Too crowded with angels

I was just starting my freshman year of college on September 11. My memories of that day slide in and out of focus, with random bits imprinted more clearly: my roommate waking me up to tell me about a plane crash (we were on the west coast); talking with my TA during 8am chemistry lab; and then nothing until getting back to my dorm after class was done, and following the stream of students into the TV room, and seeing the news. Mostly what I remember now, these almost 12 years later, is how long it took the full scope of what had happened to sink in. How it had to be an accident, and then how much I was in denial about how much structural damage the attack could have caused, like the planes were as inconsequential as a bird bouncing against a glass window. And then finally seeing the collapsed towers, and the horror sinking in.

I thought about that today, here in my adopted city. I was a few miles before the end, waiting to cheer a friend on, when I vaguely noticed some police mobilization: motorcycle cops leaving, and then sirens. I half thought, oh, the race is winding down, they’re needed elsewhere, and then I saw my friend run by, and then I went home and saw a message from my husband about the explosion. And even then, my first thought was it was an accident, or if it wasn’t an accident, maybe a couple people got hurt. And then I started to watch the TV coverage, and the injury count started to increase, and one of the dead is an 8-year-old boy.

We were lucky: we are safe, our friends all seem to be safe, my facebook feed is filled with friends and classmates who are safe and long-distance friends checking in. I keep clicking the Boston.com live feed, and reading the hospital reports, and what I really want is to hear good news: they overestimated the number of injuries, or something like that, even though I know that’s not what I’m going to see. The streets of heaven are too crowded with angels tonight. They and their families will be in our prayers.

Knowing what you don’t know

Via Slate:

I have fond recollections of Peet’s from back when I lived in Massachusetts and their brand also seems to be strong on the west coast.

As a California to East Coast transplant, this pains me a little: how can anyone not know that Peet’s is a Berkeley institution? But it’s a perfect illustration that sometimes we can’t see our own knowledge gaps. The information may be one click away, but finding it requires awareness of our own blinders.

Teaching better sign-out

I was watching this video about signouts (I know, I’m really fun at parties). But anyway I was struck by how little training we get on the communications skills aspect of medicine. At my institution we had maybe 2 talks on how to present a patient’s story formally on rounds, and a few of my residents coached me on it, and that was it – I more or less figured it out. (Not to mention that different attendings want different things from med students). Student notes have to be co-signed by a resident, so I did get some feedback on those, although I have to say, it was pretty inconsistent, in that some interns like to do things one way, and some another. But I didn’t get any formal instruction on how to sign out a patient to whoever is cross-covering, and that’s one of the key skills for patient safety.

Another perspective on hospitals as hotels

In terms of appearance, at least. I definitely believe that the design elements mentioned in the article (natural light, nature) promote healing. The question is whether that translates into measurable outcomes, and if so, which ones.

More on grocery stores

Another thing that irks me about my local grocery chains is the customer service. Not that I quite expect radiance, a la Pret a Manger, but I do appreciate basic politeness, which I define as, i. a greeting/acknowledgement of my presence, and ii. lack of attitude that I am inconveniencing anyone by my presence. The last time I went to Stop&Shop in fact the only word spoken to me the entire encounter by the cashier was “Sign”, re my credit card slip. No greeting, no please, even. Not to mention the eye rolls I was awarded for bringing my reusuable bags. It seems like a management failure, some combination of not treating employees well resulting in disgruntledness or not hiring the right people or not setting expectations of behavior.

There are obviously exceptions, and one of them is Trader Joes. People there are consistently pretty helpful and pleasant, even when it’s hectic. So it was nice to see that they treat their employees well and make their money back in increased productivity.

Should hospitals run more like hotels?

