residency


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.

Last year, I mostly viewed the scutwork the seniors demanded as an exercise of their power, nothing else. I did it, of course, but I couldn’t really see why they didn’t just do it themselves. Why the interns and juniors had to write all of the notes in the morning, write most of the post-op orders for the seniors’ own cases, write the post-op notes on the patients the seniors had just been operating on – it seemed rather pointless; or rather, too pointed: they got the fun of operating, and I got all the busywork.

Now, with a little more experience in the OR, I can see more reason to it (or perhaps, now only a year away from being a senior myself, I’m starting to rationalize giving a lot of the work to the intern). For one thing, the work hour limits hurt the chiefs a lot: simply being present for all their cases takes pretty much all the available time. Being in the hospital a few hours early every day to round would put them way over. Nevertheless, the good ones seem to know more about their patients than I do, for all they spend less time on it. The most fearsome chief I had this year seemed to be able to put me in the wrong every time we sat down to run through the list: despite having been in the OR all day, and me not, there was always some test result, some lab value, some change in the patient’s condition, which he knew about and I didn’t. He wasn’t trying to do anything in particular to me, either; he was just taking care of his service.

For the rest, writing orders and helping to get cases started, I’ve realized that “simply” doing three or four cases in the day can be quite tiring, and it’s only kindness to the seniors to use my energy instead of theirs to move in and out of the OR. (My hospital has an inefficient OR setup; neither the OR staff nor the anesthesia staff has any motivation to move quickly. It doesn’t decrease their workload or their hours, or improve their pay, to turn things around quickly. This leaves the surgery residents as the only people who really care whether it takes twenty minutes or fifty minutes to get the next case started, so the day will move more quickly if there’s one of us turning up to make sure that the patient has in fact arrived in pre-op holding, that their pacemaker is being turned off appropriately, that the CRNA is aware when the scrub tech is ready for them to come back to the room (instead of both parties sitting waiting for the other to call, as I frequently find them doing), that there are enough hands available for transport and to finish setting-up details in the room.)

So, I think my approach has changed since the beginning of internship: instead of figuring out what the chief was going to check to see if I’d done, now I look for any work at all that needs to be done, and take care of it, regardless of exactly whose responsibility it technically is. I wish I knew how to teach this work ethic to the new interns; but luckily, I think it’s primarily transferred by example, so I just need to keep doing my job properly.

Early in my intern year, I started learning one of the key principles in any residency program, which is that if anything goes wrong it’s my fault. The applications range from the mundane to the serious: wrong date on the notes because I’ve lost track of what day of the week it is, let alone what day of the month – my fault. Didn’t preround on a patient because I didn’t notice their name scribbled on the bottom of my list of consults from the day before – my fault. Didn’t reorder the statin after the patient started eating – my fault. Didn’t get in to the OR in time to help write postop orders for the chief’s big case – my fault. Didn’t make important vent setting changes till late in the day – my fault (I think I’m making that one up; I can’t say I’m 100% sure it never happened).

Today it was definitely noticeable, and the event was somewhere between annoying and infuriating for various members of the team (not least myself). One could argue that I wasn’t the only one at fault. But so to argue would be a waste of time and energy. As I’ve said, whatever goes wrong, is my fault. The chief I have this month is very helpful in this respect. Some seniors allow a little doubt to arise about whether it was entirely my fault. This chief leaves it in no question: undoubtedly, at all times, under all circumstances, my fault. This certainty saves a good deal of time and mental effort on my part. . .

(I’m not even sure myself if this is written with tongue in cheek or not; as you like it.)

By the end of the day, the beginning was so far away that I spent half an hour, while finishing orders and signing out, trying to remember whether or not I had eaten anything for lunch. It seemed as though a couple weeks had passed since then, along with an appropriate amount of excitement and emergency.

On the intern’s days off this month I get to take care of the floor, since dealing with the myriad annoying details of a busy floor is completely beyond the patience of a chief resident, especially by this time of year (there’s tylenol tablets ordered and the patient would like liquid; patient in ten really needs to be reassured, by the doctor, for the third time today, that the bump on her stomach is normal after surgery; patient in eleven hasn’t voided today – or in fact since yesterday evening; clear liquid diet is ordered, may the patient have coffee (x 3 or 4); please order physical therapy, or the patient will not want/will not be assisted to walk today; please reorder physical therapy, they lost the last order in the computer; please order occupational therapy separately; the patient being discharged doesn’t like percocet, they would like vicodin instead (great, and I already wrote all over the controlled substances script, and have to go get another one from the sub-basement safe deposit, or wherever they keep them these days); the patient has a fever of 100.2 (no, that isn’t a fever, call me when it gets to 100.4, or better yet, not until it gets to 101+); the pharmacy says the dilaudid order for the patient who had surgery yesterday has run out, he’s having pain, and I can’t give him anything unless you reorder it right now) – and I can’t blame him.

Plus some of my favorite floor consults (the patient was going to see your attending next month, but since we’ve admitted him with another acute problem, please fix this one right now), and my favorite ER consults (where my attending knows the patient is coming, and I get labs and CT ordered and my whole admission and orders written up before the ER intern fills out their T sheet; that makes you popular with the ER attendings, and the intern too, because they don’t have to call you).

But for all the sarcasm, this stuff is amazingly easy to deal with. Last year I would have spent at least a few minutes thinking about all kinds of questions, or about the slightly more real dilemmas (how to treat pain when the patient throws up with everything you give them; what to do with a blood pressure of 200/110; is a fever on the night of postop day 2 worth working up, or not); but now I’ve seen enough that this is all reflexive. I’ve finished most of the scut work by 8 or 8:30 am, and have the rest of the day free for the OR, for catching up on the ICU patients, or theoretically for studying. It’s nice to know that I’ve learned something in the last two years, if only how to deal with minor questions fast enough that neither I nor the nurse have time to get annoyed about them.

Next week the schedule picks up, and I should get some more cases. I think the chief thought I had finally taken leave of my senses (which he’s never regarded as very formidable anyway) with glee, when we discussed that part of the schedule.

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