residency


I’ve written before about acquiring my father’s knack for memorizing all the hospital’s phone numbers (due to getting paged so many times).

He has another skill which it might have been healthier not to acquire.

When driving in the car, in addition to his penchant for passing with really minimal leeway, he also likes to dial his cell phone . . . while turning corners, and sometimes while passing. My father’s passengers quickly adopt a fatalistic mindset. He’s had remarkably few accidents, for all this.

Now I also am an expert at palming my beeper one-handed, reading it, and dialing my cell phone while driving. I really ought to stop. . . but the reflex to answer the page quickly and make sure it’s not something serious is simply too strong to overcome.

(My interns are paying me back in full for some heartburn I know I must have given my seniors last year. Episodes of “why, why did they have to do/not do that?” And I know, even if I can’t remember precisely the occasion, that I did things equally foolish or foolhardy myself. The really humbling part is, I foresee that next year I’ll look at the second years, and say the same thing. . . which I means I’m continuing to do lots of stupid things now, even when no one says so. . . )

It seems like my dry spell is at an end, and I’m starting to have my hands full of transplants.

Which leads to another topic: The only thing that surgery residents love more than gossiping about each other is critiquing the attendings. I’m not really into that. (Or maybe refighting the dramatic cases; that might be the top pastime.)

I learned to do calculus and chemistry and anatomy and biochem by not questioning the teacher’s assumptions. I know that doesn’t sound scientific, but I used to ask “why?” or “how do we know that?” so much that I could never get to the main point of the lesson. So I stopped. I tried to jump into the subject: assume that all the axioms the teacher grants are correct, let’s see how it works.

Same thing with surgery attendings. I could go on and on about the trauma attendings, because I didn’t operate with them. But now that I’m operating with attendings on a semi-regular basis, I try not to analyze their personalities too much. They are far better surgeons than I am, and they’re trying to teach me something. Complaining about not fair this or not fair that is not going to help with the goal. If I concentrate on doing what they want me to be doing with my hands, eventually I’ll get beyond the words they’re using. I’m frustrated with myself when I don’t do it right; I can only imagine how frustrating it must be for someone who could absolutely do it right the first time himself to keep his hands off and let me try again. So I don’t care how harsh or edgy things get in the OR, as long as the attending is teaching.

Which further establishes my reputation among the rest of the residents as naive, because no matter which attending they’re discussing, my answer is, “I didn’t think he was so bad. We get along ok.”

Surgery residency is nearly twice as long as that of any other specialty: Five years, compared to three for medicine, pediatrics, and ER. (Neurosurgery is seven, radiology and anesthesiology five total.) This leads to some interesting relationships between junior and senior residents, and between specialties.

For example, as a second-year resident, I am as far behind my fifth-year chief as a medical student is to a senior medicine resident. They’re polite enough to treat the juniors as colleagues, though not equals, but the knowledge gap between us is as wide as between me and a second-year medical student. The more I consider this gap, the more amazed I am at their tolerance for my shortcomings.

With medicine and ER residents, it works the other way. The doctors who were medicine and ER interns with me are now considered “seniors” in their program, and can have a team of two or three interns and a couple of medical students to run on their own. Next year, while I’m only halfway through, they’ll be finishing, choosing fellowships or going through job offers.

We have a couple new ER and medicine attendings this year, who graduated from residency here in June. This means that when they were interns, our surgery chiefs were already second year residents. Understandably, though not always defensibly, this leads to a somewhat cavalier approach by the surgery chiefs to the junior attendings. The ones who are from this program are usually old friends, and things go smoothly. The young attendings from other programs, though, have their work cut out to prove themselves.

The neurosurgery senior residents, for another side of the coin, get general respect on all hands. The best ones, both trauma and ER will take their word for it, without insisting on calling the attending before acting.

It’s amazing how much the responsibility for presenting at M&M [morbidity and mortality conference] concentrates the mind. Now I’m not just worried about the patient as a person, and about my role in events; now I’m also trying to avoid having to present a complication/mortality, and then trying to figure out how on earth I’m going to explain this one. So far I can’t come up with anything even halfway presentable; it’s going to be a miserable morning when my turn comes around. No wonder the seniors look so disturbed when complications develop.

Still nothing medical to write about. I spend my days doing social work and case management. I’ve gotten really good at sitting in patients’ rooms, taking the time to actually sit in a chair (which certainly does lend a more relaxed air to the conversation), and listening to all kinds of details about their lives which are not medically related. This makes me feel like a good person, and hopefully is giving me practice at establishing rapport with people. I haven’t done some of this stuff since medical school.

