One of the most exciting things for me about making the transition from student to resident is that I am now formally in a teaching role. Interns have more contact with medical students than any other member of the health care team, which means we're responsible for making sure they learn what they need to learn, as well as trying to model "good doctor" behaviors.
When I think about the interns I really enjoyed working with, they gave me leeway to actually do stuff on my own patients, tried to involve me in formulating the plan for a patient, gave me credit for work I did, and occasionally gave me knowledge that was useful for the upcoming exams. Now that I'm on the other side of the interaction and trying to behave the same way, I've made a perhaps-unsurprising discovery -- teaching well is hard.
As a student, I assumed my interns were fountains of medical knowledge. After all, I knew X, Y, and Z from my lectures and my nightly readings, so they must already have the same things memorized. I was wrong. Medical students, please take note: particularly in the summer, your intern does not know jack. Students have time and motivation to read in detail and memorize diagnostic criteria, subtle points of pharmacology, and so forth, and they have weekly lectures to cover these same topics. I use that same time to fill out paperwork and plan my wedding. Moreover, the older I get, the less appealing I find the idea of spending an evening memorizing lists. Hence, on most topics, the medical student actually knows the correct answer, whereas the intern does not. (I presume I, as an obsessive reader, must have driven my interns mildly nuts.) As a result, the med student can actually be profoundly threatening to one's ego. After you've been shown up two or three times a day by someone who's really just average for his/her class, there's certainly an urge to divert the pesky little twerp onto a many-hours-long paperwork or telephone task. Or, in some of the less gently specialties, to provide a few cutting remarks that make clear students should be seen and not heard.
Neither of those options being entirely palatable, I've had to find a new approach: teach primarily on things that aren't psychiatry. See, they may have all those lectures and do all that reading, but 99% of them focus it on the specialty at hand, since that's what the end-of-rotation test covers. It turns out there's a reason we still have MD/DO psychiatrists and haven't abandoned the field to PhDs -- there is a lot of general medical knowledge needed to competently diagnose patients and use these drugs, especially in the inpatient setting. Maybe I don't always know the side effects of every antipsychotic, but I can recognize common abnormalities on EKGs, I know how to interpret serum electrolytes, and I know a little bit about drug-drug interactions. Plus, I can try to teach that elusive skill of "efficiency", which separates the resident who sees his/her family from the one who truly does live in the hospital. Of course "efficiency" does often mean "OK, I'll write the note and the orders that I'm legally required to do, you do the phone calls and fax this prescription", i.e. a whole lot of scut.
I'll be really interested to see how the evaluations come back for these first few months -- I'm trying to give them responsibility and help them mature from students into doctors, but that also involves assigning them a lot of work and introducing them to the high-speed pace of modern medicine. Either I'm being a good mentor, or a slave driver, and I'm not sure which.
Friday, July 31, 2009
Sunday, July 19, 2009
The Problems I Can't Fix
(Or, why current Democratic proposals for health care kind of suck, but are still probably a good idea.)
It's been an interesting and stimulating two weeks since last post. I got my very own medical student, and on Friday I had my first night of overnight call. Both are experiences I'll write more about, but after I've got a few more data points.
For now, let's talk about the (many) things doctors can't fix, by way of an example patient I saw this week. He came in to our inpatient unit this week, brought in by the police after being found trying to jump off one of our more lethal bridges. As you might imagine, he's depressed. VERY depressed. The problem is the chain of events that led up to his current level of depression:
As you might imagine, "seething cauldron of emotions" doesn't even begin to describe this man. Read that list again and think about how good a shape you'd be in if it all happened to you over the space of a few months. There's depression, but there's also a ton of anger: at his extended family, at his wife, and most of all, directed (probably not fairly) at himself. At any given moment, he's barely able to decide whether he wants to laugh, cry, hurt someone, try to put it all back together, or run away from it all right over the railing of that bridge.
