Category: Education

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Education Medicine Nonfiction Observations Systems

Who Works at a Hospital?

Who works at a hospital? (Again, just indulge me for now.)

Doctors. If you’re a patient at a teaching hospital, this includes medical students (people in school to become doctors), interns and residents (people who have earned the title of “doctor”, but who are still learning their craft), and attendings (people who have completed their formal training as physicians). If you’re not at a teaching hospital, it’s less likely you’ll see medical students and other trainees (the army of white coats tromping through the hallways). Instead, you’ll see lone attending physicians.

Nurses. Nurses play vital roles in patient care; without them, hospitals simply would not work. Nurses arguably spend the most time with patients. They monitor and observe patients around the clock. As a result, they’re often the first to realize that something has changed and thus have the responsibility to do something about it.

There are different kinds of nurses, such as registered nurses, licensed practical nurses, and certified nursing assistants. Their roles differ in terms of their training, skill sets, and responsibilities, but they all serve to observe and monitor patients and their conditions.

Therapists. Not the talky kind. There are respiratory therapists, speech therapists, physical therapists, and occupational therapists. They focus on skills and function: How can we help this patient walk? How can we help this patient talk with less difficulty? How can we retrain the muscles in this patient’s hand so he can write again?

Technicians. Radiology technicians, pharmacy technicians, surgical technicians, electroencephalogram technicians, patient care technicians… the list is long. They assist other professionals in the hospital in their duties and may have more contact with patients that the professionals themselves.

Consider an ultrasound technician. A physician may order the ultrasound, but it is the technician who will explain to the patient what an ultrasound is and perform the procedure. A radiologist will interpret the results.

A special note about patient care technicians (PCTs): These individuals often spend the most time with patients and are often a treasure trove of data for nurses and physicians. If you are a physician working in a hospital, make a point of talking with the PCTs. They’re the ones who will know if the patient slept, went to a procedure, has a change in mental status, etc.

Janitorial staff. These individuals have one of the most important jobs in the hospital: They help with hospital-wide infection control. They help prevent people from getting more sick. If you work in a hospital, thank a janitor today for what they do.

Clerical staff. This includes the clerks who serve as receptionists for the hospital units (not an easy job: imagine juggling phone calls from patients, managing the anxiety of family members of patients, paging physicians multiple times because they don’t call back…), hospital operators, all the people working in medical records, and the staff who work with the hospital administrators. Hospitals generate a lot of data. Someone has to help manage and organize all that data.

Information technology staff. Electronic health records now hold patient information. The networks fails. The mouse doesn’t work. There aren’t enough terminals. Someone can’t remember their password. The radiology images aren’t showing up. The orders didn’t go through. The IT department gets a lot of pressure to get it all right.

Food services staff. There are all the people who cook hospital meals, transport and deliver the meals to each patient, and wash the leftover dishes. These people also prepare the food in the hospital cafeteria, which feeds the rest of us who are well enough to get it on our own.

People want to eat and they want to eat food that tastes good. In the hospital it is hard to please all of the people all of the time.

Environmental services staff. These are the plumbers, electricians, HVAC experts, etc. who make sure that the electricity stays on, that there are backup generators available, that the water temperatures are satisfactory, that the ambient temperatures are within a certain range, that the windows seal tight, etc. If the building doesn’t “work”, then the hospital doesn’t work.

Pharmacy staff. I don’t know how many thousands of medications are available, but the pharmacy takes care of all of them. Whether they are amazing antibiotics that will drip through an IV or cartons of chicken soup (yes, doctors can order chicken soup), the pharmacy takes all of those orders and fills them. They ensure that medications are available in every single hospital unit and prepare medications for patients to take with them when they leave the hospital. And they have to make sure that they fill the right drug at the right dose at the right time for the right person.

There are many more people who work in hospitals; I do not omit them willfully. We often take for granted all the people who make a hospital work.

If you are a patient (or someone visiting a patient) in a hospital, I encourage you to thank all the people who have helped you. Hospital staff appreciate hearing that and want to know that their actions made a difference.

If you work in a hospital (especially physicians), I encourage you to thank your colleagues, particularly those who have a completely different job from yours. They are doing something to help you do your work. Let them know that you appreciate it.

Next time: The “rules” of the hospital.

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Education Medicine Observations Systems

What is a Hospital?

So what is a hospital? (Just work with me here.)

Hospitals are physical structures. They are buildings that have rooms and beds. People, who become “patients”, are “admitted” into a hospital and assigned a bed. Because patients receive a bed, there is an assumption that they will be in the hospital for at least one night. This is called an “inpatient” admission, because the patient is “in” the hospital. (Contrast this to a visit to a clinic, which is called an “outpatient” encounter.)

