Birthing: the miracle of life or “don’t drop it”?

May 26, 2008 at 1:14 pm (Clinical rotations)

Hospital nurses are the front line in any patient’s care. They provide his medications, they clean him, take him to the bathroom, feed him, and dutifully report the night’s events to the physician in charge. OB nurses will take this charge to the extreme. Their years of vast experience tell them that they shouldn’t let medical students or interns anywhere near a patient in labor. Despite my hospital’s policy that medical students should be involved in delivering all babies, the OB nurses will do all they can in their power to ensure that students are nowhere near the event.

For example, two sets of gowns and gloves are required for the delivery—one for the resident and one for the medical student. Medical students are supposed to be involved with every delivery in the hospital. The nurses know this, yet will passive aggressively prevent students from taking part. They will bring only one set of gown and gloves to the patient’s room, and when asked for another set by the resident, they will ignore this request and force the medical student to go on a hapless journey around the labor floor trying to find supplies. In my own case, by the time I got all the necessary equipment together and returned to the room, the patient had already delivered the baby.

The attendings are well aware of this problem. Despite multiple pleas from hospital administration, nurses continue to block medical students at every pass. This weekend was my last day on the labor and delivery rotation. Since I had not delivered a baby by myself yet, my attending told me that I would not be allowed to leave the hospital until I had caught at least one child.

My attending walked me to every nurse on the floor, introduced me, and said, “He’s going to deliver this patient’s baby tonight. Make sure that he has everything ready.” Expecting the nurses to once again have the room prepared for only the resident and not me, I preemptively went around and gathered all the necessary equipment and hid it in the patient’s room so that I would have everything laid out.

At 1:00 a.m., our patient decided to deliver. I threw on my equipment, got between her legs, and prepared to catch the baby as it made its way through the birth canal. The media portrays birthing as the miracle of life. An expectant mother has waited dutifully for nine months for the chance to see her baby breathe its first breath. In the movies, the baby always comes out perfectly clean and very beautiful. In reality, newborn babies look like aliens that are covered in fluid and shit and are very slippery.

The baby I caught came out in just one push. During the entire ordeal the father was holding his wife’s hand and telling her that everything was going smoothly. Meanwhile, I’m pulling out the baby and thinking to myself, oh shit! Oh shit! Oh shit! Don’t drop it! Don’t drop it! Don’t drop it!

I managed to hold on to this slippery creature, cut its cord, and handed it over to the pediatrician. After taking care of the placenta, my resident said, “Great, you finally delivered a baby. Now you can go home.” And just think, she’s going to be there for another six hours delivering more children.

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Misplaced fears

May 24, 2008 at 1:24 pm (Clinical rotations)

There are lots of things in the hospital to be afraid of: violent psychiatric patients who try to attack everyone who looks like their family, homeless patients who cough on you, OB nurses, and attendings who want to tell you about Jesus. Hospitals have a rightfully deserved reputation as a dangerous work environment. Despite all of these things to be afraid of, nothing will throw people into a fit greater than HIV.

Let’s be absolutely clear about the way that HIV is spread. Only a direct insertion of bodily fluids will cause this virus to gain entry. Examples include drug abusers’ sharing needles, unprotected sex, and blood transfusions. What will not cause a spread of the virus is the physical exam. Skin-on-skin contact such as listening to the heart and lungs cannot cause a transmission of HIV unless both the patient and the healthcare provider have open wounds. This concept is pretty easy to understand. Yet despite all of the research and education that goes into this disease, people-including health-care workers-are woefully ignorant about the subject in practice.

Earlier this week I had a nurse stop me during the middle of listening to a patient’s lungs and admonish me for not wearing proper protective equipment such as gloves. I just don’t understand where this fear comes from. Yes, I know that there is a stigma associated with AIDS, but I would expect at lease for a nurse to understand how difficult HIV is to transmit. Mentioning those three letters on one of the nursing floors in my hospital will instantly cause a panic. Staff will begin putting on gowns and masks as if they are expecting a chemical weapon attack. Despite all of the frenzy that a weakly communicable disease causes, many people still will not follow proper precautions in other instances. For example, if a patient has an MRSA infection-requiring contact isolation-many nurses and doctors will continue visiting the patient without wearing the proper gloves and gowns. These health-care providers will then gleefully move onto the next patient’s room and spread all manner of bacteria.

Because of the extremely high number of nosocomial infections in my hospital, management has created several protocols for handling infectious diseases. We have placed alcohol rubs inside of every patient’s room so that people can wash their hands before and after each patient encounter. And while I’m thankful for these devices, I think that we need to do more. First, let’s get rid of the white coat and necktie. Multiple studies over the past few years have indicated that white coats and ties easily transmit disease from patient to patient, so much so that England has banned white coats from clinical areas [1, 2]. Second, let’s force all health care providers to use alcohol swabs on their stethoscopes after every patient encounter [3]. I carry a pocket full of alcohol pads everywhere I go. After each patient, I clean my stethoscope similarly to how I wash my hands. If you’ve never cleaned your stethoscope before, give it a try. You’ll be very surprised by the amount of dirt that comes off in just one pass of the alcohol pad. And stay way from those silver-containing diaphragm covers. The advertisements claimed that by using silver ions, these devices can kill bacteria. In reality, however, these covers are a greater source of infection than regular dirty old stethoscopes [4].

