Steering back to safer, less political waters:

I’ve been having a peculiar experience lately. Of course I’ve grown inured to the embarrassment of concluding that a patient needs surgery, and making my case, and then being informed by the attending that I’m insane, there’s no such indication, and the patient is best left far outside the OR.

But recently, I’ve encountered the slightly more disconcerting phenomenon of being told by the chief resident that the patient doesn’t need surgery, adjusting my presentation when talking to the attending, and then being told by the attending that we should book the case for first thing in the morning. Depending on how much I caved to the chief, I then get reamed out by the attending, again, or I get credit for having made the call.

Last night was a succession of such cases. A large bowel obstruction, a variety that I haven’t seen a lot of, which people weren’t convinced was really obstructed, but the attending agreed with me. Ischemic bowel, which the intern and the ER doctor were trying to downplay as questionable, but I knew the CT was incredibly bad, and the patient’s vitals and appearance were subtly hinting at the outcome, which was that he died six hours later despite our best efforts (I can at least be glad that I didn’t waste time, and that I stuck to my interpretation enough to drag both the chief and the attending in much against their wills). A less obvious case of ischemia in a vascular patient, requiring intervention in the middle of the night. . .

Now that I’ve gotten to the seniority, and perhaps the reputation, that the attendings will usually, despite questioning me at length, book the case immediately just on my say-so (because surgeons can’t function without interrogating each other, and especially their junior members, regardless of how correct the plan is), I’m starting to encounter the weight of responsibility: I have the OR set up, the patient consented (often after being talked into it quite urgently; so that I would feel incredibly guilty if I had persuaded them so firmly, and was mistaken) and carried down to preop. Everything ready to go for a major operation, and all on my authority. I make time, no matter how much the ICU is calling me, to wait till the attending comes, so I can see what he thinks of the patient and the CT scan. I only ever once got the patient and the attending together in holding, and had the attending seriously consider cancelling. But I get very nervous at the idea that I, virtually by myself, am setting people up for big surgeries. . . what if I get it wrong?

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