ethics


We’ve now arrived at that peculiar time of the month, when the service is drawing to a close, and I am divided between sadness to leave the patients I feel responsible for, and attendings I’m now slightly comfortable with, and eagerness to move on to something new. At the beginning of the month I was disappointed in the high hopes I’d had for this rotation, but in the last week or two I’ve enjoyed the work that I actually am doing, rather than focusing on what isn’t going to happen. At last, with only two days left, I dare to recognize that I’m actually doing a good job. Which in the world of an intern means that it’s time to switch to a new subject about which I know nothing.

But perhaps it is time to move on. Today I was utterly disgusted to discover that, like every other intern by this time of the year, I hate my patients. Underneath all the other motivations and emotions, I hate my patients. I had about five or so lined up to be discharged today. One after the other, either while I was checking on them during pre-rounds, or later when the attending came around, they all discovered ways to stay in the hospital another day or two. I hadn’t previously felt much animosity towards any but one of them, but by the end of my list, I was seething. How dare they? “I think I’d just like to stay another day.” “I don’t feel quite up to going home yet.” “I don’t like the nursing home that has a bed for me; we’ll have to find another one.” The attendings, of course, blithely accepted these excuses, and even came up with some of their own: “He’s a little queasy today.” “Let’s have her work with physical therapy another day.” “The family’s not comfortable with the plan.” And every single one of the five is another ten minutes that I can’t sleep tomorrow morning, which I could have done if they would have left the way I wanted them to. 3:30am, again.

 So I’m disgusted with myself. I calmed down, of course, and said what a splendid idea it would be to keep five or six extra people on the list for another day. (They’ll leave tomorrow, but tomorrow is an OR day, so the list will still grow, despite my discharges, so the next day will be no better.) I went around later in the day and checked on them politely, and didn’t even flinch when they observed that they won’t have a ride till tomorrow evening around six, or maybe a little later (so I will be frowned upon for allowing my patients to loiter so late, occupying beds that could be used for new patients). Maybe I should dispense with my polite formulation about how we don’t evict people from the hospital, and just frown outright at such weak dilemmas?

Yes, definitely time for a new month. Or maybe a new year? I think definitely I’ll feel better in, say, July. Then, I’ll just have to get my patients out of the unit, and then the intern can worry about them.

Call me out of it, but I don’t get modern marriage customs at all.

The other day the scrub tech announced that he was planning to get engaged – had been picking out the ring with his girlfriend, had been choosing where to take her to propose, and when. So the attending, a woman, asked as if it was the most natural thing, whether they were going to move in with each other now. And he said no, but just because her parents were so old-fashioned, and might not be too happy with that. So I guess now it’s automatic that if you’re so benighted as not to live togther prior to being engaged, certainly once you’re past that point (and remember that engagements routinely last for years now) you’re expected to be living together. (And since when is the woman informed of the proposal in advance? What counts as the proposal or engagement then, the monetarily valuable moment when the ring is handed over, or the emotionally valuable moment when the need for the ring is confirmed?)

And then of course there’s the routine style of talking which all the residents – male and female – adopt, of talking concerning engagements as though the man has been trapped into a life of misery. I wonder what their wives do to them to cause them to talk so. If I were the woman, I would be insulted – or perhaps concerned about what character flaw would do that; but the women join in. Or perhaps the men ought to be insulted – that they’re considered incapable of commitment and family building without being entrapped. Why has the rise of feminism produced a social more where men are expected not to care for families, and women are expected to be as lighthearted about the whole subject as the men are?

Americans scoff at the old arranged marriages, and the Eastern regard for virginity; but I don’t see any evidence that our modern “freedoms” produce any kind of happiness.

My hospital has, among other distinctions, a pediatric psych unit. You may well ask, what on earth is a pediatric psych unit? Now that it’s fashionable to diagnose not only 15-year-olds, not only 10-year-olds, but even 7 and 5-year-olds with psychiatric diseases, sooner or later children will turn up who are “not doing well on medications,” and by somebody’s standard need to be admitted to the hospital.