My job, by general consensus, is to make him "stable and safe". My tools are a chest full of drugs and one experienced social worker. The drugs can handle #1 and #2 on that list and combat his brain's natural tendency towards depression. That may or may not help #3. Plus, they'll only cost him $5-$10 a month. We can't get him a home or a job, but social work can at least plug him into services for the homeless (and he's been homeless before, not coincidentally during his last major depression), which at least mitigates #4. #5-9 inclusive is where we start to get to problems. Obviously, I can't fix his marriage or his social environment. Nobody can. However, that environment alone isn't what's going to kill him. Lots of people survive family strife and divorce. What's going to kill him is that he's got almost nobody to lean on during one of the most ego-crushing experiences imaginable.
We do, in fact, have a cure for that as well. We call it "psychotherapy", or "counseling" if you prefer. Get him plugged in to a good therapist in the community, plus someone who can keep his med prescriptions current, and he's got a solid chance of making it through this, given that he did it once before. Only problem: therapist and doctor visits cost money. The people who benefit from them most tend to be those with serious psycho-socio-economic stressors, i.e. people who don't have any money. "But wait!" you say. "Medicaid solves this problem!" Sure. When you can get it, i.e. once you can get the application, fill it out, get on the waiting list, make it through the waiting list (which gets longer during budget cuts and recessions, even here in the "blue states"), get the card, and then find a doctor who'll accept new public-insurance patients. While I don't know the system 100%, I'd estimate minimum three months to get that set up.
In short, we have little chance of bolstering against #5 through #9 because of #10. If we want to keep this man alive and allow him to return to his former status as a contributing and functional member of society, not to mention thousands of others like him, we need a better answer to health insurance. Leaving the Republicans out of the picture for now, the Senate, House, and President all have different ideas on that better picture, with a lot of mumbling about a government-run national public health plan. Do I really like any of these bills? No. They all involve higher taxes for me, and I'm already feeling a bit of sticker-shock in terms of how much gets taken out of each paycheck (being, for the first time in my life, subject to both income tax AND Medicare/Social Security tax). As a physician, I can say that they don't adequately fix a number of problems, including really crappy Medicare reimbursement policies, liability issues, the balance between specialties, and what the heck "we pay only for quality health care" means anyway. You can see the level of imperfection by the fact that the conservative medical societies are fighting the AMA over it, i.e. the closest thing we have to a unified medical voice is seriously conflicted on the matter. That said, we can continue to bicker about imperfection, ideology, and Not My Taxes, or we can actually try to do something and save some lives. Will it work first time around? Unlikely. But until we take some steps down the road, we haven't a chance of building a health system that will actually get my patient the things he needs.
There's a lot of rhetoric about waiting times for MRIs and heart surgery and other high-visibility interventions. Nobody notices the deaths that are racking up simply due to our own inaction. None of the proposals likely to see a vote this year are excellent; all of them are just-barely-adequate enough to be better than what we have now. That's politics. We can either accept imperfection, or we can just let people like my patient fall through the cracks and, ultimately, off of bridges. I promised I'd do whatever I reasonably could to take care of the patients who come to my door. As far as I'm concerned, that makes the right answer pretty obvious.
It's been an interesting and stimulating two weeks since last post. I got my very own medical student, and on Friday I had my first night of overnight call. Both are experiences I'll write more about, but after I've got a few more data points.
For now, let's talk about the (many) things doctors can't fix, by way of an example patient I saw this week. He came in to our inpatient unit this week, brought in by the police after being found trying to jump off one of our more lethal bridges. As you might imagine, he's depressed. VERY depressed. The problem is the chain of events that led up to his current level of depression:
- He's got a strong family history of depression, including multiple relatives who died of suicide.
- He happened to only find out about those suicides recently, when researching his family in order to find some inspiration to get him through a tough economic patch.
- Because of the tough economic patch, he's been using his illicit substance of choice a bit more heavily than usual.
- Poor income, combined with spending more on substances, has dug him into some pretty deep debt and left him about to lose his apartment, if not both his apartment and his job.
