I’ve started a Residency Horror Stories series. The point is not to get you nervous about your training or being on-call or anything like that… In fact, it’s quite the opposite.
Most people think they learn best through experience. That’s true, for the most part… but there’s another piece of “experience” that is even more important than the experience itself… and that’s “the story”. We remember things as stories. We further ingrain the memory by retelling that story. And each time we retell it, there’s an opportunity to extract new insights from it and an opportunity for the listener to benefit from your story.
Now some of the medical establishment (the Old Boys Network) may be a little upset with me for saying this, but… the dry, factual version we often present on rounds is not always optimal.
Which one are you going to remember?:
49 year-old obese female with a history of type 2 diabetes and smoking who presented to the ER with severe chest pain, hypotension, and diaphoresis. Her EKG demonstrated 3mm ST segment elevation inferiorly. Cardiology was consulted and she was emergently taken to the cath lab. After a brief Vtach arrest requiring 260 Joules for return to sinus rhythm, her right coronary artery was successfully stented with two Taxus stents with good angiographic results. She was transferred to the CCU in stable condition with an intra-aortic balloon pump, IV heparin, Plavix, and aspirin.
It was my first week as a second-year resident and I was on-call in the CCU. I was called stat to the ER for a CCU admission that was described as a “49 year-old obese female with a history of type 2 diabetes and smoking who presented to the ER with severe chest pain, shortness of breath, and diaphoresis.” I was told that cardiology was consulted via phone & they recommended transfer to CCU after a VQ scan.
I went to see the patient & there’s a morbily obese lady lying in Trendelenberg, IV fluids wide open, heart rate in the 40s, and huge “tomb stone” STs on the monitor. I introduced myself and told her that we would take good care of her. She looked up at me and said, “Son, I’m gonna die tonight if you don’t do somethin’.”
I went to the ER doc and said, “This lady’s clearly having a huge RCA MI! She’s bradycardic, hypotensive, complaining of chest pain, & her EKG… well, look at it! We can’t send her to the unit with a VQ scan.”
He responded, “Well, I talked to the cardiologist on-call.” And I asked, “Well, are sure he understood what we’re looking at here? I mean, no offense, but sometimes it’s all in how we say it. I think you should call him back.”
Well, he did… the ER doc called back the cardiologist on-call and got screamed at… loud enough for me to hear it through the phone from about 4 feet away. “I said!… Admit to CCU and get a VQ scan!”.
He hung up. There I am, a new second year, one of my first nights with any kind of real responsibility and I’m disagreeing with the ER attending and the subspecialist. What should I do?
Well, there was no question… that lady said to me, “Son, I’m gonna die tonight if you don’t do somethin’.” So I did… I firmly asked the ER doc, “I’m not comfortable with this! Are you comfortable with this?!” He said, “No… No, I’m not.” So, I asked, “Well, how about TPA?” He paused… so I snatched the EKG out of his hands and ran 3 floors up to the telemetry floor. There was a cardiologist (from a competing group) and I shoved the EKG in front of him and said, “49 year old lady in Room 8 in the ER, tons of risk factors, heart rate in the 40′s, telling me she’s going to die… no labs back yet.”
He said nothing to me. He picked up the phone and called the cath lab. Together he and I wheeled her into the lab. While we were lifting her to the table, she arrested….
So which one are you going to remember? Which one will give you strength to do the right thing when the time comes. Both of those versions are true. I lived through it. More importantly, so did the patient, but not before her night got much, much worse. I’ll tell you the full story and the lessons learned in the second video for “Residency Horror Stories”… the first video will be in the next few days.
Do you have a story we can all benefit from? Tell us. Here’s the link again:
After a great response from those of you on my “new release priority notification list”, the RookieDoc Membership program is being opened to anyone that is interested. Here’s a short intro video to show you some of the things that are part of membership. If it sounds interesting or useful, click the link below the video to find out more.
If you could sit down with me and ask me any question about being successful in your internship or residency, what would it be? I’ll answer some questions on upcoming RookieDoc FAQs – these are occasional phone conferences for RookieDoc fans and members where I discuss a hot topic or answer questions.
OK. I had a sad, humbling experience on a trip to Wal-Mart last night. My wife asked me to return something and my daughter was/is sick, so I had to get a prescription filled. Not a big deal, right?
Well, three things… One. I am not a Wal-Mart guy. No offense to Wal-Mart Inc, but in my area the “customer service” there is quite pathetic. It is the type of place where those hilarious guys at Despair.com get inspiration. I have to consciously prepare myself to keep my mouth shut… suck it up… and move on.
