Sunday, November 9, 2014

Into the Burning Building

I am starting this piece 48 hours before beginning my new career as an inpatient Neuro Hospitalist at our 700 bed hospital. On one hand I am as excited as a kid heading to camp, on the other, as nervous as a fireman ordered into a burning building. Everything I have done professionally to this point has not only prepared me to possibly succeed. but in retrospect has been a clear pathway to what I assume will be my swan song. Several years ago I signed up to tutor a few courses for the preclinical medical students at the local med school . The decision to teach was supposed to be a logical segue into full retirement, but here I am, driving to work in combat boots (recently purchased for the event), ready for the front lines of battle in a level one trauma center.

A confluence of factors has brought me here. The first factor was 'need'. Currently there is only one neurologist at the hospital during the day, slugging it out, heroically doing all the work, seeing up to ten new sick patients a day and continuing to follow them through their stay. The Hospital has unsuccessfully spent a year trying to hire a second full time neurologist. Allocating 60 to 90 minutes to each new patient, this one neurologist has been understandably overwhelmed.

The second factor was my experience teaching at the local medical school. These young doctors-to-be simply do not know how to examine a patient in an acceptable manner, resulting in an inability on their part to determine if the patients are sick, 'why' they are sick and, most importantly, 'how' seriously sick. This disturbing fact is a national epidemic colorfully commented upon by the Stanford University Professor of Internal Medicine and writer (Cutting for Stone), Abraham Verghese, both in print and as a periodic contributor on public radio. Our local medical students are no exception. Ironically the primary reason for this lack of proper training is advancements in medical technology, most particularly diagnostic imaging, which has greatly improved our ability to evaluate patient problems since my days of training, and I am very happy it has. A physician can now frequently (not always) get away with assessing the medical problem merely by ordering an large number of imaging studies and later checking the results. But there are many instances where an intelligent and well trained hands-on  assessment will quickly lead to a more accurate assessment with no radiation exposure and with considerable less expense.

The third factor occurred when I applied for and was hired as the second inpatient Neuro Hospitalist allowing me  to see and follow a finite number of sick inpatients each day with two third year medical students. Now every single student will have the opportunity to see a dozen or so patients, complete a comprehensive physical and neuro exam under my direct supervision with no time constraints.

It is my view we are in the midst of a national cultural war on how to most accurately and cost effectively assess a patient. Though no one in an official capacity likely ever claims to forgo a detailed physical exam, somehow this time honored medical tradition has become a lost art. The echo cardiogram with  CAT and/or MRI scans of the entire body are too often these days accepted as the new standard of care. A while ago while on call, I was asked by a cardiologist to see a patient who was repeatedly fainting. The doctor had done a heart catherization and a long EKG reading both negative. He was concerned the patient might be having some type of seizure. After doing a complete exam, I told the cardiologist the patient did not have epilepsy, but merely a profound drop in blood pressure when she stood up, as a result of one of her medications. The cardiologist thanked me, adding:

               "It is easier for me to do a heart cath than to check the blood pressure".

This incident has become for me a perfect metaphor for what is missing in preparing future generations of young physicians. I have been teaching basic science courses over the last few years to first and second year med students. Teaching these four main disciplines heart, lung, kidney and brain has been one of the more rejuvenating experiences of my life. I have learned ten times what I felt possible for a number of reasons, mostly new developments in physiology since my time in medical school and residency. Besides being highly entertaining which is obnoxiously self indulgent, I have gotten to know almost everyone of the students. I am confident when we meet in their third year, they will accept my viewpoint about the other more traditional way to practice medicine: Doing an intensely detailed and informative physical examination is the hard way, but it is the right way, and the medical students as well as their patients will be the better for it.

I have fired a few volleys in the battle for awhile, running a third year ' selective' on the twelve week internal medicine mandatory rotation and a fourth year elective, both in my office. Like trench warfare in WWI, I have gained very little significant ground. In the office there are time constraints and the patients would be somewhat uncomfortable with even one, much less two, detailed multi-system physical examinations. Also, if they walk into the office, they are not likely too sick.

Is there a down side to what I have decided to do? Yes. My neurology group, myself included, spent more than five years weaseling out of inpatient duty, negotiating with the Medical Center, and encouraging management to hire three full time neurologists to handle the overwhelming number of sick patients being referred to this tertiary hospital. We felt the pay was lousy, the intensity of the problems were exhausting  and the patient/family disappointments, if things did not go well for the patient, were psychologically draining  and occasionally threatening. Our group's view was, ''the house is burning, run for your life''.To get back on the front lines will require a new level of energy and more importantly, a touch of invincibility, which may difficult for me to summon.

So how does an old guy prepare for this undertaking. Cycling, of course which has been my salvation for decades. This time however, it will require more than just being on the bike. I'll need to take my physical intensity to a philosophical level, to something more profound and relevant, namely The Rules, a popular unofficial manifesto of bicycle racing/training etiquette, well known by most cycling aficionados. There are 80 or so, covering all aspects of the sport, including grooming, attire, tucking on downhills, holding your line etc. But the most important and most relevant from my current position is, Rule 5:
                                   "Toughen the fuck up"