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Making the rounds

Jul 27,2010
As part of the first class of residents at Good Samaritan Regional Medical Center, Dr. David Lemons is completing his education and honing his craft.

In a single shift at the Corvallis hospital, this fledgling physician will confront a medical mystery, juggle a full caseload and, for the first time in his young career, come face to face with the grim reality of a potentially fatal disease.

This is a day in the life of a medical resident.

6:30 a.m. - Pre-rounds. The sun is just coming up over the parking lot at Good Samaritan Regional Medical Center, but Dr. David Lemons is already on the job. Seated in front of a computer terminal in the cramped residents' room on the Corvallis hospital's fourth floor, he's trying to solve a medical mystery.

Lemons has five patients in the hospital right now, and one of them, a man in his 50s with a number of small blood clots in his liver and spleen, has the young doctor stumped. He cycles obsessively through a series of CT scans of the patient's abdomen, looking for clues to explain the clots.

"We don't know exactly what's going on with him," confides Lemons, a soft-spoken 33-year-old with traces of his native Missouri clinging to his accent. "We've got him anticoagulated, so he shouldn't get any worse. But we've got to figure out long-term what the cause is."

Dr. Alissa Craft looks over Lemons' shoulder at the computer imagery. As director of medical education for Samaritan Health Services, she's in charge of training Lemons and the 10 other newly minted physicians in the mid-valley hospital network's residency program, which just got under way this summer.

"Has anybody talked about any other methodologies for getting the clots out? You might want to look at vascular surgery," she offers.

Lemons nods, absorbing the suggestion, and goes back to staring at the scans. But he's got something else on his mind, and after a minute he swivels his chair away from the computer screen.

"Dr. Craft? Just some advice here. I've got this patient coming in this afternoon ..."

The patient, a man in his 70s, had come in earlier with a persistent cough, and Lemons ordered some tests. Now the lab results are in.

"He's full of cancer. And he has no clue - all he wants is cough syrup," Lemons says.

"And you're going to see him today?"

"Yeah," he replies. "What's the best approach?"

Craft outlines several steps he can take:

Let the risk management department know you may have an upset patient on your hands.

Tell the patient you're sorry this is happening to him.

If you feel it's appropriate, put your hand on his shoulder.

"Expect anger," she says. "I would bring Kleenex."

7 a.m. - Shift change. The dayside docs check in with the physicians who've been on duty overnight, getting briefed on new arrivals and getting status updates on previously admitted patients. For a resident, this can be a good chance to pick up a new patient.

Residents expect to work long hours, but it's not like the bad old days, when some hospitals treated them like slave labor. A few years ago the federal government stepped in to halt those abuses, limiting residents to an 80-hour week. At Good Sam, most work from 6:30 a.m. to 6:30 p.m., six days a week.

"Half of our residents have families, spouses and children in town, so half of them have a real reason to get out of here," Craft says.

"I was the single resident in my program, so I know what it's like to be the one expected to stay late and work extra hours. We try not to do that."

7:30 a.m. - Morning report. Nearly a dozen residents and medical students gather around a long table in the fourth floor conference room. Most have a paper cup of coffee or tea in front of them.

Dr. Barry Smith, one of the hospital's attending physicians, stands in front of a white board covered with jotted notations. It's time for a case study.

The patient is a woman in her 40s with colon cancer. She's taking a number of different medications. She has a history of post-traumatic stress disorder. She also has a history of methamphetamine abuse and may still be using the drug - even in the hospital.

At one point, the woman became combative and threatened suicide. Hospital personnel called a Code 5, meaning restraints were needed. To complicate matters further, the patient's mother became angry and charged across the room at a doctor.

"This is obviously a very unique presentation," Smith says.

He goes around the table, asking each person in turn for their comments. He jots a list of problems on the white board: anxiety, depression, family issues, delirium.

From there he goes into a differential diagnosis, the kind of medical brainstorming dramatized on the TV series "House." What could be causing some of these symptoms? What's the best way to address them?

And what's the best way to handle a combative patient? If a Code 5 is called again, should physical restraints be used to protect the patient and hospital staff? Or could a change in medication achieve the same result?

"Meth is one of the most addictive drugs out there," Smith says. "When people go through meth withdrawal, they will do anything to get their drug."

