communication


I’ve discovered something extremely useful that the medical doctors do.

I hate walking into patients’ rooms (or into an office encounter), introducing myself for the first time, and within the next ten to fifteen minutes trying to familiarize a patient with an operation enough for them to consent to it. It feels like such an imposition – Hi, I’m Alice, you have cholecystitis, you need to have your gallbladder taken out, we have an OR slot available tomorrow morning, the risks include death, heart attack, stroke, damage to your liver/intestines/bile ducts, bleeding, and infection, please sign this paper. That is really what I say, except more smoothly, and spread out over fifteen minutes. Or, Hi, I’m Alice, your father really is not getting off the ventilator any time soon, he needs a trach and a feeding tube, he can fit into the schedule tomorrow afternoon, please sign this paper. Or, Hi, I’m Alice, I regret to say that your increasing abdominal pain is due to an obstructive colon cancer, you need to have surgery, you’re first on the list for the morning, please sign this paper.

That’s how it happens, because we try not to drag our feet about inpatients. If they’re inhouse, and they need surgery, we’ll do it within the next day or two. And I simply don’t have the time to walk by the room three times in the next 24 hours, to give the patient time to think about it, and then answer questions, and then get the consent signed. The attending will come around, too, but I’m the one who has to get the paperwork in order.

So the medicine guys are great, because they get the patients and families accustomed to the idea of having an operation, and give them some time to come to terms with it, between when it first comes up, and when we arrive to talk about it. Ok, maybe they could stand to check some coagulation labs for patients on coumadin when they call us for an urgent problem, but there’s a limit to how much surgical thinking you can ask from nonsurgeons. Maybe the patients end up with the strangest ideas about how the operation proceeds, or what they can expect afterwards, but I daresay the majority of those miscommunications come from their ears, not from the medical doctors. It is nice to get into the room, introduce myself as a surgical resident, and have the patient say, “Oh yes, they told me I need to have my gallbladder out, my children agree, let’s get it over with, where do I sign?” Sometimes I regret having the wind taken out of my sails, since the patients often don’t want to listen to my speech about the chances of recurring incidents if they leave the gallbladder in, and the possibility of nonsurgical treatment, but I can’t exactly argue about that.

The MICU was paying me back today. I got no less than seven insane consults from them today, three within half an hour in the morning, and four within half an hour in the afternoon. If they had even had a reasonable explanation for why they were consulting us, it would have been better, instead of things like, “we got this scan for (insert completely wild idea, the scan wouldn’t prove it, and why on earth were you looking for that zebra anyway), and look, there was a bowel obstruction.” That was from one of my favorite of the new class of medicine interns, so I explained as politely as I could that since the patient was completely comfortable, much more interested in getting me to adjust the tv than in discussing his nonexistent abdominal pain, completely nontoxic on exam, and his labs didn’t show any abnormalities, the chances of my attending deciding to operate based on that scan were pretty much nil.

Then there was one of the usual “the patient is septic and going into multi-organ system failure, consult surgery,” with, you will be pleased to hear, hypotension and renal failure being treated with three pressors, no fluids. I tried on that one, but I figured after pointing it out to the team three times, there was nothing more I could say about the iv fluids.

And a couple of “every other surgeon in the hospital has refused to do a feeding tube on this patient, claiming that it’s either unethical or too dangerous, maybe your attending will feel differently.” Um, yeah, when my attending gets out of the OR at 6pm today, and before he starts his eight-hour case tomorrow morning, I’m sure he’ll be thrilled to consider that one. I barely got him to listen to the other consults (after I introduced them with the remark that they didn’t call for action by us).

Somehow, I still managed to feel stressed out, because all the patients we were consulted on were indeed critically ill, and after spending a month in the trauma ICU, I still feel a reflexive urge to try to fix ICU patients, even when they’re not mine, not my problem, nothing I can do for them; so it takes me too long to get through the chart and decide for sure that there’s nothing the surgeons can add to their care. Plus the floor nurses paging me all day: “Are you going to send this patient home when he gets back from the test?” “Well, I have to see him after the test, and then I’ll be able to say for sure.” “Ok, but are you going to send him home?” And the floor medicine residents: “Are you going to do surgery on this patient?” “I don’t know, I have to ask my attending, he’s in the OR, he’s kind of busy.” One hour later: “Are you going to do surgery on this patient?” “I don’t know, my attending is still in the OR, and I haven’t gone by to ask him for the third time today. How about if I call you?” I know, they were trying to clean their list, and I do the same to them by turns (“Are you going to discharge this patient? Please are you going to discharge this patient soon?”)

