Wednesday, March 30, 2011

The Doc Will Not See You Right Now

First of all, if any well versed social media docs read this, please advise me on how to protect myself from scrutiny from my own institution (not so social media friendly) and the rules that I mention.

Secondly, I apologize to any readers that don't care about medicine/surgery/residency. This is a long rant on how my world is changing. Feel free to read on, I provide a lot of background information for you to attempt to empathize, if you dare to try.

This morning, during M and M conference, I tweeted about my frustrations with the new intern hours and promised a later blog. I have cooled off for now, but that won't last long.

Some background information:

I am a second year in general surgery residency in a community-based program. I work anywhere from 60-80 hours a week depending on how many days off fall in that week. The current rules state:

  • Maximum 80 hours worked per week (averaged over 4 weeks)
  • In house call shall not exceed an average of every 3rd night (averaged over 4 weeks)
  • Must have one day off per week, a full 24 hours without duty (averaged over 4 weeks)
  • Can only see new patients for a maximum of 24 hours
  • Maximum of 6 hours "post-call" to wrap up and get out of there basically
    • That means our maximum shift is 30 hours long which must be followed by a 10 hour break of absolutely no duty...not including driving time.

I will admit that there are a few occasions where I have worked well beyond the 80 hour limit, but averaged over 4 weeks I think the worst it's ever been is 79 hours. (And I, unlike many residents around the country, don't lie about my hours because I'm sort of interested in what they actually are.) I typically arrive between 5:30 and 7am depending on the rotation. Some days I leave at 3pm, some days 5 or 6pm, and other days later. Post call I usually plan on being there until noon, period. It's not THAT bad. Granted, our social lives still suffer (not to the extent that they did prior to the work hour restrictions). That's right, there used to be absolutely no work hour restrictions for resident physicians. It was common practice for one to work for 24 hours, be off for anywhere from 5-24 hours and be back on for 24 hours with no true days off. Believe me, MOST post call days don't feel like a day off--certainly not when you've been up all night.

Yes, I have fallen ill of the victim mentality on more than one occasion. I get sad that I can't enjoy Sunday brunch EVERY weekend, or that I can't just join the girls for lunch on any given day, or that I can't stay up late tonight because I am on call tomorrow, or that I can't enjoy happy hour on more than the very rare occasion. However, those are small sacrifices for the education I am receiving to be able to adequately and competently take care of my patients on my own when I'm done after five years--and with good technical skills to boot.

In our program, we average around 1000-1100 cases when we are finished with five years. That's a great number! Only 750 are required to qualify for the board examination. So in other words, we operate A LOT. This was a huge part of my placing this program at the top of my list. I wanted to know that I would be comfortable in an OR alone after five years without the NEED for a fellowship. I didn't want a program stuck in the old hierarchial system that prevents most lower level residents from seeing the OR. I wanted a full five years of surgical training, not four and certainly not three.

More background info: in our program, we take in house trauma/acute surgical call every fourth night for about 8 months a year (all the way through)! Chiefs occasionally have the opportunity for home call IF no one on their team is taking vacation. The only times we don't take q4 TRAUMA call (doesn't mean we aren't taking q4 in house call for something else) are:

  • As an intern:
    • Burns
    • ICU
    • Private hospital (without trauma) for two months
    • Possibly an anesthesia month. 
  • As a 2nd year: 
    • ICU
    • Private hospital (without trauma) for one or two months
    • Pediatrics
  • As a 3rd year
    • Colorectal (home call)
    • Cardiothoracic
    • Pediatrics
    • "Pre-call" at our county hospital. 
  • As a 4th year
    • Colorectal for two months
    • Cardiothoracic 
  • As a 5th year
    • One or two months at the private hospital. 
Otherwise, we cover a regular service, usually comprised of either bread-and-butter general surgery, surgical oncology, or vascular surgery. We rotate at private hospital, TWO Level 1 trauma centers (top of the chain trauma centers), and a pediatrics hospital during our five years. Each rotation is one month long.

