Another week come and almost gone, and while I feel I have had made some strides, I can't help but leave the hospital each day feeling frustrated and somewhat powerless to help. A large range of issues: operational, organizational, knowledge, skill, ego and political, all seem to combine in quietly smoldering ways. And you better believe that if patients here had any power to advocate, speak up or question, that these issues would be explosive, leading to patient relations calls and lawsuits, in addition to the deaths they can already be associated with.
A broken machine in the lab, leading to a delay in blood test results, then delays the order for subsequent imaging, which is delayed by the fact that the actual order for that imaging is on paper and it perhaps makes it (or doesn't make it) down to radiology, and when this test actually gets done, it may not be read until the next day, or even later, whenever the radiologist feels like filing the report. Apparently, I've also learned, if I am viewing the CT images on a computer on the ward, the radiologist is not able to also look through those images AND file the report at the same time. The skill of the radiologist in interpreting this wide range of images (MRI, CT, ultrasound, xray) is also unreliable. There is no radiology residency in Rwanda, they must all go abroad and come back, and there is certainly no further fellowships or specializing, they are expected to read all types of imaging. Is having the only MRI scanner in the country really that good, if the reads on those results cannot always be trusted? All of these delays lead to periods of diagnostic uncertainty, which are longer than you'd really want them to be. These are periods of time, sometimes weeks, where a patient may just sit around and wait for us to figure it out, without any further interventions. In that period of time, they may remain stable, or they may crump.
Do we owe it to our current patient, who was admitted on September 14th, with a still as of yet undetermined malignancy, to stop chasing the diagnosis (is it lung cancer or liver cancer or a germ cell tumor or a GI cancer), to stop accusing other consultants of not having done a good job ("Well, maybe they didn't really do the bronchoscopy well, maybe we should do it again"), to stop questioning the MRI scan read, now that he's so sick and we're not going to give him chemotherapy anyway, to stop letting him lay there in bed encephalopathic and altered, and just give him some freakin' morphine and let him be comfort care?! We certainly do! But this morning the attending insisted we had to wait to talk about him at case conference tomorrow, before we completely stop looking. This was despite the fact that I told the attending about the end of life discussion I already had with the family the previous evening, which seemed very reasonable to me and the other residents, to which the family were completely understanding of and wanted to proceed with. This evening, although the patient's kidneys are shutting down, my co-resident did not feel comfortable calling the attending to change the plan, because he worried the attending would be upset that we won't get to talk about him tomorrow, and won't ever reach a diagnosis. There is no room for this kind of egos in medicine. I almost feel as if having some of these diagnostic tools available to us here, has the power to make things worse, when managed poorly or unreliably.
At least our Congolese lady with the massive ascites, still as of yet of unknown origin (don't even get me started), who has been in the hospital for two weeks, is otherwise stable and quite happy, waddling with her huge stomach and she walks down the hall to the bathroom each day. And we've had fun with paracenteses with her too. Every morning we greet each other with the tiny bit of Swahili I still remember. Habari! Nzuri!
I've made some strides though. I've finally pulled the interns and residents out of their shells. They actually speak up and talk when I ask them a question, and ask me questions and ask for guidance. I've gotten the interns to take on more responsibility. They are now writing full progress notes, as opposed to the residents scrawling down some quick plan for the day, as dictated by the attending at the bedside during rounds. I've gotten the interns to take initiative and be the first person to present each patient case, as opposed to them turning to their resident to do it. I've practiced presentation skills with the interns, helping them to synthesize the patient's story, and the data. It was beautiful, this morning, the intern who never used to speak, stood up at the head of the bed, took out his notebook with all the notes written down as I had suggested, opened up his mouth to begin his presentation and.....SHOT DOWN!!! The attending cut him off and said, "So what's the diagnosis?!!" This was before he picked up his ringing cellphone mid-intern's answer to the question, so that he could then say he was heading off to his clinic, and we could finish rounds with a different attending, whose decisions he later disagrees with and tells us not to proceed with.
Come onnnnn, really?!!!!!! How can I instill good habits for future learning and floor team functioning, if the attendings undermine it? How can you attend on the wards and then leave mid rounds, and then have such a big ego as to undermine the clinical decisions of another attending you asked to help you out?
I don't mean to make all the attendings sound bad. Some of them are really fabulous teachers, and some of them would have gladly and carefully listened to the intern's presentation. Some of the attendings have pushed me to the far boundaries of my retained knowledge. What I once knew cold before my anatomy exam during my first year of medical school (seven years ago), is no longer in my daily, working knowledge bank. Yesterday, we spent 1.5 hours discussing the neurological exam at the bedside, and only got through about 1/3 of it. It was as much a basic anatomy review as it was a practical review of physical exam skills. It's humbling, as medicine often is. Old school teaching like that doesn't happen as often at home anymore.
My knowledge has also been pushed to grow by the demand for my teaching. These students and residents are so eager to drink it all up. You have a lecture about diabetes?!! We want to hear it. You can tell us about liver failure?! Bring it on. You have an EKG lecture? We'll sit here for a third lecture. Who cares about lunch, we want to learn. I guarantee you, if you put a bunch of Yale residents in a room with an attending who is lecturing, extending into lunchtime without a chance to actually go and get lunch, you'll have lots of impatient glances at watches. I packed the room while talking about EKGs today. And I think because of that, I actually know them better than I did before.