First day on call as junior resident wasn’t too bad, largely thanks to no really sick transfers or admissions coming in, and the ICU patients behaving themselves perfectly. One person had a minor airway problem, but was already intubated, so by the time I arrived the nurse had already figured out a way to make it work. Another patient wouldn’t wake up, and I was concerned about a stroke, but a young attending happened to be walking by at the moment, and came to help without me even having to ask (and started asking unhelpful questions like, “are you the only one here? don’t you have senior in-house backup? are you sure you’re the only one?” Which was kind of him to be concerned, but not extremely reassuring; I told him I’d been about to call a chief at home if he hadn’t shown up.)

My intern was good: hardworking, fairly smart, and didn’t seem too flustered by his pager going off every two minutes. It reminded me how happy I was not to have his job; although my pager was going off on a regular basis too. I told him to write short H&Ps, and he managed to fit everything into half a page – a little shorter than I had in mind, but acceptable.

The only thing I didn’t manage very well was the trauma part. The junior surgery resident, in addition to handling all ER consults, all floor and ICU consults, and all floor and ICU issues, is also supposed to attend at the trauma alerts and be of assistance, in case several patients come at once, or in case one is so sick that the team needs more help than the very young interns can provide. Somehow the trauma alerts didn’t make it as high on my personal triage system as they perhaps should have, and I didn’t get to many of them. As it was, I stayed nearly two hours after the end of the shift, finishing leftover work, so it’s perhaps as well that I didn’t spend more time with trauma. I thought it would almost have been easier if I’d been on overnight call, because then I would have had a few quiet hours after midnight in order to get things cleaned up before everyone came back.

The most bothersome part of it all was calling the attendings. As an intern, you’re shielded from the attendings (or perhaps, they from you). You tell everything to a junior resident or chief, and they talk to the attending if they need anything to be cleared. This year, I have to learn how to get all the relevant data (because no one else will be there to correct me), call the attending, present the information succinctly, and suggest a reasonable diagnosis and plan of action. The attending listens silently the whole time, giving very little idea of whether you’re on the right track, or making completely insane suggestions, and then finally gives his interpretation, and rattles off a plan, which you’re then left to implement as best you can. I hadn’t realized how time-consuming it would be, though, after having seen the new patients, to first call the chief, talk to them, then call the attending, talk to them, then call the chief back (if the patient is going to the OR, or will be soon, the chief has to know), all the while trying to write the necessary orders, arrange the procedures, and handle a dozen new calls. It’s most efficient if you collect two or three admissions and consults per service before calling people, but if you’re not careful you wind up after several hours with a dozen phone calls to make, and no time.

I have a couple more daytime calls, and then I’ll be on overnight at the end of the month. The good thing is that, in spite of the stress, I do seem to like the adventure that comes from working under pressure. It’s kind of like skiing down a steep hill – how far can you get before things fall apart?

Now that we’re getting down to the wire, I’m having the same butterflies I did last year at this time. The butterflies are riding a rollercoaster – first excitement at moving on then, and then fear at the prospect of having even more responsibility than I have now.

There’s also the vertigo-inducing exercise of turning around, as it were, and remembering how the second-year residents looked to me when I started last year. I revered them nearly as much as I revered the chiefs – and them I nearly worshipped (which is just as well, because the executive chief is the direct manifestation of the program’s control over your life). And then to turn back, and realize how lost I’m going to feel, and the interns are going to be looking at me with – hopefully not reverence, but a little respect. And looking ahead, the increasing certainty that the new chiefs don’t feel any  more confident with their role than I do with mine. . . We all perform for each other.

