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Tuesday, February 7, 2012

Finding a mentor, and the joy of working with physicians who are not sheep

Many physicians are thoughtful, intelligent, compassionate and creative, but the process of training for this job doesn't necessarily foster those qualities. And let me be clear, I have nothing against sheep, other than to have noticed that people who keep them don't seem to be particularly impressed with their problem solving abilities. I think that when we as physicians get particularly tired and overworked, we stop thinking for ourselves.

When I went to medical school at Johns Hopkins, there was a subset of clinical teachers who I thought of as the "grand old men and women of medicine." They were the people who understood their subject area with keen insight and who loved to teach. I felt privileged to be near them as they visited patients and explained their thought processes. Their ideas were fresh and they were passionate about them and they were definitely not sheep.

My recent locum tenens hospitalist job was really busy and there was a tendency to test and treat patients in ways that did not seem ideally suited to their individual needs. It was expeditious to do cardiac enzymes and then a nuclear stress test on everyone with chest pain who had any measurable risk of coronary artery disease, but I cringe to think of the cost and the radiation exposure associated with that approach. The American College of Physicians has made a recommendation that people with normal electrocardiograms who have chest pain can be risk stratified with a regular EKG stress test, without nuclear imaging without significant harm. The cost of a nuclear stress test is around $7000 whereas a regular stress test costs less than $400. Cardiologists and the hospital make more money on the nuclear tests, but the associated radiation will result in excess cancer risk. Invasive and higher risk procedures are compensated better than thinking and talking and this leads to increased use. The level of acceptance of routine use of procedures for testing and treatment is determined by the healthcare culture that is present in a hospital or community. I think the patients at the hospital where I worked got good care, but I wonder if their outcomes were any better than they would have been at an institution with more frugal use of resources.

The hospitalists in my new institution are responsible for taking care of most of the patients who are not critically ill in the hospital, but when these patients need ventilators or very frequent monitoring or vasoactive drips they are transferred to the intensive care unit where they are cared for by a physician who is assigned to just those patients, a critical care doctor. We hospitalists would occasionally go to the ICU to meet a new patient who had been adequately resuscitated to graduate to a regular medical floor, and in one of these visits I met the night shift intensivist who is also definitely not a sheep. He is an astute diagnostician and had great ideas about physiology that helped make sense of the very sickest patients. After a conversation that involved my present passion for bedside ultrasound to help manage medical patients, he offered to "show me stuff."

Physicians who are not sheep frequently do things in ways that make sheep uncomfortable. This ICU doc showed me his technique of putting in a central line in the subclavian vein using ultrasound guidance and a skin tunnel to prevent infection. Some physicians now use ultrasound to put in central lines, but rarely in the subclavian vein and I have never seen a tunneled central line placed by an intensivist. Now it is true that my exposure to this sort of thing has been limited for the last 20 years, but I'm pretty sure this is not only the right way to do it but also very uncommon. Skin tunnels prevent the bacteria that is always present on the outside of a human from getting into the blood stream, which is supposed to be pretty much devoid of bacteria. There are special central lines that are placed by surgeons that are tunneled and have special cuffs for use in lines that are expected to be left in place for a long time. The hardware and the placement process are really expensive. The procedure I saw involved the standard central line equipment and a bedside ultrasound machine and was beautiful. His procedure was relaxed and graceful and the patient was treated with respect. I was inspired.

Atul Gawande, the physician/writer for the New Yorker, wrote about being coached in doing surgery, and about how useful it was and how uncommon. Mentoring in medicine stops for most of us when we reach our final year of residency and from that time on, with the exception of short continuing medical education courses, we pretty much make things up as we go along. This year I have started to spend more time with doctors who know things that I don't know. The only way I could really do this is to pull away from the very full time nature of my primary care job and deliberately spend time listening to and watching people (doctors and technicians) who I respect. In the last few months I have seen many professionally done echocardiograms and ultrasounds, have watched my radiological colleagues do procedures and have seen a total hip replacement. Everything I watch opens up my horizons a little bit. I'm looking forward to more of this.

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