Jul 23, 2010


I don't know what day it is. Hell, I don't even know what time it is. I was driving around at 7 today, genuinely wondering if it was 7 am or pm. The sky is a mellow blue at both instances of seven o'clock and either way the moon is up, so I just wasn't sure. Even though I have been driving to this hospital for two weeks now, I still turn my GPS on to get there from my motel. Normally I'm good with directions, but this rotation has turned my head around.

I get there before it is light. Sometimes I leave after dark. Sometimes I sleep during the day and go in at night. I am so beyond tired that I don't even feel tired; instead it manifests in a mild nausea and progressive confusion. This experience reminds me of training for deep diving, to prepare for the nitrogen narcosis that occurs at depth. With many extra atmospheres of external pressure, nitrogen solubilizes in the blood and decreases oxygen supply to the brain, and tasks that you could do at surface in 9 seconds now takes 14 at depth. A divemaster will show you this deficit and prepare you that even though you feel completely normal, your capabilities are affected by the external pressures.

Even though I feel okay, I am aware by objective measures that my cognition is not sound. My GPS tells me to turn right, and I turn left, and then am surprised when it says "recalculating" because I think I've gone the correct way. I do a patient's history and physical in Spanish, and then come out and write parts of the note in Spanish, because the conversation is in my head that way. I don't seem to realize that the English-speaking chief resident isn't going to know what I mean when I write "no tiene sangrado" on the intake form. My dad thinks he's been disconnected from me on the phone when he asks a simple question, because it takes awhile for me to formulate an answer. I'm making up words that make sense, such as the neologism of being "disorientated."

A lot of these skills are tested in what's called a Mini Mental Status Exam, or MMSE. We give to patients who are elderly, confused, psychotic, or otherwise just not making sense. It's a baseline measure of basic orientation and cognitive skills.

I'm sure I have a much better chance of failing it than whomever I am giving it to.

These external pressures are real, and even if I don't feel them consciously, I am narcosed by the environment, just like diving. I'm sure this is not the best idea for patient care. Would you want someone operating on you that had been working the last 84 hours with irregular sleep? Probably not. But it's an hazing of doctors into the fraternity of medicine, a tradition of each generation of doctors initiating the next. It's traditionally thought that this creates a stronger doctor that is capable of practicing good medicine despite all circumstances, but I have to doubt that. And I question the role of the older physician in this process. A divemaster demonstrates human deficit in the face of uncontrollable external pressure and teaches each student to recognize it and compensate for it. The doctor-divemaster takes young physicians to depths to try to prove that skills can overcome human reality. My sense is that this is not good for the new doctor, and certainly not in the patient's best interest.

Que hora es?


  1. I am honored to be in a Lil Doc blog! Dad

  2. Hey Annie,

    Hope you are hanging in there! I'm sorry you have to go through the "hazing" but just keep this in mind when you are the "older physician" and you have new blood to train. Good luck!!