Interventional Pulmonology

One of the unique procedures we do in our hospital is interventional pulmonology. One of our critical care pulmonologists has developed an expertise using a bronchoscope, navigational technology, and endobronchial ultrasound to biopsy and sample lesions in the lungs that otherwise could not be reached. The technology is pretty cool; he takes a CT scan of the lungs, and puts markers on the patient and bronchoscope (camera) so that as he moves the camera, the screen shows where in the CT scan he is. This allows him to be much more accurate in sampling abnormal areas than conventional bronchoscopy (since abnormalities cannot always be seen with the camera in the lungs). There are similar technologies for neurosurgery (so a surgeon minimizes trauma to normal brain tissue) and orthopedic surgery (so a computer can simulate how a joint moves).

In the past, if someone had a suspicious lung nodule or lymph nodes, they generally could only be biopsies from outside the body; an interventional radiologist would place a needle through the chest wall. If the lesions were too deep within the lungs, however, that would be too risky. Bronchoscopic techniques where the camera enters the lungs are perfect for those lesions that are deep in the body. With these techniques, we can make sure those who need surgery get it and those with benign or metastatic lesions don't.

The anesthetic requirements are tricky. A lot of these patients have significant medical problems, particularly if they have been long-time smokers and developed COPD or other lung diseases as a result. The procedure is done through a very large endotracheal tube which can make intubation more challenging. The patient is under general anesthesia and cannot move, but the procedures can be quick, so the perfect anesthetic gets them into and out of a deep plane of anesthesia briskly, which can be hard to achieve, especially if they have cardiovascular disease or renal insufficiency. The procedures are done out of the operating room (for us, in endoscopy), and that makes anesthesiologists uneasy.

The next frontier in medicine is more and more minimally invasive procedures. We have been able to do endoscopy and colonoscopy for a long time, but only recently have our technologies blossomed for bronchoscopy, beyond just looking at the airways. As other fields develop, anesthesia must keep up with accommodating these new techniques, and this is one great example of that.

Ponderings on Suicide

Can suicidality exist in the absence of mental disease? I believe it can, though these circumstances may be rare. In considering physician-assisted suicide in states that permit it, mental health disorders must be ruled out as the impetus for ending one's life. In looking at California's 5150 section of the Welfare and Institutions Code, the part that permits involuntary psychiatric holds, a subject must be a danger to himself as a result of a psychiatric illness.

In what situations might someone want to end their life and yet not have a mental health disorder? Certainly, we think of patients with terminal illnesses with unremitting suffering. But we may also think of Socrates, found guilty of corrupting the minds of youth and impiety, sentenced to drink hemlock. We think of the Japanese Samurai code of bushido, or honor, which incorporates ritual suicide (seppuku).

Suicide is a touchy subject around here. Palo Alto has had a rash of high school suicides, leading to extensive debates, news articles, and academic research. It is awful, sad, and shocking to consider that a high school student may jump in front of a train because of stress. I hope the changes local schools are making and the awareness generated by a spotlight put on this problem will mitigate it.

But suicide is not a homogeneous problem. It's hard to empathize with someone who is suicidal because those who intervene have rarely been in those shoes. Experts conjecture on the factors that lead to suicidality, but those experts probably haven't been suicidal themselves. Our best source of knowing why people feel this way are probably from those who made unsuccessful attempts, but should we generalize what we glean from those individuals? It's almost like a group of rich people trying to figure out how to solve poverty; few of the well-meaning people working on the problem have actually felt the problem themselves.

When I rotated through psychiatry as a medical student, I didn't fully understand suicide assessment. At that time, it was almost a black-and-white thing; I had a list of questions and from those questions, I made an assessment of whether someone met criteria for a "5150." But reality isn't so clear-cut. I make a comparison to conversations with patients struggling with lifestyle changes. I probe a diabetic patient about why she isn't taking her insulin; I ask about her lifestyle, her finances, her priorities, her understanding of the disease, her ability to obtain her medication, the obstacles she has with taking it, her likes and dislikes, her hopes and fears. It's a long, painful conversation, but at the end, I begin to glimpse her holistically. Maybe this is the approach we ought to have with those who are suicidal. It is so easy to take a patient who ingested a bottle of pills, 5150 them and refer them to psychiatry. But if we truly seek to understand their behavior, we need to do a little more legwork than that.

Happy Christmas

Today, I met a 26 week old premature infant, delivered in emergency circumstances. I think of what it means to be born this day and what it means to be born over three months early, and also what it means to enter a world that can offer that child a chance. I also think of what it means to have surgery on a holiday, to spend the day in the hospital rather than at home, the subsequent days recovering. I also think of what it means to work today - and not of myself - I'm used it - but for all those I encountered today - endoscopy nurses and technicians, labor and delivery nurses, operating room nurses, anesthesia technicians, operating room assistants. I think of those working in the cafe where I grabbed a quick lunch leaving work. I think of all those who would rather be somewhere else, doing something different, seeing other people, feeling healthy and worry-free. I hope we all have happy holidays - and if not that - at least holidays where we feel loved, supported, and safe.

Code Blue

I am used to code blues being chaotic. In training, there would always be too many people in the room: nurses, respiratory therapists, residents, medical students, interns, consultants. As the ICU fellow who should be running the code, I often had trouble squeezing in, making sense of the din, and commanding the situation. I learned a lot in the first few months as a fellow about crisis management: how to quickly evaluate a situation, take control of it, and manage large groups of people. I quickly identified a lot of problems in these chaotic code blues: no clear leader or too many cooks in the kitchen, too many bodies in the room not contributing to the care, multiple people making decisions without communicating to each other. Eventually, I became proficient at running that sort of code.

In a community setting, the code blue is totally different. In many ways, it was better. On arrival, I noted three people cycling through compressions in an organized and cooperative fashion. There was a physician leader, but when he noted who I was, he quickly handed over responsibility to me. It was quiet; anyone could talk and be heard. I could quickly gather the story and make decisions. Everyone knew their role and performed it automatically; the respiratory therapist bagged the patient while the anesthesia tech set up the ventilator. A recorder and timer counted off minutes between epinephrine pushes. The other physician present, a proceduralist, put in arterial and central lines so we could send labs. I could easily settle into the role of running advanced cardiac life support, figuring out problems that could be reversed, and planning ahead. In the end, I was surprised on how well the code ran.

It makes sense. In a small hospital, everyone knows each other; most people present had been working there for years. There were no extra people (like medical students); everyone who showed up belonged there and had a function. Yet, compared to the residency setting, there are downsides. I wondered what would happen if there was a second code since all the major players were at this one (in residency, there would be enough redundant people that you could allocate resources to another crisis). We don't have last-ditch salvage interventions like ECMO. I don't know if response times are as fast. But I was impressed with how things actually played out.

A Full Hospital

It's a tricky situation. Ideally, a hospital wants to run at perfect capacity. By filling every single bed and controlling all the patients going in and out, it can run with maximum efficiency, caring for the most people, generating the most revenue. But this is never the case. A hospital can't predict how many patients are going to come through the emergency room or be sent from clinic as a direct admit. And though we try, it's also difficult to predict when a patient will be able to discharge home. There are unforeseen complications that send a patient up to the intensive care unit or changes an outpatient surgery to an overnight admission. And this affects resource management as well. How do you staff a unit when a new admission might come at any time? How do you avoid keeping unneeded bodies around but have enough capacity to meet surges of demand? I see this often on labor and delivery. Sometimes, there are extra nurses around to give a hand because the census is light. A few hours later, after a few patients arrive, it's all hands on deck and the charge nurse starts worrying about having to call more people in. These are the concerns of a hospital administrator. If you run too much below capacity or pay too many people to stick around "just in case," you'll lose money. But if you miscalculate, then suddenly you might have a queue of patients building in the emergency department or PACU, awaiting beds.

These past few weeks, the hospital has been running at capacity. I've definitely noticed it in the operating rooms and the intensive care unit. Cases get delayed because it's not clear that when the surgery finishes, the patient will have a bed in the hospital. Pressure is put on the intensive care unit to send patients to the floor and free up needed rooms. Charge nurses struggle to figure out how many extra people to call in. Everyone's tired; the delays make us cranky, and we wonder why we're spread so thin. But I simply remind myself that I am here to take care of patients; I focus on that, and let the administrators work out the stresses in the system.

Star Wars

A bad pun in celebration of Star Wars and being on a 24 hour labor and delivery call.

"Use the forceps..." - OB-one-kenobi.

Electroconvulsive Therapy

We do quite a bit of electroconvulsive therapy at my hospital. Although it sounds barbaric, it is a remarkably effective therapy for refractory depression and other psychiatric illnesses. Most days of the week, we have a handful of patients getting ECT treatments with a psychiatrist. Since treatments are frequent, we get to know each patient pretty well. Although I did ECT anesthesia in residency, we use different medications here, which is interesting. It's fun to see how etomidate (which I used in residency) differs from ketamine (which I use now), though outcomes are pretty similar; we can achieve good anesthesia and lower the seizure threshold to obtain effective therapy. The other big difference is that in training, we had two anesthesiologists doing the ECTs; the resident would give the anesthetic and attend to the airway while the attending charted. Now, I have to do both those roles, and I think that's what makes ECT a little exhausting. They start early in the morning, there's a lot of preparation for each one, and it's a lot of work multimanaging all the different tasks. Nevertheless, it's satisfying; one patient who used to be in a catatonic depression, minimally responsive to others, now talks about going to the Shakespeare festival and enjoying her grandchildren.

