For those of you who like to do math, Black Week was 140 out of 168 hours. When I went on call for the consecutive dubious double, I packed a suitcase full of extra shirts and underwear as well as a stockpile of food in case I missed a meal while toiling on the ward. During that era, there were no floats (day or night), and expectations for performance were high even if we were starved for sleep and on the verge of hallucination. As house officers, we were munchkins aspiring to be giants.
We did our own laboratory work and everything else necessary for our patients. Although called an intern or resident, I was a medical handyman and utility infielder. I pushed patients to and from X-ray, ran blood to the labs for stat readings, took EKGs, put in IVs and Foleys, counted cells on a hemocytometer, and stained sputum, urine, or cerebrospinal fluid, looking for rods or cocci or something that snapped red. Because there were no computers, I entered laboratory values on flow charts and in progress notes, using a special red pen so that the numbers were easy to see.
Given the system then, medicine was truly a matter between doctors and patients. By contrast, in medicine today, the lines blur because the doctor changes every few hours as each morning a float comes in to take care of the previous night’s admissions. Alas, the float only floats for a few hours, bobbing in the torrents of the day’s frenzied work, and then there is a hand-off to the next team, which will work through the night. Sometime the next morning (an hour precisely determined to avoid a violation of some regulation), there will be another hand-off to allow the on-call team to get finished before the clock ticks for their duty hours or, as in the Cinderella story, they turn into pumpkins or I get reported to the American Council of Graduate Medical Education.
Fortunately, modern medications can often be very effective, and it often doesn’t really matter who enters the electronic order for moxifloxacin or enoxaparin. Today, the computer is the medium of all transactions in medical care, and the doctor–computer relationship reigns supreme.
Just like a camel, which is a horse designed by a committee, rheumatology is a specialty designed by tradition, accident, and the penchant of rheumatologists for variety and the opportunity to grapple with problems that have eluded others.
Changing Times
The other day on rounds, we had a patient with a mass lesion in the brain, and increased intracranial pressure was a worry. I asked the house officer what the fundoscopic exam showed. The house officer honestly replied that, one, the patient had had a CT scan, and there was no evidence of brain swelling and, two, he didn’t have an ophthalmoscope. I gasped and sputtered.