- The just-about-to-be-a-toddler baby doesn't help with the financial issues or the life frustration.
- His wife is not from this country, and thus has limited options as far as work goes.
- His wife's parents, living far away, do not particularly approve of him as far as we can tell.
- Because those in-laws have decided to bail him out of financial trouble, they're extracting a price: they want the marriage divorced and the wife and child returned to the country of origin.
- His wife decided to inform him of the divorce, and of everything she's doing to pack up their apartment and get out of his life, as soon as he was hospitalized.
- You want me to tell you about his what? His health insurance? See above list. Ain't none and ain't likely to be none anytime soon.
As you might imagine, "seething cauldron of emotions" doesn't even begin to describe this man. Read that list again and think about how good a shape you'd be in if it all happened to you over the space of a few months. There's depression, but there's also a ton of anger: at his extended family, at his wife, and most of all, directed (probably not fairly) at himself. At any given moment, he's barely able to decide whether he wants to laugh, cry, hurt someone, try to put it all back together, or run away from it all right over the railing of that bridge.
My job, by general consensus, is to make him "stable and safe". My tools are a chest full of drugs and one experienced social worker. The drugs can handle #1 and #2 on that list and combat his brain's natural tendency towards depression. That may or may not help #3. Plus, they'll only cost him $5-$10 a month. We can't get him a home or a job, but social work can at least plug him into services for the homeless (and he's been homeless before, not coincidentally during his last major depression), which at least mitigates #4. #5-9 inclusive is where we start to get to problems. Obviously, I can't fix his marriage or his social environment. Nobody can. However, that environment alone isn't what's going to kill him. Lots of people survive family strife and divorce. What's going to kill him is that he's got almost nobody to lean on during one of the most ego-crushing experiences imaginable.
We do, in fact, have a cure for that as well. We call it "psychotherapy", or "counseling" if you prefer. Get him plugged in to a good therapist in the community, plus someone who can keep his med prescriptions current, and he's got a solid chance of making it through this, given that he did it once before. Only problem: therapist and doctor visits cost money. The people who benefit from them most tend to be those with serious psycho-socio-economic stressors, i.e. people who don't have any money. "But wait!" you say. "Medicaid solves this problem!" Sure. When you can get it, i.e. once you can get the application, fill it out, get on the waiting list, make it through the waiting list (which gets longer during budget cuts and recessions, even here in the "blue states"), get the card, and then find a doctor who'll accept new public-insurance patients. While I don't know the system 100%, I'd estimate minimum three months to get that set up.
In short, we have little chance of bolstering against #5 through #9 because of #10. If we want to keep this man alive and allow him to return to his former status as a contributing and functional member of society, not to mention thousands of others like him, we need a better answer to health insurance. Leaving the Republicans out of the picture for now, the Senate, House, and President all have different ideas on that better picture, with a lot of mumbling about a government-run national public health plan. Do I really like any of these bills? No. They all involve higher taxes for me, and I'm already feeling a bit of sticker-shock in terms of how much gets taken out of each paycheck (being, for the first time in my life, subject to both income tax AND Medicare/Social Security tax). As a physician, I can say that they don't adequately fix a number of problems, including really crappy Medicare reimbursement policies, liability issues, the balance between specialties, and what the heck "we pay only for quality health care" means anyway. You can see the level of imperfection by the fact that the conservative medical societies are fighting the AMA over it, i.e. the closest thing we have to a unified medical voice is seriously conflicted on the matter. That said, we can continue to bicker about imperfection, ideology, and Not My Taxes, or we can actually try to do something and save some lives. Will it work first time around? Unlikely. But until we take some steps down the road, we haven't a chance of building a health system that will actually get my patient the things he needs.
