communication


It seems like my dry spell is at an end, and I’m starting to have my hands full of transplants.

Which leads to another topic: The only thing that surgery residents love more than gossiping about each other is critiquing the attendings. I’m not really into that. (Or maybe refighting the dramatic cases; that might be the top pastime.)

I learned to do calculus and chemistry and anatomy and biochem by not questioning the teacher’s assumptions. I know that doesn’t sound scientific, but I used to ask “why?” or “how do we know that?” so much that I could never get to the main point of the lesson. So I stopped. I tried to jump into the subject: assume that all the axioms the teacher grants are correct, let’s see how it works.

Same thing with surgery attendings. I could go on and on about the trauma attendings, because I didn’t operate with them. But now that I’m operating with attendings on a semi-regular basis, I try not to analyze their personalities too much. They are far better surgeons than I am, and they’re trying to teach me something. Complaining about not fair this or not fair that is not going to help with the goal. If I concentrate on doing what they want me to be doing with my hands, eventually I’ll get beyond the words they’re using. I’m frustrated with myself when I don’t do it right; I can only imagine how frustrating it must be for someone who could absolutely do it right the first time himself to keep his hands off and let me try again. So I don’t care how harsh or edgy things get in the OR, as long as the attending is teaching.

Which further establishes my reputation among the rest of the residents as naive, because no matter which attending they’re discussing, my answer is, “I didn’t think he was so bad. We get along ok.”

A few hours into a busy morning – the kind that always develops when, building on a string of slow days, I have a stack of journal articles to read and paperwork to do – I got a nonsense consult. Nonsense as in, all the surgery attendings in the hospital already knew about the patient, and had discussed her condition at length and leisurely among themselves. As a result of this consultation, spread over three days, they had decided that the one attending should officially consult the other attending. Which means his resident, that is, me, needed to go put an official note in the chart to let the poor medicine team which was babysitting this patient know that the surgical attendings have changed.

So my seeing the patient and writing a formal consult was going to contribute absolutely nothing to the patient’s care or to my team’s knowledge of her; but it had to be written.

It didn’t make me any more enthusiastic that the picture I got from the chart before going into the room was of a patient seeking pain medication. Sure, she had a couple genuine chronic conditions with biopsy documentation of their existence; but she was on a lot of narcotics, plus some valium thrown in. She had been on disability for years, even before this most recent, serious problem cropped up.

I was in for a surprise.

She was polite, pleasant, and a very coherent historian (first clue; real seekers try to muddy the waters). She was able to tell me all the studies that had been done, and gave me a timeline of her symptoms and the path to the final diagnosis.

I asked how long she’d been on disability, and all of a sudden she started talking. She’d been injured a few years before, but had kept busy up till last month taking care of her father, whose health had declined precipitously. Last month he died at home.

I didn’t have to say anything at all; she just wanted someone to listen. She told me about her mother’s poor health and inability to care for her husband, about how painful it was to watch her father getting continually worse. She told me about how he joined the army right after Pearl Harbor, flew several bombing missions, and was eventually interned in Switzerland, then came back to get married and start a family.

There was a lot more – his death had hit the family hard, and it sounded like the siblings weren’t relating to each other well now – but I wasn’t looking for holes in the story any more. No slacker takes disability, then works 24/7 caring for a dying parent. Most healthy people don’t do that much.

At the end of that talk, I understand why psychiatrists don’t believe in physical exam. After that much sharing, it’s rather anticlimactic to ask if you can listen to the patient’s lungs.

When I was a medical student, and had nothing to do but shadow attendings, it usually took me less than a day to memorize their stock phrases: lines of introduction, questioning, explanation, even pleasantries, jokes, and stories, that they tended to repeat to every single patient, with very little variation. It bored me to tears, because every single doctor had his own set of phrases that he repeated all day long to every patient. To the patients it was new, but since I could have recited it myself, having to listen to it for four weeks was maddening.

