Yesterday was my first shadowing experience in the US. It has been nearly two years since I was in Venezuela following surgeons and a radiologist in local clinics and hospitals, so I was very excited, especially because I would be spending the day in the emergency department (ED). Some of what I saw was exactly what I was looking for, while other aspects of the day made me worry about what kind of profession I'll be getting myself into.
Just in case you were wondering... Yes, like on TV, everyone is as attractive as George Clooney and they're all having sex with each other like on grey's anatomy... just joking.
The term "shadow" gives the perfect depiction of what I did while in the emergency department (ED) as I literally followed around an attending physician, moving from a workstation with computers, to each patient's room. Although it was a slow day, with only 6 or 8 of the 27 emergency rooms housing patients at any given time, we were always moving from one place to another. I was impressed by the way the physician could think about and handle so many different cases and so much information at one time. While a 15yr old female was vomiting and nauseous from a head injury sustained from fainting in her art class, labs were being ordred for a patient experiencing multiple symptoms including fatigue, abdominal discomfort, trouble sleeping (just to name a few), at the same time, x-rays were ordered for an injury to a 78yr old patient's ankle that would definitely need suturing. I also loved the way that decisions were made... after briefly talking with a patient, a list of tests were sent out and a differential diagnosis was being formulated. Everything was quick, on your feet and no two patients were the same. The opportunity to see all types of people and symptoms, work with teams of nurses, residents, social workers and other physicians, while requiring an understanding of how to treat and diagnose nearly every system and issue in the body (not just the heart, and not just the skin, and not just the bones... but everything) was exactly what I could see myself doing in the future. However, I was thoroughly unimpressed by some of what I saw while shadowing...
Walking toward the first patient's room I noticed the hand sanitizer... then I noticed that we walked right by it. As a society we've known for many years that the hands of a physician can spread disease. Puerperal fever is a perfect example. Doctors, many of which carried bacteria on their hands, often from working with cadavers or other patients, assisted in childbirth. After this, the mother would become ill and die. Why did this happen? Because the physician's hands were disgusting and not clean. The point being, wash your hands before seeing every patient. That is one of the main reasons why so fewer women die from childbirth than before. I can understand that a doc working in EM (emergency medicine) might be rushed, but honestly, just put your hand under that dispenser for 3 seconds and you'll be set...
After a handfull of interactions with patients, I noticed that the amount of time the attending spent in the room was on average 1 - 3 minutes. Why did this happen?
Hypothesis 1: He works in EM so he is rushed to see lots of patients and needs to be quick...
Hypothesis 2: The resident and nurses have spent a prolonged amount of time with the patient, so the attending doesn't feel its necessary to do so...
Hypothesis 3: This guy is a *ick and has no sense of bedside manners
Hypothesis 4: There could be a lot of different reasons and I don't know what they are.
Any of those could be possible...
After visiting one of the patients that I mentioned before (presenting multiple symptoms including, fatigue, nausea, abdominal pain, missed period), we received her lab results concluding that she was pregnant. This was a learning moment. Apparently whenever you have a female patient, the first 3 things you assume are, 1. pregnancy, 2. pregnancy, and if the patient is not sexually active, 3. pregnancy.
So now that we had this information, I asked the attending, "Is this news that you deliver, or does the resident do it? How does this work?" I asked this in a way that insinuated the gravity of the situation. The woman had no inkling of an idea that she might be pregnant, but there she was on the hospital bed with a little bun in the oven.
The attending responded, "We can go talk to her now."
Pause for a moment and imagine you're a patient. The doctor walks in. He sits down. Tells you you're pregnant, and before you can say a full word he rattles off some random information including concerns about pain and pregnancy complications. You might be in shock, and that is O.K.
Now let's imagine you're the attending physician. You are in the emergency department. You walk in the room and deliver the information quickly. You vent your concerns about abdominal pain, because if it's in her right lower abdominal quadrant, it could be an ectopic pregnancy... not good.
Now imagine you are me, going into your first year of medical school. You watch a physician walk in to a room, without warning deliver news that the patient is pregnancy and see the reaction on their face of an unsettled surprise. You hear the brief explanation of why pain and ectopic pregnancy should be checked for and understand the patient is not getting any of this. You hear the patient state, "I feel like I'm in shock..." which results in more clinical information about abdominal pain being given by the attending physician, and you immediately feel like a piece of your hope and faith in your future career has been taken away from you. You then hear the patient ask for an STI/HIV screening, and watch the physician struggle to agree with it.... This is when you think, "What the hell just happened? Why did he not address or acknowledge her feeling of shock or ask why she felt the need to get tested for STI's/HIV when this patient was married with three children... WTF?"
In less than 3 minutes we were out of there. I couldn't believe what happened. A patient stated they felt shock and needed testing, while the attending only seemed to care about a potential ectopic pregnancy. I honestly can't imagine what that patient felt or how upset she must have been about how she was treated. There were so many questions to be asked, but really just two that NEEDED to be asked, "Why do you feel shocked? Why do you feel the need for STI/HIV testing?" After walking out of that room, all I could do was hope that one of the other health care providers followed up and asked the important questions that needed asking... or even just comforted her and listened to her story. On a day when the ED is running slowly and not crowded, can an attending physician afford to spend an extra 3 minutes with a patient and just listen? If not then I think I've completely lost my faith in this system, and I will fail as a medical doctor.
After leaving the ED, I remembered how I sometimes equate physicians to auto-mechanics for the body. We go to school to learn the ins and outs and then open up the hood, tinker around to see what's wrong, fix the problem, then close you up. After seeing the patient who is pregnant, I felt that when bringing your car in for some mechanical or electrical issue, your auto-mechanic may end up building a stronger, more trusting and comfortable relationship with you than your doctor... your doctor being the one you're supposed to share EVERYTHING with.
Today we had a chance to reflect on our shadowing experiences in our doctor/patient relationship class. From discussing my shadowing experience, the Dean leading the discussion who practices internal medicine, reminded us that we might end up seeing situations like these much more often than we like, however as medical students on rounds, we can be the ones to listen to the patient, and we can be their advocate. While shadowing we aren't allowed this opportunity, but I'm feeling a little more comfortable knowing that in the near future I will need to be the one to recognize an event like the one above and then work with the patient to ensure that they receive the best health care possible.
Yes it is late, so I'm off to bed. This weekend I'll be out partying and also taking care of a cat while one of my new friends leaves Boston for the weekend.
Buenas noches.
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