Tuesday, March 27, 2012

Code Blue In Real Life

As I previously mentioned, I am currently studying for my recertification in ACLS. Once again the algorithms have been slightly altered from my last test two years ago so that retaking the test is a necessity. But luckily, the good folks at the American Heart Association have been paying attention and have simplified the steps we have to memorize to pass the tests. Gone are the maddening anti-arrhythmic drugs such as procainamide and bretyllium that we used to have to regurgitate to the tester in order to pass the Megacode section. Those steps were impressed in our craniums just deep enough to get our certificate then promptly forgotten within forty-eight hours. Now the AHA has shortened the algorithms so that the only drugs left to remember are epinephrine and vasopressin. Even the old standby, atropine, has fallen from favor.

In real life, resuscitations were never that complicated.  When a code blue was activated, the team would race to the patient's bedside. The anesthesiologist would intubate the patient. Somebody would wheel in the external defibrillator and hook up the monitor. One of the medical students or the intern would start chest compressions. After a couple of minutes, the code leader would ask for a pulse check. If none was detected and the rhythm appropriate, the patient would get shocked and chest compressions would begin anew. Every few minutes the leader would call for a bolus of epinephrine. Intermittently, somebody will get the idea to give some calcium or bicarb. Once the patient deteriorated to slow agonal or asystolic rhythms, atropine would be added. Only once did somebody actually order procainamide to be started. I think it was by a third year Medicine resident who wanted to prove his acumen in running codes. I'm not sure it was ever started. I don't think anybody even knew where to get the procainamide. And I'm sure I have never seen bretyllium requested at a code blue.

I'm glad the AHA has realized that simple is best. Previously the algorithms were so complex that it was rarely followed as prescribed. They printed up little pocket cards that doctors could carry so that they had something to read off of during a code. But in reality, nobody had those cards in their wallets or pockets when conducting a code so resuscitations were always carried out by memory of a test possibly taken years prior. And the only thing people remembered was shock, epi, shock, epi... Now the AHA has come to the same conclusion.

Sunday, March 25, 2012

What Is Dead?

I am currently studying for my recertification in Advanced Cardiovascular Life Support, or ACLS. Yes, I should be able to pass this with just a brief glance at the resuscitation algorithms, but they change the protocols just enough every few years so that everybody is required to retake the test every two years to stay current, not that statistically it has made much of a difference in outcome. Deep inside I think this is all a scam by the American Heart Association to wrangle millions of dollars from health care providers.

But I digress. I was reading through my ACLS booklet when I came across what the AHA considers the definition of death. In other words, the patient is so obviously, incredibly, fantastically dead that everybody can agree that no attempts should be made to start chest compressions or bag-mask ventilations. The four conditions that make a patient undoubtedly dead are: rigor mortis, decomposition, hemisection, and decapitation. Hard to argue with that. Other than decapitation, I think I've witnessed patients brought to the emergency room with varying degrees of the others.

Reading this brought back a flashback of one of the most dramatic deaths I had ever witnessed. One morning we were called to the emergency room for a major trauma that was coming to the hospital. The EMT's radioed in that they were bringing in a patient who suffered an industrial accident involving a very large machine and massive blood loss. They were going to arrive within ten minutes. The entire trauma team was at the ready when the ambulance arrived. There was a whirlwind of activity as everybody performed their assigned duties. The patient was rapidly intubated and multiple large bore IV's were placed in the patient's exposed limbs. Blood was quickly started using Level 1 blood transfusers.

The patient had been placed in a MAST suit, or body binder, to help decrease hemorrhage and maintain blood pressure. Naturally the binder impeded the trauma surgeon from evaluating the patient so it was quickly removed. During all the resuscitation activity the patient's body had slid down the gurney and lay askew. Therefore we tried to reposition the patient to facilitate the examination. Several hands grabbed the bedsheet under the patient to hoist him higher and straighten him out on the bed. On the count of three, we pulled the patient up to the head of the bed--and his lower half promptly stayed put at the foot of the bed. The only thing connecting the two halves of the patient was a thin strip of skin and muscle.

There was a brief moment of silence as everyone contemplated what they had just witnessed. The patient was laying on the bed in two separate halves. Blood immediately poured out of the two cut sections. The patient's blood pressure and heart rate just as quickly dropped to zero. There wasn't even enough time to call code blue. All activity just froze. Even the jaded trauma attending was stunned by the sight. There really wasn't anything to do for the patient at this point. The morgue was called for a body bag and housekeeping requested to come clean up the bloody mess. The trauma room soon emptied out as everybody headed back down to the cafeteria to finish breakfast.

