ethics


On the advice of my family, who have been a little concerned by recent interchanges on this blog, including my tone, which apparently comes across as much more cynical than I intend, even to my friends, I thought I would relate a couple of incidents from the last week:

Medicine attending in the hallway: “Alice, thanks for your help with that guy the other day. I appreciate how quickly you came by to do the procedure.” Me: “Any time, Dr. Smith; you can always get me interested in sharp objects.”

CRNA in the PACU: “By the way, Dr. Alice, after you left with the patient, the two OR nurses remarked how much they like to have you in the room. They said you’re the politest resident.” Me: “Oh, really? Mmm.”

ER resident: “Wow, Alice, you guys got here fast. I was planning to send labs and have them back before you came by.” Me: “It’s ok, we like to evaluate consults as soon as possible.”

ICU nurse to student: “Have you met Alice? She’s one of our favorites. We like to hear her answering our pages, because we know she’ll always come right away and help out.” Me, silently: “That’s because I don’t trust myself to deal with things over the phone.”

Medicine intern: “Boy, you got here quickly, Alice. I just put that consult in half an hour ago.” Me: “I came as soon as the secretary called me. It sounds like you have a really interesting case – a bit more intriguing than the usual gallstones.” Medicine intern: “Yeah, I know those are a nuisance. But this guy sure is puzzling.”

Okay? I guess I’ve been doing some stress relief on this blog; but I don’t talk like that in real life, and, although this is a lot of positive feedback for one week, as far as I can trust what people say to my face, I think I’m getting along smoothly with all but maybe three ER residents and one floor’s worth of medical nurses. Now don’t make me have to say nice things about myself on my own blog again.  ;)  And of course all these nice personal interactions don’t prove anything about my skills in the OR or my clinical acumen (I feel funny even putting those words together, because I don’t think there’s much of it yet).

I’m looking for opinions/advice on how to deal with people doing impressions of others. A lot of the guys here like to do “impressions” of various attendings. To me it feels like mocking them for being older than us, or for having a pet phrase or two, or for always approaching a problem in the same way. I’m not sure whether it’s mocking, though. They don’t do it as much about the attendings we don’t like as about the nice attendings. But of course they wouldn’t do it if the attending was around, and I’m pretty sure the attendings wouldn’t like it if they heard it. I wish I could stop these conversations, but I don’t know what to say.

Ok, that’s the Dear Abby section for today. Now, some stereotypes from another angle:

Another group that my colleagues like to do imitations of are medicine residents in general (not one in particular). At one point today I had decided that was really enough, and we were setting a bad example for the medical students, and I needed to do something to slow it down, or at least demonstrate that we do respect our colleagues. And then we got a consult from the medical ICU, and the medicine resident said, at various points in the conversation, “I know there’s nothing you can do for this guy, but my attending said, ‘He’s crashing, and I’m not sure what to do about it; consult surgery.’ . . . Yes, I’ve been here all morning; it took me four hours to put in a central line, that’s why I didn’t call you earlier. . . Sure, take the chart, I’m going to be writing a note here for quite a while longer [1hr, by my count]. . . We were going to get an ultrasound to evaluate the ascites. You guys don’t do that kind of thing, do you? You just touch it.”

That, my friends, is an admission I could not make up. Every single medicine stereotype that the other surgery residents had been quoting to the med students, in living color – from one of the smartest, most competent (except for lines) medicine residents. He knew the consult was ridiculous. At least he called us about it, and we had an intelligent conversation about the patient. (And as for the ascites, yes: we had a CT, and an abdominal exam. No need to be repetitious with the ultrasounds, except if you intend to tap it. At the beginning of this year, I was puzzled when called upon to say whether someone’s abdomen was distended or not. I couldn’t tell the difference between distention (which is usually pathological) and obesity (which is physiological – not an immediate surgical pathology). I’ve learned the difference now, though. Distention, even an obese person, gives a different texture, a different quality under the skin. It’s fluid, or air, that shouldn’t be there; and you can sense how the skin is stretched in an unusual way to accomodate it.)

