Food For Thought

Wedging a little update, for public interest, between my previous and tomorrow's (final?) post, I thought I'd mention a meeting I had recently. Some readers will recall I said I'm considering resuming, part-time, my surgical hospitalist gig. In discussing details, some interesting issues came up which go to themes about which I and other bloggers have written severally: namely, the changes going on in training programs and the products thereof.

I talked with two surgeons; one was of my era, the other much younger but having finished training just before the invasion of the eighty-hour work week. They have big concerns. Having just hired a couple of the recently minted, they are finding the need to establish a mentoring program, because the newbies seem neither to have the skills nor knowledge to manage completely on their own, despite looking great on paper. This, of course, is exactly what I've written about. In fact, I've suggested such a mentoring program will need and ought to be a formalized requirement of all new trainees, given their limited experience compared to those much decried days of yore (and myre.)

The ramifications are many. For me personally, and others like me, it might suggest a future premium: who better to mentor the fresh faces than the old and grizzled and recently retired? And for me personally, and for you, let's hope we never need surgery. At least until the full effects of the recent changes are realized and dealt with. Which would be, oh, another couple of decades. So good luck with that.

The warnings are out there, in this blog and comments thereon, and in many others, as well as in a trickle of papers on the subject. I've been saying there's trouble ahead; it may or may not be as bad as my worst fears. I'm certain there are highly-qualified people being cranked out. The questions are, how many, qualified for what, and willing to do how much? And how to separate the sheep from the goats.

Meanwhile, were I to finalize the job arrangements (not yet certain), there might be food for further thoughts down the road.

Got Your Back

Where I trained, it was a very top-down place. At all levels, you were expected to inform the person next up the ladder before embarking on nearly anything. Which, as far as I'm concerned, is how it should be. Learn your limits: nothing is more important in being a safe surgeon. Ask for help, get advice, know the need. There were no mistakes as unforgivable as those of not following the chain of command.

In "Cutting Remarks," I told the story of a fellow resident who performed an emergency tracheostomy in the Emergency Room. That it turned out to have been unnecessary was not what got him in trouble. It was that when the nurse asked if she should call the Trauma Team, he said no, he could handle it, which he did, in terms of technique. But for his failure to communicate, he was called into the Chief's office and told this: "A cat has nine lives. A surgery resident has two. You've just used one. Now get out of my office."

That Chief was F. William Blaisdell, or, as we referred to him, the Blazer. A leader in the formalizing of trauma care, Blazer ran the Department of Surgery at San Francisco General Hospital while I was there, and he was one of my two most influential teachers. Some of his demands were a little annoying: no facial hair, no scrub clothes out of the operating room, wear a necktie at all times. But it was about respect. Respect for our patients, most of whom were derelicts and drunks and down on their luck. No matter. We handed every one of them a personal business card that Blazer had seen to for us, including the number of the surgery department and of the paging system.

What Blazer expected of his Chief Residents, of which, eventually, I became one, was not that we be right all the time. His expectation was that every decision we made was well thought-out, that it took full account of the situation, of all the possibilities, that the proper data had been collected and evaluated. Short-cuts, sloppiness were indefensible offenses. When I called him in the middle of the night to describe a patient and tell him of my plan, he might or might not choose to come in to assist. (I appreciated his confidence in me when he stayed away, but I always liked having him there. It'd be soon enough, I figured, that I'd be on my own. Now was the time to pick as many pearls of wisdom as I could.)

And here's the thing: if he felt you'd properly reasoned he'd never second-guess or fail to support your decision, even if it didn't work out. He'd talk it over, dissect it; teach back from the problems. But he'd stand up for you. Unlike some of the other staff.

Like most training programs, we had a weekly conference in which every imperfect outcome was discussed. "M and M" is the most common designation, for Morbidity and Mortality; ours was "D and C," for Death and Complications. The conference took up several hours of every Saturday morning, delaying the beginning of the infrequent weekend off, if such it was. But it was the best conference we had, probably the source of the most learning outside the OR. Chief Residents of each service presented the cases, but the grilling might be directed at anyone, even the loftiest of professors.

When I was on Blazer's service, the one thing I could count on, though, was that he'd be there for me. If there was a bad outcome, as long as he believed I'd done the right thing at every step of the way, he'd defend me against whatever onslaught, from whatever lofty source. Some of his junior professors were not so solid. "I told him he shouldn't do that," they'd lie. One guy in particular, whom I won't name. A tough case with a great result, he was there to take the credit, as if he'd done it and not me. But if something was imperfect, he sidled away like a crab catching the tide, wagging his tiniest claw behind him: not me, not me, not me.