Hospitals provide acute health care. “Acute” can mean “intense” (like cutting someone open to remove an organ or the delivery of a baby in a mother who has major medical problems) or “fast” (like giving a patient antibiotics through a vein to fight an infection or using a machine to help filter blood when a patient’s kidneys suddenly stop working).

Because most hospitals offer services from nearly every medical specialty, patients can experience “one stop shopping” for acute health care issues. Patients might see four different kinds of doctors, have numerous tubes of blood drawn, undergo five imaging studies, receive education from dieticians, undergo strength training with physical therapists, and talk with pharmacists about their medications.

Hospitals permit around-the-clock observation of patients. This is directly related to the previous point and is arguably the primary reason why people are in hospitals. If someone does not require frequent and regular observation, then she doesn’t need to be in the hospital. All that staffing and equipment in the hospital serve to monitor patients and their health (heart function, breathing, infection, etc.). If medical staff observe an acute change, they can then deliver an acute intervention.

Hospitals are businesses. Hospitals, like hotels, want a low vacancy rate, as this is how they make money. Sometimes patients are ushered out of the hospital sooner than expected because other patients are waiting for open beds. (I’ve worked in hospitals where, in the morning, the operators announced over the intercom a “code” about bed status. This was a discreet message to hospital staff about the census. If the census was high, then we were to try to discharge patients if we could.) Sometimes patients are welcome to stay in the hospital for another night because the census is low. This is not actually a good thing. (The longer someone stays in the hospital, he is at higher risk of developing an infection from the hospital. This is bad because infections that originate in the hospital are often resistant to available antibiotics. Furthermore, patients often get “deconditioned” because they aren’t moving around as they usually do. As muscles, stamina, and endurance weaken, that can cause problems with mobility and function.)

Hospitals are not places of rest. While it is true that people can recover in hospitals, that doesn’t mean that people recover in peace. Hospitals are often noisy places with frequent, unexpected intrusions because of all the observation, testing, and services that occur there.

Now that we have a general sense of what hospitals are, we’ll talk next about all the people who work in hospitals.

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Education Lessons Medicine Nonfiction Observations Reflection

Cancer.

As a fourth year medical student I did my “sub-internship” in oncology. I hoped that this rotation would help me choose what specialty to pursue: internal medicine or psychiatry.

One of “my” patients was a woman with breast cancer that had spread to her liver and lungs. Fluffy brown hair fell to her shoulders. Wrinkles surrounded her puffy eyes that held jade green irises. Though she was in pain, she was patient and kind.

On the evening of her second day in the hospital, I came to her room and asked if there was anything else we could help with that day. Her pale, thin lips stretched into a sad smile.

“No, thank you,” she answered. “Have a good night.”

“I’ll see you tomorrow,” I said.

She was sleeping when I saw her the next morning, though awoke without a startle when I said her name. She kept her eyes closed as I placed the cool, metal diaphragm of the stethoscope on her chest and back. She murmured her thanks before I left her room.

As the attending oncologist, resident, intern, nurse, fellow medical student, and I approached her room later for formal rounds, she called to us.

“I can’t see!” she gasped. “I can’t see!”

We surrounded her bed and the attending began to ask her questions. He waved fingers in front of her face. He directed the beam from his penlight into her eyes.

“I can’t see! No, I can’t see!”

“But you could see yesterday, right?” he asked. She turned her head as if she was looking around at us, but her gaze was over our heads.

“Yes… but I can’t see now. Does this mean that I will never see my husband and daughters again? Is this permanent?”

I tried not to cry. The other medical student and the intern also looked away, their eyes welling with tears.

We learned later that the cancer had metastasized to her occipital lobe, the part of the brain that controls vision. Though her eyes were in good working order, the part of her brain that interpreted the electrochemical signals from her optic nerves was not. The cancer had stolen her sight.

You learn a lot of things in medical school: anatomy, physiology, pharmacology, and other concrete facts about human function. You also learn about human relations, communicating with people with different agendas, the system of health care, and other topics that fall under the “informal curriculum“.

You also learn how tenuous life is. You see women give birth to dead babies. You see children succumbing to cancer. Healthy adults get hit by stray bullets and drunk drivers. Heart attacks and strokes steal time and life away without making a sound.

You begin to recognize the blessings that you previously overlooked: I can eat all the cookies I want and I don’t have to take insulin. I don’t need a walker to get around. My fingertips and toes can feel the soft fur of a cat, the hot water coming out of the shower, and the zing of static electricity. I can breathe without difficulty and without having to lug an oxygen tank around. My arms and legs move when I want them to. My balance is intact.

