I made a mistake

[Dominic90]

Hey all,

I made a mistake at work yesterday and I feel terrible.
I'm an intern in 1st year of psychiatry. A patient came in the ER yesterday to be hospitalized in psychiatry because he started to feel persecuted by others. He had a small bruise on his head, so I asked the surgeon if we should stich it and he said no, to just ask the nurses to put some bandage on it. I asked the patient where he got hurt but he was dellusional so i didnt get a right answer.
The patient was 71 and didn't have any psychiatric history.
I had him hospitalised in the psych ward without doing anything else. The resident that saw him 1 hour later in the ward called me and asked me if I orderded a brain scan. And then I realized the mistake I made, so the resident ordered the scan and it showed a subdural hematoma. So I worked with the resident to have the patient transferred in the ICU for observation. Nothing bad happened and he's supposed to be transferred in Neurology.

How could have I been so stupid? I feel terrible. The only thing I can do is go to the chief on monday and tell him I'm sorry, that I learned from this mistake but that I have no excuses for not ordering a CT scan in the ER and that I accept the consequences of my actions.

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[Dharma]

**** happens. Don't beat yourself up. This is how we learn sometimes... By getting burned and taking our lessons the hard way.

 

[Mad Jack]

Hey all,

I made a mistake at work yesterday and I feel terrible.
I'm an intern in 1st year of psychiatry. A patient came in the ER yesterday to be hospitalized in psychiatry because he started to feel persecuted by others. He had a small bruise on his head, so I asked the surgeon if we should stich it and he said no, to just ask the nurses to put some bandage on it. I asked the patient where he got hurt but he was dellusional so i didnt get a right answer.
The patient was 71 and didn't have any psychiatric history.
I had him hospitalised in the psych ward without doing anything else. The resident that saw him 1 hour later in the ward called me and asked me if I orderded a brain scan. And then I realized the mistake I made, so the resident ordered the scan and it showed a subdural hematoma. So I worked with the resident to have the patient transferred in the ICU for observation. Nothing bad happened and he's supposed to be transferred in Neurology.

How could have I been so stupid? I feel terrible. The only thing I can do is go to the chief on monday and tell him I'm sorry, that I learned from this mistake but that I have no excuses for not ordering a CT scan in the ER and that I accept the consequences of my actions.

You'll never make that mistake again. Mistakes are the things we learn from- they call it the "practice" of medicine for a reason.

 

[OldPsychDoc]

Hey all,

I made a mistake at work yesterday and I feel terrible.
I'm an intern in 1st year of psychiatry. A patient came in the ER yesterday to be hospitalized in psychiatry because he started to feel persecuted by others. He had a small bruise on his head, so I asked the surgeon if we should stich it and he said no, to just ask the nurses to put some bandage on it. I asked the patient where he got hurt but he was dellusional so i didnt get a right answer.
The patient was 71 and didn't have any psychiatric history.
I had him hospitalised in the psych ward without doing anything else. The resident that saw him 1 hour later in the ward called me and asked me if I orderded a brain scan. And then I realized the mistake I made, so the resident ordered the scan and it showed a subdural hematoma. So I worked with the resident to have the patient transferred in the ICU for observation. Nothing bad happened and he's supposed to be transferred in Neurology.

How could have I been so stupid? I feel terrible. The only thing I can do is go to the chief on monday and tell him I'm sorry, that I learned from this mistake but that I have no excuses for not ordering a CT scan in the ER and that I accept the consequences of my actions.

You're doing it right. How you're responding to the mistake is far more important than the mistake itself. You'll never forget it, your future juniors and students will learn from it, and when you're the chief you'll know how to help an intern deal with what they do.

 

[Dominic90]

Thanks for the reassurance! But that mistake is so big. I mean every medical student knows that a geriatric patient whitout a history of psychiatric illness should have a scan.. I just don't know. I had so many old patients come in with psychotic symptoms and ordered a scan, I just don't know why I didn't think about it this time around.