I promised myself I would never fall into such a rut.

One year and three months in, I listen to myself on morning rounds, and I’m boring myself. This is bad.

I know why it is, though. At first, I was so shy about walking into people’s rooms, waking them up at unearthly hours of the morning, asking them personal questions, and then trying to reassure them about the day’s events while at the same time extracting myself from the room in the minimum amount of time. With trial and error, by the end of intern year, I had figured out the phrases guaranteed to net me the most information about how the patient was doing (nausea/vomiting, bowel function, eating, out of bed) while giving the least opening for extraneous anecdotes, as well as the answer to the question “what happens next?” which would seem to give information while also emphasizing that my attending really makes the decisions, not me.

And now I just repeat those lines over and over. Path of least resistance.

I thought I would be at least middle-aged before I bored myself. 

Even when I have to explain something – cholecystitis, pancreatitis, need for NG tube, need to remain npo for another day – I have stock phrases for those too. And a generic reference to the city’s pro sports teams, if the tv is on. I need a speechwriter, is what I need.

I thought WhiteCoat’s story about medical professionals not having heard about Medicare’s new strategy to avoid paying healthcare professionals for services rendered (otherwise known as the “never” events) had to be an exaggeration.

Then I mentioned their upcoming enforcement (next Wednesday, Oct. 1) to a senior resident, and he gave me a blank stare. He seemed to think this was another piece of raving insanity, along with my defense of Palin (what can I say? when all the men in the room start attacking her, I morph into a Republican) and my objections to abortion. It took me quite a lengthy explanation to get him to think I might be right – this despite signs all over the medical records department warning physicians of the events that are now not permitted to occur, as well as notices popping up all over the charts, and random walls in the hospital. I had no idea that my time in the medical blogosphere was so well spent.

(For further information on the concept developed by some genius in Medicare (who really deserves a million dollar bonus – this scheme is going to save the government so much money – except didn’t they take it all from us in the first place? – until all the hospitals go bankrupt; do you think the government will bail out hospitals who fail because they tried to take care of patients, the way they’re bailing out the financial institutions that made foolish choices?) – excuse me. Back on track: for further information, see Buckeye Surgeon’s analysis, and this piece by Dr. WhiteCoat (as well as a good deal more on his site). Basically, the idea is that Medicare (and the private insurance companies will inevitably follow suit) picks several events which everyone would prefer not to happen, and unilaterally mandates that they will now not pay for these occurences; the goal being to promote “quality” healthcare. Which is fine for the “never” events like wrong-site surgeries and mismatched blood transfusions; those are rare and truly preventable. But then you come to things like urinary tract infections, central-line associated bacteremia, C difficile infection, wound infections, and on and on – things which we all deplore, but which there is no scientific evidence to suggest the possibility of completely eliminating. All the studies show ways to decrease their incidence, but not to prevent them from ever happening at all. I can quote you the statistics; that’s stuff I get pimped on. Anyway, basically, Medicare is going to penalize hospitals for existing in the real world. They’ll all go bankrupt. Somebody please help me figure out some alternative career options? I need to get out of this circus before the whole thing falls apart.)

(And in case you were wondering, I know that the goal of all this is to decrease costs to Medicare, not to improve patient care. Because if patient care were the point, hospitals could be held to evidence-based standards for acceptable rates of infections and other complications. But this whole rigmarole is being arranged by some accountants and their secretaries, who know nothing about taking care of sick people. . . . I’m looking for the exit, and that’s only partially rhetorical. I do not want to spend my life explaining myself to bureaucrats, and begging for permission to take care of the patients that I am morally and legally responsible for.)

Every morning I make a resolution not to get into a conflict with any attendings for the day. I usually fail by 11am. I don’t know why. I guess I hate this service enough, and am irritated by some of the attendings enough, and wear my feelings on my sleeve enough, that that’s inevitable. I’m trying to help, but trying to help when I’d rather not be in the same unit at all really doesn’t do much good. At least it entertains the rest of the residents and the nurses, watching the fireworks. I just need to not talk in front of the attendings. At all.

