Friday, May 29, 2009

The Final Straw

I plugged along for one week at [] hospital. I came into the hospital early in the morning to round on my patients, but there was always something missing when I reported to my resident, a kind and patient third year named William. Actually, there was always a lot missing. I usually hadn't talked to the nurse about overnight events, I usually hadn't looked up the vital signs, I may have looked at the Electronic Medical Record, but I often hadn't looked in the Paper Chart.

As an aside, electronic medical records promise to solve the problems and confusion arising from scattered notes written in illegible handwriting. The hospital was trying to upgrade to a completely electronic system, but, while some of the electronically written notes were easy to read, the changes were creating even more chaos. There were two computer systems- one was older, and the hospital was trying to phase it out. Unfortunately, the new computer system wasn't as user friendly so those used to the old system shied away. And then some people didn't use either, preferring to leave scrawls in the old fashioned "paper chart."

So, when I came in each morning, I was supposed to look up the vitals, carefully recorded by the nurses overnight at 4 hour intervals, in the newer of the two computer systems. Then, I was supposed to check for notes. While in a hospital, a patient may be followed by a particular service, in this case Medicine. But, while there, any number of consults may be called. The patient suddenly develops numbness and tingling? Call Neurology. Questions about a new antibiotic regimen? Call Infectious Diseases. The patient has chest pain? Call Cardiology. Funny vaginal discharge? Call Obstetrics and Gynecology. Broken bones? Orthopedics. So, during the day, any number of clinicians may have visited each patient. And, each department tended to leave notes in different places. Neurology invariably left notes in the new computer system. Obstetrics and Gynecology used both computer systems, so any notes discussing the possible etiologies of vaginal discharge could be found in either. Of course, there were individuals from every consult service who preferred the Paper Chart, leaving an actual tangible note there.

The nurses basically serve as the eyes and ears of the service. Teams of medical students, attendings, and residents constantly switch. A particular resident, for instance, may be on one of the Internal Medicine services for a few weeks and then switch to another service, vacation, or outpatient clinic. Medical students only stayed five weeks in any particular place. And, the attending physicians seemed to rotate as well. A single patient staying in the hospital for any length of time would see a great number of medical students and doctors passing through. Teams of nurses, however, tend to remain on the same floor. Not only that, during their shifts, they actually stay on their assigned floors. Doctors and medical students might be running around to clinics, the operating room, rounds, teaching sessions, or any number of activities, but the nurses are actually present, on the floors, at all times. So every morning, nurses can provide information on how a patient has done overnight. Did the patient spike a fever? Sleep well?

It was generally the job of the medical student to gather and consolidate data in the morning. But with my sudden pathological forgetfullness, this became a nearly impossible task. William took me aside, saying, "Are you confused about what you're supposed to do in the mornings?" I nodded. "I already told you this, you go to the PAPER chart, you go to the COMPUTER, you talk to the NURSES, you talk to the PATIENT, you gather ALL THAT DATA, and then you report to me..." He stopped, looking at me, and then wondered aloud about whether there was something wrong with me. William generally had a look of kind understanding. He was the sort lauded on good bedside manner, the type patients could trust, and the type not to be annoyed without good reason.

"I think I could be a good doctor one day..." I tried to explain that I wasn't usually this forgetful, that this wasn't me, that I didn't know what was wrong, but that I was sure if it was fixed, that eventually, I could function as a doctor. But the mounting tears prevented me from speaking.

"Did you have trouble during first and second year?" asked the resident. The look of kind understanding reappeared on his face. I didn't answer- a tear rolled down my cheek and another threatened to join it. The fact that I had done well during the first two years, that my board scores were excellent, almost made things worse. The resident likely took my silence as agreement. Our conversation ended with him pausing and saying "I don't think you can function in a hospital." He spoke carefully, as though delivering bad news to a patient. He paused, looking at me with a mixture of sympathy, confusion, and annoyance.

The fact that William was mild mannered and didn't routinely abuse those around him made our conversation even worse. I couldn't complain to my classmates over drinks about yet another injustice incurred at the hospital. I couldn't dismiss this or laugh about it later.

I knew he was right. I left the hospital that night and didn't return for nearly a year.

(The above post describes past events, right now I'm in school and doing fine)