Colds

This probably applies to lots of different things.

Image is from xkcd, drawn by Randall Munroe, shown under Creative Commons Attribution License.

QuantiaMD

It isn't common that I stick with a website for years, but I have been using QuantiaMD regularly for a while now. It is a community for health care practitioners (requiring an MD, DO, NP, or PA degree to sign up) with focused educational videos on many topics throughout medicine (from basic diagnosis and treatment of diseases to health care policy to physician well-being). Every field from radiology to surgery to oncology is covered. Participating in it leads to rewards, which makes it fun and engaging. The material is pretty solid and it awards CME credits. If you're interested, check it out: QuantiaMD. It does require you to verify your clinician status. Full disclosure - I do get a referral if you sign up.

Cybercrime and Medicine

Health care has its hands full with the problems we're dealing with now. There's so much that needs attention - cost of care, inequalities in care, systems improvement, personalized medicine. We could spend decades tackling those issues we've already identified. But I also worry about those problems that aren't relevant now, but will soon be game-changing. One of these is cybercrime in health care. The sophistication of cybercrime - hacking databases with personal information, identity theft, fraud, and even terrorism - has become increasingly terrifying. While this is mostly focused on governments, financial institutions, and large corporations, I think it is only a matter of time before health care becomes a target. As hospitals all incorporate electronic medical records, patient information is being stored increasingly in the cloud. Luckily, HIPAA, the Health Insurance Portability and Accountability Act that frustrates so many of us, has limited the sharing and enforced the encryption of this data. But eventually, if we don't turn our attention to the security of our patient's (and physician's) information, an attack or leak will happen. Furthermore, as more devices go online and into the cloud, the danger of malicious attacks on these medical devices increases. Being able to reprogram drug pumps wirelessly seems like such a wonderful convenience, but if that ability is hacked, it can be devastating. Nurses and doctors access controlled medications through specialized dispensing systems, and controlled medications are delivered by autonomous robots; what if the hospital lost control of these systems? Even major devices like robotic surgical equipment are double edged swords. If a surgical robot can be controlled wirelessly, a surgeon can operate on a patient in a remote location or a warzone, and we can expand our delivery of care. But it also means it's vulnerable to those with malicious intent. I really hope that this doesn't become a reality, but I also believe addressing it preemptively is the best way to ensure that.

Christmas Creep

It seems that every year, Christmas seems to sneak earlier and earlier. We lament (at least publicly; perhaps privately we cheer) the fact that decorations go up right after Halloween, sales occur hours after Thanksgiving dinner, and Christmas jingles flood the radio stations. Well, the operating room equivalent of that just happened. A surgeon walks in, plugs his phone into the sound system, and Christmas carols start playing. Although I've heard strange songs in the OR (Gregorian chants anyone?), this is one of the more unusual. At least it'll only last the month.

Thanksgiving

I am thankful for what I have, imperfect as it may be. I am slowly learning this harsh lesson, that nothing in life is perfect. Family, friends, work, marriage, self; they all have rough ends that need to be smoothed. The perfectionist in me wants to get everything just right, but I'm trying to change my perspective to viewing everything as the cliched journey rather than the destination. I accept the mistakes I make, the faults I have, the flawed expectations I have come to idealize. I learn to appreciate that which I have, which is more than I deserve, and which is more than many people ever get in their life. I am thankful for being loved, for those who care for me, for a job that gives me such tremendous satisfaction, for personal activities filled with creativity and joy. I am also thankful for those life lessons I am learning, for those nudges that guide me to becoming a better person.

November and December

I've noticed in several hospitals that the operating rooms get particularly busy in November and December. We have been operating at capacity, running nearly all rooms all day. Although I haven't looked at the data, the hypothesis is that many people want to squeeze in those elective surgeries before the year's end and their deductible resets. In addition, if one has to recover from surgery, it might as well be during the holidays. Perhaps surgeons are trying to make a little more money before the end of the year. I've always found these phenomena interesting: why deliveries happen more on weekdays than weekends, why pediatric surgeries happen more during summer breaks, and why November and December push our hospital capacity to the limits. Time feels like an artificial thing we've created, and medicine - whether rightly or wrongly - gets swayed by such external influences.

Medicine and Miracles

Medicine and miracles don't often mix. I think most doctors would tell patients we don't believe in miracles. How many times have I been in the critical care unit, holding the hands of a family member at the bedside of a dying patient? All their organs are failing; it is only a matter of time. I break the news as best I can, indicating that to the best of my medical knowledge, the patient will not survive. The family acknowledges what I am saying, but then tells me that they believe in miracles. They want to keep going in hopes that a miracle will happen. Every time I've had one of these situations, we wait hours, days, even weeks, and no miracle happens.

Yet sometimes, rarely, we find ourselves wondering whether we are experiencing a miracle. During my week in the intensive care unit, I admitted a patient who had a witnessed cardiac arrest. She came into the hospital with nausea, chest pain, and diaphoresis. While the emergency department was putting her on the monitor, she said she wasn't feeling so great, and on the EKG, they saw her flip from sinus rhythm into ventricular fibrillation. She lost consciousness, and the emergency department started chest compressions and defibrillated her heart. No matter what they did, however, they could not get her heart to stay in a perfusing rhythm. She got multiple rounds of epinephrine, lidocaine, amiodarone, atropine. She ended up being shocked over twenty times. She had compressions for over an hour. When I arrived, the floor was littered with empty syringes, open code trays, discarded equipment. But just as we were about to call it, that is, to say that there was nothing we could do to salvage this cardiac arrest, she regained a pulse and a normal rhythm. I quickly rushed her up to the intensive care unit, unsure of what the outcome would be.

We were most worried about injury to the brain. Without the heart pumping appropriately during cardiac arrest, the brain is entirely reliant on the quality of chest compressions. Many survivors of cardiac arrest have residual neurologic symptoms. Some never wake up. The best intervention immediately after resuscitating the patient is to cool him down because lowering the temperature reduces how much oxygen and energy the brain needs. It gives injured brain time to heal. We quickly began the cooling protocol anticipating that there would be significant neurologic impairment.

Imagine our surprise when she awoke, still intubated, and signaled that she wanted a pen and paper. As she wrote, we realized her brain was completely normal. In medical terms, she was neurologically intact, but what that meant was that she wrote to us about her symptoms, acknowledged us when we explained what happened, communicated with her family, and consented to her procedures. We quickly rushed her off to the cath lab and stented her heart; a heart attack had set everything off. Although her heart, kidneys, liver, and lungs suffered significant injuries during her cardiac arrest, within a few days, I managed to extubate her, stabilize her blood pressure, and transfer her out of the intensive care unit.

I have never seen someone recover like this after an hour of coding. It was truly unbelievable. All the physicians and nurses taking care of her were amazed. There is no doubt that good compressions saved this patient's life. Although it is true that witnessed cardiac arrests and ventricular fibrillation are both good prognostic factors to surviving cardiac arrest, this was still a miracle. I have never seen someone dead for an hour come back to life.

Cost of Medications

A couple months ago, the web had an outcry against a pharmaceutical company that raised the price of an antiparasitic drug outrageously. A start-up acquired rights to this old drug and immediately increased the cost by over 50 times. The whole thing felt quite ridiculous, and yet so believable. To those of us who've been in medicine for a while, this is not a new occurrence; I've seen half a dozen drugs increase in price when another company acquired rights to an old medication. I find it appalling.

The problem is that not everyone's interests are aligned. A company will try to maximize financial gain at the expense of patients. Their responsibility is to their shareholders or angel investors or employees. This may be acceptable in other markets, but when someone tries to take principles gleaned from tech companies or entrepreneurial startups and applies it to established medical systems, he might be biting off more than he can chew. We have all learned to put up with the cost of innovation; each time a new chemotherapeutic or hepatitis drug is released, there is some clamor about the cost, but we aren't trying to shame the company. Here, though, a company is capitalizing on an existing treatment, and that, I think, is crossing the line. I am not against trying to shake up a system - indeed, that's how we root out inefficiencies. But it seems morally indefensible to acquire an antimicrobial and then raise its prices prohibitively. Even if insurance companies will cough up the money for it, ultimately, it's contributing to the black hole of health care costs.

In health care, I believe companies must draw some lines on what is morally permissible. Health care workers are on the patient's side. We do what we think is best for them. We cannot allow the other factors - pharmaceutical companies, insurance companies - badger us into forgetting who we serve.

Failure of Advanced Directives

An elderly gentleman with many comorbidities including advanced heart failure is sent from his nursing home to the emergency department for shortness of breath. He is intubated in the ER and sent to the ICU. Another older gentleman with metastatic cancer who was just discharged from the hospital presents again with shortness of breath and cough. He, too, requires intubation and then gets sent to the ICU.

