Boards!

I have the first part of my anesthesiology boards coming up, and I'm feeling ill-prepared. I used to be so good at studying, but over residency, my ability to sit down with a textbook for hours on end and take notes has waned. This test is a little bit daunting, and I'm going to take the next week to focus on multiple-choice questions. I still have several overnight calls before I take my exam, so I'll also try to catch up on rest as well. Good luck to anyone else taking their certifying exams. I'll be back in a little over a week. Thanks for reading along!

If you'd like to read more medical blogs in the meantime, another plug for two other endeavors I'm involved with:
The American Resident Project has blogs from medical students, residents, and young physicians who are exploring and expressing their views on American health care.
Case of the Day is my other blog featuring medical mysteries with almost 2000 fascinating and challenging cases (also on a break for the week, but there are tons of archived posts).

Craig

The Anesthesiologist's Toolbox

A code blue is called when a morbidly obese patient is found pulseless. I am carrying the airway pager and arrive at the scene with ongoing chest compressions in an unresponsive man. One of my co-fellows is running the code, giving epinephrine, checking the rhythm, determining the cause of the cardiac arrest. When I get to the head of the bed, one hypothesis is clear. The patient has blood coming up out of the mouth. In medical training, there are a lot of situations that give me pause, and this is one of them. For an anesthesiologist, this is a nightmare situation. The respiratory therapist is unable to give effective masked breaths because of the blood and the patient's size. The patient is most certainly hypoxemic, and if we cannot get him oxygen, he won't make it. With ongoing compressions on a bed in poor ergonomic position, I suction the mouth and take a look with my laryngoscope. I can't see anything; only faint structures are recognizable, but I hear one of my attending's familiar sayings in my head: "Just put the tube in." It's really down to me; I have to secure the airway. So drawing on feel and experience, I slip the endotracheal tube in. I get positive end tidal carbon dioxide, and when we regain a pulse, the oxygen saturation is 100%.

I arrive to work to find two of my non-anesthesia colleagues desperately trying to get IV access on a patient. The patient has an AV fistula for dialysis on one arm, so only the other arm is available. I take a look at the legs and neck, but don't see any obvious veins. My medicine co-fellows' attempts with ultrasound guided IV access are futile, and the nurse tells me her best ED colleagues have tried and failed. Finally, my co-fellow asks for a central line kit even though the patient doesn't really need central access. I ask if I can give the peripheral a try. I stop by the operating room to pick up supplies and some lidocaine. The patient, who has been poked five or six times in his right arm, is wary of more pain and discomfort. But gently, I find and cannulate a small peripheral, and the patient gives me a hug.

There are a lot of things I have to learn in fellowship, but I am glad that my few years in anesthesia have given me a toolbox that few others have. These experiences have also boosted my confidence that I was ready to graduate from residency.

Fellowship

Although I usually explain what a fellowship is by describing it as an extension of residency, being a fellow is different than being a "super-resident." Although I am still a trainee focusing on a subspecialty, my role and responsibilities have expanded a bit. From a clinical standpoint, I have less busywork or "scutwork" - I no longer scribble down vitals during prerounding in the morning or write daily progress notes. But I am responsible for the big-picture of all the patients on the team. I help determine the daily plan for each patient, warding off decompensation, tuning patients up for leaving the ICU. It is easy in many medical settings to simply go with the predetermiend plan, to assume that what was decided yesterday is still good today, and my goal is to challenge that, make sure we are thinking of each goal fresh and independently. I also act as a gatekeeper to the ICU; all the patients who come in, through transfers, the operating room, the emergency department, the floor, and from codes go through one of the fellows. A lot of this clinical responsibility is new for me, and I have a lot to learn.

Even from a nonclinical standpoint, my role and responsibilities have changed. I am learning to teach residents. Teaching takes practice and experience, and I'm already figuring out how best to walk someone through a new procedure or explain my clinical decision making. As a fellow, I will participate in quality improvement and research projects. I work at a systems level, calling the nursing supervisor daily, working with unit charge nurses, and speaking to our transfer center. While I enjoyed my small little bubble as a resident, I'm learning about the bigger medical picture now.

The Tricky Business of Policing Ourselves II

This is a continuation of the prior post.

Picking a good physician is one thing. Identifying the less competent ones is much more challenging. As a whole, physicians like regulating ourselves. With requirements like continuing medical education, board recertification, and institutional bylaws, we try to identify and remediate physicians who fall outside the normal standard of care. Those who are grossly negligent, clearly unprofessional, or overtly irresponsible are easy to identify. But there's a big gray zone that's very scary. If the average surgeon takes an hour for a particular procedure, but one surgeon averages two hours, is that a problem? What if he averages four hours? If an average radiologist misses 2% of a particular finding, is a radiologist who misses 4% a problem? Most physicians participate in active learning even in practice, going to conferences and reading journals; would you find a physician problematic if he did no continuing medical education? What about the physician who has no knowledge or skill deficiencies, but who is rude to other staff? How do you approach doctors in the "gray zone?" They are colleagues, and it can be a challenging interpersonal interaction to confront one. Historically, we do very poorly in policing ourselves. But as public scrutiny falls upon substandard physicians, we need to do a better job in making our professional expectations explicit and follow through with working with the doctors that don't meet the minimum standards.