I got to assist with a trauma ex-lap (exploratory laparotomy) today. The patient was just sick enough to need it, but stable enough that no one was really panicking. The attending and chief could spare a few seconds to tell me what they were doing. In textbook style, as soon as they opened the peritoneum, blood came pouring out onto the table. They packed all four quadrants with quantities of lap pads – I have no idea how they can ever keep track of how many went in where – until the bleeding was controlled. Then they started in the corner where they knew there were no problems, and proceeded to explore. Between me being there to be lectured and quizzed, the attending being an extremely conscientious character, and the chief being the inquisitive kind who wanted to see everything and visualize every possible maneuver (Kocher, Pringle, etc) while he was there, it was quite educational. And also beneficial to the patient, who did well.

(Kocher maneuver: reflecting the duodenum medially in order to visualize the head of the pancreas. Used in trauma to gain control of the IVC, and in surgical oncology to reach tumors in the pancreas. Pringle maneuver: clamping the porta hepatis (portal vein, hepatic artery, hepatic bile ducts) to get control of devastating hemorrhage from the liver that can’t be controlled with packing alone.)

The chief spent most of the day in the ER (nine patients in two hours on a weekday morning, as though all the old ladies in the city had decided to fall and hit their heads at once, while several un-drunk drivers managed to have serious accidents), and complained that he hadn’t been able to see the unit patients. I, on the other hand, had more than my share of the unit, and would gladly have bailed out of it to share in the chaos in the ER; but we each had to stick to our own responsibilities.

I’m tired of trauma. I feel like I’ve been doing this forever, and it’s going to keep going forever. Every day starts out ok, and then goes on for a whole lifetime, with twenty lives in my hands, and thirty or forty people wanting something from me (ranging from the medical students wanting something educational or useful to do, and I don’t have the time I owe them to be educational, to the nurses as usual reminding me of what their patients need, to the attendings wanting me to do a dozen different things, reminding me of things I know I should be doing, or asking me the same question for the third time in five minutes, to the families, who need to be talked to, and all want more time than I have).

That is one thing I’ve figured out. I’ve decided which of all the trauma attendings is most difficult to work with: not the one who rounds for nine hours at a time, not the one who rounds so fast it leaves you breathless, not the one who listens to himself talking all day and gets nothing done. No, the one who lets you give a whole presentation, then asks you three times for information you stated at the beginning of the speech. And writes it down, looks at something else, and then asks you again. Halfway through rounds with him, I’m ready to scream.

Many of the nurses give me a vote of confidence by seeking me out to ask questions of. It’s nice to know they trust me to manage a lot of things – but it would also be nice if they asked the other residents sometimes!

A large part of a resident’s day is spent writing interminable “notes.” There is a set format for these, called SOAP (subjective, objective, assessment, plan), and it is pounded into one’s head as a third-year medical student. Ever after it serves as the outline for all communications between doctors, written or verbal. (One of the best ways to realize the difference between doctors and nurses is to compare the format for documentation and reporting that nurses use. It’s quite as stylized as ours, but has a very different focus. I respect them more after looking over some shoulders at inter-shift report forms – but we think very differently.) Even a brief two-sentence statement by the person requesting a consultation has the implied skeleton of this form underlying it, and it’s assumed that the parts not mentioned are not as important.

(Attendings write notes too, but they’re allowed a much larger leeway: A lot of them consistent of scribbling, in letters large enough to fill the page and obscure the fact that few words are actually being used, “Pt comfortable, improving. Afebrile. Abdomen benign. Continue plan per above.”)