And then finally, another group whom I have decided to abandon all scruples concerning, and make bitter and sarcastic remarks about without reserve: the ER, and especially the ER residents. I think, honestly, ER doctors with specialty residents in-house are obliged to do better than this, because they think a bit longer before calling an attending in from home, than before calling a resident down the stairs.

Today, ten minutes before sign-out, we got a page from the ER, for a young man who had arrived only 15 minutes before. (I know, because we were down there evaluating a genuine surgical issue when the fellow was brought back.) The consult was for appendicitis in a patient with no other medical problems. No labs had been done, and certainly no imaging. We went to see the patient, and a few moments later informed the ER resident that in our opinion, a young man with groin/testicular pain as well as right lower quadrant pain, who had a history of both kidney stones and Crohn’s disease, deserved a little investigation into other possible causes of pain (testicular torsion, kidney stones, Crohn’s disease) before being summarily dumped on the general surgery service as an appendicitis. (If it were one of those other causes, he should have been sent to urology, or colorectal surgery, or even plain medicine.) So I apologize to the excellent ER doctors in the blogosphere, but I’m giving up being polite about the ER for right now. From here on, I’m going to fight every call from them until it’s been properly – even exhaustively – worked up. And all stereotypical jokes are fair game. As my chief remarks, we’re not asking them to think like surgeons, just like doctors. Examine the patient and think for two minutes!

(My patient is dying of cancer, and I can’t fix him, I can’t help him, I can’t even make him comfortable. Every time I go to see him, he holds my hand and cries. I hate cancer. My patients are all sick, and I can’t fix them. I’m tired of sick people. Did you know everyone in the hospital is sick? I forget what healthy people look like. All my patients end up in the ICU. The world is broken and I can’t mend it. . . The creation also shall be delivered from the bondage of corruption into the glorious liberty of the children of God. The whole creation groans and travails in pain together until now; and not only they, but we also, who have the first fruits of the Spirit, groan within ourselves, waiting for the adoption, to wit, the redemption of our bodies. And we are saved by hope, but hope that is seen is not hope, for what a man sees, why does he yet hope for? Likewise the Spirit also helps our infirmities. . .)

That was a busy night. Spent a lot of time shepherding a patient who ended up going back to the OR in the middle of the night. Although too bad for the patient, it was kind of nice to have been right about what needed to happen. Then, it seemed like every drug dealer in the city decided to shoot or stab himself in the hand, and come to our ER to see about it. Such babies. For big guys who were playing with dangerous weapons in dangerous situations, they were pretty wimpy about the results. On the other hand, they were also fairly polite about it, and quite willing to explain all the circumstances surrounding their misadventure. Made the time pass while I was suturing.

Maybe surgery residency was like this before the 80hr rule, but we seem to have a very stiff ethic about responsibility for one’s own jobs now. If something is assigned to you, you’re expected to get it done somehow, without asking other people to share the work. (This applies to tasks, not to asking for help if you don’t know what to do.) We’re pretty touchy about making it clear that we can do all of our own work. It would be lazy to ask, or allow, another resident to help out; and laziness is regarded by residents and attendings alike as most of the seven deadly sins.

This was brought up because of the [rare] episode of a surgery resident and medicine resident being on the same team. The medicine resident offered to help fill out some paperwork for the surgery resident, who was shocked. They were his charts, and he had every intention of taking care of them himself – somehow, no matter how late he had to stay for it. The whole group of us then spent an entire lunch time dissecting this difference between the medicine and surgery cultures. I think the point, for us, is that we want to prove to ourselves (and to our attendings, if they’re noticing) that we’re not slacking off just because there are relief shifts.