Two. I am not a go-to-the-store-and-return something guy either. It’s just not me. I don’t like doing it. If I can get out of it, I will. (But if I’m wronged, I’m going full tilt – Better Business Bureau, letters to the home office, etc… just don’t make me return anything.)
Three. It’s the week after Christmas and the place is packed.
Anyway, I went.
There were no less than 40 people in line at the “customer service” desk (so naturally, I didn’t return anything . I briskly bobbed and weaved to get to the pharmacy pick-up line. I was number 16 in line. Ahead of me stood 15 uncomfortable-looking, elderly patients. Since 11 of the 15 folks did not have a smooth pick-up, I had plenty of time to stand there… to just watch and listen.
Here is some of what I saw and heard:
The patients in line were elderly and uncomfortable standing so long.
Most of the patients had even sicker-looking (in a chronic sense) family members sitting aisles away on empty shelves or in wheelchairs.
While in line, these patients were cordial and patient, but as time went on, frustration and fatigue began to show.
While they were waiting and becoming increasingly tired, several employees were walking out from the back talking about their break and why they need to take it now, “even though it’s busy”.
Several patients were discussing “coming back out of retirement” just to be able to afford things for daily living.
Several quoted the $4 prescriptions as the reason they were willing to withstand the “customer service” and the lines.
Despite their interest in the $4 bargain, most (8) of them were unable to actually get the $4 drug… mostly because the way it was written.
11 out of 15 had issues with their scripts being filled at all – and not one of the 11 was given a solution that they could control… The staff blamed each issue on the doctor or the government – 8 on the doctor, 2 on the government (specifically Medicare Part D), and one on both.
The second person in line (appearing to be in her late 70s) ended up being shouted at by the pharmacist, “Didn’t you read Medicare Part D?! Your doctor has to put the indication on your prescription! It’s not my fault! Go ask your doctor. We called, but your doctor is not getting back to us.”
There was one employee who was visibly working her tail off to get the patients their meds before they even reached the counter. She walked out and asked each person in line their names and began trying to get their stuff 3, 4, and 5 people deep in line. No one thanked her. No one said, “Job well done”, at least in the 45 minutes I stood in line.
Here are some tips and pearls for interns and residents to take away from this experience:
Small things on your part can make a humongous difference for your patients.
Write the indication on your elderly patients’ scripts.
Advise your patients to bring their discharge instructions with them to the pharmacy when they leave the hospital for the first time.
If you are writing a narcotic, put your DEA number and spell out the number of pills to dispense.
Try to avoid writing “Use as directed”… that doesn’t fly with some co-pays, Medicare D, and some discount programs.
Choose the medications wisely… with cost being a huge piece to factor in.
Ask your patients if they’ve ever had problems filling scripts before and what the nature of the problem was… too many to dispense, not covered by insurance, etc.
Consider titrating doses before adding new classes, if possible.
Keep an updated list of the discount meds available. And familiarize yourself with other discount programs (Target, Wal-Mart, Giant, etc).
Get in the habit of writing the generic name anyway.
If you get paged from a pharmacy outside of your hospital, it is probably regarding a patient you just discharged… Answer it promptly. That person who was just hospitalized is probably standing in Wal-Mart, or sitting off to the side waiting for a family member to fill their scripts.
If there’s a discrepancy when looking at their meds and the meds you thought they were taking at home, ask the patient. Reconcile your scripts with their current meds.
Be careful what you talk about in front of others. Sure, there’s nothing wrong with discussing where everyone wants to order from for lunch. But if you do that while a patient or their family is in earshot, you might really rub them the wrong way.
Social workers and case managers know about these patients’ frustrations and potential problems… learn from them. Ask them for feedback. And appreciate what they do. (The insurance industry is like Wal-Mart on steroids.)
When someone does something well, or goes a little further than they have to, tell them about it… thank them… let them know that it was appreciated.
Now, it is important to realize that when you actually do these things, you will not be praised. No one will thank you. No one will really notice. And that’s okay. It’s not about you. It’s about them, the patients.
And if you don’t think it’s about your patients, then quit health care right now… and go work at Wal-Mart. You’ll fit right in… probably best-suited for “customer service”.
And here are some tips for Wal-Mart and pharmacies, in general:
Put some seats or benches for your elderly patrons. Be generous and be strategic. Put them in such a way that people can remain in line and remain seated if need be.
