Wednesday, December 26, 2012

Weekends & Holidays

Ever since medical school, I've found rounding in the hospital during the weekend and/or holidays frustrating.

You'd think that hospitals would be 24-7 kind-of places, right?  I'll grant that patients certainly stay in the hospital during weekends and holidays.  Nurses and doctors attend to them, meals still come, rooms are still cleaned.  However, many of the important people who work in the hospital don't work during the weekend or a holiday unless there's an emergency.

Let's say that you're a patient admitted with chest pain.  Your initial testing was okay - you're not having a heart attack right this second - but the docs want to make sure that you're not the verge of having one.  Your medical team decides you need a cardiac stress test.

Hope you didn't come in on a Saturday night, though, because your hospital doesn't do stress tests on Sundays.  You'll spend an extra night in the hospital waiting for that stress test (or echocardiogram or non-urgent cardiac catherization) Monday morning.

Lest the cardiology department feel singled out, here are other common hospital procedures that are rarely done on the weekend, especially Sundays (with the exception of life-threatening conditions, where someone must come in from home to perform the test/procedure):
               MRIs, CT scans, ultrasounds
               Most non-urgent surgeries
               Social work assistance with transfer to rehab facility or nursing home
               Financial aid officers to set up discharge care plans for uninsured patients

I understand that all of these procedures require people who are less well paid than docs to come in and assist or perform them.  I also understand that work-life balance is important for health care workers.

Staying an extra 24 hours in the hospital, however, is not a low-stakes proposition for patients.  It's expensive, for one thing.  An average night in a US hospital runs from $3000 to $4500, depending on who you ask.(1)  And, although many are working to eliminate medical errors, hospitals still remain rather unsafe places to stay unnecessarily. Preventable medical harm kills upward of 100,000 people a year in the US. (2)

Some hospital workers who must be there 24-7 include the nursing staff.  They manage to create schedules that fairly divvy up weekends and holidays, exchanging time off during the week.  Creating schedules for hospital workers that maintain a constant presence - regardless of weekends or holidays - has been a way of life for nurses for years.  It's high time that the rest of us followed their example.

Until every service that's available on a Monday is available on a Sunday, though, our patients will see that having our weekends and holidays off are worth more to us than providing them with safe, cost-effective care.


Wednesday, December 19, 2012

Crash and burn

I teach the Evidence-Based Medicine curriculum at our residency program.  I'm passionate about this curriculum, as it teaches our residents how to be critical thinkers about the never-ending deluge of scientific data that can benefit our patients.

One of the tricky things about teaching EBM is that it involves numbers: calculating sensitivities, specificities, positive predictive values, etc.  Mixing these numbers up is not hard to do.  I create all of the materials used in this course, and I usually double and triple check my arithmetic - and then have someone else quadruple check it - before finalizing handouts and PowerPoint slides to present.

Something went terribly, terribly wrong yesterday.  The computer in the conference room was being buggy with 2010 PowerPoint, so, I opened my previously saved 97-2003 version.  As far as I could remember, it was pretty much the same.

Yeah, except that I had, in fact, actually tweaked all of the examples in between versions. The examples on the handouts that the residents had to work through. The examples on the handouts that had the wrong answers on every single PowerPoint slide.

My quadruple-checker was there, but unusually we had not been able to meet to confirm the quadruple check before-hand.  We've never had anything but a teeny tiny discrepancy before, I reassured myself.

Whoops.  Mass confusion quickly erupted as the residents started working through the problems and the wrong answers popped up on each slide.  The quadruple checker had the correct answers, thankfully, and we eventually salvaged the session by just working through the problems on a whiteboard.

I want so badly to teach that EBM doesn't have to be a scary avalanche of numbers and equations.  I want them to get the bigger picture, the concepts above the arithmetic that can enhance their patient care.  Unfortunately, today, all they got was an hour of group effort trying to puzzle through...a scary avalanche of numbers and equations.

More than teaching about EBM, though, I selfishly want my residents and colleagues to trust my knowledge and judgment.  Failing miserably in front of everyone exposed my imperfections, making me uncomfortably vulnerable.

I wish I was a perfect teacher and a perfect doctor, and being reminded that I'm far from perfect is hard to stomach.  Maybe, though, my public failure will make the people I work with a little less afraid to be imperfect around me.  Maybe this unpalatable dose of disgrace will break down any barriers I or others have about labels such as "teacher" and allow more genuine, unfettered working relationships.  That would almost make yesterday's debacle worth all of the humiliation.