So I’m trying to figure out the subtle line where, without implying laziness in someone else, I can still offer to help when another resident is truly overloaded. Especially when one resident is being pretty frankly abused by one of our worst seniors/chiefs. There’s no shame in accepting help when you shouldn’t have been given such an assignment anyway. On the other hand, this is also the attitude that lands me with cleaning up constantly after the weakest interns in the program.

If you’re wondering about the lack of Easter posts, it’s because the Orthodox Easter, which is the one I plan on celebrating, is not until April 27th. Our Lent just started two weeks ago. So Happy Easter to you Westerners (and Protestants – meditate on the fact that the date you celebrate Easter is still determined by the Catholic Church ;) ), and if you want some Easter programming, go back to April 2007, when I had the time to blog pretty extensively about Passion and Resurrection.

Not a fun night. One of the services I cover did its usual crazy thing, admitting three patients right at sign-out, and spending five hours in the OR with one of them. I’m getting a little tired of working with the intern on this service. He means well, and I don’t think he’s deliberately neglecting things; but it’s getting to the point where I feel I have to double-check every point he tells me in sign-out, otherwise the nurses will be calling me at 2am: “this patient is for the OR today, did you mean him to be NPO?” “this patient just started coumadin, do you perhaps want an INR drawn this morning?” “this patient got a transfusion, would you like to check the hemoglobin count?” “this patient was admitted the other day, would you maybe like to write an H&P for him?” and so on.

Then, the ER called us with the most outrageous consult. There was no imminent surgical issue – maybe in a few days, maybe – and the patient was to be admitted to another service, but somehow we were called to see the patient in the ER before the admitting service was called. I and the senior resident got so frustrated we actually started arguing with the ER attending, who is a frequent offender on such points. Usually as a resident you try not to get into it too much with attendings; but still. And then there’s this other ER resident who is making a habit of calling me the minute a surgically-related patient hits the door, without having even labs, let alone basic imaging (I mean xrays; I support the idea of not scanning people unless the surgeon asks for it), sometimes without a complete history or physical. I mean, he’ll call me about vascular issues without bothering to check pulses, based simply on the report he was given. I keep meaning to make an issue out of it, because all it does is make me wait in the ER for an hour before I can call anyone (because you bet I’m not calling my attending without a white count and a creatinine), instead of him waiting for an hour before calling me (because once he’s called me, I don’t dare to simply wait for the labs to come back before looking at the patient; maybe the patient is acutely ill and requires emergent intervention without labs; hasn’t happened yet, but it might). But then every so often there’s a delicate patient who I am happy to hear about quickly, so I haven’t managed to argue about it yet. And he’s senior to me, and thinks he’s being efficient, which also makes it difficult.

Finally, and this is the real reason that I am fed up with the day intern, I had to manually disimpact a patient, for the first time in my career. (Yes, I know, you’re not allowed to be done with internship, especially surgery internship, without doing this; and it so serves me right for the time I was a medical student, and ran away from helping a resident do this.) I’m not completely sure how this is the day intern’s fault, but I’m sure it connects somehow, so I’m blaming him.

Back at the beginning of the year I heard some conversation among the seniors to the effect that “it’s your worst nightmare, to be told that your patient is coding and so-and-so is running it.” I couldn’t imagine how they could say that. Now I know. There are a couple of people who already make me uncomfortable when I have to sign patients out to them. Maybe I’m just being arrogant; who knows how the other interns feel about leaving patients with me? I think I’m at least diligent, but I make lots of mistakes.

Plus, my pager broke. All the floors except for the one that pages me most often were still getting through, but the nurses on that floor became convinced that I was deliberately ignoring them, and started telling all the other night staff so, before I heard about it. Bother. I was surprised to find out how much of my identity is tied up in that little pager. I had to trade it for a different one, and I felt disoriented all night. I have my buzz, and my alarms, and my screen style; and without them, I forget how to process calls. Fortunately it’s fixed now.

