I have now completed almost a year of surgical internship, and as I’m sure you’ve noticed from my sparse blogging, I’ve had little free time for writing. It’s a shame too because surgery is just so cool.

Intern year is mostly about learning to manage surgical patients, basically people in varying degrees of health who have the added stress of having surgery recently performed on them. Although the 80-hour workweek and case requirements have pushed more exposure to the operating room into the process than previously existed, it’s still mostly medical management of patients at this stage. We are required to perform at least 750 cases in our 5 years of training. Of these cases, we are required to have exposure to a broad range of different surgeries with certain “defined” major cases counting towards specific quotas. For example, a recent requirement was added that we have at least 85 surgical endoscopy cases, including upper endoscopy and colonoscopies before we graduate. As a result, most of my day is spent dealing with medical issues with post-surgical patients, and if I’m lucky I get to go to the OR and, with an attending of course, learn some simple procedures.

As your training progresses you take care of more critical patients, with your second year largely devoted to ICU care. You also are involved more extensively in complicated cases, so by the time you’re a third year you are able to help attendings with complex surgical cases, are responsible for evaluating surgical admissions, and begin to manage patients as a chief in some cases. In fourth and fifth years you are in charge of managing whole surgical services and are operating a majority of the time. By fifth year you are a chief, and you should be preparing for eventually operating on your own as an attending or for additional specialty training in a fellowship position.

My day starts at about 5AM, when I pre-round on patients, collect the data from the previous day for the all-important list, and get signout (news on what happened overnight) from the intern who was on call. By 6AM the chief arrives, you round on the patients, and formulate a plan for the day. You’ve got to discharge patients who have recovered, manage the medical issues of your post-surgical patients, admit new patients and see the new surgical consults. Basically general surgeons get training to be excellent medical doctors who also learn to do surgery.

The day ends around 5-6PM when you either sign out to the surgeon on call overnight, or take signout from the other services you will cover overnight. Surgical interns usually cover 3 services overnight, so I might be taking care of pediatric patients, plastic patients and urology patients, or emergency surgery, minimally invasive surgery, and surgical oncology patients for 12 hours until the next shift comes in the morning. This means you work for about 30 hours straight, the maximum allowed by the new hours limitations. You address any issues that come up in the night, staff any consults that can’t wait until morning, and every once in a while deal with some terrifying emergency that arises at 2AM. It’s not that bad, but after a full shift you sleep like the dead. Saturday calls are of course the worst, because you start at 6AM on Saturday and don’t go home until around noon the next day, basically losing your whole weekend. Usually we only have to take one Saturday call a month so we don’t lose our minds.

So that’s why I haven’t been blogging. When not at work I’m usually eating, sleeping, or trying to keep my life in some kind of order. The goal though is to get back into this, to manage my time so we can still talk about medicine, and crankery, and the ever increasing tide of denialist movements. Not to mention TV shows. Anyone else seen Jesse Ventura’s new show? It’s like crank crack. Leave it to Ventura to figure out how to free-base illogical thinking.

Healthcare reform

With the recent victory of this administration in passing health care reform I felt it was time to talk again about the importance of this issue and some of my own experiences in the last year of my surgical training.

I was, and still am of the belief that reform, whatever form it might take, will be successful as long as we manage to make health care universal. Partly because our system already is universal but defective. No matter if you have insurance or not, if you show up in a hospital with a problem that needs to be addressed, we’ll treat it. We ethically can not turn people away because they lack insurance. People therefore who lack insurance regularly show up in the ER for primary care, or worse, with a problem that could have been addressed by a primary care doc weeks before but now has become so severe they have no choice but to get treatment whether they are insured or not. For instance, I had a patient who arrived in the ER with a gaping, necrotic sore on his cheek. It had started as an abscess, gotten progressively worse, and he tried draining it himself, inadequately, because he was uninsured. Over the course of a week though the sore had eaten through his face until it actually communicated with the inside of his face. The result? Two teams of surgeons later, an ICU stay, and an extensive reconstruction, a 10 dollar problem became who knows? A 50 thousand dollar problem? More?

We have a choice here. We can have an ethical system that treats people who need care in a thoughtful, sensible fashion, addressing problems through prevention, and appropriate care at the right time. Or we can have a system where people get their primary care in ERs, often showing up long past time their problem becomes critical and inevitably, more expensive. Guess which is less expensive? It’s not necessary to have a single-payer system like Great Britain, Canada or New Zealand. It’s not even necessary to have a public option as countries like the Netherlands demonstrate. You can even have a very generous system that is based on highly-regulated private insurance with subsidization for the poor, as in France or Germany. All of these systems beat ours with regards to cost and performance. What do all these systems have in common but is lacking in ours? It’s simple, they’re universal.
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