medical education


I’ve been thinking: the surgery in-training exam is really like a recitation of legends, orally recounted histories, not too closely related to facts, that define our community.

The test runs through a long series of stories, which are so familiar to surgeons and surgeons-in-training, that we only have to mention a few words of the story, to have the whole thing immediately recognized and understood.

These are some of the legends: gallbladder cancer, incidentally discovered after lap chole, invading through the lamina propria (snap answer: resect a surrounding rim of normal liver tissue); projectile vomiting in a 4wk old male (pyloric stenosis, hypokalemic hypochloremic metabolic alkalosis); medullary thyroid cancer (MEN 2; check for pheochromocytoma before resecting); knee pain and blue toes in a 50-yr old smoker (popliteal aneurysm; resect and bypass, and check for a contralateral aneurysm and AAA); mesenteric thickening after total colectomy for FAP (desmoid tumor; chemo only, no surgery).

That isn’t even English, and it certainly bears little relationship to what we actually see and do; but those are the legends that we all recognize. In that light, the ABSITE is an exercise in intergenerational transfer of epic tales. . . like the Iliad and Beowulf and Hansel and Gretel. . . That’s my explanation for the high incidence of rare diseases, the lack of correlation between what we practice in real life, and the right answer on the test, and the way the residents go around for a week afterward trading key words and comparing answers. This is our oral tradition.

I had to calm one of the medical students down the other day. We were in a crowded elevator, and he was carrying on the conversation we’d started before getting on, about what he’d liked about the surgery rotation so far.

“I got to see a craniotomy the other night on call,” he exclaimed. “They let me touch the brain! It was kind of squishy.”

In the middle of the elevator. Full of visitors.

I take back what I said about the janitors and cooks and garbage men having jobs as demanding or exhausting as doctors. Actually we’re quite different. This job doesn’t stop when you go home. Even in this era of sign-outs, and cross-coverage, and restricted hours, the job doesn’t stop when you leave the hospital, or when the clock says you’re off duty.

I’ve spent the last five days, missing meals and sleep at the majority of meal-times and night-times, not because I was required to, but because I couldn’t not. I felt obliged to do some “extra” things – double-check this or that; spend extra time making sure an NG tube was in smoothly, or that there was iv access, or that an xray got done and looked at immediately, before leaving the hospital; driving back in – and back in, and back in – to see people whom I knew logically were just fine, didn’t need me — but I couldn’t guarantee 100% for sure that something bad would not happen, because I had wanted to sleep instead of checking on something. So I checked.

There were times when I could have chewed out a resident from another service, told him to stop being an idiot, take a look in an anatomy book before calling a surgeon to say such silly things, if that’s really how little he remembers from medical school, and do his own work for a change. But I didn’t. I explained politely how impossible his idea was, then told myself that I couldn’t be 100% for certain that he was wrong and I was right, and it would be unforgiveable if the patient got hurt because I was having a turf war. So I went and did his job for him, and wrote a polite note saying a surgeon wasn’t needed.

The point is not that I should have skipped any of those things: they were plainly my duty. But they’re not in the job description, and they have nothing to do with whether or not I get paid. When I go home, I can’t stop thinking about this job, and the nurses don’t stop calling me just because I left. My professional duty obliges me to do all kinds of things that are not part of a timed job.

Like talking to the family of a patient who died. He wasn’t on my service, I wasn’t really there for the death, I still can’t figure out how I ended up being the one doing the talking. But I know I’m the only one of all the doctors involved who knew him as a person, before he was just a disaster that we were working on; and I myself am sad that I can’t ever talk to him any more. And so I went and spent time with his family, all of them in various stages of grief: some unable to talk, some angry and trying to blame me because I’m “the doctor,” some being logical and wanting detailed explanations. . . and the air in the room so dark it was hard to breathe. . .

I didn’t really know what they meant when they started talking about professionalism in medical school. Now somehow I’m here. I don’t know if I was always this obsessive and paranoid (I can’t call myself dedicated or thorough; maybe someone else will, some day); but I am now, and I have to be, and there’s a compulsion inside me, that I caught from the doctors who trained me, and I can’t not act this way.

ICU rounds post-call ought to be banned by the Geneva Convention.

Come to think of it, really they’re already covered under the Fifth Amendment – cruel and unusual punishment.

If the computers weren’t so heavy, I would have been throwing them at the end of rounds. I hate it when the attending asks you the same question three times, and then makes a decision based on the information you told him not existing. Or when, on post-call rounds, he starts explaining in excruciating detail why you should never do – what his senior colleague did two days ago, and it’s now somehow my error.

It was funny to start with, but now I’ve had enough of this business of six different attendings each laying down the law to me about something, and then turning around and calling me a fool for having gone along with their colleague’s plan. Also it was a bit of a let-down, having kept a patient so sick we didn’t expect him to last three hours alive all night (honestly, by not touching him at all), and being a little pleased with myself on that score, to have the attending show up and be angry about the only single order I made on him all night. Come on, the guy is still alive. Isn’t that worth a little tolerance? Did you really expect me to cure him, too?