They sent me on a donor run today. A donor run is when a transplant surgeon travels to an outlying hospital to harvest organs. As far as I can tell, there’s a call schedule shared between the transplant surgeons in a large area, but going out usually implies that you plan on using at least one of the organs at your own institution. Usually this is the liver, since this is the trickiest to harvest correctly, and the surgeon likes to know that no useful pieces were accidentally left behind, and no unrecognized variant arteries were damaged.

“They” sent me, as in the senior residents universally declined to go (bad time of day, weekend, weather, etc), and were secure in the knowledge that I would jump all over the opportunity if they let me. When I told the attending I was being sent, his response was: “You? !! Oh, really. I guess so.” Later on: “Why on earth did they send you? Where are the other guys? They’re a bunch of lazy slackers . . . I’m going to be grouchy about this for an hour. Go to sleep.” Five minutes later: “Do you tie well?” Me (afraid to claim something I won’t be able to live up to): “I wouldn’t want to say that.” Surgeon: “You should be able to tie well. If not, you should be practicing. If you can’t tie well, no attending will let you do anything. . . So, Alice, can you tie?” Me: “Oh yes, very well!”

This surgeon is young, dedicated, ambitious – aggressive, even. He makes himself available at all hours, ready to go on donor runs at any time, and then come back and spend the next eight to twelve hours transplanting what he harvested. I called him once at night to say I felt uncertain about a patient. He reassured me over the phone, and then fifteen minutes later turned up in the patient’s room, sitting down to chat with him, and then to explain the lab results to me in detail.

He holds himself to very high standards, and he demands the same from the residents. When he called to tell me to go on this run, one of the senior residents remarked, “He’s an old school surgeon. If things aren’t exactly right, he’ll get upset. Don’t take it personally.” I’m still not sure what he was talking about. I take this attending’s remarks personally to the extent that I’m pleased he recognizes me now, even if he’s not exactly thrilled to have me with him. I’ve made mistakes around him, and he knows that. On the other hand, after a few hours of sleep, he was much more cheerful, and by the end of the trip kept repeating how much I’d learned today, and how I would learn even more, and get to do more of the procedure, on future runs. I know that I don’t know enough – anatomy, surgical technique, transplant lore – and the best way for me to learn more is to have him firmly unhappy when I don’t work hard enough.

As for the procedure itself, what can I say? Regard for current news prevents me from going into much detail, except to say that the patient had sustained clearly unsurvivable injuries, and was pronounced brain dead before we were even called. The entire proceeding was marked by respect for the family’s wishes (allowed to take this, not allowed to take that, make things look good for the family), and some (limited) sorrow over a young person’s tragic death. Not too much of that, however, because frankly this is a brutal procedure, and the only way to do it is to completely block consideration of the donor as once-living (he’s dead now, completely dead now) and to concentrate on the patients whose lives will be saved by what we did. I did my best to do exactly what the attending wanted, and although my skills still leave a great deal to be desired, I did tie well enough not to tear blood vessels or leave them leaking, and at least I answered all the anatomy questions correctly.

Some people question the ethics of transplantation, denying the existence of “brain death.” I’ve thought about this a fair amount, since this would be absolutely impossible to do if there were any question of the donor being in any sense alive. (Remember that one of my reasons for staying out of ob/gyn, in the end, was concern about the abortifacient nature of contraceptives, since almost every single one acts in some aspect by preventing implantation of a conceived child.) I concluded in the end that brain death, when rigidly defined (absence of every single brainstem reflex, no confounding circumstances, after extensive testing) and properly diagnosed (by two doctors from separate services, apart from the transplant surgeons) is a real entity. This patient, for example, still had oxygenated blood flowing to his organs, but only because of aggressive ventilatory support and several iv pressors. In fact, our work was made more difficult by the fact that he was becoming very difficult to oxygenate, or to maintain a pressure on. He was indeed dead, and his body was on the edge of shutting down despite all our technology. We hastened nothing. I think some of the lay objections stem from a confusion between brain death (the concept that the brain is as vital an organ as the heart or lungs, and once it stops working, the rest of the body will follow shortly) and “permanent vegetative state” (which is a vague and difficult to diagnose condition in which the person breathes on their own, but doesn’t seem to respond to stimuli; this is what people recover from on very rare occasions). People cannot recover from brain death.