 

[nexus73]

Was he seen by an ED physician or did you do the physical evaluation?

 

[LasVagus]

It also sounds like you weren't the only one who missed it. That fact won't make you feel any better, but it is a reminder that mistakes in medicine generally involve the Swiss cheese model (a whole of bunch of misses lining up together). In addition to you not ordering the scan, there was apparently an ED doc who evaluated an elderly patient with altered mental status and a bruise on the head and called a psych consult before ordering a brain scan...? The good news is that there were colleagues behind you double-checking your work, so the system worked. In the not-too-distant future, you will catch a junior's mistake. They will feel like you do now, but you will tell them this story and they will feel better. Now get back out there, doc

 

[Dominic90]

the physical evaluation was done by a medical student (that's the politics of the hospital, unless there are somatic comorbidities). She said the physical exam was normal. I talked to the surgeon about the bruise after I got the call from the other resident to ask him if I should have ordered a scan (he said well, you didn't ask me about a brain scan but it would have been wise to order a ct scan). WTF?!

 

[Dominic90]

It also sounds like you weren't the only one who missed it. That fact won't make you feel any better, but it is a reminder that mistakes in medicine generally involve the Swiss cheese model (a whole of bunch of misses lining up together). In addition to you not ordering the scan, there was apparently an ED doc who evaluated an elderly patient with altered mental status and a bruise on the head and called a psych consult before ordering a brain scan...? The good news is that there were colleagues behind you double-checking your work, so the system worked. In the not-too-distant future, you will catch a junior's mistake. They will feel like you do now, but you will tell them this story and they will feel better. Now get back out there, doc

Actually since the patient had psychiatric symptoms, he was not seen by an ED doctor. They call the psychiatrist first in that case and that was up to me to ask a consult from the ED doctor which I failed to do.

 

[splik]

I don't see how it is helpful to blame yourself for this. You are an intern, you are supposed to be supervised and the system is supposed to have enough checks and balances to avoid a bad outcome. IN this case the patient was eventually correctly diagnosed. It is unfortunate that the hospital sent a 71 year old patient for psych eval without evaluating them first. This would fall below the standard of care (geriatric patients should first be medically evaluated). If there had been a bad outcome, although you would have been named on the law suit, you would likely be very quickly dropped. The hospital clearly has some serious deficiencies that make that make them liable for significant damages if there is a bad outcome.

Another lesson is never believe anyone in the ED who tells you that the neurological examination in normal. It is rarely done at all.

 

[hello1234!]

the physical evaluation was done by a medical student (that's the politics of the hospital, unless there are somatic comorbidities). She said the physical exam was normal. I talked to the surgeon about the bruise after I got the call from the other resident to ask him if I should have ordered a scan (he said well, you didn't ask me about a brain scan but it would have been wise to order a ct scan). WTF?!

So it's not the surgeons job to determine when to order a head CT on your patient especially if you were curb-siding them to ask a specific question about a bruise. Why the "WTF"??

The patient was admitted without having a doctor doing a physical exam? No documented neuro exam on someone who bumped their head prior to admission orders???

You are the doctor. You never get to say, the med student said x,y, and z without verifying it. If you learn anything from this, learn to never say "the med student said it was normal" ever again.

Internship is about learning. As long as you learn from this and continue learning you'll be fine. I still remember my biggest mistakes from residency and still think about them from time to time.

 

[Dominic90]

So it's not the surgeons job to determine when to order a head CT on your patient especially if you were curb-siding them to ask a specific question about a bruise. Why the "WTF"??

The patient was admitted without having a doctor doing a physical exam? No documented neuro exam on someone who bumped their head prior to admission orders???

You are the doctor. You never get to say, the med student said x,y, and z without verifying it. If you learn anything from this, learn to never say "the med student said it was normal" ever again.