There's a lot of rhetoric about waiting times for MRIs and heart surgery and other high-visibility interventions. Nobody notices the deaths that are racking up simply due to our own inaction. None of the proposals likely to see a vote this year are excellent; all of them are just-barely-adequate enough to be better than what we have now. That's politics. We can either accept imperfection, or we can just let people like my patient fall through the cracks and, ultimately, off of bridges. I promised I'd do whatever I reasonably could to take care of the patients who come to my door. As far as I'm concerned, that makes the right answer pretty obvious.
Wednesday, July 8, 2009
Letter from an Unfilled Grave
Today, I had the profoundly odd experience of reading someone else's suicide note. The person in question chose a particularly non-lethal method, and is chilling out on my inpatient unit. However, he left a three-page note to his family, which we found in the back of his chart. Reading it, even in a well-lit unit with lots of noise, is an eerie experience. We all, like Walter Mitty, walk around with a screenplay in our heads. Sometime today, you've daydreamed about the conversation you might have with a friend, or partner, or co-worker, if only there were no tomorrow and no consequences.
This note is one man's personal drama, poured out on the page. Without going into too much detail, it is the last lament of a bright, but nerdy man who was socially awkward in high school, never got the hang of this "dating" thing, and found himself approaching middle age without any hope of having the relationship he'd wanted for decades. On one level, it's heart-breaking, because this whole mess could have been prevented if only one person had reached out along the way. I think I respond to it in particular because I can see aspects of my own teens-to-twenties in his life, and realize how close I might have come to being this guy. On another level, it makes me want to strangle the patient. He deliberately kept all of this, including a suicide plan in place for years, carefully concealed from his family, friends, and everyone around him. One single "help me", and he'd have been in a much healthier place, years ago. In that sense, the note reads like a paean of self-pity and misplaced pride. Of course, that's depression for you. It distorts your world to the point that killing yourself seems like a more rational option than calling your parent or sibling. And, for all we try, our lovely society continues to attach such stigma to it that people would rather die than admit they're depressed.
This guy got lucky, or perhaps he finally managed to find a way to ask for help while preserving his ego. Either way, he's got a solid chance. I went to college and grad school with a LOT of people who aren't too far away from being him. Chances are, you know someone like this. Shy, nervous, a little geeky, but nice. You wouldn't date him, but he'd be good material if he just cleaned up a little and got over his fear of rejection. Or, maybe his problem isn't romance, it's jobs. Or research. Or any other failure-prone endeavour. Take a moment to think of whoever you know fits that description, and see if you maybe couldn't do one thing to get his head screwed on a bit more tightly. You might save his life.
This note is one man's personal drama, poured out on the page. Without going into too much detail, it is the last lament of a bright, but nerdy man who was socially awkward in high school, never got the hang of this "dating" thing, and found himself approaching middle age without any hope of having the relationship he'd wanted for decades. On one level, it's heart-breaking, because this whole mess could have been prevented if only one person had reached out along the way. I think I respond to it in particular because I can see aspects of my own teens-to-twenties in his life, and realize how close I might have come to being this guy. On another level, it makes me want to strangle the patient. He deliberately kept all of this, including a suicide plan in place for years, carefully concealed from his family, friends, and everyone around him. One single "help me", and he'd have been in a much healthier place, years ago. In that sense, the note reads like a paean of self-pity and misplaced pride. Of course, that's depression for you. It distorts your world to the point that killing yourself seems like a more rational option than calling your parent or sibling. And, for all we try, our lovely society continues to attach such stigma to it that people would rather die than admit they're depressed.
This guy got lucky, or perhaps he finally managed to find a way to ask for help while preserving his ego. Either way, he's got a solid chance. I went to college and grad school with a LOT of people who aren't too far away from being him. Chances are, you know someone like this. Shy, nervous, a little geeky, but nice. You wouldn't date him, but he'd be good material if he just cleaned up a little and got over his fear of rejection. Or, maybe his problem isn't romance, it's jobs. Or research. Or any other failure-prone endeavour. Take a moment to think of whoever you know fits that description, and see if you maybe couldn't do one thing to get his head screwed on a bit more tightly. You might save his life.
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