“She thinks that this is a hotel.” That phrase gets spoken a lot in hospitals, about a certain type of patient who seems disinclined to leave, even after their medical problems are resolved. It frequently but not always seems to be a woman, maybe middle-aged, with kids and lots of responsibilities at home or work, who is unable or unwilling to set limits on what they can reasonably do there, and is thus very reluctant to go home again. And so when you tell them they’re ready for discharge, they mentions some new ache or pain, which sometimes must be evaluated, prolonging her stay…and then the process repeats itself the next day. Even though it’s not (necessarily) on purpose, it’s still frustrating for the medical team, who see the culprit as taking time and resources away from those who are actually sick.

And so patients are stereotyped: people who bring their own pajamas or pillows are suspect, because it looks as if they’re settling in. Don’t let them get too comfortable, is the feeling, because then they won’t want to leave again. I think this is part of the reason there hasn’t been more of a movement to reorient hospital routines so that they’re centered around patients, instead of the needs of the hospital staff: on many services, it’s impossible to sleep after 5am, because of repeated interruptions for vital signs, phlebotomy, medication administration, and 1-4 visits from people on the medical team. Not to mention that no one seems to understand the global picture of what’s going on with the patient; you would think the doctors would, but one of the surprises of medical school for me was how much stuff happens that the medical team isn’t involved in (or is involved in only nominally): immunizations and fall risk by nursing, placement by case management and physical therapy, random visits by the chaplain or social worker because someone thinks it’s indicated. (It’s not that the nurse necessarily has a better handle on what’s going on, either – information gets lost when they change shifts, and also their focus is less on the medical issues.) Some units do a really good job of having interdisciplinary rounds where everyone communicates, but on most it’s pretty haphazard. And this general state of disorganization makes life uncomfortable for patients, which encourages them to want to “go home so I can get some rest”. I know that part of this is inertia/resistance to change and not active hostility to patients overstaying their welcome, but the general attitude in most hospitals I’ve been in is not one that prioritizes patient comfort.

Is Step 2 CS worth the cost?

NEJM has an article about the cost of the clinical skills portion of Step 2, response here. Basically the test, which is taken as a medical student and required to become licensed as a physician in the US, costs more than a thousand dollars, and even more if you’re not fortunate to attend school in one of the 5 measly cities in which it is administered and have to travel to a testing site. The test, which is pass/fail, consists of a bunch of stations with actors pretending to be patients with common problems: sore throat, back pain, anxiety, etc. You rotate through the stations, talk to and examine the patients, and then document your findings, and you’re evaluated on specific things that the powers that be have determined are important: if memory serves, they include asking the right questions, washing your hands, picking the right parts of the body to examine and doing it correctly, as well as certain patient-centered communication skills such as recapping what they’ve said so far. They also evaluate your English language skills (obviously a gimme for American students but this exam is also taken by people who went to med school in other countries and want to practice in this country).

It’s actually kind of fun, at least by the standards of taking a test. The issue is, it’s super easy to pass–98% of US students pass the first time, and 91% of the remaining 2% pass on retry. (Foreign grads do less well, but still almost 80% pass the first time.) And unlike the other medical licensing exams, it’s pass/fail, so there’s no way to differentiate who does well and who just squeaked by. So the argument is, why do we have a test that’s crazy expensive and doesn’t tell us that much? Having had to fork over my ridiculously large chunk of change, I totally get this argument. Eliminating it would be one less source of stress for students.

Except. There is the truism about what gets tested, gets learned. And even if most of my classmates didn’t necessarily study for CS in particular, we did more broadly, because preparing for it was incorporated throughout the curriculum. Medical schools want to stay accredited, and so they are motivated to change the curriculum to make sure their students pass. The patient simulation exercises that we do are actually helpful: unlike the majority of clinical time as a student, when you are either talking to patients unsupervised or watching as your resident or attending does the talking, you get to practice interacting with patients and get immediate feedback about how to improve from your instructor, classmates, and the “patients” themselves. That’s why unlike, say, professional meetings, simulation improves clinical performance and may even impact patient safety. 

Would schools do these simulations anyway? Maybe, since there’s good evidence that they’re an effective teaching tool. On the other hand, they’re expensive, and med schools aren’t always the most profitable of endeavors. So from that perspective, maybe keeping CS around for a while isn’t such a bad idea.