November 1, 2009
Leave a Comment
August 10, 2009
I was scrubbed in today for a while, and witnessed the most violent outburst of anger I’ve seen in four years spent around some pretty volatile men. (I say witnessed, because as far as I can tell I wasn’t too close to the center of the target; I’m not sure how much he blames me, but we’ll see about that tomorrow.) My first reaction, besides shock at the amount of cursing, was, “how did he ever get this way? I can’t imagine ever getting to the point of being this angry, or expressing it so openly.”
And then I realized that I’m probably a lot closer to that attending than I would like to think. For instance, the other morning, I had to do several procedures with a nurse who probably qualifies as my least favorite ever. There are some nurses I dislike because I don’t think I can trust their medical advice (ie, they’ll say, “Dr. X would always start z medication now,” whereas in fact Dr. X hates that medication, and anyway it’s not at all indicated at the time); there are others whose opinion I might trust, but I dislike the fact that they are never available to help with problems in their rooms or their neighbors’. This particular nurse qualifies on many levels.
The harder I tried to get all the pieces lined up to get the procedures done in her room, the more ways she seemed to come up with ways to frustrate my efforts (I will allow that she was probably doing this unconsciously, in a sincere attempt to take good care of the patient; nevertheless it added up to thwarting all of my attempts to work efficiently). Finally, I was so angry and tense I would have been happy to throw some trash on the floor, except I knew that would bring our conflict way out in the open, and put an end to any forward momentum at all. As it was, I doubted that I would be able to do the procedure safely, I was so upset.
That morning, I got past it with a few prayers, and some meditations on the insignificance of these procedures to the course of the day, and how it didn’t really matter if I spent an extra fifteen minutes doing them safely.
But I can easily see how, if I had the power to throw things and yell without fear of retribution, and if the procedure I was doing was far more weighty and vital, I might well have chosen that as a method of venting stress, reasoning that it would be better to get it out so I could go on to concentrate on the procedure, rather than trying to keep it politely in, and be so tense that I couldn’t control my hands properly. I can even see how enough of these experiences as a resident, controlling anger, and then watching my role models express it, could make me happy to do the same when I reach that level. (This deliberate choice of a method of stress relief, to get back to the job at hand, would also explain the curiously swift changes of mood of most surgery attendings: they get very angry, then they calm down, and are back to joking and friendly. A few of them don’t let go, and they’re the really scary ones.)
I hope not. I know Paul said “be ye angry, and sin not,” and I’ve got to think that throwing things in the OR, even if only at the floor and not at people, probably counts as sinning while being angry. (Irony there, folks. I know quite well that it’s wrong. Don’t want you to get too concerned about me.)
July 24, 2009
Answering to one attending is difficult enough. Answering to three or four at the same time, about the same patients, is extremely tricky (I’m not going to try to explain the structure of this group of attendings; I still haven’t figured out exactly where the power lines are, which is no doubt part of my problem). When discussing any given decision in the patient’s management, the attending you’re currently talking to is liable to take exception, and start asking how that decision came to be made. You never know if he’s just trying to figure out which of his colleagues has taken the greatest interest in the case recently, or which of his colleagues is wrong-headed enough to be pursuing this particular plan. Or perhaps he knows (and you don’t, yet), that whatever you’ve been doing is so completely off-target that none of the other attendings could possibly have approved it, so either you misheard what they said, or you’re doing it entirely on your own; either way, you’re in trouble. Or perhaps his questioning is simply in the time-honored surgical variation of the Socratic method, in which he attempts to shake you off your commitment to a correct answer.
If you’re just doing the wrong thing, and you can figure that out, it’s relatively simple. Then you merely get to figure out why it was wrong, and what to do next. But if it was one of the attending’s colleagues doing something that he thinks was incorrect, and you’re left trying to explain it, the opportunities for committing a faux pas are endless. You could imply that his colleague was right, and he’s wrong to object; you could imply that he’s right, and you never agreed with his colleague, which is a little better, but still disrespectful to the colleague. Or you could inadvertently make plain that despite the apparent importance of the subject (since they’re all asking about it), you really don’t understand the difference between the two plans at all, or the significance of whatever the difference may be.
