Curtain Call

After five years as a resident and fellow at Stanford, I turned in my badge and left for the last time. I get nostalgic about these moments. There is poignancy and longing and reminiscence and triumph and wondering. Here are a few memories that flashed through my head this last day.

-Sneaking out of noon conference as an intern to wander the Rodin sculpture garden and see the Gates of Hell with the woman I would eventually marry.

-Watching the construction of the new hospital from all angles. I remember noticing trucks ceaselessly carrying out dirt at 2AM, being awed by the magnificent crane raising girders, and seeing the hospital take form as I crossed the skybridge to the ambulatory surgery center.

-Picking up my locked box of controlled drugs at the operating room pharmacy each morning and carefully counting the number of vials of fentanyl, lest I get in trouble for not returning them all. This went away when each operating room got an electronic dispensing machine.

-As an intern, before I got a bike, walking about half an hour from Menlo Park to the hospital. On my way in, I knew all the short cuts to shave off precious seconds getting to the hospital and memorized the traffic light pattern at Pasteur; on my way home, the walk was cathartic: all the tenseness and emotions released before I got home.

-That weird feeling after spending a year in the ICU where I could look at each room and picture a patient or a major clinical event that happened there. Corner pocket code blue, the room where I placed a dialysis catheter in a patient with an INR of 10, the isolation with the young man we desperately tried to save over months, the room where we did an emergency cricothyrotomy. E221-E264, I can picture something in every room.

-Even seeing an elevator triggered the memory of resuscitating a patient by squeezing in blood while we were trying to get them from the emergency department up to the operating room.

-Grabbing a handful of candy...from the consultant bribe box in the emergency department, the pre-op clinic as I passed through to the ICU, the ASC nursing administration office (who I'm pretty sure never knew I stole candy), the GME office. Sometimes you just need a little sugar.

-Medical student saying I was "amaaaaazing."

-Those bitterly cold mornings as I rushed to anesthesia grand rounds.

-Half-way through a pediatric anesthesia case in the basement of the children's hospital when I get a call that my house had been burglarized - not all memories were good.

-Going home post-call with the airway pager and fuming as I had to run back to the hospital and hand it off.

-Taking computers-on-wheels with a co-intern (who, again, I eventually married) to an empty waiting room outside the coronary care unit so we could write our notes while listening to live music in the atrium.

-The look of relief both I and my critical care crisis nurse would get when we arrived at a rapid response call and saw each other.

-When I was on medicine, that outdoor space outside of B3/C3 where I escaped for respite. I ate lunch there, I cried there when patients died, I talked to my parents there when I was unexpectedly stuck at work, I napped there in the sun, exhausted.

-Getting my exercise as I ran to codes in the ambulatory surgery center, about four flights of stairs away.

-After five years, finally figuring out the traffic patterns to avoid getting stuck in a stretch of red trying to get onto Sand Hill and 280.

-Watching my world get bigger. As an intern, I lived on B3/C3 and it felt overwhelming. A year later, on the acute pain service, I ran from managing catheters on D ground to epidurals on F3. As a fellow, being expected to put out fires everywhere, simultaneously.

-Ethics meeting in the boardroom where there are screens everywhere; we had a powerpoint projected on at least six locations around the room.

-The pre-op area where half way through residency, they switched from pre-spiked IV bags to having us prepare them ourselves. The first few days, there was a puddle of saline on the ground as we all struggled to figure it out.

-One of my favorite north ICU nurses mentioning that she reads this blog. Boy, was I embarrassed.

-About to leave the ICU on my last day when nurses and respiratory therapists surprise me with celebratory cake.

I know there are dozens more memories to share (and I decided not to mention the VA and Valley). I am most fond of those short, fleeting, and wonderful moments spent with patients, colleagues, medical students, residents, attendings, nurses, respiratory therapists, anesthesia techs, and others who made my life so rich, my work so easy. Not only did I work with them, but I got to know them as people, understand their stories, learn about their passions. There was this point of realization during my fellow year that I knew a huge number of people in the hospital: co-interns who are now attendings, medicine residents who rotated through the ICU, surgery chiefs who I worked with in the OR, consultants who knew me by name. Through the last five years, I made so many friends, and for that, I am grateful. Thank you.

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Social Reforms

The recent Supreme Court rulings on equality in marriage and against the three strikes rule for offenders have been very refreshing. They feel like pivotal decisions that impact my community and matter to me. In some ways, they feel so revolutionary that I might look back decades later and reflect on how our society has evolved. These past few days have gotten me thinking that there are a lot of social issues that I feel strongly about. They matter to me, and not because of my values or principles or upbringing, but because I take care of patients for whom these issues change everything. I think beyond my friends and colleagues who are gay, but also to my patients who are gay. I think of the children I've cared for who have same-sex parents, inmates I've seen who've spent their entire life in prison, and victims of discrimination and violence. Small changes like affirming the right for marriage and due process will make a significant difference for these people. As a physician and as a person in the community, I ought to stand up for those issues that matter to me. We do not live in a bubble, we do not operate solely in the hospital, and our patients' problems are not purely medical. We have the obligation to speak loudly, support those reforms we think will help our community, and engage in a collaborative society.