The unit has stopped whirling a little bit, and settled down to more straightforward feverpaced activity. I had my first patient go into a grand mal seizure in front of me – actually the first real seizure I ever witnessed, and she had to go and be in status epilepticus for nearly forever. The seniors were all off elsewhere, in traumas, so I was left rummaging through my memory of the neurology rotation in medical school, and telling the nurses, “Since this patient has been in status for the last 30 minutes, her neurons are seriously burning out now; and we’ve already tried multiple doses of three different medications, so at this point I don’t particularly care what medication that we have to get from the other end of the hospital that the neurosurgeons do in these circumstances, iv valium is the handiest thing we haven’t tried yet, go ahead and push it.” And it actually worked. After we stopped the seizures, then the neurologists, neurosurgeons, and seniors turned up, and of course all looked at me skeptically: “Who’s seizing? I don’t see the patient moving at all.” No, because she’s had high-dose ativan, dilantin, valium, and propofol, she better not be seizing. So I was reduced to imitating the seizure for them, and the EEG confirmed my diagnosis. But I can hardly feel pleased about handling it, because it makes this patient’s prognosis so bad, and the family doesn’t seem to understand yet how bad things are.

I’ve also spent too much time in the last week talking to doctors about their relatives in the unit. Something funny is up, there are so many doctors’ mother/grandfathers/aunts/cousins through here lately. It’s a tricky conversation. You have to show courtesy between professionals, and also deference, since they’re all attendings a long way into private practice, and you’re just an intern. On the other hand, mostly they’ve been in very non-surgical specialties (pediatrics, heme/onc, family medicine), so in all honesty, between their nonsurgical mindset, and how far they are from medical school and internship, I may be (and my attending definitely is) a little more familiar with the management of critically ill trauma patients than they are. I’m still trying to figure out the exact phrases to use for telling them something that they may or may not already know or remember. But they are certainly the most wonderful historians; they can tell you all the medical history, medications, allergies, and surgical history of the family member; it’s like having a walking medical record. And then there’s the concern that if I use a technical term incorrectly, they’ll walk away thinking, “What kind of incompetent residents do they have working here, they can’t even name the fractures correctly?” Mostly, though, it goes ok. Just as I would be in such circumstances, they’re very glad to get some definite information in medicalese – the guild language.

Correction to the last post: I guess there was one attending in the group whom I didn’t totally antagonize. If we were playing a game of “pick one attending you’d like to be on the good side of,” I’d have chosen him, since he’s powerful, and has a very sharp tongue when he’s displeased. Actually, I don’t know how, I seem to have impressed him well enough that as I spent the morning stumbling through rounds, he remarked a couple of times: “I know Dr. Alice is a very good resident. In fact, she’s one of the best we’ve had all year. I don’t know what’s happened to her this morning, but I guess we can excuse her for one day.” Mmm, thanks; I suppose there’s a limit to how many days I can work straight, no time off, pushed to the limit, pulled in a dozen different directions for critically ill patients every ten minutes, without starting to crack a little bit. So I picked a good attending to stay friendly with.

In other ways, this day has to have been one of the worst of the year. More than one patient with seriously bad outcomes, which are maybe somehow someone’s fault. I can’t honestly tell whether it’s truly my fault, but I keep getting caught in this whirlpool: I should have done something different, I really should have; could I have changed this? was it physically possible for me to be in enough places to have caught this? I should have known; I should have, I should have. Some of the more senior residents saw me standing still, I guess looking as miserable as I felt, and made some remarks that I shouldn’t get too personally involved with the patients. I told them briefly what had happened, and they backed up. “Well, as bad as that, ok.”

All year, when I breezed through things, the seniors and chiefs have told me, “We’re paranoid, and after you have enough patients get hurt around you, you’ll be paranoid too.” The last month I think does it for me, and especially the last few days. Now I know why the best doctors here are obsessive about every single detail – because you never know which detail is going to come back to bite you, maybe to kill or maim your patient.

The best junior residents I’ve watched all year were the ones who came in early and stayed late, even when they were working night shift, or post-call, to double-check on things, and watch over patients till the oncoming team had thoroughly grasped the situation. Now I know what drives them, and I resolve to simply stop caring what time of day it is. I’ll mark my hours how I please, but I’ll stay, every single time, till I know all the details, till the next team knows all the details. Nothing outside of the hospital matters compared to making sure I’ve done the best possible for every person I’m responsible for. I am sick of seeing what can happen when things slip through signout; perhaps more precisely, I’m sick of worrying about whether something slipped.