It makes me sick to see these poor children in the ER with this diagnosis on their charts. To my mind, drugging your 7-year-old with high-powered anti-schizophrenic medications like abilify and zyprexa (remember the horrible side effect profile of most of these drugs: zyprexa is well-proven to cause diabetes, for instance) is downright child abuse; not to mention then allowing strangers to incarcerate them in a “hospital” because they’re not behaving the way you want them to.

The usual story is that they’re being violent at school: kicking, hitting, maybe even biting the staff. Folks, since when is a 50-pound child a threat to anyone? Are you really telling me you can’t control a normal-sized first grader? You have to admit him to the hospital for this? The problem with these children is that their parents are too lazy to discipline them properly. I support corporal punishment; which these children clearly haven’t had enough of. Now, once they’re this violent, I could see an argument that more violence of any kind in response won’t help. Ok, fine. But I guarantee you that anyone, if put in an empty room and left strictly alone, will quiet down sooner or later. Maybe two hours later. But far better that their parents or teachers should spend that time watching out of the corner of their eye (rather than giving the child a wrestling match and a shouting match, the way he wants), than that these little children should be institutionalized at this age.

Can you think of a worse thing to do to a child who’s already having trouble adjusting to the world, whose family situation is no doubt very fluid and unreliable, than to take him away from everything he knows and put him in the four walls of a hospital?

The crowning irony is that these children, here in the ER, seem well-behaved. They’re not bouncing off the walls, or yelling, or demanding anything. They sit quietly, smile at us, cooperate with everything. If there’s any point where they can be got to do this, then with proper encouragement, they can do it all the time. Most often, their family will say in bewilderment that the child is fairly cooperative at home; maybe annoying, but not completely out of hand. It’s only at school that they go completely wild. Maybe because they’re locked up all day with peers who are having just as much trouble as them?

These children are being abused. I hate to think of what their lives will be like in ten or fifteen years, when they become young adults who’ve never been given the chance to cope with the world except through the film of psychiatric drugs.

I used to think that all those ethics case discussions about how to manage several needy patients with limited resources were purely imaginary. After all, this is America. Even though the cost may be astronomical, and the hospital may have no chance of ever recouping that cost (they’ll get a fraction from the insurance companies, if the case managers are very good, and less than that from the family of a real train wreck), patients still get the best possible care. (To be precise, we never really discussed this stuff in ethics; the cases were more along the lines of, sister wants to withdraw life support, brother and nephew disagree, what do you do? or, trisomy 18 baby in a woman who’s at high risk for significant cardiac disease, what do you advise her? Something even as vaguely practical as allocation of scarce resources never crossed the lips of the ethics professors.)

But a few months ago I worked in a unit where there were several sick patients: seriously sick, as in a mortality rate of close to 50%, with treatment. Without treatment, the mortality rate would have been 100%, and three days ago. The hospital had a limited number of nurses with the training and experience necessary to staff that unit. There was a limit to the number of OR-hours and surgeon-hours available to perform the repeated surgeries that each of the patients needed on a fairly regular basis. Sometimes (don’t ask me whether we ought to be blaming the nursing staff (I suspect not), the pharmacy (I suspect yes), or the hospital administration (always in the running when blame is being assigned) ) we came close to running out of certain medications.

So when one person can have surgery today, and the other will have to wait for a day, and perhaps slide further into sepsis in the meantime, who gets to go first? The sicker person, who more desperately needs the surgery, or the less sick one, who has a better chance of surviving the surgery? Who gets the medicine, the sicker patient, or the one more likely to recover at some vague point in the future? Who gets more nursing attention, the younger but sicker patient, or the older patient who’s less sick, but also has less of a reserve with which to fight the illness? To add a twist: who gets surgery/medicine/attention, the less-sick patient whom we suspect to be on the verge of permanent vegetative state, but not quite (if only we could ever get the sedation low enough to make ourselves sure), or the totally septic patient whom we hope to have fairly well preserved mental status? In the calculus of deserts (in the old sense of things deserved), how do you rank severity of illness, likelihood of recovery, age/youth, likelihood of meaningful neurological recovery? What about family? If the family doesn’t care enough about this person to come and visit even once over the course of weeks, does that tell us that they’re a pretty worthless person? Or does it say that we need to advocate even more strenuously for them since they lack the natural advocacy of relatives? Does the number of relatives who show up weeping at the bedside have anything to do with the value that we assign to one patient compared to another, or does it merely make it more difficult for us to give sad messages to the larger family?

