[1] The Plan and Pickup

As detailed in my last post, signout is an extremely important process and is the initial and primary means of high-yield information gathering for the night shift resident. Day residents are often tired and worn out by signout time, making it difficult to execute an effective delivery of all of the important details that a night shift resident covering all of the patients requires. Accordingly, it is the night shift resident’s job to ask the important questions when important information is left unsaid.

Of the many details that are valuable, I find that there is special significance in the day team’s plan of action for the patient. The night shift resident’s job is sometimes viewed as a “float” position where one simply tides the patients over until the next morning when active patient care can continue; the job in that case is very passive and only activated in reaction to new developments. Sometimes the team’s plan for the patient is glossed over during a signout process or even omitted. However, the night shift resident covers half of the twenty-four hour day, and much can be done during that time (albeit in smaller, discrete measures, given that the night shift resident is covering a much larger patient census). Sometimes medication titrations started during the day (e.g. for blood pressure control or diuresis) can be continued during the night. Sometimes a new therapy or plan started during the day shift might result in a less desirable outcome, requiring that it be reverted back to the original regimen during the night shift.

Inevitably, small details of care are omitted from signouts, whether intentionally or unintentionally. Nonetheless, the night shift resident can assess the team’s plan and pick up where they left off by following up on ordered studies, touching base with collaborating services or nurses, etc.

[2] The Preemptive Measures

Anticipation is a valuable skill. Being able to predict needs and requests can save valuable time. For example, at my current hospital, the order set for cardiac telemetry does not include a system to indicate whether or not the patient can leave the hospital floor without telemetry when being transferred to another part of the hospital for testing (e.g. Radiology). Residents have to manually type in a text order to give the nurses permission to release patients to the transport team. Accordingly, whenever I start my night shift, I look to see which patients are scheduled for overnight tests, determine whether it is reasonable for them to be off cardiac telemetry monitoring for a period of time, and then indicate such in the ordering system. Placing a few orders and touching base with nurses early in the shift helps prevent the potential slowing down of care delivery when one is dealing with multiple consults, admissions, codes and triggers, and other unpredictable developments.

[3] The PM Rounds

For me, there is great value in laying eyes on each patient. Unfortunately, the 8PM start time for my night shift is past the bedtime for many patients, so they are hidden behind curtains in dark rooms. Nonetheless, I make a concerted effort to locate all patients and mentally store an image of where patients are and what they look like (if I can see them). That way if something happens later requiring me to rush to the bedside, I know exactly where to find each patient. I try to lay eyes on the patients whose clinical statuses are more likely to change, and I examine the patients who are quite sick and are already changing in stability. With regards to examinations, I find that it is important to think about the patient’s pathology, their baseline examination, and the likely changes that one might see with the most likely complications. For example, a patient with a large cerebellar hemorrhage might develop brainstem abnormalities or depressed level of consciousness on examination, so that’s what I would look for as an indicator of worsening clinical status and a trigger for intervention.

[4] The Face Time

The geography of my night is unfortunately split between three locations: three floors in three different buildings, separated by a series of bridges and elevators. Furthermore, the Neurology floor is on the top floor of one building and the Emergency Department is on the bottom floor of another. Accordingly, I find it useful to split up my night into segments where I can minimize my migration from one section to another. Generally, I spend the first four to five hours of my twelve hour shift on the floor where most of my department’s patients are located. This is the start of the nursing shift as well, so there is more activity, more requests, and fresh pairs of eyes reviewing the orders and the patients themselves. The night shift is the best time to get to know the nurses in a hospital with regional admissions: there’s only one doctor on the floor, and that’s me! During those first few hours, I can be a useful resource to the nurses, both by providing some insight conveyed by the physician teams and by helping to facilitate the care ideas generated by the night nurses. Putting in this face time early in the rotation is quite valuable, too, because one develops relationships of trust with the nurses and can better triage requests and nurse assessments when brought to one’s attention later. After the floor patients quiet down, I usually migrate down to the call room which is closer to the Emergency Department where I can more easily set up camp, eat and drink, write notes, and run to either the floor or the ED as needed.

[5] The Quiet Place

Although the hospital is quieter at night (literally), there is still a cacophony of telemetry beeps, yelling and moaning patients, and chatter. A large part of a physician’s job is documentation, and writing well requires mental focus. For me, I can generate clinical documents much faster if I can find a quiet place, be this the call room, a quiet hallway, or an empty conference room. Finding a quiet space and making it a frequent stop during the night shift can help improve efficiency when the admission and consult notes start piling up. Some people prefer to work to music, so finding a room with a computer where one can play Pandora or an iPhone/Android on speaker can help facilitate the written work that needs to be done.

[6] The Energy Food

Shifting to the night schedule can screw up one’s gastrointestinal clock. I eat breakfast and dinner at the usual times, but I have switched lunch to a post-midnight meal so that I don’t have to wake up in the middle of my daytime nap to maintain my calorie intake. However, despite changing over to the night schedule with my meals, my stomach continues to growl constantly and loudly between 4AM and 7AM, or until whenever I can next eat.

