A friend at church gave me a copy of Atul Gawande’s new book, Better: A Surgeon’s Notes on Performance.
I don’t enjoy reading Gawande’s writing, I think for two reasons: he writes so well it makes me depressed about my inelegant efforts here, and he takes his work so seriously that it makes me feel inadequate and guilty about all kinds of things I remember doing, or not doing. He is not a comfortable author for doctors to read.
For instance: responsibility. When I was a medical student and something was missed, I could always tell myself, “You should have noticed that, you should have taken care of that, you should have drawn attention to that – but it’s ok, that’s what the residents are for. In the end, it was their responsibility, not yours.”
Now there’s no more such comfort. Occasionally the thought occurs to me, “I really should have caught that – but then, the chief and the attending should have, too.” I don’t let myself believe that, though. Interns really are there for the details. The others spend so much time in the OR, have so much more of the big picture to look at, that they rely on the interns to catch a lot of details. Yes, they often do find things that I overlook. But that doesn’t change the fact that, at baseline, they’ve told me that it’s my job to be the team’s eyes and ears, and so if a detail slips past us, it’s my fault.
This last month, there’ve been several times I’ve found myself looking at the chart and kicking myself. A lab value overlooked till the next day, a dose of medication not ordered or not given, a pathology report not noticed, a radiology report missed. I am now the generic “resident” in Gawande’s stories who is the first person to miss a detail which eventually becomes a major problem. There is no longer anyone else to take the blame for me. Now and forever, the details are my responsibility. When I’m a chief, I’ll have interns, and if they miss something, I’ll still hold myself responsible. It is no longer permissible to share.
It doesn’t help that, as I finally realized at the end of the month, my resident last month was not the greatest. He seemed friendly and helpful enough, so at first I didn’t notice a problem. Later it became clear that, although he was supposed to be there to catch my mistakes, I seemed to spend a lot of time catching his. There were times when he said, I’ll take care of that patient’s results; I’ll look at those reports; I’ll put in those orders – and a day or two later I’d realize he’d missed something. Nothing horrible or deadly, so I didn’t say anything. There were enough other incidents that the chief and attendings knew about that I didn’t feel a need to point out his failings. But I’m developing the surgeon’s paranoia. Never trust anyone, they tell you. Students lie. Interns lie. Chiefs lie. Even attendings lie. Check everything yourself. Never believe anyone. You’re responsible – so don’t leave yourself open to the mistakes of others. Doublecheck everything.
In five months, not only will they let me do surgery – but I’ll be a junior resident, supervising the interns, and the very last vestiges of non-responsibility, of having somebody else to share the blame with, will disappear.
They didn’t explain this part in the med school brochures, how heavy this is, how you can’t stop thinking about the details you missed, the ones you can’t remember if you checked on before leaving.