with? It seemed like I’d need a team of specialists in the room with me just to provide primary care. Sifting through the befuddling acronyms, I felt my stomach turn. I recognized some of the letter combinations, but every unknown acronym felt like a small knife in my side. Were they using a different set of abbreviations at Columbia? I suddenly missed the immediacy of surgery, of just fixing something right then and there, showing Axel, and moving on. I reread the note from the beginning and began Googling the various combinations of letters that weren’t immediately recognizable.

My palms broke into a light sweat as I typed. What if this patient had other problems— problems that weren’t on this list? Patients were more likely to focus on things they could feel, like a sore knee, than on things they couldn’t, like diabetes or high blood pressure. How could I possibly address old issues and new ones in one short clinic visit? While the computer performed the search, my thoughts drifted back to Carl Gladstone, as they had every time I found myself with a moment of free time. Was he going to be okay?

I had to say something.

After twenty distracted minutes I was only a third of the way through the patient’s medical record, but sitting behind the large desk I did feel somewhat like a real doctor, at least more than I did in the cardiac care unit. Feeling a moment of modest inspiration, I hopped up from my swivel chair and decided to test out the blood pressure cuff. In medical school I’d always found the contraption cumbersome and knew from experience that fumbling with it would be a dead giveaway that I was new in town. Once satisfied that I could hold the stethoscope in place with one hand while pumping up the cuff with the other, I returned to the medical record. After fifteen more minutes of referencing and cross-referencing, I had to shut my eyes.

Was it really possible to memorize and retain all of this knowledge? And more important— was it necessary? Or did real physicians retain a core of crucial information and simply look the rest up on the fly? Baio seemed like he’d seen it all before, drawing on experience to guide his decision making. As I dug deeper into the chart and all hope of diagnostic parsimony appeared lost, there was a knock at the door.

I sprang up from my chair and opened the door.

“Dr. McCarthy,” the receptionist said, “your one P.M. is here.”

“Okay,” I said. “Great.”

“Do you want to see him?” she asked.

As I glanced at my notebook, I momentarily wondered whether any answer besides yes would be acceptable. In truth, I thought I’d need another hour before feeling prepared to see the patient.

“Well,” I said, folding my arms, “I suppose I should—”

“It’s one forty-seven P.M.,” she said. “He was almost an hour late and your one-thirty P.M. just arrived.”

“He seems kinda sick,” I said.

 “Maybe we could do a shorter visit or—”

“I’ll send him in,” she said and closed the door.

A moment later, a stocky bearded man in a faded barn jacket entered the room and extended a callused hand.

“Sam,” he said firmly.

“Matt. Mr. McC—— Dr. McCarthy. Please have a seat.”

I waved my hand across my desk like I’d just performed a magic trick. “You actually gave me some time to familiarize myself with your chart.”

The fact that Sam was even upright and walking into my office under his own power came as a small surprise . After reading the long list of conditions in his chart, I was expecting a borderline invalid, but Sam looked rather well. He was husky, with shaggy gray hair that drooped into his eyes, and if Heather saw him on the street she might whisper to me that he looked like a sheepdog. “Terribly sorry I’m late,” he said. “Didn’t know you guys still used charts.”

His smile revealed crowded, champagne-colored teeth. “It’s mostly computerized,” I conceded, “but yes, some records are still on paper.”

McCarthy, Matt (2015-04-07). The Real Doctor Will See You Shortly: A Physician's First Year (pp. 56-59). Crown/Archetype. Kindle Edition. 
After slogging through all of the passages containing the word "chart," I found nothing else discussing the use of health IT.

How about searching the word "computer"? "18 matches found." But, not all that revealing.
Ashley had greeted me that morning by saying, “Don’t do anything without running it by me first. Are we clear?” Before I could respond, she’d launched into the array of tasks that needed to be completed before rounds— rattling off assignments like wheeling a patient to dialysis and transporting a vial of blood to the chemistry laboratory— faster than I could write, and then withdrew the work delegated to me just as quickly, explaining that it was quicker if she just did everything herself. This was becoming a regular routine, and it made me feel expendable and potentially dangerous. It was clear she considered me a liability, someone who still couldn’t enter computer orders related to HIV care or write notes as proficiently as she could. Our brief exchanges were reminiscent of a naughty child and a frustrated babysitter. Her friends called her Ash, but she’d instructed me to call her Ashley. The intentional distance she put between us made me anxious. Even though we were hardly a personality match, I wanted to click with her. I wanted to click with everyone...