In the next few days, I meet with family members of both patients. Both patients have, in fact, expressed to their children that they would not want heroic life saving interventions. They would not want to be machine dependent. They might not have even wanted to be intubated had they been given the choice. In one case, the patient arrived from the nursing home without any records; no one knew about his DNR order until his daughter arrived. In the second case, the patient had been discharged home from the hospital several days earlier and immediately filled out an advanced directive to be DNR, but had not had the chance to notarize it.

In both cases I met patients with such severe comorbidities that their quality and length of life was limited. They told family members they would not want intensive care interventions if they became acutely and devastatingly ill. Yet somehow, whether by fault of system or no one's fault at all, they were intubated, on pressors, and in the ICU. In both cases, after lengthy family conversations, we transitioned the patients to comfort care. They spent the last few hours of their lives in peace, but the preceding few days were fraught with unneeded intensive medical care.

This is not an unusual occurrence. Why does it happen? How can we have such a technologically and medically advanced society and yet not get someone's wishes about their end of life right? Part of it is the fragmentation of data; a nursing home or primary care doctor or kitchen magnet contains the necessary information, but it's not passed on where it's needed. An emergency medicine physician, in absence of better information, errs on the side of doing more. It takes days for family members to convene and agree that the right course of action is to let go. All in all, we are talking about a lot of unneeded suffering and medical waste.

This is a problem we must solve. It is not fair to patients - and one day, it will happen to us - to not have final wishes respected. Even an intervention as simple as a bracelet might avert unnecessary harm and cost. There's a lot of worry that unlike an allergy bracelet, a DNR bracelet might dissuade health professionals from taking care of a patient. But I argue that if we go around sticking tubes in people's throats, IVs in their necks, and electrical paddles on their chests against their will, we're not caring for them at all.

Prayers

It is easy to forget our fragility: the fragility of human nature, the fragility of compassion, the fragility of civilization, the fragility of human life. We float through our everyday lives with such buoyancy, never really examining what we have and what we could lose. We can lose a lot. We have a lot of skin in the game. Strangers across the world tug at our emotions. Images of suffering, chaos cry out to us. Stories make us tear up. Emotions burst from the floodgates: disbelief, astonishment, fear, concern, anger, pity. We are fragile creatures, and we need to help each other, support each other, unite hand-in-hand. So much of our time is concerned with ourselves, with the small things, the frugal. Today is not that day. Today is a day where what we can give, what we can write, what we can support matters. We strengthen those connections we've made across continents, across generations. There are no strangers to humanity, and I hope that today, we let our humanity shine bright. No whisper is left unheard.

Image shown under Creative Commons Attribution Share-Alike License, from Wikipedia.

Names

I recently participated in a writing workshop and wrote a quick piece on names. Names are such fascinating things. We have little control over our names, and at some point in life, most of us wish we had a different name. They represent our identity, carry our heritage, connect us to family. The ten minute writing prompt was to write about our name. A few other physicians in the group suggested I post this.

My name changes each day. Every time I meet someone new, I struggle with what to call myself. If the patient is young and looks frightened, then I grasp his hand warmly and call myself Craig. If she looks skeptical or her lips are pursed or if she has more than two allergies, then it is a firm handshake and Dr. Chen. If the patient has been through World War II, or any war really, then it's back to my first name. They want to give me a title, to give me authority, but they command too much awe in my eyes. They've seen and weathered so much it feels disingenuous to establish a rank and hierarchy around them. If the child is old enough that I might ask what he wants to be when he grows up, I call myself Dr. Craig.

My name feels different rolling off different tongues. A nurse calls me doctor, and I insist on Craig. A surgeon calls me Anesthesia and I insist on Doctor. A ninety year old nursing home patient who has broken her hip, sensorium clouded by pain and confusion, calls me by the name of her late husband. I grasp her hand gently and don't say a thing.

Book Review: The Life-Changing Magic of Tidying Up

Many anesthesiologists are obsessive-compulsive. We get territorial over our workspace; we have our syringes aligned in a certain order, our drips plugged into the central line a particular way, and our clutter minimized. There's good reason for it; when a crisis happens, we want to know exactly where our emergency medications are, how many blood products were given, which IVs go where. I almost have a ritual in setting up my room, organizing it as the case is underway, and cleaning up at the end. And it's been life-saving, allowing me to maintain control under stress and pressure.

Perhaps this is why I so thoroughly enjoyed Marie Kondo's The Life-Changing Magic of Tidying Up. Filed away in perhaps the most boring section of the library, this book lays out a method to simplifying, cleaning, and organizing one's life. She's very particular in her demands, insisting on a certain attitude, conviction, method, and order to tidying one's possessions. And somehow, with this, she has created an international bestseller. I know a few people who have used her method, and they all swear by it. The goal is to surround oneself only with possessions one loves.

It's a very short book and an easy read. I think it's probably appealing both to the obsessively clean and the hopelessly messy. Even if you don't follow through with the whole process, it's somewhat enlightening in showing what a clean and organized life could be and how to get there. I really enjoyed reading it.

Image shown under Fair Use, from npr.org.

Culture and Medicine

Along the same vein as the last post, culture has strange influences and tendrils in medicine. We learn in medical school to respect different cultures, to understand why some may be reluctant to trust physicians while others want paternalistic physician-driven decision making. We try to be culturally sensitive, adjusting our approach to patients in a way that honors their perspective and values. These politically-correct statements sound obvious and easy but the practice is not so straightforward.

My last call night on labor and delivery, I met several patients of a particular ethnic background. In each case, when the nurse called me to discuss an epidural, I met a husband that completely dominated the conversation. When I asked the laboring patient something, the husband would interject with the answer. When I tried to obtain consent for the procedure, the husband would want to give it. As I explained what she might feel with the epidural placement, he reinterpreted my words and fed it back to her. It was as if she didn't speak English - but she did. He acted as an interpreter even though there was no language barrier.

It was a bizarre and jarring experience. Coming from a Western culture that tries to empower women, I was taken aback. How could it be that these women had no voice? I tried to engage them directly, but they shied away. They wanted their husbands to broker the interaction with the physician. I was torn. To try to foist everything on the woman seems to be forcing my point of view on her. But to allow the husband to be the sole spokesperson seems to perpetuate this feeling of discounting the patient. I was surprised how much I struggled with this one. In the end, I wanted to give each patient at least several opportunities to speak up and express her wishes and desires. If it was clear they wanted their husbands to speak for them, then I felt more comfortable with this strange patient-doctor relationship.

Denial

A 60 year old woman suffers a massive stroke and is admitted to the intensive care unit. Her course follows a similar one to many patients with this degree of injury; it gets worse before it gets better. Initially, she is able to speak, even if her speech is garbled and difficult to understand. But over the next few days, despite interventions, her brain begins to swell. Her mental state declines to the point where she needs to be intubated to help her breathe.

Over the next two weeks, her family struggles to understand her illness. Her recovery is minimal at best. I cannot remove the breathing tube because she has periods of apnea - where she stops breathing - and has no reflexes to protect her airway. Her eyes open to voice, but she doesn't follow commands. Her stroke is devastating. The recovery for such an injury takes months. We start recommending a tracheostomy and feeding gastrostomy, surgeries that will aid her recovery.

Each day, I speak to the sister and daughter. They see small changes and think they are big changes. They remember when she first came in and could speak, and don't understand why she cannot do so now. They expect recovery within days.

The denial is fascinating and frustrating. They can explain that both I and the neurologist believe she will take months to improve and that she needs the tracheostomy and gastrostomy. They can repeat back everything I say. Yet immediately after they do so, they say, "But I disagree. I think she will get better soon. I think she's made huge improvements compared to yesterday. I thank you for the medical opinion, but I simply don't believe it."

I am sure other specialties or professions are trained to handle these conversations, but I felt woefully unprepared. How do you pass along information to help someone make an informed decision when they simply decline to believe it? What tools or strategies exist to help someone move beyond denial? I tried to engage them in many different ways; our physical therapists had them see how much assistance she needed, I printed out resources in their language, I asked for a "cultural ambassador" to see them. Yet all I could do was give them more time. Not all challenges in the critical care unit are medical in nature.

Image of intracerebral hemorrhage shown under Creative Commons Attribution Share-Alike License.

2101

Oops! Usually I like to note a post when it falls on an even hundred. After all, this only happens two or three times a year. But it's been unnaturally busy. I wonder a little if busy is simply the new normal. It's not just being a doctor; so many of my friends outside of medicine also have lives that move so fast, hobbies that soak up free time, projects they commit to. Is this a phenomenon of our generation and time? Or is it simply the way things have always been, and I've been too oblivious to notice?

Sometimes, I wish I could find some measure of tranquility, some calm where I can breathe. There is so much I should reflect on. I try to, in this blog. There are patients and families I want to think about. Reactions that I want to examine. Desires and hopes I want to pursue. Doubts I need to clarify. Experiences I want to write. Medical knowledge I'd like to acquire.