On the other hand, as I contemplate being on call the Fourth of July (I was expecting that; given the small number of junior residents, and the surgical attitude of “throw them in the deep end and see if anyone figures out how to swim,” I knew I was going to be on call very early in the month), I realize that this month, as nightmarish as it’s been, has made me feel very comfortable with handling all kinds of calls about ICU patients, and semi-comfortable with the prospect of juggling admissions, consults, and disasters by myself. I guess there’s an element of familiarity about it too: I’ve been looking ahead to this kind of responsibility for a year, and I think I know better what’s expected of me (if not what I should expect) than I did heading into internship. (Now if various seniors would just stop making rueful remarks about me being a junior in three days. I can’t tell if they’re serious or not, or how concerned they are.)

Thanks everyone for the encouraging comments. I think things are getting better overall; I can handle four more days.

Today continued to be splendid. My efforts to discharge patients to the floor succeeded mainly in disgruntling the floor staff, and led to one of my . . . episodes . . . with an attending today. All the hard work didn’t do me much good, because we just admitted more patients through the ER as fast as I could discharge them to the floor.

Yes, I seem to have ticked off every single attending in this group – three of them today. That has to be some kind of record for the worst resident performance ever, wouldn’t you think? With one of them I really did something wrong – forgot something that a resident four days away from being a responsible junior resident shouldn’t forget. That was very bad, dangerous even. As everyone within hearing range pointed out to me, I can’t do that stuff as a junior resident, I have four days to mend my ways, and I’d better watch out. And I have to agree with them, which feels worse..

The other two attendings, I don’t know what happened. Apparently I’m such a bad communicator that even when I say, “Yes, sir, absolutely,” meaning, “Yes, sir, absolutely,” it comes across as “No way, you #$*&^, why are you even asking me? &^%” Or that’s what the attendings told other people they thought I’d said. Which is pretty hopeless. Because if a nurse is angry, and I respect her, I can go talk, and we usually sort it out. But there’s absolutely nothing an intern can say to an attending even by way of complete apology that doesn’t make everything worse. My latest plan is to say nothing but “yes” in the most colorless voice I can come up with, to anything that anyone says to me (except requests for pain medicine). I’m sure the only attending I haven’t infuriated yet will perceive this as incompetence combined with negligence, and then I’ll have antagonized a quarter of the attendings at this hospital. Brilliant, Alice.

On a brighter note, I took care of some sick patients today, and except for that one really disastrous oversight (ahem) did ok; a lot better, I think, in the department of not panicking when patients are screaming and blood pressures are dropping. I certainly refrained myself from paging people and suggesting calling the OR, which is a key technique (since the junior residents are relied on, at night, to sort out who needs surgery and who doesn’t, and when an attending needs to be called in from home, or not).

Four days to go, and then, as everyone as explained to me, I’ll really be in trouble, so much so that this month will look like cake. At least that stops me worrying about hospital politics, and gets me back to considering how incompetent I may be, which is slightly more cheerful, because it’s at least within my control.

The trauma service has a lot of paperwork associated with it. There’s a three-page form to fill in when the patient is admitted. Obviously, when you’re first trying to stabilize the patient, there’s no time to fill in forms, so these tend to get written when the team is waiting around in the CT scanner (there’s a law engraven in stone, that at least one trauma resident must be with the patient at all times until they’re finally dispositioned, due to way too many bad experiences with patients coding, seizing, freaking out, or having serious neurological deteriorations while going through CT; even when it’s located inside the ER, any branch of the radiology department has the capacity to seriously impact a patient’s condition; we don’t call it the cave of death for nothing).

The nurse is there filling out her papers too, and the scanner techs have forms as well, so it starts to sound like a game of Go Fish:
Tech: “What’s the medical record number?”
Resident: “Here you go, it’s 18009834321232; what time is it right now?”
Nurse: “What size did you say their pupils were?”
Resident: “4mm, reactive to 2mm bilaterally; what were the admission vital signs?”
Nurse: “36.5, 89, 112/54. What scans are we doing?”
Tech (exasperated): “The same scans we do on every single trauma patient who comes through here, regardless of their mechanism of injury.”
Resident: “Hey, don’t look at me, that’s the chairman’s policy; we’ve been trying to explain to him for ten years that someone who fell down the steps and landed on their bum doesn’t need their belly scanned for a splenic rupture, or that people who got shot in the belly don’t need their head and neck scanned for epidural hematomas or Cspine fractures.”
Attending walks in the door: “What were you saying? Let me tell you about the octagenarian I took care of who fell out of a wheelchair and ruptured his spleen. . .”
Resident, sotto voce: “There is such a thing as clinical suspicion, physical exam, and directing your scans based on lab results and xrays, rather than giving everyone enough radiation to cure a low-grade case of lymphoma.”
Attending: “Did you finish the form yet? Did you look at the cspine scan? Is there a spinal cord injury? Is the spleen ruptured? Do we need to call the OR? Stop gossiping and do some work around here, people!”