Saturday, March 24, 2012

Eleven Thousand Dollar Colonoscopies And Other Hospital Follies

Some people refer to California as a socialist state. We have an ultraliberal all-Democratic state government that many people feel is anti-business and anti-growth. Yet occasionally they do some things that actually are quite helpful. A few years ago the the state legislature passed a law requiring California hospitals to publicly disclose all fees charged at their facilities. It also demanded the cost of the twenty-five most common procedures at each location be made public. The state then gathered all the data and put it into a public database called the Chargemaster. It is fascinating reading. The costs that are submitted reflect the amount that an uninsured patient will likely face if he presented to that hospital. It doesn't take into account substantial discounts that are usually made when hospitals negotiate their fees with the insurance companies.

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Let's take a perusal of one hospital in California, Stanford University Medical Center. Printed here is a copy of the twenty-five most common procedures up to June, 2011. I was astonished to find that they charge $11,222 for a colonoscopy with biopsy. An upper endoscopy with biopsy, which may take all of five minutes or less, will present the patient with a $10,962 bill. A transforaminal epidural steroid injection will set a patient back $10,918 for a case that may take no more than five to ten minutes.

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Just so that the good people at Stanford don't think that we're picking on them, let's choose a Southern California hospital next, Ronald Reagan UCLA Medical Center. UCLA's  list shows that in general they charge a bit less than Stanford. Maybe it is because they are affiliated with a state run public university. But if you don't have insurance, the prices can still be ruinous. A colonoscopy with biopsy will cost a patient $3,817 while an EGD with biopsy will lighten $4,684 from one's checkbook. Even more fascinating is the comprehensive charge list made by UCLA. Here you can find that a dessert and beverage will cost the patient $10 and if the patient needs a ventricular assist device, he will get socked with a $291,460 bill.

Finally, let's browse through a massive Excel database submitted by another large California hospital, Cedars-Sinai Medical Center. Again, anything that is done inside the hospital building will be charged. If you need blood, the Y-type tubing used to hang blood will cost the patient $110.82. The anesthesia charges for the first hour of surgery including an arterial line results in a $5,814.36. That is separate from the doctor's fee and the cost of the arterial line itself which is $668.19. Breast implants at this Beverly Hills hospital will cost anywhere from $123 to $6,280.07. Just so the guys don't get left out, inflatable penile implants range in prices from $1,175 up to 26,518.81. Hmm. Wonder why the men get "shafted" for more dough? Oh, and don't accidentally choke on your food while you're in Cedars. Hard to believe, but performing a Heimlich maneuver on you will cost $102.17. But if you're chocking to death, I'm sure you won't mind paying that charge instead of shopping around for the best prices.

If searching by every hospital is too laborious, there is even a database for comparing the price of a procedure between different hospitals. Here you can find some common procedures such as child delivery or joint replacement and how much it costs across different hospitals. For instance, a diagnosis of chest pain in Los Angeles County will cost a patient $37,799 at Olympia Medical Center but only $4,704 at Motion Picture and Television Hospital.

Sure it is easy for people to tell patients to shop around for the best prices before going to the hospital. As you can see the prices vary enormous from one location to another. But when you're sick, who has the time or the energy to search through all these huge databases and compare prices? The information is here, at least in California. But this won't lower the cost of healthcare. I think perversely people may decide that they want to go to the most expensive facility for their treatment, since the priciest means the best, right? So back to the drawing board for the government in their attempt to lower healthcare costs.

Wednesday, March 21, 2012

Is This Really Necessary?

Somebody had the bright idea to do this at our hospital. These shiny new timers were recently installed on our anesthesia machines. As you can see by the label, the sole purpose of the timers is to remind the anesthesiologist when it is time to give a patient another dose of antibiotics.

Why did our department do this? I think it is because there is some Joint Commission rule about a patient getting a second dose of antibiotics a few hours after the initial pre-incision dose. This is all in the name of preventing surgical wound infection. If a subsequent dose of antibiotics is not documented, this will result in a TJC red flag.