It makes me feel like a bad surgeon. Why do I not have anything else to do with my time? A surgery resident is doing something wrong if they are not busy. I keep going through my list looking for something to do, and except for the occasional consult (who now gets the complete history and physical, including review of systems, social, and spiritual history – some of which I have been in the habit of omitting when rushed), I have very little to do.

On the other hand, since it seems like every other surgery resident in the hospital loves Obama, there is no shortage of conversations opening with, “You actually like Palin? She’s an idiot. She’s never been outside this country. She likes to ban books. She likes guns. She believes in abstinence-only sex education. She is opposed to abortion at all times. Isn’t that horrible?” And I grin at them and say, “No, that sounds just perfect to me – except for the idiot part and the banning books part, which the media made up.” And we’re off. I think my political and religious convictions have a perverse fascination for my more liberal colleagues, and they can’t stop coming back to check if I still believe this stuff.

(And yes, I give up, all the rabid Obama supporters hating on Palin have convinced me: I’m voting Republican this year. Once I find the absentee ballot registry form. When does another chance like this show up: A Vietnam vet (from the Hanoi Hotel, no less; those guys are some of my biggest heroes), and a gun-toting pro-life soccer mom with five kids. Compared to an America-hating socialist with no clue about policy – and the only policy ideas he does have consist of taking more of my money to give to the unemployed, and nationalizing my job; after he surrenders to the terrorists, and invites Ahmadinejad to the White House.)

Last year I got used to the idea that I was responsible for what the medical students did. I was supervising, so it was always my problem. If I hadn’t noticed what they did, that was my problem too.

“My problem” is getting bigger this year. Now I’m responsible for the interns too. If we’re on the phone, and I don’t ask them for some information, the fact that neither of us knows it is my problem because I should have asked, not theirs because they didn’t check in the first place. If I tell them to do something, and it doesn’t get done, it’s my problem, because I should have checked back on them. If they misorder something, it’s my problem, because I should look at their orders.

Human nature likes to blame other people. It’s really hard not to blame the interns; they’re so handy for it. But it’s not fair to them; they’ve only been doctors for three months. I’m the one who knows about all these details, and I’m the one who should be double-checking all of it. If anything gets missed or goes wrong, it’s my fault. Always.

I told myself that for three hours this morning. Now I believe it, and hence can feel appropriately guilty for the weekend’s errors. Every single mistake I make could change someone’s life. It’s starting to get to me. I don’t even need to bring the lawyers into the picture. After thinking about this for a couple more days or weeks, I’ll be so paranoid about hurting someone or missing something, lawsuits won’t even be part of my reasoning. That should make me a better doctor, but it’s no fun thinking about it.

(And nothing particularly bad happened this weekend; just details. I need to have a higher standard for myself than the attending does. I need to be more upset about what I miss than any attending or chief resident will be. Even when the attending agreed with my decision, if it didn’t turn out right, I can’t blame him; I have to blame myself. I should have known better.)

(And then some people call me ‘intense,’ with a connotation that means I should back off, let things go. I can’t. I make enough mistakes, without trying to let go too.)

This whole home call concept takes some getting used to.  One of the major lessons I learned last year was how to be on the spot: if a patient’s sick, you don’t wait to get called, you keep walking by. If you do get called, you give some preliminary orders (oxygen, fluid, ekg) on the phone, and then get over there so you can see for yourself. And you don’t leave in five minutes; if there’s nothing else urgent, you stay around to see how things go; work on the computer, make some calls, but stay handy for a little bit. And of course the cardinal lesson in medicine: trust no one, neither those junior to you nor those senior. Everyone lies; verify it for yourself.

Now I have to reverse that. I’m getting a little better at jumping wide awake in the middle of the night, so the intern calling doesn’t have to repeat himself ten times. But you have to have all the answers – maneuvers, tests, medications and doses – completely memorized; that’s the only way they’ll come out coherently at (ahem) 3am. (How about my attending for president? He’s really good with the 3am phone calls. And I’m sure he’d come up with a more practical healthcare policy than the politicians have.)