Thank God, we never had to make an explicit decision along these lines. Perhaps the patients just sorted themselves out; or perhaps the residents kept their doubts to themselves and let the attendings, in their own consciences, reach a conclusion, and then announce to us who needed surgery tomorrow, and who could wait for a few days. I don’t know how objective their decisions were. That’s why I’m in no hurry to be an attending.

(It would be interesting to hear from friends in Africa how they handle these dilemmas. I suspect that when resources are truly and absolutely limited, there’s no hesitation in choosing the youngest patient, the healthiest patient, the most neurologically intact, and the one with the largest number of caregivers/family members.)

I’ve been thinking for a few days, ever since this excellent edition of SurgExperiences came out, about these posts by a neuropsychologist (whatever on earth that is – I can’t decide whether it’s more or less scientific than a psychiatrist or a psychologist) about informed consent for resident involvement in surgery (and follow-up). He tells the story of arranging a tonsillectomy for his young daughter, and how, after finding the most experienced and best-recommended surgeon available, he specifically questioned that surgeon about the possible involvement of residents, and then insisted that the attending be the one to do the whole surgery on his daughter. He advocates all patients being equally inquisitive into exactly who will perform their surgery, and clearly feels that patients are getting sub-optimal care if part or most of their surgery is performed by residents.

My first response was anger, probably triggered by guilt. I used to think about this issue – is it fair for me to practice on my patients? How up-front do I need to be about the fact that this is only the first or second time I’ve done X procedure – central line, arterial line, lipoma excision, cholecystectomy, etc (as we proceed towards more complex and riskier matters). As a student, and for the first month of internship, I felt very guilty about practicing on somebody who was expecting to be helped, and who might in fact be in more danger than necessary as a result of my inexperience. It got to be too much for me. I decided, quite successfully, to ignore the whole issue. However feckless I might be right now (or a month ago, as I can feel my technical ability growing every day), in less than a year, I will be a junior resident, responsible to supervise interns and students. I will be alone in the ICU, and I will have to be able to do all kinds of things. People’s lives will depend on it. And right now, I’m more scared of my attendings’ and chiefs’ wrath than of consequences to the patient. It’s a motivator, and quite effective. Usually it makes me more thorough and efficient; sometimes it makes me callous or cavalier. At any rate, I can’t afford to ponder the ethical implications of learning by doing on a patient who hasn’t exactly consented to be my first effort.

Thus, when Dr. Carone urged patients to protect themselves from residents like me, I felt rather angry. Who is he, a non-physician, someone who clearly has little to no experience with the sharp end of anything, to denounce residents who are desperately trying to learn necessary skills? If everyone actually took his advice, I would be out of a job – and in ten or twenty years, we would all be out of surgeons (and interventional radiologists and cardiologists, and ob/gyns, and urologists, etc).

Second thoughts suggested that perhaps I’m over-rating the number of people who would respond as he did. I think a fair number of my patients have recognized, to some extent, that I am still in training, that I am relatively new at a lot of things, or at least that I’m of lower status than the attending. After all, I do introduce myself carefully as “Dr. Alice, a resident working with Dr. Attending.” All of us are careful in our explanations to defer to the attending, making it clear that he has more experience than us, and that he will have the final say in all matters. Even if the exact hierarchy isn’t clear, the fact that we’re lower in rank is clear, as well as the fact that we’re much younger than the attending. Relatively few of my patients have asked more specific questions like, exactly how many times have you done this, exactly how much of the surgery will you do (or in July, when did you graduate from medical school)? (And in my case, since I look like a college student, even in scrubs and a white coat, I’m sure my lack of experience is written on my face.)