While the idea may be noble, to me its implementation seems to be a waste of precious hospital dollars. First of all, the timing of a second dose is usually at least four hours after the first dose is given. Very few of our operations go that long. So right there, the necessity of getting these stop timers is questionable. Then, there is the arguable need to buy a shiny and expensive looking electronic timer when there are far cheaper alternatives readily available. Almost everybody has a cellphone with a built in timer that can be used for the same purpose. In residency, we used to write the times that an antibiotic needed to be redosed on a strip of tape that we would attach on the anesthesia machine. Then of course there is the old mental trick of actually remembering to give the antibiotic on time without any external reminders. Aren't the alternatives easier, and cheaper, than buying these fancy chronographs?

Tuesday, March 20, 2012

Worst Songs To Play In The Operating Room

Anesthesiologists are often the DJ's in the OR. Since the surgeon is scrubbed in and the circulating nurse is busy running around getting equipment or entering information at her nursing workstation, we are frequently the only one free to put on some tunes. Plus anesthesiologists have the most awesome taste in music.

As the official OR disk jockey, we're responsible for the music that a patient hears when he is wheeled into the operating room. Usually I try to keep it upbeat. However sometimes I can't be responsible for what comes out of the speakers when Pandora is playing my 80's playlist. Or what happens when the shuffle function on my iPhone spits out an unfortunate song choice.

So here is my list of songs that should be avoided when a patient comes into the OR. Granted any loud rap music should probably be banned forever from the room, unless you happen to have some hip hop gangsta as your patient. But the song selections here are particularly lamentable when a patient presents for surgery. They will quickly have you searching for the fast forward button.

Live Like You Were Dying by Tim McGraw
Excellent country song. Not something you want to remind a patient when he is about to undergo a Whipple operation. No need to tell the patient he should have lived life at its fullest before succumbing to terminal cancer.

Another One Bites The Dust by Queen
An awesome sports anthem. Great for taunting an opposing team. Not so hot when the patient is about to get put under by you. Can you push the propofol any faster so the patient won't realize the familiar thumping beats herald the start of this song about failure?

Anything by Michael Jackson
Thanks to a certain convicted felon by the name of Dr.(?) Conrad Murray, propofol is now a household word. Rightly or wrongly, patients automatically have a wariness when told they will be receiving the drug as part of their anesthesia. They're association of propofol with celebrity addiction and death instead of the miracle of modern anesthesia is unfortunate but at least that's one less thing I have to explain when I give them my spiel about potential risks and complications of getting an anesthetic.

So that is my list of songs that should never be played when a patient enters the operating room. You may not be able to avoid it when one of the songs suddenly pops up on your random play list but try to discreetly skip to the next song before the patient breaks into tears.

Monday, March 19, 2012

The Invasion

D-Day for our hospital's implementation of our new EMR system finally arrived. Over the weekend, multiple frantic emails were sent out to everybody to remain calm and orderly. The hospital promised that there would be plenty of support for anybody who needed help. The program went live over a weekend to introduce the staff slowly to the computers. They even offered free food the entire weekend. Damn, why can't I ever be on call when there is free food?

When I arrived on Monday morning, I was overwhelmed by literally an army of support staff roaming every hallway, nursing station, and anywhere there is a computer. The multitude of assistants seemed to outnumber hospital staff two to one. I heard the hospital spent millions of dollars getting this system running and I can see where a lot of the money went. We even hired anesthesiologists from other hospitals who have already transitioned to this EMR program to come help us specifically on anesthesia related matters. What a sweet job that must be.

The problem that many of us feared would happen, that there would not be enough computers to go around, was resolved by the appearance of multiple portable workstations. In the electronic era, when the nurse, the surgeon, and the anesthesiologist all need a computer, usually at the same time, one computer per patient is not going to be enough. Now there are computers everywhere. EMR's must have been conceived by a conspiracy of Dell Computers, the federal government, and hand surgeons specializing in carpal tunnel syndrome.

The months of planning actually paid off pretty well for anesthesiologists. With the help of a couple of volunteer anesthesiologists, the IT guys developed templates that made entering the patient's histories quite painless. Just click, click, click, and you're done. I can definitely get used to this.