Internship is about learning. As long as you learn from this and continue learning you'll be fine. I still remember my biggest mistakes from residency and still think about them from time to time.

Thanks for your input. I agree, I shouldn't blame the surgeon.

Actually that patient was hospitalized against his will. Here's the full story (I don't know how it works in the states, I'm from Belgium), that patient went to the police to complain about his neighbors but the story seemed odd so they escorted the patient to another hospital for a mandatory psychiatry evaluation. The psychiatrist there has to evaluate 3 criteria to have a patient hospitalized against his will : the presence of a mental illness, dsngerosity for the patient or others and the fact that a patient doesn't want care. The 3 criteria must be there. So the psychiatrist there said that he had to be hospitalized against his will and he was sent to our hospital where he only saw a psychiatrist. (Me). The etiology of the fall wasn't clear. So yeah it wasn't seen by an ER doctor, that's up to me to ask a consult if I think it's necessary. In this case it was but I didn't realize it.

 

[Armadillos]

Actually since the patient had psychiatric symptoms, he was not seen by an ED doctor. They call the psychiatrist first in that case and that was up to me to ask a consult from the ED doctor which I failed to do.

I've only worked at a couple hospitals and it's always the ER docs who see patient first then consult psych after their work up, is this sort of set up typical??

 

[Dominic90]

I've only worked at a couple hospitals and it's always the ER docs who see patient first then consult psych after their work up, is this sort of set up typical?? Honestly, if I were in your position I would consult the ER on every single patient over the age of 50 no matter how good they look.

It's typical here in Belgium but it leads up to a few problems. I think I will always ask for a consult if the patient is over 50 like you said. You just never know.

 

[Armadillos]

It's typical here in Belgium but it leads up to a few problems. I think I will always ask for a consult if the patient is over 50 like you said. You just never know.

Don't do what I say, ask your supervisors what to do.

 

[Dominic90]

Don't do what I say, ask your supervisors what to do.

Well they say that if the patient doesn't have physical illnesses that I should just ask the medical student to perform a physical exam and if it's abnormal then I should ask a consult.

 

[wolfvgang22]

Medical causes for altered mental status should always be ruled out before assuming a psychiatric diagnosis.

 

[slappy]

Thanks for your input. I agree, I shouldn't blame the surgeon.

Actually that patient was hospitalized against his will. Here's the full story (I don't know how it works in the states, I'm from Belgium), that patient went to the police to complain about his neighbors but the story seemed odd so they escorted the patient to another hospital for a mandatory psychiatry evaluation. The psychiatrist there has to evaluate 3 criteria to have a patient hospitalized against his will : the presence of a mental illness, dsngerosity for the patient or others and the fact that a patient doesn't want care. The 3 criteria must be there. So the psychiatrist there said that he had to be hospitalized against his will and he was sent to our hospital where he only saw a psychiatrist. (Me). The etiology of the fall wasn't clear. So yeah it wasn't seen by an ER doctor, that's up to me to ask a consult if I think it's necessary. In this case it was but I didn't realize it.

Yes, this was mostly your fault. Mostly, because you're still a trainee, and your hospital should have required you to staff the ER evals with an attending. If this is a freestanding psych ER, you're still responsible for doing the essential medical workup unless you have good documentation of them being done at a different facility recently. It's also not unheard of for trainees to be implicated in lawsuits. AMA had a page full of such instances - you should be able to find them if you did a google search. Just get into the habit of staffing patients, even if they don't want you to. It's one of the important means of learning.

 

[Shikima]

First lesson, ERs are not always complete and thorough.

 

[Dominic90]

Well, I think we can all agree I'm mostly responsible for what happened. I think I should own up to it. How do you think I should present it to the chief? I was thinking of just apologizing and saying that I realize that things could have been much worse and that I have learned from this mistake. But I don't want him to think I'm a crying baby. Or should I ask to be transferred in another unit?