8:10 a.m. - Morning rounds. Lemons grabs his clipboard and hits the stairwell, detouring around the sleep lab and emerging on one of the third floor medical/surgical wards, where he stops to talk with the nurse assigned to his clot patient.

"She's the nurse that's here all day," he explains. "Sometimes they see things I don't see that can be real important."

Next comes a chat with a satellite pharmacist on duty at the nurses' station. They discuss the patient's anticoagulation regime.

After popping into the patient's room for a look, he logs onto a computer terminal at the nurses' station to check the man's latest lab results.

"No changes," Lemons sighs. "Just looking for something that might jump out."

He wants to talk with the surgeon to see if a procedure to remove the clots makes sense in this case.

"Right now, whatever the recommendation is, I wouldn't fight that. I could go either way on it," he says.

And even though he's only a couple of months into a three-year residency, his opinion really does matter, Lemons says. He likes the fact that Good Sam encourages a consultative relationship between residents and attending physicians.

"We get quite a bit of say here, which is real nice."

At 9:20, he's down on the second floor, on a progressive care unit. The man in 2304, Timothy Hasenstein, has been in the hospital almost two weeks, since falling ill at his son's wedding. But today Lemons is bringing him some good news.

"I've talked to the surgeon, and it sounds like you're good to go home today," he announces.

That gets a big grin and a thumbs-up from Hasenstein. Lemons coaches Hasenstein and his partner, Ruth Giegerich, on the follow-up care he'll need at home.

She says she's happy with the treatment he's received from residents and attending physicians at Good Sam.

"I like the team approach," she says. "It's better to err on the side of too many doctors, right?"

10 a.m. - Attending rounds. Residents and med students meet with attending physicians in the hospital's brand-new intensive care unit to review cases in groups, depending on which rotation they're assigned to.

Lemons joins Drs. Tricia Nielsen and Eric Sharp, the other residents currently on internal medicine rotation, and Jennifer Erickson, a third-year medical student. Leading the session is Dr. Ashley Forsyth, a ponytailed osteopath who carries the tools of his trade in an old-fashioned black leather bag. He's one of Good Samaritan's hospitalists, physicians who deal strictly with inpatient cases.

Reviewing the notes on various patients, Forsyth asks Lemons about Hasenstein.

"He's going home today," the resident reports.

Forsyth seems surprised. "Going home?"

"We're sending him home this afternoon," Lemons confirms.

After quizzing Lemons on the discharge decision, Forsyth leads the whole group into Hasenstein's room to see how he's doing.

"It's a pleasure to see you get better," he tells the patient. "You were stumping us for awhile, but I think we've got you figured out."

The group moves on, and Forsyth asks Erickson to summarize the case of a woman with osteoporosis.

Sharp, who has lagged behind, catches up. He's chewing on something.

"I love nurses, and nurses love me," he says, looking pleased with himself. "They give me chocolate."

11:20 - Back on the ward. With attending rounds over, the residents go back to checking on their patients.

Lemons snags a free computer terminal to catch up on his paperwork. He scrolls through the latest lab results on his patients, making notes in the charts on his clipboard.

At 11:35 he spots Dr. Dana Penner, the surgeon he's been wanting to consult about his clot patient, on his way into the man's room.

"Dr. Penner? I'm David Lemons," he says, holding out his hand. They confer briefly in the corridor, and Lemons comes away looking like a man who's reached a decision

"Dr. Penner says surgery has too many risks and is not going to do him any good," Lemons says. "That kind of opens up some treatment options.

The medical mystery remains unsolved, but at least the range of possible responses has been narrowed.

It's now 11:50 a.m., and Lemons goes in search of another free computer so he can get started on Hasenstein's discharge papers. It's a big job.

"I need to talk to everybody," he says. "I need a discharge planner."

12:30 p.m. - Noon conference. The residents and medical students converge on a ground floor conference room for lunch: pizza, fruit, soda, cookies. Lemons, still behind on his paperwork, arrives late, followed by Sharp.

Dr. Takiko May, a hospitalist with Samaritan Albany General Hospital, is giving a PowerPoint presentation on end-of-life decisions. One slide is titled "Cardiac Arrest Jeopardy."

"On TV," she asks, "what percentage of patients survive resuscitation? Somebody actually did a study. It's about 67 percent."

