JKB over at gunfreezone asks why medical training requires doctors to do rotations in specialties that are not their own, pointing out that engineers in one field don’t have to also do internships at a civil engineering firm, a mechanical engineering firm, a structural engineering firm, and a chemical engineering firm. He states that it looks like a complete waste of the student’s time. The reason that medicine does that is actually pretty simple, so let me give a simple explanation.
It isn’t likely that a mechanical engineer will do something that will have a direct effect on a chemical engineer’s job. That chemical engineer isn’t likely going to have an issue with avoiding the problems that a structural engineer is having. Imagine if a mechanical engineer tightened a screw a quarter turn, and this caused the hydraulic fluid to become acidic and then the building collapsed. Not so in medicine. Sure, people in medicine tend to specialize, but the human body is a complex system, and changes to one system have profound effects on the others.
Let’s say that I am in cardiology and I have a heart failure patient who is in fluid overload. There are a number of drugs that one could choose from to get rid of those fluids. I could try furosemide, or perhaps bumetanide. Perhaps torsemide, or even hydrochlorothiazide. Any of those medications would likely solve your patient’s issues, but which one of these is going to be detrimental to the patient’s kidneys? Do I want to choose a potassium sparing or a potassium wasting diuretic? How will that react with the patient’s preexisting autoimmune dysfunction? I could consult a nephrologist, an endocrinologist, and an immunologist, but doctors largely don’t stand around most of the time having huge arguments. That only happens on TV shows, not because there are no egos involved, because there are. Medical people are just too pressed for time to keep doing that, so wouldn’t it be easier if I already knew?
So for that reason, most in medicine learns a little about every system and specialty before going on to gain a deep understanding of their specialty. Nurses, doctors, PAs, NPs, all of them.
The first comment on that post complains about sterile fields and how they are “superstition.” Sterile fields are there to prevent post procedure infections. You can’t see infectious agents. Perhaps you didn’t touch anything. Or maybe you bumped into something that was covered in S. aureus and didn’t notice. How do you know? Can you be sure? If you are wrong, you will know in couple of days when your patient goes septic. You can’t bet a patient’s life on “the ten second rule.” Certain behaviors are high risk, so procedures get written in to the process to reduce or eliminate those higher risk behaviors. That includes treating everything that “breaks field” as though it was covered in an infectious agent- because it might be, and there is no way to know for sure. So you toss the offending object aside, and use one that you KNOW is sterile.
As an example, the most common cause of hospital caused infections is a CAUTI (Catheter Associated Urinary Tract Infection). It’s caused by a catheter introducing a pathogen into the urinary tract. That can affect the kidneys. It can cause Acute Kidney Injury. In some cases, that can cause Chronic Kidney Disease and ultimately kidney failure, or it can cause septicemia (a blood infection), which leads to death. Because of this, there are procedures that need to be followed when inserting, caring for, and ordering indwelling catheters. Can you violate that procedure and get away with it? Sure. A few times. Maybe only once. But one thing is sure, you will eventually wind up with a septic patient. So the procedure is there to prevent that.
22 Comments
Aesop · October 9, 2022 at 11:18 am
A here we see the difference between actual medicine, and “I saw a couple of pages over at WebMD”.
Medicine isn’t car repair. You don’t just learn about the lug nuts. You have to know how everything affects everything else, as it always does.
For them to be at all similar, you’d have to learn how to work on the car.
While it’s running.
Driving down the road.
At which point, changing a tire while tooling down the interstate takes on a whole new aspect, doesn’t it?
And while you could change the car’s paint job or trunk carpeting without affecting the driving behavior, bodies are vastly more complex. That nick or blister on your toe turns into a septic wound, which lands you in the ICU for septic shock, and you lose a foot, because you have diabetes, ignored that little nick, and got gangrene and osteomyelitis and nearly died.
We regularly have med students in my ER doing their emergency medicine rotations.
A bare few want to come work in the ED for their specialty after med school. Most don’t. Which is good, because we don’t need all of them, just maybe 2% of them.
For the others, it’s a once-in-a-career opportunity, to see the considerations in, for example, how their anesthesia practice may overlap when we get a critical trauma patient, whose airway is still mostly on the handlebars of his motorcycle back at the accident.
Or a family practice doc seeing how the ED docs handle management of the patients they’ll get a couple of weeks after their crisis presentation for new-onset diabetes and DKA, or a severe stroke.
Or how 1/3rd of their patients forever will have a psych component.
And on and on.
