Sometimes, when I am feverish or sick, I have bizarre dreams with flights of ideas. My mind fixates on the strangest things (including work things) and no matter how much I try, no matter what meditation techniques I employ, I can't get these strange thoughts and images out of my head. I wonder whether that is what patients with delirium experience. Delirium is a really common hospital problem where a patient waxes and wanes in their attention and orientation. If you take a perfectly normal high functioning executive and give her an infection, treat her with antibiotics, stick her in the intensive care unit where she is awoken every hour, exchange her clothes for a gown, place tubes and lines that tangle her up, she will get confused. It's easy to imagine how she might not remember where she is, how she might become paranoid, how she might even have hallucinations or delusions.
We underestimate how tough it is to be an inpatient, especially in the intensive care unit. These days, I am at most in the hospital for a twenty-four hour stretch, and even that is enough to drive me crazy. I cannot begin to fathom being elderly or sick or alone for days or weeks in the hospital. I know there are a lot of initiatives to improve hospital life, and I make a big point of it by identifying patients that don't need to be woken up through the night, but it's still not pleasant.
Families also underestimate this problem. In the intensive care unit, I see patients at the end of life. Families recognize this but also want us to "just keep doing what we're doing" whether for more time or for a miracle or because they cannot stand to stop. Even though I can treat pain and anxiety and constipation and nausea and a dozen other symptoms, I cannot eliminate all suffering. The hospital is not a dignified place. It is not a comfortable place. It is a necessary place that comes with risks, benefits, and alternatives, just like everything else.
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3 comments:
Dr. Chen,
As I prepare to transition into my final year of medical school, I am ecstatic to have found your blog today. I have been fortunate to know that anesthesiology is the correct career path for me for some time now. Looking ahead, I am very intrigued by the possibility of completing a critical care fellowship and practicing as a critical care anesthesiologist. Reading about your experiences, I am truly inspired and feel that this may potentially be my ideal career. Thank you very much for sharing.
My medical school in the Midwest is associated with two smaller hospital systems with ICUs run by medicine and surgery. If you ever have some time, I would be really curious to learn about your schedule on a monthly basis. Do you split time between the ICU and OR or do you work strictly in the ICU? Do your colleagues in critical care anesthesia have similar set-ups or is there some variation depending on the hospital system/institution? Any advice going forward would be appreciated.
Great question, but it's not really straightforward to answer. My advice is to talk to as many critical care intensivists as you can. In the U.S., most critical care units are staffed by pulmonologists (as opposed to Europe where last I checked, the ratio actually favored anesthesiologists). Particularly in private or community hospitals, a large proportion of departments are solely run by pulmonologists. I'm in a rare community hospital that actually has both anesthesiologists and pulmonologists in the ICU (and we are greatly outnumbered). Most places that have intensivists from different backgrounds (internal medicine, pulmonology, anesthesia, surgery, neurology) are large academic institutions or the VA. Keep this in mind if you choose the field; it's not easy to go into private practice and find a job that balances both specialties.
There are a number of reasons for this. Aside from historical or conventional reasons, money plays a big factor. Anesthesiologists can make more relative value units in the operating room than the intensive care unit. Private anesthesia groups don't have a large incentive for getting into the ICU. Most groups run lean in order to maximize revenue, and it's hard to organize scheduling between OR call and the ICU.
Nevertheless, I think it is important for anesthesiologists to be in the ICU (as well as those from all other backgrounds). The intensive care unit really requires a multispecialty approach, and we bring a lot of skills and knowledge to the table. Most community ICUs are mixed medical-surgical units, and we know the surgeons well. We understand the perioperative period best. We have special expertise in the airway, resuscitation, cardiopulmonary evaluation, and crisis management. But we also recognize our limitations; my medicine colleagues have more experience with other organ systems, interacting with other consultants, holding family meetings, etc. I strongly believe a multidisciplinary unit where all the attendings collaborate, especially in difficult cases, improves patient care, quality, and satisfaction.
In any case, the reality of it is that most anesthesia-trained intensivists who continue to practice critical care do so in academic or VA settings. However, I do know of some private practice anesthesia groups that are expanding their boundaries to cover the ICU. This is something strongly pushed by the American Society of Anesthesiologists, that we become physicians of the perioperative period, including covering critical care and pain management (the so called "surgical home" idea). It also integrates a private practice group with the hospital so that hospital administration recognizes what they bring to the table.
So regarding the specifics of your question - I spend the bulk of my time in the operating room. I spend about 20% in the intensive care unit, a 21 bed mixed medical-surgical-cardiothoracic unit. We cover a week of days at a time (Monday-Friday) during which I have no operating room responsibilities. We cover random night and weekend calls; if I'm on call for the ICU at night, I still have a day of cases in the OR (but it's usually light). We share this schedule with a group of pulmonologists who we have great relationships with. The schedule is made between the two departments so that my ICU and OR schedules don't conflict. I love my ICU time, and it reminds me of a lot of why I went into medicine, but it exhausts me. I enjoy my OR time as it tends to be a little less tiring.
Most critical care units have similar types of schedules. At my residency, for example, the ratio of anesthesia and non-anesthesia critical care faculty is about 50/50 so between two teams, there is almost always an anesthesiologist. They are on for a week at a time, and all the other weeks, they work in the OR, in teaching, or in administration. Nights and weekends are covered by random attendings who do work the daytime (but of course, nights and weekends are easier with residents).
Regardless of what you choose, when you finish, you'll get emails with locums tenens or per diem jobs, and the ICU ones are all quite similar: day or night shifts, usually a week at a time. Some look specifically for pulmonologists (to take pulm consults), others are open to any critical care trained physician.
I hope that helps! Please let me know what else I can answer. Thanks again for the comment.
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