PGY 39, Day # 366

PGY 39, Day # 366

Back in the SICU again

This is my transitional week; my last week of ICU duty for PGY 39, and the start of my first week of duty for PGY 40. That means we have the short timers now and newbies to start on July 1 ... house staff that is.  In other words, the more experienced interns and residents will move up a notch, while the interns move in.  This transition is always exciting

A few observations/thoughts/teaching points from rounds  ... these reflect my collective experience ... not just this week's events.

1. Monster Healthcare Organizations (as well as other corporations and governments) generate momentum and inertia that is dependent upon size and responsiveness. Like Giant Ships (eg. Titanic) they have a tendency to "stay the course" for many reasons, not the least of which is the failure to have accurate "sensors" in and on the front lines and they lack facility to change direction. In other words, they loose their sensitivity to the people they are serving and the servers (providers), get preoccupied with and distracted by things that are essentially phobias, impose top down "solutions" to non problems, increase burdens on front line providers, interfere with quality front line care and, basically, miss the mark on many opportunities to improve care quality and outcome.  Basically, they lack the ability to move smart and fast.  Electronic Medical Records are a perfect example of new technology that was imposed top down without proof of effectiveness and safety.  This technology consumes between 25% and 50% of front line provider time, and that takes away from patient care time.  Scribes can eliminate the time wasted on computers, but the safety and effectiveness of first generation EMRs is yet to be determined.  My bet is that drastic changes in form and function will be mandated in the near future.

2. Benchmark Quality "Standards", lower the quality of care, by justifying mainstream levels of performance. In other words, mainstream performance becomes a standard by default. This is dangerous in healthcare, where optimal performance and outcome is always the goal and mainstream performance may well be substandard. Disinguishing comparative benchmarks from true quailty measures is a serious problem that can only be addressed through solid scientific research.  This research should take the form of Continuous Quality and Performance Improvement measures that review 100% of care provided and examine the impact (outcome) of changes in practice, new techniques and technology.  The goal is to optimize patient care constantly and to raise the bar continuously.  That is the only way to provide the best possible patient care at all times.

3. Causes of vascular injury in trauma

4. Need for and Implementation of Continuous Quality and Performance Improvement Process to Measure Outcome: Provider Role

5. Need for Advanced Directives to prevent unnecessary and inappropriate care

6. Comparison of Morphine and Hydromorphone, cost, effectiveness, dose, side effects

7. Arterial and Venous Gas Embolism

8. Brain and Spinal Cord Protection Strategies

9. Nosocomial Pneumonia, Colonization, Transmission and other assorted issues related to Ventilator Associated Pneumonias and Hospital Acquired Pneumonias

10. Targeted Strategies for Patient Care and Organ Preservation in the ICU

As I was about to leave the hospital tonight, during a conversation after evening rounds with my night coverage resident ... one of the more experienced and competent residents on service ... about patient care and teaching, and the fact that this is "a labor of Love", and stating, "It is a good thing I love what I do."  We both laughed about the difficulties encountered in teaching and providing services, and I think he got the point that I reiterate on a regular basis. Specifically, "there is not enought money in the world to make this right."

I have to give it up now, and try to get some sleep.  On call, but the coverage tonight is solid, and tomorrow will be a Long Day! 

PGY 40, Day 1 meets PGY 1, Day 1!  LOL ... we will see how that goes.

Love to all!

"Love is the Power, Care is the Mission, Safety and Optimal Care are the Goals and The Hippocratic Oath is our Guide."

You can quote me on that.

Dr. Mike

Life is Love™©

StepWisely®™©

The Art of Medicine

April 7, 2012

PGY 39, Day 282

Some Preliminary and Recurrent Thoughts on The Art of Medicine

To MASTER the Art of Medicine, the Physician must learn to combine the best available science with love of People, Humanity, Life and each Patient in such a way as to do what is best for each and every patient at all times.  To protect these most vulnerable of our population in time of need is to “do no harm” and to “do the right thing” at all times, as a matter of professional obligation.  These fundamental operating principles are based upon long standing Medical traditions, embodied in the ancient “Oath of Hippocrates” and cemented in our minds upon graduation from medical school, at which time most, if not all of us had “taken” that Oath, in one form or another.  These fundamental rules have been passed down from generation to generation, because they work for our Profession, the Doctor and the Patient.  I take that Oath seriously.

 It is said that it takes 10,000 hours to become a MASTER craftsman, and it certainly takes years of experience beyond medical school and post graduate training, to gain Mastery in Medicine.  After this, the MASTER PHYSICIAN should be well prepared to put his or her talents to work for the OPTIMAL benefit of EACH PATIENT BEING SERVED.  Easily said, but not so easily done … and as time goes on, it is harder and harder to SERVE PATIENTS as we are trained and obliged to do.  Why?  Third party interference and the Business of Medicine make it increasingly difficult and sometimes impossible for Physicians to meet Professional Obligations.  In other words, to put it bluntly, The Profession of Medicine, The Art of Medicine, The Practice of Medicine and The Doctor Patient Relationship have all been hijacked by the Business of Medicine to increase profits and/or “cut costs”.  Thus, each Physician’s professional obligation to carry out the Oath is often in conflict with the third party driving forces in the American Medicine Marketplace we know today. 
To be continued ...

Have a great day!
Dr. Mike