One thing that really irritates me is when the attending covering a service for the weekend changes all the meds. I'm of the philosophy that weekends are just for emergencies and it's arrogant to think that you are better at managing a patient you just met than the primary team, who knows the patient very well. So I think orders should only be written when absolutely necessary.
But some of the attendings I rounded with during residency seemed to look at the weekends as an opportunity to fix all the patients' problems. I remember one attending Dr. McGill was particularly bad about it. She would flip through all the charts, saying things like, "Why is this patient on so many medications? She shouldn't be on this many medications!" Then we'd decide on a Sunday morning if the patient really needed that second dose of Colace.
Seriously, on Sunday morning I don't think it's appropriate to start changing all of the medications of a patient I just met. If that makes me a bad doctor, then so be it.
But situations like these were the most annoying of all:
Dr. McGill: "Why is this patient [that you never met before] on Zosyn?"
Me: "Uh... well..." [checks sign-out sheet] "He has MRSA pneumonia..."
Dr. McGill: "Yes, but he's already on Vancomycin."
Me: "I guess the Zosyn is to double cover."
But my hypothesizing wasn't good enough. Nor was the fact that the primary attending Dr. Brown's note from yesterday said "Vanco/Zosyn for MRSA pneumonia" and the signout said something similar.
So after discussing this for several minutes, Dr. McGill said, "Call Dr. Brown at home and ask him why the patient is on Zosyn." (She had his number in her PDA.)
Me: "You... you want me to call him at home on a Sunday morning?"
Dr. McGill: "Yes. He won't mind."
Me: "But... what's he going to tell us? He knows the patient is on Zosyn. It was in his note. Do you think it's a mistake??"
Dr. McGill: "Just call him."
I was pretty horrified by having to do this, but like a good soldier, I did it. And Dr. Brown said exactly what I thought, which was that the Zosyn was for broader coverage. I honestly didn't get why we had to call him. Did she think that he was suddenly going to realize that he made a big mistake by putting the patient on Zosyn and Vanco? Dr. Brown is a really good physician and I know he wouldn't have made a mistake like that.
Anyway, this is one of the many reasons I hated weekend rounds.
You are easily horrified...
ReplyDeleteI think having to wake up your attending at 7AM on a Sunday morning to ask them an asinine question is a legitimate reason to be horrified.
DeleteI totally agree that calling an attending at home is one of the worst things, particularly for a not good reason. Having to do things that you don't think make sense, like calling attendings with dumb questions, is one of the worst things about being a trainee.
DeleteOh well....only three years left...
Add to the fact that in these cases the RESIDENT has to page the attending for something that isn't urgent, and the attending will likely chew the resident out for paging him/her to ask a stupid question.
Deletecan you write some stories of things you actually liked during your whole training process? School-Residency.
ReplyDeleteThanks
I don't think anyone is interested in reading a love letter from me to my residency program. Positive stories aren't nearly as entertaining as train wrecks.
DeleteIt's true. We love to hear the horror stories.
DeleteFizzy, I imagine that you prefaced that call with "my ATTENDING wanted me to call you to ask ". In these situations, if the attending is reasonable, he/she'll understand where you're coming from. Dr. Brown probably knew of Dr. McGill's idiosyncracies...
ER MD
Once on Sunday rounds the covering attending called the Chair of the Dermatology department at 8AM to inform him that his residents weren't returning their (not even remotely urgent) pages quickly enough. Actually, first he made me page the chair (who also didn't return the page -- thank god) and then he called him himself.
ReplyDeleteDid Dr. Brown chew you out in the end?
ReplyDeleteNo, he was actually very nice about it, considering.
DeleteFizzy, we are not interested in hearing love stories about your training;)
ReplyDeleteWhoa. And I can't even get the doc who's cross-covering weekends/nights to write for a tylenol for a patient with a fever of 40.
ReplyDeleteOne of the Senior consultants in my training got beyond angry when someone changed his patients medications without a very very good reason over the weekend. Or as he said "WHY is it that all the patients getting admitted has their medications changed by some doctor, even if the medications are working fine and they are not admitted due to that medical problem?" As a nurse, we loved him. It is not fun to have to start new things on the weekend, just to have to answer for it on Monday when the hometeam is back and the covering doctor miraculously is not picking up their phones!
ReplyDeleteJust want to tell you that I love reading your residency tales and I loved your book. ~MK
ReplyDeleteGood point, bad example. Weekend doc was right on. If you already know you have MRSA pneumonia then you don't need the Zosyn for double coverage. Extra antibiotics just lead to collateral damage(aka resistance) You only need to double coverage for psuedomonas....
ReplyDeleteIn general terms I do agree with you, the primary team should be making the decisions, but everybody needs some oversight. ;)
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ReplyDeleteI kinda dread having to call attendings from other services, particularly when it's a lame question (like calling an internist to manage a surgery patient's hypertension) or said hematologist... er, staff consultant says she's pissed off from getting pages while in a meeting.
ReplyDeleteHaving said that, while working on the unit this week, I've been impressed by the good-faith commitment to getting involved by ID and surgery. But getting ophtho to come see a trauma patient with multiple skull and facial fractures and a swollen painful right eye required explaining that, no, I was not able to examine his visual acuity. "Eye dentists" indeed... I can certainly understand being unsure of the clinical question, but if ICU is calling you to see a trauma patient, that kind of guff is just unacceptable.
Zosyn doesn't cover MRSA.
ReplyDeleteBut a lot of times you don't get a sputum culture to know 100% it's MRSA. If they have MRSA risk factors and Pseudomonas risk factors, they get both.
I think I would be horrified to call that attending too!