[Ever wonder if there are aspects of medicine that TV shows, even fairly accurate ones like Scrubs, don't show on TV? Ever wonder why, despite advances in technology, some aspects of medicine still seem stuck in the 1950’s? Let’s discuss.]

As sarcastic as I can be about the field of medicine, surgery is truly something that I find enjoyable. 

One of the aspects I truly dislike, though, is DICTATING.

God, what can even say about dictation? In medicine, dictating is when you regurgitate into words everything that was done during a surgery, or during a patient's hospital stay, with excruciating detail (excruciating being the operative word). 

Dictating is that black menacing cloud whose specter ominously creeps across the otherwise sunny day known as a day in the operating room. 

Dictating is necessary, yes, especially when there are complications, but make no mistake, it is evil. 

It's not even so much the act of dictation, but the particularly incomprehensible way most hospitals still go about doing it. Even at the fairly 'fancy' hospital I work at these days (by which I mean working lights in every room), they still use an offensively inefficient and appallingly ancient system to transcribe and record operative notes.

First of all, the process involves a phone. 

If you're a youths, and you dare ask me what this is, I'll kill myself. I swear. source

A phone. As though time and technology had never evolved beyond Alexander Graham Bell to the development of computers, texting, Seamless, and near-total avoidance of real-time communication with other human beings, we must begin with a telephone.

Then, you dial the dictation number, where you will hear this cheery, static-ridden message:

“Welcome to the dictation system for the ____ Hospital.”

Then, you encounter an equally inaudible and particularly painful automated menu consisting of queries about:

• physician ID number
• dictation type
• hospital site
• patient medical record number
• the date of operation. 

An answer is required for every single question, or 

source

An especially fun situation: when your menu doesn't specify which options are associated with which telephone key, but instead, ask you to read its automated mind. Making an assumption that pressing #1 will lead you down the right path may seem logical, but isn't, as logic is not to be included in the process of medical dictation; for this reason, some menus don’t even include an option #1.

Even when you know what numbers you must type to cross the River Styx, typing the answers may pose another Herculean trial. Hospital phones like to test your dexterity and ability to adjust to challenges by either:

1) having sticky keys, or 

2) not registering properly unless you allow a good one-second pause between entering digits. 

Patient medical record numbers are particularly entertaining, usually consisting of a string of 10+ digits, any of which, if you type incorrectly, will require you to hang up and restart the whole process once again. This means listening to the chipper and dreaded menu from hell, again. And even after the numbers are entered correctly, you face another challenge: the pound key (for the youths: that's the one that looks like hashtag). For sometimes you have to press ‘#’; sometimes you don’t. 

Which adventure will you choose? 

They will sometimes mercifully tell you whether ‘#’ is required. 

But, sometimes, they will yell at you for pressing the pound sign. 

Sometimes, they will passively aggressively hang up on you. 

Sometimes, you will try not to slam your head repeatedly on the table and cry.

And then - AND THEN - you dictate! Which really means that you will parrot the exact same phrases again and again, because essentially, unless there are major complications, every case is performed in the exact same way. If you are an intern, and you have three hysteroscopy/D&Cs in a row, you will have to recite the same string of words and phrases three separate times, with increasingly angry and sloppy enunciation, for the sole reason that they must be recorded under three different medical record numbers. 

(My poor beleaguered interns, if I can give you any hope about subsequent years of residency, it is this: advancing to second year will be better simply because you have more complicated cases, and thus a decreased number of dictations to do.) 

At the end - OH GOD THE END - it’s of utmost importance that you jot down the “job number.”  Not only is it proof that you did the dictation, but when your dictation from your cellphone doesn’t go through because, for some reason, only obsolete technology is compatible with this ancient system of record keeping, (or when your landline phone keys stick and enter in the wrong medical record number, or the wrong operation date), someone can use this number to scan through reams and reams of transcribed notes and charts to find the paragraphs that you painstakingly regurgitated into the phone so that you won’t have to go through this whole damn process again.

