residency


My perspective on time in the hospital has certainly changed in the last two and a half years. I remember, even as recently as the end of my intern year, watching the clock intently as the end of a shift got closer, and being very antsy if something came up at the last minute to prevent me from leaving. I also used to spend a good deal of time pondering my days off for the month, and exactly when they fell, and how far apart they were.

I don’t pay as much attention to those specific times any more. I come in as early as I need to so that I can round on patients to my satisfaction. (To me, that means reviewing all the drips on ICU patients, reviewing and correcting all labs, and reviewing the most important consultants’ notes [for me, infectious diseases], before signing in with the team.) I stay as late as necessary to tuck my patients in for the night, and make sure that I’ve checked the intern’s orders from the day. If a case is running late, I expect to stay late with the chief, and don’t pay too much attention to the time. The work is becoming more important, and the time less important.

Which is actually less stressful. It’s almost more peaceful, not thinking so much about time of day. Of course, the corollary is that I’m so busy I scarcely look at the time except when I need to date a note, or in terms of figuring out how cases are running in the OR (usually not that important; our OR is so chronically slow and late, there’s always time to do another chore before the next case starts).

As for days off, after pulling a couple stretches of four weeks straight (between one month and another), working two or three weeks straight through isn’t such a big deal anymore. Four weeks, though – I was definitely getting pretty crazy by the end of those. That was more definitely dangerous for patients than working 30hrs straight.

You get acclimated to anything, I guess.

It’s starting to dawn upon me that all the chiefs and attendings I’ve found very annoying or stressful have actually been teaching me a great deal. Most of them, because it was their personal demand for excellence and thoroughness which was irritating me; a very few, because their laziness was forcing me to take more responsibility for being the thorough member of the team.

Too bad that it usually takes me six months after a rotation to realize what any particular chief or attending taught me.

But I recognize now that my regard for getting some degree of social history; my attention to looking at all the available imaging; my goal of knowing absolutely all the details of the medical history before calling the chief or attending; my thinking about electrolytes in the ICU; my thinking about DVT prevention – they all came from chiefs and attendings whom I found nearly intolerable at the time – because I wasn’t yet prepared to think that hard or that thoroughly about “only” a surgical patient.

Now if I can just think of that when I’m getting annoyed at someone. . . what is it that they’re teaching me?

I remark on the above, in order to avoid relating in detail how extremely annoyed I am at an ER resident and attending, who called us ten minutes before signout with a claim of appendicitis, on a college-aged female, without obtaining a white count, a pelvic exam, or a CT scan. I’ll grant that the CT scan is probably unnecessary. But they seriously seemed to expect us to book the patient for the OR without knowing any lab values, and without anyone having done a pelvic exam. (She had pain, but no peritonitis.) Please tell me if I’m mistaken, so I can stop being annoyed at them; but in the real world do ER physicians call surgical consultants without either a CT or a pelvic, on a young, sexually active female patient?

(I’m sure they’re teaching me how to be polite to frustrating referring physicians. . . like the PCPs whose first test for gallbladder disease is the HIDA scan. . . I haven’t quite learned it yet.)

M&M last week was scary. Scary as in, I don’t let myself say, I would never have made that obvious of a mistake. Instead I say, someday I will be the one to make that mistake, so I better watch out.

No details at all, just the lessons I got:

Never believe anyone. Verify everything for yourself. Seriously, not just an axiom.

Look at all xrays as a matter of course. In addition, I must personally look at every CT done on every patient I’m caring for (let’s say done within the last week), regardless of whether radiology has read it, and regardless of whether other surgeons have told me it’s ok.

Every CT, slowly, head to toe. Then on lung windows, head to toe again, slowly (this is a different penetration view of the CT, to show lung findings, abdominal findings in a new light, and check for free air).

If a patient feels like they’re doing badly, start from scratch and look through the whole story again for yourself.

I’ve gotten through the first week of nights without any major disasters. That isn’t a good thing; that means they’re still out there, waiting for me. . .