You also realize, with some dread, that all of that can change in an instant. So you better enjoy the blessings while you got ’em.

My mother was sent to the hospital with urgency the day I returned to California to visit my parents. She was subsequently diagnosed with metastatic lung cancer.

I am grateful that I could advocate for my mother while she was in the hospital. I am also thankful that I could translate what was happening—not just from English to Chinese, but also from medical jargon to plain English—to my parents.

I was struck by the degree of confusion and uncertainty throughout her hospitalization. Things that I knew as a physician were not at all obvious to my parents. Things that I knew as a concerned family member were not at all obvious to the physicians.

I was and remain humbled.

As a consequence of this, upcoming posts will focus on how health care in hospitals work, what hospitals can do differently to help patients understand what is happening, and things that both medical staff and patients can do to make the hospital experience better for everyone.

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Education Homelessness Policy Reflection

Commercial Sexual Exploitation.

I recently attended a presentation given by one of the founders of The Organization for Prostitution Survivors (OPS).

If you or your organization want to hear a compelling, educational, and thoughtful talk about commercial sexual exploitation, I encourage you to contact OPS.

The talk did not necessarily alter the way I go about my work as a psychiatrist, but it did challenge my assumptions about prostitution, highlight the different perspectives men and women have about sex (to be clear, the talk was not at all “anti-male”), and encourage me to reconsider the influences of our culture on commercial sexual exploitation.

I’ve included my notes and reactions from the presentation below. Any errors and lack of clarity are entirely mine.

The speaker (a man) began with a discussion about the social construction of gender. What does it mean to “act like a man”? The stereotype is that a “man” excels at sports, fights well, doesn’t show emotions (particularly sadness, fear, etc.), is dominant, and is skilled at and knows a lot about (heterosexual) sex.

Boys learn these stereotypes throughout their youth. Boys are eventually introduced to pornography, which may actually serve a means of male bonding (passing around a copy of Playboy, sharing links to online pornography, etc.). Pornography doesn’t teach boys how about sexual relationships, but instead offers flat, two-dimensional representations of women solely in the context of sex. Masturbation leads to orgasm, which is a potent reward for viewing women as sexual objects (instead of actual people).

The speaker then asked the audience for adjectives attributed to “good girls” and “bad girls”. The assumptions about “bad girls” are often the same for prostituted women[1. The speaker used the phrase “prostituted woman” instead of “prostitute” for the same reason that I use “man with a diagnosis of schizophrenia” instead of “schizophrenic”. Let’s please remember that we are talking about actual people here.] (they have multiple sex partners; they drink alcohol and use drugs; etc.). The words we use to denigrate women are synonyms for prostituted women: whore, slut, etc.

As a consequence, prostituted women become a legitimate target group for male violence. We somehow come to believe that it is okay for men to hurt prostituted women. They are, after all, “bad girls”.

The speaker discussed Gary Ridgway (the “Green River Killer”), who sought out prostituted women and murdered them. Nearly half of the women he killed were under the age of 18. The speaker asked why the media consistently describes these women as “prostitutes” and omits that nearly half of them were, in fact, “children”? What if we described Gary Ridgway as the “most prolific killer of children” in American history?

The speaker then described how a former pimp would find and select women (girls). His strategy was essentially this: If he spoke to a woman and she responded with any direct eye contact (even if she was flattered), he would walk away and end the “grooming” process right there.

Why? Because he knew that those women who made no eye contact with him already had life experiences that would make the pimp’s job easier. “Someone else has already beaten her down so I don’t need to do as much to make her work.”

The speaker then noted that researchers often wonder about the mental health of prostituted women… but why hasn’t anyone examined the mental health of buyers and pimps (mostly men)? Prostituted women often develop PTSD, which is unsurprising given the chronic trauma they endure while working. What is wrong with us as a society that we haven’t shown the same interest in what is “wrong” with the johns?

A discussion followed about the words we use to describe men viewing women. In the US, we often say that men “ogle” or “leer at” women. Those words have a “hubba hubba hubba!” quality to them; men who want an interactive, romantic relationship don’t “ogle” or “leer at” women. When was the last time you heard of a man “beholding” a woman?

One of the most striking points the speaker made was when he asked, “To the men in the audience: What do you do to protect yourself from rape?”

Silence ensued. Some men in the audience were perplexed.

“To the women in the audience: What do you do to protect yourself from rape?”

Many women answered immediately: “Travel in pairs.” “Keep my drinks with me at all times when I’m out.” etc.

Both men and women in the audience were stunned at the disparity of responses.