The only glitch occurred when I tried to enter my preop orders for my first patient. I clicked on my orders and thought I was finished. However the nurse said I had not yet signed my orders. Sigh. So I go back in and again signed my orders. The nurse still says my orders were not signed. After having prided myself on not needing any assistance yet, I finally succumbed to reality, swallowed my pride, and had one of the assistants come over to see what's wrong. We go through the process all over again. This time when I clicked to sign, the assistant saw the problem right away. I didn't actually sign it. I had clicked "sign and hold" instead of the "sign" button right next to it. And that is not to be confused with the "pend" button that I can also use on orders. I clicked "signed" and finally the nurse got my orders. We are only 30 minutes late for our first case. Not great but not as bad as people feared. At least I'm not the last one into the operating room which I consider a win for me.

The day started roughly like that for everybody. But it slowly smoothed out and by the afternoon the operating rooms were functioning pretty well, albeit slow. For anesthesiologists it's easy. We only have two sets of orders to write: preop and postop. Those orders were usually standardized anyway, even before the EMR. Therefore it was easy for IT to basically copy our previous orders from paper into the computer and all we have to do is electronically sign them. For the other hospital staff though, it could be quite a nightmare. Their postop orders could be quite challenging, especially since you can't just freehand write "Labs in AM, CBC, BMP, PT/PTT." Now there are cascading menus for ordering lab work, X-ray images, PRN meds, etc. There are submenus for stat, urgent, during the day, next day, every day, etc. Some orders require justification, like for chest films. Don't worry. There are cascading menus for that too. You can't just write the reason you're ordering something. It has to be one of the choices on the menu. It takes awhile to wade through all these choices. They're there. You just have to look for them.

Despite how painful the transition has been, and they forewarned us that the first six months of an EMR startup is usually very chaotic, we have muddled through quite well. The anesthesiology department has been commended for how smoothly our staff has adapted to the computers. We are not usually the ones holding up a case because of EMR issues. There is no turning back. This is the future of medicine. As we get further into our implementation, the bugs will eventually be worked out, or we will change how we work to fit the computer. I tend to think that it is the latter that will happen.

The Agony Of EMR Instruction Class

Before our hospital converted to electronic medical records, we were told we had to take a class on using the new system. And not just any class. We were stunned to find out we would have to take an entire day off on a weekend to attend. The whole thing was expected to take EIGHT hours. What the... How can a computer software take eight hours to learn, many people demanded. The glib answer that was told to us was that this is not like playing Angry Birds. This is a professional level program that requires hours of training and weeks to familiarize. It is the equivalent of learning something as complex as AutoCAD or Photoshop Pro. These programs are not designed for school children, or adults with the mindset of school children. There is even a test at the end of the class that we must pass before we can be considered successfully trained. And besides, we were told, the IT guys have already streamlined the process down to eight hours. Most other hospitals who have used this program typically required sixteen or more hours of training before certifying someone to use it. We were getting off lucky. So there.

With much grumbling, we scheduled the day we wanted to come in and waste a glorious weekend day. Thankfully our department had set up training days that were designed just for the anesthesia portion of the program. That way we didn't have to sit there and listen to how a hematologist can order a bone marrow biopsy on the system. We were also warned not to come in late. After they close the door, no one is allowed to enter. No one is also allowed to leave early either as the exam would not be handed out until the very end. But at least they will provide food and refreshments. Alas mood enhancing alcoholic beverages would not be one of them.

The morning of the lecture, we filed into the conference room which now looked like Mission Control at NASA. Rows of computers were sitting everywhere facing a lectern. We were instructed to write on a piece of paper how we would like to be addressed and hang it on the back of the monitor so the instructor can see it. Most people wrote their first names. Several wisenheimers wrote "Doctor".

The lecture started exactly on time. The instructor was very friendly and decently knowledgeable. But if somebody knows more than you about something they would seem knowledgeable whether they are smart or not. Shortly it became obvious why eight hours of instructions are necessary to use the EMR. The choices were bewildering. There were buttons and highlights all over the screen. The button labels and icons were not that helpful. Just finding your own patients took multiple mouse clicks to get there. The lecturer moved with the speed of somebody who has given the same talk dozens of time. Soon people were asking him to slow down and repeat himself. It was tremendously difficult to watch his actions on his big projector screen while attempting to do the same ten seconds later on our own computers.

The frustrations mounted quickly. After awhile, instead of asking how an action is performed in the software, my colleagues started asking why it was done that way. Why can't we order something one way instead of the other way? Who decided that the default selection should be A instead of B? Questions were asked of one of the anesthesiologists who sat on a committee that helped decide how the anesthesia portion of the system would work. It started to get ugly. The lecturer tried to answer their questions as best he could, but they were not satisfied.