So there we have it. Evidence shows that white coats, neckties, stethoscopes, and artificial nails are a source of infectious disease transmission [5]. My hospital requires medical students to wear white coats, wear neckties, carry stethoscopes with them at all times, and has no policy regarding artificial nails. And the result is that we do a pretty good job of infecting people with C. diff, MRSA, and Klebsiella. Maybe what we should be doing is telling everyone that all of our patients have HIV. That way, they’ll be sure to carefully protect themselves from any communicable diseases.

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Counting down the days

May 19, 2008 at 9:35 am (Clinical rotations)

Every morning I wake up, look at my alarm clock, and groan in agony as I have to go in one more day. Given that within the past week my resident has twice shown up late for rounds, I believe she is experiencing the same phenomenon. I keep telling myself that I have less than a month to go in third year. After that, I’m taking two months to study for both parts of STEP II, and then it’s off to do my externships. I won’t see the inside of my hospital again until October. I’m eagerly awaiting the beginning of fourth year. It’s all classes than I signed up for with a focus on my specialty. I pick some difficult courses as well as some real sleepers. After all the work I put in during third year, I’m looking forward to a break. By the time mid June rolls around, I will have gone 50 weeks continuously in the hospital with only two weeks off for winter break. That’s the longest I’ve gone without some kind of extended vacation—and it shows. I can tell from my writing on this website that my creativity has really gone on a decline. I’m working on some new material that I can unveil once rotations end. But until that last day arrives, I’ll keep counting down my time using my old friend, the Donut of Misery.

Donut of Misery

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Price gouging the insured

May 19, 2008 at 12:43 am (Uncategorized)

The United States currently has about 47 million uninsured people.  Every year politicians, social groups, political commentators, ethical theorists, and medical student organizations try to come up with relief to the so-called “problem” by claiming that we need socialized medicine, higher taxes on the wealthy, a reduction in the amount of healthcare that is given, or any number of other scams that closely resemble Canada in price and England in quality. 

My own hospital caters to a large uninsured population.  Every day we provide numerous CT scans, x-rays, surgical procedures, intravenous immunoglobulin, radiation therapy, chemotherapy, and all manners of treatments that are given free of charge to our patients while inching us ever closer to bankruptcy.  Like most places, my hospital has taken to overcharging the insured to make up for the any losses incurred by caring for low-income people.  For example, merely walking in to the gyn emergency room immediately racks up a charge of $1000.  Once the ultrasound and blood tests are ordered, the bill quickly rises from there.  This charge is lobbied against everyone, regardless of their ability to pay.  We know full well that many of our patients—especially the ones seeking pregnancy tests—will never pay the bill.  Therefore, we are forced to charge exorbitant amounts to other people so that their insurance company will cover the difference.

Case in point: let’s consider my hospital’s trauma center.  After a car accident or gunshot, paramedics will quickly mobilize to bring the patient to a trauma center where a team of surgeons will run through the ABC’s of trauma, stabilize the patient, run him to the CT scanner, and take him to surgery if necessary. The cost for the initial evaluation is $29,000.  That price does not include surgery, hospital admission, or any critical care expenses.  Naturally, insurance companies realize what a scam this is and will only pay half of the price.  The patient is then left with a bill for $15,000—an impossible sum for most Americans.  The end result—even for an insured patient—is that the bill is left unpaid.  My hospital has become so fed up with not receiving reimbursements for its services that it immediately sends its bills to a collection agency without bothering to contact the patient for payment.  The hospital tries to explain its actions of double charging the insured by stating that it needs a method to cover the expenses of the poor.  I call this practice something else: price gouging.

In most states charging double for a good or service is illegal.  I would love to see an investigation into the practice of overcharging the insured.  Most consumers would be ashamed if they knew what healthcare really cost.

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1-800-IDEA-MAN: business school for doctors

May 11, 2008 at 9:50 pm (1-800-IDEA-MAN)

A common fallacy shared by many medical students and pre-meds is that doctors are isolated from business practices such as marketing, management, and finance. A rude awakening is applied to anyone upon graduating residency when he discovers that the laws of economics apply to medicine just as easily as they apply to any other employment field. Many doctors are woefully unprepared for running a hospital or clinic. Many of the private practice physicians I know resort to hiring an office manager to take care of the billing and staffing issues. While we would all love to believe that our medical school and residency program endowed us with certain skills, getting paid by insurance companies for all that knowledge becomes more difficult. Therefore, I propose a business school meant for physicians.

