medical education

Okay, now I’m annoyed. I left the hospital at 8:30pm, not because the patients were so sick or I was so busy (although they were and I was), but because the attending took twelve hours to round. I’m telling myself that I’m not upset just by the time of day, but because the time was wasted. I’ve stayed till 8 and 9pm before, and not been too unhappy, because I was doing procedures, or taking care of a patient who seemed too unstable to sign out. But twelve hours rounding?

This is the attending who can be found in the hospital most nights of the week, regardless of the call schedule. This morning we came for sign-in, and he told us about something he’d taken care of overnight. “But you weren’t on call last night. You’re on call tonight.” “Yes, but I was here, taking care of some things.” Um, sure. Today, the night shift nurses had gotten their change of shift report and were ready to discuss their patients, before we finished rounding on some people. Totally insane.

On the bright side, I am now better at putting in brachial and dorsalis pedis arterial lines than I am at radials, better at IJ than at subclavian central lines, and very handy with an emergent chest tube. I skipped half of rounds, taking care of those things. (That encompasses two or three patients who are terminal, and need their families persuaded that it’s ok to withdraw care; two critical head injuries in the ER that needed to be checked on every two hours; a tension pneumothorax that came up out of the blue; an emergent intubation; and a-lines and dobhoffs scattered like pepper and salt all over the unit.) And at the end of all that, I still had a long list of things to be done; I could easily have kept busy until midnight just fixing the feeding tubes, changing vents and checking repeat blood gases, and repeating electrolytes on my patients. That’s what sign-out is for, because this stuff goes on around the clock. So now I have one hour to eat and do anything else – scribble this – before I go to sleep and get ready to start again, with another slow attending, in the morning. At least the attending today has a sense of humor, and doesn’t mind if we crack jokes about his lengthy rounds; the other attendings take themselves much more seriously, and are consequently more difficult to work with, since there’s less legitimate stress relief.

One week. I can do anything for one week, right? And then I won’t be an intern anymore.

(And to be precise, I learned several tricks about chest tube placement; got to do a needle thoracostomy (actually two, just to be sure we did it right); got enough practice to get a dobhoff feeding tube in right on the first try; learned how to calculate how many amps of bicarb are needed to correct a base deficit (wt in kilos x .25 x base deficit = meqs of bicarb; don’t ask me why, I take this attending’s word for it); reviewed what to do for traumatic diabetes insipidus; did a bronchoscopy, and got the best explanation of bronchiolar anatomy I’ve heard yet; changed another whitman patch (basically velcro over an open abdominal wound, used to gradually pull the fascia back together) at the bedside; reviewed inumerable chest xrays, head CTs, and abdominal CTs, and discussed the significance of a wild variety of findings; and had at least six significant discussions with families; and exchanged jokes with an intubated patient (and what kind of a day is it when you feel cheered up by an intubated patient teasing you? unbelievable). Put like that, it was 15 hours very well spent. Until I wrote all that down, I’d forgotten some things that happened in the morning.)

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

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

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

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

Somewhere in the last couple of years, I was near a city where the Body Worlds display (or one of the copy-cat shows) was stopping. After thinking about this for years, I’ve had enough of the ads (as it keeps travelling around the country), so here you go.

There are two primary ethical objections to these displays:

1) Our common humanity is denigrated by dissected bodies being displayed to public view as a matter of entertainment and moneymaking.

From a Christian perspective, the body is an integral part of what it means to be human. The Bible describes God forming Adam’s body and breathing life into it, and says that Adam was made “in the image of God.” To turn the human body into an object to be displayed for the enjoyment of crowds makes this crowning miracle of creation nothing more than any other animal displayed in a zoo.

But even if you wish to avoid a religious rationale, surely we can agree that the concept of Body World is of a piece with the modern entertainment culture, where horror films like Saw, Saw II, and Saw III (not to mention all the rest of their ilk) are viewed as acceptable amusements. Violence perpetrated on human bodies is now just a way to pass the time, not something revulsive. Similarly, Body World teaches us to accept the image of human bodies dissected, distorted, displayed – for our entertainment.