  • "Main" hospital (also a Level 1 trauma center) 
    • Five people on a team
      • Chief
      • PGY-4
      • PGY-3 typically covers ICU at night
      • PGY-2 typically covers ER
      • PGY-1 usually a surgical intern covers floor at night
    • Four teams
    • Q4 in house call for trauma/acute surgery/floor calls and ICU for all services
  • County hospital (a Level 1 trauma center)
    • Four people on a team
      • Chief (PGY-4 or PGY-5)
      • Junior (PGY-3 or PGY-2) typically covers ICU at night
      • Interns (one surgical and one medicine/transitional/orthopedics intern) cover ER
    • Four teams
    • Q4 in house call for trauma/acute surgery/floor calls and ICU for all services
  • Private hospital 
    • Four people on a team: Chief, a junior, and two interns
    • Average Q4 call (home call as a junior or senior) rotates between the four, only one resident on call every night for floor/ER 
    • A "closed" ICU for the most part
  • Pediatrics
    • Two residents at the pediatrics hospital
    • Q4 in house call for floor and ER
  • Colorectal service
    • Two residents
    • Home call for floor/ER
  • Cardiothoracic
    • One resident
    • Home call for floor/ER
  • Transplant
    • One resident
    • Home call
  • Burns
    • One resident (from our program), one 2nd year and 4th and one or two more interns from another program
    • Q3-Q4 in house call for floor/ICU/ER, only one resident on call each night
  • County hospital ICU
    • One resident
    • Takes Q4 in house call for the ICU
  • "Main" hospital ICU
    • One or two residents
    • No call
  •  County hospital "pre-call"
    • One resident who covers "specialty" service cases during the day: vascular, breast, CT 
    • No call
  • Anesthesia
    • One intern
    • No call
So even though we have 8-9 residents a year, we get pretty spread out among services. Of note, we currently have no specific trauma/acute care service nor do we have a night float system.

The new rules coming up (and forgive me I don't know ALL of them):

  • Interns (PGY-1) can work a maximum of 16 hours in a shift
  • Interns must have 8 hours off between shifts
  • Cannot exceed more than 80 hours per week
  • Required full day (24 hours) off per week
  • Interns cannot take more than three months a year of "night float" call
  • All residents have a maximum of 4 hours post call (total max of 28 hours per shift)

How has our program decided to address this? (I'd love to know others' new plans too). Well, interns will just be working from 6am to 6pm. That's only 12 hours. I thought they were allowed a full 16??? Interns will not be taking night call, period.

That means:

  • At the main hospital:
    • After 6pm, the 2nd year covering the ER, the 3rd year covering the ICU, and the 4th year who is typically in the OR operating on all those patients the 2nd year has seen in the ER are all now required to make up for one whole person's amount of work. 
    • Our chiefs will not be able to take home call. We will be spread too thin if they aren't there.
    • When someone is on vacation, that means only THREE residents will be available as one will be long out of town and one won't be allowed to work. With ~40-45 residents in our program, you can almost plan that there are at least 3 weeks of every month (at the main hospital where we have the biggest team) where SOMEONE is on vacation. 
    • Patients on the floor will not be responded to in such a timely manner because the other residents will all be busy in the ER, ICU, or OR and unable to leave their position immediately.
    • Less OR time for everyone. Cases go uncovered. 
  • At the county hospital:
    • There is only one resident in the ER after 6pm--being someone that is not a resident actually trained by our program (or one that even cares about general surgery). 
    • No extra intern to place lines, chest tubes, etc. requiring the junior level resident to stay out of the OR. 
    • Consults will not be seen in a timely manner. We will likely be seeing consults well into our "post call" hours.
    • Any elective cases will not go after 6pm. No more "clearing the board" and doing chole's at 1am UNLESS it's absolutely necessary because we simply don't have the man power to keep extra people in the OR and off the floor/out of the ER.
    • The wheels will fall off. Less OR time for everyone. Cases DON'T go. Patient's don't get their operation.
  • At the private hospital:
    • Only two of the residents will be able to take call at night. Currently chief residents typically cover nights that we don't have attending staff on ER call. Therefore, this will become a home call situation and chiefs will not be able to take these 4 calls a month. 
    • Interns will not be seeing patients at night to work them up to operate on them the next day. If they did, they would have to leave before their case went.
    • Less OR time for interns but not more OR time for everyone else because they will already be working. 
    • Also remember, we can't take more than q3 call, so we can't just take more calls as juniors or seniors.
  • Transplant
    • Interns can't take night call. No organ donations for you!
    • Less OR time.
  • Burns
    • Interns can't take night call. Only two residents to cover call otherwise (and we can't be q2). 
    • Possibly a shift work thing between interns here could work, but STILL not appropriate.
  • Anesthesia
    • No interns on anesthesia. We can't afford to lose the manpower.
  • ICUs
    • Interns can't take night call. They usually don't anyway. We have managed with this in the past. But interns on the basic services aren't around, this will be detrimental.
  • "Pre-call"
    • Possibly turns into a night float system to help teams out. However, this means one less resident around to cover cases during the day.
    • Less OR time. Cases go uncovered.