Unfortunately, my suggestion will be slapped down by many of the naysayers within the pre-med and medical school community. A lot of them will say, “If I wanted to go into business, I would’ve gone to business school.” What’s worse is that many physicians have a pretentious, self-righteous attitude that says that they should be shielded away from the profit-seeking motives of businessmen. But I see it differently. I say that anyone who pursues a job paying more than $100,000 a year should have a profit-seeking mindset.

While I don’t suggest that we all go out and get MBAs, I do think that there needs to be some instruction on how to run a business so that physicians can learn to accurately charge for their services. Fourth year medical students would be the best candidates to reap from such a system. I envision a month-long Kaplan-style course where students are taught for 40 hours a week in various business topics. The courses would be condensed, focused on medicine, and would provide real-world instruction for how a doctor should conduct his clinic. And if you think that working for a hospital as either a hospitalist or an emergency physician will shield you from needing to know about business, the only person you’re deceiving is yourself. The physician who knows how to properly bill for his time will be able to generate more revenue for the hospital, thus making him a more valued employee.

For the month-long business course, I envision something similar to the following schedule:

week 1—mornings: economics, afternoons: management
week 2—mornings: accounting, afternoons: marketing
week 3—mornings: finance, afternoons: business law
week 4—medical billing

A video series of these courses could be available online along with a condensed textbook so that practicing physicians and residents could also study this subject. While everything would be taught in one month, there is no need to water down these subjects. Consider an undergraduate management course. Usually, a semester-long class is taught in 40 one-hour lectures. When I took management, I was continually frustrated by how slow the material was being taught. Certainly physicians can cram all of that information and more into 20 hours. Further, by making all of the subjects centered on medicine, doctors would be more likely to enjoy pursuing these classes. Just imagine learning how to balance books, create advertisements for your practice, resolve conflicts amongst your employees, how to pick better assistants, and the laws regarding incorporation of a company.

With this knowledge, physicians would have a more employable skill set. I would imagine that anyone who sets up such an online course would have no shortage of doctors willing to pay to learn those skills.

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Was that my alarm clock making that noise?

May 4, 2008 at 9:49 pm (Clinical rotations)

I started my obstetrics and gynecology rotation this week. Hence, why I have not been able to post anything in quite a while. The hours are a lot like surgery: I get up around 4:00 a.m. so that I can make it to the hospital by five o’clock. I’m usually there for about 12-14 hours. I then come home completely exhausted, study what I can in what little time I have remaining, and then fall asleep into an almost coma-like state. I worked all seven days this week which, after I get through the next week, I will have put in 13 days in a row. I worked more than 80 hours this week. And while that may seem like a lot, given that my residents were always in the hospital before I arrived and after I left, I am certain that they were putting in close to 90-100 hours.

My previous rotation, family medicine, spoiled me with its relaxed work schedule. I would get up around 8:00—8:30 if I didn’t feel like going in—and then would spend a leisurely eight hours in the office before coming home and chilling out for the rest of the day. Since I had had the bulk of the third-year curriculum prior to starting family medicine, outpatient primary care was a breeze to me. I never bothered studying; in fact, I only spent three days doing a half-assed attempt at practice questions so that I can get ready for the shelf exam. But now that I’m on ob/gyn, everything has changed.

When I woke up at 4:00 a.m. on Tuesday morning, I heard the awful sounds of a siren that for a few seconds I was convinced were coming from outside my window. I figured that an ambulance must be running down my street to bring the latest victim of a shooting to the nearby hospital. When I finally realized that the sound was coming from my own alarm clock, I was greatly annoyed at the misfortune I would have over the next six weeks.

Ob/gyn residents are a lot like surgery residents: they have terrible hours which violate federal work-hour rules, they get greatly annoyed at medical students and have a short temper, and they are so stressed from the work that is constantly dumped upon them by the hospital and the attending that I’m surprised one of them has not brought a gun into the workplace yet and started shooting up the nurses station.

We try to break the monotony in this rotation by allowing students to work shifts in the emergency department, catching gynecological cases. I’ve mentioned before that my hospital serves as an urban walk-in clinic for many of the uninsured people of my city. In the past week, I have seen the 6—SIX!—people come to the emergency department solely to get a pregnancy test. They had no other complaints other than wondering whether or not they were carrying a baby. My resident, my new hero, tried to explain to these women that a trip to the emergency department costs almost $1000 for all of the laboratory work and eventual ultrasound that we would perform. These women, with their glazed over looks, just brushed off the notion that they should ever have to pay for health care. Two of them even became annoyed when my resident suggested that they could go to Walgreen’s and purchase a home pregnancy test for $10. One replied, “I just don’t have enough time in the day to go to the drugstore!” To which my resident replied, “Didn’t you just spend three hours and our waiting room? Driving to the drugstore, purchasing a urine pregnancy test, and then driving home certainly takes a lot less time.” But then again, why should any of these women care? Health care is free after all. Having the latest cell phone is more important than having insurance. And hell, while we’re at it, let’s not bother trying to use birth control to prevent another pregnancy anyway.

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