 

[Salpingo]

Well, I think we can all agree I'm mostly responsible for what happened. I think I should own up to it. How do you think I should present it to the chief? I was thinking of just apologizing and saying that I realize that things could have been much worse and that I have learned from this mistake. But I don't want him to think I'm a crying baby. Or should I ask to be transferred in another unit?

Do you think that the medical student or surgeon should feel guilty for what they did? My sense reading your post is that you don't (at least not consciously). Your supervisors probably feel the same way. They obviously want you to learn and become competent, but they don't really have anything to gain from you punishing yourself. If this is something warranting remediation or discipline, they'll take the appropriate action. In the US, every ACGME program should have a way of reporting a medical error, even if it didn't result in any harm. Not sure what the process is like in Belgium, but you can find out. There were multiple misses here that should be reviewed, not just yours.

These are complicated thoughts and emotions, and tough to dissect over the internet. We finally have a chance to prove ourselves competent and it feels like total **** when we don't live up to the standards we hold for ourselves, or imagine that others hold us to. Looking on the bright-side, you gave your resident a chance to be the hero, but I'm sure it would have felt better if you could have been that person. There will be many more opportunities to save the day, and there will be more times when you mess up (just wait until your first suicide). Give yourself some time to feel bad, but also stay ready for the next patient. If you can't get back into it within a week or two, get help outside of the forum.

There's been a rise in the US of interns and residents literally killing themselves. Its hard to imagine it when you're in the thick of things, but there is a life after internship and residency.

 

[Dominic90]

Nope I don't think they should feel responsible.
I think I have learned how to deal with cases like that in the future but at the same time I think I should go to the chief to inform him of what happened. Trying to cover it up and hoping he doesn't find out is not a good solution in my opinion. I think it shows I'm honest if I confess.

 

[Armadillos]

If it makes you feel any better, it doesn't seem any harm was done to the patient. You can make the most terrible mistakes in the world, but you have zero liability if it doesn't directly cause harm. Sounds like your off the hook and nothing actually bad happened. Learn from this, but don't worry/ruminate about it.

I've heard of medical/surgical residents admitting patients they didn't realize were dead...

 

[Armadillos]

Nope I don't think they should feel responsible.
I think I have learned how to deal with cases like that in the future but at the same time I think I should go to the chief to inform him of what happened. Trying to cover it up and hoping he doesn't find out is not a good solution in my opinion. I think it shows I'm honest if I confess.

Also stop looking at this like your confessing a sin. Sounds like an outside hospital evaluated a patient, missed the bleed. You also missed the bleed in the ER. Inpatient team caught the bleed. Patient then got appropriate care. The hospital that transported a patient with a brain bleed to a psychiatric ER is one who really screwed up.

Atleast in my state for an ER to transport someone involuntarily to a psych hospital, you have to sign paperwork assuring they are medically stable for psychiatric hospitalization.

 

[FlowRate]

Well they say that if the patient doesn't have physical illnesses that I should just ask the medical student to perform a physical exam and if it's abnormal then I should ask a consult.

I'm just so curious about this. Do you know what the reason is that you're told to have someone with *less* medical training than you do an exam? e.g. is this for the med students to get experience? are you so overwhelmed that 5 minutes doing a physical exam is a burden? does psychiatry in belgium completely eschew the role of physician?

 

[smalltownpsych]

Rule number one is to always look for physical stuff before psychiatric. In the adolescent residential treatment business that I was in a number of kids have died because in psych we tend to see everything through that lens. Where I worked we instituted some very strict policies about head injuries in particular. I would get resistance from staff, but a brain bleed can kill and everything else can wait. If I see a bump on the head and patient acting strange, I am going to make sure someone addresses that first.

 

[Dominic90]

I'm just so curious about this. Do you know what the reason is that you're told to have someone with *less* medical training than you do an exam? e.g. is this for the med students to get experience? are you so overwhelmed that 5 minutes doing a physical exam is a burden? does psychiatry in belgium completely eschew the role of physician?

