Choices

In the last hour, I suddenly became overwhelmed with just how many choices we make in a day. We choose whether or not to wake up in the morning to drag ourselves to school [some might argue that this isn't a choice ... but let's just go with it].

We choose what to eat when we're hungry. We choose which lane to drive in. We choose how we spend our time [such as right now, I am actively choosing not to study].

In life, we make a lot of choices that we don't think twice about because for the most part, they are trivial.

But if you really think about it, some everyday choices we make affect those around us. Something as simple as smiling at a stranger as you hold the door open could be the highlight of someone's day. Cutting someone off as you merge into another lane could ruin the rest of that person's day. Sometimes, I think we forget just how interconnected we all are; most of the time I think I am just minding my own business and living in my own little world, but there's no such thing. We all end up influencing another human's life at some point in time, whether we acknowledge it or not.

In medicine, our choices hold even more weight. This thought is exciting and chilling all at once; our choices can lead to bringing a new life into this world or ending one prematurely. Our words can tear a family apart or bring tears of joy to a patient. Our actions truly impact the life of our patient, whether we like it or not.

This is the path we chose. We want to help people. We want to heal people. But in the end, there is no escaping the reality that we won't always be right. Most of the time, there is no such thing as black and white; there is just an expanse of gray that will only morph into clarity retrospectively.

Amanda Xi is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Ann Arbor, Mich. She has a Bachelor of Science in Engineering [Biomedical Engineering] and Master of Science in Engineering [Biomedical Engineering, again] from the University of Michigan. This post originally appeared at her blog, "And Thus, It Begins," which chronicles her journey through medical training from day 1 of medical school.

Labels: Amanda Xi, And Thus It Begins, guest post, medical education, medical student, work-life balance

More

posted by Amanda Xi at 1:00 PM   0 Comments

Six in 10 doctors using digital tablets

Six out of 10 doctors are using digital tablets for work, mostly iPads, and half use them at the point of care, according to a survey from health care market research and advisory firm Manhattan Research.

But is it a good thing?

The online study surveyed 3,015 U.S. practicing physicians in more than 25 specialties.

Tablet use for professional purposes almost doubled since 2011, reaching 62% this year.

Physicians using tablets, smartphones and desktops/laptops spend more time online on each device and go online more often during the workday than physicians with one or two screens.

Adoption of physician-only social networks remained flat between 2011 and 2012.

Physicians reach out more frequently to and are more influenced by colleagues they formed relationships with at school or at work than peers who they first connected with online.

More than two-thirds of physicians use video to learn and keep up-to-date with clinical information.

Is this a good thing? How can doctors manage three computing platforms and still connect with patients? ACP Internist addressed this topic in its April cover story.

Labels: new technology

More

posted by Ryan DuBosar at 7:00 AM   0 Comments

Life at Grady: Please and Thank You

The following post, by Kimberly Manning, MD, FACP, first appeared on her blog Reflections of a Grady Doctor. It is reprinted with permission. All names and identifying information have been changed to protect privacy.

For the most part, I've always been a "please" and "thank you" kind of girl. I have my mother to thank for that. She has always been the kind of person who is gracious with people---but especially strangers. Got it on a badge in the grocery store? Mom will greet you by your name and thank you by the same. And if she wants something from you or needs you to handle something for her, you can at least count on a nice ice-breaker about how you are before she jumps right into it.

With this upbringing under my belt, I blended perfectly with one of the very first senior residents I had assigned to me during my internship. His name was Antoine and he was probably one of the kindest, most polite people I'd ever met. It astounded me to see him interact with people. Everyone from the head nurse to the man pushing the wastebasket in the hallway had his full attention. I loved that about him. He called each and every one of them by their name and, when he didn't know it, would make a point to learn it. There was something so mindful about the way he treated people in the hospital. They all seemed to have his respect which I quickly learned was a very effective way for him to get theirs.

But of all the things I watched Antoine do, there was one thing that always stuck with me. Every single time he wrote an order in the chart (this was before everything was electronic) he always started it with "please" and then, just before his signature, he would write those two words I've heard my mother say a million times "thank you."

Now, to you, this may not seem so odd. But trust me--in a hospital chart it was quite unusual. No matter how small the order, without fail, he always had those signature words flanking the request.

Please discontinue Foley catheter.
Thank you, 
Antoine R., M.D.

or

Please:
1. Advance to regular low sodium diet.
2. Give patient 2mg Morphine Sulfate now and then q4 hours as needed for pain.
3. Offer pain medication q4 hours. 
4. Arrange for Physical Therapy consult.

Thank you,
Antoine R., M.D.