And the fellows want to know why I’m sometimes reduced to stuttering incoherently during rounds, as my life flashes before my eyes, and I try to pick which one of these equally impossible situations I want to get into, as I try to explain why the patient is on xyz medication. (Catch them ever helping with an explanation, even if they were involved in the decision! As the junior resident, I am perpetually assigned to be the one presenting on ICU rounds, and thus perpetually the one trying to explain myself.)
Some of the attendings are even more devious. We’ll be calmly proceeding with an operation (a setting where I’m usually safe from being questioned about details of ICU management, since it would be too distracting from the case at hand), and the attending starts what seems to be a friendly inquiry into how the rotation is going, and how the ICU is working. Next thing I know, I’ve somehow managed to say something incriminating about the actions of myself or the fellows. . . I ought to have figured out by now that these attendings are far too complex to ask pointlessly friendly questions. . .
July 12, 2009
I’m not old enough to be doing this much reminiscing, but something about having spent two years at this is making me retrospective (is that an adjective?). In medical school we changed specialties every few weeks. It’s still a bit funny to be spending years straight on one thing, and to plan to spend even longer on an even smaller area of that. . .
Anyway, when I was a medical student on surgery I was fascinated by the trauma service. Most medical students who have any procedural (or should I say violent) bent at all are; they’re attracted by the excitement of the trauma bay, and the acuity of the ICU. They don’t understand how the residents get frustrated by caring for geriatric and head injury patients instead of doing surgery.
So it was July, and I was supposed to be doing something else, but I decided to spend the night with the trauma team; their assigned medical student wanted to do peds, and had no interest in contesting my presence. A patient on the floor needed a chest tube. It was one of the first for the intern, so there was no chance for me to get involved, but I went along to watch. The main thing I remember was the violence of it, and how the patient seemed to be having so much pain. As a student I couldn’t tell for sure whether the surgeons had premedicated him adequately or not, but I was a little shocked by how they all focused on explaining the steps to the intern, and getting the tube in, and seemed not to care how much the patient was grimacing.
We had a chest tube to put in on the floor today. I always hate chest tubes on awake patients; at least in the trauma bay the gunshot victims are short of breath enough to understand that something needs to be done quickly. On the floor, the problem isn’t that acute, and it’s harder to justify. This lady certainly qualified. Her effusion was occupying nearly 70% of her thorax. I made sure the nurse gave her some medications ahead of time, so they could take effect while we were laying out our supplies and setting up, and I did my best to let her know what would be happening.
But I was thinking more about the technique of the insertion, and how angry I was that the fellow felt the need to supervise me. For crying out loud, I’m a third year resident now (just two weeks and I already feel confident calling myself that). I put in a dozen chest tubes just last month, assisting the trauma team at night. I know how to do it, and how to do it quickly. I know about numbing up the periosteum and the pleura, about entering the chest over the rib rather than under it (to avoid the intercostal artery and nerve), about dilating the tract with the hemostat, angling the tube in so it goes up and posteriorly, and suturing it tightly down afterwards and putting an occlusive dressing over it. I don’t need supervision anymore; and especially I don’t need this guy, neither whose character nor whose knowledge do I respect, chattering away giving me superfluous instructions (the opposite of what the last three attendings told me), and disturbing the patient by the graphic nature of the instructions. She doesn’t need to hear about how doing it the wrong way will cause excessive bleeding, while it’s being done.
It went in smoothly, for all that, and the only commotion came from the fellow, not me. Despite adequate iv pain meds (she was as sleepy as I could tolerate on the regular floor), and plenty of correctly applied local anesthetic, she wasn’t really comfortable. The tube irritates all the pleura it touches, not just where it goes in. But once I was sure she’d gotten all the meds she could, it was more important to finish the procedure in a timely manner, and technically correct, than it was to spend time trying to calm her down. Once I was done, the pain would alleviate. So here I am, just like those residents I wondered at only a few years ago. I don’t know if that makes me heartless, or a good surgeon, or both.