Every time residents bring this up, we get brushed off. Even though we are the ones that do the work day in and day out, we are told by our administrators that this is how it will be--without lending an ear to concerns. We have often mentioned specific trauma services, a night float system (which I know from experience works very well for at least one other institution, with less residents). We have also mentioned having interns work 6a to 10p or 2p to 6a, or 6p to 12 noon--the full 16 hour shift. No matter what, "post call" no linger exists in an intern's vocabulary. I'm not sure anyone has the right answer, but just taking one or two residents out of play for 12 hours a day--the most terrible idea ever. Eyes glossing over and continued attempts at dismissal of the subject when we mention the so-called "plan" during the most appropriate time, i.e. when a majority of the residents, involved staff, and the department chair are all in the same room and have an hour to spend together, is also terrible.

All in all we fear everything will fall apart. Part of this is due to surgeons' egos and the fact that we all think we know a better way of doing this. Another thing is the culture of residency, especially surgical residency. One expects another to work. And work hard. There already exists a chasm between the physicians that trained without any work hour restrictions and those of us limited to 80 hours. This will provide yet another divide. Poor little interns are going to catch a lot of flack for something that isn't even their fault. A lot of this is fear of change. In my opinion, that is a well warranted fear.

If we don't have manpower, patients don't get seen, studies don't get ordered, drugs don't GED administered, and surgeries don't happen. In the worse case scenario, that means patients die. gloomy, cynical side of me coming out in full force. Concern for patient safety also coming out in full force.

So patients go unseen, and residents don't see them to learn from them. They operate less. They deal with less problems. They see less complications. They work up less patients. They lose out on valuable training time. That means residency has to be lengthened in terms of years. From my understanding, this is how it is done in Europe where many countries have 60 hour or less work week restrictions. Surgical residency is six years or more.

The other bad thing: how will these new docs function when they are faced with 24 hour call alone? I'll let you infer.

All of this in the name of sleep--the other side of the coin. If residents aren't well rested, they make more mistakes. True. Less mistakes to learn from and more opportunity for mistakes when they are faced with a sleepless night later and have never been forced to function under such circumstances.

Other sad fact, each year this will apply to more and more residents at different levels, not just interns. So you are less trained at EVERY level--not just one year.

Any honest 20-something can tell you that more free time away from work does not necessarily equate to sleep or even rest. It often means more dinners out, more happy hours, more brunch-time mimosas, more pick-up kickball games, more nights out with the family, more time visiting friends in other cities, etc. All of those things I miss. Yes, I miss sleep but I do sacrifice some to gain a life. It will be interesting to see if these residents rate their happiness any higher than those of us not subject to the new rules. I fear not. It will also be interesting to see how many of them sleep during those hours off, as opposed to taste the newest brew at the local bar or take the kids to the zoo.

Perhaps we are sacrificing manpower, time for patient care, and education for more time with family or the sandman. On the other hand, perhaps we are sacrificing manpower, time for patient care, and education for more mimosas.

Tuesday, March 29, 2011

Everyone Is Entitled to My Opinion

Thanks to Emily (at Simply Southern) for being my first official follower! Thanks for the support and the great blog to read!

So I get the whole place posted on my blog (with a few modifications coming in the near future) and I get a strange twitter comment from a person I don't know (that's a good thing--unknown people following my blog!) that said:

"IMHO: Too much clutter! Afraid I'd fall in a booby trap!" (Their typos corrected of course.)

I'm obviously not much of a minimalist, and I still have some traditional roots in my contemporary style. However, this quote definitely has me thinking, and likely contributed to a good two days of "writer's block" due to fear of more of the same. As of this moment, I'm over it. Amazing what that clawfoot tub can do for a girl! But...

