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A Fresh Pair of Eyes

September 19, 2021
by Mark David Siegel

Hi everyone,

Last week on Fitkin, we diagnosed hypogonadism, diverticulitis, restless leg syndrome, and possible Crohn’s Disease with eye, joint, and lung manifestations. We used a YNHH Care Signature Pathway to guide imaging and antibiotic choices, we asked if it was safe to continue apixaban in a patient with a fib and low platelets, and we used Y-access to return a patient closer to home. We learned that one patient played the drums and another had a dog named Gizmo. No patient had been admitted directly to our team and a couple had been hospitalized for weeks. Some were seeking diagnoses after years of mysterious symptoms.

In my nearly thirty years at Yale, I’ve never seen the hospital this full. We’ve become a magnet for complex patients from all over southern New England, and because we’re so busy, patients often have workups and treatments started before we see them. And because patients are so complex, many are destined to stay with us for a long time.

Since my internship, I’ve heard people say we should only admit “interesting” patients to the teaching teams and that we should transfer patients off when there’s “nothing left to learn.” These suggestions seem reasonable at first, but then I ask: have we really learned all we can from our patients? Have we diagnosed all their problems? Is there really nothing left to do to help them?

Yesterday on rounds, we listened to the heart of a nonagenarian awaiting transfer to an SNF. She had a harsh systolic murmur and an absent A2. Afterwards, we reviewed her echo and the resident taught us how to identify the aortic valve, which was barely moving. Later, we worked with the nurses to calm a demented patient, weighing the pros and cons of olanzapine. Afterwards, our intern described a recent exposé in the New York Times, which showed how some SNFs misuse antipsychotics to make up for inadequate staffing. Earlier in the week, my co-attending, Dr. Kwah, helped us decide if we should add cephalosporins to a patient’s allergy list (we didn’t). Throughout the week, we rounded at the bedside and treated every patient with respect and compassion, no matter what their life choices, no matter what their social challenges, no matter what the color of their skin.

In the weeks ahead we’ll discuss ways to increase the number of fresh admissions to the teaching teams. In the meantime, let’s acknowledge this: There’s no end to the diagnoses we can make, the questions we can ask, or the care we can give- even when patients have been hospitalized for months, even when other teams have seen them first. There’s a reason our medical center is one of the best and busiest in the world, just as there’s a reason residents flock to Yale for training. Let’s treat each patient encounter as an opportunity to learn and to heal, and let’s approach each patient with a fresh pair of eyes, because when we do that, there’s no end to the treasures we can discover and the good we can do.

Enjoy your Sunday, everyone. It’s time to bike down to the hospital to join my team.


PS- For further reading, on the value of a fresh pair of eyes: Nighttime Cross-Coverage Is Associated with Decreased Intensive Care Unit Mortality. A Single-Center Study


Submitted by Mark David Siegel on September 19, 2021