I have a friend who meditates each weekend, for hours at a time. He spends an entire afternoon simply in nature, focusing, relaxing, observing, listening, seeing. Every weekend, he takes a day where he doesn't talk to anyone. He simply exists. I admire him so much for that.

I worry sometimes that this world has too much stuff, too much excitement, too much going on. I have totally bought into it. But I wonder what it would feel like if we could slow everything done, just for a little bit. These are some of the meandering thoughts I have as I finish my week in the critical care unit.

Working Hard

There is a phenomenon that happens in medical training where you work harder than you ever thought you could. Perhaps you think pulling all-nighters and camping out in anatomy lab for an exam is hardcore. Then you get to your obstetrics rotation and find yourself being woken every half hour for a delivery. Then you rotate onto the general surgery service and find yourself in the hospital for 36 hours straight. You arrive one morning and leave the following evening. You call your very best friend (there's no time for anyone else) and tell them about your experience.

Then you get to be an intern, and maybe the hours are fewer - just thirty - but you find yourself more exhausted than ever. Now you're really responsible for patients. Hour after hour, you get admission after admission, and then nurses page you and you're not sure what to do and you can't get a hold of a consultant and then a patient's labs come back totally unexpected and then a patient has to go to the ICU and you're being paged by the pharmacy to adjust your vancomycin dosing. Plus, there's cross-cover. You frantically get orders in but get behind on writing your H&Ps so that by the time 2 or 3AM rolls around, you have a stack of papers and an empty head swirling with exhaustion. You try to keep your patients straight.

A year later and you're a resident overseeing a gaggle of interns, trying to catch their errors before they happen. Or maybe you're an anesthesia resident in the operating room learning a totally new field, working with a machine you barely understand, surgeons that intimidate you, a constant fear that something will happen in front of you that you can't solve. You work harder than you ever thought you could.

Let me tell you, this doesn't end. It is true that being an attending is generally much easier. But I'm in the middle of a week where I'm learning how hard I can work. The intensive care unit hit 18 patients, and I'm the only ICU doctor here. One patient, young, has a failing heart, lungs, kidney, liver, bone marrow, and immune system. Another crossed death's door and we pulled her back with an unbelievable resuscitation. One has an unexpected stroke. Another throws up a pint of blood. There are arterial lines, central lines, intubations, and dialysis catheters to place. There are code discussions and family meetings to address. Consultants wait and tap their foot. Nurses need orders. The unit clerk needs transfer orders because there are no beds. Over the day, I get four new admissions. No notes get written until evening, and now, because I am ultimately so responsible, I sit for hours trying to make sure I didn't miss anything. Driving home, it occurs to me that this one patient really ought to have a central line, and maybe I should drive back and put it in. I don't see my spouse; I don't talk to family; I haven't been on facebook in days; I check my email at red lights. I eat one meal a day, and it's in the hospital cafeteria; at least, I have a lot of Halloween candy. Three days down, two more to go.

I'm sure there will be a time where I work harder than this. But for now, I am being pushed beyond what I thought I could do. It feels like a familiar experience, and surprisingly, I like it.

Staghorn Calculi

This is a doodle my wife made.

The Internal Medicine Physician

My father is an internal medicine doctor. It is the physician I have always admired: the kind, humble, soft-spoken doctor in a pressed white coat listening to a patient with a stethoscope, laying hands and making the unexpected diagnosis. His brain is a repository of knowledge, not only of obscure disease states involving every organ, but also of the latest clinical trials, a truly evidence-based practitioner. He is comfortable in every setting, seeing healthy patients in clinic for their annual check-ups and dying patients in the hospital at the end of their life. His patients adore him; his colleagues respect him.

I thought a long time about going into internal medicine; much of it not only appeals to me but also caters to my skill set. But upon seeing the real nature of internal medicine, I knew I could not do it. I've never enjoyed clinic, and in the hospital, internal medicine takes the role of the dumping grounds. If a patient has no home; if his illness is undifferentiated, he is too complex, or no one wants to take ownership, he goes to medicine. Medicine residents spend call nights admitting patients with "failure to thrive," "weakness," and "abnormal lab values." A patient who falls and breaks their hip may not go to orthopedics; they end up on medicine. While some valiant attendings try to recreate the bedside diagnostician of yore, internal medicine, as I have seen it, has been relegated to the care of older patients with many comorbidities, none of which can be cured. They try to patch what they can to get these patients out of the hospital knowing that in a few days, weeks, or months, those patients will return. It can be a depressing job.

When I was an ICU fellow, the medical ICU was the internal medicine equivalent for critically ill patients. There were so many situations of a patient with a surgical illness who was simply too sick to survive surgery, and because of that, they came to my medical ward. Even trauma patients with some complicating arrhythmia made the surgical intensivists too scared; they came to me. I was by default the accepting ICU fellow for any patient who was intubated, needed pressors, or was too altered to remain on the floor. There was a burden associated with this role.

Although I love taking care of patients, it's hard to be the "default." For this, I respect my internal medicine colleagues so much more, for having a role I could not fill. I wear the hat for critical care patients, and I actually enjoy it, but it has taken me a long time to understand what it means to be the one who has to step in when everyone else steps back.

Ethics in Practice

On call, I am paged for a potential emergency case in the cath lab. A 90 year old woman with atrial fibrillation threw a clot to her brain. She presented several hours ago with a dense stroke; she couldn't speak, couldn't move her left side. The neurologist who saw her ordered tPA, a clot buster, but because of the extent of the stroke, wanted our neurointerventional radiologist to see her. The interventionalist thought he could guide a catheter into the blood vessels of the brain and pull the clot out. This would require general anesthesia, so I was called in.

When I examine the patient an hour later, her symptoms are markedly better. She has begun to talk and can lift her left arm and leg against gravity. Her examination is fascinating, the kind of thing that convinces medical students to go into neurology. She understands what we're saying to her, but has an expressive aphasia; she can't say complex sentences. When you ask her to tell us her name, she says she can't say it. But when you ask her, "Is it Sarah? Mary? Angela?" she'll answer correctly. If she doesn't get better from this, it will change her life. She lives independently; in fact, she has no other family members. Devastating strokes can take away someone's entire way of living. Although she was much better than when she presented, she still had real deficits.

The ethical dilemma arose. She didn't think she was having a stroke. Consequently, she didn't want to have the neuro interventional procedure. She consistently said she didn't want invasive procedures. But this was founded on a delusion of not having a stroke, which could have been caused by the stroke. It's a little confusing. In medical school, informed consent seems like such a straightforward thing. How could it be an ethically wrought subject? But at 2AM, with a stroking 90 year old patient, a procedure without risk that could return someone to independence, it's a real challenge.

On our investigation, there was no one else to make decisions for this patient. That, of course, would have been the best recourse. So I really probed the patient's competency to make this decision. Other than her disbelief that she needed the procedure, she seemed to understand what it involved and the risks. She adamantly didn't want it.

I also was not so sure that the benefits of this procedure outweighed the risks. She had already gotten significantly better with tPA, and a procedure like this can lead to further strokes and bleeding. The best trials for this procedure looked at the larger proximal vessels where tPA is less effective; her strokes seemed to be more distal. 

Ultimately, in talking to the patient, neurologist, and proceduralist, we decided to cancel the case. It is not ethically permissible to force a patient to undergo a procedure she does not want. The patient's lack of insight into her disease blurred the solidity of informed consent, but we felt that she understood enough to decline it. We admitted her to the hospital in hopes that with further anticoagulation and therapy, she will get better.

Board Exam

The anesthesia oral boards are quite a surreal experience. The testing happens in a specialized center in North Carolina, and coming from the West Coast, the flying and travel for a two hour exam is a weird feeling. For that short session, I spent ten hours in the air and the rest of the time in airports and the hotel. I imagine this is not so unusual for other professions like businessmen and consultants, but for me, it just felt strange.

I think compared to other tests, this feels like one where last minute cramming won't help. You're either ready or not, and what you do in the last twenty four hours before the test probably makes only a difference in self-confidence. This might apply to studying as a whole. It's hard to know how to prepare for the oral boards. Practice is the most important element as being able to articulate your thought process is essential for passing. But outside of that, I really wasn't sure how best to prepare. Some people say reread major textbooks. Others find review books useful. There are only a handful of actual released old exams. But for me, textbooks seemed too detailed and review books too superficial. Practice exams were helpful, but without "model answers" it's hard to gauge how you're doing. It honestly does feel like the kind of test for which the entirety of residency (and fellowship) prepares you.

It goes by fast. Suddenly, you're getting off the shuttle and sitting down in the exam room. You flip over your exam stem, and your eyes quickly lock onto those keywords that you know will guide your scenario. Some questions you can predict. Some topics you know you aren't prepared for. But in a blink of an eye, you're sat down in front of two stern-faced examiners. They rapid-fire questions to you across the table, cutting you off just as you're getting mid-stride, probing to get you to sweat. They throw complication after complication and just as you wrap your head around what's going on, they move on. You never feel fully in control of anything.