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Then there’s the form to be filled out when a patient is transferred from the ICU to the floor. Lately, due to a surplus of work to be done in the ICU, we’ve been rather remiss about filling these out. At first, this led to complaints from the floor team to the attendings, which led to a rather nasty reaming-out during morning report.

After that, I think the floor folks felt bad about getting us yelled at so much, but they still wanted their updates about patients being transferred, which leads to whispered conversations in the hallway when we think that particular attending won’t notice:
PA: “What exactly surgeries did he have while he was in the unit?”
Me: “As far as I can tell, he had his spleen taken out, and then something happened which turned the wound into a disaster, and he spent the next two weeks with an open abdomen, before we put a vac and a whitman patch on it, and then it finally got closed one week before I sent him upstairs.”
PA: “But exactly how many times did he go to the OR, because the insurance company wants to know for their records?”
Me: “I honestly have no idea; I don’t think they dictated op notes every single time, because things didn’t really change for a while; and then there were all the vac changes/whitman patch advancements at the bedside – do those count? And anyway, I came on service after everything had been closed, so I don’t know.”
PA: “Did he ever get the post-splenectomy vaccines?”
Me, feeling bad because this is really important, and could lead to the dreaded OPSSS (overwhelming post-splenectomy sepsis syndrome) if we don’t get it right: “I don’t know, shouldn’t that be in the nursing or pharmacology records?”
PA: “Yes, but his chart was so thick it got edited three times, and all the important pieces are missing.”
Me: “Well then, just give them to him again, I’m sure it won’t hurt anything.”
Attending, coming around the corner: “What’s going on here?”
Me: “Um, we were just. . . discussing post-splenectomy vaccines, sir.”
Attending: “Good, give us a power-point presentation tomorrow morning about the indications for vaccines, and how long after splenectomy they ought to be given.” (Which is not funny, because there’s a big controversy about this, since the best immunological response is if you give the vaccines before taking the spleen out, but obviously in trauma you can’t plan that; next best is to do it 10-14 days after surgery, when they’ve gotten over the stress of surgery; but many people advocate doing it 1-2 days after surgery, so they don’t get discharged from the hospital and lost to followup and never get the vaccines at all.)
Me, to the PA, ironically: “Catch me ever talking to anyone in the hallway again!”

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My favorite is the form documenting a patient’s risk factors for developing a DVT/PE, and what we plan to do about it. They’re so nice, because once you finish filling them out, and inform the attending that based on the results you plan to a) use only SCDs (sequential compression devices) on the patient’s legs, b) give them subq heparin, c) scan their legs regularly for DVTs, d) prophylactically place an IVC filter, one of the attendings is guaranteed to respond: “That form is all nonsense anyway. Just give them lovenox. I don’t care what the contraindications are, lovenox takes care of everything.” Ah, that’s great, could you just write that on the bottom of the form, or better yet, make it so I don’t have to fill out the form, since you’re going to have the same answer anyway?

I’m so frustrated and annoyed, I’m not going to write anything. Some of the attendings are driving me crazy, and so are some of the seniors.

The patients themselves are not bad, especially since I seem to have randomly picked up all the people who are chronically on the vent. I’m familiar with them now, and am getting used to the slow dance of changing one vent setting (oxygen flow, pressure, volume, rate) at a time, and waiting to see if they’ll gain the strength to start breathing on their own again, while keeping a careful eye out for pneumonias which will knock them back by at least a week.

Now if some people would teach, instead of making criticisms all the time, and about things that I didn’t actually do, or had a good reason for doing but they won’t let me get a sentence out enough to even suggest that I had a rational reason for my actions. . .

I’m not talking, see.

I have more stories from vascular, but the best ones are so unique, they’re almost worthy of being published case reports, so I don’t want to tell them for a while, for hipaa-type reasons.