All of them learn metric tons of information from a few weeks of real-world work like they’ll never get it from a book, and how it all inter-relates with everything else. Including, under supervision of board-certified ED MDs, working up patients, presenting them, and treating them, from stitching up their accidents, to prescribing their meds and course of therapy, bearing in mind all their body systems and other conditions, which latter they’ll be doing for the rest of their medical careers, in whatever specialty, however less urgently than it’s done in the E.D. And why, if they screw it up, the ED will be fixing their mistakes.
And people that think sterililty and infectious disease prevention in the hospital is mythology, are simply ascientific morons too stupid to know what they don’t know. That’s the “masks don’t work” crowd, in one second’s summary. Now you know what became of the kids who ran with scissors and ate the paste in arts and crafts class. There’s no nice way to say that, so there it is.
Having more than 2 doctors discussing a patient at one time in-hospital is purely TV trope, because they’re all busy doing their jobs for hundreds of patients, and they don’t have time to get into pissing contests in person. Ten times out of nine a doc may do a phone call in or out, and half the time, the nurse is passing on the info, not another doctor, because we see the patient for an entire shift, not a 3-minute drive-by, even in the ED.
While I’ve had 79 patients at once (yes, really) all to myself in the ED, and occasionally I get 8 minor ones, the usual is 1-4 at a time for a 12-hour shift.
The docs are juggling 10-20, pretty much always, for an 8-hour shift. So they only get a few commercial breaks with the actual patients, unless they’re in full cardiac arrest. They don’t have time to deal with other docs, except on the phone, for a few minutes, who half the time don’t even call back, day or night.
If people who opined about “how it is” or “oughta be” spent a shift or three in an actual ward, 89% of them would STFU, and go back to what they know, and 1% would have their eyes opened, and be a little more understanding of the rolling disaster that is current medical care under the best of systems, and then they’d yell at their congressweasels to get the government the F out of health care, because every time they touch it, they screw it up harder.
The other 10% would still be idiots, because they can’t help themselves.
Even the cops and paramedics only see part of the picture, when they’re around, just as we only see the part of their job when they’re around us.
My favorites are the people who come in yelling and screaming and making recockulous demands because they saw an episode of Scrubs once, and try to tell all of us how we should be doing our jobs. They either surrender or walk out after two minutes of bad cop-bad cop from I or my colleagues, because nobody’s got time for that kind of stupid shit in the moment. The trauma docs simply intubate them, and they can figure it out themselves when they get extubated a day or two later in the ICU.
Divemedic · October 9, 2022 at 4:36 pm
I will say that, when I transitioned from Paramedic to RN, there wasn’t much from a medical standpoint that I learned. What I learned was how to look at things from a nursing perspective. It requires a whole new way of thinking about what you already know, with a different approach, a different set of goals, and different expected outcomes.
That is why there are different specialties. The human body is an incredibly complex machine. No one can know and understand it all.
Vlad The Non-Impaler · October 9, 2022 at 5:51 pm
I was wondering who the long winded blowhard was because I read the comment before looking at who wrote it.
Now I see it was the Great Aesop.
A more “Often Wrong But Never In Doubt” human will be hard to find.
“While I’ve had 79 patients at once (yes, really) all to myself in the ED”.
Bull. Shit.
I *maybe* but not really, could believe 79 pts in a 12 hour shift (esp. if those hours are in fast track) but 6+ pts per hr and only 8(!) are minor ones. BWAAHAAHAA!!
He must work in that special ED where all the pts are critical except for the occasional, rare minor one that sneaks past triage.
Good luck convincing anyone who has worked in an ED the rooms turn over that fast.
A 79-1 pt ratio!! BWAAHAAHAA!!
Divemedic · October 9, 2022 at 7:29 pm
You know that Aesop and I have had our issues so I am not afraid to disagree with him when I think he is wrong, and I agree that 79 seems a bit high, but large ratios are not unheard of. I work in a 50 bed ED. When the ED is full, we pull labs, get X-rays, then treat non-critical patients in the lobby. The medic and RN assigned to triage are responsible for them. The most I’ve ever seen being treated in the lobby by that single nurse is 35. That is a ratio of 35:1. I’ve spoken with admin about this and told them what an unsafe condition this is, but the answer I got was “We have no choice. Thanks to EMTALA, we can’t turn them away. We also can’t ignore them. So do the best you can with what you have.”
Now I know that 79 is a lot higher than 35, but I don’t think it’s impossible, either.