There are two scenarios (plus several "grab-bag" miscellaneous questions). One situation was easy for me, given my training, and that was actually quite fun; it felt as though I was having a conversation with the examiners. The second was much harder, but I think that's okay; they want to see if we derail when we encounter a few bumps in the road. And then, all of a sudden, you're back in the airport, mind still ajar.

It's a strange experience, and a costly one, but so far, I have faith in the system that it's necessary and that it works. I wonder if someday these will occur virtually; although there is something to seeing people in person, the world is quickly digitizing, and it seems that taking two days off work for a two hour exam may become obsolete.

Challenges in Private Practice

Although as a whole, community practice patients are healthier and less complex than those at tertiary academic centers, we do get our challenging cases. On call two different nights, I am asked to do two similar emergent cases. A 90 year old man who has so far survived two heart attacks, a coronary bypass procedure, kidney failure on dialysis, and two leg amputations for uncontrolled diabetic infections is admitted from the emergency department with belly pain. Exam and imaging are consistent with dead bowel; without surgical resection, he will not survive. Over the last few hours, he has been started on three different vasopressors to marginally support his blood pressure. His heart is racing at 120 beats per minute (pretty much close to the maximum expected heart rate for a 90 year old), and he is breathing fast and deep with the assistance of a pressured mask (BIPAP). The second patient was similar, a 90 year old man with a critical aortic valve stenosis who presented with abdominal pain. His heart valve stenosis was so severe that for years, his cardiologist recommended a valve replacement, but he kept on refusing. On the telemetry floor, he has a code blue when he is unresponsive, requiring CPR and intubation. Further imaging suggests that he, too, has dead bowel. He is on two vasopressors supporting his blood pressure.

I really enjoyed anesthetizing these two cases. It reminded me why I went into critical care; I like the hardest parts of medicine. And it's not only the medicine and procedures; these cases challenge me to consider whether these patients really needed surgery, to have that hard discussion with families about the risk and seriousness of the patient's condition, to communicate with surgeons about the plan. In these cases, I really took ownership. These patients needed my utmost care and attention; they forced me to use skills that I don't routinely think about. In fellowship, I became proficient with assessing the heart with ultrasound. I learned how to mitigate risk in line placement. I learned how to anticipate and treat complications before things got too late. These were cases where I was never bored; I was always moving, thinking three steps ahead. They were the type of cases where we would be nearing the end before I even picked up my charting. They develop a rhythm and cadence, where I am fully immersed. All my thoughts outside the operating room were on hold; it is how imagine surgeons feel when they are in the most critical parts of surgery.

Both patients were (at least physiologically) better and more optimized at the end of surgery and anesthesia. At the end of the night, I knew, had convinced myself, that I had done all I could to my utmost ability. Satisfaction in medicine comes in many different forms, but some of the most profound moments occur when I am fully immersed in a challenge and surprisingly happy.

Death with Dignity

Ever since Oregon passed the Death with Dignity Act, many states have considered passing similar laws to allow physician-assisted dying. The whole "death with dignity" movement is a fascinating one to me because it has changed so dramatically over the last few decades. In the past, medical associations, most physicians, and most medical education took a stance against physician-assisted dying. They found it not ethically permissible for a physician to prescribe or administer a medication with the intent of ending someone's life. This is quite different from palliative care and the principle of double intent. Here, a medication can be given if it is intended to treat pain, anxiety, or discomfort even if it may incidentally hasten death. That has been ethically defensible since Sir Thomas Aquinas. If someone is suffering, we have the means and obligation to treat it even if it means a shorter life. But prior to "death with dignity" laws, we would not give pain (or other) medications to someone who wasn't suffering even if they had a terminal diagnosis.

Recently, California has considered legislation legalizing "death with dignity." Notably, all such laws (in the U.S. at least) have very narrow scopes. They allow an adult patient with a terminal diagnosis and less than six months to live to initiate a request for a lethal dose of medication. Any physician, pharmacist, or health care provider who has moral objections does not have to participate. There must be witnesses and a second medical opinion. The patient cannot have a psychiatric illness that would impair decision making. Even after a request is authorized, there is a waiting period before the prescription may be filled. If there are any concerns for the ability to make an informed decision, a psychological evaluation must be completed.

Many of the initial objections to this measure - that masses of patients would commit suicide or coercion would be a major problem - simply haven't borne out. For the most part, it seems that those who choose to "die with dignity" have appropriate medical illnesses and evaluations.

This is a tough ethical dilemma. I believe that in some circumstances, people should have the right to choose how they die. Faced with a progressive terminal illness that robs one of independence, mental faculties, and wellness, a patient can and should be able to choose otherwise. Even though hospice may take care of pain and anxiety, the question is one of choosing how to die. We are able to choose many things in our life; it seems that we should still maintain control over our death. In addition, many of patients' fears at the end of life revolve around lack of control. I believe this empowers patients even if they never use it.

The greater question is whether physicians should aid this, and I'm not sure I have the answer. We go into this profession to treat disease, relieve suffering, and ensure wellness and happiness. If we have no more treatments for a disease and a patient wants more than relief of suffering - wants instead, agency and control, should we be the enablers? I think every physicians needs to ask herself that question. It is new, uncharted territory. In no case should any physician be required to participate. But I think that giving physicians the option to help patients in this way is not out of the question.

There are many forms of suffering. We treat pain, anxiety, air hunger, constipation, confusion, agitation, and a dozen other different symptoms and sensations at the end of life. But what about existential suffering, that feeling that one has lost control, independence, and agency? Maybe that's a category better left to priests and clergymen. But maybe it is a type of suffering we too can aid. I wait to see how the medical community adapts to these changes in scope and practice.

The Impossible Situation

One of the common problems on the anesthesia oral boards is the "impossible" situation. A patient's medical problems, surgical needs, and anesthetic risks all create conflicting priorities such that no course of action is without significant risk. Whatever you decide - cancel a case, proceed with a general anesthetic, try a spinal, optimize medical therapy - will ultimately end in some complication. It is a game of weighing risks and benefits and trying to choose the lesser evil. Examiners use these questions to get an appreciation of whether the examinee can reason through difficult situations, appropriately articulate the risks and benefits with each decision, and commit to a choice and handle its complications. These are some of the more stressful situations that come up in oral boards; hopefully I'll be ready for them. I'm going to take this week off blogging to prepare.

Preparing for Oral Boards

The anesthesiology boards have two parts, a written examination and an oral examination. While this used to be the case with most specialties, many have done away with the oral part. For anesthesiology, I think it is here to stay. The written test focuses on medical knowledge, understanding of physiology, pharmacology, and disease states, interpretation of data, and textbook facts. However, a critical part of being a safe and effective anesthesiologist is the medical decision making in what we do. Since so much of anesthesia is real-time, we don't always have the luxury to break open the textbook, look up information, or consult our colleagues. The oral exam assesses our thought processes, response to changing situations, and clinical reasoning, It probes the grey area of medicine, the weighing of risk and benefit, the approach to uncertainty, and the situations which have no right answer. I think in this respect, it is an exam that is here to stay.

Of course, the process isn't the easiest. It's time-consuming and expensive. Over the last year (and again in the next year), every few weeks, hundreds of newly minted anesthesiologists fly across the country, stay at a hotel, and take this standardized exam. Dozens of examiners, well-established professors and community practitioners, also fly across the country to administer the test. It's a little mind-boggling how much goes into this. (One wonders whether someday it'll be digitized).

We are all nerves and stress while we take this test, just over an hour of examination time. We get two patient scenarios, and for each one, two examiners proceed with rapid-fire questions trying to befuddle and stump us. The scenarios never go smoothly; part of the test is to assess how we manage surgical and anesthetic complications. You never know when you get the right answer since the virtual patient will always do poorly. The examiners also probe in increasing depth, asking question after question until all you have is, "I don't know." They want to see how candidates do under stress, and it's fair, because real life anesthesiology is stressful. The good examiners reveal nothing, and an hour and a half later, we are ushered out, dazed and shocked. At least that's how I imagine the experience to be.

I have been studying quite a bit; the exam can cover any aspect of anesthesiology, including areas I don't currently practice such as neonatal anesthesia, cardiac bypass, and pain management. But since it's more than just medical knowledge, I am working on how I present myself, my communication, and my thinking under time pressure. I'll probably take a break from the blog in a few weeks as I get closer to the test.

No Longer a Resident

I've noticed a substantial change in how I'm perceived and treated now that I'm no longer a resident. Though I've always been treated with respect, now that I'm an attending, I've noticed that my interactions with other health care providers is different. When I express an opinion, it's taken seriously. When I make a decision, it's not questioned. I'm asked to do far less busywork that is unrelated to my specialty. My fellow health care providers - surgeons, nurses, consultants - really feel like colleagues, equals. When I was a resident and fellow, I could sense a hierarchy, which no longer seems to exist.

I'm sure that to some degree, this is a result of working at a community hospital with no residents. All physicians are equal members of the medical staff. The culture does not have to deal with those in training. At an academic center, I've always noticed that even among attendings, experience and rank makes a difference. A young attending may be questioned more, relegated to more tedious duties, taken less seriously. I'm quite fortunate that for me, such prejudices are minimal if they exist at all.