IS it too cluttered? Do I need to spring clean the decor?

What do YOU think, Goldilocks? Is it too cluttered? Is it not enough (unlikely)? Is it just right?

If it were your place, what would you change? What pieces would you do away with? What pieces absolutely have to stay? Are there ways I could make what I have more functional with less "stuff"?

Here's your chance y'all, your opinion matters. At least for today. (Sarcasm. I'm fluent.) Let me know your thoughts.

Sunday, March 27, 2011

The Grand Finale

Ah, here we are. At the end of the week (or at least what I am currently regarding as a week) and at the end of the tour. Here is my master bathroom, completely remodeled. It's the perfect oasis for relaxation at the end of a long day in the OR.

The leopard print walls that convinced me to go with the "safari"-ish theme in the master bedroom obviously inspired the rest of the animal print in the bathroom. Sadly, I had sort of "been there, done that" with animal print. As much as I love it, I think I've currently had enough (in my own home, that is). Also notice the carpet in the vanity and plain white tile by the shower which was just your generic white tiled shower. The countertop is an old poured marble one with some cracks in the sink. I don't have many pictures to show you, but I felt cramped in this room due to all the doors everywhere. And I didn't even have a closet door! There was just a red curtain hanging in the open doorway to the closet since a door had not been installed previously. The open door here is a full size door and extended all the way to the opening to the closet. The full size door in the shower area extended almost to the shower itself. While I was lucky enough to have a mirror on the back of one and a robe hook on the back of the other, the doors really made the rooms feel even smaller to me.

This is the good part! I traded in the dated animal print wallpaper, countertop, carpet, and tile for almost everything brand new. The only thing wasn't replaced was the cabinets.

The door to it all! I have been dying for a "barndoor" for a while! It's a great space saver and looks cool too! I found this door at an architectural salvage for less than $100 (and solid wood as well). It's finish was very similar to my headboard which was perfect. The door pull came from Signature Hardware.

The barn door slides out of the way to reveal my FABULOUS bathroom. I really have no other word to describe it. Classic black and white stripe walls, black and white checkered floor (with a twist), a clawfoot slipper tub. I could go on and on (much like this project did)!

This was prior to it being completely finished. But you can see the new doors here. The louvered door to the closet and the small bifold door to the shower room.

It's a real closet door!

The white cabinets stayed, but I found the new black glass knobs at Hobby Lobby for a quick update. The countertop was replaced with black granite and a porcelain white vessel sink. The countertops now feel taller too. Chrome accessories top off a contemporary version of a classic look. 

I traded the old plain white tile for this look. The white tile is simple porcelain while the black squares are glass/granite tile mosaics.

The best part of the redo is the new soaking tub! It's such a fabulous experience. The bath tub is actually acrylic (not cast iron) and was custom painted by the guys at Signature Hardware.

Of course I didn't trade out the tub/shower for just a tub (not in a master)! The shower enclosure converts the tub into a perfectly functional shower. There is also a handheld shower head for use during those long soaking baths. I don't have them yet, but riser mounted baskets for shampoo/soap are on their way.

For now, I hide my shampoo in this "Chalk it Up" flower pot from Hobby Lobby on a cute small column found at Uptown Country Home in Dallas. This will stay even when the shower accessories come!

All those feminine ruffles come from Target. They were perfect for the look I was going for--French, feminine, and fabulous. Notice the robe hanging in the corner. I replace the full size door with a bifold "closet" door that takes up much less space in the bathroom and actually made room for a towel bar.

Ah! Time for another blissful candlelit soak, glass of wine, chocolate, and a good read.

Night Night Time

On our way to the end of this journey...

The big part of the redo really involved my bedroom and bathroom. While I was afraid of going "drab" or borderline "emo", I couldn't settle on an accent color for my bedroom. More red? Yellow again? Maybe purple? What about pink? So in the end, I went with grey...and that has made all the difference.

My master bedroom was originally the reused decor of a previous guest bedroom. I traded in my king bed for a queen (for space purposes obviously), and the guest bedroom had the linens and everything ready to go. Not only that, but this townhouse came with a master bathroom wallpaper with leopard print (and I sorta liked it). That was very fitting for the "world travel/safari" theme I had going in the old bedroom.

