medical education

I’ve decided that I’m being too nice to the medical students. I let them ask me really dumb questions (like what the patient’s ins and outs were, when they should look on the vitals sheet, or what exact surgery the patient had, when they should look on the op note, or what diet the patient is on, when they should look in the orders, and medical knowledge questions that I should be asking them, not vice versa). They like it, of course, but it’s not good for them. For one thing, it gives them a false impression of what surgery is like. No one else is going to be as soft as I am, either to students or to interns. For another, it makes them unprepared to meet real trouble. One of my students, for instance, is going to join a service where I know the chief literally tortures the medical students, psychologically. He does it to the interns too, so I know, but I’ve seen him go way overboard on the students. My student is going to get cut to pieces when she meets him, because I haven’t given her any practice at standing up to tough questions, and thinking under pressure.

So after these meditations, an unfortunate medical student on a specialty service whom we had consulted on one of our patients made the mistake of asking me what was going on with the patient, since he couldn’t read the handwriting in the chart. I’m afraid I astonished my junior resident (again, after my essay in bad jokes) by becoming quite stern, and asking him if he had access to the electronic medical records, and whether he had looked the patient up in there before asking me (of course he hadn’t). Then I regretted it, and gave him a nice summary of the situation, and warned him to go find the details in the computer before trying to present to his residents.

I need to find a happy medium: being demanding enough to teach them well, without going too far the other way and being unnecessarily strict.

It’s funny. At the beginning of the year, I felt no different than the medical students, and had the greatest difficulty telling them what to do. Now, I feel ten years older than the third year students, and was astonished to discover that my “young” students are actually older than me.

In medical school the family medicine folks are in charge of teaching you how to get a nice, detailed history from the patient. They mention things like not interrupting, letting the patient tell their own story, asking open-ended questions, and so on.

The ER, although a very different setting from a family medicine office, actually likes lots of details in the history. If you don’t ask when the last meal was, who the primary care doctor is, when they were last seen, how much they used to smoke, you can be sure the attending will want to know about it, and have some reason why it’s important.

But there are special circumstances:

Elderly male, well-known lung problems, brought in by squad, short of breath. He’s not a healthy color, clearly struggling to breathe (you can see all the accessory muscles). The resident is dutifully attempting to get a history: when the problem started, what makes it worse, when was he last hospitalized. The attending walks in, takes one look at the patient, one look at the monitor (tachypnea, sats in the low 80s), and says: “There’s only one important question here: ask him if he wants everything done.” The man says yes. “Then call respiratory, because this isn’t going to last much longer.”

A rather painful ER shift. I had to call some surgical consultants, and they were less than thrilled, to put it mildly. My colleagues acted as though the fact that I am a surgeon ought to prevent me from calling other surgeons into the ER. On the other hand, when I tried to make a surgical assessment of a patient and act on it (giving pain meds to someone whose pain I thought was clear enough to warrant an immediate surgical consultation, but who then became pretty comfortable by the time they got to the ER), they weren’t happy with that either. So I’m just a little bitter with the guys who I thought were my friends for getting so uptight on me. I tried to play it as some ribbing back and forth, but they wanted to take it farther than that. This is the first time that I’ve really felt I’m not able to play the men’s game by their rules. I guess I just need to stop thinking about this in personal terms.

As for the clinical question, I’d welcome opinions on the subject of giving pain medications in the ER before the surgeon evaluates the patient. It serves me right, actually, because a few months back I gave another ER resident a hard time (jokingly, I thought) for doing the same thing, and he fiercely quoted me some literature articles (such as this one) decrying such an inhumane practice. I think perhaps one might avoid inflicting too much suffering on patients by distinguishing between community practice, where it might be an hour or two before a surgeon gets in to the ER, and academic practice, where the surgery residents make it a point of pride to evaluate any consult within ten or fifteen minutes.

Either way, I was insulted that the surgical team wouldn’t trust my evaluation of the patient. My physical exam skills haven’t been changed by the fact that I’m working in the ER this month. I’ve been laughed at enough times for taking abdominal pain seriously when it isn’t that I think by now I have a good idea of what constitutes “severe abdominal pain” for a surgeon. When surgeons say severe pain, or a rigid abdomen, they mean they want to go to the OR now. If that’s not your management plan, then the patient’s belly isn’t that bad. That’s why we don’t appreciate it when medicine consults us for “acute abdomens” in patients who are sitting up, talking, and drinking. The ER attendings, on the other hand, are frustrated at me for discounting abdominal pain of the gastroenteritis/pregnancy/peptic ulcer variety. So I know the difference between serious pain and non-surgical pain. (A surgeon at my medical school described it best. She said, “If the patient makes any  movement quickly and easily when I ask them to, it’s not an acute abdomen. With real peritonitis, the patient won’t move unless they absolutely can’t help it.”)