Night time is all about triage. When you get three pages exactly at the same time, which one do you answer first? Two interns calling you, who do you answer first? Two consults in the ER, which one to see first? Two attendings to call, which one goes first?

More complicated: An admission in the ER, and an ICU consult which is probably nothing – but you won’t know for sure till you look for yourself. A floor consult which probably needs surgery, and an ER admission which probably doesn’t need surgery – again, nothing for sure. An ER consult which needs surgery, and an ICU patient with a pressure of 60/40 and no lines.

Sometimes, like the ICU patient whose vital signs are not compatible with long-term survival, it’s easy to figure out where to go first; and the attending will just have to get woken up an hour later to hear about that patient in the ER. More often, it’s not that simple; you have to trust the interns to give you an accurate picture of the consults they’ve seen, in order to figure out which ones get priority. And if you don’t get the right picture from the interns, it’s still your fault, because if only you trained the interns better, or asked better questions, or listened to them more carefully, you wouldn’t be missing the important facts.

As a rule of thumb, I tend to rank vascular above general surgery. Vascular patients are more likely to have strokes and heart attacks, and if there’s something wrong with them, they’re liable to bleed much more dramatically than general surgery patients. Also, lack of blood supply, to any object, is likely to be irreversible faster than most cases of peritonitis.

Strangely enough, the resident I mentioned in my last post, one of those guys who always gives off an air of glacial calm, which I would give anything to achieve, passed me in the hall this morning: “You’re sick of nights, aren’t you? I know. It was the scariest month of my life.” Not sure whether to be happy that after all he too was disturbed by the level of responsibility, or dismayed by further proof that all the people I admire are in truth as clueless and scared as I am – suggesting that I’ll never achieve that state of calm, because it doesn’t actually exist.

I have become my own old enemy. I used to wonder at the residents riding the interns and medical students – how could they be so harsh, when they had so recently come through the same thing themselves.

I know now. First, it doesn’t seem recent anymore. Intern year is a rapidly fading memory – let alone medical school. That was a different person, in a different galaxy. And second, I’ve realized that my program and my hospital will deteriorate rapidly if the interns aren’t taught surgical ethics. My seniors taught me – forcefully – about work ethics, responsibility to patients, responsibility to team members, deference to attendings and chiefs. I didn’t enjoy hearing about it when they thought I was out of line; but now I appreciate the strength of the standards they passed on – and I want the interns to learn the same thing. In a few months, they won’t be interns any more; and if my class has failed to communicate what seem to me basical principles (don’t leave till the work is done; don’t leave without signing out your patients properly to a responsible person; don’t walk away from a patient whom you’ve just decided to transfer to the ICU; don’t forget to write a note about any important patient encounter, or any procedure you do; don’t assume that the ER will get a patient to the OR quickly, or with appropriate medications; don’t assume. . . anything) – then they can’t teach it to the next class of interns.

I like my hospital, a lot actually; I feel very possessive about it, especially alone at night in the dark hallways; and I want it to continue to provide good care. Which is why my interns and medical students are going to find me being stricter for the rest of the year.

This job is unique because every decision, every action, seems to have a moral quality. If I make a mistake, it’s not merely an error, it’s wrong. I feel it to be so – a sin against my patients – and my superiors act similarly horrified. Not only major failures: misjudging the need for an operation; choosing the wrong course intra-operatively; failing to recognize an important change in the patient’s condition – but the small ones: tying a knot wrong; not cutting exactly in the plane between tissues; forgetting to order morning labs; one liter too much or too little in resuscitation; imperfect phrasing in a note.

I don’t think this is just in surgery. It seems to be across the board in medicine, part of the nature of professional responsibility. Perhaps the rigidity of surgical training means it’s voiced more clearly, but I think my friends the medicine residents feel just as badly about errors small and large.

That’s the problem, of course – there are no small errors in medicine. Every single mis-step could have disastrous consequences, even if most of the time things work out ok. Getting morning labs a few hours late, to take one example, could mean missing a significant acidosis or hemorrhage for a length of time that could impair our ability to respond quickly and effectively. Sure, it would be rare for a few hours to make much difference; but I can easily picture it happening.

So every decision, every action or lack there of, carries a tremendous potential for guilt, which only increases with the size of the decisions. And every night, you can go home and spend hours second-guessing yourself: was I wrong? and if wrong, how wrong?

Other jobs may have long hours, but I doubt that any have this weight of moral implication attached to every moment.

I don’t know whether it’s good for my patients or bad for me, but today was the first time I had to make the decision to intubate a patient. (Other times, the decision had already been made.) It was actually pretty straightforward: RN: “Alice, the patient’s sats are in the 80s, and I can’t make them come up.” Alice: “I see you have him on a nonrebreather mask and have been suctioning him. Sir, can you open your eyes? Can you talk to me? No. Ok, the sats are dropping further, let’s start bagging, let’s call anesthesia.” Done. It’s usually a bad sign when you can intubate without paralytics or sedatives. Then we spent the rest of the day trying to figure out which came first, the chicken or the egg: the altered mental status or the respiratory failure.

