Hard working

I’ve never worked this hard.  It’s only been one month, but it is already apparent just how much harder I will be working over the next few years than I have ever worked before.    As a medical student, I had spent 2 years pretending to be an intern, and I thought I had it down.  But there are at least 3 key differences between being an intern and being a student.

1. No one double checks your work.  As a student, 99% of everything you do is repeated by someone else.  Whether it’s your history, your physical exam, the orders you write, the documentation, almost all of it is duplicated by a supervising physician.  Of course I still have supervision as a physician-in-training, but as opposed to 99% duplication, it seems like there’s only about 10%.  That means extra vigilance on my part and an added layer of responsibility if I miss something.
2. Volume.  As a student, you are typically assigned a small number of patients to follow.  As a resident, you are expected to be a work horse.  My first month was in the emergency department, often evaluating and working up four or five patients simultaneously (the more senior ER residents frequently carry seven or eight or more at a time, boggling my mind).
3. Real responsibility.  As a student, you may write notes, orders, see patients, but if you don’t, someone else is responsible for covering what you don’t get done.  Not anymore.  If I don’t do it, it simply doesn’t get done.  That means zero slacking off, delivering 100% on commitments that I make.

I’ve quickly become to feel like a machine at work, powered not by my own volition, but simply by the demands of the environment.  This leads to a certain sense of disembodiment, as though I am watching all of my actions from above, but not directly motivating them.  It almost makes the work easier, as I don’t feel the need to exert willpower to get the job done. I can just watch myself get it done.  But with that comes a degree of depersonalization, and I hate to say that I now can understand the vacant stares I’ve seen on residents’ faces over the last two years.  They weren’t deliberately ignoring me, uninterested, or rude, they were just working hard.  I hope that my realization of this will allow me to fight back against such mechanization and help me to continue to be a human being throughout this process.

Goals

Pauline Chen, MD  had an interesting piece in the New York Times a couple weeks ago about residency training.  She recounts a story of how she lost control and snapped in grocery store line under the stress of her training.  Experiences like this are not uncommon, she explains, and are often the result of burnout caused by the imbalance of personal and professional life that residency often demands.  She speaks with Dr. Neda Ratanawongsa, lead author of a recent study on resident burnout from Johns Hopkins.

“The [residents] who are happier,” Dr. Ratanawongsa observed, “are the ones who have held on to one or two things and have said, ‘I’m not just another resident. I play the guitar, I run races, or I go home to family.’ They don’t do these things to the same extent as they did before residency, but they do them enough to maintain a sense of self.”

Robert Centor, MD offered his advice over at DB’s Medical Rants:

While in training, I always had 3 priorities for my off time.  I played basketball most every off day – even post call.  As an addicted basketball player during that time, I knew that i need the sweat.

I always read fiction.  For some reason I did not feel guilty that I did not just read medicine.

I always listened to music.  Music made me happy then, and makes me happy now.

And my major priority was my wife, and during residency my daughter.

All of this talk of burnout and balance has gotten me a little worried myself.  Our chief residents advised us during orientation that if we could survive this year just with our personal relationships intact, we should consider it a success.

Though I have just barely begun to experience the stress of training, it is clear to me that establishing priorities for my personal life is going to be key to maintaining some happiness.  Setting a few concrete goals seems to be a reasonable way of establishing those priorities (and someone has told me many times that writing down your goals goes a long way towards achieving them).  Here are my goals:

1. Staying close with loved ones.
- I will call my family at least once a week.
- I will talk to my girlfriend in some form at least every other day.
- I will talk to old friends at least once a month (blog comments count!)

2. Fitness/health
- I will do some form of exercise at least 3 times a week, even if only a short jog.
- I will cook at least two meals a week

3. Personal enjoyment/entertainment
- I will  read at least 4 books for pure pleasure this  year
- I will watch Lost, The Office, and 30 Rock
- I will watch one or two movies  each month
- I will write something on this blog at least once every two weeks (hopefully more frequently)

4. Recreation

- I will do something fun outdoors at least once a month
- I will try one or two new recreational activities each year

I will be creating a Goals page to track these goals and keep myself accountable.  Wish me luck!

Day one, as easy as ABC

“HELP! We need a doctor in triage now!”