In general, I’m going to miss this month. Usually it’s a service the residents love to hate, because it’s so insanely busy, and the patients, though wonderful people, have a propensity to spiral at any moment. You have to have a much higher level of suspicion for all kinds of things, from heart attacks and strokes to UTIs and wound infections.

But I had perhaps the best chief of the year, and one of the best junior residents, and the attendings are great. Most vascular attendings are. There’s something about the field that attracts people who like to dissect a problem with protracted analysis (for ischemic disease in the leg, you can do almost innumerable angioplasties, you can do femoral-femoral bypasses, iliac-femoral bypasses, femoral-popliteal bypasses, femoral-anterior tibial bypasses, femoral posterior tibial bypasses, and all of the above with either harvested vein or one of three different kinds of prosthetic grafts; now let’s discuss which one would be best for this patient), and yet also enjoy intense surgeries which can last all day long and get into serious blood loss and potential for complications. It’s different from general surgery, which I think tends more toward quick, clear-cut solutions (either the bowel is dead or not, so you should operate on it, or not).

Sign-out at the end of the month is time-consuming. Figure 15-20 patients per intern, plus 5-10 consults, all of whom need to be explained in rather more detail than just the nightly sign-out (which, if the person’s been there for a few days, often consists of “post-op day three, eating ok, working on increasing activity and planning for discharge; no impending problems”). At the end of the month, you need to give what surgery was done, why it was done, what the other medical problems are, what you’re doing about them (on vascular, this consists of a lot of afib-coumadin and hypercoagulable disorder-heparin drip arrangements, as well as blood pressure meds and other things), what infections they’ve got and what antibiotics have been gone through so far, how well they’re walking, what their family situation is like and how likely they are to have good help at home when they leave, in addition to who needs surgery in the next few days and who’s at risk for major cardiac or respiratory issues in the near future. Plus, it’s nice to give the next intern a heads-up about which attending wants his notes written by a certain time, which attending hates consulting endocrinology, which attending wishes you would consult all the specialty services and don’t mention medicine to him, which attending does all the fistulas, and all the details that keep you from stepping on the invisible mines. That takes 3-45 minutes, if you’re both being conscientious; and then you still have to go and get signed-out to about your new service. It’s nice when it happens on weekends, there’s more time for talking. Otherwise you find yourself running up against the end of the day, when staying for an hour and a half (total, spread out) could mess up your hours.

And then, I also like to walk around and say goodbye to my patients, especially the ones who’ve been there for more than a day. I don’t know what they think, but I’m under the impression that we have a little bit of a relationship, at least some recognition by them that I work for their surgeon and have been trying to take good care of them, and it’s nice to give them some warning that a stranger will be walking in to wake them up at 5am tomorrow.

Pursuing the issue of work hours: suppose a patient dies right before change of shift. The family has been notified briefly on the phone (via a message, because no one is answering, or perhaps a conversation cut short by grief and shock), but won’t arrive for at least a couple of hours. If the day team goes home as planned, the only person there to talk to the family will be the night float junior resident, who, with all the good will in the world, is overworked. Even if he gets time to talk to the family, they’ve met him maybe once or twice before, and have discussed little of their loved one’s situation with him. The attending and chief who did most of the interaction with them will be gone. As residents, we’re not about to ask our attending his plans, but we doubt that he’ll come in from home, on a night he’s not on call, to discuss how one of his cases went bad.

Your initial response, and our instinct, would be for at least the chief to stay in the hospital (trying to use the time to study or do something else productive) or perhaps arrange to come in from home when the family arrives.

But the chief has been operating late into the night for the last several days, and was in the hospital almost the entire last weekend. Staying a few extra hours to wait for the family, or even coming back for an hour later on, will push him over the 80hr limit, and hinder him from fulfilling his responsibilities later in the week. He can either stick with the rules, and satisfy himself with having spoken on the phone, or ignore the rules, misreport his hours, and stay around to fulfill this last ultimate duty to a patient and family, to talk with them personally about the death.

This is an extreme but very plausible scenario which illustrates the basic problem with the 80hr rule: an outside agency (government, and the ACGME, which is not surgery-specific) imposes an iron-bound rule which sets our regard for the law and for honesty in our reporting at odds with all professional instincts and obligations, and leaves us feeling guilty no matter which we end up following.

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