Dictating gets really entertaining for the transcriber at 3 am after an stat cesarean section (or two or three). During night float and call, I have definitely, and more than once, lost my train of thought or starting mumbled nonsense in addled delirium while dictating. One time, I fell asleep while talking, woke back up after an unknown amount of time, and sheepishly finished the dictation; I still wonder if the transcriptionists actually listened the whole recording and managed to find my poor dictation peering out from behind a long, long silence.

The particularly frustrating part is that there is a solution, and this solution is extraordinarily easy: computers. The nationally-required electronic medical records system. AKA just typing the damn note into the system.

The advantages:

1) typing, for many people, is faster than talking - and it’s certainly easier to go back and correct mistakes or add to the dictation 

2) you can make a template for each case type, then copy/paste and alter as needed

3) you can be sure that while trying to decipher your mumbled and monotonous 500-wpm dictation, the medical transcriptionist didn’t accidentally write that a medication was given “trans broccoli” instead of transbuccally, or that Clearasil was placed at the surgical site instead of the usual Premarin.

4) when you fall asleep on the keyboard, you can always erase the rows of ggggggggghjklhjkyuiojhf without the risk of embarrassment or the wasting of your hard work.

5) in the case of discharge summary dictations, you can add to it gradually over time, rather than at discharge, which saves time and decreases inaccuracy due to impatience or lack of knowledge of the medical course of a patient who has been in hospital for 8 months, and has been passed between 10 different teams of physicians.

5) you can save money by not hiring medical transcriptionists, who probably can't hear what you're mumbling anyway.

Spread the word. Tell your local hospitals if they will listen: Computers - they EXIST! Let's use them.

Next time in Medicine from Yesterday, Today!: pagers. I mean, really,

Foreword:
Persistence was never my strong point.  If it didn't come easily, or quickly, it usually just didn't get done.  So many half-finished knitting projects are languishing around the house as a result.

But it doesn't mean that I can't strengthen that frail muscle of perseverance.  So here's to re-newed beginnings, a re-restart, another grand re-openin', another show.

Here's to another blog entry, and hopefully, more to come.
- - - - - - -

In the past, when I would declare with melodramatic sorrow that I was on call on the next day, many friends would look askance at me and hesitantly ask, "But...that means you can still come out tomorrow for a little bit, right?"  At which point I would return their confused look, because it seemed clear to me that it meant I would be in the hospital for the next 24 hours.

Reflecting on the confusion of what constitutes 'being on call' made me finally realize that people in medicine have their own weird little languages and kingdoms and phyla that years of 'House' and 'ER' still have not elucidated to the general public.  I mean, what other people still use pagers?  The last time I spotted them actually being used in pop culture was in Clueless, the movie from 1995.  Last referenced in modern times by 30 Rock in the form of Dennis Duffy, the Pager King, who with his mullet and hockey-and-classic-rock loving ways, is a living tribute to the late 80s/early 90s.

But a little illumination:  there are, in fact, different types of call - at-home call and in-house call.

Some residents, such as senior medicine residents or very specialized doctors like dermatologists or oral maxillofacial surgeons, take call - that is, caring of patients or taking consults on patients related to your specialty - from home (AKA at-home call or pager call).  They only come to the hospital when their ancient bulky pager beeps, and only when the person paging them lays out their case insistently and fairly begs them to come in, i.e. patient is practically dying, or at the least, very, very sick. Thanks to smart phones, most of the time dermatologists don't even have to come in:  take a pic, click send, and they'll call you back with a diagnosis.

On the other hand, OBGYN residents, regardless of seniority, most always take call from inside the hospital (AKA in-house call).  We live for 12-24 hours inside the hospital, without contact with the outside world.  (One of my residents truly thought that the hurricane devastating our area was called Hurricane Sally.  SALLY.  Not much better:  when I'm on call, I only know if it is raining or sleeting or snowing when I'm actually being soaked on my walk back home after call, because we have no windows nearby on Labor and Delivery, and thus never see what's happening outside.  For me, weather is something you experience, not something you look outside and prepare for.)  We are working most of that time, taking care of the post-surgical patients, sorting the pregnant women who are actually in labor/having actual problems from those who are not, trying to get babies delivered, and arguing extensively with the ER, for whom we are basically the female organ examination-and-ultrasound service.  We still, unfortunately, must carry our shrieking, bulky pagers.  