The most important thing with regards to food and drink is to keep up one’s energy levels and hydration. As an on-call intern, I spent my on-call budget on a cache of Life Waters; I would keep four or five bottles in one of the physician conference rooms, and then I would down one bottle at a time to stay hydrated throughout the night. Now, as a night shift Neurology resident wandering between different floors and buildings, I keep close tabs on the water machines and on my supply of food (whether in my bag, locker, or the conference room fridge) so that I can snack throughout the night and stave off hunger and dehydration. Everyone has different preferences for on-call food: make it tasty and energizing!

[7] The Rally

Inevitably, fatigue ensues. With fatigue comes a loss of willpower and the onset of complacency. When the hours wear on and one is nearing the end of the shift (particularly in the 4-8 AM hours), it is important to buckle down and push through. Stretch, snack, or take a quick power nap to reenergize and refocus. The end is near: race to the finish!

Hopefully, these tips will be useful to those who will be doing the night shift, which is to say, virtually all residents now that the 16 hour work day restrictions have come into effect for interns. However, don’t be a night float and just muddle through through the night. Be a night rider!

Do you have other tips or strategies for surviving and adapting to the night shift? Please post your comments and suggestions below.

What is a signout or pass off?

By its nature, it is:
[1] A temporary yielding of responsibility for a patient’s care to another physician.
[2] A process by which one prepares the covering physician to perform at maximum capacity as if he or she were the primary physician directing the care of one’s patient.

These two aspects of the signout are essential and intertwined; one cannot exist without the other. Some residents eagerly throw the responsibility for their patients at a fellow resident without adequately preparing them for anticipated or potential overnight complications. On the other hand, some residents overprepare their night shift colleagues, poring over every lab value and detail, while also signing in from their home computers to update electronic signouts and notes. The best strategy is to find the right balance of information transfer and a secure handing over of patient care responsibility.

Granted, it takes two to tango: signout requires both an effective transmitter of information and an actively engaged recipient. The person receiving the signout needs to know what questions to ask and needs to know when to jump in regarding a clarification or to keep things on track when the other resident starts to lose steam and digress.

What are the essential elements of the signout?

While some residency programs and hospitals are trying to standardize signout processes and even study their efficacy, the current process lacks standardization across programs and hospitals. Nonetheless, a few key details form the backbone of a solid signout. Signout can take a long time and is often interrupted by pages and requests, so the most important information that requires verbal transmission must be shared first.

[1] The Red Highlighter – “Which patients are the sickest? Which patients are changing in condition?”

Identifying the sickest patients alerts the on-call resident to the patients who need to be re-evaluated more frequently or who are most likely to have complications or changes in condition overnight. This helps the resident prioritize his or her time and also potentially evaluate these patients early during the shift so that reevaluations later can be compared to a baseline examination.

[2] The Code Status – “Which patients are DNR/DNI? Are any patients CMO?”

Night shifts in particular can be chaotic, and nothing is more chaotic than a Code. Accordingly, the algorithms underlying Codes are meant to provide order and structure for a situation where interventions must be rapidly delivered. However, not all of these interventions are desired by the patient, and so the Code Status must be the hand that stays the trigger finger in these cases.

Identifying patients who are “comfort measures only” and may likely pass during the shift helps the on-call resident prepare, particularly if he or she has questions regarding the cause of death (which will have to be documented and can be an ardurous process).

[3] The One-Liner – “Mr. T is a 43 year old man with a history of hypertension, coronary artery disease, and diabetes presenting with intermittent substernal chest pain for one day, most likely representing acid reflux.”

This skill is learned by medical students, but it still requires honing and perfection throughout residency and beyond. It is important to be able to convey key details of information in a compact amout of time and space. This includes age, pertinent past medical history, the presenting complaint, and the suspected diagnosis.

This is also a common area which can balloon in size and detail: the entire past medical history does not need to be conveyed, only the important aspects. Nonetheless, these details can be important, and it helps to provide some detail in a written version of the signout. For example, it helps to know the left ventricular ejection fraction for a patient with Congestive Heart Failure, that a patient with chronic renal insufficiency has a baseline creatinine of 1.6, that a patient with CAD has coronary stents, and that a patient with a prior left MCA stroke has residual right arm and face weakness.

[4] The Plan – “He is being ruled out for myocardial infarction and evaluated for other causes of chest pain.”

The “second line” following the one-liner should indicate what is being done for the patient. In particular, night shift residents are often called to the bedside to update patients and their families regarding the medical team’s plan of action because that is the time when family members are off work and can visit their loves ones in the hospital. This information also helps the night shift resident think about the direction of the patient’s care and potentially offer contributions in the form of suggested investigatory testing, additional history taking from the patient, or collecting collateral information from visiting family members. This can empower night shift residents to continue the work of the day time.

[5] The To-Do’s – “He has cardiac enzymes pending at 2000 and 0400.”

This part is a no-brainer. If there are specific tests to follow up or re-evaluations that must be done at a particular time, this should be communicated clearly and concisely. A plan of how to react to potential data points is also important here. For example, what should be done if the patient’s lungs have more crackles than before? What should be done if the patient’s blood pressure drops below a desired range?

[6] The Contingencies – “If he has recurrent chest pain, reassess, check his telemetry, and consider a repeat ECG. If his cardiac enzymes turn positive, call the Cardiology fellow and consider Heparin.”

Part of the day resident’s job is to anticipate potential problems or complications that might occur based on his or her current knowledge of the patient and the suspected disease process. This should accordingly be communicated to the night resident, and they should plan together how to react to these situations. In some places, these are called “disaster rounds” where the residents discuss worst-case scenarios and develop plans on how to deal with them.