I glanced up from the computer where I was fumbling my way through the electronic medical record (EMR).  I’d heard this kind of panicked beckon dozens of times before, as a medical student, and I’d learned to calmly look around and make sure that the nearest doctor was hopping out of her chair to run in and save the day.  But as I turned my head from side to side, I realized that the back side of fast track was completely empty, save for myself and the flushed-in-the-face nurse, staring me square in the eyes, and pointing towards triage.

This can’t really be happening, I told myself.  It’s an intern’s worst nightmare: your first day on the job, there’s a catastrophe, and you’re the only “doctor” around.  Except this wasn’t a nightmare.  It was my first day, just a few hours into my first ER shift, there was a catastrophe, and I was the only doctor to be found.  I stuttered as I stood up from my seat, considering whether I should log off the EMR as we were so persistently reminded always to do during orientation just a few days earlier.  In retrospect, it’s clear where my priorities should  have been, but as you might imagine, I was a little nervous.

I ran down the hallway, following the nurse who had fetched me.   What am I doing? I asked myself as I rounded the corner.  Is this really happening? Do they really think that I’m a doctor? The thought amused me and I smiled as I fought back the urge to laugh out loud at the absurdity of my being called in to help.

In triage, writhing on the floor in pain was a young man, perhaps a few years older than me.  ”Oh, God, it hurts!” he screamed out.  I knelt down beside him, introduced myself, and asked him his name.

“What’s the matter?” I asked.

“I feel like I’m going to die!”

There are not many things that a patient can say that truly scare you, but in medical school you are taught that this is one of them.  When a patient says this, you listen and pay attention.  But pay attention to what? I wondered as I sat there beside him.  How do you approach a chief complaint of “I feel like I’m going to die!”?  Do you ask questions like, “When did you start to feel this way?” or  ”Do you feel this way all the time, or does it come on go?” or the dreaded, “On a scale of 1-10, how much do you feel like you’re going to die?”  Of course, a detailed history of the present illness is completely inappropriate in this setting.I glanced around the room.  Several other patients and family members had gathered around.  They were all staring at me.  Holy crap! They all think that I actually know what I’m doing! What am I doing?

The approach to medical emergencies almost invariably starts with an assessment of the “ABCs”–a handy acronym that tells you in a prioritized fashion, how to approach an emergent situation.  Fortunately, I remembered these three letters before I launched into a series of questions about the patient’s family history.  Oxygen is food for your tissues.  Without it, they die rather quickly.  It is the first order of survival.  The ABCs assess a patient’s ability to get oxygen from the air into the blood and circulated to the tissues.  A is for Airway, which is most important.  You can have a perfect set of lungs and a perfectly beating heart, but if you can’t get oxygen into your lungs, it doesn’t matter.  To do this, you need an airway.  This gentleman clearly had an airway as he was screaming at me.  This also meant that he had the B, which is Breathing.  If your airway is open but you don’t inflate your lungs, you don’t pull any air into your body.  Your heart can pump to its heart’s content (excuse the pun), but again, if no oxygen reaches the blood vessels in the lungs, it’s no use.  The C is for Circulation.  If A and B are in place, but blood can’t circulate, it does no good. Circulation is quickly assessed by checking a pulse.  This gentleman had a strong pulse.

By this time the nurse had started to take the patient’s vital signs, which provided a little bit more information.  His heart rate was accelerated, but not dangerously so.  His blood pressure was normal–another confirmation that his circulation was good.  And his oxygen saturation–a measure of how much oxygen is in the blood–was very high.  Although I had no idea what was wrong with this gentleman, I relaxed a little bit, knowing that he was unlikely to expire in the next few minutes.  But the patient was still screaming in pain.

Fortunately, at this time the attending physician (the experienced, supervising physician) had arrived and took over the assessment.  I had survived my first disaster, which of course, ended up not being much of a disaster at all (though the patient ended up being quite sick, he will likely do well).  Later on, as I went back to my charting, I realized that I had actually handled the situation more or less appropriately.  When I needed it, my training kicked in and told me what to do.  Not too bad for my first day, I thought.  But I quickly reprimanded myself; I may have done well this time, but there are still many mistakes to be made.