communication


Before we started the third year of medical school, the clinical years, they had us do a workshop on breaking bad news. We had to (individually) tell an actor portraying a young woman that she had melanoma, and then help her deal with the shock of the diagnosis, and get her to understand a bit of the prognosis and the treatment plan. I did pretty badly, as I recall. I blurted out the news baldly, and then sat there, unsure whether to hold her hand, and unable to control the conversation enough to communicate anything else meaningful through her (very fake) tears.

I don’t know if I’m any better at it now, but it’s not for lack of practice. In surgery, there’s a lot of times when people come to see you, somehow not realizing that if they’ve been sent to a surgeon, they’re going to have surgery. Whether it’s in the office, or the ER, or a consult in the hospital, I’ve had a lot of conversations along the lines of: “We now know what the problem is, and you need to have surgery in half an hour/in two hours/tomorrow/next week. The risks of surgery include, but are not limited to, death, serious injury, abscess, wound infection, respiratory failure. Please sign the paper.”

That is of course merely an outline. Depending on how much time we have, I try to spend a little while explaining the diagnosis, and how it leads to surgery, so that it doesn’t seem like we’re recommending this out of the blue – that there is in fact a reason for the commotion. Then I explain what we’ll do during the surgery; depending on how much blood and guts is involved, I may edit this extensively. Then the consent, which always sounds bad inside my head; if somebody asked me to sign a paper accepting all those risks, I don’t think I’d cooperate.

The more of an emergency it is, the sicker the patient usually is, the less likely family members are to be handy, and the more of a rush I’m in. Usually, after calling the attending and the OR, I have half an hour to get the consent signed, have my note written on the chart, get blood drawn for type and cross, a last minute EKG if needed, antibiotics ordered (and call the pharmacy and explain that I mean now, not tomorrow), get the patient transported to pre-op holding, and a quick talk with the anesthesiologists about what we’re planning and what kind of lines might be needed. Plus answering all the other pages I’m going to get in the meantime.

So sometimes, like last weekend, it really does boil down to this (at the top of my lungs, because of course the elderly patients are all hard of hearing, more so under stress): “You have a very serious problem, and if you don’t have surgery you will almost certainly die very soon. You need to have this surgery, right now. But even if we do our best, there’s a very high risk that you will still die, or end up in the ICU, even on a ventilator, for a couple of weeks. Do you understand that? Ok, please sign.” (That was for mesenteric ischemia – dead gut, which had already been sitting around for a while. And then the nurses found the DNR papers, and I had to persuade everybody that since the patient had just insisted that they wanted to have surgery, and wanted everything done, the DNR orders were implicitly revoked, and it was ok to intubate for surgery. Why are DNRs always there when you don’t want them, and never when you need them? Fortunately for all concerned, our preop assessment turned out to be an overestimation of the seriousness of the situation, and the patient spent only one day in the ICU.)

Which is all to say that, as in my medical school days, I’m still trying to figure out how much time to spend commiserating and comforting, and when to move the conversation on to what our plans are. Sometimes it’s easier to have the pressure of the impending OR to set the timetable.

Saying “I told you so” in medicine is not very enjoyable. Usually something pretty bad has to happen for things to get there, and by that point it’s no fun knowing that you were right.

Of course, you also have to have had the guts to stand up for a while, disagreeing with the chief and the attending, in order to be able to say I told you so. Mumbling it to myself, that I would have been right, if only I’d had the courage to say out loud what I thought, is even less satisfying. I’m not good at arguing with people for days on end. Maybe when I get more confident with my judgments, and better at giving an explanation (rather than falling back on “it just doesn’t add up your way”), I’ll get better at sticking with an unpopular conclusion.

I have a knack for tripping over the elephant in the room. But I ask you, how was I supposed to know that the attending got consent for an operation, performed it, and explained the procedure to the family afterwards – without ever stating outright that the patient had cancer? I don’t know, maybe he said it and the family were too upset to hear it. But I hate trying to backpedal when I say “cancer” casually as part of my explanation of the recovery period, and the family acts as though they were still hoping the object in question was benign, or perhaps a false alarm entirely. I’m getting good at a spiel for “I don’t explain this, I don’t have a lot of experience with this, I don’t want to misinform you, my attending will explain in due course,” along with my spiel for “swelling after surgery is normal” and “use the incentive spirometer or you’ll get a fever” and “please start walking now or you won’t be able to go home.”