Aesop · October 12, 2022 at 3:55 pm
Vlad,
Fortunately your total lack of knowledge of the situation doesn’t change the realities that occurred, and what I actually did. You should listen to Divemedic.
Working as I did at the hands-down busiest ER west of the Rockies, and on many days the busiest ER on the planet, a 79:1 ratio, while abnormal, wasn’t unheard of. Thankfully that peak was rare.
In fact, I inherited that situation from my day shift counterpart, who could tell exactly the same story.
The breakdown was as follows:
As the third RN assigned to triage that 12-hour shift in 2002, (the other two nurses sorted incoming patients all shift long), unlike my colleagues with 5-8 critical patients around the horseshoe, I was responsible for 10 people sitting in chairs right in front of Main Triage.
I also had 24 more in the outer waiting room, including 8-10 with chest pain, who were getting full cardiac work-ups, including serial cardiac enzymes drawn and EKGs every four hour for the entire shift.
Besides them, I had everyone who couldn’t sit up in a chair on arrival, and the admitted med-surg and pre-op patients who’d been worked up and admitted, but for whom no bed in the hospital was available. That was 12 gurneys right behind triage, two deep by six across, and another 28 gurney patients conga-lined all around the hallways of the department. IIRC, 3-4 of these were appendicitis cases waiting for AM emergency surgery. I also had all the trauma downgrades who didn’t need immediate surgery, and there were five more of them, including one with 12 holes from 6 gunshots, that miraculously were all meat, and no bones, arteries, veins, or major nerves, and another guy with two completely and multiply-broken closed leg fractures from getting stopped by his dashboard at 50 MPH.
All at once. From the get-go. Not total. Now.
I had no tech, and no help. When I got report, I re-asked the day shift guy I took over from “No seriously, how many patients?” and he repeated to me “79”. I asked him how often he was checking vitals, since the standard was every 1-2 hours, and napkin math told me that at 5 minutes@, I’d take 6-7 hours to go from A-Z, and back to A. He looked at a couple of charts, and it turned out he was doing vitals on them every 6-7 hours. QED.
So I had to do vital signs as quick as possible. Also satisfy requests for pain meds, nausea meds, blankets, urinals and bedpans for non-ambulatory patients (that was all 57 of them on gurneys), as well as water or food for those who were allowed to eat or drink. Anyone who got discharged? My job. Anyone who got admitted? My job to call report, take them to the floor, and bring back the empty gurney, all solo. And still care for the other 78 peeps.
I spent the first 30 minutes after report finding all my patients, writing down their names and locations, and making a pile of their actual medical charts. Then the next 11 1/2 hours running over anyone not in full arrest or treating same by trundling a portable VS machine, doing vital signs and fulfilling all other duties as quickly as possible, while trying to keep an eye and ear on every patient scattered over 5000 ft² in three different areas, and entering their chart notes (no computerized BS), while the even more critical medical and trauma patients came and went around me.
By morning, I had gotten down to “only” 12 patients, after getting 6 more med/surg admits, 3 patients eloped from the waiting room, 41 got admitted, and 29 got discharged, all accomplished solo by yours truly in one hellacious shift.
A few years ago, going through my papers, I came across the official ER notepaper, a trifold paper towel, on which on the day I had written all 79(+6) names and their locations, and dispositions, which I had kept at the time, hoping to wave it in front of JCAHO, who was coming for their tri-annual hospital accreditation visit.
Instead, they took one look around the department at 7:01 PM on a night shift when I wasn’t working, saw the typical 100-patient scene that looked like the train station scene in Gone With The Wind after the Battle Of Atlanta, including gurneys stacked head to toe on every square foot, and said “Privacy issues must be challenging for you”, and left the ER, never to return on that accreditation visit.
We passed, btw.
Currently (in only Califrutopia), ER nurses are restricted by law to 4 patients max, and since that ratio law passed, the most I’ve had direct responsibility for has peaked at “only 37”. That time at a less acute hospital, and only 9 times the maximum ratio considered safe, instead of the old record 20 times. How lucky.
(Oh, and that rule was also waived for COVID, when I had 20+ regularly – i.e. at least 2-4x/month – for weeks on end.)
If not for HIPPA, I’d root around in my files and post a pic of the paper towel roster, but even without it, I was there, and I did it, and if you think it didn’t (and doesn’t) happen, it says more about what you don’t know about “how it is” than it does about what I actually did.
Thanks for vividly illustrating my original comments about people who learned everything they know about real life in the medical field from WebMD etc., and sincere best wishes with your next guess. Glad you find reality so funny. It’s the only way most of us “in the biz” can keep our sanity.