One of the greatest nightmares of medical school, gross anatomy, for centuries an illegal secret, and until recently at least a private activity, has been turned into mass entertainment for the crowds. I cannot express to you what it was like to cut up a human body, to destroy what another human person had used to live in, to love with, to see the sky from, the feel the ground by. . . At least I had the comfort, the excuse, that I was doing it for a reason – to be able to help hundreds of other people live, love, see, feel, a little longer, a little more comfortably. And it was, at times, a paltry excuse. To saw a skull open? To split a pelvis in half? To peel the skin off a face? To split a hand into useless threads? Who can do that calmly and claim to be still human himself? These phrases are the description of a monster’s activity. At least we had a reason; and I think our humanity survived. 

But what excuse is there, for the general public, to go and stare at bodies split open, splayed apart -amusingly posed? If you want to know what your inside is like, read Grey’s Anatomy; get a plastic model from the school supply stores; read Netter’s, if you prefer color. If you want to know how the thing works, there is no scarcity of physiology books, in all ranges of readability. The craze about Body World has nothing to do with a sudden hunger for anatomical knowledge. It stems from a fascination with the forbidden, the weird, the indecent.

Like the rest of the violence and indecency which is now commonplace in our society, the Body World displays serve the purpose of destroying our conscience and filching our reverence for humanity as something separate from the animal kingdom.

2) These particular humans almost certainly had no say in the disposition of their bodies; and even if you allow that it might be all right to use bodies this way, if their owners had knowingly and completely consented, it is wrong to participate in the exploitation of individuals who in their lifetimes were the victims of a cruel state.

We all ought to have known better than to think that Chinese bodies were come by honestly (and you had only to look at their faces to know they were Chinese). Recently ABC’s 20/20 removed the possibility of further self-deception by investigating the body-selling trade in China. Protest as he may, the inventor of plastination cannot deny that his original bodies came from a shady source, as he is now loudly promising not to use unethically obtained bodies anymore. The news stories mention thousands of people currently offering their bodies to be used in these displays, but the fact remains that there is no good documentation of the origin of the bodies that are currently touring the country. And for anybody who thinks any Chinese person whose body is being used actually freely consented to this arrangement, I have a bridge in Brooklyn to sell you.

But, even if all the unethically obtained bodies were cremated, the objections in my first point would still be reason enough not to see these exhibits.

For a much better-written exposition of the moral objections, please see Thomas Hibbs’ essay, “Dead Body Porn”.

I’ve learned the geography for maybe 120 miles around my new city by dint of making polite conversation with my patients, and hearing that they live in such-and-such a city, ten miles east of X small country hospital, and two hours north of our place; and so on. Thus, my picture of the surrounding territory consists of outcroppings of towns labeled predominantly with the names of our referring hospitals.

The attendings and chiefs are a step ahead of me. They know not merely the hospitals, but the physicians who transfer patients to us regularly. In fact, they know them too well for their own happiness.

There’s one doctor in particular, I’m not sure yet whether he’s ER or a surgeon, but when the attendings hear his name (“Dr. Smith called about transferring a patient to your service”) an expression of disgust comes over their face, usually accompanied by several unprintable words. We’ve figured out, through too much experience, that when he bills a patient as stable and ok for a regular floor, we’d better prepare an ICU bed, and maybe have the OR on standby. Whereas when he describes a patient as septic, on death’s door, requiring urgent operation, we can safely order a regular floor bed, and consider whether a CT scan might suggest the need for surgery, or simply send the OR staff to bed. If he describes right upper quadrant pain, it’s invariably in the left lower quadrant. If he says the patient has no cardiac problems, they’re most likely in decompensated heart failure and/or infectious endocarditis. If he says a patient has necrotizing fasciitis, we can safely conclude that it’s simple cellulitis. If he says there’s a rigid abdomen, it’s sure to be as soft as a kitten.

The real problem is when he says he’s not sure what’s going on. Then we have nothing whasoever to base our conclusions on.

So my question is: was he always this poor of a doctor, or did he change after he left residency? If I’m a conscientious, careful resident, and learn how to accurately assess my patients, will that protect me from becoming this kind of terror to my colleagues? Or is it that once you leave the demanding academic environment, where there’s always someone looking over your shoulder and evaluating you, it’s just as easy to slip into this lackadaisical, “we’ll let the big hospital handle it,” mode? What can I do to keep myself from becoming this doctor?