Most of the attendings here have a policy that they won’t discuss pathology results until the patient leaves the hospital after surgery. I can see their point, after watching families and/or patients so devastated after learning the extent of the cancer that they have no will for recovery. But then the attending isn’t the one talking to the patients and families three times a day, and trying to sidestep the only question that people really care about – what did you find, how big was it, how bad is it, is further therapy needed . . . and of course, how much time do we have. People always think they want to know the worst of it right away, but perhaps it’s not best for them to know. I’m ok with saying that I’m not the attending, so what he chooses to tell the family isn’t my responsibility; but I wish he would give me the cue card for what he did say.

You know the teamwork/collegiality concept is having a bad day when a nurse walks up and starts commiserating about how difficult it must be for you to keep on executing the attending’s unpopular plan in the face of opposition from the nurses and two or three separate groups of consultants. I fell back on the “no comment” defense. No matter what I think of the attending’s plan, as long as it doesn’t seem positively unethical, I’m not going to express my doubts to the nurses or to nonsurgeons. Besides, as far as I can tell, he’s the expert in this area, and is much more likely to be right than his detractors are.

One of the medical students, one week in to his surgical rotation, confided after rounds that he’d been shocked and disconcerted by the attending swearing copiously at my presentation about the first two patients, who’d had some significant setbacks overnight. Myself, I had simply been reassured that he was cursing at life in general and some consultants’ practices in particular, and was not blaming me for any of it; and as long as the cursing wasn’t directed at me, I wasn’t too upset. The effect of a year and half with surgeons, I guess.

Something in my social interaction/internal regulator is malfunctioning, and has been for a long time. I think, perhaps in self-delusion, that I can read body language fairly well. But I seem very bad at picking up clues to expected behavior patterns.

Which is to say, half the time I’m being rebuked for not acting aggressively enough on a problem, and half the time I’m getting this extremely frustrating kind of comment: “Well, Alice, I was surprised to hear that you did XYZ. Normally I wouldn’t expect a junior resident to do that kind of thing. I guess it worked out ok, but it seems rather. . . assertive.”

It happens more at this children’s hospital, but I get it at my home hospital too (and boy am I homesick for that place). I would really like to go with the theory that the men can’t handle a woman being appropriately tenacious (supported by the fact that I seem to get along ok with the female attendings and senior residents, and get these comments more from the guys), but I hate to disregard the suggestion that I’m doing something wrong without further consideration.

So I consider, and then I get in trouble for not acting fast enough or firmly enough. . .

I have to do what I think is right and necessary, because then I don’t feel guilty. Rubbing people the wrong way is not really a sin; failing to fulfill a responsibility is (to my mind).

That, and wait for the day when I won’t be a junior resident anymore; then maybe finally I won’t have so many chances to be out of line. Or wait for a closer mark, the day when I get out of this top-heavy, academically hide-bound, hierarchy-driven, dysfunctional hospital. (I said I was homesick; my home hospital never seemed so efficient, friendly, rational, and lovable, as when seen from this remove.)

One of the ER bloggers a while back mentioned something about “knowing how to talk to surgeons on the phone,” and I didn’t know what he was talking about. I do now.

There is nothing more annoying, in the middle of the night (or a busy day), than to get an ER doctor trying to give you a five-minute presentation on a patient. I really do not care what time the patient went to the outside hospital, or how exactly they got transferred here; unless the creatinine is 3, I don’t care what the chemistry shows; unless you have a positive urinalysis, and are apologizing for calling me anyway, I don’t care what the urinalysis showed (yes, sterile pyuria – white cells and no bacteria – can help confirm a diagnosis of appendicitis; on the phone, I still don’t care); unless you got a CT scan without asking us (which would be ok, if it shows appendicitis), I don’t care if you got xrays on a patient whom you think has appendicitis; I also do not care which ADHD and asthma meds the kid is on (unless they include high-dose oral steroids); I don’t care whether (when calling for appendicitis), you think the abdomen is distended or not, or whether Rovsing’s sign is positive or negative. All I really want to know is, what room is the patient in, and a name or medical record number, so I can track them down when they change rooms. Apart from that, you can be as impressed as you like by the abdominal exam; you could think they have peritonitis. I don’t care, I have to touch it for myself, and until you give me a room number I can’t do that! (At my own hospital, about half the ER residents, I would care what they think about whether the patient is truly surgical or not; here, I haven’t had time to learn to trust the ER staff, so. . . I don’t care whether they think there’s rebound or not.)