When I first moved in, I had the bed in front of the windows. I really like walking in on the foot of the bed; however, I hate blocking all the natural light that comes through all those windows. So, the first thing I did was rearrange (and trade old, dingy pillows for new ones). Unfortunately, you know longer walk in on the foot of the bed. But there's lot of space and the windows let in more light. Do those pillows look familiar? They ended up embellishing my dining room chairs.

As with the rest of the home, the black and white theme was introduced along with the grey as the room's accent color. I aimed to mix fabric and texture more so than color in this room to make it feel like luxury, not gloom. After a mishap with one "handyman", I ended up replacing the carpet with vinyl wood floors (Konecto) and purchased this awesome black and white houndstooth rug for something warm to step on to in the mornings.

I love this Ballard Designs headboard. I waited for 3 whole months to get it...I think that might be the first time I've actually witnessed the fact that good things come to those who wait. Like I said, texture (not color) in this room. Silk in the drapes, ruched duvet and shams, tuxedo pillows and skirt, sweater pillows, and velvet throw. I just want to stay in it!

My nightstand. It's the last of my great grandmother's dining chairs (same as in the dining room) that I painted black. The lamp is the same one previously seen on the dresser with a couple coats of white spray paint and new black shades that costs me $1 each at an architectural salvage in Fort Worth. My dogs have added their personal touch to the corner of the da Vinci book. I have used a chair as a nightstand in the past, it works perfectly for a small space!

The chest of drawers. That crazy peacock was moved from the living room to this room. I love the crystal candlesticks that contribute to the "bling" this room has along with the silver accessories.

On top of the dresser. Memories of Brewster's first time at the beach and fun frames from Target and Hobby Lobby. The books, my favorite being Night, are ones I took from Mom's large collection of leather bound books. She's kind of a big deal. 

Making room for a tv harder than it should be. This seems to work out well, and all the cords are hidden, so at least I've gotten that far. The trunks used to be regular, run of the mill, wood. Again, more spray paint turned them into contemporary, metallic pieces that perfectly added more texture to the room.

And that door, well it leads to the 6 week long adventure that is the grand finale of Design Week.
Brewster is still offering up cuddle sessions. Brewster's favorite time is night night time! It's the perfect overcast day for some snuggling in that comfy bed! 

Not So Socially Awkward

Apparently my weeks end on Sunday, and for that, here's the end of Design Week. I took a "weekend" on Friday and Saturday so forgive me for delaying the best of my home!

My living room has been quite the project. I knew I wanted to do black and white in the living room when I moved in. I also knew I wanted to accent it with peacock blue. Mom somehow convinced me to buy a blue leather sofa, and it has worked out quite well. The biggest problem with my living room is it's layout. It's very long and very narrow which makes it hard to place furniture for entertainment purposes. It also has one very awkward wall that I'm still having fun decorating.


I really liked how the room APPEARED to be full, but it was TOO full. I loved the heavy black furniture, but there wasn't much room for anyone (except Chester my old greyhound). Unfortunately, the great entertainment cabinet I had blocked the air return, and I had to opt for something more energy efficient.


I traded in the heavy console pieces I loved for some lighter, more vintage pieces like the coffee table. The heavy coffee table I had before has been replaced by this cute, antiqued one painted with aqua and black harlequin. That itself opened the room tremendously.  (Please forgive the iPhone picture!)


I rearranged the room at Christmas to fit the tree in the corner. I ended up keeping the furniture in the same place after I took the tree out to make room for super cute "new" club chair. I've yet to decide what I think about the new floor plan. If you have ideas, please send them my way!

Traded in the big entertainment cabinet for this cute console table that I found at Canton Trade Days.

Brewster at Canton Trade Days

And here you have my wonderfully awkward wall. I have had a lot of "fun" trying to figure this wall out. It is still in progress. It's currently in need of a mantle at the least!

Brewster also likes the rug in the living room. This is the fabulous blue sofa my mom convinced me to buy. I "recycled" the pillows from my old bedroom in my previous house. There's much more space to walk around this room now, but this arrangement has made that awkward wall the focal point. Eek!

Does this chair look familiar to you? 
Perhaps from my "That's What She Said" post?

This chair got it's contemporary and precious (although it was already precious) update from 
J&B Interiors in Fort Worth, Texas.