I think I may have said this before on here – only once or twice – but this has been absolutely the best day ever. Better than all the previous ones. I got to first assist/perform a whole big case, one which I later realized is actually pretty rare because of the unusual approach the attending took.

I was on call overnight, and you can imagine my dismay when (after a night filled with the almost cliched scenes of dark cars pulling up outside the ER and dumping out gunshot victims) just as I was setting out to round on my patients, on a tightly calculated schedule (calculated to allow for the longest possible nap prior to starting rounds, that is), I was paged by the ER. It was a patient for my service, so there was no way to duck. What was more, he needed surgery, urgently, so it took a while to see him. (Not one of these “oh yes, a wound infection, give some antibiotics and send them to the office in a few days” kind of ER consults.) The whole time, I was simply fidgeting to get out of there, trying to figure out exactly how late I was getting, and how many plans were spiraling out of control.

It was not until the attending said, after rounds, “Ok, Alice, go get the patient on the table and page me when you’re ready” that I realized what a wonderful day I was having. He didn’t even mention the chief on call, or any of the other junior residents in the hospital. I, of course, did not make any reference to them either, for fear that he would realize the oversight and correct it before we had scrubbed.

It wasn’t an oversight, of course. This attending is actually interested in teaching, not just residents, but interns. I cannot imagine where he gets the patience from. “Hmm, Alice, you probably shouldn’t have cut that. Stitch please. . . Ok, bovie through here, carefully, carefully. . . Next time try not to bovie [the skin] [the bowel] [my hand] [whatever else it might be].” “Time to sew this up. See how these three layers connect? Put the stitch there. No, that’s too little; no, that’s too much; no, don’t hold your needle like that; no, don’t tie the knot like that. Ok, next stitch.” I mean, I was beginning to run out of patience with myself. I have no idea what inspired him to put up with me so much, and in the middle of a busy morning.

Some persons were concerned about me doing a case post-call. I said, perhaps more precisely than I should have, that there was absolutely no way I would consider leaving the hospital when there was the prospect of doing a) any case b) this precise pathology c) a patient I had admitted from the ER d) a case I had been invited to by the attending e) a case with this particular attending. It was my decision to stay, and my decision to stay after the case and tie up loose ends with my patients on the floors, before signing out (because the ends were loose due to me being in the OR, so it wouldn’t have been right to hand them off like that).

The other night I wandered into the ICU just to look around. Our vascular surgeons seem to be going through another AAA phase, with record numbers hitting the door in the last few weeks, and I wanted to see how things were going in the ICU.

I found one of the junior residents, Joe, just getting into a difficult discussion with a patient’s family. He was an old man, with a lot of problems, and this time around they had all caught up with him at once. He was in respiratory failure, on a ventilator; his kidneys were failing, and he had already had one round of dialysis; his blood was filled with a raging infection, which didn’t seem fazed by all the antibiotics he was receiving; his liver was starting to look bad; and the monitors were showing more and more abnormal beats, indicating that his heart didn’t have far to go either. The resident explained to me, behind the nurses’ station, that he had received a very frustrated signout on this patient: “He’s in multi-system organ failure. There is nothing we can do for him surgically, or medically either. He shouldn’t even be in the surgical ICU, since he hasn’t had surgery recently. Just make the hospitalists take him, or something. It’s hopeless.”

Joe was not one to take a passive approach. He decided that since no one else had managed to get very far in talking with the family, and since he didn’t want to be the one running multiple hopeless codes on this old man through the night, until finally he didn’t respond to ACLS protocol any more, he would tackle the job of getting DNR status from the family.