The Tricky Business of Policing Ourselves I

This is a tricky blog for me to write. I want to make it clear that I'm not focusing on my own experiences or institutions, but instead, talking about a more general problem in medicine. How do we deal with physicians who are less competent or even grossly incompetent? Doctors hate it when outside authorities try to regulate us. We want to regulate ourselves. But it is mighty hard to do so.

It is a simple fact of life that some people are better than others. Some anesthesiologists are better than others. Some surgeons are better than others. Unlike auto shops or restaurants or dry cleaners, it's hard for consumers to know which physicians are best. I have witnessed surgeons whose technical skills are poor but whose bedside manners are great who are beloved by their patients. I have witnesed incredibly talented surgeons with little interpersonal charm who aren't liked by their patients. Do patients like the gastroenterologist that finds nothing on the colonoscopy or the one who is more skilled but finds the cancerous polyp? Being a doctor engages so many skills - bedside manner, physical examination, delivering bad news, procedural ability, decision making, knowledge base, and more - and only some of these are immediately apparent to a patient. That is why we like feedback from our patients, but we don't like public rating systems. It might be okay to choose a pediatrician online based on ratings of their touchy-feely nature, but in picking a cancer surgeon, I'd want the meticulously skilled one, even if he's a grouch. It's hard to pick the right physician; there is no clear criteria and no public forum where this information is available.

Furthermore, there are nuances in figuring out who is best at a particular thing. For example, it is easy to pick a world-renown neurologist, but if that person is the foremost expert in Parkinson's disease, consulting them for seizure management might not be the right thing. I've seen this time and time again where a patient picks a "famous" surgeon but for the wrong procedure. As I see more of the world of medicine, I learn that interpersonal connections between physicians is a really powerful factor. I can tell you which anesthesiologists I would want, which surgeons I'd pick, which consultants I'd see. And I'm happy to advise patients when they ask. I have no idea what's out there on Google, but I'd wager it'll have biases and misinformation.

Under Construction

When I was a child, I was never all that interested in construction. I didn't play with Fisher-Price trucks, never wore a construction hat. I was more curious about astronomy and dinosaurs. But as I walk through the hospital now and see the transformation of the campus as new buildings and structures go up, I can't help but be amazed. The building of the new Stanford Hospital isn't the most convenient thing; patients have to navigate around construction sites and parking can be frustrating. And it's such a long-term project that I'm not sure I'll be at Stanford when the new hospital opens in 2018. But it's also really cool just to see everything happen. Each week, I see new changes; pylons and pipes and infrastructure and walkways. The cranes outside the pediatric hospital are mindboggling. The amount of dirt removed from the construction zone is tremendous. What a project. It's also a bit strange to think that the areas where I locked my bike intern year have been demolished and the secret shortcuts I would take are gone. Hospitals feel like structures that simultaneously never change and are always under construction.

Image from sumcrenewal.org, shown under Fair Use.

ICU Fellowship

Although I like to say that the decision was never clear cut, I also think my choice to go into critical care medicine was a natural one. Even though I love operating room anesthesia, I miss some of the things it doesn't encompass. My fascination and curiosity with general internal medicine draws me back to the vagaries of diagnosis, the nuances of treatment. My most interesting cases and patients are often the critically ill; when I go home, I don't dwell on the surgeries that went exactly as planned, but I do think about the patient who had unexpected decompensation or the ICU patient whose pressors I adjusted. Ironically, in the last three years, I've focused my education and learning on a narrow slice of medicine and now I want to step back and learn everything else. This year as an ICU fellow is a great opportunity for me to undust those books on infectious disease, engage those rusty neurons on differential diagnosis. The other big draw for me to the critically ill is my interest in the end of life. What do most people want at the end of their life? Is the ICU appropriate for various medical conditions? How do we treat patients and families in critical period? Can we improve the system and the care we deliver? I hope that as an ICU physician, I will be a leader that engages and influences the system to deliver intelligent, appropriate, humanitarian care. Although another year of training will be tiring, I am actually quite excited to re-engage medicine in a different light and round myself out as a doctor.

Transitions

The physician-in-training goes through many, many transitions. From finishing undergrad to getting our first white coat to starting clinical rotations to Match Day to earning our MD degree to writing our first order as interns to finishing the exhausting internship year to starting as senior residents to finishing residency, there's a lot to celebrate. Interestingly, for me, out of all those transitions, the one between residency and fellowship was the most understated. A lot of it is circumstantial; I'm staying in the same institution and the same department, and I'm working with many of the same people. There's also little time for us to reflect on this change; on June 30, I was a resident, and on July 1, my contract as a fellow began. I went home from work one day and showed up with a new badge, a new role, and new responsibilities. I see many of the same people at the hospital, treat some of the same patients, and have a fairly similar routine.

