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.