Psychiatrists aren't allowed to perform a physical exam here. They say you can't for two reasons :

1/ You are very likely to miss something since you don't deal with physical illnesses anymore
2/ It is wrong for the psychiatrist/patient relationship

Is it different where you're from?

 

[OldPsychDoc]

Psychiatrists aren't allowed to perform a physical exam here. They say you can't for two reasons :

1/ You are very likely to miss something since you don't deal with physical illnesses anymore
2/ It is wrong for the psychiatrist/patient relationship

Is it different where you're from?

Maybe if you properly report this error--as you should--"they" (hospital? program? department? scuttlebutt?) would rethink that. I think that a psychiatry resident needs to have sufficient comfort with the neurological exam to perform it when indicated.

 

[calvnandhobbs68]

Psychiatrists aren't allowed to perform a physical exam here. They say you can't for two reasons :

1/ You are very likely to miss something since you don't deal with physical illnesses anymore
2/ It is wrong for the psychiatrist/patient relationship

Is it different where you're from?

"Not allowed" to perform a physical exam sounds insane to me. I'm sure most psychiatrists don't perform many physical exams, but there's no one here telling them they "aren't allowed" to.

 

[nancysinatra]

You might have made a mistake by not getting a head CT, but a bigger mistake was made by your hospital if they are triaging elderly patients with head injuries to psych. Learn from your mistake, hang in there, and don't let people make you feel bad about the situation.

 

[nancysinatra]

Rule number one is to always look for physical stuff before psychiatric. In the adolescent residential treatment business that I was in a number of kids have died because in psych we tend to see everything through that lens. Where I worked we instituted some very strict policies about head injuries in particular. I would get resistance from staff, but a brain bleed can kill and everything else can wait. If I see a bump on the head and patient acting strange, I am going to make sure someone addresses that first.

You're doing the right thing, but I just want to point out that psychiatry is not the only specialty that tends to see things through a "psych" lens. The OPs patient might well have been triaged to psych, and not to the main ER, because he reported paranoia. Ok so what. The patient was 71 with no psych history and a current head injury - the triage team should have caught that one. The fact that they didn't is evidence of their own bias. And it sounds like, in this case, an hour later, the psych resident caught it. Which is why we have residents overseeing interns. System works, right?

 

[Choledocholithiasis]

Well they say that if the patient doesn't have physical illnesses that I should just ask the medical student to perform a physical exam and if it's abnormal then I should ask a consult.

Now I'm just plain curious, who does the med student chief to? Only to you in this case or do they also present to an ER attending?

 

[SeniorWrangler]

I used to work at a facility where we had a PA to do physical exams instead of the psychiatrist, but I don't think there are any places in the US where you would have a medical student do the only physical examination, for the simple reason that you couldn't bill for an admit note. In your country things must work differently. This ultimately comes down to the eternal conflict between the ED and the consultant. I used to make ED docs mad by refusing to take geriatric psych admits without basic screening labs, but once in a while the psychotic guy would turn out to be septic or hyponatremic.

 

[FlowRate]

Psychiatrists aren't allowed to perform a physical exam here. They say you can't for two reasons :

1/ You are very likely to miss something since you don't deal with physical illnesses anymore
2/ It is wrong for the psychiatrist/patient relationship

Is it different where you're from?

1. We deal with non-psych illnesses every time we get paged to talk to a patient about chest pain, or when one of our patients is hyperglycemic, and every time we admit someone to the unit who has some sort of medical issue. Personally, I taught physical exam skills to MS2's when I was on my research year. I don't anticipate becoming so rusty that I'm not able to perform at least to the level of a 3rd year medical student.
2. In some circumstances, but we have to be able to assess for medication side-effects in outpatients and assess for urgent medical issues when inpatient (albeit that's likely leading to a medicine consult, they would be very angry if I hadn't at least examined the patient.) Granted, I don't plan on doing genital exams on my patients, although there have been times when we've had inpatients with legitimate genital issues who we had residents cross-cover so the primary resident didn't have to do those exams. (We had a patient who cut off his own penis and the wound needed to be serially examined--surgery rounded daily but wanted it to be checked more often than that.)

