Teaching Hospital Caste System

Lions and tigers and bears?

No…

Medical students, interns, and residents, oh my!

What in the glory is a Fellow (and should I allow her to treat my daughter) and where in the hell is the Attending, anyway?

(See Maternal Coat & I Was The Mamma to read more about why these questions became so important to my family in the care of The Oldest Girl.)

Medical students are persons still attending medical school who have yet to earn their Medical Degrees.  In their third year of a four-year program, medical students rotate through the different medical services of the hospital to learn the rudiments of case management and to become familiar with the different areas of medicine so that they can choose their specialization.  Much like a simulation model, medical students are on the floors to get an idea of patient care and to practice writing orders, but they are not directly responsible for patient care. After graduation from medical school, doctors earn their M.D.s, elect their area of specialization and enter a three-year residency program.  The first year of this program is called the intern year.  Interns are primarily responsible for patient care.  During the second and third year of residency, doctors are referred to as residents and follow patient care while being directly responsible for the supervision of interns.  After completion of their residency programs, most doctors begin to practice in their field, like pediatrics, gynecology, or family medicine.  Others decide to pursue advanced training in an area of specialization like pediatric cardiology. Referred to as fellows, these physicians enter a three-year educational program.  Fellows oversee patient care and resident training while developing their expertise in a medical specialty.  Attendings are the doctors at the top of the hospital medical caste system.  They are ultimately responsible for the care a patient receives and directly supervise the residents.  Attendings are not only teachers in this capacity, many also hold teaching posts in the medical school associated with their hospital.  Although the nuances of this medical training hierarchy makes for good television, it also increases the volume of people and amount of repetition and stress with which a family or patient must tolerate.  It took over two days for me to learn the answer to the question I had asked myself during The Oldest Girl’s test. How many cardiologists does it takes to read an echo?  It takes only one, maybe two if s/he calls for a collegial consult as was done in The Oldest Girl’s case.  Not only were all the other doctors who were in the room not cardiologists, they were there as much for their own training as my daughter’s care.

This answer demanded that I ask more questions.  The Oldest Girl had lain on her back crying for hours during the echocardiogram.  Her screams of protest echoed cannon-like in my head.  The number of people in the room did not necessarily increase her discomfort, but it did raise my own.  I felt like a carnival sideshow.  A phantom carney’s voice mocked me, “Step right up Ladies and Gentlemen.  See the world’s most incompetent mom’s inability to comfort her daughter in her hour of need.  Witness her desperate attempts to quiet her with her breasts.  Listen to her voice crack as she tries to sing consolation.  See her doctors’ frustration as they wrestle a tough diagnosis.  Watch the dramatic events unfold as they happen.  It’s all included in the price of tuition.”  Our privacy had not been invaded in the traditional sense.  Nosey neighbors had not peered through the slats of their venetian blinds to catch a moment of impropriety.  It was instead an intrusion of one system upon another, in this case the hospital machinery upon the already strained dynamic of my family.  Again a sense of double reality distorted my attention.  On one hand, The Oldest Girl’s doctors needed me calm and focused.  I was their best conduit of information about her condition, its onset and its progression.  I was the keeper of her history, the only one who could report the events they needed to hear.  On the other hand, the teaching hospital’s system and multiple layers of caregivers taxed my composure and distracted me.  I knew I had to organize a plan to secure as much of my strength and energy as could be safeguarded.  This made me keenly aware that I had to actively investigate my rights to secure my role as a member of The Oldest Girl’s team of caregivers.  I needed a plan to guarantee that only the best, most qualified doctors provided her care, regardless of the medical training hierarchy.  And I had a deadline.  The Oldest Girl was scheduled for a heart cath and possible surgery.  Oldest Girl was fighting for her life.

My fight was to honor hers through the creation of the best possible circumstance I could organize.  The similarity of how I observed the teaching hospital faculty treat family members reminded me of the public school system dynamic I was a participant of, and made me respectful of how carefully I needed to proceed.  I did not want The Oldest Girl to be labeled as the patient with “a problem mom.”  I needed to conduct myself in a professional manner to get what I wanted.  I noticed a direct relationship between the quality and amount of information that was shared with me and the staff’s perception of my wellness.  They talked to me differently based on how tired I looked, whether or not I had showered, how emotional I was and whether or not I was alone.  Given this variance, one of the first things I did was to request to read The Oldest Girl’s medical and floor charts to insure not only that I had access to all information related to her care, but also to check my retention and comprehension of it.  The right to review medical charts is one of the patient/parental rights in fine print, my experience suggested that it is not a popular request.  I was given access to The Oldest Girl’s chart, but with resistance, I had to push to assert my legal right, and even then could only view it with a hospital staff member present.  Reading the chart was an extremely validating experience for me.  Because I was so emotionally engaged in the situation, I had predicted that there were things that I had not heard or understood about The Oldest Girl’s condition.  I was relieved to find that this was not the case upon reading the chart, which helped me feel more focused, and in control.  It helped reinforce my understanding of The Oldest Girl’s medical needs, which were her primary care providers and what the plan for her treatment was.

The redundancy of the chart bolstered my unease with the medical training system practiced in the teaching hospital culture.  It seemed backwards logic to me that the interns with the least experience were directly in charge of daily patient care, while the attendings assumed more of a management role.  I wanted The Oldest Girl’s attending intimately involved with her treatment.  The next step of advocacy I took was to request that only those primary care providers interact with The Oldest Girl and our family.  The caveat, “that’s just one of the things you have to put up with at a teaching hospital,” is not wholly accurate.  Medical students, interns, and residents cannot participate in patient care without consent.  Parents can designate their child’s case a non-teaching one, even in a teaching hospital.  This step reduced the volume of people we needed to interact with on a daily basis and helped to lessen the sense that The Oldest Girl’s room was a high traffic area during rush hour.

I spoke at length with The Oldest Girl’s cardiologist about this as we reviewed the details of her upcoming heart catherization.  He explained that although it was not routine, the team had decided that The Oldest Girl should be intubated during the procedure because of the “unknown” status of her airway.  Intubation is the process of inserting a breathing tube down a patient’s throat so that breathing can be controlled by a ventilator.   The respiratory symptoms that had initially brought us to the hospital had become more severe.  At that time, we did not know if this was due to heart failure, an airway collapse, or both.  Because of this uncertainty, her cardiology team wanted to make certain that her airway was controlled in case of an emergency.  Her cardiology attending told us that if it was determined that The Oldest Girl needed surgery that she would remain intubated until after the surgical repair.  We asked who would be performing the heart cath, intubation and surgery and, were assured that only the best would be doing those jobs.

I did my best, it wasn’t much
I couldn’t feel, so I tried to touch
I’ve told the truth, I didn’t come to fool you
And even though
It all went wrong
I’ll stand before the Lord of Song
With nothing on my tongue but Hallelujah!