Since this was my first senior resident, of course he became a very important role model for me. Which reminds me -- always take your role as a supervisor (particularly one that is early in someone's training) very, very seriously. Your good--and bad--habits live on through them.

(Click "more" below to keep reading this post.)
Anyway. Following Antoine's lead, I did the same thing. On every single order I wrote, I added that simple start and closed with that signature gesture of gratitude. And just like it did for my senior resident, it strengthened my relationships with the nursing staff and ancillary teams. Especially when combined with my mother's early example.

Please and thank you. Simple enough, right?

This brings me to a something that happened to me just a few weeks before I moved to Atlanta. I'm not sure what got me reflecting on it, but it remains one of the best things that has ever happened to me so I thought I'd share.

The Please and Thank You Doctor

I still remember one of the first times that I ever called the hospital operators. Announcing myself as "Dr. Draper" still sounded funny. Especially since it wasn't preceded by the word "student." Though I don't remember exactly what the call was for, I do remember how surreal it still felt to be a doctor. Entrenched in habit, I am certain that once I got over being a full-fledged physician, that it went something like this:

"Thank you for calling MetroHealth Medical Center where your health is our primary care! This is Operator Margaret. How may I be of assistance to you this morning?"

"Good morning, Margaret. This is . . .uh. . .Dr. Draper. You doing okay today?"

"Uhhh. . . I'm well, thank you. How may I direct your call, Dr. Draper?"

Very early on I recognized that this follow up question -- "how are you?" or rather "you doing okay?" invariably caught people off guard. Particularly over the phone.

Kind of like Antoine signing his orders with "thank you."

That response -- a pause followed by what I am certain was a smile through the phone -- always warmed my heart. That's when I moved that practice from just "habit" to something more deliberate. I made a decision to add a tiny ray of sunshine to any operator, desk clerk, or lab tech I spoke to over the phone.

So those early nervous exchanges soon evolved to this:

"Thank you for calling MetroHealth Medical Center where your health is our primary care! This is Operator Drema. How may I direct your call this afternoon?"

"Operator Drema! This is Dr. Draper. How are you enjoying the lake effect snow this week?"

"Awww, hey Dr. Draper! What's with this snow? It's April!"

"I know! I left a message for the mayor of Cleveland and told him that Canada called. They want their weather back."

And invariably that operator would chuckle and then professionally move right into the point of the call. Over time, I came to "know" nearly every single operator. So much so that on the very rare instances that I heard an unusual name, voice or accent I would introduce myself. And even welcome them.

It was kind of like Mommy in the grocery store. On steroids.

I was at Metro for five full years. Four as a resident and one more as a chief resident. This meant that I got to know and greet a whole bunch of operators over those years. By the end of my time there, those salutations were easy and familiar. This was very interesting considering in all of that time I never once saw a single one of them face to face.

I used to have thoughts of marching down into the basement to greet them all in person. But after three years or so I had created this entire idea in my head of what they all looked like. The woman with the throaty, deep voice was a snappily dressed transgendered person. The man with the super deep voice looked like Barry White. The operator with the squeaky voice was four foot eleven and had hands tinier than those of a toddler. She even needed her head gear specially fitted since she was so small. I imagined what race they were, what kind of make up they wore and even came up with visions of sparkling gold teeth for one of them. So this stopped me from destroying my imagery by going down there.

Goofy, I know. But residency is hard so you have to amuse yourself however you can.

My final weeks at Metro were spent attending on the wards. Even though I was a chief resident, back then we were credentialed as junior faculty members. This meant that we not only got to do some formal teaching on the wards as attendings, we also "got to" fill in holes for faculty who couldn't fulfill their duties for whatever reason. I was given the great fortune of being the finger in the dyke for a senior faculty member who'd decided on a last minute sabbatical.

Even though he was on wards.

Uh, yeah. This kind of stunk since my last day was June 24 but this time frame I had to step in for was from June 1 - 15.  Yes. I loved working on the wards. But not up to the last week before I was trying to move from one state to another.

June can be a tricky time because it is the last month of the academic calendar. What does that mean? It means that working that month can be either a gift or a curse. On the gift end, your residents and interns are seasoned and independent thinkers and workers. Your teaching focus can be more on patient care and medical knowledge than just logistics of how to get things done or worrying about errors. Kind of like working a shift on a job with a veteran worker versus the guy or gal that's still in trainee mode.

So yeah. June can be totally awesome for that reason, but conversely, it can absolutely suck dish rags for the very same reasons. Sometimes by June the interns know (or think they know) just as much as some of their residents. The dynamic becomes bumpy and uncomfortable. The interns feel micromanaged and the residents feel frustrated. There's also the risk that the resident already has a job and has mentally checked out of residency. They give the interns carte blanche to do whatever they want while then veg out in call rooms on twice fluffed pillows. Even if all hell is breaking loose.