Unrestrained

One thing I've encountered a lot on the trauma side of the surgical ICU that I don't understand is the unrestrained driver (or passenger). Like unhelmeted bicyclists, this just seems like something that should not happen. The injuries sustained by someone without a seat belt or helmet are so much worse than someone using safety equipment. Similar to cigarettes and gun regulation, these are simple, vastly important, and easily underestimated public health issues we need to address.

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Medical Versus Surgical Critical Care

When I was a medical student, I was surprised to find that a pulmonologist may be in charge of surgical critical care patients or an emergency physician trained in ICU could run a medical unit. But after this year of training, it makes sense. The issues that come up in critically ill patients are very similar regardless of whether a patient is "medical" or "surgical." A patient may have respiratory failure due to multiple rib fractures or a transfusion reaction or multifocal pneumonia or widespread infection, but a good intensive care physician should be able to support them regardless of the exact cause. The treatment of organ failure simplifies down to a knowledge of physiology and pathophysiology. Our training crosses disciplines because the issues that threaten critical organ systems don't care whether the patient is post-operative or succumbing to cancer or pregnant or a victim of trauma. The issues we focus on in the intensive care unit are in some ways universal.

Although the case mix differs between a medical unit and a surgical unit, the problems are largely the same: altered mental status, respiratory failure, hemodynamic instability, renal failure, fulminant liver failure, infection. For surgical patients, I need to recognize when someone needs to go to the operating room, but I don't need to be a surgeon to understand that. I have a superficial but adequate grasp of specific operations, and being an anesthesiologist helps a lot. Translating my skills and knowledge from the medical ICU to the surgical ICU ends up being quite easy. Over the last year, I have learned to care for a sick patient regardless of the cause and even in circumstances where we don't know what the cause of their illness is. I understand now why intensive care physicians of any background can care for patients in a mixed medical and surgical care unit.

Distracting Injuries

In trauma resuscitation, we learn not to get sidetracked by "distracting injuries." When we assess the priorities in a trauma patient - securing the airway, maintaining breathing, and supporting the circulation - we are told not to be distracted by other things the patient may have. When we practice this in simulation scenarios, it's not a big deal. But in real life, it happens to be a lot easier said than done.

A drunk motorcyclist hits a parked car and lands face-first into the pavement. When he arrives, he has profuse bleeding from his facial fractures, to the point that he needs to be transfused multiple units of blood. The gurgling noises he makes suggest he's not able to breathe independently; the blood pooling in the back of his throat is starting to be a problem. The emergency physician, however, wants to get CT scans of his face to look at the extent of the fractures. In doing so, he loses his window; the patient has a cardiac arrest. An emergent breathing tube needs to be placed, and this is not easy; the blood in his airway and the ongoing chest compressions complicate matters. The patient subsequently has a prolonged stay in the surgical ICU.

A victim of a car accident has a mangled extremity; he has over a dozen fractures in his leg. During the trauma resuscitation, though, the leader methodically goes through the priorities for resuscitation, ensuring that the patient's breathing, blood pressure, heart, and lungs are uninjured before leaving the vital organs.

In the chaos of the trauma bay, it is easy to get flustered, lose track of things, and put the patient in danger. When you learn things by the book, they sound so simple, but in the heat of the excitement and emergency, it is easy to be distracted by nonimportant injuries.

Incidental

A patient getting a heart workup for chest pain has the incidental finding of a large lung nodule. Her chest pain is due to critical aortic stenosis, causing symptoms of dizziness, fainting, and shortness of breath. With her severity of aortic stenosis, her life expectancy is only a few years. Nevertheless, the cardiac surgeon wants the lung nodule worked up. The patient undergoes a video-assisted thorascopic surgery for a wedge resection, but this is emergently converted to an open lung surgery because her anatomy is challenging. Post-operatively, she develops a severe pneumonia. Her lungs are so severely impaired that she eventualyl needs a tracheostomy. She has multiple drains placed in her chest, requires high doses of blood pressure medicines, and stays in the ICU for weeks. The worst part? The pathology from the lung nodule shows a benign mass. She was never going to die from this lung finding.