But again, I think Dr. Carone underestimates residents, as well. We are doctors, after all. For what it’s worth, we do have the diploma, and an unbelievable number of tests of all sorts that we’ve already passed. We are under continuous, fairly close, supervision, especially in the OR. On the floors, on the other hand, we are the workhorses. We see patients in the middle of the night in the ER, admit them to the hospital, start the series of tests, give the attending his first sight of the situation by phone, and take care of all the emergencies in the hospital. When a surgery patient starts bleeding out, who do you think shows up first, the resident or the attending? The intern, actually. When someone’s blood pressure drops, who has to take care of it? When someone develops chest pain or tachycardia, who’s on the spot to evaluate them and order urgent medications and tests? Or when your pain is out of control in the middle of the night, who gets woken up to do something about it? Otherwise, we’ll deal with it, and let them know later that we have things under control. If Dr. Carone’s daughter developed bleeding after surgery, and had to be brought back to the ER, I’ll bet anything that since the surgeon used residents, his daughter would have been seen and probably treated in the ER by residents. Only if her bleeding was so severe that it required immediate re-operation would the attending have been called in. Since he has no surgical experience, he may not understand this: dealing with the complications of a surgery requires some pretty intimate understanding of the procedure itself. If he excludes residents from the original surgery, he’s just hurting his daughter if, God forbid, she has a complication.

To conclude: I resent Dr. Carone’s attempts to deprive me of the chance to learn my trade. On the other hand, I’m challenged by his insistence on truly informed consent. I’m thinking about experimenting with my current census: telling them point-blank that we are all interns and have only been out of medical school for six months, and see whether they object to us participating in their surgeries. I know at least a few will, because just a week ago there was such an episode. On the other hand, I think we’ve built a good enough rapport with most of the patients that they’d be willing to keep working with us.

And after all, practically, what does Dr. Carone really want? Where does he think the surgeon who operated on his daughter got his experience, except by operating on other people’s children? Why should he expect to reap the benefit of the chances those other children took, and never be involved in the process himself? Is he really prepared to decimate the supply of future surgeons, simply so that current patients can feel more secure? If my experiment turns out badly, I will still feel such an overwhelming obligation to my future patients that I will continue to take advantage of current opportunities, without looking the gift horse too closely in the mouth.

(All this without mentioning that most of us are complete hypocrites on this subject, and would be very reluctant to have surgery by our fellow residents, have our babies delivered by OB residents, or our children seen by pediatrics residents. I think if it came down to it, I might, just because I would feel so guilty if I didn’t. I’m not sure how much of my theoretical reluctance is due to doubts about residents, and how much is due to pure determination never to be a patient myself. At least I’ve put myself down for organ donation on my driver’s license. To refuse that would be just too much hypocrisy for my conscience to handle.)

Absolutely awesome. I had settled down for a boring call day with no interruptions but to put foleys in, but no. A vascular consult came in for compartment syndrome in a guy with such a massively dramatic medical history that no surgeon would ever touch him – except that his leg was about to die. The chief took one look at him and called the
attending, who took one look and called the OR.

Determined to stay in my place, I didn’t say anything about being involved in the surgery, just asked to watch. The chief told me to scrub, and the attending handed me the bovie (without asking about the electrical principles behind its function!). I kept waiting for one of them to take the sharp instruments away from me, but no: the chief suctioned, and the attending kept drawing dotted lines, and I cut, and cut, and cut. We opened not only all four calf compartments, but two thigh compartments as well (so rarely done that even the orthopedic guys we checked with couldn’t tell us how to do it; google is an awesome textbook). I could not believe what was happening: I was
really doing surgery. I was so shocked, and anxious not to displease the attending (who had just met me for the first time), that I could hardly enjoy it at all, till we were done.