This how-to guide should provide some structure and tips on how to make signouts systematic and effective. Signouts will continue to be a part of practicing medicine, wherever and whenever one is involved in patient care. Are there other aspects of the signout process not listed here that you believe are important to include? Has your program developed signout strategies that are particularly helpful or effective?

While tablet computers have a variety of uses for consumption by medical trainees such as reading textbooks (whether through the Kindle or iBook stores, individual apps developed by big publishers, or through interactive textbooks that are being developed) and watching instructional videos (e.g. how to perform an arterial blood gas), production of new content has major barriers. In particular, most people do not find the glass keyboard of the iPad comfortable enough to type anything longer than a short e-mail. Even for me, someone who has used computers since an early age with good manual dexterity, I find that even the iPad 2 with its faster processing speeds and reduced typing-key-to-screen delay is too cumbersome and can be a hindrance to efficiency, an achievement so rarely acquired in health care delivery settings. I have tried using text expansion and templates to speed up the process, but writing an admission or consultation note remains a chore.

[ Hypothesis ]
Accordingly, I was very excited to discover the Clam Case, a keyboard case for the iPad and iPad 2. Unlike other keyboard cases, it has a hard shell and seamless method of connecting the Bluetooth device to the iPad. I suspected that this device might succeed where others might not: in facilitating a rapid means of text input in the medical setting into a device that is built for speed and convenience.

[ Results ]
The Clam Case, as one might expect from the name, has two halves like the shell of a clam. The iPad snaps into place in the top half: two lips hold the iPad tightly into place. The top half has indentations to allow for head phones and the charger to be plugged in; recesses for the power, orientation, and volume buttons to be accessed; and a cutout for the rear camera to take pictures and video. Unlike with some other cases, the alignment is perfect. The bottom half houses the recessed keyboard, two indicator lights, and rubber bumpers on the top and on the bottom to protect the iPad screen and provide friction on the bottom to prevent sliding. The bottom half has a small USB port for charging with the cable provided (which can be plugged into the same AC adaptor as that used by the iPad). The two halves are connected by a tight hinge which feels very sturdy.

The case itself has a spectrum of orientations. When completely closed, it provides full back, front, and edge protection for the iPad as though it were a laptop. It can then be pulled opened and angled in the same way (90 to 120 degrees) as a laptop. However, it doesn’t stop there: the hinge rotates a full 180 degrees, allowing you to use the keyboard face of the bottom half as the support/stand for the device, allowing for easy access to the screen when reading at a table or watching a video. Finally, the case can be fully folded back and used as a tablet held in one hand and directed with the other.

The case does have some weight and nearly doubles the weight of the iPad. Of note, much of the weight is in the top half of the case, meaning that tilting the screen too far back while it rests on a slanted surface that the rubber grips can’t hold as well (like a lap) can cause it to topple over if one isn’t careful.

The case comes in three colors: white, black, and a limited edition aluminum/brushed metal finish.

Typing on the keyboard is surprisingly pleasing. The keyboard is notably smaller than a full-sized keyboard, but this is the same trade off one would find with a netbook of a similar size. After a few minutes, I found that I could easily touch-type the way I would with a full-sized keyboard.

The Bluetooth connection between the keyboard and iPad is one of the best features. After the initial setup, the keyboard connects to the iPad 2 automatically. Like other magnet cases, the iPad 2 activates the lock screen or turns on when the case is opened. After clicking any key on the keyboard, the keyboard emerges from its “sleep” or “suspend” mode and immediately connects to the iPad as indicated by the flashing Bluetooth symbol at the top right of the iPad screen. After a couple of seconds, the synchronization is complete, and one can start typing. As expected, the keyboard returns to a sleep mode when it has not been used for some period of time. It is possible to turn on and off the keyboard as well when one does not want to accidentally press the keys (for example, when using the case in tablet mode wherein the keys would be resting against a surface such as one’s forearm).

Lastly, the keyboard offers a number of features that would be missing from a non-keyboard case: keyboard commands (such as copying, pasting, cutting), arrow keys, easy access to numbers and letters and punctuation on the same spread, and finally special characters (such as accents).

[ Discussion and Conclusions ]
While all keyboard cases would add much needed ease of use and additional functionality to the iPad, the Clam Case appears to stand ahead of the crowd. After inserting the iPad into the case, the device and case truly feel unified. One does not need to keep plugging and unplugging the iPad from the keyboard. Many other cases have a “pasted-on” feel to the keyboard which might add extra bulk but very little form factor or protection, but the Clam Case makes one forget that this isn’t actually a traditional laptop. The landscape orientation feels much more natural for word processing than does the portrait orientation used by some other keyboards, an orientation that is better suited for stylus writing on the screen.

The convenience, utility, and form factor do come at a price, though: $150 for the iPad and iPad 2 versions. Most keyboard cases come at a price ranging in the $50 to $150 range. Nonetheless, while some balk at the idea of spending more money on an already expensive device, the money could be very well spent if the added functionality is worth it. For me, my impression thus far is that the added value of a solid keyboard for generating medical notes (in the setting of a medical record system that lacks text expansion, a medical team structure that suffers from long rounding times and frequent activities that removes one from the ward computers, and a service that has a high admission and consultation rate) is well worth this price.