I’ve figured out what my problem is: I don’t have any common sense.

There was a patient today, and I just couldn’t get it right. The only good thing about the whole humiliating episode was that I erred on the side of overestimating the patient’s illness, not underestimating it. (Humiliating as in, now anyone in the hospital who had any doubts about my competency/intelligence/character has had them answered – not in my favor; ok, I guess the entire hospital wasn’t paying attention, but it feels like most of the surgery residents were.) I was starting to feel the slightest bit hopeful about next year, but not any more. Actually, I’m not so worried about myself, as about the people who will be getting called by me, since I’m clearly no good at assessing situations.

Honestly. I messed up, and the only conclusion I can come to is that I have no common sense. And I don’t know where to get any. You would think, if it came with experience, after ten months I would start to be able to at least add two and two, or simple things like that. You can’t get it out of books, because I’ve been studying with unheard of diligence for the last two months, and it’s not doing me much practical good. It wouldn’t seem to come from anecdotes, because I’ve read a great many medical blogs and memoirs with enjoyment, and that doesn’t help either.

So what do I do? I don’t think I’ve made enough spectacular blunders to get fired, although that would certainly save both me and the attendings a lot of headaches next year. The only two practical things I can think of are: I didn’t keep my hands in my pockets, or my mouth closed; and, I should walk away for ten minutes and come back before making any conclusions. I’m reduced to formulas like this for at least reducing the impact of my lack of common sense. Maybe it’s just that I still need a lot more experience, which is definitely true, but the other interns don’t seem to make the same kind of mistakes I do. Like they were born with surgical intuition, and I wasn’t. . .

Because I was at the hospital late this afternoon (late as in, past civilian office hours), I got to see a complication in a patient our service operated on earlier in the month. It was the first time I’d ever seen or heard of, and it was a great experience to figure out what it was and then call the chief and treat it in the ER with him. Because we sent the patient straight home, the team members who weren’t in the hospital that late will never see it, and if things get busy this weekend, they may never even hear what happened.

There’s a rumor floating around that the ACGME (bureaucratic organization that regulates all residency programs) may be looking at imposing 60hrs/week rules. I sincerely hope that this is an urban legend, since I haven’t had anyone close to a program director verify it yet. . . but given the number of insane, counterproductive things that the government and other agencies are doing to the healthcare system, I could believe it.

All I can say is, I hope they wait till I finish residency to do that. If not, I think I would finally have a chance to practice civil disobedience, as I have always longed to, and flagrantly disobey the rules.

We barely have enough time right now. I know the chiefs who are graduating this year have expressed a great deal of angst about being the first class to go through completely under the 80hr rules. They have no idea how their skills will match up to the real world in July. They’ve said things about having less experience over all, feeling less confident than they think their predecessors a few years ago did. Maybe it’s just the usual nervousness before taking another big step. . . but maybe they’re on to something.

I can not imagine what we would do with further hour restrictions. We’re already limited to 12hr shifts. The only way to cut time down further would be to move to 8hr shifts – and then 2/3s of the residents (afternoon and evening shifts) would be simply wasting their time, being present in the hospital purely for coverage reasons, and the occasional emergency surgery, since most of the surgery action happens in the morning and early afternoon.

There’s a physical impossibility in here: surgeons do most of the things that medical doctors do – admit patients, round on them, order and evaluate tests, discuss the results and plans as a team – and in addition, we have a whole ‘nother day’s worth of work to do, in the OR. Doing 2x or 1.5x as much work as another specialist would do simply takes more time. I suppose we could also not round on patients before surgery, just catch up on them piecemeal between cases. But considering how many near-disasters have been staved off during morning pre-rounds, I can only conclude that patient care would suffer abysmally from such a change.

Somebody keep the ACGME tied up with some paperwork for the next 4 years, please.