At which point, with impeccable timing, my beeper went off: “xxxx STAT.” The nurse was almost stammering: “This patient is unresponsive, we just found him like this, he’s bradying down, his blood pressure is dropping, what should we do?” I couldn’t even catch the patient’s name, or which attending the call was for. I just got the room number
and ran – after calling over to my senior resident that he’d better get up there too. Running through the hall gave me time to think, and come up with a semi-coherent plan. I actually was working through the ACLS ABCs when the crisis team and senior residents arrived. My main failing – admittedly significant since the chief complaint was
bradycardia – was forgetting to get him on a cardiac monitor. Now I know why the test situations insist on you saying all the things you want – oxygen, ivs, monitor – because on the floors, the nurses don’t always know that stuff! I did get the oxygen, and we were looking for ivs (because this insane hospital doesn’t allow the nurses to have iv equipment on the floors, we had to page someone else for that); it was just the monitor that I forgot. The patient magically perked up when we tried to get a femoral
stick. I was extremely relieved to realize that the correct surgical procedure at this point was to turf to medicine for a workup.

So next time: order the ivs, monitor, oxygen, and fluids, while still on the phone, before starting to run. Another round or two, and I’ll even be able to think of the proper meds, too. (This is incredibly well-staged training I’m getting: last weekend, some close calls, but the seniors were right there with me. This weekend, a close call that
I started to handle on my own. In a week or two, I’ll be up for the real thing. Statistically, it can only be a few more calls away.)

———————–
The night continued well. I set my beeper to wake me up every hour to check on that patient, and the nurses usually paged me about five minutes before my alarm, because of some concerning signs. So I would stumble around the call room, trying to remember how to put my coat on, and run upstairs to see him, and call the senior. We went through the routine about three times before the nurses got totally frustrated with the interactions between the admitting medicine residents and the consulting surgery residents, and with the patient’s instability, and insisted on him being moved to the ICU. I continued to observe how my senior was unfazed and almost unconcerned by things which were wildly distressing to the nurses, and fairly alarming to the medicine people.

This senior resident is amazing. He was supposed to be keeping an eye on me and my four specialty services, and the general surgery call intern, and her five or six services, plus all the ICU patients. Somehow he managed to be always available and reassuring to both of the interns, more on top of all of our patients than I was (shame on you, Alice), and also in the trauma bay assisting that overworked team as they took admission after admission all night. Plus he was in at least two surgeries that evening. I don’t know he pulls it off, but I want to be like him. That’s something I am truly pleased with at this program: all the residents, juniors, seniors, and chiefs, seem very strong. I unreservedly trust every single one I’ve worked with so far, and I’m impressed by what I’ve seen of the others on rounds or in M&M. I do hope this is not just the luck of the draw, but something that can be taught, that by next year I’ll be as knowledgeable and cool as they are.

I’m still working on learning the surgery culture by observing them. Apparently I had a misconception about overnight call. The point is not to go to sleep if you can. The point seems to be to stay up, keep moving around and checking on the critical patients, so that you know what’s happening before the nurse (or the intern) calls you. I think that’s how the other residents achieve an apparent omnipresence: always just walking up to whichever patient is crashing, or into whichever room a procedure is about to happen in.

Which brings up the PEG (percutaneous endoscopic gastrostomy) tube. The senior resident sent me to do one, because the other intern “had already done tons.” So I didn’t feel bad about taking a procedure away from her, since I hadn’t even seen one of these yet. The attending, the most senior trauma surgeon, was amazingly pleasant when I said I’d never done one before. He walked me through it in such a way that I didn’t get too nervous to think straight, and actually managed to do every step myself without much fumbling. I can see how these will get boring in a few years, but yesterday it was just enjoyable to do a necessary procedure, one of the basic general surgery skills, without tripping.