We must know the essential qualities of an ideal physician. But where can we find them? Certainly not in popular culture. Physicians of the past had Marcus Welby; we have Gregory House and the fickle white coats of “Grey’s Anatomy.” But we also cannot rely on other external influences including our teachers (physicians who trained in a different era) and our patients. We must see beyond the nostalgia of our predecessors and the approval of our patients and their families to determine the true core values underlying the makings of the ideal modern physician.

[1] Excellence

The first measure of a great physician is excellence in clinical judgment: the accuracy of diagnostic methods, the thoroughness of approach, and the effectiveness of proven clinical decision-making principles. This obviously arises with the necessary prerequisites of intelligence, intellecutal curiosity, and well-developed logic and critical thinking skills. What follows, and is just as essential, is the ability to carry through the plans of action dictated by the clinical reasoning process, whether through coordination of care, the administration of pharmacotherapy, or the application of steel to the diseased body. Merely having good clinical reasoning and technical skills is not enough, however. The tireless compulsion to perform at maximum capacity is the true meaning of excellence.

However, always striving to deliver the best care possible should not be equated with ordering every test and calling every consultant. Rather, there is a careful balance between acting prudently and aggressively taking action.

[2] Compassion

A great physician enters this profession with a love for humanity. A great physician, despite the hardships of training and temptation of cynicism, never loses this love for his or her patients. Compassion is a core value of humanity as a species, and it is the primary fuel for the physician’s mission. For the modern physician, compassion represents the underlying emotional connection formed with each patient despite the bureaucracy, paperwork, and lack of time, and this connection is the fundamental basis for healing.

[3] Loyalty

The modern physician never works alone. Health care delivery, with the practice of medicine at its center, is reliant on teamwork. Loyalty means a great deal to the physician. It represents his friendship, support, and guidance of other care providers such as nurses and technicians. It represents the development of camaraderie within a specialty field among fellow residents and among physicians as a category. It represents respect for his mentors and teachers and the carrying of their messages and teachings to future generations. And it also represents the commitment to help fellow physicians see their mistakes and correct them in a supportive manner. (This last one, in particular, is incredibly important because past generations of physicians did a poor job of internal policing and correction, thus allowing the encroachment of outside parties who inevitably tend toward seeking punishment for mistakes instead of re-education or reform.)

[4] Fortitude

While our forebears wax poetic about the hardships of their storied early careers, it is important to understand that these comparisons are as based in reality as the practice of phrenology. The practice of medicine is constantly evolving and introduces many new challenges while attenuating others. Whereas physicians in the past may have worked longer shifts for more continuous stretches of days, they also did not have the same burden of paperwork, the complexities of care coordination, or even the complexities of addressing the wishes and perceived needs of patients (i.e. paternalistic care is much easier to deliver, but it is not better). Nonetheless, the underlying message is valuable: the willingness to persevere against hardship is a core value for physicians, because our jobs are not easy. We cannot give up once we have picked up the mantle for our patients. This is not to say that resident physicians should not complain about abuses and injustices or strive to make improvements in their lives, but often it is necessary to hunker down and push through the barriers, shoulder to the wall.

[5] Honesty

Last but not least, the practice of honesty is a core value of the modern physician. There are numerous occasions within the lives of a young physician when she is called upon to lie, bend, or obscure the truth: when a colleague makes a mistake but she must document her findings accurately and diplomatically, when a more senior colleague or attending physician comes to a conclusion that she does not agree with, or when it is requested by a family member or senior colleague that a suspected diagnosis not be revealed to an inquisitive patient. Nonetheless, there is no way to gain the trust of one’s colleagues and one’s patients if honesty is ever compromised. A forgotten exam maneuver should never be filled in with a fabricated finding. A question regarding the possibility of cancer as a possible explanation should never be sidestepped. The foundation of integrity is trust, and trust cannot be earned without consistent demonstration of honesty. A modern physician must be all of these things.

Do you have other ideas for core virtues modern physicians should have? If so, please write back in the comments section!

Energy

As a senior at Harvard College, I took a course taught by Psychology professor Tal Ben-Shahar on the Psychology of Leadership during which a key theme was the cultivation of energy. A number of researchers in the business realm studied the habits and behaviors of high-stress/performance professionals (Olympic athletes, FBI hostage rescue operatives, trauma surgeons, etc.), and they found a unifying principle: that time is a limited resource, but energy can expand and grow. Performance failures are often attributed to the lack of time, but a significant part of the effectiveness of performance during a finite time period is related to the energy levels of the performer. This intuitively makes sense: at the end of a long work shift, every task, no matter how simple, takes longer and is more prone to error. Accordingly, improvement in performance should focus more on maintaining, growing, and effectively using one’s stores of energy and less on “time management.”

However, cultivating energy in the setting of medical residency training is very difficult. Over the past year and a half, part of my psychological programming has centered on self-preservation through protection of apparently limited energy stores. Time for sleep became more precious than ever. Forgoing social engagements for quiet nights at home became the rule. A constant reminder of the burden of fatigue played out in the form of a memory of a previous teacher’s only slightly hyperbolic experience: “After residency, I slept for three months.” A premedical advisor, a resident at the time, told me, “When you train in medicine, you can only bring one other thing with you, such as a hobby. For me, it was my marriage.” After each thirty hour or more on-call shift, my first priority was to sleep and allow my brain to heal, expecting that any deviation from this would result in worsening performance during subsequent work days and overnight shifts with accompanying demoralization.

