Sunday, July 15, 2007

The Touch of the Master's Hand

You'll have to forgive my recent absence, as I am going into the fourth week of my third year. I started on the OB/GYN rotation, and 70+ hour weeks elbow deep in you know what have prevented me from effectively getting anything of quality out. This article will stray from my usual reveries inspired by the blatant economic ignorance of the world in which we live and instead try to come to terms with the much smaller world in which I now find myself.

My school has an amazing hospital, and I mean that in both a good and a bad way. This is a place where medical students will scrub into cases that are still legends in the minds of many practicing surgeons. These are sometimes known as the quintesential "Jackson Specials." This is also a place where it can take over five hours to get a wheelchair for a patient who has been discharged or where it may take seven hours to get back a lab on a critical electrolyte. As one of my attendings says, "welcome to the Jack."

The University of Miami is unique in many ways, one of which is the fact that all medical students rotate through gynecologic oncology as part of the 3rd year OB/GYN clerkship. As someone whose interest in OB/GYN is mostly academic, I have been pleased that this is the case. Our "Gyn Oncs" carry the heads of surgeons, while maintaining maybe just a touch more humanity than those on the surgical service. I have to admit, I have largely enjoyed it (most of it). I will not pretend that I haven't been asked to complete some completely ridiculous tasks, some of which I have openly refused to do, or spent an occasional useless extra hour on rounds. By and large though, these things have been less than I feared. I have now scrubbed a number of cases, and I have yet to be yelled at by anyone but a scrub nurse, whose colleague actually apologized to me for her behavior. We even became friendly during that cases (Nothing else to do while watching 3 hours of laporoscipic surgery while your idle hands sit motionlessly on the patient's thigh).

What these weeks have done for me is pull everything into a frighteningly clear perspective. I understand the politics, the motivations of the physicians and other students, the thoughts of the patients, and who seems to be getting what out of what. It's odd.

Unlike many students, whose first unsuspecting marches into the lands of surgery or OB/GYN send them into a full retreat to the safe have of anesthesiology, I have actually been somewhat inspired. I wouldn't say that I am in awe, but I cannot help but feel a deep respect for some of the people with whom I have already had the pleasure of working. A particular attending of mine scared me to death with a particularly brutal form of humor at our first meeting. By the second time I met him, I realized that he cared more than most. He wasn't alone, but he was a striking example. For the first time since anatomy, I have questioned a commitment to Emergency Medicine and longed for scalpel.

This has really gotten me thinking about some of my friends who are pursuing "lifestyle" specialties (and I am not including EM as a lifestyle specialty as it is often defined). We could say it's all about the money, and it always is, but the mind numbing professional life that often defines a lifestyle specialty seems like it shouldn't always be the source of such glee from people who have spent their entire lives trying to stimulate their minds in a fashion that overwhelms all of their peers. Medicine has traditionally been safe, but I cannot believe that most of the people that enter the field do so only because it has been safer than other fields that also have a signficant up-side and a much smaller time investment.

With all of the problems in medicine today, I think that the most fundamental question has to be: what is going wrong with medical eduation? When I first went to medical school, the long hours of residency were actually a perverse attraction, an asset to the profession if you will. I imagined a world where people strove for excellence, often spending years trying to perfect their skills. I imagined doing what needed to be done. Medicine may have been a world of prima donas, but it was a world in which that arrogance was earned. Atleast that's what I thought.

As I stood watching my intern run around like a headless chicken the other day, I realized that residency and the long hours have very little to do with perfecting one's skills. Skill comes with experience, which happens by default in an 80+ hour work week, but the system is incredibly flawed. More than the usual banter about hospitals taking advantage of interns, it is as much what the resident fails to get than what the hospital gains that is the problem. Academically I understood this before, but I didn't really get it until now.

I frankly didn't enter medicine to learn how to be more empathetic, use the team approach, or any other politically correct method of medical training of today. It's not that empathy and team work aren't important. They just have nothing to do with why I went to medical school. I came to become a highly skilled practicioner, a master of my craft. I came to learn how to be a go to guy, a person who commanded respect because he earned it, and someone who has the skills to provide for himself autonomously. In modern medical training, I fear that these may be the very attributes that are most in jeapordy.