I was frankly curious. Much as I hate to think about it, in four months I’ll be the one left over night with four or five ICUs full of patients, and I’m sure it won’t be long before I run into this problem. I wanted to hear what he said. It helps that Joe is about six foot four, with a quarterback’s build. I don’t think I’ll ever make as impressive and authoritative a figure as he does. He told the son and daughter quite bluntly that their father was in bad shape. He explained how all his organs were failing at once, and went through the list of heroic interventions which were necessary just to maintain the status quo. Then he got down to it. “Your father is not going to survive this. I’m sorry to say this, but he is going to die, soon. The question is, how much more do you want him to go through before he dies? Right now, if his heart stops, we’ll do everything we can, giving him drugs and pushing on his chest. It might work for a little while, but it’s not going to reverse what’s going on here.” Within an hour, they signed DNR papers, and the old man died that night.

I believe that what Joe did was good. He helped the son and daughter understand what was happening, probably better than anyone had before. He helped them come to some kind of terms with their father’s impending death, before it happened. He decreased the patient’s suffering, by not forcing him to go through futile codes, and letting him go a little more peacefully. He helped the surgical team, by solving a problem for them.

I’m sure that within a year, I will do the same thing. But right now, I can’t picture it. I tried to imagine the words in my mind, but somehow, despite how much my understanding of “end-of-life issues” has changed in the last eight months, I still can’t make those pessimistic words come out. I still try to think of what might happen well, how things might turn around. I tried to imagine a discussion about “do not intubate” status, which is an oxymoron and a disaster (how can you code somebody, or even try to do pressor support, if you can’t maintain an airway? it’s useless). Some recent tragedies have demonstrated that DNI status simply ties the doctors’ hands. The patient should be either DNR, if everyone is ready to let go, or full code, if it seems like a survivable illness. But whenever I try to put words to that, I find myself arguing for full code. Maybe things will get better; we shouldn’t give up yet.

I think Joe had it on his list for the night: “Check CBC on Mrs. Adams. Serial abdominal exams on Mr. Jones. DNR status, likely death, of Mr. Smith. . . ” Maybe after I run a few hopeless ICU codes, it will be easier to go hunting for DNR status, just another item on a list.

Since I actually had a whole day off today (sleeping in is so rare, I fantasize about it now the way desert travellers fantasize about water – I dream about sleeping past 4am) – there wasn’t much to talk about here. (The other day I took a ten-minute nap in the call room, woke to find it light outside, and ran halfway down the hall before I realized that I was already at work, and had not just overslept to an unbelievable degree.)

Until my sister called. I trust she’ll excuse my turning our conversation into a blog. She’s involved in some discussions about medical ethics, specifically involving the concept of positive and negative rights. Positive whats? I said.

Positive rights, it appears, are a big concept largely developed by those who want us to believe that we can/should/do depend on the government for everything. Even in the basic discussion found in Wikipedia, you can see the difference between these new “positive rights” and the classic natural right theory on which our Constitution was based. Positive rights essentially mean that you have a right to have something provided for you – healthcare, education, food, income after retirement, income while unemployed. Natural rights, on the other hand (which have now been redefined with truly Orwellian freehandedness as “negative rights”), simply mean that you have a right to not be something – killed, kidnapped, robbed (since the three natural rights are life, liberty, and property).

Positive rights are a key concept for those who argue that a healthcare is a right which ought to be provided by our kind, beneficent, ever-growing government to all Americans. Somewhere, somehow, the socialists introduced into popular American thought the concept that being alive isn’t enough, if you’re not also happy, healthy, and fairly well clothed and housed. So if we are to truly enjoy the right to life, we also have to have the following rights enforced – in other words, funded – by the government: secure retirement (social security); healthcare for the poor and elderly (medicare and medicaid); funds with which to not be employed (unemployment benefits); education (free public education); and very soon now, healthcare funded by the taxpayers in the classic redistributionist scheme of socialism.

