The neurosurgery chief resident has so much autonomy I’m jealous. He does cases almost singlehandedly – far less supervision than I’ve seen a general surgery chief have. But it comes with a price. He also has so much responsibility, sometimes it hurts to watch. Today a critically ill patient was on the receiving end of several miscommunications between various team members. The patient is in such critical condition that I doubt that anything short of a major dose miscalculation or misadministration (which thank God we’ve so far avoided) could do any more harm; but it’s certainly not helping, either. There was no one person totally at fault; which means in the end, the chief takes responsibility. Just watching him listen to the trail of errors unfolding at signout, watching his shoulders sink as he chose not to get angry at anyone, but simply to take the guilt on himself and call the attending with it – was painful just to watch, being totally on the outside and knowing I hadn’t contributed. I’ve written before about how as a medical student I admired the interns who accepted responsibility for mistakes I’d made while they were supervising. I hadn’t completely realized that this responsibility just keeps growing. The chiefs have a whole team full of residents and students that they’re responsible for; it’s all on them, in the end. (I guess the attendings are responsible, too, but the chiefs are more directly involved; and I haven’t seen many attendings hesitate to ream out a chief or a senior when they could choose to accept involvement in the problem, rather than distance themselves.) (His silence, of course, probably made the rest of the team feel worse about the mess than we would have if he’d chewed us out.)

As for the patient and the mistakes themselves: definitely signout was involved. Too many signouts between too many people added up to a seriously jumbled decision-making process. We’ll see in the next few days how much the patient has been affected.

The residents wound up signout with some appreciative quotes from House of God. When I was a first-year student, I thought I would acclimate myself to my new world by reading this much-referenced classic. About three pages in, I gave up on the obscenity and cynicism. So far I’ve avoided returning to it; but it’s probably a marker for my deterioration that I now think the quotes are funny and witty rather than crass. (To make it clear, this is not a book recommendation; I would not want to be responsible for somebody getting this stuff in their head. There’s no benefit to reading this or any other book about life being miserable in residency. If you’re the general public, it’s too much information. If you’re a med student, you’re already stuck, and there’s no need to borrow trouble. If you’re a resident, you know for yourself, and there’s plenty of dark humor right in your own hospital. And if you’re a practicing physician, you survived, so why think about it anymore?)

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