My wife's grandfather, who happens to be a former physician and one who trained in the early 60s, talks of medicine with a gleam in his eyes. He saw himself as a detective almost, personally charged with identifying an ailment that plagued his patient. He said very little about spending hours on discharge summaries or writing the 800th soap note on a patient in 2 days. I suspect that there used to be a lot less of that. Between these things and the dreaded "rounds," which were far less frequent in those days, the modern resident has to spend the bulk of his brain power fitting himself into a stereotypical behavioral mode and becomes as much an underpaid clerk as a physician. Yes, residents used to work longer hours, yes it was often bad, yes there was probably a better way, but atleast they spent many of those hours learning how to practice medicine, which is something notably missing from training today. In fact, the current policy wonks want nothing more than to turn all physicians into nothing but "members of the team," who will diligently and thoughtlessly pour out mesh terms over considering the uniqueness of a patient. Doing anything more would put them above "the team."

As I watched the hands of the attendings in one of my most recent surgeries, I began to question whether those hands will exist in another 50 years. It has nothing to do with 50, 80, or 100 hours a week. It has to do with the desire of the student and the willingness of the teacher. If these two actually care about each other, they will take care of each other, and the hours will be doled out in a way that is subjectively satisfying, rather that some arbitrary number of hours of scutwork. As the teachers become less willing, by choice or by mandate, the desires of the student will migrate elsewhere. Without a paradigm shift, my generation will be entirely educated in a sea of thoughtless conformity by a bunch of bitter old geezers who know that the whole thing is wrong. That can't go on forever. Then comes the next generation, and who will we teach?

5 Comments:

Anonymous ch_boku_shi said...

I really agree with your "go to guy" idea. My thoughts of being a doctor, were and are still in a way, are that you take care of people and find out what's wrong with them. And treat them. Not look at them for five minutes, ask them a few questions, then send them out. I'd rather have to do all the stuff the nurse does myself. But I like old-style medicine even if it was "barbaric" by today's standards. I really hope that you can be the go to guy because then there will be hope for me when I get to med school.

5:38 PM  
Blogger MiamiMed said...

It's not so much that I want to go back to barbaric medicine, or that I don't appreciate not having to do all of my own blood draws. There is no problem with having a division of labor. That doesn't mean that everyone within that division equals everyone else.

P.S. After your second blood draw, you'll realize that while you should know how to do it, you won't mind passing that particular task along when possible.

7:09 PM  
Blogger Zagreus Ammon said...

The Golden Age of medicine is long-gone. While it was great for the docs, it also failed the population; helping individuals from time to time, but the possibility of finding a good doctor to cure you was based on fortune more than anything else.

Today, health is about chronic disease, trust/confidence/relationship and obviously the use of technology. There are strange expectations about the roles of physicians, who should pay for what and how it affects the doctors, the patients and the government. If that ain't complicated, I don't know what is.

Ever wonder why so many myths need a golden age in the past and the promise of new golden age in the future.

There is plenty of value in medicine, we just have to figure it out.

5:36 AM  
Blogger MiamiMed said...

Frankly, I'm not really talking about a golden age per se. I'm talking about a paradigm shift in medical education, in which some of the quality of the training is lost. My concern is that that quality cannot be regained. Lots of things are better today, both in terms of treatments AND hope. These changes still require a highly skilled practicioner.

7:45 AM  
Blogger Mr Scolex said...

I'm not as far a long as you, and I may be mistaken, however I think that you have written about two extremes of a topic that must be balanced, sometimes delicately. You should be the go-to-guy, and you should be the general. You should also be a member of a team. I've had the good fortune to see real doctors, nurses, and ancillary staff do this, and it was really an excellent environment to be in. Nurses were skilled and experienced and fed very good information and opinion to doctors. Doctors made decisions, sometimes agreeing, other times disagreeing. Nurses would provide feedback, but the doctors always ran the show. This is a significant change from how medicine used to be as described by some of our professors, where any feedback or disagreement by a nurse or other staff member was completely out of line and would provoke incredible rage from a doctor.

Additionally, as a student or intern, yes, there are skilled nurses who may not have as much physio memorized, but they know medicine better. There was a Scrubs episode that was pretty excellent in describing a point where power changes hands. I suppose there's a trick as an intern to find skilled nurses to learn from, and not idiots, who are plentiful everywhere..

4:54 PM  

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