These kind of rights were not even in the imagination of our Founding Fathers. As I told my sister, Ron Paul is mild compared compared to what James Madison, Thomas Jefferson, Benjamin Rush, John Hancock, and the rest of them would have to say if they were around to see the current state of affairs.

Let me quote the Declaration of Independence – at length, because I love these thundering phrases:

When in the course of human events it becomes necessary for one people to dissolve the political bands which have connected them with another, and to assume among the powers of the earth the separate and equal station to which the Laws of Nature and of Nature’s God entitle them, a decent respect to the opinions of mankind requires that they should declare the causes which impel them to the separation.

We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness.
— That to secure these rights, Governments are instituted among Men, deriving their just powers from the consent of the governed,
— That whenever any Form of Government becomes destructive of these ends, it is the Right of the People to alter or to abolish it, and to institute new Government, laying its foundation on such principles and organizing its powers in such form, as to them shall seem most likely to effect their Safety and Happiness. . . .
(emphasis added)

The Founding Fathers based their claim to independence, and later the Constitution, on the political philosophy of men like John Locke, who taught that human rights are granted by God and the laws of nature, not by the gift of any government. If a “right” is given to you, it can also be taken away, and so is not unalienable. Universal health care, if, God forbid, it materializes in this country, will not be an unalienable inborn right of all humans. It will be a gift from the government (at taxpayer expense, of course). As such, should the government ever decide that dissidents don’t deserve free healthcare, or that it can no longer afford healthcare for anyone, this “right” will disappear as easily as it was created.

The natural rights, however, depend on no human for their existence. We are all alive by the gift of God. Our right to freedom – freedom of action, of thought, of speech – comes with the rationality that God gave us. The government can try to limit these rights, but humans everywhere continue to break through repressive rules. Property is also a right which even the youngest children understand. The Communists’ efforts to eradicate this concept failed. The peasants always worked hardest on the little plots of land which belonged to them, not on the acres which belonged to the “soviet.”

The government’s function is only to protect these rights, not to create them. The government’s job is to prevent people from being murdered, being kidnapped, or having their property stolen. Again, the government’s role is preventive, not creative or donative.

There is no such thing as a positive right. It’s socialist-speak for “things that we want the government to give you so you will lose your independence and become dependent on the government for all aspects of life, and thus obliged to follow all the government’s [politically correct, atheistic, humanist, socialist] whims, whatever those may turn out to be.”

To equate healthcare with the true human rights is to denigrate the suffering of those whose human rights are truly being violated. For an American, a citizen of the wealthiest country in history, for whom the poverty level is ten times above the standard of living of most modern countries, to have to spend their own money for healthcare, is not, by the wildest stretch of the imagination, on the same level as Jews, Rwandans, Sudanese, and others being the objects of genocide; or as Chinese and Cuban dissidents who spend decades in labor camps for daring to question the ruling party; or as Christians in Saudi Arabia, Pakistan, and Indonesia, or Muslims in China being tortured and killed for their beliefs; or as blacks in South Africa being oppressed for decades as an inferior race; or as the white farmers in Zimbabwe being driven off their farms and deprived of their livelihood; and the list goes on. These are true human rights violations. These are indeed appalling crimes against humanity. To even mention the absence of national healthcare in the US in the same breath is a slap in the face to all these people, and only undermines the validity of the very concept of human rights.

We’ll see if my sister tells her friends all that. I’ll be proud of her for being a disruptive firebrand in the hypnotic echo chamber of liberal academia if she does.

(And please don’t quote the UN Declaration on Human Rights to me. The UN put Libya and Sudan on the Human Rights Commission. To quote Shakespeare, I snap my fingers at the UN.)

News from the UK: Rules of the Koran are more important than hygiene, according to UK’s Islamic Medical Society. Actually, make that cultural standards, not Koranic rules, since the Koran itself doesn’t really specify the precise nature of modest women’s clothing. The imams have just taught that whatever they wore in Mohammed’s time has to have been the heavenly standard. Sort of like chronological snobbery taken to the extreme.

