medical education


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.

Finally, a quiet night. I kept getting pleasantly surprised when I answered my pager: “Oh, sorry, wrong person.” “Can so-and-so have tylenol?” “Can so-and-so have ambien?” “Oh, sorry, wrong person.” Some people hate those mistaken identity pages. I don’t. They feel to me like getting a surprise rebate, or a 50% off coupon.

I even got to scrub in and assist on a case which went really long (three hours after I got there, and more after I had to leave to take care of some things). The attending, whom I hadn’t worked with before, was polite to the assistants, funny, and kept explaining what he was doing almost nonstop, which was terrific. Some attendings hardly talk at all in surgery, and if you do ask a question, they answer under their breath (and behind a mask – almost impossible to hear). Attendings who just chat about what they’re doing in the OR are so much more educational.

There was one patient who developed afib overnight, actually much faster than I’ve seen before. Fortunately he was comfortable the whole time, and I did everything just about right, down to calling the right people at the right time.

Only three more nights of this. I’ve got another three hundred pages to go in The ICU Book. I’m now into the fluids and electrolytes section, which is where I think there’s a hole in my scientific thinking box, because ever since first year med school I get hopelessly lost at this point. I did just barely manage to grasp the mysteries of FeNa (a way to evaluate low urine output which looks like a problem from advanced algebra), but as for hypervolemic/normovolemic/hypovolemic hypernatremia/hyponatremia – I get to about the first level in the branching decision tree on that subject, and my eyes glaze over. Especially since this author starts the chapter out promising to explain a very simple way to approach the whole problem – and then it turns out that the whole evaluation depends on your assessment of the patient’s total body water status, which he himself admits is very difficult to assess reliably, since signs like edema don’t develop until you have 4 or 5 extra liters on board. So basically his simple method boils down to, take a guess about the water status, and then make the rest up from there. (Sorry, non-medical folks, if this doesn’t make sense to you, it’s because it doesn’t make sense to me either.)

At least he gave a very concise explanation of the mechanisms and bad effects of hyperkalemia (high potassium), and what specifically to do about it, which will be very comforting in the future.

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