residency


Thanks to all for your good wishes. Saturday was not too bad. We all survived. I feel like I didn’t do any worse than last year; and after those weeks at the children’s hospital threw off my study schedule, that was really all I was hoping for. I figure I’ll give it a few weeks, and then see if I can get motivated to study for next year. Third year residents and up take a more clinically-focused exam, which would seem easier since it relates to things we do, instead of facts about biochemistry and labs, but apparently they don’t think so.

This weekend was a little bit crazy; maybe I’ll have time to tell war stories later in the week.

Sorry folks, not much to report. All of the residents are carrying the little ABSITE review book around constantly, and even managing a few minutes to look at the inside rather than the cover every now and then. We’re also spending some time analyzing our choices over the past year (whether to dedicate more time to patient care, or perhaps to worrying about patient care, or to studying for the ABSITE), and wondering whether those choices will in the end have any impact on our scores.

It’s hard to express how stressful this test is. For one thing, program directors and fellowship directors make it clear that the scores matter tremendously. (Partly because they’re supposed to predict how well you will do on the boards, and partly because the scores are a matter of prestige or chagrin to the programs.)

Surgery residents tend to be people who did fairly well with tests in medical school; this is a somewhat competitive specialty. But this is a test that we’re all scared of; and it’s a test that half of us are going to do below average on. I’ve only taken one of it so far, and it was worse than any test in college, the MCAT, any test in medical school (including the end-of-year comprehensive final), or any of the USMLEs.

So I’m not looking forward to Saturday.

This is a problem. I’m studying for the ABSITE, trying to make up for time lost in December, which means reading through the review book every couple of days.

And every single chapter brings up vivid flashbacks of all my worst patients. I’ve only been doing this for a year and a half, and I’ve got quite a collection: patients whose death I feel (irrationally) responsible for; patients whose death I blame myself for even though I couldn’t have done anything different; disfigured faces and limbs; lives ruined by traumatic injuries; abused children; families crying in the ICU. Patients dying of a PE in front of my eyes; burn victims; pancreatic transections; vasculopaths; spinal cord injuries.

I don’t know how Bongi lives with his collection. For mine, for now, stop studying for the ABSITE (one week to go); but when it gets bigger, that won’t be enough.

Have I mentioned how much I’m looking forward to getting back to my own hospital?

And yet, with the anticipation, I’m starting to think again about the responsibilities I will resume. After all, my chief complaint (as it were) at this hospital has been the lack of responsibility – being treated again as an intern when, in my own mind, I’m ready for more than that.

Perhaps a little more humility would be in order. How many times here have I concluded something – the abscess needs or doesn’t need drainage; the patient doesn’t have a surgical abdomen – and turned out to be wrong (the abscess needed the opposite of what I thought; the child had perforated appendicitis; the patient needed more or less iv fluid than I had provided). Sometimes I found out I was wrong simply because a senior person came and looked and recognized something (specific details, or even just a gestalt) that I had missed. Other times the senior person expressed puzzlement where I had been too certain, and obtained further tests, or admitted the patient for observation, and thus found the correct diagnosis.

The only major category of being wrong that I haven’t explored extensively here has been whether a person needs intensive care, and how aggressive to be with a patient in intensive care; and the only reason I haven’t hit that one is because I was insulated from the critically ill children. Children heal so well, and have such resilience, that if they’re stable enough to be sent to the floor in the first place, between their reserves, and the nursing care, which is a little more flexible than in an adult hospital, they almost always pull through without needing to be transferred to the ICU.

Sure, I was trying to draw the right conclusions with very little experience: a total of only 6 weeks exclusively with surgical pediatric patients (whom I never encountered in medical school). I do have more time than that with adults – but 18months is so little compared to the chiefs, let alone to the attendings who’ve been in independent practice for a decade or two. Suddenly I’m a lot less confident about going back to junior call and night float.

Surgery residents have a refrain which we use to comfort ourselves on many occasions: There’s a reason it’s a five year program.