Now, I am reevaluating this world view. I know there are physiologic bases for energy and fatigue. If nothing else, I have certainly performed enough Neurology consults for “weakness” that end up being medical evaluations for severe fatigue. There are limits to what the human body can routinely do. However, is routine the operative word? Can you change the human body’s routine to gradually require more and more energy mobilization and expenditure? Perhaps fatigue and chronic “sleep debt” are less a function of a depleted pool of energy, but rather, they represent a diminution of the means to quickly access energy stores. Am I still suffering from fatigue accummulated during my intern year, or am I “out of shape” with regards to acquiring energy? If so, what is the physiologic basis by which the body can be trained to more quickily mobilize stored energy? Can it be traced to an enzymatic process? At this time, I am managing to exercise on my elliptical machine almost every day, even if only for short bursts, yet even a fifteen minute session can keep me awake for hours in the evening working on projects and having meaningful conversations with my wife when otherwise I would sink deep into the couch and watch television.

Granted, there is a distinction between energy and willpower that I will not discuss in detail now. For the time being, my resolutions follow:

Abstract
[ ] Learn to cultivate energy
[ ] Train to mobilize energy stores

Concrete
- Exercise on the elliptical machine daily
[ ] for 7 days, [ ] for 14 days, [ ] for 1 month, [ ] for 3 months, [ ] for 6 months, [ ] for 1 year

Serenity

Many people find benefit in learning the art of meditation. It is not hard to see why this might be useful: we are constantly bombarded with information and sensory stimuli. For example, I can count seven electronic screens in the room where I am writing this entry, four of which are within my range of peripheral vision, three of which having shifting/rotating images. In addition, our interconnected world is filled with strong emotional stimuli: sensationalist news reports written to inspire a passionate response, Facebook photograph uploads of parties and weddings and gatherings that you wish you could attend, and status updates whether through social networks, e-mails, text messages, or more frequent (and incredibly inexpensive) cell phone calls. As with sleep, there is a strong desire to disconnect with the world and find a moment and place of peace.

As for me, I am terrible at meditation. Closing my eyes, counting, and other mind tricks are not enough to quiet my brain. When I wake up in the middle of the night, my mind immediately jumps to the tasks for the next day, including orders I need to place in the hospital, patients and colleagues I need to call or e-mail, and measures I need to take to make the day slightly more manageable. During intern year, I spent both my waking and asleep hours at the hospital: my dreams often involved walking the hospital corridors and running to Code Blues.

Nonetheless, I would like to find ways of calming the mind. One way I hope to do this is by rediscovering hobbies and pasttimes and exploring new ones. One disheartening development related to medical school and residency training was the loss of hobbies, including music and sports. And yet, a great deal of the benefit of these activities is the switching of focus from agitated and worrisome thoughts to a singular purpose, whether to create beautiful melodies, perfect a form or dance routine, or win a game.

One unexpected activity I have adopted is woodcarving, specifically whittling. For some time I have longed for an activity that uses the fine dexterity of my hands and also one that can produce something. One game I used to play as a younger man was to peel the skin of apples in a single uninterrupted spiral. I find much charm in this quote attributed to Michaelangelo: “Every block of stone has a statue inside it, and it is the task of the sculptor to discover it.” There is a beautiful simplicity in the art form: a block of wood, a knife, and a very small repertoire of cutting techniques that can be learned intuitively. So far, I have spent the past week gradually carving away at a small block of basswood to make the traditional first project which requires that one learns a few basic techniques: an egg. While I have only aspired to carve for ten minutes each day, I find myself cutting for longer periods of time as my mind quiets, relaxes, and finds some serenity.

Abstract:
[ ] Find serenity

Concrete:
[ ] Learn basic techniques of whittling/small woodcarving
[ ] Carve an egg
[ ] Carve a set of calipers
[ ] Carve a scholar’s rock
[ ] Carve a cheese knife
[ ] Carve a rabbit

Focus

For most of my life, I have followed the path of the jack-of-all-trades. I have often enjoyed the ability to learn new skills quickly, but mastery has not often been part of my trajectory. This has partly been due to having a wide variety of interests and a limited amount of resources (e.g. not having the money to have music lessons at an early age). Nonetheless, my career trajectory is moving me towards subspecialization, most likely in the field of Vascular Neurology, the field that is concerned with the treatment of stroke. Part of my passion for stroke comes from the fact that I have interest in many aspects of it: the disease pathophysiology (the many etiologies), the emerging and changing acute and neuroprotective treatment modalities, the need for better public health methods to get people to the hospital faster, the variety of care delivery strategies that different centers have established, and the great deal of research going into stroke rehabilitation and adaptation to post-stroke disability. Nonetheless, as my training progresses, it will help if I can explore this field with the aim to find a point of focus for my energy and intellectual desire. As such, my resolutions this year are:

Abstract:
[] To develop a point of focus

Concrete:
[ ] To find a concept of stroke that is not well understood and prepare to study it
[ ] To find an aspect of stroke care that can be improved upon and develop a means to achieve improvement