 

[digitlnoize]

Actually since the patient had psychiatric symptoms, he was not seen by an ED doctor. They call the psychiatrist first in that case and that was up to me to ask a consult from the ED doctor which I failed to do.

This is just plain stupid. Anywhere else like this? In our ED, the ED docs see everything, then call for psych after they've ruled out medical causes with labs/imaging and a history/physical exam.

 

[HarryMTieboutMD]

Love this thread- any ED system that triages to psych without an attending ED physician at least looking at the patient is broken.

More importantly, I want to echo- EMBRACE your mistakes and LEARN from them. For 99% of residents learning medicine comes from seeing a lot of patients and reading (ie, in this case you have a bunch of topics you can read about- when to image, late onset psychosis, natural history of SDH, etc etc etc). Being in the middle of everything and making fast judgment calls is one of the best parts about being a doctor.

Also I'm glad that doctors are taking back how we train residents from the pathos-influenced hegemony of lawyers and politicians. Sidney Zion is one of the worst humans to ever exist and can continue to rot in hell for what he did to resident education (not our fault his daughter did coke while taking an MAOI).

 

[deleted736562]

Love this thread- any ED system that triages to psych without an attending ED physician at least looking at the patient is broken.

More importantly, I want to echo- EMBRACE your mistakes and LEARN from them. For 99% of residents learning medicine comes from seeing a lot of patients and reading (ie, in this case you have a bunch of topics you can read about- when to image, late onset psychosis, natural history of SDH, etc etc etc). Being in the middle of everything and making fast judgment calls is one of the best parts about being a doctor.

Also I'm glad that doctors are taking back how we train residents from the pathos-influenced hegemony of lawyers and politicians. Sidney Zion is one of the worst humans to ever exist and can continue to rot in hell for what he did to resident education (not our fault his daughter did coke while taking an MAOI).

? Are you referring to decrease in workload and hours in residency? I can't really imagine how stopping insane 120 hours per week schedules and 36 hour shifts as 'terrible things for resident education'.

 

[michaelrack]

I don't think there are any places in the US where you would have a medical student do the only physical examination, for the simple reason that you couldn't bill for an admit note. .

you could bill for a psych eval- 90791 or 90792- without a physical exam

 

[Merovinge]

Also I'm glad that doctors are taking back how we train residents from the pathos-influenced hegemony of lawyers and politicians. Sidney Zion is one of the worst humans to ever exist and can continue to rot in hell for what he did to resident education (not our fault his daughter did coke while taking an MAOI).

I have read about him superficially but could you explain more about why he is one of the worst humans to exist?

 

[Spectre of Ockham]

I have no excuses for not ordering a CT scan in the ER and that I accept the consequences of my actions.

Shouldn't the EM doctor order the CT before calling in a psych consult ?

EDIT : NVM I saw your answer and it seems that the ED or worse the entire hospital is run by a MM (massive *****).

Head trauma and no physical - Dear Lord. Someone should be skinned and salted for this.

 

[HarryMTieboutMD]

? Are you referring to decrease in workload and hours in residency? I can't really imagine how stopping insane 120 hours per week schedules and 36 hour shifts as 'terrible things for resident education'.

Actually it has been absolutely horrible for resident education. I felt short changed during my intern year not getting to do workups on patients admitted overnight or when on not float not being able to see them from beginning to end. I actually like the original Hopkins model of interns living in the hospital and being around 24/7 (hence, house staff, while Halstead left at 4pm to go to morphine) for one year. So, generations of physicians before us did it to an even more extreme degree, and we still have high rates of depression/substance/suicide, so it's not like changing work hours improved physician wellness. And stigma remains equally high (hence why even when resources are available people don't seek care)

In fact, burnout is higher than ever and looking at the large amount of medscape data on the subject, the number one reason is bureaucracy, interpreted as hospital admins (also spawn of satan), insurance companies, and to a lesser extent the government dictating how we are supposed to practice. I would MUCH rather take q3-4 call on our inpatient unit now as a PGY3 (in clinic) than do another effing duty hour survey!