——————–
Of course, after such a splendid night, I was due for a fall in the morning, and boy, was it a fall. Teaching rounds went on for a couple of hours, and I was just thinking how exciting these could be when I actually knew some of the answers, when we walked into a patient’s room, to discover first of all that he was being allowed to do the exact thing the attending had just been lecturing us about the importance of him not doing. Which would be my fault, because I checked on him yesterday, and saw it, and didn’t realize how contrary it was to the attending’s plan. Then, the mother brought up an aspect of his condition which, let’s just say, I ought to have known about. I felt a little bit upset at her for waiting a week to tell the attending about it, instead of telling me, when I’ve been in and out of his room three times a day for the last week asking if there’s anything else he needs, but honestly, I should have asked, I shouldn’t have needed to be told. When we got outside the room, one of the attendings looked at me and said, “So, generally speaking, from an intern’s perspective, it ought to be . . . humiliating. . . to find that out on rounds.” What could I do except look at the floor? I was in fact humiliated, and there was nothing more to be said. Fortunately it was close to the end of rounds.

That’s surgery. Either an honest concern for the patient’s well-being, or else sheer pride, not to be shamed in front of colleagues, should motivate one to know every single detail, no matter how irrelevant it may appear at the moment. Details, Alice, details. What good does it do to have fun playing with sharp objects, if you can’t be trusted, or can’t trust yourself, to know everything about the patient outside the OR? (But I did a whole surgery yesterday!)

Two more days left on this service, and then on to a hopefully fresh start on a general surgery service.

Enlightening would be the best word for today. The attending basically informed me that I’ve been doing something in very poor form (just surgeons’ etiquette, not patient-care related, fortunately) all month. Which was kind of crushing to find out, but at least he did tell me, and at least I know before I get to the general surgery service next month, and start annoying the attendings I’ll have to work with for five years. I also got a little more insight into exactly how useless the attendings and senior residents think interns are. Which is almost more liberating than anything else, because it means they expect us to be making dumb mistakes.

Shortly after that conversation, the medical students gave me their evaluations to fill out. I just barely managed not to say, Who, me? Evaluate you? I don’t know any more than you do! Instead I pulled myself together and gave them an encouraging evaluation, trying to be as specific as possible. There was really nothing to put for “needs to improve on.” I love these girls; yesterday we got two ridiculous consults half an hour before sign-out, and the chief sent them to see the patients and write the consults. I just had to listen to their reports, eyeball the patients, and write a few sentences on the bottom of the note. It felt so good not to be alone with those two consults at the end of the day. So any medical students reading this, I just want to let you know that even when you feel useless, you can be incredibly helpful, at least to the interns.

(One of the senior residents today was regretting the fact that her service doesn’t have an intern, and she has to see all the consults and ER patients by herself. So I guess we’re useful to them too, but I had already figured that out.)

Tomorrow is my first overnight call. No doubt I will be badly disappointed, but given the low census on some of the services right now, I’m expecting a quiet and boring day. This calls for a stash of crocheting and books in the call room.

Also, today I discovered a random training session for the computer program, and went and got the instructor to show me how to do the transfer and post-op orders that were giving me so much trouble. There were in fact, as I had hoped, a couple of functions that I hadn’t known how to use, which should make things a little faster. There’s still the slight matter of potassium having a theoretical interaction with basically every commonly used medication (from morphine to phenergan to colace), and having to go through three steps to force the computer to overlook that interaction for every single medication. But there’s no hope of persuading the bureaucrats to take that function out of there, even though the residents are now grimly joking that we’re so used to ignoring that “serious interaction” dialogue box that we probably won’t notice when a real interaction does show up.

This evening some of the residents went out together, and a drug rep footed the bill. That was the first time I ever felt personally involved in such a relationship with “big pharma.” Before, I could always put the responsibility on the doctors in whose offices the lunches showed up. But this time I was part of an agreement, and I benefited directly. I’m not sure how guilty I should feel about that. For right now, it’s more important to be part of the residents’ activities than to split ethical hairs.

