scientific progress goes "boink!"

this is a tough time of year for many people in the hospital. for interns, their first year is about 2/3 complete, which means rejoice! only a few more months of being the bottom of the doctor chain; but this comes with a price.

while intern year is stressful and awful in many ways, it is also great, and one of the reasons that makes it so is the obscenely steep learning curve--in just 8 months one's knowledge of clinical medicine probably increases by a factor of 100, at least. now that it is mid-february, most interns know what they are doing 80-85% of the time, and they can handle nearly all the mundane, routine issues that come up in daily patient care. perhaps more importantly, their confidence has increased exponentially as well. this means that they are no longer afraid to interpret information and make decisions based on this, and then tell people what to do.

this is a great feeling because after years of feeling lost in the endless sea of information they are finally able to make some sense of it all, to focus on and synthesize the salient data, ignore the chaff, and move forward. hooray!

the pejorative side of this issue is that interns still have to do all the mindless gruntwork at 8 months that they did on day 1, which is essentially data collection, presentation, and paper work that needs to be completed by an MD (when in fact it could be completed by a moderately-well trained primate). this is frustrating since they realize that they now have actual skills as a physician--they can think critically and independently--but are still doing what amounts to secretarial work.

this evolution is in contrast to the careers of nurses and, in reference to my prior post, often leads to friction. nurses are extremely valuable, and there are great nurses, especially in the ICUs, and they absolutely improve patient care, which leads to better outcomes for patients. but nurses are not doctors; they are not trained as such, and they generally lack the clinicopathologic knowledge that doctors have been building since the first day of medical school. the veteran nurses know quite a bit, but it is generally due too pattern recognition rather than a true understanding of pathophysiology.

this can lead to problems in complex, multi-factorial disease states, such as heart failure. in a somewhat simplified scenario, if the heart can only pump forward 2/3 of the fluid that it receives, the remaining 1/2 will back-up behind it, in places like the lungs, legs, etc. if some of the fluid is removed from the body, then there is less net fluid which the heart must pump, and this can relieve the backup (i am talking about removing the liquid component of blood, which is essentially a bunch of cells and proteins floating around in water).

seems pretty simple, right? well, it can be and often is, in say, 7 out of 10 cases. however, it can be significantly more complicated if in addition to the heart failure, there are other, co-morbid conditions, such as poorly functioning kidneys from diabetes, hiv, liver dysfunction from hiv medications and a history of alcohol abuse, peripheral vascular disease, and mild cognitive dysfunction from early multi-infarct dementia. not so simple now, as there are multiple reasons for this patient to have fluid derangements, and treatment is further complicated by the fact that target organs may not be responsive to medications.

as i said, in a basic case, the treatment may be medication x, but in the above patient, medication x may actually be harmful. and this is where doctors (and specifically interns) and nurses are at odds. the latter, in general, lack the complex knowledge and understanding needed to make the aforementioned decision about medication x. interns however, are beginning to realize that they, in fact, do posses the ability to grasp the nature of the situation, or at least the realize that it is not a simple case and the usual treatments may not work. furthermore, they now have the confidence to speak their mind and make decisions on their own;they are progressing, and this is difficult for nurses to except.

why? look at it this way: in july i was the the new guy; i didn't really know what i was doing (i know, i'm switching to the first person here). i lacked a great deal of knowledge and confidence. in some respects, the nurses know a lot more than i did, particularly when it came to completing many of the simple tasks that i was expected to do, even though they weren't things that really "required" an md to complete, that is just how they are done. jump forward to february and now i posses much of the same prosaic information about daily hospital operation that i formerly lacked but the nurses did not and the playing field is somewhat equalized. in addition, i have my 4 years of medical school, which have increased my fund of knowledge, plus 8 months of residency which has furthered both my knowledge and confidence.

can you see where this is going? every year it's the same process: interns come in green and timid and a year later they are seasoned and confident. three or four years later they may be attendings at the same hospital; now they are in charge. contrast that with the career of a nurse whose duties and leadership roles never really change (this is not totally true, as there are levels of nursing seniority, but nurses will essentially always be subordinates of physicians). at this time of year the transition is taking place for interns--i am taking a step forward, but the nurses are standing still. this is often difficult for them to except, particularly the ones who have been there for years as they have seen hundreds of us ascend from lowly interns to successful attendings, all while they have continued to do the exact same thing.

it is not always a problem--there are certainly arrogant interns just as there are needlessly cantankerous nurses--but it can certainly can be, as evidenced by my previous rant. 6 months ago i might have relented and just put in the orders myself, but at this point i call bullshit when i see it. i have the confidence to ask people to do things, but also, when necessary, to tell them to do it. therein lies the transition, and the true difference between doctors are nurses: at the end of the day, i can tell them what to do, and they cannot do the same. i am not a bellicose or capricious person, and i do not seek to wield power just for sake of doing so, but when it comes to medical decision making, that is what doctors do, and sometimes you must speak loudly in order to be heard.

i refuse to let myself be needlessly pushed around, although i realize that this sense is likely somewhat over-developed merely as a reaction to having been the lackey for the last 8 months. i am usually open to criticism and suggestions, but if someone is going to antagonize me by questioning my medical knowledge and judgment, they damn well better be able to back it up with a cogent, rational, and knowledge-based explanation which, sadly, nurses are generally not able to provide.