This particular June was mostly a curse. The team didn't fully gel and the service was busy. On top of that, I was no better than they were. My mind was halfway to Atlanta already and my feet were ready to be inside of Grady Hospital. My patience was short with my resident at times and also the petty arguments he constantly got in with the interns. Back then, all interns got the final week of internship off as an unpaid (though super-welcomed) vacation. So even they were out to lunch in that final week with me.

Despite all of this, we slugged it out and took good care of our patients. The days were long and this was before duty hours reform so by long I mean waaaaay more than the current 16 hour maximum. Call days morphed into post call days that lasted 36+ hours. And even though I wasn't the one who had to sleep there all night, I was the one responsible.

And seeing as I was almost getting ready to LEAVE for GOOD, seriously? I just wasn't in the mood for all or any of this.

So I'm not sure of the exact day, but late in the afternoon on what I believe was two days or so before I was to finish my two-week stint I got paged to the floor. What I distinctly remember is that I was all the way down in the Radiology department with one of the medical students. I'd gotten tired of waiting for someone to transport our patient to the CT scanner so, with the help of the student, we had just wheeled our patient down there on our own.

Since I was pushing this ginormous bed through the hall way, it took a moment for me to reply to the page (which back then were only numerical). Subsequently, the person calling paged me two more times in a row.

Ugggh. I got to the nearest phone and call to see what's going on.

"Dr. Draper? I'm sorry to keep paging. This is Mrs. Tift."

"Mrs. Tift? Hey, there, I'm sorry to take so long. We were transporting our patient to CT. Is everything up there okay?"

"Oh yes, Dr. Draper. I was just calling you because we need you to come back up here soon as you finish. Someone left something up here for you."

And since I was in wards-mode, I immediately thought it was something that would add to my work. Or my headaches.

"What is it, Mrs. T? Should I be worried? Should I run up right now?"

"It's not a medical emergency. Just come on up when you finish."

"Can I send one of the interns right now? They're both on the floor."

Mrs. Tift spoke back in her impossible-to-read, stoic voice, "No, Dr. Draper. This requires the attention of the attending physician."

Now. Let me just say that I'm the kind of person who doesn't do well with things like this. Like, when someone says, "Hey, I have something to tell you later" that never works for me. I worry. I fret. And then I press them until they tell me right then and there.

So, of course, I speed up the transport process with my trusty med stud and safely get our patient into the CT suite to wait in queue for an image. You'd think I would have strolled back to the ward after that, but being the nosy and worry-warty person that I am, I pretty much jogged. Which made my unfortunate medical student feel a need to do the same.

We trotted to the elevator and finally got to the ward. I walked briskly to the nurses' station where Mrs. Tift was and approached her. Anyone nearby could see the urgency in my body language and, I'm sure, the tired in my eyes.

"Hey Mrs. Tift. You said there was something that needed my attention?"

And stoic Mrs. Tift looked me square in my eye and smiled so big and wide it almost scared me. She held her right hand out and gestured to something--then she nodded and smiled some more.

I looked around to see what she was talking about. I scanned the area for a stack of papers needing my signature or better yet, a long, lost stethoscope from my internship. Seeing neither, I swung my head back to her and looked puzzled.

"You don't see that, Dr. Draper?"  She let out her signature raspy laugh. "That has your name on it."

And since I still looked confused, Mrs. Tift put her hand on what she was referring to and pushed it toward me on the counter.

It was an absolutely spectacular bouquet of long-stemmed pink roses. Beautifully arranged in a vase with a card peeking out of the top.

"Looks like you have an admirer, Dr. Draper!"  Mrs. Tift winked at me and had no qualms about standing right there to check my reaction as a marker of from whom they came.

"Roses? Who in the world would send me roses?" I asked. And I was serious. My romantic life in Cleveland was non-existent. So I had no idea who they were from. In fact, I felt kind of scared to even open the envelope.

"Not just roses," a senior nurse named Mrs. Vogel chimed in, "TWO DOZEN of them. You go, girl!"  And slowly but surely, the nurses started gathering near me to get the scoop on my suitor.

Problem was, there wasn't one.

So finally I ripped open the envelope and read the card inside. And by the time I got to the end of the very short note, it was as if someone had punched me in the chest and knocked all of the wind out of me. Then, like someone flicking on a sprinkler, I began to weep. A deep, hard, tired weep.

The nurses and staff all looked worried. Mrs. Tift came around the counter and put her arms around me. And I turned my head into her bosom and just wept and wept. She patted my head and back and asked if I was okay. I nodded hard but couldn't stop crying.