I no longer trusted myself to remember anything unless it was written down. There were literally hundreds of small tasks and new factoids that popped into my brain over the course of the day, and I found it impossible to keep track of them all without committing them to paper. And prioritizing it all required yet another set of skills. “Yes, ma’am,” I said awkwardly. My daily scut list looked like a madman’s diary, every inch covered in scrawl. I often thought of Axel, imploring me not to write on my hands. “

And if I can give you one piece of advice, it’s this: be efficient.” 

“I’ll do my best.” 

“But efficiency necessitates competency,” she said. “There’s too much to know. Information is generated so quickly. And at your stage you’re still trying to learn the basics.” Again, Ashley was right. Scores of scientific journals were constantly churning out new and at times contradictory medical information. We would never have time to read it all and were in need of a competent curator. In many ways, Baio had filled that role for me in the CCU . But I needed to do it myself now... [ibid, pp. 112-114].
Notwithstanding the paucity of health IT references, this looks like a worthy read. It's amiably well-written and painfully candid through the six chapters I've thus far read.

All part of my endless contextual learning quest, always trying to better grasp the clinicians' point of view as it pertains to clinical pedagogy, physician workflow, and the ever-increasing, inexorable use of digital health IT as part of workflow.

Just some of the clinician-focused books I've cited in this blog:

apropos of "pedagogy,"
Forget SXSW - Austin's Most Radical New Idea May Be In Medical Education
David Shaywitz

Austin, the birthplace of Whole Foods, Dell Computer, Heritage Boot (just bought my first pair), and SXSW (never been) is in the process of launching something even more radical: a fundamentally new way to think about medical education and the role of an academic medical center.

At the core of this effort is a new medical school to be built in Austin, funded in part by revenue from an increase in local property tax (Proposition 1, approved in 2012) and in part by a gift announced in 2013 from the Michael Dell and Susan DellFoundation, after whom the school will be named.  The first class is slated to begin in 2016.

The big idea – at least from the perspective of the founding team – is this: traditional academic medical centers are (as they see it) essentially clinical care factories that throw off a lot of revenue, a small fraction of which is used to support (on average) 50% of the research and 90% of the educational activities associated with medical schools.

Like many health policy experts, they look at the healthcare system, and see a huge amount of “waste” (“waste” was perhaps the most common word I heard in my conversations) – unnecessary or inefficient care, and the costs associated with this waste.  Or rather, in the case of most hospitals, the enhanced revenue associated with this waste.

How can you expect a medical school to train physicians to think innovatively about reducing waste, or pursue serious research on waste reduction, the new Dell Medical team asks, when the results of this waste are responsible for such a large share of medical school revenue?  One leader at Dell Medical described this as “the ultimate conflict of interest.”

As if this wasn’t enough, I also detected an undercurrent of concern from Dell Medical leaders that much of the research agenda at traditional academic medical centers tends to be driven by reductionist basic scientists, keen to defend and if possible, augment their territory.  Their approach, Dell Medical executives seemed to suggest, are often not informed by the sorts of broader questions you would ask if you were truly focused on improving the health of the population in front of you.  The implication is that the direction and emphasis of traditional academic medical research is driven more by the political power wielded by scientists rather than by any concerted effort to discern and respond to the actual health needs of a community, which may require less focus on molecular description, and on more on prevention and care delivery...
Interesting. Go onto this by way of my daily stop at The Incidental Economist.


I could not attend HIMSS15 in Chicago. Health issues. Nice recap by Katie Bo Williams here.
What you missed at HIMSS15: The biggest announcements, afterparties and IT buzz

More to come...

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