When non physicians interfere with any aspect of clinical practice, the results are horrendous, so we can claim a small victory in the work hour limit reversal.

I have read about him superficially but could you explain more about why he is one of the worst humans to exist?

His daughter, Libby Zion was an 18 yo who was taking Nardil (and doing blow on the side- it was the 80s) who was admitted to NY hospital. She had nonspecific symptoms though did have "jerks" (possibly clonus) and was given demerol (bc i guess that was standard) back then and then went into full serotonin syndrome (not well known back then; also that demerol could be an offending agent was also unknown) and died. Sidney Zion was a powerful lawyer who of course went on a vindictive spree against the residents, filing criminal charges (thankfully they were acquitted) but wouldn't let up, which through a "long train of abuses and usurpations" led to work hour limits.

The fact that a POS lawyer with connections who had a wayward, out of control daughter is responsible for nearly a generation of physicians missing out on one of the most amazing (yet difficult) experiences in their careers makes him a horrible person and absolute pariah

 

[deleted736562]

When non physicians interfere with any aspect of clinical practice, the results are horrendous, so we can claim a small victory in the work hour limit reversal.

And your assumption is that physicians at the leadership level somehow operate in a vacuum and are themselves not under pressure from hospital administrators. I personally don't believe for a minute that whatever ACGME comes up with is merely intended for resident education. Residents are very useful cheap labor and many hospitals depend on their services. Back in the good old day, residents would also need to do a lot more scut work (EKGs, blood work..etc).

As for effect of hours, it is very hard to believe that pulling out crazy and inhumane hours is not detrimental for patient care, moreso in psychiatry than in any other specialties, as the first thing that goes is one's ability to empathize. The studies that I do know that looked to at least burnout clearly establish a relationship between hours worked and burnout (Hours worked per week was associated with a higher risk for burnout (OR, 1.02 for each additional hour; P < .001) http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1351351 ).

 

[HarryMTieboutMD]

And your assumption is that physicians at the leadership level somehow operate in a vacuum and are themselves not under pressure from hospital administrators. I personally don't believe for a minute that whatever ACGME comes up with is merely intended for resident education. Residents are very useful cheap labor and many hospitals depend on their services. Back in the good old day, residents would also need to do a lot more scut work (EKGs, blood work..etc).

As for effect of hours, it is very hard to believe that pulling out crazy and inhumane hours is not detrimental for patient care, moreso in psychiatry than in any other specialties, as the first thing that goes is one's ability to empathize. The studies that I do know that looked to at least burnout clearly establish a relationship between hours worked and burnout (Hours worked per week was associated with a higher risk for burnout (OR, 1.02 for each additional hour; P < .001) http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1351351 ).

Thats my point- the hospital administrators mandate useless crap like patient satisfaction surveys etc and have no interest in

The study you cited is a 2011 cross sectional study among attending level physicians, and yes it is well known that being forced to work extra hours to see more patients to meet whatever overhead costs you have is going to contribute to burnout, but it's what each patient visit consists of- notes that are compliant with medicare billing standards, prior auths, paperwork paperwork paperwork that probably drives it!

 

[Kahreek]

head bruise/ head trauma history + altered mental status = scan

 

[Kahreek]

Psychiatrists aren't allowed to perform a physical exam here. They say you can't for two reasons :

1/ You are very likely to miss something since you don't deal with physical illnesses anymore
2/ It is wrong for the psychiatrist/patient relationship

Is it different where you're from?