In real life, she notes, far fewer survive such heroic measures. It's important to talk with patients facing life-threatening illnesses about what they want done in such a case, she says.

"Being a good communicator is essential to your work as a physician," May tells the group, a sly grin starting to spread. "Unless of course you're going to be a radiologist."

As the lunch meeting breaks up, the residents file out of the conference room. Several stuff cookies or bags of chips into the pockets of their white lab coats: fuel for a long afternoon.

Lemons is still at the table, madly scribbling prescriptions for Hasenstein's release. Sharp and Nielsen help him check the discharge papers.

Lemons and Nielsen hand their pagers to Sharp. They're working in the outpatient clinic this afternoon, and he'll be covering their patients for them.

"We're not stepping on each other's toes. We're just trying to help each other out," Sharp explains. "It's the nature of medicine. We have to learn to work together as a team."

1:35 p.m. - Clinic hours. Lemons leaves the hospital and walks across the street to the Neville Building, home of Samaritan Internal Medicine, where he spends one afternoon a week seeing outpatients.

Before getting started, he checks in with Dr. Stanley Nudelman, one of the clinic's internal medicine specialists. He tells Nudelman about one of the patients who's coming in today, the one who has lung cancer but doesn't know it yet.

"Oh, Lord," Nudelman says. "I would call oncology, see how soon we can get him in. Let's see if we can get him in this week."

At 1:48, Lemons ducks into an exam room to see his first clinic patient.

Nudelman says he's excited to be working with residents. Before coming to Corvallis to become Samaritan's first staff physician in 1992, he was an associate clinical professor in the University of California at San Francisco School of Medicine.

"As soon as I found out there were residents here, I jumped at the chance of teaching again," Nudelman says. "All the ones I've met are very capable, conscientious, willing to learn. And I learn from them, too. It's not just a one-way street."

Of the 11 residents in Samaritan's inaugural class, four, including Lemons, intend to specialize in internal medicine. Three others plan to become family practitioners, and the other four are going into psychiatry.

Their residencies will last for three to four years, depending on specialty, but all will get on-the-job training in a variety of disciplines, with rotations in neurology, inpatient care, psychiatry and other aspects of medicine.

At 3:05, Lemons finishes with his first clinic patient and consults with Nudelman about his next case. Then they resume their earlier conversation about what to do for the recently diagnosed cancer patient.

At 3:10, Lemons calls the oncology department. After he gets off the phone, Nudelman, who was listening in, offers some advice.

"You said, 'Is this something you want to see soon?'" Nudelman observes. "I would've said, 'I want you to see him soon.' That's the difference between an old man and a young resident."

The next patient is a complex case. He had gallbladder surgery two and a half weeks earlier, but the incision is still draining and he's not recovering as fast as everyone had hoped. The surgeon thinks he might have to go back under the knife.

"I'd rather be hit in the head with a golf club," says the patient, sitting in the examination room with his wife.

Lemons is sympathetic. Today's exam shows some hopeful signs, but he can't rule out another surgery.

"I hope you don't have to go through that again - you've had your share and a lot of other people's share of problems," he says. "Well, you're a work in progress."

"Let's not have too much more work," the patient replies.

The little joke gets a laugh from Lemons, who asks, "Anything else I can do for you?"

The man's wife answers for him.

"Just get him home," she says.

It's now 3:50, and Lemons is running late for his 3:30 appointment. This one is the cancer patient. Time to break the news.

It's a dramatic moment in what has already been an eventful day, but Craft points out that the realities of being a resident rarely equal the medical soap operas on prime time television. Over coffee in a patio outside the hospital cafeteria, she parses some of the differences between TV and real life.

"In my experience, there's not quite as much sex as in 'Grey's Anatomy,'" Craft deadpans. "Does it happen? Sure - but not here.

"'House' is probably a little more farfetched," she adds. "There's no mystery service that diagnoses all the medical mysteries that come into the hospital. It's the internal medical docs who do that."

At 4:25, Lemons is back from meeting with his cancer patient. It's the first time in his career that he's had to deliver such a devastating diagnosis.

It wasn't easy, for either of them.

"He was fairly shocked," Lemons says. "We sent him right over to the oncologist."

Lemons wasn't quite sure how to begin the conversation.

"I asked him how he felt and what he thought was going on," Lemons says. "He wanted to know. His first question was, 'What did the CT show?' So I told him."