This and other similar cases illustrate some of the incredibly bad consequences that can result from one simple medical decision. Every test we do can have incidental findings - findings that are abnormal but unimportant. Scans we order may show normal variations of anatomy, artifacts that end up being nothing, and disease processes that ultimately don't matter. But as physicians, we are biased towards chasing these findings. While most of the time, these extra tests and interventions don't cause significant harm, injury, or suffering, some small percentage of the time, consequences can be devastating. This woman's aortic valve narrowing was life threatening. But because of an incidental finding her physicians wanted to chase, she underwent operations fraught with complications for no benefit. She will never get to her previous level of functioning, and probably will never have her valve replaced. Not only did we shorten her life, but we made the end of life one of intensive care and intensive suffering.

When I receive these patients in the surgical ICU, I come into the story too late to change the course of events. But I try my best to reorient the surgeons and other physicians to doing what's best for her. There is a surgical mentality (in my opinion) that if a patient suffers complications, the surgeon wants to do everything to right it. And I can understand that; the surgeon feels guilty even though complications are a normal part of his work. But he will put a patient through a lot of medical tests, interventions, further surgeries, and potential suffering just to fix his mistake. Sometimes stepping back and looking at the big picture suggests that we should simply stop. Sometimes, we need to recognize that our mistakes cannot be fixed.

I write about incidents like this because I think we can do better. They are terrible situations where medicine has done wrong and a patient has suffered, but if we do not realize what is going on, we will never resolve the problem. Each medical decision and judgment can dramatically change the life of a patient. Sometimes incidental findings are not worth investigating. Sometimes if a patient has complications from therapy, we cannot save their life. In these situations, we ought to consider palliation and attention to suffering rather than persistent attempts at cure.

Surgical ICU

I spend my last month of fellowship on the surgical side. The last time I was in the SICU was as a second year resident, but in many ways it has not changed. I especially enjoy the SICU because it really benefits from an interdisciplinary structure. I learn an incredible amount from the surgeons, but feel that I can teach them a whole lot from the anesthesia or medical side.

The SICU usually averages fewer patients than a medical ICU service. The patients come in several flavors. Some undergo complex surgeries where an ICU stay is expected. We see all the post-operative liver transplants, and for me, it is great continuity as I see them pre-operatively in the medical ICU. Sometimes, patients undergoing large abdominal and vascular cases come to the ICU after their surgery. For the most part, these patients have scripted courses; we wake them up, take out the breathing tube, wean the blood pressure medicines, start their rehabilitation, and send them to the floor. These can be pretty satisfying as everyone is getting better. The second set of patients are those who have setbacks after their surgeries. They usually aren't doing so great on the floor, with persistent infections or complications. These patients have the courses of our medical ICU patients; they can be long, protracted ICU stays where we battle each complication one by one, trying to stave off setbacks. Here, nutrition, rehabilitation, and therapy are crucial to getting our patients better. Lastly, the SICU takes our sickest trauma patients. Often, when a trauma patient arrives, we don't even know their name, much less their other medical problems, medications, allergies, and issues. While Stanford gets a lot less trauma than other hospitals, we still get a handful of car crashes, assault cases, and falls-from-horses. Some of these patients are merely admitted for observation and leave the ICU quickly. Others, especially those with traumatic brain injury, have long and uneasy courses.

For an anesthesiologist, understanding the surgical concerns and seeing the patient's trajectory after the operating room is important. It's easy for us to simply focus on the snapshot of time when we anesthetize a patient. But as physicians, we need to engage in improving every part of the patient's experience. Similarly, working with the surgeons outside the operating room improves our relationships with them inside the O.R. As anesthesiologists, we have a deep and unique understanding of what happens to a patient during a surgery. The postoperative setting for a critically ill patient is simply an extension of the operating room.

Book Review: Thieves I've Known

My first creative writing class was also the first course Tom Kealey taught as a Stegner fellow at Stanford. I was an impressionable freshman and the class convinced me to get a minor in creative writing. Soft spoken, insightful, and understanding, he weathered me through my first few attempts at writing. He was early enough in his career to both understand my motivations and aspirations as well as remember that terribly steep learning curve as a writer. Through my undergraduate years, writing was always a challenge; my premed classes were easy. Writing kept me up late at night.

Only recently did I get a chance to read Thieves I've Known, a collection of short stories. The winner of the 2012 Flannery O'Connor Award, it is a loosely related collection of stories with vaguely overlapping characters. One of the unifying themes is the age of the main characters; all are at that brink of transformation from child to adult, the short story bildungsroman. Brilliant with dialogue, the stories succinctly capture a sense of the soul searching for answers, the bridging of estranged relationships, and the encountering of something dark. Although you can tell the stories come from the early part of an author's career, they bubble with potential. When I read the stories, I can actually hear Tom's voice reading them in my head.

It's been a while since I picked up a short story collection, and even longer since I thought about my college mentors. Thieves I've Known has been a genuine pleasure.