As is the case with many other solutions to problems encountered in the practice of medicine, the answer must come from within: the cultivation of greater self-discipline. One of the most important skills learned by interns and later refined throughout residency is the art of time and expectations management. The expectations and time demands imposed on training physicians by program leadership, attending physicians, chief residents, nurses, case managers, hospital administrators, and (last but not least) patients and their families are inevitably unrealistic and conflicting. For example, training physicians are expected to be in multiple places at once, frequently criticized for poor attendance at mandatory educational conferences or teaching rounds whilst simultaneously performing a necessary invasive procedure for patient care or discharging several patients timed to deadlines set by the case manager. Pagers are constantly invading the conversational flow of patient interviews, sometimes with messages urgent and other times mundane, sometimes informative and other times meaningless (the classic number page). New parties now have a greater foothold in the domain of attention of the training physician through electronic connections: loves ones, friends, and family. Physicians, previously unanimously choosing “dedication” and “commitment” to their patients in the form of long, isolating hours at the hospital over the cultivation of family and non-professional friendships, now have new methods that help maintain connections to the outside world during the breaking down and remolding process of medical school and residency training, a process that often involved the shedding of relationships. The current task at hand for the young physician is to develop the most appropriate methods of triaging the demands for their attention: focusing first on immediate patient care needs, attending to urgent personal matters when time allows, and delaying less time sensitive matters to off-work hours.

Underlying the criticism, however, is an unsustainable proposition: that technology is the enemy of the patient-doctor relationship. Over time, the impression has developed that computers and information technology draw training physicians away from the bedsides of their patients. In reality, the major factors that remove physicians from the patient’s room are the exponential paperwork demands (produced at the computer) and the processing of greater amounts of clinical data (read on the computer, in the form of laboratory values, imaging scans, or consultant reports and physician notes). In other words, the technology itself isn’t the problem: technology merely facilitates the information and documentation overload demanded by a litigious and defensive culture of practice. Technology can, in fact, bring physicians back to the bedside: doctors can update patients on their most recent lab values, check and update medication lists, explain their medical conditions in the context of an MRI or CT scan displayed on a tablet, use three dimensional models to explain basic principles of the function and dysfunction of individual organs (such as the brain or heart), and show them where to find trusted medical information sources on the Internet. Eventually, more digital documentation such as progress notes and discharge instructions will be easily generated by physicians at the bedside, minimizing the time spent at computer bays. In due time, both senior and training physicians will need to face the true problems within the practice of medicine and the delivery of health care that are underscored by the adoption of new technology.

Of course, in traditional medical training environments, needs are the purview of the faculty and desires are a secondary objective, the icing on the cake. In the eyes of a senior attending, a resident needs a rigorous, all-encompassing, militaristic training. There must be an obsession with perfection (whether intrinsic or extrinsic). More work is not punishment; it’s dedication. A resident is like the blade of a knife: she must be honed and sharpened, but this inevitably cannot happen without guidance from a strong arm toward a hard rock. Some, if not all, of these views are shared by many residents, particularly as rapidly changing work hour restrictions and efforts to protect new residents (and patients) further accentuate the learned forgetfulness of the brutal, early training experiences of more senior resident physicians. In this school of thought, asking for help or complaining about fatigue or excessive work load is a sign of weakness. The drive to perform comes from passion born of commitment, not of love for the job. Concepts such as resident happiness, job satisfaction, and morale often do not occupy the minds of residency program leaders and may not, by themselves, seem to be worthwhile investments at the expense of other program objectives.

The benefits of improving morale, however, are tangible and considerable. Neurology, in particular, is a field that until recently has traditionally had great difficulty in recruiting young physicians-in-training. Neurologic diseases are considered by students and residents to be difficult to understand, and the quality of the teaching of Neurology often worsens between preclinical and clinical years, suggesting that Neurology clerkships are likely not effective in inspiring students to pursue Neurology as a field [1]. Recruitment might be improved by modifying student experiences with preceptorships and more direct involvement with faculty members [2]. However, generating interest in Neurology among clerkship students and recruitment of the most attractive potential applicants may both arise from closer attention given to the needs of Neurology residents.

What do Neurology residents need to improve their morale and happiness? According to the surveys conducted by Adair et al., morale was most closely linked to supportive relationships between the faculty and residents and among the residents [2]. While support may be fostered in a variety of ways, this most certainly incorporates components of regular feedback (with both constructive criticism and encouragement), representation of the needs and concerns of residents with the program leadership (i.e. the knowledge and convincing belief that their concerns are being acknowledged and addressed), and a cohesiveness among residents generated either by frequent social interaction or a strong internal work culture (or both). Put more simply, residents who believe that they are being supported are more likely to share their interests and enthusiasm for Neurology with clerkship students, support one another in times of difficulty, and feel happier and more motivated to pursue clinical excellence in their training venue. Residents who feel unsupported are probably more likely to ignore or fail to interact with students, protect themselves and avoid opportunities to alleviate the burden of another resident, and feel unhappy and less enthusiastic or energetic to pursue the work that is “beyond the call of duty”: calling a patient after work hours, spending extra time giving individualized and meaningful feedback to students, and taking extra steps to ensure that the best clinical care is coordinated and delivered (leaving nothing to chance).