Nurse Vogel came to my side and finally asked what everyone was surely wondering. "What was it, Dr. Draper? Is everything okay, honey?"

In response, I looked up from Mrs. Tift's safe embrace and handed Nurse Vogel that card. She read it and immediately covered her mouth. Tears welled in her eyes, too. Nurse Vogel had known me since my very first days as an intern, so I trusted her to see that card. And also to read it out loud which is what she took it upon herself to do.

To the "Please and Thank You" doctor with gratitude. Thank you for always taking the time to be kind. Please don't ever stop. Wishing you the best in your future endeavors.

Respectfully, 
The MetroHealth Hospital Operators

And that card had the signatures of every single one of them. Drema. Irma. Margaret. Charles. Vera. Amanda. All of them.

It remains one of the proudest and most moving moments of my entire life. In fact, just writing about it has me reliving it and bawling all over again.

Before I went home, I took the elevator to the basement. I asked two people how to get to the operators' suite and finally found that vacuous room where they all worked for all those years. I walked right in with that giant bouquet of flowers and thanked each and every one that was there. I hugged their necks and thanked them right back for taking all of my calls for the past five years and for always making me feel like I wasn't a burden.

And, of course, they said, "You weren't."

And you know? The Barry White man was a tall, thin Caucasian man. The tiny-voice lady was taller than me and quite big-boned. The throaty, deep-voiced person was just a lady with a throaty, deep voice. And no, not a single person had gleaming gold teeth. So that imagery was dead for good. But that's okay because the reality was so much better.

Now. Please . . .pardon me for such a long post. I didn't mean for it to be--I really didn't. And listen. . .thank you. . . seriously, thank you for taking the time to read here. I mean that.

Respectfully,

Kimberly M.

More

posted by Kim Manning, MD at 7:00 AM   0 Comments

Dangerous electrolytes, part 1

At the Internal Medicine 2012 meeting, I presented a one-hour session on dangerous electrolyte disorders. The patient presentation I used has many parts, so I thought you would like to work through this one.

The patient, a 40-something-year-old woman, has a long history of alcohol abuse. Recently she has had minimal oral intake with much vomiting. BP 100/60, pulse 120
120, 67, 32, 99
1.9, 21, 0.7, 8.9

pH=7.6
pCO₂=26
pO₂=100
HCO₃=21

Your job is to identify all the abnormalities in this panel, and suggest the sequence of events most likely to result in these numbers. What other information do you want? More information will continue next week.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Associate Dean for the Huntsville Regional Medical Campus of UASOM. He also serves as a frequent ward attending at the Birmingham VA Hospital. This post originally appeared at his blog, db's Medical Rants.

Labels: db's Medical Rants, diagnosis, guest post, Robert M. Centor

More

posted by Robert Centor, MD at 9:00 AM   0 Comments

"THIS is Marketplace"

Thousands of fans wrote in after hearing my commentary this past Friday on the radio program Marketplace. Many of them had important questions:
"Did they fly you out to USC for the interview?"
"Is Robert Reich really that short?"
And of course, "So what does Kai Ryssdal actually look like?"

Well, sorry to disappoint.

I recorded the commentary at KWGS, the Tulsa NPR affiliate, several weeks ago. Not only did I not get to meet Kai Ryssdal at USC, apparently former Labor Secretary Reich records his commentaries somewhere in Northern California and doesn't trek down to L.A., either. [Though I hear he wears platform shoes when he records to make his commentaries sound more authoritative.]

If you have about two minutes, you can listen to the piece right here on GlassHospital by clicking on the play button embedded just below:


Feel free to go to the Marketplace website and leave comments on the commentary (!?) if you like this sort of thing and want to further my egotistical campaign to become a regular contributor there.

If you're really a glutton for medicine and radio (and GH), you can also catch a whole episode of the medical student-hosted and produced show RadioRounds right here.

Lastly, to complete the radio trifecta of media over-saturation for the week, click here sometime after 5 p.m. central on March 25 and you can hear StudioTulsa host Rich Fisher interview me about the rise of hospitalists in the U.S., based on the article I wrote for the Atlantic.com. You can also stream the show live from the KWGS website; the show airs at 11:30 a.m. and 7:30 p.m. central time

This post by John H. Schumann, MD, FACP, originally appeared at GlassHospital. Dr. Schumann is a general internist. His blog, GlassHospital, seeks to bring transparency to medical practice and to improve the patient experience.

Labels: career choices, Glass Hospital, guest post, John Schumann, primary care shortage

More

posted by John Schumann, MD at 11:00 AM   0 Comments