Ok, I’m back online. This rotation is nearly over, which is a good thing, because honestly I’m more depressed, miserable, and angry than I’ve been in residency so far (except maybe on trauma; and that was made more tolerable by having friends around, residents and nurses I knew and trusted). Now I’m trying to figure out what to say when I get back “home,” because several of the residents were teasing me that I’m so optimistic, but the peds rotation would destroy me. They were mostly right; I’m just hoping it’s not permanent; and I don’t want to admit it to them. There were three rotations of second year that I knew would be absolutely horrible; one down (almost), two to go.

Anyway, I’ve been remembering the things that made me go into surgery in the first place (a decision that I’m not up to defending right now, just hoping I’ll feel better about it once I get away from this place). One particular story I remember because at this hospital we had a child develop a wound dehiscence after an abdominal surgery. Supposed to be pretty rare in kids, and the M&M on the subject was protracted, to say the least. A dehiscence is when the fascia (not just the skin) comes upon. There are two main reasons: you didn’t sew it properly to start with, or the patient’s tissue, for various reasons (debilitation, radiation, steroids, infection, to name a few), is so weak that it simply doesn’t hold even the best suturing.

I was on call on ob/gyn, and in between the deliveries and an ectopic pregnancy case, the team got called about a patient in the ER. She’d had an abdominal hysterectomy about a week previously, and had gone home shortly afterwards, apparently healing well. She dehisced at home, fortunately only to a minor degree, and came in to the hospital. As a medical student, of course I was fascinated, and tagged along the whole way; but I was also frustrated by the OBs’ response. The intern went and looked, and paged the senior; he went and looked, and called the attending. She didn’t believe him, and went to look too. At that point they agreed that they supposed it was a dehiscence, and called the surgeons to ask for advice.

I’ll never forget the surgery intern (who was after all tall, handsome, clever, and only not cocky because he was smart enough to warrant his own confidence). He strolled in, looked at the wound briefly, and remarked, “Yes, it is dehisced, sure enough. You’re taking her to the OR, right? You don’t need us for anything, do you?” The OB attending agreed that this was her plan, but insisted that the intern bring his senior, and even the surgery attending, in to look at things in the OR. Her explanation also sticks in my mind: “I never saw anything like this, even in residency. I’m not sure what to do with it. And maybe we ought to run the bowel [surgical speak for starting at one end of the small intestine and looking carefully till you get to the other end, to make sure there are no injuries or other anormalities], and I forget how to do that.” So the attending surgeon, being dragged out of a sound sleep (they were required to take in-house call, but counted on the seniors to shield them from any disturbance except a trauma requiring a laparotomy), came in to the OR and explained to the OBs that when the fascia comes apart – you should sew it together again. The end. And if you want to run the bowel – you start . . . at one end. . . and proceed . . . to the other end.

I’m not trying to make fun of the OBs, because they were overall good at what they did (that attending was one of the weakest), and I understand that dehiscences would be much rarer in a population of relatively healthy women (overall younger than the general surgery population) having elective hysterectomies. But to a medical student, it was noteworthy. Even then, several months before I did my surgery rotation, and got swept off my feet, I started to think that I’d rather be sure of the basics.

I still hate this rotation. But I expect I would have found at least one occasion to be equally miserable if I were doing ob/gyn, as I originally planned.

I ought to tell another story, where the joke is on us. We had a pregnant woman staying with her sick child at the hospital. One evening, the nurses called the fellow in a bit of excitement: the mother was having contractions, with increasing frequency. He ran upstairs, and became quite excited himself, and eventually with great commotion hustled the lady off to an adult hospital with an OB ward. Myself, I regarded it as less of a problem. First, unlike the fellow, I’d known she was pregnant prior to that night (just by looking; I guess he didn’t notice). Secondly, I considered that with her contractions still 8-10 minutes apart, she was unlikely to deliver within half an hour, which was plenty of time to arrange transfer (second pregnancy; maybe I was being too pessimistic). Thirdly, I privately thought it would tremendous if we did have to assist with the delivery after all. Of course, that was the thought that was really upsetting the fellow.

Tomorrow I’m starting a long rotation at a children’s hospital. It’s a long drive away, and a completely different culture. Not to mention a new hospital to get lost in, a new computer system to learn – and children to take care of, just to make everything extra high stakes. I can’t forgive myself when an adult does poorly; what am I going to do about children with bad outcomes? I haven’t been this scared of a new rotation since two Julys ago.