This feeling of support inevitably rises to the foreground in the answers to questions posed by prospective applicants regarding resident happiness. While the reputation (prestige) of a program and geographic location are important determinants of the initial selection of programs to which a fourth year student will apply, the interactions of the applicant with current residents and faculty members is the deciding factor in the ordering of programs on the rank list [2]. It is now common knowledge among residents, residency applicants, and astute residency program directors that the most important part of the interview day is the casual dinner the night before (or a similar event on the interview day) when the residents can freely socialize and express their sincere opinions on the program. It would logically follow that the most effective method a program director has at his disposal to recruit the most attractive applicants is to attend to the morale of the residents and their perception of support.

References
[1] Zinchuk AV. Attitudes of US medical trainees towards neurology education: “Neurophobia” – a global issue. BMC Med Educ. 2010 Jun 23;10:49.
[2] Adair JC, et al. Survey of training programs’ means for promoting neurology and attracting trainees. Neurology. 2006 Sep 26;67(6): 936-9.

Time of Consult: 11/24/11 1527

Chief Complaint: not recognizing family members, emotional outbursts, ? Seizure

HPI: The patient is a 19 year old left-handed man who presents with acute, brief episodes of altered mentation. During the past two days while at home with his family, he has appeared to his family members to be more withdrawn, moody, and irritable. He has frequently made statements such as “I hate family gatherings” and “I hate Thanksgiving” and “This totally blows.” When his Aunt Mildred tried to give him a hug, he squirmed and cried out as though in pain. During the five hours of family photographs yesterday, he was thought to have alternating left and right face twitching to which he explained to his father who confronted him that he couldn’t stop the twitching. He has appeared more agitated this morning prior to Thanksgiving dinner. One hour prior to dinner, he walked into a room filled with arriving relatives and family friends, stopped short, stared with a terrified look for several seconds, and then stated loudly, “Who are these people?” Five minutes later, when Aunt Mildred called it upon herself to retrieve him to socialize with the extended family, he was found in his room, “flopping on his bed like a fish out of water.” Aunt Mildred called for help, and her husband, Uncle Ray, thinking that the young man was possessed, attempted to exorcise him. Finding this ineffective in calming his fit, EMS was called and brought the patient to our ED. Neurology was invited to evaluate for the possibility of seizure.

On further questioning with the patient in isolation from his family, he admits that he is very stressed and does not want to spend Thanksgiving with his extended family. He recalls the entirety of the previous events and did not have any impairment of consciousness. There was no tongue biting or lip lacerations. There was no bowel or bladder incontinence. He has no history of seizures. He denies ever having had olfactory or gustatory hallucinations, tableau/deja vu sensations, out of body sensations, or macropsia/micropsia/visual distortion.

PMH: None

Examination: Unarousable to sternal rub and nailbed pressure when family members are by the bedside. Spontaneously open eyes, alert, oriented when the family members are outside the room. No tongue or lip lacerations. No neurologic deficits.

Urine toxicology negative, serum toxicology negative

Assessment: 19yoM with episodes of full body movements and emotional outbursts in the setting of being in a stressful environment, most likely representing an acute stress reaction and possibly malingering. The patient’s presentation is less likely representative of seizure.

Recommendations:
- Consider a social work consult to help offer the patient coping mechanisms for his current predicament. 
- The patient may followup in Neurology Urgent Care.

Thank you for this interesting consult.

—–

Time of Consult: 11/24/11 2150

Chief Complaint: altered mental status

HPI: The patient is a 52 year old right-handed woman who presents with an acute change in her level of consciousness. She was celebrating the Thanksgiving holiday with several family friends when after the sixth course she stood up and announced quietly to her husband, “I have a little bit of a headache. I’m going to go lie down for a minute.” She walked into the living room at approximately 1950 and was not seen by the other members of the party for at least twenty minutes. At 2010, when the dessert course was being passed around, the patient’s husband went to retrieve her and found her slumped over on the couch. Thinking that it would be very impolite to miss out on the rest of the social occasion, he made several vigorous attempts to arouse her, including splashing water on her face and performing a sternal rub. When none of these measures worked, EMS was called. When they arrived on the scene, they took a fingerstick glucose which was 632. She as brought to our ED for further evaluation. A noncontrast head CT was performed in the setting of headache. Neurology was invited to evaluate the patient for altered mental status.

PMH: Diabetes mellitus

Examination: Lethargic but oriented and rapidly recovering after receiving 20 units of insulin and intravenous normal saline. No neurologic deficits.

Noncontrast Head CT: no abnormalities

Assessment: 52yoW h/o diabetes with severe hyperglycemia in the setting of a very large meal. 

Recommendations:
- Please advise the patient, who is a diabetic, to mind her portion sizes, especially around holiday meals such as Thanksgiving. Please advise her to continue to taking her insulin as prescribed.
- The patient may followup in the Neurology Urgent Care clinic.

Thank you for this interesting consult on this day of giving thanks.

—–

Chief Complaint: slurred speech, bilateral arm numbness, Code Stroke

Time Code Stroke Called: 11/24/11 2357
Time of Neurology Evaluation: 11/24/11 2359
Last Seen Normal: 11/24/11 2030
Intravenous tPA administered? – No
Reason if not administered – Seriously?
I was present at the time the head CT was performed and would have reviewed the images within 20 minutes of the patient’s arrival had the patient not urinated in the CT scanner.

