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.”