Apart from the fact that at least half the doctors in the hospital have completely illegible handwriting, and that it would be nice if we actually talked to each other every now and then, the problem with these notes is that they require you to commit to an opinion, publicly and irreversibly. They’re especially terrifying to medical students and interns, because you have to write down something meaningful about what you think should be done next – when you often have only the vaguest idea. I’m more used to it now, but it’s still a little threatening to be the junior resident writing notes; my plans are supposed to be actually valid, and all the other doctors involved will give some real weight to it. It’s like getting an essay paper back every couple of hours, to go by and see what the attending end up writing, and whether my idea was at all similar to his. And if not, everybody gets to read and compare.

I love hernias. Repairing an inguinal hernia seems to be an activity most akin to juggling several balls while standing on your head facing backwards. In other words, after doing it a couple of times, and reading three different textbooks prior to the most recent effort, I still have only a minimal understanding of which piece went where and why.

There are four or five main layers to the abdominal wall, I get that much: skin, fat, Camper’s fascia, Scarpa’s fascia; then you get the external oblique muscle – but down that far, there’s only the external oblique aponeurosis, which runs into everything else; and the internal oblique, and its aponeurosis; and the transversus abdominis, which blends into stuff, and the transversalis fascia; plus the preperitoneal space/fat, and the peritoneum itself. Now if all that would just lie flat, it would be enough trouble. But then it bends, apparently through a warp in the space-time continuum, and you get the inguinal ligament, Cooper’s ligament, the external inguinal ring, the internal inguinal ring (if only I had One ring to bind them all!), and the cremaster fascia. I keep reading the textbooks, and turning them around and around trying to figure out what Cooper’s ligament is and how it relates to all the rest of this stuff, and I still can’t see it. As a sign of how lost I am, when they illustrate this anatomy unilaterally, they usually don’t label left/right, up/down, and I can’t even tell where we’re at, or whether we’re looking from the inside out, or the outside in, let alone where things connect to.

So it’s a good thing I’ve been doing this with one of the quiet attendings. He doesn’t say much of anything unless you’re recklessly out of place (for instance, being so awe-struck by the sight of the hernia suddenly dropping back through the hole – a hole, any hole - actually the internal ring - back into the peritoneal cavity, that you completely forget how to tie knots, and start tying them a couple inches into the air, when he mildly observes that maintaining tension on the suture tends to make for a tighter knot, and thus a more durable repair). (That was last time, this time I got a grip on myself, and the suture, too.) Anyway, although I have no doubt that I’m making all kinds of wild gestures through my lack of comprehension of where we are or what we’re going to do next, he hasn’t said anything, at least to me.

I feel like this is fascinating enough to keep doing straight for a couple of months at least; maybe by then I’d figure out which way is in and which way is out.

(In other news, when the ICU nurse warned me that the critical care attending was doing things with my patient, and likely to go farther, I tracked him down, and remarked in a polite manner that I’d been talking to the patient’s family. He informed me in a rather high-handed tone of his intentions to completely manage my patient in the future. I said no, now that he mentioned it, the patient was on my attending’s service, and the surgical team felt quite comfortable taking care of the foreseeable future. He did a double take, and I stuck my chin out and said we could handle it quite nicely, thank you. It felt good to get that out in the open, and certainly he hasn’t been seen or heard from since. Unfortunately it didn’t improve my patient at all. I wish I could ward off the angel of death as easily as that.)

I was fuming this evening, and the rest of the residents were tickled. They think it’s a joke, to see how much strong language I’ll use when I get upset. So far I only go in for colorful epithets; they’re waiting to catch some dirty words, which makes it dangerous to get angry around them.

One of the critical care consultants is driving me crazy. He interferes with my patients, and he shouldn’t, and I haven’t quite got up the nerve to tell off an attending from another specialty (and I rather doubt that it would do any good if I did; he strikes me as being very good at looking down his nose at anyone who tried it).