The legends are that the children get good care, but the residents are miserable. Lots of people have given me advice for the next two months, and it adds up to, You need to start being harsh, because no one will watch out for you. You have to be prepared to push others out of the way to accomplish your goals. Don’t take — from anyone, stand up for yourself, otherwise they’ll walk all over you.

Reportedly the work hours and regulations are a dead letter at this hospital, primarily at the expense of the residents in the position I’ll be filling. So I’ll be back to the old dilemma, do I break the rules and push myself over the limits for several weeks, so that the patients get taken care of, or at some point do I develop some ethical boundaries, and actually report what really happens? I fantasize about putting my foot down and sticking to the rules, but I know I’ll end up doing what I’ve always chosen at this point: take care of the patients, and ignore the rules.

For the rest, I think I’ll stick with my old pattern here too: maybe the other residents who hated this place started with a bad attitude. Maybe there are some new people in authority now. Either way, there are things I need to learn here. (Calculating micronutrients and ccs of iv fluids for neonates a couple of times every day, what’s not to be thrilled about?)

And the old residents’ standby: They can hurt you, but they can’t stop the clock.

The real problem with the second year of residency is that after spending a year figuring what people expected of me, and starting to be good at meeting those expectations, suddenly the rules have changed, and I’m back to square one in my real-life sudoku game.

Always do what the attending says to do; I’ve got that one.

Except for when the senior catches me and says, “The attending said to do what? Don’t you know that that’s completely contraindicated in the immediate post-op period? Why did he say that?”
Me, under my breath: “I didn’t really interrogate the attending about what he was thinking.” Aloud: “I think perhaps he felt that the patient’s response to these medications meant that. . .”
Senior, continuing: “Why would you think that? That’s completely illogical. Have you read anything about this? Did you mention these three labs to him, and explain that all the recent evidence shows that these results strongly suggest an opposite course of action?”
Me: “I told him the labs, but I didn’t say that they meant he should do the opposite. Would you like me to call him and tell him? sotto voce Perhaps you would like to tell him yourself?”

On the other hand, when I feel so skeptical about the attending’s plans that I perhaps don’t quite push them through, I get in trouble about that too.

Never argue with the chief; I know that rule.

Except when the attending, rounding alone with me, asks, “What were you all planning to do with this patient?”
Me: “Well, sir, based on these lab results, we thought we would give X medication and see how he responds.”
Attending: “What?! That’s completely the opposite of what needs to be done. Have you been paying attention to anything for the last few weeks? What gave you that idea?”
Me: “Well, sir, the chief thought that since the CT scan didn’t look so bad, we could afford to. . .”
Attending: “Forget what the chief said. You tell me: What are you thinking here?”

This kind of merry-go-round happens most often on the subject of pressors. There are only five in common use in surgical ICUs (a couple others that the cardiac surgeons rely on, but I haven’t used them yet), but the debate about which one to use when rages endlessly. Every attending and chief has their pet pressor, and hates another one fiercely. Some of them have good reasons, others have only anecdotal evidence. The chances of the attending and chief that I answer to agreeing on which pressor to use is probably less than 1 in 5. The chance of my choice of pressor being acceptable to either of them is even less. So my real reason to try to keep my patients’ pressures up is so I don’t have to recite the sympathetic neurotransmitters and their functions to both the attending and chief a couple times a day.

It’s like tiptoeing across a lake of very thin ice, every day. Every once in a while I make it across, and the attending nods and says, “Very good, Alice, take care of it.”

Ok, I think the unannounced hiatus is over. No administration characters came after me, so I’ll be around until the next time I can’t even stand to talk to people.

I was going to say even the politics hadn’t really gotten to me that much, but today I realized differently: being a junior is a bad place to be as far as politics is concerned. For one thing, we get a lot of attention: the attendings and chiefs interact with us more, and depend on us more, than they do the interns. So whatever we do right, or more likely, wrong, is sure to be noticed and commented on by multiple people – possibly in front of us, certainly behind our backs. This knowledge can induce near-paralysis in some juniors; and the resulting mockery only makes it harder to function. I’m trying to avoid that pitfall; but being too cocksure will get you in trouble, too.

