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.