Exile1981 · October 9, 2022 at 12:13 pm
1st year engineering we learned about ither disciplines. Later after i had specialized i had classes on affiliated fields of engineering, mostly so I understood how the interface between their parts and mine worked.
We even had to take a hands on machining class, that class made me truly understand that just because you can design it does not mean anyone can build it.
BobF · October 9, 2022 at 2:00 pm
Small ex.: I have Chronic Kidney Disease and hypertension. I take a handful of pills morning and evening. On two occasions my cardiologist has changed my BP medication from an existing one to a fairly new one that was better for my kidneys. Kidneys aren’t his field, but he remains aware of and reacts to changes in my nephrologist’s field. He is also involved with my pain management scheme as it affects his, cardiovascular, area. Damn, I’m glad his isn’t a narrow focus way.
Steve S6 · October 9, 2022 at 3:48 pm
Yes but. Too many docs then specialize and stay in their lane. Wife was in a head on (other driver crossed double yellow fully). Great ortho for the knee injury; dashboard knee he called it, including separated ligament. Once knee was stabilized he pronounced her good. Did not address pain in lower leg as the knee (his specialty) was fine. No referral even. Turned out to be injury to L5 and nerve impingement; chiropractor found it. Also have had in-laws doctors mess up prescribing something contraindicated with other meds they were on. So the cross training isn’t working out in the real world. Too often you get, oh then talk to your other specialist about that. Neither coordinates with the other.
Divemedic · October 9, 2022 at 3:51 pm
In the hospital, the ED nurse and ED doctor are the ones who coordinate. Outside the hospital that is your primary care provider.
The specialists have to specialize. The ortho caring for your knee isn’t going to look at neuro in the back. You should have mentioned the leg pain to whichever doctor it was that referred you to the ortho. It was that doctor who should have been the one who made sure the spinal issue was handled.
With medication interactions, the pharmacy where you fill your medications is supposed to catch that, even if the doctor misses it. That’s why a pharmacy has to have at least one PharmD on staff, and is also why you should fill all of your prescriptions at the same pharmacy.
Gerry · October 9, 2022 at 4:19 pm
My wife has secondary progressive MS. She had a wound from a fall that developed into an ulcer. She can’t walk so she has developed edema in her legs and venous reflux in her deep veins. Meanwhile she lost muscle control for her bladder so she’s had a catheter for the last year.
Each of her doctors, I think there are five now, understand all the problems but they stay in their areas of expertise. So far they work well together.
Divemedic · October 9, 2022 at 4:42 pm
That is exactly how it is supposed to work.
Don Curton · October 9, 2022 at 5:30 pm
Your engineering example ain’t quite accurate. A mechanical or structural engineer could make a change that affects the process and the chemical engineer has to review and sign off. So yeah, there is a lot a cross-field dynamics. The difference is that making a change in the field takes weeks, months, years and requires numerous cross-discipline reviews. Where doctors are too busy to consult and the patient needs an answer RIGHT NOW, engineers generally have lots of time to consult. So, not quite the same. Your point stands, but the example is a little off.
Divemedic · October 9, 2022 at 7:24 pm
Which of course makes my point: It sucks when someone who knows little or nothing about your profession tries to tell you about what you do for a living.
Don Curton · October 9, 2022 at 7:51 pm
Absolutely agree.
Aesop · October 10, 2022 at 1:56 am
Patients rarely need an answer RIGHT NOW.
If they do, it’s not an emergency.
If it is an emergency, the patient generally isn’t up for “Twenty Questions”.
QED
Bonus Round: See if you guess where the noun “patient” comes from.
Bonus Bonus Medical History:
Napoleon was famous for making a lot of casualties in France (and all over Europe), but by way of payback, all that loot extracted from the French monarchy in the New Republic went to a phenomenal treasure trove of new public hospitals all over Paris, which all specialized in something. Eye problems went to the Eye Hospital, skin diseases all went to the Skin Disease Hospital, births all went to the Maternity Hospital, and so on. Thus medicine met statistics for the first time, and left the Dark Ages of quackery and secretive cures. Everybody told everybody what worked, and what didn’t, and life expectancy and success rates consequently soared.
And it was all free to anyone, with one caveat:
You will do what the doctor orders.
Yappy backtalkers had their pallets picked up bodily, carried out oh-so-carefully, and gently deposited at the curbside of the street, with the cheery and sincere benediction “God be with you, Mssr.” And that was that. STFU and listen, or GTFO and cure yourself. Pick one.
