Showing posts with label Respect. Show all posts
Showing posts with label Respect. Show all posts

Friday, December 9, 2016

Medicine In A Time Of Hate

Pranay Sinha, a third year medicine resident at Yale, shared his experience with racial hatred post presidential election. He thought he would be lauded for going above and beyond the call of duty taking care of an older white patient. Instead he was shouted down and fired by the patient. This sets Dr. Sinha into all sorts of mental turmoil.

Was he being singled out because he is a foreign medical graduate? Was it racial intolerance, since he never saw the patient treat white doctors the same way? Is it acceptable for doctors to be angry at their patients? When patients are sick and vulnerable, are they responsible for their words and actions? Should he develop thicker skin or should doctors demand respect from their patients the way we show respect to them? Has the presidential election emboldened people to drop their facade of tolerance and revealed their true colors?

As physicians, it's hard to get angry at patients without coming off as uncaring and impatient. I've had patients swing at me with their fists, spat on, scratched at, verbally abused, or generally not following orders. Yet I attribute them to the patients' general circumstances. They're in an unfamiliar environment, practically naked, most likely hungry and cold, with needles stuck in them or getting stuck every single day. I try not to judge them based on their aggressions. But many days it requires the patience of Job to make it through the day. And frequently, when I see the patient again later on they have usually forgotten about any slights that have been thrown my way and we can resume a normal relationship. But it is a challenge every doctor has to master to have a successful career, no matter their color or ethnicity.

Tuesday, May 6, 2014

The Most Vulnerable Anesthesiologists

It's already May and another class of anesthesiology residents will soon descend upon the world as full fledged attendings. Many of you are already so brimming with confidence that you can barely stand doing cases with the attending standing in the same room. Little do you know that the first six months after finishing residency will probably be the most challenging period of your careers.

As the newest anesthesiologists, you will arouse the highest suspicions and given the shortest leashes. With your heads full of hair and wrinkle free skin, patients will inevitably ask how long you've been in practice. There will be an awkward pause as you ponder how best to answer that. Should you tell the truth about your recent graduation or tell a little white lie? You ultimately decide that your integrity and the patient's trust is paramount so you answer the truth--two weeks. You will then get the wide-eyed anxious stare of somebody about to enter the abyss. No amount of reassurance that you have spent years of training will comfort the patient the same way a few strands of gray hair can accomplish. There is no fix for this. You can only continue your usual affable way and laugh about it while proving to the patient, her family, and the entire hospital staff that you are worthy of wearing your hospital ID badge that identifies you as a staff member of the Department of Anesthesiology.

But patient acceptance may be the least of your worries. When surgeons find out there is fresh meat in the OR, it's like a seasoned lion about to pounce on a naive young gazelle. The surgeons know that the newest anesthesiologist will not want to be labeled a trouble maker right out of residency. They will take advantage of your willingness to please even if it is against your better judgement. They will make you do anesthesia that would get you thrown out of your oral board exams in a heartbeat. I once had a patient who simply couldn't help himself and ate a bagel on the way to the hospital the morning of his surgery. Naturally I cancelled the case when I heard about his transgression. But guess what. The surgeon went down the hall and asked one of our youngest anesthesiologist to do the case. And he took it. Whether all the big dollar signs that were flashing in his hungry eyes made him do it or he was intimidated by the surgeon, he just turned himself into a CA1 as far as anesthetic judgement was concerned. You think that this will never happen on your watch, but believe me, it happens all the time.

What's worse than the surgeons taking advantage of you will be your fellow anesthesia colleagues doing the same. Everybody knows that when you start in a new group, you want to be known as the team player. You don't want to rock the boat and make any sorts of demands that will stigmatize you for as long as you work there. Every new anesthesiologist is so insecure that he will do virtually anything if asked by one of his more senior partners. Within days of getting your call schedule, your phone will be ringing off the hook from your fellow anesthesiologists asking to trade calls, usually for a weekend or holiday call. Some may even ask you, ever so slyly, if you could simply just take his call that night because he suddenly "remembered" he had a family event planned and can't be at the hospital. Not wanting to appear to be difficult, and hoping this little favor will grant you more job security, you will bite your tongue and agree to take it. Of course this tiny act of kindness is quickly forgotten by the other person and your job security is no better off than it was before.

You will also quickly understand what it means to have patients get dumped on you. As an eager, indebted physician, the entire OR knows that you are hungry for work and money. Therefore don't be surprised when another anesthesiologist asks you to do his last case for him since he says he doesn't want to stay late. Thinking that you could use a few bucks, you quickly agree. Then you see the patient that rolls into the preop holding: 78 years old with CHF, ejection fraction of 20%, morbid obesity, diabetes, hypertension, renal insufficiency, hemoglobin of 8, for an exploratory laparotomy for small bowel obstruction. You curse under your breath that no amount of money is worth this medical risk. But since you have already agreed to do it you bite the bullet and do the best you can with what modern anesthesia has to offer you. You notch it up as one more scar on your way to becoming a seasoned, respected anesthesiologist.

So enjoy your last few weeks of residency while you still have the chance. You are currently at the pinnacle of your medical career for the next few years. You may strut around the OR's like you're the second coming of Ralph Waters, but in the next few months you will get beaten down until you barely know which direction of the epidural needle is up. You will question everything that has been taught to you in the last three years. Not until you have answered all these internal doubts will you at last truly be known as an equal partner in your department. Or until the next year's class shows up.

Tuesday, December 15, 2009

Surgery Without Anesthesiologists

Another aspect of the story in the New York Times about a heroic 43 hour surgery really bothers, no angers, me. Besides the enormous expense of this procedure for questionable long term benefits, on a more personal note this article barely mentions the anesthesiologists involved in the care.

Toward the end of the surgery, when the liver was reimplanted, the operating team encountered some serious difficulties:

The liver bled profusely. Transfusions could barely keep up. Over the next few hours he needed 30 pints of blood. But even as the bleeding abated, his blood pressure and body temperature dropped, and his blood turned dangerously acidic. Drugs to correct one problem made others worse. He was sinking into a vicious cycle that could kill him.

Who was there giving all the transfusions, and the pressors, and other life saving maneuvers to try to salvage this 43 hour operation and the patient's life? There is not a mention of the work of the anesthesiologists at this critical juncture in the operation. It's as if all those interventions happened by magic. There is a single quote from an anonymous anesthesiologist in the entire article. Of course he, or she we will never know, is talking about the surgeon, describing him as having "soft hands." Blech.

On the 8th photo of the slide show, they actually described what the anesthesiology team was doing during the operation:

During surgery, anesthesiologists transfuse blood and other fluids and drugs, and monitor the patient's heart, breathing, blood pressure and blood chemistry, in addition to administering anesthesia.

That sounds like a pretty generic job description, something I do every day. That gives no indication of the exhausting work that must have been going on behind the drapes keeping this patient alive. Even the surgeon's PA had a picture and was mentioned by name in the article. But the team actually responsible for keeping the operation going is only shown as a single arm hanging up albumin and PRBC. Anybody can slice and dice a body into pieces. It is up to the skill of the anesthesiologist to make sure the patient survives this "attack" and wakes up afterwards in relative health and comfort. But thanks to writers of the New York Times, the public will continue to be ignorant of the vital roles we play.