Today was a different attending, and he had to leave to go see another patient when we were most of the way done with a breast case, so the fellow was very nice and let the students and me sew all over the skin incisions. It took rather a long time, but we managed it. I even took the occasion, since I was sewing in a circle (which means that half of the stitches are going to be very difficult to do righthanded) to try sewing lefthanded. It wasn’t as hard as I had thought. After all, only two years ago, I had no idea how to sew righthanded, and am still learning it very carefully. It was actually almost easier to go lefthanded, than to struggle with the righthanded angles. Yesterday’s attending is so ambidextrous that it took me several days to realize that he preferentially sews with a different hand than he writes with, although he switches between both very smoothly. I’ve already seen many situations where it would save time and effort to be able to use my other hand, so I’m going to take every opportunity to sew lefthanded (not cut, so much, because it annoys people when you struggle to cut lefthanded, chopping away at the suture they’re holding, when you could do it with a single righthanded snip). I can scrawl a little, lefthanded, but it’s scarcely legible. I keep resolving to practice with everyday activities, but those are so subconscious I can’t remember to do it.

There was a lecture today about ethics, which of course practically meant end-of-life rules. The speaker was a very calm and reasonable-sounding doctor, so I didn’t react immediately, the way I have to most ethics lectures so far. After a while, though, it became clear that, after he was done emphasizing the patient’s right to choose, and the patient’s right to refuse treatment, and the ambiguous meaning of “futile care,” the bottom line implied message was, we need to give our patients every opportunity – almost encouragement, even – to refuse treatment or ask for DNR orders if they want them. Which is mostly true. But it left completely untouched the corollary, which is that if a patient or their family make an informed decision to pursue treatment a while farther, we have to respect that, too. If we truly claim that our final value is patient autonomy, it is hypocritical to only respect that autonomy when it leads to a decision that we approve of, ie to withdraw care or move towards DNR.

Because my sense is that the old axiom of healthcare, the doctors always want to keep going, even when it’s hopeless, is no longer true for the ethicists or the generation of young doctors who’ve been indoctrinated by them. My colleagues don’t always want to keep going. We see most ICU care as meaningless and futile, and think that most patients with more than three comorbidities ought to sign a DNR. (Take it easy, that’s a rhetorical generalization.) We don’t need merely to be lectured about respecting a patient’s wishes to let go and die more naturally, but also to respect a patient or family’s wishes not to be starved or anesthetized to death before they’re ready.

So of course I spoke up in lecture. Now I’ve got the beginning of my trouble-maker reputation made.

This is also slightly hypocritical on my part, because I wouldn’t want to stay in an ICU for more than a week or two myself, and then only if you trapped me there. But for one thing, I have no right to generalize that to my patients. I have observed that most elderly people value their lives far more than the young and healthy would think possible. For another, I wouldn’t want to be seen by a doctor under almost any imaginable circumstances anyway; which is not reasonable, and is not characteristic of the general population. So the fact that my colleagues and I would probably sign DNR orders and refuse most tubes and nutritional maneuvers for ourselves should not encourage us to extrapolate that onto our patients.

I somehow chose for my presentation topic for this Sunday a complex ventral hernia repair mechanism which our team is in fact scheduled to perform on Monday. My usual rhythm of preparing a research project is ticking along: I procrastinated until the deadline was over my head, then started researching in a way that the librarians will never teach you (best described as free association of ideas), and managed to print out a small library of the main articles on the subject. I also discovered a bunch of nice, gory pictures. So with any luck, I’ll be able to put it together tomorrow, and make some semi-lucid statements on Sunday. The fellow encouraged my hopes that if I sound informed on the subject, the attending might let me actually participate in the dissection on Monday. This would be amazing, because so far my role in surgery has been limited to sewing things back together. Which is great, but only half of a surgeon’s job. I need to learn how to take it apart too.

(Yet another person told me today that I’m too nice to be a surgeon. I should start a pool on how long those statements will keep coming.)

When initially presented with the idea of being personally involved in sex-change surgery, I was too shocked to say anything immediately. I guess that proves I’m out of touch, since it happens enough to be fairly well-documented in the medical literature, and since none of the other members of my team (and I will state that I am not working on the west coast) seemed at all surprised or disturbed. Perhaps their statements implied the attitude that “I would never do that, myself,” but no judgment was implied concerning the individual’s choice, or their own decision to participate in that choice.