Next time, if the aggressive chief is around, we might skip the “call anesthesia” part. At this hospital, anesthesia residents are always available (although available might mean 10-15 minutes away, not always good in a less controlled code than this one was), so the intubations are almost always done by them. But the equipment is there in the ICU, and there’s something to be said for knowing how to intubate when you have to. Of course, there’s never a good time to learn. Where I went to school, there were no anesthesia residents, and the surgery residents were responsible for intubating any time a code was called, or for trauma patients in the ER – so they learned pretty quickly.

Also for the first time I supervised another resident putting in a subclavian line. I’d tried to supervise before, but my tolerance level for teaching on awake patients is still pretty minimal. We both did better with the patient intubated and sedated.

I think I’m turning into “friendly reference material” for the interns, since they can be pretty sure I won’t mock them if they ask questions. I’m afraid I’m also behaving like a mother hen, trying to help some of the weaker interns who are getting picked on. I’m not sure I’m approaching the situation correctly, and I hope that I know enough myself that my advice doesn’t end up getting them in more trouble. I also wonder whether my kindness doesn’t undermine the high demands inherent in surgical residency; eventually, patients will die if you make the wrong choices, and getting a harsh response to a stupid answer is only preparation for that. But I figure there are enough men around here who will provide that aspect, it shouldn’t unbalance things too much if some of the women adopt a gentler approach.

We’re revisiting the subject of restricted duty hours. As Aggravated DocSurg comments in his humor-laced sarcasm, any sane person would be happy to be working less; so I must not be sane, to be a resident arguing for longer hours. But I think the “old fogies” have a point; and we ought to listen to them before it’s too late to turn this around.

This essay by a neurosurgeon (beyond being an extraordinary demonstration of how to claim to be superhuman, without being arrogant) has applications for all surgeons. Dr. Vates argues that neurosurgeons are unique because they deal with the only non-replaceable, non-repairable part of the human body, which is true; and that they are a breed apart, and that’s true as well. But he also suggests that if you think a surgeon’s ability to perform complex or delicate operations is impaired by fatigue, the solution ought to be to get really good at the procedure, so as to have room to work with when you’re tired. He repeats the line, which ought to be a self-evident truism, but apparently doesn’t compute for the folks at ACGME, that there are no hour restrictions in private practice, and that if we’re concerned about fatigue impairing judgment, that too should be practiced first under supervision.

Apparently some idiots are seriously proposing limiting the work week even farther, to 56 or 48 hours. I object. 80hrs is barely enough now; frequent readers of my blog will have recognized that I regard this as a rule made to be broken. If they cut it down to 56, they will have to extend the length of the residencies; right now, most people are 30 by the time they finish residency, let alone non-traditional students. Lifestyle may not be an issue under that regime, but paying back debts in time to have some money saved for retirement will be.

So I highly approve of Dr. Vates’ solution: The ACS needs to take its toys and leave, ie opt out of the ACGME, and set up its own standards for residency accreditation. Of course, since ACGME recognition is a prerequisite for Medicare to pay for anything, and for board eligibility, this is the kind of thing that would have to be orchestrated with 100% participation, essentially a boycott of the ACGME by the surgical specialties. I’m looking to see where I can sign a petition to that effect. . .

I’ve been reading some of the never-ending controversy in the medical blogosphere about the 80-hr week (some are talking about 57hrs as though it’s a definite development; that had just better not be true). I thought I’d add a slightly different perspective:

Today I worked about 14 hrs – came in an hour earlier than I was supposed to, and left an hour later than I was supposed to; not bad for a surgery intern. At the end, I walked away from a sick patient who will likely to go the OR tonight, I’d guess around midnight. When I left, he wasn’t acutely decompensating; his pressure had stabilized and he didn’t need to be intubated, yet, although there were more lines being put in. I had admitted him; he was one of the traumas that came in all together, and by the luck of the draw, the triage information was inadequate, and the senior residents went with patients who seemed sicker, but turned out to be in better shape. So I’d worked him up, admitted him, followed him for several hours. Then I was told to leave, while his final outcome was still unclear: could we handle him nonoperatively, or would he require one of the now nearly legendary trauma ex-laps (exploratory laparotomies)? (legendary because so many blunt trauma injuries are now managed with just observation or angiography)

If I had thought that I would get to participate if I stayed for the surgery, I would have stayed eagerly. But I knew that the senior resident in-house would get to do anything that was the least bit interesting about him; just because I’d admitted him didn’t mean I’d get to do anything meaningful in the surgery. So I left.

I don’t know which came first, shift work, or the attitude that seniors get all the cases. I’d stay more if I thought I’d do more. As it is, I’m sorry to miss seeing exactly how it plays out, but since I wouldn’t see the inside of him anyway except from a distance, I figure sleep is good, and I’ll hear in the morning exactly how many hours of borderline pressures, and how low of a hemoglobin, it took to get him to the OR, or not.

Next Page »

Follow

Get every new post delivered to your Inbox.