Bottom line: you called the surgeons because you want us to touch the patient. So give me the location of the pain, and the location of the patient, and stop talking. The best calls are from the male PAs, who usually are not too chatty: name, age, medical record number, chief complaint, white count, “I think it’s real” or “I’m not sure, just come see.” End of conversation.

Unfortunately, I don’t know a polite way to say that to attendings, fellows, or residents I don’t know (ie the entire ER staff at the children’s hospital),  so I get very frustrated at night.

I’m also puzzled by this: the surgery resident’s ethos puts a lot of stock in instant response: if you call me with a consult, I will be there in five minutes if I’m not doing something important; and if I’m in the OR, I will be there five minutes after the end of the case. (And if the nurses call, I will address their concern immediately if it’s urgent, or as soon as it comes up on my triage list otherwise.) In fact, sometimes it’s the only thing that keeps me going at night: I can’t think straight, I’m not sure which elevator goes where, or what floor I’m on or am trying to get to, but I will be in the ER two minutes after getting called. So why do the ER people call, then act surprised when I show up? Or why do the general peds teams call us at night with a consult “for you to see in the morning”? If you call me now, I will see it now; I will not save work for the morning. If you don’t want the patient and family woken up at 11pm, don’t call me at 11pm. (I know some residents aren’t like this, but it’s not just me, because I learned this from the chiefs getting angry at me if I wasn’t ready to report on a consult within ten minutes of getting the call, or the first time they heard about it, whichever came sooner.)

Ok, I’ll stop being grouchy now. I hope I have any personality left at all when I get away from this hospital.

I finally figured out what’s wrong with all the portrayals of doctors on TV. They show emotion.

They have to, of course; they’re actors, for one thing. And basically, the drama would be a lot less gut-wrenching if the doctor didn’t act heartbroken when delivering bad news.

Real doctors don’t do that. We learn to hide emotion, from everyone – our colleagues as well as our patients. For example:

- Fear. This one is especially important to hide, perhaps because it’s such a constant companion. After all, fear is what makes us good: you have to be scared of how easily something bad could happen, in order to work hard at preventing it. You have to have seen vent-associated pneumonia, and fear its return, to really care about preventive measures or early diagnosis.

But it has to be private. After all, they say surgeons are like sharks: they attack at the smell of blood. Fear of not knowing the right answers only draws more pressure.

As for fear of the outcome for a patient, that has to be hidden, because such things only get stronger by being shared. If everyone in the trauma bay getting ready for a bad level I admitted their fear, we wouldn’t be able to function. Some of the seniors lately have been demonstrating that to me. The trauma pager has been going off again and again, one trauma after another, and now a really bad one. The patient was intubated en route, which is not good, and the confused early reports suggest that there’s something seriously wrong. The nurses and techs run around, laying the room out, assembling the monitor wires, getting the ventilator set up beside the bed, laying out the needles for starting ivs and drawing blood. They’re efficient, but the atmosphere is hectic. Then the senior physician in charge walks in. It could be the ER attending, or a chief surgery resident. They walk slowly (when there’s time), and move deliberately; no wasted steps. Calmly, loudly enough to be heard, they start arranging: who will stand where, who’s responsible for which part of the resuscitation, who’s in charge of the airway, who’s standing by to place a central line, where the thoracotomy kit is if it should be needed. Their calmness settles everybody down, and keeps the room from exploding into chaos when the patient actually arrives. (The worse a trauma is, the quieter the room is. When things are really bad, no one chatters, for fear of drowning out important information.)