—————-

Of course that isn’t true – on another level. Of course I said I’ll never be the one to make that awful of a mistake. It’s a game of roulette: if I concentrate hard enough, maybe I can make it through; as though will-power can bend chance, or concentration will never fail. . . but if we didn’t all think there was a chance we could try hard enough to not make the mistakes, we would have to stop right now.

In one sense it was a bad night, because I didn’t get much sleep, spent a lot of time in the ER, and had my patient die anyway. On the other hand, I surprised myself by handling the problems well. I probably shouldn’t talk about it too much, being just starting into a month of night float, with so many upcoming opportunities to make mistakes and act idiotically. But . . . I talked on here a lot, especially a year or two ago, about how much I admired the senior surgery residents. . . how they took control of bad situations, and knew what to do, and stayed calm. I thought I would never be like them. Much to my astonishment, and I have no idea when or how it happened, I found myself acting like them last night.
 
It was one of those messy situations, where the ER knows the patient being flown in needs surgery of some kind, but the diagnosis is unclear till the patient can be seen and have a CT scan. At least this time they called the surgical services ahead of time; perhaps after the series of fiascos last week our attendings yelled at them enough to impress the importance of calling ahead for ruptured AAAs and such like. (Not that the ER got around to informing the surgery residents, but my radar is getting pretty good.) Which meant that I, also bearing past miscommunications in mind, called the OR ahead and had them getting ready. So everyone was in the right place when the patient arrived.
 
He looked deceptively good for about 30 seconds, and then fell apart. Maybe it was a little longer, because I had time to at least make sure to my own satisfaction that he belonged to my service and no one else’s, so he was mine. Then it was the usual chaos of trying to intubate and do CPR all at once, get iv access, get monitors on, get blood and fluids lined up. . . The ER attending was technically responsible, because we were in the ER, and the patient hadn’t been officially diagnosed yet (I was just extrapolating freehand, taking the most pessimistic interpretation of the available data); but I was responsible too, because I knew if we could stabilize him, my attending needed to operate on him; and if you’re a surgeon and you’re present, you can never blame anyone else for anything that happens. The ER nurses and attendings knew he was ours, so they kept looking to me for directions. Gratifying, but scary.
 
Also I got a central line so fast, despite my hands shaking, that I was almost too surprised to finish threading the catheter. Now the ER folks think I’m magic, which is fine, I guess.
 
I’m not saying I have the calm part completely down; I was certainly pacing back and forth, and – not quite wringing my hands, but touching everything, the ivs, the bags of blood, checking for pulses repetitively. But I didn’t change orders and contradict myself, or give orders too often to be meaningful, and my voice wasn’t squeaking.
 
In the end we stopped. Despite occasional fleeting spontaneous pulses, we weren’t getting anywhere very encouraging with CPR, and it was clear that the patient was never going to be stable enough to move to the OR, let alone even start an operation on, which made further efforts futile.
 
The only thing I really still want to fix is, my voice keeps breaking when I talk to family members. It’s bad enough getting a midnight phone call to say your loved one is dead or dying, you would think the doctor should at least be able to speak coherently and audibly. It doesn’t really do much good for me to call people to give them bad news, and then have my voice be too shaky to communicate anything except that something bad is going on, leaving them to imagine for themselves what that must be. . . I know, sympathy and emotion from the doctor are good. . . but when you don’t know each other from Adam, probably simple transfer of information would be more valuable.
 
I especially hate calling 80-something wives – widows – who you know are home alone in the middle of the night. They’re half deaf, and sleepy, and don’t want to hear that their husband is dead. . . and when they do hear you, you can hear them just about collapsing. . . but so often the wife is the only phone number listed, and if you want to reach the adult children you have to go through her. . . . and you can’t just not tell people, and hope the morning will make it better. . . I have no idea how, but the ER social worker does miracles. She discovered the pastor and sent him over to keep her company. Now that was probably the most useful action of the night (and another profession to add to my list of people besides doctors who don’t get to sleep at night).

The attending called me “honey” while explaining a difficult step in a complex operation. He apologized immediately, and we ignored it. That was after he said I was doing a good job.

