Like what you read? Want more?

May I kindly direct you to some of my more formal (read: edited) work through the Society of General Internal Medicine (SGIM) Forum.  My articles appear in October & November of 2009, February, May & June 2010.

Prescient Dreams

While the clinic day officially ends at 5:30 (or 6 or 7), it is not quite as easy to let go of the day.  A mix of feelings follow me home, anxiety, hope, frustration, concern and sometimes good old fashion curiousity.  Most recently, I saw a wonderful gentleman who reported that he was feeling vaguely unwell, but similar to a time when he had a blood & heart valve infection in the past.  He looked well, so we drew appropriate bloodwork (probably more extensive than normal given his history) and sent him home.  But apparently my mind did not. 

That night, I was plagued by a recurring dream of a heart, isolated from the body, floating in space.  (Disclaimer, I have recently been playing Super Mario Galaxy 2 which features many isolated planets, floating in space).  Anyway, in this dream, one of the valves was clearly off/infected, and was the focus of my attention.  I awoke several times feeling uneasy, unable to shake the dream. 

The next morning, after this poor night of sleep, I received an early morning page that the patient did indeed have positive blood cultures, and after admitting him to the hospital, a formal diagnosis of endocarditis It seems my brain was working overtime, trying to warn me of the obvious. Medical residents, working even as we sleep... work hours violation?

The Most Poetic Description of Clinic I Have Ever Heard...

From Ben Chesuk & Eric Holmboe's How Teams Work- Or Don't- In Primary Care: A Field Study On Internal Medicine Practices, Appearing in Health Affairs, May 2010.

"The physicians we observed experienced a workday as a series of nonstop, one-on-one interactions with a
stream of patients, with little or no interaction with others on the team. Physicians at all three practices worked within a bubble of frantic activity, right from the start." 

That's about right. 

Incompetent or Evil?

Often times in residency I have had the experience of being the recipient of a patient from another care team.  Outside or inside hospital transfer, Emergency Room sign out, ICU admission for worsening status.  A common sentiment amongst my colleagues on the medical and nursing side, is that patients are never quite as billed, usually sicker/more complex.  Now, I acknowledge the inherent bias in being on the receiving end--simple/non-ill patients are rarely transferred.  We only see the tough cases, and that is one of the benefits of being a tertiary referral center. 

But that is not my focus here.  When a transferring team sends us information ahead of a patient that does not match the patient's history (allowing for reasonable status changes in transit), the failure lies along an axis that runs between incompetent and evil.  On the one hand, maybe they are overworked, poor systemic support, just came on shift, have a different perspective or information, have not had a chance to look at the whole picture, etc.  On the other hand, maybe they just want a difficult (medically or socially) patient transferred quickly, no questions asked and will say or do whatever is necessary within reason to accomplish the transfer. 

Incompetent or Evil, that is the axis.  I would also argue that lazy is on that axis, right about at the center of it.  A little incompetent, a little evil, but the wrong information story told no matter the reason.

Glad to be done with night float...