Things we do on call:  slap things on unsuspecting residents' backs

 Why must we be in the hospital?  There usually are not that many OBGYN residents in each program (unlike the armies that constitute Surgery and Medicine), and because of restrictions on duty hours, we already have the minimum possible number of residents on call.  The attendings at our program are usually not that active in managing the course of their patients' labor; that falls to us.  Emergencies and labor can pop up at any time, usually truckloads at a time.

Things we do on call 2:  model the latest in recyclable scrub coat fashions - note the hand-torn fringe

In any case, I guess it would be hard to deliver babies or rush ectopic pregnancies to the OR from the screen of my iPhone.  (Darn.  Work on that, you geniuses at Apple or Google).  And I, for one, have never been on an empty Labor and Delivery.  An axiom of the universe:  THERE WILL ALWAYS BE SOMEONE IN LABOR AT ANY GIVEN TIME OF DAY.

Things we do on call 3:  print out prescriptions for the patients leaving the next day

I've heard rumors of other programs in the Midwest where senior residents stay at home and just come in for emergencies or surgeries like cesarean sections.  When someone at the end of their third year of residency blithely posted on their Facebook wall , "Last night call ever!", I seethed in jealousy AND confusion for a few minutes, and then had the courtesy to click LIKE.  Even though I suppose this would be feasible since I live half a block away from the hospital (the view from my 9th floor apartment looks squarely on the hospital facade), which is both convenient and depressing, with the volume of deliveries at my hospital, I would be woken up at least three times a night to run back over for a c-section, and would likely spend the rest of the time sleepless, dreading the shrill call telling me to run back to the hospital again.

Things we do on call 4:  take care of babies (only while inside the mother)

Plus, years of residency have made me neurotic.  Whatever little I can control on Labor and Delivery, I MUST control it; this means doggedly going between the intern and the second year and the third year resident, making sure everything is taken care of, and at the minimum, okay.

Also, sidebar, call rooms:  NOT glamorous.  Not, at least the ones on my Labor and Delivery, used for any type of 'Grey's Anatomy' extracurricular activities.  Not even used for more than two hours at a time, usually.  They are small and cramped.  They are really, really cold.  There are rumors of bedbugs in the past.  The sheets are changed, sometimes, I think (though, to be honest, we're usually so tired that we don't really care.)  There is this giant conical thing protruding from the ceiling with a giant hole in it, which I refuse to examine closely in fear of what it might be, though I hope it's from some sort of flooding from the floor above that resulted in blistering of the ceiling?  I don't know, and I don't want to.  I also once had a new pair of pretty running shoes stolen from the call rooms, which makes me resent the call room AND my attempt at betterment and exercise at the same time.

Things we do on call 5: bring a dash of the holiday spirit, in a culturally open, comprehensive, and medical way.

In summary:
1)  Being 'on call' means that you are taking care of patients in the hospital, taking calls from patients who think they may need to be the hospital, and seeing patients of other specialties that may need your expertise.
2)  In house call = in hospital, AKA that resident can't (or at least probably shouldn't) hang out with friends outside the hospital that entire day.  Pager call, or home call = close to hospital, AKA that resident can hang out with you until the ancient beeper calls.
3)  Some specialties do not need to be in the hospital when they are on call; some specialities always need to be.  The type of call and the amount are residency program dependent.  (Some food for thought for those of you in medical school still considering which field to go into.)
4)  Call rooms are nothing like TV would prepare you for.  They are mostly unpleasant.

'Til next lesson.

Disclaimer:  Take everything I say with a grain of salt.  I tend towards the sarcastic (clearly).  ER, dermatologists, and senior medicine residents work very hard, and pager call can be equally as stressful as in-house call if there are many emergencies that you have to come into the hospital for.  Being a resident in general means hard work.  And OBGYN calls are busy, but manageable.  But generally, I think what I've said is true.