Once again, more studying got done than my brain can really stand. Learned all kinds of things about the biliary tract, including, in detail, what to do if you injure the common bile duct during a laparoscopic cholecystectomy. Which is actually fairly irrelevant, since although I’m afraid such an event may be in my future (incidence stable at 0.5% for the last several years), hepatobiliary surgery has never crossed my mind as a specialty, so I am sure I will not be in a position to repair the injury adequately. The general tenor of the lengthy textbook discussion was, interspersed with detailed instructions on how to repair every variety of injury, admonitions to refer such patients very early on to a major center and an experienced hepatobiliary surgeon. So mainly I learned something else to try very hard not to do; of which I already had a long list.

I’m still not happy with my moral position during conversations which I disapprove of. But at least I resolved, again, to try very hard not to say anything I wouldn’t say if the subject of the conversation were in the room. Maybe I can’t help what other people say; but I don’t want to contribute.

I really love this type of patient conversation:
Me: “. . . So basically everything that brought you in to the hospital has been corrected, and you are ready to go home, although you do need to continue taking these medications.”
Patient: “Great, I feel fine, I was ready to get out of here yesterday. Let’s go.”
Spouse (with the most suspicious tone of voice you can imagine): “You’re not kicking him out of here again, are you? I’m sure he was deathly ill with this xyz the last time you discharged him, because he was sick immediately [although we didn't come back to the hospital or talk to any office staff for a month].”
Me: “Ma’am, I understand your concern, but I assure you that there were no signs of this problem the last time he was discharged. And anyway, right now [laundry list of tests] have all been completed, and show that the problem is completely under control. The best thing is for him to get back home and on the road to recovery, and you just let us know immediately if anything concerning comes up.”
Spouse: “They should have listened to me the last time. . .”

Which is such a horrible note to close on if, as there’s a decent chance given his underlying disease, the poor fellow gets sick again and has to come back. But right now he’s fine, and he wants to go home, and I want him to go home, so please, try and give some credence to the long list of negative test results. Some people do seem to feel better after you explain it all in detail; but this lady had our negligence firmly in her head, and she wasn’t listening to reason. Ah well. I’m sure we can resume the discussion at the next admission.

I’ve studied so much the last couple days I feel like I’m bursting. Apparently I’ve discovered the secret to studying at the hospital: don’t bring any other books in, and have nothing of the slightest interest occurring in the world, so that reading news sites and commentary is more boring than reading a textbook. Actually the surgery books are fascinating, especially since I asked the chief for some recommendations. I’ve now discovered a book I clearly should have been reading since the beginning of the year, Chassin’s Operative Strategy for General Surgery, which explains how to think about operations, and all kinds of details of practice that I’ve learned exist, by stumbling against them, but never really heard why they are that way. And then of course the usual assortment of gigantic textbooks, in one or two or three volumes, which are certainly not boring, but can be very discouraging: flip through any one at random, and there are nearly 2,000 pages of dense information that I ought to know and would like to know – and it takes forever to read any one chapter.

At least I finally figured out that nowadays one operates on acute cholecystitis within the first few days. (Yes, I told you I was a bad surgery intern; it took me nine months to figure that out. My only excuse is that this is the first month that I’ve spent much time with plain old general surgery – except August, and I wasn’t conscious then.) Somehow I had gotten the impression in medical school that one operated urgently on small bowel obstructions, and tried to wait six weeks before operating on cholecystitis (infection of the gallbladder, usually due to stones blocking the cystic duct) and biliary pancreatitis (inflammation of the pancreas due to gallstones getting stuck in the common bile duct), so I kept being puzzled when the surgeons here operated a lot sooner. My current program isn’t the most innovative, but apparently it’s a generation ahead of my medical school program, because all the current literature (it wasn’t even hard to find) says that it’s best to operate immediately, before too much scar tissue and other complications develop. (And for biliary pancreatitis within a few days, as soon as the pancreatitis seems to resolve, because it will likely recur if you wait much longer.) (And you should wait a few days to see if a small bowel obstruction will resolve on its own – more than 80% do – and only rush to surgery if the patient is toxic on presentation. That I did figure out a while ago.) So very slowly, I’m learning a couple of key concepts. (This kind of information you won’t find in the textbooks, which are a couple of years behind recent research, and also, for all of the data that they cram into those books, they still don’t seem to have much application to daily life on a surgery service. Obviously I need to read some more, till I get to the relevant part.

