Tuesday, September 18, 2012

Day 94 - dose 5 coming right up!

Today was a quiet day of visiting with Eva, reading a bit, sending email and two miles of indoor walking (and art admiring!).

It was a nice day without a whole lot of excitement (just like we like our days in the hospital). Tommie has been asking for a while that I explain what rounding is, how it works, etc. and it is relevant to the most recent excitement here so I guess it's time.

When a patient is in the hospital, it is important that there is one doctor in charge of them or one ends up with the "too many cooks" syndrome. Therefore, when a patient is admitted, they are given a single "attending" doctor who is their main cook. It is usually the doctor who will care for the problem that most makes the person need to be admitted to the hospital, but not always. Some doctors (mostly specialists) don't have patients on their services and sometimes a patient will come in with, say, a broken hip, but have so many other medical problems that even though the hip brought them in, they are really better served by a doctor who can manage their diabetes, high blood pressure and heart failure. The attending doctor decides which other doctors can be involved in the patient's care, writes the admission and main orders (and in some hospitals, writes all the orders) and is in control of the general course of the patient's care.

Because doctors are human, most doctors admit to "teams" where Dr. A is the day time doctor, Dr. B is the night time doctor and Dr. C will be taking over during the day in three days. Sometimes the "team" aspect of the work is split up even more, especially in teaching hospitals. These teams usually consist of something like a first year resident, a second or third year resident and an attending (a fully trained and certified doctor who could practice independently). Sometimes there are fellows (trainees who have finished residency but are working on speciality certifications like oncology) or medical students. Different teams do it differently, but the basic idea is that there is a certain amount of "work" that needs to be done for each patient and they divide it up. Perhaps the intern (first year resident) will write the note (that serves as the main record for billing and legal purposes as well as to communicate with the rest of the team) and examine the patient thoroughly. The second year resident may double check the key points of the exam, and make sure the labs are adequately treated. The fellow may double check the key key points of the exam, chat with the patient, confer with specialists and then the attending writes the final billing note (mostly referencing the other notes, but summarizing them and especially if he or she disagrees with any of their conclusions, correcting them), examines the most important findings of the patient and answers the patient's questions.

Every patient in the hospital gets that done every day. Every attending or at least every team in the hospital has a list of all the patients they need to see every day. Seeing the patient, checking up on their labs, radiology, any tests or procedures they've had, producing notes and dictations as needed for communications and/or billing, conferring with other doctors who are caring for them, answering the questions, making a plan for getting them moving in the right direction and coordinating their discharge plans are the components of "rounding" on patients. Doing all of those things on all of one's patients is "rounding."

From the patient perspective, what rounding feels like in a teaching hospital is that a collection of people, some together and some separate come in one or more times per day. Here, for me, usually the attending comes in separately towards the end of the day. (Rounds start with sickest patients and discharges first. Also, sickest and most interesting are most likely to be visited by large groups. This explains why I get seen usually by people who are alone and at the end of the day.) In general, you want to listen to the plans of the attending because they are the ones who really decide the plans. Sometimes other people on the team are better at answering questions because they may have more time or more ability to understand what a patient might want in an answer. My current attending, like Dr Hill, is good at answering questions so that is nice, but not all have been.

I get attached to my attendings as they are the ones figuring out my plan and keeping me out of trouble. Because I understand that the attending is really the main cook of the team, no matter how many other junior cooks there are, when my attending changes, I really like to know. Perhaps if I did not understand exactly why the attending role was so vital to me, I might not be so concerned about their coming and going. I mention this mostly because in the past when attendings have left without saying goodbye, I have been unhappy and without a full explanation of how the attending thing works, it might not make that much sense why I would care if just one person on the team changes.

My attending, Dr Meehan, has two more doses of cytarabine planned for me in the next 24 hours and then I get to go home. I am very happy.

I hope you are happy with your short term plans, too.

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