July 1, 2009
In one day, I managed to get two people in the unit I started working in to hug me; got one person to yell at me; got three attendings to call me by my first name without reminders; and put in two Swans (as much as in the previous year together). If I can get these to balance out, the next month might not be too bad. (Although I was starting to get that uncomfortable vibe that becomes so familiar to residents, where on the first day of the month all of the attendings claim to be delighted to have you around, and foretell plenty of hands-on learning, whereas within a few days it becomes obvious that you’re still only a scut monkey.)
Yesterday I also had the biggest fight I’ve ever had with a nurse. Previously, when people say I don’t get along with nurses, I’ve been puzzled. This one was not puzzling. My patients were falling apart. I was moving somebody to the ICU every hour or two, without having the time to stop and think about why exactly they were deteriorating (which makes me extremely nervous and snappy) and there were consults from the beginning of the night still waiting to be seen, and major procedures waiting to be done – and the nurse was trying to quiz me about why I’d decided to do this and not that. I tried explaining nicely, I tried telling her I’d cleared it with my attending, I tried offering to discuss it with any other doctor in the unit whose toes she thought I might be stepping on, but she wouldn’t stop harassing me. Eventually I turned my back on her and told her I was done talking (after she’d carried the argument into the room of a conscious patient whom I was trying to assess for a pressure of 80/40 on pressors). After she finally left, the other nurses in the area had a few rude words for her communication methods, so I know I wasn’t the only one feeling annoyed and frustrated.
I’ve mentioned before how some of the senior residents tease me about doing procedures at the drop of a hat. It’s been a while since I acted like that. Lately, working nights, I’ve been so tired and frustrated that I’ve avoided procedures as much as I can. But in the last 24 hours it all started coming back, I think related to being now responsible for only one ICU instead of four (and thus not having to fear what could happen in a distant corner while I’m tied up in a sterile field), and that the most acute ICU in the hospital (cardiothoracic), where there’s no time or leisure for avoiding lines and tubes. I’m reacquiring my knack with sharp objects, and it feels good; surgeons are supposed to be comfortable moving quickly with knives and needles. When I was avoiding procedures, I felt an uncomfortable camaraderie with the naval captains in Patrick O’Brian’s books, questioning their courage when they decided it was wisest to avoid an engagement with the enemy – but not any more.
June 28, 2009
I’ve written this post in my mind nearly every week for the last six months, and finally I’m so angry it’s coming out.
Half the bitterness and cynicism among residents comes from the job itself – long hours, seeing people suffer and die and often being helpless to change that. But half of it comes from the way we’re treated by administration. When I was a student I saw this, listening to the residents talk about their grievances against the hospital. Back then I couldn’t understand; I heard the aching bitterness, but I had no idea where it came from.
Now I know. The residency administrators are one thing; they use us like pieces in a puzzle, to fill out the schedule and get the work done, but at least they know our names, and have some slight regard for us as individuals who will carry the name and the honor of the place when we graduate. The hospital administrators are a separate breed. I don’t think they even know that residents exist. Perhaps they suppose the work gets done by robots, or by magic. Certainly they have no hesitation to take actions which gut our educational experience, and change our lives permanently, for the worse, at a moment’s notice.
This is what really gets me: I work so hard for this hospital. I do more than is written in the contract, or than is my obligation as an employee. I go out of my way to try to keep patients happy with this hospital. I apologize when apologies are needed, even when it wasn’t my fault (poor communication to families; housekeeping inadequate; nurses too busy to respond to call bells). I talk to irate families even when it isn’t my patient, I’m just covering, and technically am not required to get involved at all. For all its shortcomings, I do like this hospital (perhaps even love it, because it’s my home, and because I like the people here, although not the administrators); I actually do think about making it successful, keeping it in business. And for that, we get slapped in the face by the administration. They don’t realize or care that the face of the hospital, to all of their patients, is the residents and nurses whom they abuse.