It has been suggested to me that a Christian in this situation is free to exercise God-given skills, without being responsible for the larger ethical scenario, rather as a painter might take a contract to paint a night-club, without being morally responsible for the use the owner then made of the building he had helped to put in working order. For one thing, I’m not completely sure the painter could do that. For another thing, I see two distinct actions there: the painter painting a neutral building, and the owner then making use of it for sinful purposes. To me, there’s more of a separation there than if I personally perform the [surgical] actions which enable another person to flagrantly violate God’s law.

(I should also state parenthetically that I am discussing the case of a sex-change operation undertaken for psychological reasons, not the far rarer case of a child being born either as hermaphrodite, or with ambiguous genitalia. That’s a different matter.)

It was also suggested to me that in my brief interaction with plastic surgery, I’ve already been involved in surgeries which I would consider wrong to seek for myself, ranging from liposuction to breast augmentation or face lifts. (I wouldn’t include breast reduction in there, because I recognize that there are often real medical considerations leading to this kind of procedure.) But the others don’t address any genuine medical need; they didn’t add to the patient’s physical health, and one could argue that no operation performed on the body can truly contribute to spiritual health, either. These patients were indeed rebelling against God’s design of their body. Nevertheless, they limited their rebellion to seeking to become more feminine (or masculine), rather than less feminine (or masculine). Perhaps I’m being inconsistent. Perhaps I should refuse to participate in any purely cosmetic procedure. Nevertheless, there seems to me to be a significant difference in degree, if not in kind, between trying to augment natural, God-given features, and trying to destroy or completely replace them.

Even setting aside what one could call religious-ethical objections, there are still medical-ethical objections to these procedures. The basic mandate for all physicians is, “First, do no harm;” which corresponds to the surgical principle, never to perform any invasive procedure unless it’s medically necessary. By no wild stretch of the imagination can these sex-change procedures be considered medically necessary. The patient was a healthy male or female to start with, and would have remained so, had we not interfered. Just because it has taken so many hormones that its identity is now ambiguous, does not constitute a medical need for surgery to match the hormones. Not only is there no need, the operation does positive harm, by exposing the patient to all the associated risks of anesthesia and surgery, as well as mutilating healthy tissue. On these grounds, even non-religious doctors ought to refuse to do these surgeries.

That’s what I wish I could tell my team. But it’s good enough that the fellow is accepting my recusal, and the attendings aren’t asking questions. I guess there’s still a limit to how much I want to rock the boat, even now that I’ve graduated.

(And all of this reasoning would not prevent me from treating such a patient if they presented with a plain problem, like appendicitis, or even a complication of this specific surgery, such as a wound infection. God’s sun rises on the just and on the unjust.)

Life is getting complicated. Yesterday I had my first serious run-in with a drug-seeker who did.not.want. to leave the hospital, especially not on the level of narcotics I was prepared to prescribe for him. The fact that one of my colleagues had – let’s say, taken a strategy I would not have chosen, to get the patient off their back a couple nights ago only complicated matters. . . I was very frustrated. The patient would probably be diagnosed with borderline/histrionic personality disorder if seen by a psychiatrist, and although I knew objectively that there was nothing much wrong with him, he sure took me for a guilt trip. . .

Next week one of the attendings is doing a transgender surgery, which the chief proposes to send me to. I was too shocked to see the case on the schedule to make any objections when it was first discussed. Also, to be honest, the thrill of being first assistant on such a big case is seductive. But I don’t see any way to excuse the matter – either the patient for asking for it, the attending for agreeing, or myself for assisting, if I were to do so. Breast augmentation (the most major cosmetic surgery I can think permissible) is bad, but it’s not downright evil. This would be mutilation, in open rebellion against all God’s laws. I don’t think I can or should do it. Not looking forward to explaining to the attending that I disagree with his ethics, or to the chief that I’m going to back out of the biggest case I’ve been offered in my career to date (1 week and x days) . . .

One reason I steered away from OB was to avoid ethical issues. Ha.

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