The speaker then discussed the issue of consent: Consent for sex should be an “enthusiastic yes!”, not something that requires negotiation. In prostitution, the exchange of money for sex is coercion. Economic coercion is never true consent.

The speaker also commented that buyers aren’t paying to learn the reality of the prostituted woman. If the girl is 16 years old and the buying man asks her age, of course she is going to say that she is 18. If he asks her if she has a pimp, of course she will deny it.

The speaker then challenged the audience to speak up even when someone tells a sexist joke against women. Doing so helps to construct a world of equality where women aren’t reduced to sexual objects. He commented that a sexist joke is on a continuum that also includes a man forcing his wife to have with him (“why did I get married if I couldn’t have sex with her whenever I wanted?”), paying a prostituted woman for sex, rape, and murdering women.

The speaker shared that prostitution “is like domestic violence on crack”. The cycle of abuse applies to both. He reported that prostituted women leave and return to their pimps between seven and ten times before leaving for good. It is often difficult for the women to leave because they often identify with their pimps due to something like Stockholm syndrome, though “trauma-bonding” is probably more precise. Prostituted women also frequently develop drug and alcohol problems as a means of coping with the ongoing trauma associated with the work. (Imagine getting into the cars of buyers multiple times a night without knowing if you will get hurt; imagine a pimp beating you because you did not bring back sufficient earnings; etc.)

The speaker also discussed the “bad date list”, which has historically been a paper list that prostituted women have passed around with names and identifying information of buyers who don’t pay, hurt the women, etc. He said that they hope to develop a “bad date” app because of the ubiquity of smart phones.

The speaker closed by discussing different models of managing prostitution in societies. He said that he is strongly opposed to legalized prostitution. He cited some data where states and countries with legalized prostitution often results in more sex trafficking and prostitution. He gave the example of Germany: The demand for prostitution has gone up since it has become legal, so Eastern European women are often lured and trafficked into Germany to work as prostitutes.

He expressed hope in the “Swedish model“: Sweden has taken the approach that women working in prostitution are victims and, thus, the selling of sex is not considered a crime. However, buyers, pimps, and traffickers are prosecuted to the fullest extent of the law. Some data suggests that, as a consequence, there is less visible prostitution and fewer women working in prostitution.

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Consult-Liaison Education Informal-curriculum Lessons Medicine Observations

Informal Curriculum: Lesson 1.

It’s been over a year, but I haven’t forgotten about the Informal Curriculum.

The first recommendation in the informal curriculum in medicine, which I still believe is “paramount, the most difficult to define, and often challenging to implement”[1. It is no coincidence that a topic that is “paramount, … difficult to define, and … challenging to implement”, is also difficult to write about.] is to be a person.

What does this mean?

Be the best professional person you can be. Be a person who actively listens to patients, who shows empathy and emotions. Be courteous. Show humanity. Be a person.

Non-psychiatrist physicians seem to have an easier time with “being a person” than psychiatrists. Psychiatrists, as a population, can be weird. We can demonstrate exceptional skills at not being people. Sometimes we come across as intrusive, awkward, and odd.

I get it. I’ve had peculiar interactions with psychiatrists who knew I work as a psychiatrist. That might explain why the conversations were even more uncomfortable than expected. (Those are stories for another day.)

Do note that this recommendation exhorts you to be a professional person. This doesn’t mean that you tell your patients about your relationship or health problems, how crappy of a day you’re having, or why your political views are correct. That stuff makes you a person, too, but that doesn’t make you a professional person.

If patients are telling you things that worry them, be a person and acknowledge their worry. If they tell you something funny and it’s not inappropriate to laugh[2. Being a person does not mean that you toss clinical judgment and boundaries away. There are times when you shouldn’t smile and laugh, even if you want to. That topic is beyond the scope of this post.], smile and laugh. Talk with them like they’re people, not diseases or case studies.

Be a person.

Patients often want to share a connection with their physicians. Patients suffer and worry. They want to know that you care about their suffering or worry. That’s what actual people[3. Yes, there are anecdotes that people will share their woes with and find comfort in a computer program.] do: They care about the suffering and worry of others.

Be a person.

Why is this paramount? Why is this my first recommendation in the informal curriculum?

Because relentless forces exist in medical training and work that can transform you into a non-person.

You use words that most people don’t use. Most people don’t talk about MELD scores, Glasgow Coma Scales, or HIV classification systems. You see a lot of emotional and physical anguish. You see people who are ill. Sometimes they cry. Sometimes they scream. Sometimes you see parts of them that they will never see. Sometimes you see them die.

These are the things that can make you turn into a non-person.

So make an effort every day to be a person. If you’re not, none of the other suggestions in the informal curriculum will matter.