Saturday, December 02, 2006

New Attending

My new attending for the month started off well. Tall, soft-spoken, I'll call him Dr. C for "Castilian"--I think he may be Spanish. He didn't place a lot of demands on the students at our meeting--he even said we could choose to write H&P's. We're finally allowed to do long and short call--every other call, I get to go home in the afternoon. He made an arrangement with the residents to come to the hospital at 5 pm on call days, to round on the earliest-arriving newly admitted patients. It all sounded well and good. He's new to our school and this hospital, but has worked in our hospital district before.

Today, we were post-call. I woke up at 0430 so I could get to work by 0530 to round at 0630. At 0445, the other student paged me to say that the attending had changed his mind--we wouldn't round until 0730, and the other half of the team would go first. I got a wee bit more sleep, finished my H&P (I only had one new patient), and got to the hospital by 0700. Between vitals, seeing patients, and writing my note, I was ready to go by about 0800.

The rot set in by 0930 when we still hadn't begun to round--Dr. C was still with the other half of the team. We finally began around 1000. For some reason, Dr. C insisted on seeing the patients he'd already seen the evening before, as if he'd never seen them before. What, then, was the point of him spending so much time there the evening before? He also started ordering multiple tests on patients that were maybe not so necessary (like a D-dimer on a patient with chronic chest pain, most likely related to GERD). One of my patients had a cough and a fever, with sputum production and some hemoptysis. His CXR showed an upper lobe process. My diagnosis? Pneumonia. My attending, for some reason, started worrying about fungus balls, and ordered a stat CT of the chest. What did the CT show? "Ground-glass opacity in the upper lobe"--the radiology resident told me "if he clinically has pneumonia, then he has pneumonia, honey". This CT gave us absolutely nothing that would help us. The patient wasn't severely ill, he's responded well to antibiotics overnight, he's not requiring oxygen--did we really need to start chasing zebras? I was finally dismissed by one of the interns at 1400 (well past the 30 hour rule for the rest of the team--at least I'd gotten some sleep).

I'll make the "I'm lazy" argument--I don't like chasing tons of labs. I'll make the "primum non nocere" argument--every test has risks to the patient; nothing is totally benign. I'll make the statistics argument--every test could be falsely positive or negative. My old attending, Dr. H, railed at us about "pre-test probability"--clinically, how likely is it that the test will be +/-, and then order those tests which will change your therapy. Now, I know why he harped on us about this.

Another thing. If a residency group is going to enforce the 80 hour week/30 hour shift rules, the attending should take care not to round for so long that 30 hours comes and goes while the team is still rounding. If you get there at 0600 on call, then you *should* be leaving by noon the next day. We should not be rounding until 1400. This is how residency programs get in trouble (when this stuff happens all the time--let's hope this was a one-time thing).

Damn, now I miss Dr. H. Sure, I was terrified of him, but he used rounds to direct patient therapy and to teach. Rounds today had no purpose; we did a lot of sitting while the attending wrote lengthy notes on each patient, then asked every patient if they had any breast masses and when their last breast exam was (even the men). I realize his specialty is heme/onc, but still. Another Dr. H-ism holding true: "Pick your specialty and you'll pick your disease."

Between the agonizing long rounds (until 1400 on a post-call day) and my new, disorganized, slow intern, it's going to be a pitiful 2 weeks.

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