Fear also has to be suppressed when talking to patients or families. They ask for the truth, but they don’t really want to know what we know. Even when things are unquestionably bad, the news has to be broken gently, maybe over the course of a couple conversations – because they need to be able to keep functioning. And if the worst-case scenario is only a shadow in my head, there’s no need to torment the patient and family by discussing what will most likely never happen. If I look excessively worried, that scares people so badly that they can’t think; the other children still need to be fed and put to bed.

- Sorrow. I learned this probably in August or September of intern year, and keep relearning it: if you cry about every patient, there’s no time or energy for actually working. Really, I’m hurting my patient if I allow more than a minute or two to consider how awful their predicament is, and how tragic it must be for their family and friends. I need to be thinking about can be done to make him better.  Crying wastes time; meditating on the nature of evil wastes time.

- Of course anger has to be hidden as well (another emotion that TV doctors are frequently good at). Anger, like fear, wastes time and clouds judgment.

Above all, emotion is unprofessional. We’re supposed to be cool, calm, rational – in charge. And that means not showing our colleagues or our patients what we really feel. Drama is for the soap operas, not for professionals.

Ok, I think the unannounced hiatus is over. No administration characters came after me, so I’ll be around until the next time I can’t even stand to talk to people.

I was going to say even the politics hadn’t really gotten to me that much, but today I realized differently: being a junior is a bad place to be as far as politics is concerned. For one thing, we get a lot of attention: the attendings and chiefs interact with us more, and depend on us more, than they do the interns. So whatever we do right, or more likely, wrong, is sure to be noticed and commented on by multiple people – possibly in front of us, certainly behind our backs. This knowledge can induce near-paralysis in some juniors; and the resulting mockery only makes it harder to function. I’m trying to avoid that pitfall; but being too cocksure will get you in trouble, too.

In addition, since we’re sort of in the middle of the hierarchy (ok, only one step above the bottom), we hear from everyone: the chiefs find us safe confidantes for their views on the attendings, the other chiefs, the interns, and our fellow juniors (the hardest to handle). The interns, once they stop being scared, tell us what bothers them the most about the chiefs and attendings. And of course the juniors as a group are constantly trading between each other the latest gossip or tips about each other, the chiefs, and the attendings. (As in, “X chief will yell at you if you so much as give a bolus without letting him know; so I call him all night long.” Or, “Z chief is unlikely to answer pages or phone calls anytime after 7pm, so don’t waste effort on him unless you need him in the OR.”)

But it’s the up and down gossip that drives me crazy: in the last two months, I think every single chief has said something bad to me about every other chief, and every other junior. And I sit and listen to them. The worst part is, I know when I’m not there they have to be saying the same things about me to someone else – and which one of the people whom I think to be my friend is listening, and agreeing?

The last week I was planning what to write when I got back on here. I thought of reworking the old cliche, that we’re not really like those medical dramas on TV. Then I thought, with all the personalities going on here, and all the sick patients we take care of, and all the nurses and doctors who really do get together, the only differences are 1) the dramas play out more slowly, over days and weeks, and things rarely climax in a fight in the front lobby 2) the people who get together do it outside the hospital. Other than that, there are enough subplots going on to keep two or three soap operas running.

Some doctors have a great way of interacting with patients. They strike a friendly, humorous (when appropriate) note immediately, and the rest of the proceedings are just like a plain conversation. They can crack jokes that the patients find funny, and always have a wisecrack response to the patient’s jokes. This especially works for the young male residents, who pick up the inner city slang, and can speak that dialect without sounding fake.

I’ve never been like that. I can be professional, calming perhaps; I flatter myself that I’m good at explaining the problem and the potential solutions in understandable terms. But camaraderie and humor are not my suit.

So I was tickled today when I went in to talk to a patient who’d been giving the nurses a bit of a hard time, and suddenly found him laughing as though the two of us had a private joke. “I like your style, doc,” he said. “You and me get along. We understand each other. I like your style.”

I don’t know what I did differently, but it was fun that he was so satisfied. Now when I have to tell him something he won’t like tomorrow, maybe it will go a bit smoother. . .

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