It feels really nice to be done with training, to be recognized for my expertise. I never minded being a resident or fellow, and I don't mind being asked to do busywork or to justify my decisions. But my life feels so much smoother now that such things are a rarity.

Solo in the Operating Room

All through residency, we are never by ourselves during the induction or start of anesthesia. An attending has to be in the case at all its critical points. Even though I may manage an entire anesthetic independently, I always had a shadow in the back of the room, ensuring that my decision making was sound, that I didn't miss anything. Now as an attending myself, I end up being solo in the room. In some ways, it's not that different; during the latter part of residency and during fellowship, I became comfortable anesthetizing someone and securing the airway. But there's still a psychological strangeness to it. I have to be sure, really sure, about each of my decision points. In residency, if something went wrong and I didn't know how to fix it, I always had someone to turn to, a crutch to lean on. Now, the buck stops here. That takes getting used to.

The truth is, I'm not really on my own. The wonderful thing about my anesthesia group is that all my colleagues and I are a team. We collaborate, help each other, call on each other. For difficult cases, I don't hesitate to see if someone can lend me a hand. In an emergency, I can always call for help, even in the middle of the night. The anesthesia group is structured this way for patient safety. I'm not truly alone; I just need to recognize when I need someone else.

Nevertheless, that moment before induction of anesthesia, I always hesitate. I go through my mental check-list. I take a deep breath. What we do isn't trivial. I am glad I've been well-trained.

Health Care Innovation Contests

I probably should have mentioned this earlier, but Medstro is hosting several competitions soliciting ideas for health care innovation. Sponsored by The American Resident Project, this is a forum to try to stimulate ideas on creating value, connecting underserved populations to care, using technology, and promoting team-based structures. Open to anyone - physicians, medical students, start-up entrepreneurs, patients - these contests crowdsource your ideas on how to make our health care system better. I am one of the many judges and I've been reading dozens of entries, all of which are exciting, creative, and potentially game-changing. The deadlines are coming up soon, but if you have an idea, a solution to one of the myriad of problems we face today as health care providers and patients, then please let us know. We want to hear from you.

Airway Equipment in Private Practice

In training, we get used to having a wide array of devices for placing a breathing tube. This is the purpose of education; each device helps us better familiarize ourselves with airway anatomy, anesthetic techniques, and decision-making in challenging cases. But the truth is, only a handful of techniques have been shown to be definitively better than standard laryngoscopy in clinical trials. Most of the other fancy devices are just that. So in private practice, where it isn't cost-efficient to stock every single gadget and gizmo, we have only a minimum selection of devices. At first, this feels like a disappointment, but over time, I've realized I simply don't need access to every single new device. In fact, it's probably better to be proficient at only a few approaches rather than mediocre at many. With a gum-elastic bougie, video laryngoscope, and fiberoptic bronchoscope, I should be able to intubate any patient. And, those are the techniques (along with an intubating LMA) which have been shown through trials to be the most effective in the difficult airway. I do miss the unusual techniques (gum-elastic bougie, intubating with an Aintree catheter, lightwand) that I no longer use. But I also feel that I've gotten better at my technique with simple direct laryngoscopy since I have fewer backups to bail me out.

Pre-Ops in Private Practice

There are many differences between academics and private practice. For someone like me, who spent the last five years in an academic medical center, the change can be a little jarring. Some of it has to do with money; if something doesn't justify its cost, then in private practice, it's eliminated. In academics, research, teaching, and the latest evidence are emphasized. In private practice, safety, conservative management, and efficiency are king. I don't think either perspective is necessarily better or worse; it's simply a difference in mission.

Even before a patient arrives for surgery, the process is quite different. In residency, patients go to a "pre-anesthesia clinic." They are seen by a resident or a nurse practitioner who reviews their medical history, checks their medications, and ensures that they are appropriate for elective surgery. An anesthesiologist determines what laboratory and other tests (like EKG or chest X-ray) are necessary prior to surgery. The patient receives information on how to prepare for their operation, gets an overview of what to expect, and asks questions. However, preoperative clinics end up costing a hospital or anesthesia group; pretty much everything we do is not reimbursed by insurers. There may be some cost savings if the pre-op clinic decreases last-minute cancellations or reduces complications. But overall, it's a thankless endeavor. It also requires a lot of coordination; we try to schedule appointments right before or after a patient meets their surgeon. But if one clinic is delayed, it can greatly impact the other. I've had many patients coming from out of town complain because the process of getting ready for surgery takes all day.

This kind of thing is not practical in private practice. Our surgeons have offices in many locations, and it would be impractical to have all our patients go to a separate anesthesia clinic after their surgical appointment. We don't have the staffing to see every pre-operative patient; in residency, that clinic had over five nurse practitioners a day along with a resident and an attending. Furthermore, we don't necessarily like the idea that the person seeing the patient pre-operatively is different than the physician caring for them on the day of surgery. To make things more efficient, the anesthesiologist caring for a patient gives her a phone call the night before surgery. It can make the end of my day quite long, but it allows me to ask for whatever information I think is necessary and gives me the opportunity to introduce myself to a patient. I think it minimizes inconvenience to the patient. However, there are limitations. I don't do a physical exam until the day of surgery. If I identify something that needs to be optimized, I don't have much time or opportunity to do so. I don't control what tests are ordered. Nevertheless, it ends up being the most cost-effective way to ensure our patients get a reasonable pre-operative evaluation.

Spice

As I try to make some chili oil with ghost peppers, I think of the strange sensation of spice. To me, spicy foods have a terribly irresistible attraction, even when they're so hot, I'm suffering. And spice has an odd medical association with neuropathic pain. I've even had patients describe pain to me, not just as "hot" or "burning" but actually "spicy." What is it about this perception that some of us crave and others fear?

The active component of chili peppers, capsaicin, is a fascinating compound. In fact, when it was discovered that some spiders have capsaicin in their venom, it became the first compound found in both plant and animal anti-mammal defense mechanisms. Exposure to mucous membranes, skin, and the lungs can cause medically significant irritation. Yet, it's not an entirely bad compound. Some of us love our spicy foods because capsaicin can induce a sense of euphoria, perhaps from release of endorphins. We actually treat neuropathic pain like shingles with patches on the skin. The two faces of spice fascinates me. How can something evolve to be a highly irritating defense mechanism, yet give us such pleasure and reduce pain when used in particular forms?

Image of ghost peppers shown under Creative Commons Attribution Share-Alike License, from Wikipedia.

Book Review: The Golem and the Jinni

One of the best books I read recently was Helene Wecker's The Golem and the Jinni. It is an impressive first novel and reminds me strongly of Jonathan Strange & Mr Norrell. As historical and fantasy fiction, it takes place at the end of the 19th century, a time period I love. She describes the adventures of two magical beings, a golem and a jinni, who encounter each other in New York City. The juxtaposition of these fantastical creatures with turn-of-the-century New York actually isn't that strange. They are immigrants that live within pockets of immigrants, trying to understand and assimilate into human culture. To me, this novel evokes the experience of strangers entering a strange land, and the magic in it doesn't feel gimmicky; rather it feels quite natural, as if such things ought to belong.

Her plot is engaging, fascinating, and inventive. Her characters are memorable and easy to sympathize with. The writing is accessible and beautiful. I never felt bogged down by the book, and though it takes a leisurely pace, it meanders and dips into such intricately described lands and situations that the reading went fast. I really loved this book; it was a well of relaxation that sopped up the stress of my last few weeks.

Image shown under Fair Use, from Wikipedia.

Satisfaction

I call a patient the night before his surgery to walk him through the anesthetic. "Every time I have anesthesia, doc, I get horribly nauseous. I've had seven surgeries and it's been the same each time." A challenge. This, in itself, is not an insurmountable one. In residency, I encountered plenty of patients with severe post-operative nausea and vomiting. With the right combination of ondansetron, dexamethasone, propofol, and scopolamine, I can achieve a comfortable anesthetic.

But then during surgery, a second challenge presented itself. The surgery he was having is not expected to having bleeding, but unfortunately, altered anatomy lead to a sheaf of blood vessels right where the surgeon was working. He got into a bleeder and couldn't get control. Over half an hour, we lost almost a liter of blood. I went into active resuscitation mode; no longer able to attend to the propofol drip, I turned on anesthetic vapors. In between placing additional IVs, sending a type and cross, and managing the blood pressure, I worried that this case could end quite badly. We had to get an extra surgeon to control the bleeding. At the end, the patient was quite swollen after being prone three hours longer than expected.

I stayed late to make sure he recovered from anesthesia and surgery adequately. Stopping by the recovery room, my hair mussed from my surgical cap, my feet weary from standing all day, he said, "I have no nausea. I feel great. Good job, doc."

Ethical Gerrymandering

On the ethics committee today, we discussed an interesting historical change with kidney transplants. There have always been ethical considerations around the concept of live organ donation. With living donors, you are taking someone who is healthy and intentionally injuring them with no medical benefit to them. Doctors are violating that principle "primum non nocere" - first, do no harm. Medical ethicists have been drawing and redrawing the lines on what is acceptable; what risks can we allow perfectly competent adults to choose? What transgressions are our surgeons willing to undertake? It seems, over time, we keep redrawing those boundaries. As we realize we need more and more organs, and cadaveric donors can't meet the need, we seem more willing to gerrymander.