HPI: The patient is a 45 year old right-handed man who presents with slurred speech and bilateral arm numbness. He was at a bar with two fellow bachelors passing the time on the evening of Thanksgiving. He arrived at the bar at approximately 2030 after which he proceeded to drink significant amounts of alcohol. He was nursing a bottle of whiskey in his left hand and a shot glass in the right hand with his elbows pressing up against the bar. He was sitting in this position at the bar for about three hours. When he downed the last shot, he said to his friends, “Hey, I can’t feel my arms;” at least, that’s what they thought he said. His speech was thick and barely comprehensible. One friend laughed at him (and he laughed along), but the other was more concerned and called EMS. He was brought to our ED for further evaluation and was triaged as a Code Stroke.

Of note, the patient’s review of systems is significant for anxiety and recent stressors including his wife leaving him, his dog dying, and his truck breaking down.

PMH: None significant.

Social History: Musician.

Examination: Strong odor of ethanol. Awake but inattentive. Disinhibited. Paresthesias along the lateral aspects of both arms from the elbows to the fourth and fifth digits. Bilateral arm and leg ataxia. Unstable gait.

Serum Alcohol level: 376

Assessment: 45yoM p/w slurred speech from alcohol intoxication and bilateral sensory disturbances from ulnar nerve compression.

Recommendations:
- The patient’s slurred speech should resolve once he sobers from his alcohol intoxication. His arm numbness/paresthesias will likely resolve with time as well; he should avoid maintaining the aforementioned position for prolonged periods of time.
- The patient may followup in the Neurology Urgent Care clinic… if absolutely necessary.

Thank you. No really. Thank you.

Happy Thanksgiving!

Managing information is an incredibly important skill for physicians at all levels of training. For example, the overwhelmed intern needs to learn how to manage the information overload that arrives in the form of vital signs, lab values, physical examinations, plans discussed on resident and attending rounds, and consultant recommendations. When managing ten or more patients, it is essential to develop a means of organizing, triaging, and prioritizing data points and tasks. For me, as a newcomer to the Neurology clinic, I need to figure out how to keep track of my patients, determine when to bring them back to clinic, manage long medication tapers, solicit the advice of experts when there is little evidence to guide therapy, schedule emails and phone calls for updates, and develop information management tools for my patients to help them organize their own self-care. Recording all of this on paper would be a logistical disaster and would not be portable. I initially started with a password-protected text document that unfortunately could not effectively layer or link information. I have finally started using a database program, Bento, to help organize my patients, each with their own dossier containing information regarding their last visit date, their next visit, their diagnoses, a brief summary of their cases, and a checklist of items to follow and monitor. So far, it has offered me a quick, easy, and secure method of recording and accessing information on my patients separate from the hospital electronic medical record. With any luck, this will help me maintain a visual on the grand overview of my clinic and prevent the dreaded “lost to followup.”

A year has passed, and I have been promoted. I earn better pay, my name is emblazoned across my jacket, and I have a new stripe to indicate my rank. I am now a second year officer of the House, and I have started this new assignment with one young officer to supervise: a first year, an intern. Admittedly, this is a cushier assignment than those assumed by many of my comrades in officer training: the hours are still long, but these western waters are calmer, these crews more experienced and seaworthy. I have new responsibilities: whereas last year I theoretically was always supervised in person, I now command respect as an officer and representative of Her Majesty’s fleet (Her Majesty, of course, being the Queen of medical disciplines, Neurology), and I often stand alone. I received the first call from the port master, the Emergency Room, as word of a distressed vessel traveled with the frantic hum of the helicopter blades. Upon arrival, I was immediately notified and was at the bedside in minutes with the attending physician speaking directly to me and asking for my recommendations as I stepped into the crowded room with eyes turning to me: “Where would you (Neurosurgery) like the blood pressure? We were planning to go to the CT scanner immediately; do you want a plain CT or a CT angiogram?” A member of the Emergency team recognized me and called me amiably by name. It has only been a few weeks, but I have a name, a reputation. Immediately a voice from within relayed, “Keep the systolic blood pressure under 130. We usually use Nicardipine. I would like a CT angiogram of the Head.” A handful of times in the past I have been involved in time-sensitive critical care, including in cardiac arrest codes, but often as the ensign delivering chest compressions or running to the phone to call for more specialized help. But now, the bridge is yours. Although ultimately my attending, my captain, was the primary force steering this ship through the storm of blood and steel and electricity, I was everywhere: by the bedside monitoring the patient’s condition and teaching apprentices, in the scanner control room identifying the aneurysm, coordinating the collection of supplies for a ventriculostomy, sending in my crewman to place the drain (knowing this was his chance to learn and shine), speaking with family about the upcoming procedures and the hard road ahead, and signing out to nurses and doctors in the ICU as we pulled into dry dock and out of the fire and rain. At each step, each individual performed admirably, and I was there to see it all, there to direct and guide and encourage and compliment.

I have a name. I have a command, however modest, and a role to fill in service of the Queen, of Neurology, and of the men and women of her domain whose suffering I can alleviate. I have a responsibility to not be that consultant belittling those without specialized knowledge or that physician recklessly dispersing patients rather than seeing assignments through to the end. I have a junior officer who is eager to break the rules to continue to serve and be at the front lines, and I have an obligation as his commanding officer to protect and guide him, to use him where he can be most effective and gain the most experience and not waste his skill and energy on tasks another officer might feel himself too senior or superior to perform. I accept this new assignment. I am a resident.