It used to drive my mother crazy that I didn't have a clock (large enough to read anyway) in my living room, so here it is. The peacock plate at the top of was part of the inspiration for the rest of the room.

I recently saw a post from a fellow blogger about decorating with books (a very Kate Spade kind of thing to do). I chose this one, because it's an Apache blessing I love and the colors were perfect.

I love the new "cafe sign" trend. Words of wisdom found everywhere. 
This is my daily reminder not to "settle". 

Since my living room and dining room are technically one big room on the same floor, I used elements in both places to pull them together. The blue wall in the dining room brings the blue from the living room all the across the floor. The blue glass bottles here echo the motif found on the hutch in the dining room.

I AM a surgery resident afterall! The top two books I pick up on a near-daily basis. The ancestry of Brittney Lee Culp, M.D. happens to be the hard work of my mother's as she know has our family traced back to the 1200s on one side! And no surgeon should live without a vintage (or vintage-replica) of a good anatomical atlas!

While I am running low on ideas for rearranging this room, and especially that awkward wall with the fireplace, I do have a couple left. I'll share them with you as I complete them. But please feel free to comment with ideas! Here are a couple "overhead" views (as best as I could manage) in case you need inspiration yourself!
Please excuse Chelsea and her nap time.

Brewster is offering himself up for a great cuddle session. However, we're not quite to the grand finale, and Design Week is almost over.

Thursday, March 24, 2011

That's What She Said

In light of the room I'm blogging about today, I've appropriately titled this one with my favorite quote from "The Office". Of note, "that's what she said" follows just about 50% of everything a surgeon says, and no, it has not gotten old.

My office occupies the "loft"-ish area at the top of my stairs on the 3rd floor. I love the french doors and all the natural light. Sadly, I'm not at home much during the daylight hours to take pictures to show you just how lovely that natural light is.

A bright mix of colors that complimented the painting. ("Godzilla" by Jonathan Revett) I loved this room, even though it was somewhat more traditional than my current taste. It was comfortable and bright, but the new remodel off this room wasn't really working with all the primary colors. More on that later...

The black and white scheme takes over, and yet I was able to keep some of my favorite pieces--like that artwork, the color red (of course!), and especially that anthropologie lamp shade!

My desk is actually a kitchen island that I picked out from Ballard Designs. It used to serve as a kitchen island in a previous home, then as a sideboard in another home, and now it's my desk. Who knew a kitchen island could be re-purposed so many times, and do it all so well? 

I love the French, vintage, and little bit of narcissism I have mixed into my "work wall". This wall is fabulously functional AND feminine. 

I added in tulips (another favorite) to bring the yellow from the painting across the room, and for a daily "pick me up".

With all that red, black, and white, I couldn't help but throw in a little plaid (another favorite, thanks to my Scot-Irish roots) in the form of a pillow (another favorite). There's plaid in the dog bed too! Have you noticed a theme here? Perhaps I should have titled this one "A Few of My Favorite Things". I spend a lot of time in this room when I'm at home. So, I figure, I might as well surround myself with tokens of love--even if it's a somewhat narcissistic kind of love. (Winning!)

The Container Store contribution was significant here. Do you KNOW how much trouble that place can be?

Lastly, I found that fantastic urn at White Elephant Antiques when I first started my project of redecorating the house. I apparently couldn't live without it (add it to my list of my favorites as well). My friend Kendall (over at Lower Oak Lawn) gave me the rather self-descriptive quote with its perfectly colored frame--if only it were about vodka rather than champagne!

Again, the office is just at the top of the stairs, so I'm sharing my stairwell at the same time. The first piece I commisioned from one of my best, and most creative, friends, Mrs. Anna Jones. The others are the remnants of my more traditional decor (notice their earthy tones) that I wasn't quite ready to part with. They all seem to have a happy home on this wall together.

Once again, I find myself up way past bedtime. (Which definitely does not equate to winning.) Productivity was severely lacking after arriving home at 7:30pm and indulging in the new episodes of Grey's Anatomy and Private Practice. In fact, I even lost the time to soak in the tub again tonight (another favorite). Here's to enjoying a few of your favorite things...even if that includes sexual innuendos followed by obnoxious counts of "that's what she said" and bi-winning, Charlie Sheen remixes.

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