Every competent medical doctor is a physician and a surgeon. (yup i know what the surgeons here are going to say, but just deal with it,it is the truth).



regardin 2/ , i dont even get it.

 

[Merovinge]

Every competent medical doctor is a physician and a surgeon. (yup i know what the surgeons here are going to say, but just deal with it,it is the truth).

regardin 2/ , i dont even get it.

That concept must somehow be based on the (clearly faulty) assumption that the same psychitrist doing the physical exam is also going to be doing long-term psychotherapy. There's something to be said about not doing a rectal exam on a patient who you are later going to be asking about childhood rape.

Having said that, ED psychiatry takes a lot of time to do a good job with anyway. Mostly tracking down collateral and accurate med histories, along with fairly long interviews when able. I think the US system that has ED docs medical/legally responsible for med clearance is reasonable. I also think it's reasonable for a psych ED to exist near a regular ED and be able to consult the ED physicians for patients. What isn't reasonable is for a med student to only do an exam and forbid the psychiatrist from doing so.

 

[Mass Effect]

Also I'm glad that doctors are taking back how we train residents from the pathos-influenced hegemony of lawyers and politicians. Sidney Zion is one of the worst humans to ever exist and can continue to rot in hell for what he did to resident education (not our fault his daughter did coke while taking an MAOI).

Give me a freaking break. There is nothing that states that doctors (outside of maybe neurosurgery) working 100-hour shifts learn more than doctors working 80-hour shifts or that doctors working 40 consecutive hours learn more than doctors working 24 consecutive hours. All this outrage is that someone outside the sanctity of medicine dared to have an opinion -- shared by numerous other industries, by the way -- about the effects of sleep deprivation on someone making life and death decisions. Your melodramatic statement is why residents are treated like inhumane robots, so don't think you're viewed as a hero to medicine. A hero to hospitals? Sure. Not to medicine.

 

[clausewitz2]

Actually it has been absolutely horrible for resident education. I felt short changed during my intern year not getting to do workups on patients admitted overnight or when on not float not being able to see them from beginning to end. I actually like the original Hopkins model of interns living in the hospital and being around 24/7 (hence, house staff, while Halstead left at 4pm to go to morphine) for one year.

so basically what you're saying is "oh, you have a family or any other kind of external obligations that aren't medicine? GTFO of the profession."

This is definitely how you attract the best and brightest into the field, ayup, and not people who don't have any better alternatives.

 

[Wilf]

so basically what you're saying is "oh, you have a family or any other kind of external obligations that aren't medicine? GTFO of the profession."

This is definitely how you attract the best and brightest into the field, ayup, and not people who don't have any better alternatives.

Harry likes to make provocative idealistic statements about the profession and has mentioned multiple times that training should be more rigorous. The two biggest problems with his ideas:
1. Back in the day doctors made more money and society was much more respectful of doctors (parents used to teach their children to respect doctors, judges, professors, etc). Most medical students/residents would not agree with this explicitly but it certainly is important.
2. A better and more efficient way to have good doctors is to be more selective in the initial screening process (admission to medical school).

 

[deleted736562]

Harry likes to make provocative idealistic statements about the profession and has mentioned multiple times that training should be more rigorous. The two biggest problems with his ideas:
1. Back in the day doctors made more money and society was much more respectful of doctors (parents used to teach their children to respect doctors, judges, professors, etc). Most medical students/residents would not agree with this explicitly but it certainly is important.
2. A better and more efficient way to have good doctors is to be more selective in the initial screening process (admission to medical school).

The biggest problem is that there's nothing that suggests overworking residents makes them better doctors or improves patient care. The same administrative influence that Harry is complaining of is behind these kind of suggestions or policies.

Incidentally, the recent switch back to 24 hour calls for interns was based on the "FIRST" trial. People can read the paper and make their own judgements, but it's pretty astonishing how quick ACGME was in recommending changes based on very questionably inferences that don't even test for the changes ACGME was requesting.