Tomorrow is my last day at this hospital, and next week I'm moving onto the next one, where I will be for four weeks. There was more than one complaint from the residents today about why I can't stay an extra week at this one. That too was humbling. I think they like having me around.
A broken machine in the lab, leading to a delay in blood test results, then delays the order for subsequent imaging, which is delayed by the fact that the actual order for that imaging is on paper and it perhaps makes it (or doesn't make it) down to radiology, and when this test actually gets done, it may not be read until the next day, or even later, whenever the radiologist feels like filing the report. Apparently, I've also learned, if I am viewing the CT images on a computer on the ward, the radiologist is not able to also look through those images AND file the report at the same time. The skill of the radiologist in interpreting this wide range of images (MRI, CT, ultrasound, xray) is also unreliable. There is no radiology residency in Rwanda, they must all go abroad and come back, and there is certainly no further fellowships or specializing, they are expected to read all types of imaging. Is having the only MRI scanner in the country really that good, if the reads on those results cannot always be trusted? All of these delays lead to periods of diagnostic uncertainty, which are longer than you'd really want them to be. These are periods of time, sometimes weeks, where a patient may just sit around and wait for us to figure it out, without any further interventions. In that period of time, they may remain stable, or they may crump.
Do we owe it to our current patient, who was admitted on September 14th, with a still as of yet undetermined malignancy, to stop chasing the diagnosis (is it lung cancer or liver cancer or a germ cell tumor or a GI cancer), to stop accusing other consultants of not having done a good job ("Well, maybe they didn't really do the bronchoscopy well, maybe we should do it again"), to stop questioning the MRI scan read, now that he's so sick and we're not going to give him chemotherapy anyway, to stop letting him lay there in bed encephalopathic and altered, and just give him some freakin' morphine and let him be comfort care?! We certainly do! But this morning the attending insisted we had to wait to talk about him at case conference tomorrow, before we completely stop looking. This was despite the fact that I told the attending about the end of life discussion I already had with the family the previous evening, which seemed very reasonable to me and the other residents, to which the family were completely understanding of and wanted to proceed with. This evening, although the patient's kidneys are shutting down, my co-resident did not feel comfortable calling the attending to change the plan, because he worried the attending would be upset that we won't get to talk about him tomorrow, and won't ever reach a diagnosis. There is no room for this kind of egos in medicine. I almost feel as if having some of these diagnostic tools available to us here, has the power to make things worse, when managed poorly or unreliably.
At least our Congolese lady with the massive ascites, still as of yet of unknown origin (don't even get me started), who has been in the hospital for two weeks, is otherwise stable and quite happy, waddling with her huge stomach and she walks down the hall to the bathroom each day. And we've had fun with paracenteses with her too. Every morning we greet each other with the tiny bit of Swahili I still remember. Habari! Nzuri!
I've made some strides though. I've finally pulled the interns and residents out of their shells. They actually speak up and talk when I ask them a question, and ask me questions and ask for guidance. I've gotten the interns to take on more responsibility. They are now writing full progress notes, as opposed to the residents scrawling down some quick plan for the day, as dictated by the attending at the bedside during rounds. I've gotten the interns to take initiative and be the first person to present each patient case, as opposed to them turning to their resident to do it. I've practiced presentation skills with the interns, helping them to synthesize the patient's story, and the data. It was beautiful, this morning, the intern who never used to speak, stood up at the head of the bed, took out his notebook with all the notes written down as I had suggested, opened up his mouth to begin his presentation and.....SHOT DOWN!!! The attending cut him off and said, "So what's the diagnosis?!!" This was before he picked up his ringing cellphone mid-intern's answer to the question, so that he could then say he was heading off to his clinic, and we could finish rounds with a different attending, whose decisions he later disagrees with and tells us not to proceed with.
Come onnnnn, really?!!!!!! How can I instill good habits for future learning and floor team functioning, if the attendings undermine it? How can you attend on the wards and then leave mid rounds, and then have such a big ego as to undermine the clinical decisions of another attending you asked to help you out?
I don't mean to make all the attendings sound bad. Some of them are really fabulous teachers, and some of them would have gladly and carefully listened to the intern's presentation. Some of the attendings have pushed me to the far boundaries of my retained knowledge. What I once knew cold before my anatomy exam during my first year of medical school (seven years ago), is no longer in my daily, working knowledge bank. Yesterday, we spent 1.5 hours discussing the neurological exam at the bedside, and only got through about 1/3 of it. It was as much a basic anatomy review as it was a practical review of physical exam skills. It's humbling, as medicine often is. Old school teaching like that doesn't happen as often at home anymore.
My knowledge has also been pushed to grow by the demand for my teaching. These students and residents are so eager to drink it all up. You have a lecture about diabetes?!! We want to hear it. You can tell us about liver failure?! Bring it on. You have an EKG lecture? We'll sit here for a third lecture. Who cares about lunch, we want to learn. I guarantee you, if you put a bunch of Yale residents in a room with an attending who is lecturing, extending into lunchtime without a chance to actually go and get lunch, you'll have lots of impatient glances at watches. I packed the room while talking about EKGs today. And I think because of that, I actually know them better than I did before.
Tomorrow is my last day at this hospital, and next week I'm moving onto the next one, where I will be for four weeks. There was more than one complaint from the residents today about why I can't stay an extra week at this one. That too was humbling. I think they like having me around.
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