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.)

Brad’s version of the established and respected surgery practice of critiquing your juniors rudely in front of a large audience during stressful moments made for a rather unsettling night. At one point I found myself standing outside a room with two nurses (we having all been found fault with, loudly, me most of all). One of them said, “I’m just going to defuse some anger here before going back to my other patients.” I told her, “Then one of us needs to move away, because this cubic foot of air doesn’t have room for all of our anger.” Six hours later, I can tell myself that the attendings speak to the residents this way all the time, in the middle of the OR, during both elective and emergent cases. Seniors to juniors is quite normal, as well, I suppose. You copy your role models. This is surgery, a side I haven’t had much experience with yet, but it’s probably not too late to start.

There was a ruptured AAA tonight, and I got to scrub in and help. I saw the red mass of hematoma accumulating in the mesentery, and the attending’s deft discovery of the right spot for cross-clamping, more by feel than by sight. I learned that everyone’s hands shake with adrenaline – including the attending’s; but that doesn’t need to keep you from sewing neatly. And the whole OR listened to the chief being chewed out for not doing x y or z more efficiently. It comes with the territory. I guess.

Bottom line, my patients are all still alive. The nurses were right, and the certain knowledge that the attending is going to be angry with Brad and me because of what happened doesn’t give us the right to blame the nurses for doing their best.

One more night this week.

Sunday night is usually bad. The nurses are disgruntled about working the last shift of the weekend, the residents who were on during the day don’t clean up as neatly as on a weekday, and the patients who were trying to wait out the weekend finally give up and come in to the ER.

I spent the first four hours handling situations that had been developing all day. The patient had been short of breath, and finally somebody noticed that they were desatting as well. The patient had been tachycardic, and the nurses decided it was high enough to be worth calling me about. The patient had been febrile all day, and now high enough to need some investigation. And the ICU patients were apparently falling apart just the same, only more so, so Brad was too busy to help me at all. Amazingly enough, everyone turned out ok.

Sometime in the wee hours of the morning, the code pager went off. I had just dozed off, and was so startled I didn’t even go to the correct floor at first. It didn’t really matter, because it was one of those “patient found down, we just noticed” kind of codes, where the patient was clearly -dead- from the beginning. No lines were called for, so Brad and I stood in the corner and watched. (Or rather, I watched, and Brad critiqued the medicine residents running the code.)

Two hours later, the pager went off again, for a room just down the hallway (yes, you’re correct, this is one of the floors the surgeons hate). It felt like deja vu, but at least I managed to get the right floor. I had the line kit opened by the time Brad arrived, but I figured he would want to do it himself, since this was a witnessed arrest and thus rather more urgent. I should have known better. Brad can be quite arrogant and abrasive (for this whole code, he was telling me things like, “What do you think you’re doing? Don’t you know how to do that? Come on, you know better than that. What are you thinking?”); but he does want me to learn. He made me put the femoral line in, and completely to my surprise, it actually went where it was supposed to go, and fast enough to be useful for fluids and drugs.

So now I feel bad, because I was just thrilled to have gotten the line in, and couldn’t even particularly consider the patient, who is no doubt dead by now. Which is really awful of me to be happy on such an occasion. But now that I know how, I should be able to manage much more easily at future emergencies. So I’m grateful, in a very weird way, to this patient for teaching me this, and to Brad for making me do the line.

As we were in the ER evaluating a patient, we came across an EKG which was rather interesting for its complete normality (in a patient with a list of medical issues as long as your arm). So I started quizzing the student (yet another one of these bright-faced, eager fellows who plans to do surgery) and making him read it in order. I like to force students to go through EKGs neatly (rate, rhythm, P waves, QRS complex, ST segment and T waves) because I had a hard time learning EKGs, and I was halfway through fourth year before some cardiologists impressed on me the importance of reading EKGs in an organized way. By now, I can glance at them and get a gestalt (no afib, no ST/T wave changes suggestive of an MI), but I still have to go through carefully and make sure I’m not missing an AV block or a bundle branch block or something else with zebra-stripes. Anyway, in addition to the overall plan to make medical students not fear surgeons, and to impress on them the five causes of postoperative fever, I hope to make EKGs a little less fearsome by teaching an organized approach.