But yes. Now religious scruples trump scientific principles, and keeping a few inches of your skin covered is more important than taking good care of your patients. One wonders why these women are involved in health professions, anyway. Do they not find it disturbing, or at least hypocritical, to be looking at naked male patients, while they refuse to lift their sleeves enough to wash properly?

Here in the US, there’s an uproar if Christian pharmacists propose not to dispense abortifacient drugs due to their religious principles. And all they’re doing is offering a slight obstruction to health care (if you insist on calling the destruction of life health care) (and yes, this is weighted language to be using about RU-486). But it seems to be all right, at least by Muslim standards, to downright forcibly endanger your patient’s health because you’re so concerned about letting your wrists be seen in public.

I have some pretty high standards of modesty myself, but this is ridiculous and hypocritical. Let’s see whether the UK health community is able to respond appropriately, or whether the once-proud Britons have truly become slaves, the new dhimmis. (Which is the Arabic word for conquered peoples who are allowed a few protections as second-class citizens as long as they submit to all Islamic laws.)

A friend at church gave me a copy of Atul Gawande’s new book, Better: A Surgeon’s Notes on Performance.

I don’t enjoy reading Gawande’s writing, I think for two reasons: he writes so well it makes me depressed about my inelegant efforts here, and he takes his work so seriously that it makes me feel inadequate and guilty about all kinds of things I remember doing, or not doing. He is not a comfortable author for doctors to read.

For instance: responsibility. When I was a medical student and something was missed, I could always tell myself, “You should have noticed that, you should have taken care of that, you should have drawn attention to that – but it’s ok, that’s what the residents are for. In the end, it was their responsibility, not yours.”

Now there’s no more such comfort. Occasionally the thought occurs to me, “I really should have caught that – but then, the chief and the attending should have, too.” I don’t let myself believe that, though. Interns really are there for the details. The others spend so much time in the OR, have so much more of the big picture to look at, that they rely on the interns to catch a lot of details. Yes, they often do find things that I overlook. But that doesn’t change the fact that, at baseline, they’ve told me that it’s my job to be the team’s eyes and ears, and so if a detail slips past us, it’s my fault.

This last month, there’ve been several times I’ve found myself looking at the chart and kicking myself. A lab value overlooked till the next day, a dose of medication not ordered or not given, a pathology report not noticed, a radiology report missed. I am now the generic “resident” in Gawande’s stories who is the first person to miss a detail which eventually becomes a major problem. There is no longer anyone else to take the blame for me. Now and forever, the details are my responsibility. When I’m a chief, I’ll have interns, and if they miss something, I’ll still hold myself responsible. It is no longer permissible to share.

It doesn’t help that, as I finally realized at the end of the month, my resident last month was not the greatest. He seemed friendly and helpful enough, so at first I didn’t notice a problem. Later it became clear that, although he was supposed to be there to catch my mistakes, I seemed to spend a lot of time catching his. There were times when he said, I’ll take care of that patient’s results; I’ll look at those reports; I’ll put in those orders – and a day or two later I’d realize he’d missed something. Nothing horrible or deadly, so I didn’t say anything. There were enough other incidents that the chief and attendings knew about that I didn’t feel a need to point out his failings. But I’m developing the surgeon’s paranoia. Never trust anyone, they tell you. Students lie. Interns lie. Chiefs lie. Even attendings lie. Check everything yourself. Never believe anyone. You’re responsible – so don’t leave yourself open to the mistakes of others. Doublecheck everything.

In five months, not only will they let me do surgery – but I’ll be a junior resident, supervising the interns, and the very last vestiges of non-responsibility, of having somebody else to share the blame with, will disappear.

They didn’t explain this part in the med school brochures, how heavy this is, how you can’t stop thinking about the details you missed, the ones you can’t remember if you checked on before leaving.

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