This week I’ve been taking a semi-break from research and grant writing and have been back in the hospital. Academic medicine is a weird thing and difficult to understand until you are really in the thick of it. Early on, I talked about it a little bit here. One thing that comes with academic medicine is being ‘on service’. Although 75% of my time is taken up with research and administrative duties, I still take care of patients. It is the reason I went to medical school after all.
Caveat: I’m not technically on service this week…it’s a variation, but let’s talk about what it’s like.
Being on service means that you are leading a team to take care of the patients in the hospital admitted under your specialty, or ‘service’. Service time looks different from institution to institution, but the underlying theme is the same. It’s pretty exhausting and quite stressful, but here’s how it breaks down.
Rounds: Patients are monitored all day when they are admitted to the hospital, but generally formal “rounds” are done 1-2 times per day depending on how sick the patient is. Before rounds commence, some team members will review the previous days vital signs, events, and upcoming plans for the next 24 hours. This data, along with a current physical exam and any patient/parent questions or concerns will be presented to the team during ’rounds’so that the next 24 hours of care can be determined.
Here are the team physician players at my institution:
The Resident Physician: The resident physicians can be recognized by the sheer number of them. They are most happy in packs of 3-4 but can survive in pairs. The resident physicians usually have multiple papers and run the computers during rounds. These are also the sneaky physicians who will tiptoe into the room at some ungodly hour and examine the patient and maybe speak with a family member if one is awake. In pediatrics, there are three levels of residents. The most junior resident is called an intern or first year and then those in the 2nd or 3rd year of training are called upper levels or senior residents.
The Fellow Physician: The fellow can be recognized by the multiple questions, phone calls, pages, and distractions that are pulling them away from the herd of people that are trying to complete rounds. The fellow will be the who’s who guide to the hospital and other service lines.
The Attending Physician: You can recognize the attending physician because we may be more age challenged (but not always) than the other physicians surrounding us, our pockets are generally empty, we usually tote caffeine and ask “who’s next?” a lot. Fun medical fact: when an attending physician asks the same exact question as a resident physician and gets a completely different answer, this is called History alternans. You would be surprised how often this happens and its the ire of every intern. From the vantage point of an intern, this job looks cush. It appears that the attending carries coffee, people listen to them, and they aren’t bogged down by paperwork. In reality, we carry coffee, communication can still be a challenge, and there is more paperwork than one could ever imagine. Be that as it may, the attending’s job is to efficiently round on all of the patients and impart some wisdom on the physicians in training in the process.
Let me tell you a story of my first days as an attending on service.
I was approximately 7 or 8 weeks pregnant and from the moment I woke up until the moment I went to sleep, I felt like vomiting. Not a good start. The day before I started service, I said to my friend “I think I can handle anything as long as I don’t get an APL (type of leukemia). I had never personally taken care of an APL patient but I knew they could be very sick at diagnosis and was wary.
I arrived bright and early on the first day and touched base with my fellow…unbeknownst to my barfy self I walked into a disaster. My team had been ‘on call’ that night so we took any patients that came through the ER. I think there were probably 20-25 patients on my service that day and overnight we had gotten 3 new leukemia patients and a patient known to us had come in with what looked like a relapse.
The fellow was busy compiling consents and orders and making procedure requests for the new patients. The amount of work and effort that goes into the first few hours of a new leukemia diagnosis can be intense. Most times the children need blood product transfusions to be safely sedated for procedures. That takes time. If the family has been told in the ER they have leukemia, they have been up all night waiting to talk to the oncologist. There will be many questions. If they haven’t been told, there will be many questions. Jockeying procedure spots and calling in favors to get the new leukemia a spot takes time…everything takes time and we needed time x3.
I triaged the patients with the fellow and we had to make a decision.. set everything in motion and round on the new kids last (which is pretty rude when a family’s world is upside down) or just take the hit and know that the rest of our patients would be seen much later in the evening and we would be bombarded all day with updates and orders. We decided to take the hit and start working our way through the new leukemia patients. Two were on our normal floor and one was off the floor. Per the residents reports they all seemed OK so we started with geographic closeness and went to the first two patients on our regular floor. Half way through the first patient, I got a page from the hematopathologist (doctor that looks at blood cells). I was expecting it because they had to review the slides from all three new patients when they came in that morning.
Hi Dr. Kim, this is Wendy returning your page.
Wendy, do you have patient John Doe?”
Yes, I do
This looks like APL.
I looked at my fellow and probably mouthed an expletive. We quickly finished the first patient and went up to see John. John was sick. Way sicker than my interns realized. I immediately called a senior physician, who referred me to an even more senior physician because “he probably has the most experience with APL”. After I talked to him, I called two more senior physicians for advice while setting up a transfer to get John to the ICU.
The next two weeks I barely slept. Every day something new would happen that made me continually question my skills and competence.
Every other night we had at least one new kid come in to our team (we have two oncology teams that run simultaneously) with a new cancer. Every 48 hours I had to tell a family that their child had cancer. It was brutal.
John required intensive monitoring and stabilization with blood products. I had an alarm on my phone for every 4 hours to check his labs for the entire two weeks. Jane did experience a relapse. When we rounded on the stable patients I would dive into the break room and steal saltines to fend off the impending vomit.
The bone crushing fatigue of early pregnancy, coupled with the stress and lack of sleep of being on service made me question my sanity. My team, my patients and I all made it through those two weeks. I have never felt so terrified, exhausted, proud, and grateful for really wonderful colleagues as I did those two weeks.
This week I am back in the hospital seeing patients and things are much calmer than they were back then, but I still love the organized chaos that is a bustling oncology unit for kids. Today we talked about death but we also had fun. Today we celebrated the small victories like labs good enough to make it to a concert. Today we were grateful for volunteers that give selflessly and answered the call for a last minute makeup application to make a young girl feel glam. Today I’m frustrated that my chemo doesn’t seem to be working the way I want for John Doe #2. Today a nurse taught me something about a medication I didn’t know.
I still think I have the best job in the world, even when it’s hard. Hands down my patients and families make it the best ever, but a close second are those people I can call on in a bind – from medical help to makeup help.