So then I offered the student to leave and get some food while I waited for Brad to get down there, and he said, “I want to stay around as long as possible, because people say you’re a good teacher, and I don’t want to miss anything.” You could have knocked me over with a feather. Me, a good teacher? I’m almost afraid to meet the medical student on call for the night, because depending on how enthusiastic they are, it’s only a matter of time till they come up with some (fairly basic) question I don’t know the answer to. So for the next five minutes I was almost stammering, re-evaluating every statement that came to mind in light of my new persona, and then I turned around and paid him for the compliment with a pretty lengthy pimping session (nicely, of course!). I hope he feels educated now! (The ER interns were laughing at me, standing in the middle of the ER on a Friday night, discussing the treatment of afib, and guidelines for blood transfusion, and the clotting cascade, etc.)

Work hours: The other night one of the chiefs chased an intern out of the hospital, saying, “You have no idea how much trouble you’re going to get us in if you stay around like this.” Which just struck me as funny, because the chief himself clearly wasn’t going to leave for another couple hours. At least at this program, the 80hr rule works out to, interns and second years are carefully protected, and then as you pick up more responsibility, you’re expected to get the job done, no matter how long it takes – and just make sure the records look pretty. Which is ok with me, at least on the protected end of the list, because that’s how it works in practice. You can’t dump work on your partners all the time; you have to make sure your patients are taken care of. (Although I’m rather insulted by the assumption, when the chiefs warn me about hours, that I don’t know how to keep the records neat as well as they do. Four months is plenty of time to pick up on how that works. If I want to stay and watch a case, I know better than to let those hours count.)

Continuity of care: With a night float system, continuity largely depends on how conscientious the day folks feel about signing out. Some of the interns are very good; they’ll print a list for me, write a brief summary of what procedure the patient has had, how much progress they’ve made towards a normal diet, and any other issues that might crop up over night. Other interns just barely tell me when they want a post-op check done, and forget about advance warning on who’s been short of breath, tachycardic, febrile, or anuric. This far into the month, I know most of the big players, and have admitted nearly half of the lists, so I don’t need signout as much now as I did at the beginning. Still, if you ordered a CT to rule out PE, it helps to let me know to look for the results. (This is one thing I think medicine is better at: they seem to have a more official, engraved-in-stone approach to signout responsibilities.)

I never thought I would enjoy lectures this much. When I was interviewing, I was rather incredulous about the residents professing vast enthusiasm about how many lectures they had. Now, the chance to take time away from the constant issues on the floor is always welcome. So is the opportunity to concentrate on learning. There is so much I
don’t know, and need to know *right now*, that I’m glad of any chance to learn it. Plus, M&M can always be counted on for some fireworks. Whether it’s our one particularly fierce attending interrogating a senior, or an argument where the vascular attending decides to tell the trauma attending how to handle a trauma code, or a chance to dump our frustrations on the computer specialists who come to explain how to use the new system – academic days are always exciting.

It would be both difficult and dangerous to tell a surgery attending that you appreciate him, so I’m going to use this as an outlet to repeat how much I like my program. The hospital is good, most of the nurses are good, the food is edible, there are plenty of computers around (whether for checking labs, or playing with email). I like and respect the majority of the other surgery residents. The attendings are mostly much nicer than I had hoped for, and all seem to be enthusiastic about teaching. This program is as good or better than I could have hoped for, and I’m happy to be here. (No matter how grumpy I get sometimes.)

A couple of times every day I need supplies for patient care, and every single time I have a reason to smile: the nurses gave me a secret code to get into the supplies. Like most hospitals, this one keeps not only the medications locked up, but also all the basic supplies, like needles, syringes, gauze pads, wound dressings, lubricant, stitches, cotton swabs, steri-strips – you name any useful article, and it’s locked up. Which for most residents means that every time they want to do anything more advanced than touch a patient, they have to interrupt a busy nurse, get her to go into the locked room, open the locked cabinets, find the hidden items, and sign them out, before they can do anything. Towards the end of last month, whether because they now trusted or me, or because I had made myself so annoying, one of the nurses gave me a secret code. I had thought it would take me a couple of years to arrive at this, because so far I’ve mostly seen chiefs entering the supply rooms alone. But now I have a code (I have a code!) and I can get supplies for myself. I can do things on my own, and I don’t have to bug the nurses. I’m still thrilled every time I do it, because I hated asking the nurses. (It was always a dilemma: ask the one who’s already in the room doing something, the one who’s closest, the one at the other end of the station who doesn’t look too busy, or go find the nurse for the patient you want to take care of right now?) Now I can take out drains, sew incisions, change dressings, take cultures, and several other small jobs without having to waste time finding a nurse and wasting her time, too.

I’m also slowly starting to understand exactly how draining it is on the neurosurgery residents to be on overnight call q4 or q5, forever, and never leave the hospital before noon the day after. They don’t sleep on call nights, either. They’re responsible for an ICU full of sick patients, a floor full of post-op patients, and there’s always something in the ER. Usually there’s at least one emergent surgery overnight. I really can’t blame them for getting as irritable as they do, whether it’s their call day, and they’re contemplating the coming night, or the day after, when they’re exhausted, but have too many jobs to do to leave the hospital. I try to help, but there are some things that I’m no good for: placing ventriculostomies, for example.

