My flights out of town to go skiing in the Rockies got cancelled. Panic. Thank God, my parents were able to find some other flights, which in a very circuitous manner, after visiting most of the major airports west of the Mississippi, arrive at the desired location, some 24 hours later than had been hoped. So by way of calming down and wasting time this afternoon, I am going to write about one residency program that I absolutely definitely do not want to go to, and I don’t care if they read this. I wish they would, I would like to be able to express to them how horrified and disgusted I am by their ideas. (If I’ve got the technology worked out right now, I’ve also stored some posts for the next week or so, which should pop up in order. Some of you may have seen them out of order last night. I don’t get along with my computer.)

This residency program prides itself on being on the cutting edge of surgical education. Apparently they realized they couldn’t compete with the big names like Stanford and Johns Hopkins, et al, for federal research grants, so they decided to specialize in something else. No problem with that. But I have huge and tremendous objections to people who think that the more liberally they scatter words like “objectives” and “goals” and “evaluation” and “organizational mission” and “objectives” and “quality” and “feedback” and “questionnaire” and “verification” and “meeting goals” and “objectives” around, the better they’re becoming at something-or-other.

In my opinion, there’s a serious problem if an organization has to sit down and write out some meaningless bureaucratic gibberish like, “Our goals are 1) to provide the highest quality surgical education possible, 2) to foster a supportive, non-punitive, learning environment. . . etc.” You get the idea. That may sound like someone’s script, but I just made it up. If you have to spell that out, not just do it because some bureaucrats are making you, but because you honestly believe that you’re accomplishing something through it, you have already failed to realize how people’s minds work. Just having your goals written down doesn’t help. How are you going to find out whether you’re meeting them – which is always a key part of this kind of bureaucratese? Are you going to ask your residents point-blank if they feel supported and non-punitive, whatever those words mean? Are you going to waste their time by having them fill out dozens of questionnaires (which is what this program does)? I have yet to meet a questionnaire which adequately addresses the real issues. For instance, regarding first-year classes, my school was always giving out feedback forms to the students, with questions like: where the class hours adequate? was the schedule adequately made known to you? were there an appropriate number of tests? did the professor use multimedia presentations? To which one would be obliged, honestly, to answer that those things were well done. But they never ask whether the professor speaks in an audible voice, or with an understandable accent, or whether the material he presents bears any resemblance to the test, or whether he is capable of making an intelligible explanation of the material. (Two or three professors failed on most of those counts, and of course it was nearly impossible, on the feedback forms, to accurately represent how useless their lectures were – since the questions were never about the important things. Other professors were great teachers, again for reasons not mentioned on the feedback forms, so they got good reviews on the forms – but it was still meaningless.) Anyhow. I’m not going to go to a residency program which is always pushing papers for you to fill out, and arranging your life by means of papers which other people fill out on you.

But that’s not my major concern. That could be just a nuisance. That kind of form-filling gibberish is swarming over everyone these days. But no. This program is committed to a new style of teaching surgery: by computer simulation. They have a fancy simulation lab, which 1st, 2nd, 3rd, and 4th year residents are required to spend time in. Now, I have no objection to simulations per se. I had a great time with my school’s sim-man. One can practice on them without endangering patients, and they can teach a fair amount. But they are not a substitute for real patients! This program thinks they are. Their interns, although trying to be as cheerful and salesmanlike as possible, had to admit that they feel that they are pulled away from real OR time and real patients, in order to play in this lab. That’s not good. If the program thinks that a computer can totally and adequately simulate the weird and un-textbook anatomy of a real patient, they have a problem. If they think that they can adequately assess a resident’s skills based on this lab, they have a problem.

And this isn’t just a fascination with new technology. It goes beyond that. I will quote – directly quote – a very important person at the program, who said to us, of their fancy schemes for accessing lab information and so on, “This will make rounds so much easier. One hardly needs to see the patient. Now, in the ICU – ” I thought he was going to say, in the ICU it’s still important to come and check on the patient; no – “In the ICU, one doesn’t need to see the patient at all. They’re intubated and sedated. What are you going to learn from looking at them or touching them? All you’re going to do is treat their lab values. You can round from your computer at home.”

I’m gagging at this moment at that memory. One doesn’t need to look at one’s patients? One doesn’t need to touch one’s patients? So how will I ever know the meaning of abdominal distention, or pale, clammy skin, or respiratory distress, or jaundice, or abdominal masses, or fluid waves in ascites, or — or — or –, if I don’t make a habit of coming in the morning to check on them? Just because the patient is intubated and sedated, they need to be looked at carefully. Is there inflammation around the iv sites? Are there coarse breath sounds? Is there new pedal edema? Yes, with a good surgical nursing staff those things hopefully would be noticed and reported. But 1) maybe the nurses are overworked, and it would be good to have another layer of doublechecking, and 2) I need to learn to look for and see those things! It’s great that a nurse with 20 years experience can recognize them and their significance. The only way I’ll get to be reliably good at assessing a patient is by looking at them myself.

This surgeon proposed that there’s really no need to come in at 5am to round on your patients. It’s unpleasant for the patient (ok, yes, I did know that when I started doing it, although by now I don’t feel as guilty anymore), and no one benefits from it. Really? The patient doesn’t benefit by having their climbing white count assessed at 5am rather than at noon? The patient doesn’t benefit from having their inadequate urine output noticed at 6am rather than at noon? And relationally, the patient doesn’t get anything from knowing that their care team is up early and late, thinking about them? The residents don’t benefit from developing discipline and learning to work efficiently in order to get done before surgery starts? Khaagh. Quoth he, everyone’s been wasting their time for the last 100+ years. We’ve now discovered that it’s not necessary to work more than 60 hours a week. (So if I’m unfortunate enough to match here, I will be doing a lot of moonlighting, thank you very much!)

I felt like cleaning mud off my shoes when I got away from that interview. With difficulty, I managed not to tell them to their face what I think of their plans. What really bothers me is that they intend to spread this way of thinking across the country, by having ACS and the RRC enforce their funny ideas about simulation labs and work restrictions on all the other programs. So I got one useful thing out of this interview: I know that I want to go to a program as unlike this as possible, and I’ve got one or two in mind.

You don’t need to look at the patient, indeed. Fiddlesticks. If they would like to go sit in the Marianas trench and deal with a patient on the moon, they’re welcome to. I intend to treat patients who are in the same room with me, and who may not have access to a CT scanner. The most appropriate phrase that comes to mind is Ransom’s refutation of the devilish Unman, when he says to the Green Lady of Perelandra, “What men call progress, in an egg is called going bad.”

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