Nevertheless, I think this transition is an important one. I am consciously choosing to continue as a trainee; I don't have to, and sometimes I wonder if I should just go and practice anesthesia independently. Even though I am still learning, there are aspects of medicine in which I am fully qualified, and that's important for me to remember. I am donning on more responsibility and doing so with deliberation. I am taking on a greater role as a leader, teacher, and advocate. I am moving from passive career shaping to an active one, and I should take as much advantage of this year as I can to direct my learning, passions, and career to where I want to go after my twenty-some years of formal schooling.

Leaving Anesthesia Behind

Finishing anesthesia residency and moving to critical care fellowship is an odd feeling in several ways. This will be the best I am at anesthesia for a while. After three years of 60 hours a week, I've made anesthesia rote and muscle memory. The operating room is my home and I feel exquisitely comfortable there. But during my year of critical care fellowship, I will be leaving the operating room behind and putting the practice of anesthesia on hold for a year. There is no doubt that I will become rusty, and in talking to people who have been through this, it won't be anything that affects patient care or outcomes. But I will be slower, less efficient, have to think more, and less certain as an anesthesiologist. My instincts will dull, my comfort level will disappear. Yet I am choosing to do fellowship because I think advanced training in critical care will make me a better physician overall, and when I finish and return to a mix of anesthesia and critical care practice, I will be able to refresh all that I've honed in the last few years. I will miss the operating room; there is no doubt about that. But I will continue to think about, learn about, and engage anesthesia even if I am not actively doing it this year.

Book Review: David and Goliath

I've been listening to audiobooks on my commute and recently finished Malcolm Gladwell's David and Goliath. Listening to audiobooks is very different than reading a book. My attention is divided and I lose track of things when I get distracted. It's harder to follow long narratives, and I don't start and stop at natural points - it depends a little on my commute.

Taking all those things into consideration, I was a little disappointed with David and Goliath. I've enjoyed other writings by Gladwell, including Blink and shorter essays, but I think this along with Outliers missed my expectations. Like his other writings, he takes case studies and stories that curious because they defy our initial assumptions, impressions, or preconceptions. But the things he chooses aren't all that mindboggling; it reads a little case studies from a standard introductory psychology, social sciences, or economics class. He also tries to unify his narratives into an overarching theme echoing the Biblical tale of David and Goliath. I think he really falls short; I was not convinced by any of the conclusions he drew.

Overall, a mediocre book that lies in the shadows of his prior bestsellers. I think it is time for me to find a new nonfiction science writer.

Image shown under Fair Use, from Wikipedia.

Numbers and Things

We keep a case log of every patient we anesthetize and every procedure we do. Mostly, it is to make sure we hit the minimums for various types of anesthetics and cases. At the end of it all though, it's interesting to think about what I've done over the last four years. I've logged 1,540 patients and 6,760 procedures (the definition of procedure is quite vague so each case usually involves checking at least 2 boxes). Over thirty of those cases involve cardiopulmonary bypass; over 50 were C-sections; 50 were neurosurgeries; over 30 were lung surgeries; and 30 were traumas. Of my 125 pediatric patients, 5 of them were less than 12 weeks old. I've placed over 160 epidurals, 100 spinals, and 120 peripheral nerve blocks. It's a strange way to summarize the core of my training, and also a little strange to put it out there, online. There are residents, I'm sure, who have done more of this or that, and residents who have done less. I've met all the minimum requirements with lots of room to spare, and more importantly, I feel comfortable doing all these types of anesthetics and procedures. Doing a certain number doesn't guarantee proficiency, but having done this many, I've hopefully reached it.

Graduation and July 1

So much has happened, and there's been no time to blog. The next several posts will be about events in my life because I've been going through a lot of transitions lately. I might spend some time narrating my last few months and reflecting on the end of residency. Along with that, I'll have to find time to update different parts of this website and my profile on American Resident Project.

We had graduation a week before our official last-day-of-residency. It was lovely; the department invited our significant others, parents, and families, and it was a wonderful opportunity to introduce them to our faculty and mentors. It was also really fun to meet the families of our co-residents. The graduation dinner really allowed us to celebrate and honor the teachers and peers we've worked with for the last few years. We each got a personal twitch monitor to help us in our professional careers, which I thought was both fun and endearing. We spent the night dancing away with our friends.

Today is July first, and I've written about this day in many blogs in the past. For me, I now wear the badge, privilege, and responsibilities of "critical care fellow." It is very intimidating, and I'm sure many blogs will be forthcoming about what ICU fellowship is like.