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Maintenance of Certification

The last few posts were a set-up for this one. For a while, there has been a big debate within the medical community over this process of "maintenance of certification," also called MOC. Recently though, there have been some opinions and editorials published about it in the lay media, so I figured I should write about it.

Each specialty has a board that determines the criteria for granting certification to physicians in that field. Several generations ago, board certification was like a diploma, awarded when one passed all the exams and met all the requirements. However, as we began to recognize that medicine changes drastically over time, we realized that it makes more sense to limit the length of certifications and require recertification. That way, we could continually ensure that board-certified physicians practiced up-to-date cutting-edge medicine. For most specialties, recertification occurred every ten years.

However, along with changes in medical education, specialty boards moved towards requiring a continuous process for recertification. This received a lot of criticism as it is quite onerous and costly. Research has never shown that requiring board recertification improves patient outcomes. As a result, many physicians find its burdens significant and relevance questionable.

We are starting to ask whether test performance reflects a physician's competence. Tests must be written so the answers are black-and-white, but the true difficulties in being a physician are all about handling the gray zone. Tests are designed to be comprehensive, but physicians may only want to practice in a limited scope. A commonly cited example is that anesthesiology boards will test knowledge of pediatric anesthesia whether or not the physician has a job that involves pediatric patients. Many find that they are being tested on things that are not relevant with their actual job. Test questions take years to validate so they are never really fully up-to-date.

I believe most physicians don't like MOC because of the economic consequences. These programs are expensive. Recertification can cost up to tens of thousands of dollars, particularly in specialties (like mine) which require in-person oral examinations across the country. Furthermore, there is a lot of murkiness about whether boards have a monopoly (since it is very hard to find a job without board certification) and how much its executives make from this enterprise.

I believe there are a lot of unspoken consequences of requiring all this bureaucratic paperwork. Each day I take off in order to participate in continuing medical education is a day where I am not taking care of patients, not contributing to society. I am completely happy doing so if I believe what I'm doing will help my practice and my patients. But a lot of MOC activities aren't what I'd choose to improve my practice. I am extraordinarily driven to learn more, improve my skills, and engage in learning, however, MOC recognizes and requires only a very specific and narrow set of activities. While I agree physicians need to govern ourselves and ensure professionalism and lifelong learning, I don't think the system in place is set up to do so effectively or efficiently.

Management Science

Perhaps it is "about time" or maybe it is trying to fit a square peg into a round hole, but management science has come to medicine. Health care administrators and leaders have started to recognize business tools as ways to improve health care delivery and systems. We are starting to get education about industrial standards like Toyota's manufacturing standards. The Lean process is a strategy to eliminate steps that represent wasted effort. Six Sigma principles reduce defects or poor outcomes. We learn about how to recognize, implement, and sustain changes. Some thought leaders have advocated medical school courses dedicated towards strategy, operations management, entrepreneurship, leadership, behavioral economics, and negotiations. Hopefully this will translate to more efficient delivery of care, less waste, and improved outcomes. All of a sudden, medicine is more than just medicine.

Professionalism, Governance, and Regulation

Though it is a dry topic, as I transition from training to independent practice, I find the paperwork of medicine is a big deal. At the same time, there is a lot of talk and argument about the governance of medicine within the medical specialty and in the greater public community.

The state medical licensing board protects the public by licensing medical practitioners. However, I am not convinced this has been working ideally. In 2014, less than half of 1% of physicians in the U.S. had any disciplinary action against their licenses. Is this too much? Is it too little? In an ideal world, I think we would be quite pleased to have such a low rate of license limitations, suspensions, or revocations. However, I suspect that the mechanism of regulation simply does not catch all those who need to be disciplined. State licensing boards only identify the very worst offenders, those who've had so many complaints or such egregious violations of the law that their licenses must be reconsidered. But a state licensing board is not positioned to regulate those physicians who are only slightly under par, not completely up-to-date, or mildly technically deficient.

The other issue with state licensing boards is that in the future, I expect more health care will be delivered across state borders. Telehealth will become a tool to shore up geographic differences in health care delivery. Locum tenens work has been used for a long time to provide care to areas that need physicians. The world is getting smaller, and to me, there shouldn't be a reason why standards for physicians should differ by state (though I do understand that the legal rights of the states were broadly vested in the Tenth Amendment to the Constitution and specifically articulated in the Medical Practice Acts that govern licensure state-by-state).

In addition, there are other regulatory, accrediting, and certifying organizations such as the Joint Commission. What is their role and relationship for the individual physician? Where to specialty societies fit in? How do we guarantee that all this bureaucracy improves physician self-governance, education, quality, and safety challenges? From this side, as a consumer, I feel so much is duplicated from organization to organization. There is so much paperwork and red tape. Like most, I just want to be a doctor, and I hope the systems that have arisen are more aid than hindrance.