He feels badly for his patient. Suddenly, this case has become very personal for the young resident.

"The last thing he said was, 'I guess I have to get my affairs in order,'" Lemons says.

"They don't train you for that."

6 p.m. - Residents' room. Back on the fourth floor of the hospital, nearly 12 hours after their shift began, Sharp and Dr. Ben Hudson, a resident doing a rotation in nephrology, are wrapping up for the day. The conversation turns to the high cost of medical education and the low wages of medical residents.

Sharp finished med school about $270,000 in debt. For Hudson, the figure is closer to $300,000. Both men have families, so neither can afford to start repaying his loans on the salary Good Sam pays first-year residents, a little over $40,000 a year.

"You don't come into medicine for the money," Sharp says. "That's for sure."

At 6:20, Lemons walks through the door. He's finished his clinic hours and is more or less caught up on his paperwork, including the forms for the patient who's being discharged today. He needs to check in with Sharp, who's been carrying Lemons' pager all afternoon and covering his patients.

"On Mr. Hasenstein," Lemons says, "the prescriptions are in there, the discharge sheet is done, I wrote 'discharge home.' Everything's done except for dictation, right? So I don't have to worry about him."

That's right, Sharp confirms: "He's tucked in."

6:35 p.m. - Journal Club. Once a month, the residents and medical students get together after work to discuss a recent article from a medical journal. They meet over dinner in a modular building nicknamed "Flamingo Flats," the temporary headquarters for the residency program while the latest round of construction continues at the medical center across the street.

While attendance is not mandatory, most of the residents are here. Everyone wants to make a good impression, in hopes of either being offered a job when their residency ends or getting a strong recommendation for a fellowship or a position in another hospital.

The atmosphere is relaxed. Most of the residents have had time to change into street clothes. Hudson and his wife, fellow resident Mandi Hudson, have brought their daughter, a sweet-tempered 6-month-old who has everybody smiling.

Over a takeout meal of Hawaiian chicken and rice, Craft starts the discussion on this week's reading assignment, an article from the Archives of Internal Medicine titled "Yield of Diagnostic Tests in Evaluating Syncopal Episodes in Older Patients."

The article prompts a debate on evidence-based medicine: Should doctors always base patient care decisions on the best available research, even if there's an outside chance that the recommended treatment will be insufficient? Or should they order batteries of expensive tests to protect themselves - and their hospitals - against potential lawsuits?

It's a tough line to walk, Craft says, especially in emergency situations, when there may not be time to wait for lab results.

"People say, 'I can't practice and I won't practice cookbook medicine.' We don't want you to practice cookbook medicine. But we do want you to get the best medical history and physical exam possible and ask good questions."

7:35 p.m. - Off the clock. After a spirited and wide-ranging discussion, Craft declares this meeting of the Journal Club adjourned.

"Go do whatever," she says. "Be with your family. Save a life."

Lemons allows himself a yawn as he gets up from the table.

"I'm done," he says. "I'm going home."

He isn't done quite yet, of course. Not really.

Lemons is still discussing cases with Sharp and Nielsen as the three go their separate ways. It's close to 8 p.m. by the time he gets to the parking lot, deep in shadow as the sun goes down behind the West Hills. And after he gets home, he's got another two hours of reading to do: more journal articles to absorb.

"It's an everyday thing," he explains. "You have to read to keep up."

And if there's any time left before he collapses into bed, Lemons might give a little thought to where he wants his career to go from here.

After his three-year residency at Good Sam - and assuming he passes his board exams - he has several options. He could try to find work at a hospital. He could go into prvate practice. Or he could apply for a fellowship to pursue a subspecialty.

"My two choices right now are nephrology and hematology," he says.

He also has to decide between inpatient and outpatient practice.

Lemons likes the intellectual stimulation of the hospital, where doctors see an ever-changing assortment of complex and interesting cases and work together to solve medical mysteries. He also likes working in the clinic, where he has the chance to build long-term relationships with his patients - even if that means sometimes being the bearer of bad news.

It's another one of those tough calls physicians have to make, and one that Lemons - just three months out of medical school - isn't ready to make quite yet.

Frankly, he confesses, he hasn't had much time to think about it.

"There's so much going on," he says.

This article was written by Bennett Hall and first appeard in the Gazette Times on Aug. 29, 2009.