It’s an innovation desperately begging to be reinstated en masse, society-wide, in the entire medical system.
John Fisher · October 10, 2022 at 3:44 pm
Ask the civil engineer how much he needs to know about chemical engineering to build a refinery or a chemical engineer the same question about civil engineering (I know that in 2022 that is a fictitious example but…).
Engineering has places that are mostly in the domain of one engineering discipline but has others that span 2 or more. Electronic packaging is one example; it spans electrical, mechanical and materials engineering. Semiconductor manufacturing is another place where multiple engineering disciplines cross. In my career, the interdisciplinary problems were a lot more fun.
Eric Wilner · October 11, 2022 at 1:26 pm
Missed this initially; just got here from GFZ.
Even with the rotations business, there are major issues.
At various times, a few years ago, I had occasion to take someone with unusual (but far from unheard of) long-term medical issues to the emergency department at the county hospital, back in Silicon Valley.
This person’s primary care was through the county medical system, which you’d think would put those documented medical issues in full view of the county ER docs, but apparently not. On one occasion, this led to a prescription for an antibiotic that turned out to be on the strictly contraindicated list (as in, several days in the hospital shortly afterward). On another, the ER doc prescribed morphine to tide the patient over until actual treatment would be available next morning. After much delay, the nurse came out with the syringe and asked some questions that ought to have been answered right there in the patient’s file, like “do you have any history of low blood pressure?” (Er, yeah. Should be in the file. Repeatedly. Or maybe the doctor could have asked that during the brief interview with the patient, before writing the prescription?)
Seems the patient is responsible for carrying around a list of safe / not-safe drugs and checking the prescribed treatments against the list. And this is likely to annoy an overworked and grumpy ER doc, no?
Divemedic · October 11, 2022 at 2:47 pm
Yeah, sharing of medical files is something that isn’t universal. That’s why the nurse asks those questions, and is one of the reasons why nurses and pharmacists make as much as they do, and why they are required to have such comprehensive educations.
At least a couple of times a week, I catch things missed by the doctor. Like the time he ordered morphine for gouty arthritis. I had to go and point out to him that opiates don’t work on pain caused by gout. Anti-inflammatories work better. Something like Toradol, Mobic, or a corticosteroid.
I have a friend who is a pharmacist, and she gets all kinds of grief for refusing to fill a prescription that is contraindicated by the medical condition that another prescription they have is given for. It goes like, “The doctor wrote it. Just fill the prescription like he wrote it. All you are there for is to count out the pills.”
So many people try to circumvent this by going to multiple pharmacies.
Eric Wilner · October 11, 2022 at 4:05 pm
This was all within the county medical system (much of it from that same hospital, and even the same ER), though, so you’d think the sharing of files wouldn’t be an issue. I suspect everyone was just too overloaded to look at the patient’s files, or to ask pertinent questions – and that was years before the Pestilence. I really hate to think what that hospital is like now.
Divemedic · October 11, 2022 at 4:20 pm
Systems don’t always work well together. There are different hospital systems in Florida that have ten or more hospitals: Advent Health (formerly Florida Hospital) with 42 hospitals, Baptist Health (15 hospitals) Community Health (11 hospitals), HCA (the national giant with 54 Florida hospitals), and Orlando Health (12 hospitals). Even within systems, they don’t all share records with each other, and sometimes hospitals within 2 different systems will share info that they don’t share with a hospital in their own system. This is mostly because of computer system compatibility and IT reasons.
Years ago, the problem was even worse. My hospital recently changed from an old software (Cerner) to a newer one (Epic). We can’t look up many of the records from the old software system because they are not compatible. Blame the computer nerds for that one.
Hospital informatics are a real problem.
Eric Wilner · October 11, 2022 at 7:38 pm
Ooooh, yeah. IT changes… local(ish) medical center switched to a New Improved Patient Portal this year, and not only did nothing transfer over (medical records, patient accounts, any of that), but the new one is missing some really basic functionality, like “send a message to my primary-care doctor.”
I assume some of this is IT contracts being poorly negotiated, but I’m sure some of it software refusing to export data in any way that could be imported by a competing product, for obvious reasons. Which, again, partly reflects poor negotiation; institutions really ought to refuse to buy (or especially rent) software that doesn’t play nice with exporting/importing data in documented ways.
Divemedic · October 11, 2022 at 8:29 pm
But look at how much money the hospital saved!
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