The Steep Learning Curve

"In a hierarchy, every employee tends to rise to his level of incompetence."
-Laurence J. Peter

This week, I have had three separate conversations with three of my fellow interns about how incompetent we all feel.  The common theme is that it's like we're not really learning anything, and that we're getting worse (or at least not getting better).  I don't think that's really true, though.  The difference is that when we started residency four months ago, we were so ignorant about the practice of emergency medicine that we didn't even know how ignorant we really were.  Now we're almost equally as ignorant as we were then, but we know it.

Our eyes have been opened to our deficiencies on many levels.  We've seen what the upper level residents can do, and we don't measure up.  We struggle to handle the entire pod of patients when we're working one-on-one with an attending overnight.  We're starting to learn how to do procedures like central lines and lumbar punctures, but we're painfully slow at it.  We're not confident enough to argue when we come up with a plan for our patients and the attending wants to do something else.  We're too early in training to have developed our own practice style, and so we wind up doing something different for patients with similar chief complaints, depending on what that specific attending wants to do. 

For example, some attendings are very cautious and will CT a lot of people, while others lean away from doing very much testing in low-risk patients. It's a fine line to balance: do we want to risk missing a ruptured brain aneurysm in the 24-year-old with a new-onset headache if we don't do a head CT?  Bleeding in the brain is a potentially lethal condition that can be treated if caught early.  Or would we rather do the head CT and risk causing that patient to have brain cancer in twenty years because of excessive radiation exposure?  Not to mention that the cost of CT scanning every patient with a headache is prohibitive.  Or that every bed kept full with a non-sick patient who doesn't really need to be there means that a potentially sick patient is kept sitting out in the waiting room because no bed is available.

I don't have a good solution to this problem, and I suspect that the reason there is so much variation in attending practice is because they don't have a good answer for it, either.  Once again, we arrive at the conclusion that much of what we do in medicine is not based on good evidence.  Since I have too little experience to even rely on clinical acumen, it makes the judgment call next to impossible for me.  The daily struggle with this problem is yet one more thing that I was ignorant about before I started residency, and being aware of it now makes me feel even more incompetent as a physician.

Driving Myself Crazy

"I had to stop driving my car for a while....the tires got dizzy."
-Steven Wright

Warning: this post is a rant wherein I feel sorry for myself.  So if you don't want to read a pity party rant, you should stop reading now.

I'm halfway through with the Milford community site rotation, and it has stopped being fun.  Well, not the rotation itself; I still like working in the ED.  I'm talking about the 45 minute commute I have to make before and after each shift.  The end-of-shift commute is the worst part, because the last thing I feel like doing after an exhausting day in the ED is making the 25 mile drive back to Worcester.  If it's a day shift, I get back to the Worcester area just in time to hit rush hour traffic.  If it's a night shift, I'm driving home down an unlit highway in the middle of rural Massachusetts where I can't see anything outside the range of my headlights.  Sometimes, if I'm really lucky, it starts pouring so hard that I can't even see where the exit is, or someone almost runs me off the road.  (Each of those things has happened to me once so far.)  It could be worse, I guess.  At least I haven't had to drive through a blizzard....yet.

But what really has added to my misery is that my schedule is now moving backward (getting earlier and earlier) instead of forward (getting later and later).  Usually our shifts are scheduled so that we do days, followed by evenings, followed by overnights, and then back to days.  The rationale is that it's a lot easier for your body to adjust to staying up later than it is to try to go to bed earlier and get up earlier.

Well, on this rotation, the shifts have been scheduled backward for the person who is working the weekend (me) so that the person who has the weekend off (one of the second year residents) can get out earlier on Friday before his weekend off.  But that means I go from working evenings this week (4PM-midnight), to working afternoons this weekend (noon-10PM), to working days starting on Monday (8AM-4PM).  Since our weekend shifts are ten hours instead of eights like the weekday shifts are, I'll get done around 10 or 10:30 PM tomorrow night, drive home, get about six hours of sleep, and drive back out to Milford early Monday morning.

The fact that I will be the one having Friday evening off next week right before my weekend off doesn't make me feel better about being on this schedule now.  At the same time, it's not just the schedule itself that's bothering me.  I'm annoyed with myself, too, because I know I'm making a bigger deal out of it than I should be.  I mean, some people drive this far to work all the time, day in and day out.  (I have no idea how they stand doing it.)  Plus, it's just one weekend.  My other work weekend at Milford will be followed by a string of overnights at UMass, which means that my schedule will be moving forward again, the way it's supposed to be.

Even so, I'm still upset about it.  And being this cranky about something that really isn't that big of a deal in the whole scheme of things tells me something about how sleep-deprived I probably am.  On that note, I'm going to bed so that I can make that drive again tomorrow.  Sigh....

Milford

 "It's rural America.  It's where I came from.  We always refer to ourselves as real America.  Rural America, real America, real, real America."
-Dan Quayle

I came into residency knowing that I was going to do a fellowship and go into academic EM, so I was not especially excited about being required to do two months of community EM.  The more that people kept talking about how great it would be for me to get to see "bread and butter" emergency medicine, the less excited I felt about it.  I don't like butter.  Never have.  Never will.

Well, I do like bread, and I do like working at Milford.  Nearly all of the attendings there are UMass grads, so they're familiar with our program and make great mentors.  They advised me to focus on seeing the types of patients I feel least comfortable with.  That means I have been focusing on eye complaints, peds and ortho since those are some of my weakest points. I've seen a bunch of patients with broken bones and helped with reductions. I saw a kid with scarlet fever, including the sandpaper rash and strawberry tongue. I saw a cool tox case. I've gotten to do some procedures and resuscitations.

There are other good things about working at Milford too.  One is that the shifts are mostly only eight hours instead of ten, and cleanup doesn't take as long at the end of the shift. I'm usually only running over the end of my shift by a half hour tops.  Another is that they give us a bunch of coupons for free meals, and we even have time during shifts to go down to the cafeteria and get food.  Plus, we don't have to discharge patients ourselves like we do at UMass; at Milford, the nurses do it.  But the best part is that I'm the only resident there during my shifts, and I can cherry pick which patients I want to see.  So, no pelvic exams for me this month! The only thing I don't like about this rotation so far is having to drive there and back every day. It's going to be an expensive gas month. 

One other thing about the town of Milford is that so many of the people there are native to this area of the country.  So I get plenty of people asking me where I'm from, even though MY English is accent-less.  My English is so accent-less, as a matter of fact, that I have to make an effort to control myself every time I hear someone speaking with a strong Masshole accent.  To a non-New Englander like me, that accent sounds too funny to be real.  It's funny to the point that I have been known to strike up conversations with random strangers on purpose, just so I can hear them talk.  It's not only the way they talk, either.  There is a sign on one of the printer paper trays in the Milford hospital ED that says, "Please close the draw gently." That is exactly how the locals pronounce the word "drawer."  No one to whom I have pointed out this phonetic spelling had ever noticed, and I still have no idea if it was done on purpose or not.  But it's wicked funny.