In addition, since we’re sort of in the middle of the hierarchy (ok, only one step above the bottom), we hear from everyone: the chiefs find us safe confidantes for their views on the attendings, the other chiefs, the interns, and our fellow juniors (the hardest to handle). The interns, once they stop being scared, tell us what bothers them the most about the chiefs and attendings. And of course the juniors as a group are constantly trading between each other the latest gossip or tips about each other, the chiefs, and the attendings. (As in, “X chief will yell at you if you so much as give a bolus without letting him know; so I call him all night long.” Or, “Z chief is unlikely to answer pages or phone calls anytime after 7pm, so don’t waste effort on him unless you need him in the OR.”)

But it’s the up and down gossip that drives me crazy: in the last two months, I think every single chief has said something bad to me about every other chief, and every other junior. And I sit and listen to them. The worst part is, I know when I’m not there they have to be saying the same things about me to someone else – and which one of the people whom I think to be my friend is listening, and agreeing?

The last week I was planning what to write when I got back on here. I thought of reworking the old cliche, that we’re not really like those medical dramas on TV. Then I thought, with all the personalities going on here, and all the sick patients we take care of, and all the nurses and doctors who really do get together, the only differences are 1) the dramas play out more slowly, over days and weeks, and things rarely climax in a fight in the front lobby 2) the people who get together do it outside the hospital. Other than that, there are enough subplots going on to keep two or three soap operas running.

We had journal club earlier this week, the first one of this academic year that I haven’t managed to find an excuse to avoid. . . Ahem. Actually, I go to journal clubs and conferences religiously – in the truest sense of the word, since there is an exponentially higher chance of my getting to any given conference than to church that Sunday. (Come to think of it, M&M has an eerily religious quality to it: everyone always comes, and confesses guilt. . . absolution not to be had reliably, though.)

I was the kind of student who could never skip class even when I knew for sure that the professor mumbled in a foreign accent, had never explained a concept meaningfully in his career, and would spend the entire class going over the first two pages of notes (out of 50). So now, even though I know that I will inevitably fall asleep halfway through the lecture (it’s a real point of suspense, whether I’ll be able to last past 20 minutes; I consider staying awake to the half-hour mark a real victory), I go to every conference, unless I am unavoidably detained in the OR. The surgery residents I knew in medical school were very nice folks, but that was one thing they taught me quite sternly: never skip lecture unless you have an ironclad excuse, and only a code qualifies for that.

So, as I say, having made it to my first journal club this year, I discovered that it’s much better this time round: The interns are usually called upon to present, by way of making sure that they get educated, and learn to be responsible enough to read the articles. Then the chiefs are invited to comment, in the confidence that they will have something worthwhile to say. The juniors are, for a rarity, left to themselves. It was quite a novel sensation, to find myself senior to a whole crowd of interns, and consequently with no need to worry about how I was going to explain some complicated piece of statistical reasoning in three minutes flat, to an attending who knows it all backwards and forwards anyway.

(Don’t worry, the juniors make up for it at all other conferences, where any time you see a CT scan coming up, you know you’re going to be asked to read it and defend a management plan based on your reading. Depending on how genial the attending is feeling, he may correct your misreading before asking for your plan.)

Sorry, nothing much to report here. I’m functioning as the social worker again: sort out nursing homes, home care, jump through the different insurance companies’ hoops about how one qualifies to be allowed to take this or that medication. The nurses and case managers and I just shrug our shoulders and give up; it really doesn’t matter any more what the doctor says. We’re forced to prescribe and practice with our hands tied by bureaucrats with no medical training, but we’re the ones who will get sued if anything goes wrong.

It won’t even necessarily take Obama getting elected and passing his socialized healthcare plan through a completely Democrat Congress to get me out of medicine; it’s not like I need a lot more excuses; but that would sure make a good one. These high school kids ask my advice about how to get into medical school; whereas what I ought to be giving them is advice how to stay out of this debacle.

Hold on for a couple days, I’ll write you something more cheerful after I get another case. The OR is still magic – the best anti-depressant.

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