That's not a fair characterization of the situation; over time, our surgical and anesthetic techniques have improved and we have outcomes on these donors. Other than the minimal perioperative risk, their long-term mortality is the same. They are at slightly higher (still <1 a="" accepting="" an="" and="" are="" around="" be="" but="" can="" course="" decision="" do="" donate="" failure="" follow-up="" higher="" if="" kidney="" listed="" long-term="" majority="" much="" need="" not="" of="" organ.="" p="" pain="" priority.="" regret="" risk="" suffering="" suggests="" surgery="" the="" their="" these="" they="" to="" transplant="" vast="" volunteers="" willingly="" with="">
From an ethical standpoint, we've also started recognizing the social benefit of donation. Cutting someone and removing a kidney may do a person no medical good, but they may benefit if the recipient is a spouse, sibling, child, friend - or even, stranger. Now, we accept nondirected living donations. We even encourage this to become a "donor chain" where one donation motivates a recipient's family or friend to reciprocate. With adequate psychosocial evaluations in place to ensure there is no coercion and consent is proper, we think breaking that rule "primum non nocere" is ethically defensible.

Conversations like this is why I love medical ethics. It's endlessly fascinating and provides a lot of fodder for discussion, argument, and learning. What do you think?

1, 2, 3

I recently saw the play "1, 2, 3" by Lila Rose Kaplan at the San Francisco playhouse. It was phenomenal. The play explores the lives of three sisters who are separated when their terrorist parents are caught. The three sisters grow up in different foster homes, and each struggles with coping with her past. One of the sisters discovers a passion for ballroom dancing, a catalyst for the play to explore interpersonal relationships for these women who have lost so much. The play is beautifully written; the dialogue is sharp, the humor on pointe (and puns are scattered through the play), the staging spare and natural all at once. The story is poignant but not sentimental, challenging our preconceptions of what shapes a person, what influences a child, and how personality can drive one's motivations and decisions. The acting was captivating; you could see amazing connections between all the actresses and the actor, and the characters they brought to life reminded me of people I knew. It was quite spellbinding to see how they focused so much energy and emotion on the stage.

I wish I went to more plays. It was incredibly refreshing. My wife went to college with Lila Rose Kaplan, and we could not give a higher recommendation to go see this play. In a time and society where movies, computers, and social media are king, it is easy to forget art forms as beautiful as this.

Image shown under Fair Use, from sfplayhouse.org.

Intensive Care and Anesthesia

Now that I am back to doing mostly anesthesia, there is no doubt in my mind that doing subspecialty training in critical care has made me a better anesthesiologist. It could simply be the effect of doing another year of clinical training, but I think it's more than that. It's also more than just the book learning, the medical knowledge of being in the ICU. Critical care does teach a lot that anesthesiologists don't regularly think about; we look at trials on complex ventilator management, focus on organ systems anesthesiologists are less familiar with, and see the natural history of complicated disease processes. But there's also a skill component to it. One of the most important things I learned as an ICU fellow is the ability to manage complex crisis situations in an articulate fashion. So often as an ICU fellow I would arrive at a code with no idea who the patient was or what happened, but I would be expected to take control of that situation. In the operating room, I translate those intangible skills into assessing the last-minute emergent add-on case of a sick patient needing major surgery. When time matters (when seconds count), I quickly determine what I need to know to care for someone effectively. In the last year I also learned leadership and communication skills that we don't often get in medical training. When a medical crisis happens, I keep calm, and indeed, I notice that in my anesthetic management now. Situations that used to cause me panic and cause my brain to lock up now flow smoothly. I am a much better physician after a year of ICU training.

This fascinates me because I had all the knowledge and procedural skills I needed to be an anesthesiologist after completing residency. Fellowship just put me into a myriad of situations that accelerated learning from experience. I think most physicians who deal with crisis situations learn these nuanced approaches and subtle perspectives over time; ICU fellowship simply drew it out of me.

Return to Anesthesia

During my year as a critical care fellow, I didn't do much operating room anesthesia at all. At most, I would be rushing one of my critically ill patients back to the operating room for an emergent surgery while the assigned anesthesiologist was getting there. As a result, I was a little apprehensive about being back in the operating theater. Everything came back surprisingly quickly. It's hard to shake old habits; once I got back in the room, I started noticing my previous routines. Like most anesthesiologists, I have particularities in how I set things up, and those flooded me like instinct. I ride a bike sporadically enough that I get that feeling too, and it's a weird sensation, all apprehension and reassurance.

Currently, I maintain my workstation like a resident; I have a lot of redundancy, some backups, preparation for the rest of the day. It's pretty inefficient, and I think in the near future, I will refine my routines to save more resources and time, For now, however, I am glad the operating room feels easy, familiar, and safe after a year in the intensive care unit.

Regulation of New Doctors

Sorry for the late blog post! Work, call, moving, and settling into a new place have been exhausting. We're still working on the Internet connection in our house, and I'm still waking up extra early and staying extra late trying to get to know my practice.

The privileging process of new physicians is a long yet necessary one. I have joined a physician group that contracts with the hospital. In being employed by the group, they have gone through my diplomas, records, resume, and references. But although the group is contracted to a hospital, the hospital itself must vet my records in order to add me to their medical staff. So in the process of getting a job, I feel like I've been doing everything in duplicate. After going through my CV, contacting my training programs, and checking with the state medical board, the hospital granted me temporary privileges.

But how do you know that a physician you hire is going to be okay? How does a hospital come up with a policy to approve radiologists, primary care physicians, anesthesiologists, and psychiatrists? The easiest way, and the way most places do it, is through peer review and proctoring. During my first few anesthetics, I had a proctor evaluate my technical skills and decision making. It certainly helped to have someone familiar with the system who I could ask questions. Because the truth is, the medical side is easy; I've been doing anesthesia and critical care for years. Figuring out the hospital and how things work is much more challenging.

After the proctoring period, my privileges are temporary until half a year when a retrospective review of my records dictate whether I can be approved for permanent privileging. Overall, it seems a lot of paperwork and busywork for me to do what I'm trained to do. And it also duplicates so many other processes - board certification, residency requirements, oversight of the state medical board. But I guess it's a way for everyone to protect themselves and have multiple evaluation systems to prevent a dangerous physician from practicing.

Money and Time

Residents are paid a fixed salary. I believe the amount of money we make as residents is comparable among all residency programs throughout the nation. In fact, other than a cost of living adjustment, graduate medical programs are not allowed to increase (or decrease) a resident's salary. The purpose of this is to prevent applicants from deciding on a program because of its compensation. In order to keep all residency programs on a level playing field, the salary is set. Of course, programs can tweak this value by adding an "education fund" or other type of stipend, so it's not a perfect system.

Nevertheless, this means that regardless of the hours we work as a resident, the money we make is constant. In fact, working longer hours and extra days means the amount of money we make per hour goes down. As a result, when looking purely at the finances, we hope to do less work, have fewer cases, and see fewer patients. Of course, money is hardly the biggest driver in residency, so we work the hours we do and enjoy seeing more cases because of the education, training, and inherent value of patient interactions.

On the other hand, after we finish our training, the amount of money we make is directly correlated with our productivity. Instead of wishing for quiet call nights, we would rather be busy all night. If we've committed to working that night, we might as well make money from it. This all seems obvious, but it is a paradigm shift for us. While a very long add-on list might be a little discouraging, at least we are making more money per hour rather than less.

Orientation Again

One advantage to doing my residency and fellowship at the same place I did my undergraduate years was knowing the hospital. This was a stark realization as I started orienting for my job. The simplest things I took for granted - where to park, how to get to the anesthesia workroom, the numbering of the ORs - I had to relearn. None of it was a big deal, but it adds a veneer of stress as I started my job.

It's a strange realization. The medicine is not scary or hard. I am not worried about my ability to resuscitate a patient, intubate, or put in an epidural. Rather, it is the context that challenges me. How do I get these drugs? Where is the difficult airway cart? Which epidural solution do we use at this hospital? Unfortunately, I cannot anticipate all these questions, and so much of it is learned on the job.

Orientation day focused on getting me access: keys, passwords, fingerprints. But learning how to use everything is something I will learn in the next few weeks. I can get onto the electronic medical record, but the first time I have to look up an old echo report, I will have to dig through the chart. The tour was a whirlwind; soon I will slowly have to figure out the shortest paths from place to place. It is similar to meeting all these new people; I've been introduced to them all, but only with time will I get to know them. I think orientations always are like this, a blur, a whirlwind, and for me, it conjures equal parts stress and excitement.

Overheard

From my wife Carolyn (a neurologist): "I want to have a Big Sur relay team called the Upgoing Toes."

The Babinski sign is a reflex that is normal in infants; when stimulated, the toes fan and go up.

Image shown under Creative Commons Attribution Share-Alike License.