Consider having a health professional (MD, DO, NP, PA, Pharm D, etc) that can write scripts for the edits and tweaks that someone else simply forgot… things like indication, quantity, etc.
Consider having a looping video that explains procedures, policies, what’s needed, etc. so that people don’t have to wait in line to find out that they’re missing something.
Keep track of all of the issues that prevent people from getting their scripts on the first trip up to the counter… use that list to get to the root causes… or at least publish it. If it is truly the doctors, then send the list to me, I’ll get it out there.
Try to hire people that “own” problems, not the Me-Myself-and-I types that consistently shunt blame.
Remind your workers that it might be viewed as a little inconsiderate to discuss their breaks while frustrated customers look on. Remind them to consider how they would feel.
Tell your pharmacists that it is a very, very rare patient that ever “reads Medicare Part D”… In fact, I’ve never met one.
There’s my rant, but there are lessons in there, though. I learned a lot standing in line at Wal-Mart.
I made a short 7 minute video as a quick introduction to Twitter and how you can use it to get tips and strategies for your med school rotations, internship, and residency. Just click on the video image below to get started. You will need the most up-to-date QuickTime player (free version).
Even though a blog is often the writer’s soap box… that’s not what I’m going to do with this particular subject. I’m just pointing it out for med students, interns, and residents… just to be aware that there are even more changes being discussed in resident work-hour reform. I want to suggest that you reserve judgment. Here’s why…
It’s easy to think about yourself in the short-term and think, “Heck yeah! I want to limit my work hours!” But be careful, there are definite pros and cons. And we are talking about a dynamic system here.
Part of being remarkable in your profession is your ability to “see systems”. You should know that one tweak in one part of the system may have profound implications in other parts of the system. And in this “me world” you might miss the effects on other parts. And in this “right now world” you might miss, even, the longer-term implications for yourself.
But I’m not going to go there right now. (RookieDoc members – I’ll teach you how to overcome the cons with a whole separate bonus module…) Just keeping you informed here by linking to an interesting article and an interesting blog post. Check them out.
You don’t want to just survive your internship and residency, do you?
Of course not. You want to excel.
But most of the books…
most of the websites…
and nearly everyone you talk to out there…
They all seem to warn you about what a disaster your internship and residency can be. They speak of grueling nights on-call; rarely, if ever, seeing your family and friends; and getting utterly embarrassed by attendings in front of everyone. They worry you with talk of malpractice, needle sticks, medical errors, and boards preparation.
Well, it doesn’t have to be this way. In fact, it isn’t this way. I should know… I’ve been there…
And I’ve posted some videos to help you to have success in your internship and residency. Just go to this tips and pearls for residency video to start.
Most residency programs offer an education stipend or allowance. If you’ve purchased anything related to your training lately, make sure you submit your receipts. I posted Reimbursement Request Templates in the RookieDoc Members Area. Just plug in your information, print, and hand it in to your program.
By the way, for those of you in the RookieDoc Mastery Orientation Program, make sure you submit your receipts for reimbursement. RookieDoctor.com services should count under your education stipend. If your program does not reimburse you, send me the program address and a contact person and I’ll see what I can do. So far, every program that receipts have been submitted to have accepted them.
Just an FYI for students of the RookieDoc Mastery Orientation. There’s a bonus module posted on going beyond “surviving” internship and residency. There’s a spectrum with “failure” on one end and “mastery” on the other. And, frankly, “survival” is too close to failure. Find out what’s next notch over closer to “mastery”.
A huge part of your training is getting feedback – constructive feedback. Too often you will come across upper level residents, attendings, and supervisors who give useless feedback. And you should not settle for feedback that is useless.
Here’s what I mean…
Let’s say you go and ask your attending, “Dr. BossMan, I was just wondering how I’m doing. Am I doing okay?”
You will see, the problem lies in how you asked the question. Invariably, the answer will be “Fine. You’re doing fine.” Or, “You’re doing great. You have nothing to worry about.”
Useless. Completely and utterly useless.
This kind of “feedback” will not help you improve. It will not help you to form good habits, nor will it alert you to bad ones.
Here’s a better question for your attending… “Dr. Advisor, can you take a moment to look over this H&P and tell me how I can make it better?“
You can do this with any particular area you want to improve in. Note writing, history taking, presenting patients, introducing yourself, signing out patients, running codes, etc. Whatever it is.
I just added more to the feedback portion to the RookieDoc Orientation Mastery Program to help you optimize your feedback – templates and scripts – exact phrases to try for yourself. You really need to form good habits now.