The last couple weekdays I spent feeling useless again. I should be used to that by now, but after the neurology rotation, where I was expected to a complete history and physical for almost every patient admitted to the service, and write a full note that the attendings would rely on for their dictation, it was pretty frustrating to be back down to having the residents surprised when I managed to write two progress notes in the morning, after the intern already saw the patient and wrote all the orders for the day. I couldn’t even pretend to have thought, myself, of what needed to be done.

Then we were on call Friday. That wasn’t much better, because after I saw a patient in the ER, the intern saw him too, and then the resident, and it was plain that they were astonished at me going to the trouble of writing a useless H&P on the patient, because they were just going to duplicate it all anyway. That’s what I dislike about non-university hospitals; they just barely manage to handle residents, but medical students are beyond their scope. We’re too much of a malpractice risk, if they let us actually do or write anything.

Saturday was a great deal better. The night float got swamped with patients, so we had a lot of work on our hands. (6 out of 7 nights at this hospital, the medicine call team gets to go home for the night, and comes back in the morning to see their patients, write orders, and discharge people, while another team takes call for that day.) I saw a third of the list by myself, and figured out most of the things that needed to be done for them. I did the paperwork for one whole discharge, and ran errands for some others. It finally seemed like the resident and intern accepted me as of some slight value to the team. It’s really pathetic that I care so much for them to want me around, but there it is. I do feel like I have all the skills I need to be an intern, and I can’t wait to move to the next level, having some real responsibility – and authority.

One of the patients they sent me to see was a long-term ICU patient, belonging to our sister team, for whom we were cross-covering. The intern thought she was just in her usual status quo – trached, barely conscious, stuck in the ICU because she has no insurance and we’re having no luck getting a nursing home to take her without money – and I could write a quick routine note. It wasn’t that simple for me. I spent more than half an hour examining her and reading through her chart. We’re supplying basically all of her body functions. The ventilator has to be kept in balance with her oxygen and CO2, her IV fluids need to be matched with her electrolyte deficiencies, and her nutrition needs to be maintained through a G-tube. This day, she had spiked a mysterious temperature, and efforts to track down the cause were so far unsuccessful.

As I walked away, having spent twice as long as I’d intended sorting through her chart and figuring out the three things that absolutely had to be done for her over the weekend, I was wondering: the intern was going to come and look at it too, much more efficiently than me; I’m unable to actually write any of the orders she needed; she’s not my patient, I’m not going to see her again till next weekend; why did I have to be so thorough? I’ve been discovering that, lazy and irresponsible as I can be away from the hospital (just ask my mother), I have an overpowering sense of responsibility and thoroughness in the hospital. Why do I care whether I caught every last detail about this patient? She’s been here for a month, nothing is going to change because of what I did or didn’t do in one morning.

But that’s what it means to be a professional. I have to notice every single detail about every patient I’m ever assigned. Every abnormality on the exam, every clue in their history, every change in the lab results. I have to notice it all, and think about it, and do something about it. I can’t ever miss anything.

I think the bottom line is probably pride. It’s not like I care, personally, about every patient. Especially trached, unconscious ones in the ICU. I ought to care, of course, but it’s hard to be emotionally interested in a person you’ve never met before, who can’t talk to you. The real motivation is pride. I don’t want the intern to think that I missed something I should have been able to see. I don’t want the other medical student, when she sees her patient again on Monday, to think less of me because I failed to write down some routine fact. I don’t want the attending to look down on me because here I am almost graduated, and I didn’t notice the low potassium. I don’t ever want any of my colleagues to look down at me because I missed something – anything. So I obsess about every detail. We all do. Maybe some of my colleagues have a more innocent, more innate sense of responsibility; but I think it’s the same for most of us. You take a bunch of intelligent people who’ve never failed yet at anything they tried hard for, and make their value within that closed community revolve around doing every detail right, and we’ll be obsessively responsible, sure enough.

Pride is a mortal sin. Letting anything happen to my patients would be, if possible, more mortal. I’m stuck.

Jesus, please don’t let me kill anybody in July; or any time after that; please.

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