Chief to junior on rounds, sharply: “Don’t guess. You know or you don’t know. Guessing is making it up.”

Attending to senior during M&M: “You believed the pre-op H&P from the office chart? Don’t you dare do that on my service. Be more compulsive than that.”

A couple more months of witnessing this (and receiving my fair share of it, too), and I will be obsessive about details. Which is good. That’s what I admired about surgeons, and I still do. They are the people who have the least tolerance for any kind of avoidable error. You don’t know what the patient’s home medications are? Why not? Did you talk to the patient, to their family, call their nursing home, have records sent from the other hospital, call their family physician? Only if you’ve done all of that do you have an excuse for not knowing their meds and doses. You don’t know what the pre-op CT looked like? Did you dig through radiology records? Did you make multiple requests for records from the other hospital? Did you go through the attending’s office looking for the CD? Only then do you have an excuse for not knowing what the lesion looked like on CT. As for current labs, recent vital signs, and recent imaging, when those are available in a chart or on a computer, there can never be an excuse for not knowing those, or having them written down handy. Aspects of the physical exam? With the patient in a bed somewhere in the hospital, no excuse not to know every reflex, murmur, skin lesion, and scar. Especially if the attending is asking about it. (Maybe you don’t need to know all of them, but you’d better have figured out which ones of them are going to be relevant, and know those.)

Eventually, I’ll get tired enough of wasting my time and losing face in front of patients by going back to check on these things that I’ll remember to ask about everything and look at everything the first time I’m in the room. Then, I will really be a good doctor. For now, the only thing to do is to be obsessive about rechecking the details, so the seniors and attendings can’t find anything that I don’t know. After all, that’s what morning rounds are really about. Part of it is taking care of the patients, figuring things out early enough in the morning that we can get all the needed tests and procedures done before people go home in the evening. But at a deeper level, every morning is an exercise in obsession: how much detail can you find out, how fast, and present in how precise an order? Most surgeons aren’t born obsessive-compulsive; they practice hard to get that way.

This might sound ridiculous. But mistakes can kill. If you don’t notice a patient’s low potassium, they could have a fatal arrhythmia within a few hours. If you don’t notice that no one has put SCDs (compression boots) on the patient, they could die of a PE the day you want to send them home. If you don’t order the pre-op antibiotics, the patient could get a serious, if not fatal, wound infection. If you don’t notice a gradually increasing heart rate, the patient could die of anything from a heart attack to sepsis before you catch up.  (And this isn’t even mentioning details in the OR itself, which I have no idea about yet, but which I am sure are even more ominous.) You never know which detail is going to trip you up; so you have to know all of them.

Our medical student is amazing. I think he was academically abused in the not-too-distant past, and responded by studying insanely, so that his grasp of basic science is unassailable. For some reason which I have already become too cynical to grasp, he is wildly enthusiastic about this whole med-student/surgery rotation deal, and simply begs for scut to help us with. (I used to be pretty enthusiastic, but this guy is out of even my league.) He sees more patients than any other third year I’ve heard of, and he knows the patients. He may not know what the plan is with them, or what to do next, or which parts of their labs to be concerned about, but he knows all the facts.

The only thing that keeps him from being dangerous to me (the way that insanely bossy fourth year student was) is that he thinks things through too much. I’m afraid the attendings are having fun with this. They’ll ask him a relatively straightforward question (as pimp questions go), and he’ll start reciting a chapter from Robbins’ pathology, rather than giving the one-word classic answer that they’re looking for. It cracks the residents and me up; which is rather rude on our part, but he seems to be surviving. I asked him if he was sure he wants to do surgery, and his answer was, “Of course I do. What else is there?” Poor guy. But he’ll be good at it; he thrives on hard work and long hours. Even though some of his questions are ridiculous, none of us mind answering, because he obviously wants to learn and understand his patients. (Although it’s a little bit funny how he’ll ask me questions, to which my instinctive response is, That’s exactly what I was going to ask myself; but it helps me think things through, to be forced to give him a reasonable explanation, and not just, This is how we do things.)

The medical school at this hospital is tough, way harder than mine. Their expectations of their students are so high. I would much rather be an intern here, matched, all set, on track in spite of my poor preparation, than a student. They take overnight call with ridiculous frequency (considering that the residents don’t), have lecture with uncomfortably regularity, and have all kinds of requirements and oral tests to get through. They are going to be much better prepared (for a surgery residency at least) than I was; and I don’t miss their shoes.

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