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Shooting For What I Want

Shooting For What I Want

I'm starting out. For 3 years in my Resident's Column, I've shared the excitement, frustration, and even outright anger that I experienced as a second-career psychiatry resident. Because I had completed a different residency years earlier, I was in the position to step back a bit and observe my experiences in a way that would have been impossible the first time around.

But now I am in a different position. Now you, the readers of this column, are the ones with experience. For the first time, I will bear the weight of the true responsibility of psychiatric care. While I intend to network and seek professional supervision, I will no longer have the luxury of consulting an attending psychiatrist for assistance with difficult situations. This is a situation that most readers of this column have faced already, perhaps years ago. And so I ask myself, what do I have to offer?

I think of my friends who are still in residency. Some are in fellowships and others have a year or two remaining in the general program. And I remember my thoughts 15 years ago, as I finished my residency in anesthesiology. As I think of that time of my life, my memories are merged with disjointed images. I picture baby robins nudged from their nest, not quite ready to fly on their own. The proverbial young actress from Omaha steps lightly from a bus in Times Square and meets an exciting character who claims to have her best interests at heart. A college football player swaggers into the draft with untested bravado, sure that he will become the next Jim Thorpe. All of these scenes contain hope for a great future, fear of the unknown, confidence in one's abilities, and the genuine risk of independence.

I imagine that people of different personality structures will have varied affinity for the different scenarios presented here and that each person may vacillate between scenarios depending on his or her day-to-day experiences, the seasons, and even weather forecasts. Rather than test my own bravado before experienced psychiatrists, I will try to share my successes and failures as the first robin, the naive actress, or the star athlete . . . my perspective changing, I would expect, with my own day-to-day experiences.

For introduction, I am a Midwesterner who has lived "out East." I have worked for health systems, for the federal government, and as a member of a single-specialty group. I am old enough to remember what those my age call the "golden years" of medicine. And I now share the train ride, with all other physicians, toward the great wall that we all know is ahead—the change in health care that will come sooner or later that will include restructured reimbursements, cloaked rationing, a single-payer system, more uninsured patients, or a combination of all of these. As health care costs increase and baby boomers grow into an already-stressed Medicare system, the only thing certain is that things will change.

I have already witnessed changes in health care that would have alarmed my early instructors. Individual physicians are now interchangeable employees. Treatment plans are influenced by payers and administrators. And the once-respected concept of the art of medicine is almost seen as obsolete in a world of scanners and treatment protocols. These changes have come in subtle fashion. We were the frogs that were placed in the tepid water, and we didn't notice the rising temperature.

When I worked as an anesthesiologist, I remember the first time that I received a quality assurance memo asking why the medication that I administered during a code did not strictly follow Advanced Cardiac Life Support (ACLS) guidelines. I attempted to ex plain to the quality assurance nurse the value of thinking physiologically—that when the reason for the cardiac arrest is considered, the choice of catecholamine may vary from protocol. I tried to point out that a milligram of epinephrine in a 90-year-old woman is a different drug from the same dose in a 20-year-old man. Weeks later, I was dismayed when the hospital required physicians to join the emergency medical technicians and nurses in rote memorization in ACLS certification classes, as if it were a given that we could not be trusted to have adequate knowledge of physiology. But back then I had cases to do, people to treat . . . and the administrators had nurses who did nothing but create more protocols and who had the time to write more letters. Not worth the trouble, I decided. Where is that protocol sheet?

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