The last time I had to deal with medical consultants trying to manage critical surgical patients was in the burn unit last fall, and then at least I could tell myself that I knew nothing about critical care but what I was picking up from the nurses (if they reported something to me from overnight, I knew they considered that important, and I should pay attention), so I couldn’t possibly presume to criticize the medical folks. Now, admittedly, I am far behind a board-certified critical care specialist, but I do know more than I did then. I also think that spending a month learning to think like the most finicky doctor I have ever met, one of the trauma doctors who will spend an hour making sure that every single thing is perfect for one patient, has taught me something.

So, I (and my chief) object tremendously when this particular consultant (the rest of his group does it too, but he’s an egregious offender) tries to take over the entire management of a surgical patient whom he was consulted on either for vent management, or as a courtesy because the patient is in the ICU.

Today, without talking to anyone from the surgical service, he sat down with the family of a patient he’d met yesterday, and told them the patient was essentially brain-dead, and they ought to withdraw care, basically now. Then he ran into me inside the unit (I had just come up to have a similar, but perhaps more gradual and gentle, conversation), told me flatly that he’d told the family care was futile, and he expected “we will end up withdrawing before too long.” I was furious; I think there was smoke coming out of my ears. That’s my patient. I spent a month taking care of him, nursing him along, watching him slide out of my reach; I was heartbroken when I came back one morning and found him on death’s door in the ICU. I have talked to his daughter every day for a month. I know him; I know his family. He’s mine; or at least he’s my attending’s. This jerk met the whole group yesterday in the middle of a disaster; who does he think he is, to go telling them things like that, without talking to us? My attending or I should be the ones to say, We’re sorry, we failed, we couldn’t save him, he’s going to die, it’s best if you let him go. (And he’s not brain-dead; he’s not good, he’s not conscious, but he’s not brain-dead. I really hate it when consultants, usually critical care or neurology, try to call my patients brain-dead when they’re not.)

Grrr. I think next time I meet the guy doing things with my patients, I might say something; hopefully (in that grand British phrase) more in sorrow than in anger: “I’ve known this guy for a month, I’m really upset by his condition, and I feel like it would be more appropriate for someone like me or my attending, who have a rather longterm relationship with the family, to be the ones to break this news and discuss this situation with them. Now git!”

I thought it was hard being the intern and figuring out how to relate to the attendings and all the various levels of residents senior to me.

Figuring out what to do with my intern is even more complicated.

He’s not brilliant, but he tries hard enough that I can’t just write him off as a bad job. But how do I balance between pushing him hard enough that he learns what he needs to do to make a surgical service work, and being friendly? How do I let him make enough mistakes that he takes things seriously, but keep anybody from getting hurt? There are so many things that he ought to be doing, that we’ve told him about, but he forgets or doesn’t know how. So do I just do them myself, which would be the simplest, remind him endlessly and start looking like his mother or older sister, or let them go until he gets embarassed in front of the chief and/or attendings, to make him remember?

He’s not like I was as an intern, which also makes it complicated. If I’d had an intern as naive and hopeful and trusting, and incompetent, as I was, maybe I’d know better how to relate. Someone who says, I want to do it right, but is rather clueless, seems to me easier to deal with than someone who talks brashly and confidently, but doesn’t have the knowledge or skill to back it up. An intern mouthing off like a senior resident throws me off. The older residents have earned the right to make flippant remarks; my intern doesn’t have the experience that in my minds earns a little tolerance for making unkind remarks about nurses or patients. If the chief says he doesn’t care, I know that his record of hard work, long hours, and lives saved show he doesn’t really mean that. But for my intern to say that – it’s too early. The attending can say, “Ah, fibromyalgia, consult rheumatology,” because we know he has the experience to be confident that there’s nothing really the matter; the intern needs to think a little deeper before brushing someone off.

But I’m not the censor. My intern is an adult, and needs to sort things out for himself. I try not to comment on his attitudes or remarks, just on his work. Hopefully in a few months he’ll learn what’s acceptable and what’s not. I trust the nurses, too, to set him down when he needs it. They can do that better than I can. Time will tell. Like me, he needs to see bad things happen just to learn that they can; then he won’t talk about them so lightly.

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