Now, I’m upset, not because I think it was sexual harassment, but because it’s plain that I have failed to behave maturely enough and professionally enough to earn respect from my attendings. The hardbitten senior female residents would not get called “honey.” The idea is hilariously incongruous.

I don’t want to be as tough as they are, but I certainly don’t want to be regarded as a child by the men whom I need to teach me. Perhaps I need to give up on the first wish. I speak as definitely as I can, and keep my voice as flat as possible. Not helping, I guess. I really ought to cut my hair, but I refuse to do that; it’s one of the last pieces of my identity from before surgery. All the really hardcore surgery women have their hair chopped quite short. At first I took comfort from the residents who kept their hair longer, but now I realize that those are the ones who, because of the personalities and career goals that go with keeping feminine hair, are not much respected either.

Trauma rotation, as the senior resident, later this year, should be interesting. I will either break down completely, or I will learn to stay on top of a mountain of acute information without appearing – not flustered, but excited. Perhaps that’s the element I’m missing. I guess it’s childish to be visibly excited about a dramatic problem, or visibly concerned about a patient deteriorating regardless of all efforts. I need now, not just to keep my face still, but to keep entirely still. Resolved, not to walk around while thinking. . .

One of my friends, an intern, is struggling with the belief that they killed their patient.

I’ve thought that more than once, and in cold reflection I believe it to be true in at least one and two halves. That is, one I’m personally responsible for, and about two others I’m definitely responsible for significant failings. There were several other times that I felt very guilty about for a week, but as time passes I think my responsibility is less weighty in those. I haven’t written about them before because, in close temporal proximity, I was too upset to write, and I didn’t want any time correlation for the lawyers to find.

The one patient that I think of particularly, I personally failed to notice something, and that thing being overlooked led to another thing, and the complications of that other thing led to the patient dying. So it’s not like I directly administered an overdose. But it seems reasonably certain that if I hadn’t overlooked that particular thing, the patient would have been much more likely to survive. Also there were several other doctors, both residents and attendings, from my own and other services, who also had cause to notice that particular thing and act on it, and none of them did, either. But it was my patient, on my service; so I can’t decrease my own fault by saying that others, who were not as directly responsible, although more senior, made the same mistake. It comes down to, my lack of attention led to the patient’s death.

The other times are similar: I didn’t do anything – I didn’t cut a major artery, or cause a laparoscopic injury – I’m sure those are down the road – but I failed to pay close enough attention, or to pay attention soon enough, and then the patient died. If I had done a better job – if I had done well the job that I was supposed to be doing – it probably wouldn’t have ended the way it did.

I don’t know what to tell my friend, though. There’s no way around it. Sometimes I’ve tried to reason with interns (because they’re the ones to whom it happens for the first time; for the rest of us, the feeling of guilt is familiar and feared) and tell them, in this case it wasn’t their fault. But inevitably there comes a time, probably before six months are out, when there is no honest way to reason out of it: it really is my fault – your fault – our fault.

I can’t remember now how I dealt with those times. By not thinking about it, I suppose. I considered the facts enough to realize what I had done, maybe asked a senior resident what they thought about it, and then I closed a door in my mind. I think the phrase is from King Lear: “That way madness lies.” Now, one part of me knows I’ve killed people, and the rest of me is for all practical purposes unaware of that fact. It takes time, though, to get that door closed, and to keep it closed. And so for a week or two, it’s quite miserable. M&M helps a little, to have it out in the open. The attendings’ conclusion, surprisingly enough, has rarely been as harsh as my own. After all, only I know exactly when I knew certain things, and exactly what conclusions I drew from them, and whether I could have taken certain actions sooner than I did. The final picture, in public, is always a bit blurry; the blame never settles very definitely. Inside my own mind, though, I know that I failed – and it will happen again, no matter how careful I am; it will happen again. . .

It’s hard to watch interns learning that.