Mental Health and Economics

This is a post about money and medicine, but not in the sense that immediately comes to mind. Those who study the epidemiology of psychiatric diseases note a really interesting fact. The prevalence of mental illness increases as a country's economic wealth increases. This happened in post-war America, and is happening now in China. There are a lot of potential reasons for this; as the average wealth of a society increases, the poor who previously did not seek medical care are able to enter the health care system. In poor countries, mental health is grossly underfunded; perhaps as countries gain wealth, they are able to build up those systems. Most likely, the prevalence of disease has always been the same, but the illnesses are better recognized and diagnosed. Maybe in an aging society, diseases like dementias become more pronounced. Although once proposed, I'm not sure that wealthier societies have a direct causal relationship to more psychiatric problems.

I wanted to write a post about this because the vast majority of medicine - doctors, hospitals, media spotlights, research, awareness - neglects mental health. Worldwide, the prevalence of these diseases is increasing and its economic impact is astounding. While illnesses like depression, anxiety, obsessive-compulsive disorder, PTSD, and schizophrenia may not cause that many deaths, it severely impairs patients. The burden on family is huge, and the costs to health care systems should not be underestimated.

Even so, pharmaceutical companies have made and are making fortunes from these diseases. Antidepressants represent an enormous market and will become even bigger as third-world countries become wealthier. Is this the right solution? Are these pills sufficient or necessary to the management of mental health? Are they effective enough to justify their cost? Are we devoting enough resources to research, awareness campaigns, support systems, and nonpharmacologic approaches to tackle this global problem?

It is easy, especially for me, to write about crazy anesthetics or cutting-edge surgery or life-and-death critical care cases. But if that's all I did, that would be missing the point. Even though we all specialize in some small sliver of medicine, we need to be cognizant of the big picture, thinking about diseases with the most burden, and promoting ways to mitigate their impact.

Smoking in Europe

Between finishing fellowship and starting my job, I spent a few weeks in Germany and the Czech Republic. One thing that really struck me was the prevalence of smoking, especially among the youth. Frankly, it was shocking, especially coming from California. I think I had the same reaction I get when I encounter lifestyles that we don't see often in California, such as vociferous anti-gay or pro-gun activists. While I know people like that exist, my social circles just don't include any. In any case, the number of smokers really got to me. I think most doctors have some sort of large-scale grand health-related wish: vaccinations, improved care to HIV/AIDS patients, attention to peripartum morbidity, clean water in third-world countries, tacking social inequity in health care delivery, etc. Mine used to be reduction of waste in health care systems (both physical waste and unnecessary tests, procedures, and medications). But now I think stopping smoking would be a close second.

Real Estate in the Bay Area

This is not really related to medicine, but it is a pertinent nightmare about living in the bay area. Over the last few months, we started throwing around the possibility of buying a house. In the last year or two, a surprising number of our friends have made that impressive first purchase around here. On the other hand, our friends practicing medicine in other parts of the country have been happily living in beautiful, large properties for years. While I had heard a lot about trying to buy in the bay area, I wasn't ready for the shock of it. The housing market is a little ridiculous around here. Before ultimately renting, we made a few offers for houses, averaging around fifteen percent above list price, and for most of the places, we weren't even close. The crazy silicon valley competitors here have distorted the market so much that even bidding hundreds of thousands of dollars above the list price isn't enough to secure a house. Ultimately, we realized it wasn't in the cards this year; we'll give it some time and see where the market goes.

...And In Conclusion

After a bit of soul searching and a lot of conferring with mentors, I decided to take a private practice position in Mountain View. The group of 30 or so anesthesiologists runs incredibly smoothly under very focused leadership. I'll have the opportunity to do operating room anesthesia, labor and delivery, and attend in the intensive care unit. It really allows me to participate in all the aspects of anesthesia that I wanted to do. The members of the group are all very friendly and happy, and I look forward to getting to know them better. I took about three weeks off between finishing fellowship and starting the job so it's coming soon. I'm a little nervous but I think this will be great for me.

The Job Hunt V

I ended up considering six different job opportunities as well as one that was primarily non-clinical (multidisciplinary translational research). The groups varied from small (ten anesthesiologists) to moderate (forty anesthesiologists). They were all-physician practices that did not employ nurse anesthetists. Some operated in only one location while others had contracts with many different small surgicenters and surgeons. There was considerable variation financially, with differences in expected salary up to $100,000. Some groups did everything from neuroanesthesia to obstetric anesthesia to pediatric cases to trauma. Others had a very narrow scope. Call schedules weren't that different between groups, and depended mostly on whether obstetrics and trauma needed to be covered. Most groups were subsidized by the hospital they contracted with. Most groups appeared to have great relationships with their surgical colleagues and administration; some even had prominent leadership presence. As I am additionally trained in critical care medicine, I was also interested in opportunities to work in the ICU, and among private practice groups, this was very rare.

One aspect of private practice physician groups I had to learn about was the concept of "buy-in." For many groups, when a physician initially joins, they are an employee rather than a partner or shareholder. They may have to work for several years at a lower salary and without a vote before they can become a partner of the group. This is known as the "buy-in." There was significant variation in how this was set up, but for all groups, voting on business matters was limited to only a subset of physicians, and for most groups, salary and bonuses depended on how long someone had been part of the group. I don't particularly like the concept of the buy-in, but it seems to be a non-negotiable constant in many practices.

The Job Hunt IV

Whereas applications for undergrad, medical school, residency, and fellowship usually involve extensive essays and short answer questions, jobs usually only want a CV. My cover letter was short, only a paragraph. I sometimes wonder how groups differentiate between applicants since I'm pretty sure my CV looks very similar to those of other graduating residents or fellows. Perhaps this is why connections and networking matters so much.

Then, there's usually a short telephone interview and then an all day in person interview. Unlike medical school or residency, the process goes two ways; I am as critical in evaluating the potential job as they are in evaluating me. Well-trained highly motivated doctors with integrity are a huge value to the group, and they spend a lot of time trying to recruit us. As a result, the interview process is very benign and cordial, at least in my specialty. I try to meet and talk to as many members of the group as possible to get the widest perspectives of what it's like to work there. Sometimes, recent members have differing opinions than the old guard. Each group and hospital has a different flavor of patients and procedures, different relationships with staff and surgeons, and different ways of managing the finances. Unlike prior application processes, it's hard to compare one opportunity with another. It's not always apples to apples. Early on, I learned there's no perfect job for me, and I have to figure out what I'm willing to sacrifice.

The Job Hunt III

For me, the process was strangely straightforward. Because of my wife's job and our preferences, we only looked in the Bay Area. The job market here involves a lot of inquiries and networking. I basically went through all the groups I had heard about and all the hospitals that existed in the Bay Area. I asked around for insights and opinions about the groups. I did some researching to get a sense of how big they were, the hospitals and surgical centers they served, and the demographic of the group. Then I sent a quick email to the leadership of the group. During the process, everyone was cordial, but most groups were not looking to hire.

In anesthesiology, at least, the market goes through ebbs and flows. When there is a lot of uncertainty in health care, as with the Affordable Care Act, changing reimbursements, and shifting supply-demand structures, physician groups tend to batten down the hatches, ready for a lean season. There is uncertainty at every level; hospitals have to stay out of the red, groups have to renegotiate contracts, even large health care systems like Kaiser try to move to predict the future. Thus, when I started looking, jobs were scarce, but over the year, I realized most of the scarcity was a result of doctors being conservative. Once they realized the Affordable Care Act didn't ruin everything and other policy changes transitioned smoothly, they became more willing to expand their group.

The Job Hunt II - Geographic Variations

Even within the United States, medicine is highly geographic. In medical school, we all learn about and lament geographic disparities in health care delivery and outcomes. However, when we start looking for a job, we're just as reluctant to go to rural America. It's unfortunate, and yet a harsh reality. It seems that the best way to get physicians into places that need them is to recruit medical students from those areas and backgrounds.

Nevertheless, geography is perhaps the most important factor for a graduating resident in search of a community position. Even a year before I finished, I started getting postcards from places that were desperate for an anesthesiologist. If you're interested in the Midwest or South, a job awaits. These really aren't bad options; given the salary increase moving from resident to attending and the low cost of living in many of these places, it is a great way to work down debt. Furthermore, many of these areas are in need of well-trained physicians, and it can certainly fulfill that desire many of us have when we first enter medicine to really help a community.

Nevertheless, because of family, friends, our social network, our fear of inclement weather, our personal desires and goals, or any dozen other reasons, we tend to stay in the place we did our training, and often, that means in places that are replete with physicians. The Bay Area, for example, is a tight market. When I first started sending out letters of inquiry, half of my emails got no response, and a quarter got a "Thank you for your interest, but we're not looking to hire." Only a few groups were actively and publicly recruiting; most were only looking around through contacts or not necessarily in need of another doctor. Thus, all my colleagues in the Bay Area felt intense pressure if they wanted to stay. In fact, more than half my residency and nearly 90% of my fellowship class ended up leaving this area because there simply weren't acceptable jobs. This can be really scary, and it's why even for a well-trained highly qualified physician, finding a job isn't a walk in the park.