Within the next year, I think I won’t be able to care about public relations anymore. Like so many of the other residents, I’ll retreat into doing only what’s required by the book, nothing more, because the people we work for don’t even give us the benefit of the rules. (I really think they’ve broken our contract in more than one way, in a legal sense as well as moral, but I’m too exhausted to look it up, and what would I do about it anyway? Fight them? I can’t risk my place.) And when I graduate and go to work on my own, you can believe that I’ll never trust a bureaucrat farther than I can throw them. Administration is always out to screw the physicians and nurses – that’s the most important lesson I’ve learned in residency so far; and when I’m not part of the slave labor force any more, believe me I’ll remember it.
June 22, 2009
Most of the residents on call that night were women, and it was a very bad night, multiple disasters at the same time. Towards morning, a couple of us were standing in the hallway, in between ICU errands, propping up the walls and playing one-up: whose disaster was the worst. One of the older nurses walked by, one of my favorites (her name and her face remind me of one of my aunts); she saw how tired we were.
“You doctors don’t get enough credit,” she said. We figured she had to be joking – what nurse would say that out loud to residents? but she went on. “It takes some special drive to do what you do. We nurses complain sometimes, but when was the last time any of you worked a 40 hour week?” We nodded slowly, realizing that she was serious. “When I was young, getting out of school, there were no female doctors. It couldn’t be done. It really was the old boys’ club. Good for you.” And she disappeared down the stairs.
I turned to the other residents. “Maybe we should have let the old boys keep their club, and we could be sleeping.”
Sarcasm aside, I can’t believe she actually said that to us. Maybe there’s hope for relations between senior nurses and female surgeons.
June 19, 2009
May 11, 2009
I love texting on cell phones. It used to be, if you wanted to ask the chief a question, let alone the attending, you thought about it long and hard. Is this worth calling or paging them, distracting them from what they’re doing, making an incident out of the fact that I can’t figure it out for myself, or worse yet, can’t remember what they told me to do?
I’m sure for the chiefs, there was also an element of wanting to know things (how’s that patient in the unit doing; is the new admission here yet; did the attending agree with my plan to operate on this patient tomorrow), but not wanting to keep paging the junior residents repetitively for minor things.
Now we just text each other. Forget about waiting for answered pages, or spelling out your message to the operator. Text messages range from brief notes (“rounds at 8;” “meet me in OR 12;” “urine output better?”) to complex instructions and algorithms. Even some of the younger attendings have cell phones that they’re comfortable with us texting them on with brief messages, though of course not a first-time presentation of a new patient (“CT normal, will admit for pain control;” “OR got an emergency, your case is being pushed back”).
Although in general I would make a philosophical case against the rise of text messaging (it encourages communication without commitment; you want to say something, but don’t want to have to listen to the other person’s answer), in this case it dramatically improves real-time communication, and relieves stress for the junior team members, since texting is not as big of an intrusion or an admission of inadequacy as paging would be.
May 4, 2009
I guess my communication style can’t be that bad. The family involved in the conversation that inspired my last post said so many good things that the attending complimented me on it – and it has to be pretty good for an attending to go out of their way to say something positive.
Then today I was operating with the most demanding attending in the program. All the residents, even the most senior, are a little scared to operate with him, not because he’s mean, but because he has such high expectations, and doesn’t stop pressuring you. For the junior residents, being intellectually lazy, sometimes we’d almost rather not operate, than be with him. But today, I thought the comments were at a pretty minimal level, and after he left the room, the tech said, “It was so nice to have you today. Thank you for doing such a good job.” I said I thought I’d been remarkably slow, and the nurse responded, “No, compared to days with other residents, this was very smooth and quick.”
Which has given me so much job satisfaction, and no doubt a big head too, that something bad will undoubtedly happen shortly. The end of the year tends towards pride and stupidity; all the residents start to think about the new status they’ll attain in July (attending, fellow, chief, not-the-most-junior, not-the-intern), and correspondingly have far too good an opinion of themselves and their judgment. I can see it in myself and my colleagues, and yet I can’t quite stop myself from feeling extraordinarily satisfied that in less than two months I’ll be a third year resident, only one year away from fourth year, and that’s only one year away from the fifth year, and before you know it I’ll be done. . .