The worst part is not being there. I have to trust the intern (fortunately the ones I’m working with are quite competent) to assess the situation correctly; without seeing things for myself, I have to figure out the key information, and think of things to ask about that the intern may not have considered. Then we come up with a plan, he hangs up to go do it – and I’m supposed to go back to sleep, instead of lying there worrying about whether either of us missed something, whether the patient is going to get worse before our treatments take effect, whether I misjudged the significance of a piece of information, whether I told him the wrong dosage on a medication. If I were in the hospital, I’d keep looking over the labs, ekg, chest xray, till I felt more confident. But I can’t keep calling the intern to go over things again.

(A bonus last week: in desperation, I dredged up a treatment I’d read about as of historical value only, but it was the only thing available or applicable for this patient. Not fun to play that card from long distance, but next morning the patient was nearly all better. I don’t know whether that old-fashioned trick did it, or whether he wasn’t as sick as we thought. Remind me not to read the historical section of the textbooks, it leads to unsettling decisions.)

Going back to sleep is also tricky. After getting called, I spend the next couple hours unable to sort out whether the phone ringing and the patient deteriorating are happening in my dreams or in real life, and I can’t shake the feeling that it’s really high time to get up and go to work, no matter what the clock says. I used to react the same way to pages at night on call, so hopefully this will get better with time.

I got to the evening service yesterday, and spent some time chatting with other young people afterwards. Or, to be more precise, listening to them chatting, since I only have one topic of conversation these days, and I try not to impose it on people outside the hospital.

They were discussing how long an 8-hr business day is compared to a day of college classes, and how much longer a 10-hr day is, when they get really busy and the boss makes them work late for a day or two.

I was laughing to myself. We residents work six hours on a weekend day, and consider that we have the day off. We work 13-14 hours, and are happy to get home at a reasonable time. 15 is annoying, but it comes with the territory. I really had not comprehended what life is like for people who pick a more normal career. 8 hours a day, with an hour for lunch? (An hour for lunch? The program director would fire me on the spot if he found me taking more than 20 minutes for lunch, and that’s assuming I had no work at all to do anyway. Ten minutes, or zero, is more like it.) What do they do with all that free time?

As the Count tells Inigo, “You have an over-developed sense of vengeance.” I think I and my colleagues have a severely over-developed sense of – what? responsibility? delayed gratification?

The chief was complaining to me today that there’s not enough work to do: either I do it all and he’s bored, or we share and we’re both bored. I don’t think I was born this way, but somewhere in the last year they taught me that sitting still for more than three minutes is unnatural, likely a sign of criminal negligence of something, boring, and just plain shouldn’t happen. I’ve been indoctrinated, so thoroughly that I regard this as a good thing. There’s so much more time in the day if you only sleep for five or six hours, and work hard all the rest of them.

But it is fun to talk to people outside the hospital, and remember that there’s more to life than illness.

I started reading Greenfield’s section on transplant. It starts with a 30 page chapter on transplant immunology.

It’s taking me about five minutes to read each page.

This is going to take a long time.

(There are the occasional hilarious comments, such as “Presumably, these multiple V region families arose by an evolutionary process of gene duplication followed by mutation of individual family members. . . the combinatorial possibilities are extremely large, showing why the immune system is able to generate antibodies for virtually all known antigenic determinants.” So they write this long chapter to explain how little they understand these cellular processes, but how miraculously well they turn out – the human immune system works against virtually every virus and bacteria – and conclude that it’s all a matter of random chance. No possibility that an intelligent Designer arranged everything that way on purpose.)

I’m still only two pages in.

Hopefully this will go faster when I get to the clinically relevant sections. . . fifty pages away.

What can I say? Nothing much happened today. The sick people in the unit over the last week either died, or got well enough to leave. We’re left with a population which is overall more likely to get out and do well than we’ve had for the rest of the month.

The month is almost finished, unattainable as that has seemed for so long. The next few months seem in prospect to be a little better. Certainly more opportunity for operating. The attendings I’ll be with have their own quirks, but not as wild as the trauma attendings, and more to my taste. (Surgeons who leap at every excuse to get in the OR are just more natural than surgeons who take every excuse to stay away from it.)

I’ve been getting back in touch with some old med school friends lately. We haven’t talked in a while, but our lives are still so similar – the shared crucible of medical school, and now a language and a society open to very few – that we fell back in as though we’d never said goodbye. All we have to do is start talking about this unbearable attending, that crazy patient, the hospital cafeteria, the unbelievable paperwork – and we instantly have a thousand common topics of conversation. Fun, comforting, but also a little eerie. This is such a tiny guild that I’ve joined.

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