My eyes started glazing over. Why are my colleagues throwing accusations at this poor instructor? Don't they understand he is only here to instruct us? He is not the one who designed the software and really has no say in how it works. He's only here to help us with the program that we have. I can't believe how absurd these people are. During a particularly long stretch of arguments, I sat back and pulled out my phone and started playing games. There really was no point in following the conversation since it was obvious that nobody in the room can change how the program functions. I'm just resentful that people are dragging this out and wasting a beautiful day fruitlessly bickering about this instead of quickly finishing it so we can all go outside and enjoy the rest of the weekend.

The hours ticked by. Soon enough lunch break arrived. Some people wanted to skip the 45 minute lunch and continue into the afternoon portion of the class. The instructor wisely said everybody take lunch. I think we all needed it. The afternoon session was more of a lab, applying the information we gained from the morning and solving a series of scenarios that were given us. It still took a lot of help from the assistants that were roaming the room to get people to understand it in even a rudimentary fashion. The exam itself was not bad. It was an open book test and we could freely ask anybody in the room to help. I couldn't wait to get out of there. I whizzed through the exam, got my passing grade, and headed out into the fading sunlight. Yes it was easy enough to use the EMR in a classroom setting with people at your beck and call to assist you. How will this work when the time comes? And will I remember any of these instructions when the system goes live in a few weeks. The countdown's on. 

Sunday, March 18, 2012

In Pursuit Of EMR Nirvana

Our hospital is undergoing an epic conversion to electronic medical records. The process has been taking place for years. The federal government has mandated that all patient records be recorded electronically by the year 2014. They even have an incentive program available to bribe doctors and hospitals into adopting the new systems. If the carrot doesn't work, by 2015 the government will start wielding its big stick and penalize facilities for not using EMR's. How's that for a refutation of "live free or die"?

Naturally there has been great anxiety about the process. We have all heard the tales of how other hospitals' adoptions of EMR's have fared. Worker productivity falls 50% as everybody tries to get up to speed on the new system. Doctors and nurses quit out of frustration as they try to reconcile with their new electronic overlord. Our hospital administration has held rallies to allay the fears of going all electronic. Balloons and T-shirts have been handed out as goodwill gestures. Much cake has been sliced and ice cream scooped to encourage people to look kindly at the approaching demise of the paper chart.

For weeks every time we logged into the hospital computer, a countdown clock was displayed prominently telling us how soon we were switching to EMR's. This had the perverse sensation of facing a coming apocalypse. As the time ticked down, our emails became more frequent and urgent. Everybody MUST take EMR classes to ensure that we knew how to work the software. Failure to register at one of the classes could lead to disciplinary actions. Doctors were asked to not admit as many patients for the first few weeks while everybody fumbles with the computers. The operating rooms were expected to slow down as turnover time between cases was expected to double.

The future is now. The clock of the apocalypse recently counted down to zero and we turned on the EMR switch. We have now gone about 90% electronic, with a few minor details that still remain on physical paper. It has been an enlightening past few weeks. I'll be writing a series of reports to let the curious know how it went. We've all heard the wonderful tales of how EMR's will save American health care. Now you can follow along and read the reality of taking away centuries old medical tradition and in one stroke going all digital.

Friday, March 16, 2012

Stealing From The Hospital

White collar crime is a huge burden in America. According to the FBI, the cost of white collar crime is over $600 billion. It is so pervasive that people don't even think of it as a crime. Who amongst us hasn't taken a pen found in a desk drawer at the hospital? Maybe you've taken several sheets of typing paper home to fill your own fax machine. In the operating room, people take clean lap sponges home all the time because they make the perfect polishing cloth for your car or furniture. Every time you see a doctor walking around in scrubs from another hospital, which maybe located hundreds or even thousands of miles away, that doctor is openly proclaiming his involvement in white collar crime.

I think nowadays one of the most common forms of stealing from the hospital is the usurpation of its electricity. Literally everybody does it. Most people I know, and just to be perfectly honest including myself, charge their electrical devices at the hospital. In fact, many people, again including myself, try to charge our phones or tablets or laptops completely before heading home for the night just so we don't have to pay for the electricity. Sure it may only cost the hospital a few cents to charge up my evil iPhone, but multiply that by thousands of employees and you can clearly see how this will affect the facility's electric bill and drive up health care costs.