I was talking with one of my friends who’s a third-year family practice resident at another hospital, and was struck again by the note of sympathy and pity in her voice when we talked about our plans for the next few years. Come to think of it, our choices three years ago are beginning to have very divergent consequences. She’s a senior resident, in charge of a team, with a much better call schedule than the juniors, and lots more time on outpatient rotations, with their normal office hours, instead of the 12hr days of inpatient (at that, her inpatient day is still only 8-10 hrs). I’m still a junior resident, a year away from even beginning to have any right to my own opinion or being expected to operate significantly. In less than twelve months, she’ll be free to get a new job and move wherever she wants. I’m not even halfway through.

Inside the hospital, it’s even stranger. The third-year internal medicine and ER residents that I’ve “grown up” with – run codes together, taken their consults, commiserated with during ICU months – are also now seniors, making plans for fellowship or practice. And I’m still here. . . and still here. . . and still here. They’re the seniors on their service, and I’m still just above the interns, still very careful to be respectful to the chiefs (in a way, more difficult now; when I was an intern, I was in awe of them, and not in much danger of speaking out of turn; now, the chiefs and I are almost friends, but there’s still a line of respect, and if I cross it too casually, they will definitely react).

And yet, except when I’m talking to these friends about their lives next year, it doesn’t really bother me. Inside the world of surgery, this is our normality. It takes 5-7 years. We’re earning the privilege of operating on other humans, and it doesn’t come cheaply. (I’m on an upswing tonight; they told me I might get some good OR time next week. . . we’ll see if it happens.)

Answering to one attending is difficult enough. Answering to three or four at the same time, about the same patients, is extremely tricky (I’m not going to try to explain the structure of this group of attendings; I still haven’t figured out exactly where the power lines are, which is no doubt part of my problem). When discussing any given decision in the patient’s management, the attending you’re currently talking to is liable to take exception, and start asking how that decision came to be made. You never know if he’s just trying to figure out which of his colleagues has taken the greatest interest in the case recently, or which of his colleagues is wrong-headed enough to be pursuing this particular plan. Or perhaps he knows (and you don’t, yet), that whatever you’ve been doing is so completely off-target that none of the other attendings could possibly have approved it, so either you misheard what they said, or you’re doing it entirely on your own; either way, you’re in trouble. Or perhaps his questioning is simply in the time-honored surgical variation of the Socratic method, in which he attempts to shake you off your commitment to a correct answer.

If you’re just doing the wrong thing, and you can figure that out, it’s relatively simple. Then you merely get to figure out why it was wrong, and what to do next. But if it was one of the attending’s colleagues doing something that he thinks was incorrect, and you’re left trying to explain it, the opportunities for committing a faux pas are endless. You could imply that his colleague was right, and he’s wrong to object; you could imply that he’s right, and you never agreed with his colleague, which is a little better, but still disrespectful to the colleague. Or you could inadvertently make plain that despite the apparent importance of the subject (since they’re all asking about it), you really don’t understand the difference between the two plans at all, or the significance of whatever the difference may be.

And the fellows want to know why I’m sometimes reduced to stuttering incoherently during rounds, as my life flashes before my eyes, and I try to pick which one of these equally impossible situations I want to get into, as I try to explain why the patient is on xyz medication. (Catch them ever helping with an explanation, even if they were involved in the decision! As the junior resident, I am perpetually assigned to be the one presenting on ICU rounds, and thus perpetually the one trying to explain myself.)

Some of the attendings are even more devious. We’ll be calmly proceeding with an operation (a setting where I’m usually safe from being questioned about details of ICU management, since it would be too distracting from the case at hand), and the attending starts what seems to be a friendly inquiry into how the rotation is going, and how the ICU is working. Next thing I know, I’ve somehow managed to say something incriminating about the actions of myself or the fellows. . . I ought to have figured out by now that these attendings are far too complex to ask pointlessly friendly questions. . .