Lately we’ve been having some object lessons on the theme that just because you’ve closed the skin in the OR, the patient is not out of the woods.

The other day we had a patient give a few good coughs as the anesthesiologist started to wake them up. Shortly afterwards the surgery resident (not me) noticed a fair amount of swelling at the operative site. A few moments of consideration led him to conclude that this was probably not just normal fatty tissue. He called the attending back in (this is where I entered, seeing the attending heading back, and figuring if he was that interested, it was worth me seeing too), and the wound was opened up to disclose a large amount of fresh blood. After clearing their way in, they found a bleeding artery, which would have led to serious problems if the patient had gotten out of the OR or up to the floor with it.

Then there’s the story from neurosurgery making the rounds: a young woman involved in an ATV accident was brought into the ER with altered mental status, and developed a blown pupil (dilated, no contraction with light). CT showed a subdural on that side, so she was rushed to the OR. After the subdural hematoma had been evacuated, the skin was closed over the site. A junior neurosurgery resident then came in to take over for the senior who had done the case, just to get the patient back to the ICU so the senior resident could take care of some other issues. The junior flipped through the patient’s history, and then decided to take a look at the blown pupil for himself. His next remark was, “Which pupil did you say was blown?” This led to the realization that both pupils were now dilated and unresponsive. The patient was rushed to the CT scan, which revealed an epidural hematoma on the opposite side of the head. By the time they got her back to the OR, the patient was bradying down (Cushing’s triad, in response to increasing pressure on the brain: as the brainstem is forced down into the foramen magnum, you see bradycardia, hypertension, and irregular breathing). Her life was saved by the fact that the neurosurgeons were just in time to get the epidural hematoma out. Which was due to the attentiveness and inquisitiveness of the junior resident.

My takeaway lesson: I need to be more particular about investigating these details, particularly in postop patients. In vascular patients, I usually do check all the pulses just out of curiosity, whether postop or on new admissions. But just because you’re handed a postoperative patient, with the assumption that they’re all fixed, doesn’t mean that everything is necessarily ok. No time to relax till the patient is stable in the recovery room, and not quite even then. Verify all pertinent findings, and relevant negative findings, for yourself. For example, when getting signout on a patient in the ER, that their abdominal exam is benign – take the time to go down, say hello, and check for yourself before you let them be discharged or sent to the floor for simple observation.

The NG tube issue was addressed today, to such effect that the nurses started calling me to inform me that they had neglected to note the ins-and-outs for two hours. Which is of course what I ought to expect for making a nuisance of myself; but I’d honestly rather that they pay over-meticulous attention to the matter, than to ignore it entirely. I would rather be known as “that nasty surgeon who obsesseses about ins-and-outs” than have my surgical patients as neglected as they have been.

 Our chief this month is a great teacher. He doesn’t make a big splash, being much less flamboyant than many surgical chief residents I’ve known; but he will quote you the numbers on almost any question you ask, and break down the ten different histological subtypes of any cancer, with their differing prognoses. Sometimes people are annoyed with how meticulous and painstaking he is, but I’ve found by experience that whenever I’m about to try ignoring one of his directives, on the grounds that it’s simply too particular, its value will promptly be proven by catching or preventing a problem with a patient. Today he was teaching one of the medical students how to sew. It was the end of the day, the end of a long case, and I’m not sure I would have even tried to let the student sew. The chief not only handed him the needle-driver, but spent twenty minutes instructing him in precisely the right way to place the stitches. I was amazed by his patience. It paid off, too, because the second half of the incision was one of the neatest closures I’ve ever seen a student make. I need to be more careful with my students.

It’s both rewarding and annoying, after a month on nights, where no patients truly belong to you, and random patients keep popping up with problems, to rediscover the ownership of an individual service, being once again completely responsible for a finite group of people. I’m also discovering what fun it is to be simply consulted on patients who have been admitted to hospitalists. I admit that I can see why the rest of the surgeons like this arrangement so much – almost no work to do except operate. It still feels like cheating to me – dancing without paying the fiddler – but it is smooth.

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