Now take a look at the picture above. This car belongs to a doctor who is parked in the physician's parking lot. The car is a Karma Fisker, one of those fancy schmanzy plug in hybrids that in this case costs over $100,000. But that doesn't mean the owner didn't mind having somebody else pay for his car's propulsion fuel. Being the first one at the hospital with one of these allows him to monopolize the few electrical outlets in the parking lot, which is used by the maintenance people to clean the lot. But imagine when electrical and plug in hybrids become more commonplace. Soon everybody will be wanting to plug in their car at work to save money. Somebody may even bring in a multi-outlet power strip so that more cars can be charged simultaneously. This will be like everybody charging their cell phones at work but multiplied by a thousand times in costs to the hospital.

Is it wrong to do this? Absolutely. Will the problem get worse as more electrically powered cars and other devices proliferate. You bet. Is there any excuse to justify spending six figures on a car then being too cheap to pay for your own electricity? Yes. Al Gore made me do it.

Wednesday, March 14, 2012

Quoting From Wikipedia On Rounds Is A Bad Idea

The surgical attending was pimping his med students and residents pretty hard in the operating room. Question after question he stumped the operating team. The students had the unfortunate luck of traditionally being asked first, with the least amount of time to think of an answer. Then the torture would move up the ranks until the chief resident was in the hot seat. I was highly entertained, plus I learned a lot too from their suffering.

As the case continued, the attending started a new question, naturally with the medical students. However this time, one of the students almost appeared giddy. He knew the answer to this question. He could barely contain himself as he elatedly quoted some statistical figure back to the attending. Since the question was obviously too easy, the attending pursued the same subject for more details. "From which study did this result originate?" he asked the student. "I'm not sure, " replied the student. "I read about it on Wikipedia."

You could have heard a pin drop after that. The attending turned dusky red under his mask. "Wikipedia? Really? Are you serious? You have the nerve to stand here and talk to me about Wikipedia? What did Sabiston say about this condition? Did you read the Archives of Surgery from 2009 that published the study?" The tirade went on and on. I could actually see the student shrink in stature.

I almost felt sorry for him. The answer was right. The reference was wrong. Wikipedia may be used by millions of people and contributed to the demise of encyclopedias and textbooks, but in medicine, it is not considered a prestigious and reliable source like peer reviewed journal articles. The truth was understood by everybody in the room. There will be no quoting Wikipedia to this attending.

Saturday, March 10, 2012

Fifty Ways To Prevent Burning Out

Job burnout. That's a problem almost all of us have experienced. Whether it is medical students cramming for their umpteenth exam or an anesthesiologist getting called in the early morning hours for another D+C, we've all thought about saying "I've had it." and walk out the door and on towards the greener pasture on the other side of the hospital front door.  In the February issue of General Surgery News, Moshe Schein, MD, a surgeon with a self-described work experience of over three decades, lists fifty things we can do to prevent capitulating into career sullenness and despondency.

While some of the advice are specific to surgeons, the majority are applicable to everyone, including anesthesiologists. Listed are the usual platitudes about treasuring your family life and maintaining an exercise program to stay healthy. But there some nuggets of wisdom sprinkled in there that are worth considering. For instance, there is this little tidbit at #27, "In the lecture hall he preaches what he heard at the last association meeting, but in practice he continues to do what he did since his residency." So don't just do something just because you've done it the same way for twenty years. Medicine is constantly evolving and our practice should too. 

There is also this astute quote at #49, "The young man knows the rules, but the old man knows the exceptions. … The young man feels uneasy if he is not continually doing something to stir up his patient’s internal arrangements. The old man takes things more quietly, and is much more willing to let well enough alone." As I gain more experience with anesthesia, I find that I tend to jump less often at the slightest change in heart rate, less likely to intervene at the merest shift in blood pressure. Through painful experience, I've learned that doing something, anything, over the smallest fluctuation in vital signs usually leads to overcompensation as the body will naturally attempt to get back into equilibrium. It can take nerves of steel, and faith in your own personal observations, to understand that. Now I patiently watch the patient carefully and only treat when it is clearer that the patient needs some assistance from me to get back into balance.

Even in this age of constant economic turmoil and medical uncertainty, medicine can still be a wonderfully fulfilling career. But expectations have to be changed, not necessarily lowered, to get the most job satisfaction. No longer is working 80 hour weeks and missing family milestones indications of a successful physician. And it never should have been.