Overnight call in the cardiac ICU is one of the most stressful things I’ve ever done, partly because all the patients are extremely sick, but also because of the number of people I have to answer to. By this time I am a little used to sick patients, who don’t necessarily respond as expected/desired to my maneuvers, forcing me to keep thinking of new things to try. But in this unit, I have not only a large number of cardiothoracic surgeons as attendings to answer to (and they are the most forceful and demanding of the surgeons I’ve worked with), but there are also the critical care attendings (with a level of expertise and devotion to detail that are also new to me, and a penchant for asking for evidentiary backing for my decisions), as well as the fellows, again a level of hierarchy that I haven’t dealt with much before. So many people with the potential to second-guess me in the morning make even simple decisions stressful, let alone hard decisions.

The funny thing is, with all of that pressure, I’m not getting questioned about my actions as much as I had expected. I think I’ve moved to a different level in the resident-attending relationship. In some hospitals, the interns are put in the cardiac unit, and it’s a wild ride. Here, we take a safer route, and the residents on cardiac are expected to have a fair amount of ICU experience, and to be prepared to take extensive responsibility in the unit. As a result, when not doing something absolutely incorrect, I think we’re starting to share in the collegial tolerance that exists between “grown-up” doctors. We know that there are several acceptable ways of getting the same thing done (you could use fentanyl, versed, or propofol for sedation; you could use one super-antibiotic, or two weaker ones with cross-coverage; you could operate based on clinical findings, or you could double-check with a CT – no big deal as long as things are stable), and so we learn not to criticize colleagues who don’t do it exactly our way – as long as the job gets done, and the differences in method don’t threaten the patient.

It’s a strange sensation, but I think I’ve started to reach a point where I’m allowed to make some decisions in that atmosphere. We might have an academic discussion because the critical care attending prefers fentanyl to ativan, whereas my experience has been to avoid narcotics unless I think pain is contributing to the agitation; but I’m not in trouble for doing it one way or the other, unlike how I might have been last year, three weeks ago. The more I think about it, though, that only increases my responsibility. . .

I’ve written this post in my mind nearly every week for the last six months, and finally I’m so angry it’s coming out.

Half the bitterness and cynicism among residents comes from the job itself – long hours, seeing people suffer and die and often being helpless to change that. But half of it comes from the way we’re treated by administration. When I was a student I saw this, listening to the residents talk about their grievances against the hospital. Back then I couldn’t understand; I heard the aching bitterness, but I had no idea where it came from.

Now I know. The residency administrators are one thing; they use us like pieces in a puzzle, to fill out the schedule and get the work done, but at least they know our names, and have some slight regard for us as individuals who will carry the name and the honor of the place when we graduate. The hospital administrators are a separate breed. I don’t think they even know that residents exist. Perhaps they suppose the work gets done by robots, or by magic. Certainly they have no hesitation to take actions which gut our educational experience, and change our lives permanently, for the worse, at a moment’s notice.

This is what really gets me: I work so hard for this hospital. I do more than is written in the contract, or than is my obligation as an employee. I go out of my way to try to keep patients happy with this hospital. I apologize when apologies are needed, even when it wasn’t my fault (poor communication to families; housekeeping inadequate; nurses too busy to respond to call bells). I talk to irate families even when it isn’t my patient, I’m just covering, and technically am not required to get involved at all. For all its shortcomings, I do like this hospital (perhaps even love it, because it’s my home, and because I like the people here, although not the administrators); I actually do think about making it successful, keeping it in business. And for that, we get slapped in the face by the administration. They don’t realize or care that the face of the hospital, to all of their patients, is the residents and nurses whom they abuse.

Within the next year, I think I won’t be able to care about public relations anymore. Like so many of the other residents, I’ll retreat into doing only what’s required by the book, nothing more, because the people we work for don’t even give us the benefit of the rules. (I really think they’ve broken our contract in more than one way, in a legal sense as well as moral, but I’m too exhausted to look it up, and what would I do about it anyway? Fight them? I can’t risk my place.) And when I graduate and go to work on my own, you can believe that I’ll never trust a bureaucrat farther than I can throw them. Administration is always out to screw the physicians and nurses – that’s the most important lesson I’ve learned in residency so far; and when I’m not part of the slave labor force any more, believe me I’ll remember it.

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