The Student Prints

I like med-student blogs. They remind me of the excitement, the frustration, foreboding, and fun of those times. More than that, from the quality of the writing and the depth of the thoughts expressed, it gives me hope that when I'm sick there may still be doctors out there interested in taking care of me in the way I'd have taken care of them. On the other hand, some of what I read is disturbing.

It's a predictable pattern: someone writes about her/his surgery rotation, and -- if not perfectly word-for-word -- certain statements will be made, and an inevitable array of comments will follow. The cast of characters is always the same: the asshole resident, the overbearing and brutish professor, the student who hates everything about it, sometimes with one or two who love it (and whose motives and sanity will likely be challenged.) Rarely, there might be a supportive resident or two. The behaviors described recur time and again. Berating, humiliation; a senior attending who not only treats the students and residents like shit, but his patients as well. The author, and the commenters, in the most vituperative and unforgiving of terms, validate their owns similar experiences and roundly condemn the surgeons and their method of teaching.

Keep your fingers off the keypads for a minute, kids: I'm with you. The reason this is disturbing is that it's true, and I hate hearing it. By far the worst thing to read -- and I've read it in commentary by patients as well -- is the description of a doctor (any doctor, but particularly a surgeon, because they seem to be the most frequent offenders, in these fora, anyway) being disrespectful and uncaring toward a patient. For that, there's no excuse, ever. And whereas I don't think for a minute that it's limited to academe, I believe -- from observation -- that such behavior is more common within the ivory walls than outside. Maybe it's tenure; maybe it's the academic rat-race; or maybe it's slop-over from the anti-Socratic method of discourse that's become embedded in surgery training like dogshit in a Doc Martens.

The operative phrase is "shit runs downhill." Profs dump on the chief resident, who dumps on the senior resident, who dumps.... But it needn't be like that. I wasn't like that.

In training, as I worked up the ladder, I was a good and patient teacher (or so I'm saying!) I had interns and junior residents over for dinner; I made jokes on rounds, and pitched in on the scutwork. I relished showing technique and explaining reasons for things. I rarely -- if ever -- grilled, and when I did, it was to get somewhere rather than to debase. It can be done. I don't recall chewing someone out, ever. But when I became a real doc, bearing all the responsibility myself, some things changed. I NEVER treated my patients with anything less than respect and empathy. But I know I could be hard on the nursing staff, and even referring docs, when I thought something had been done less perfectly than I demanded of myself. Believe it or don't, I was much harder on me than on anyone else if anything diverged from my view of excellence, but I make no excuse (OK, I do: it was based on hyper-perfectionism and not arrogance): things can be said in less off-putting ways. (In fact, in my second incarnation, after brief retirement and time to relax and reflect, as a surgical hospitalist I had an entirely different attitude. Nurses who'd known me before said they'd never seen me so happy. I think it partly had to do with sleep. And, yeah: being old and beat up enough to let some things go.) But there's a point here.

Not everyone will buy it without offense, yet it's true: surgery is the court of last resort. A surgeon is judge, jury, and -- God forbid -- executioner. Every other doctor can punt, and they do. Often. A surgeon can't, especially in the OR. And so, whereas it needn't be as punitive and degrading as it is in some places, surgery training will always be long, and hard, and demanding. I accepted a certain amount of misery when I went through it (and worked hours far more brutal than now) because I felt urgency and necessity. I thought then, and still do, that surgery training does more than the others to inculcate a sense of responsibility, the knowing of one's limits, and a commitment to perfection; and it must, because there are no hiding places in an operating room. If some students are put off by it, it's not entirely a bad thing. They will, and should, make another choice.

I read a student blog the other day. The writer said she hadn't read up on the operation in which she'd be participating, and was taken to task by the operating surgeon. With relish, evidently. Her post was followed by lots of comments deriding the attending in particular and all surgeons in general. There was an echoing chorus of animus: they're dehumanizing, bunch of egomaniacs, surgeons are terrorists. But along with the cringe of embarrassment for being associated with the evident scum of the earth, there was a twinge of an opposite thought: if I were to show up to an operation unprepared, someone might die, or be maimed forever. I'd hope that people who choose to become surgeons are the sort that don't need reminding, and are, in fact, the kind that wouldn't show up unprepared in the first place. But in training, some do. And they don't last. If they don't respond to whatever method the attendings or the senior residents bring to bear to point out and correct their failing, they get tossed. As they should. And, as someone who might some day lie on a table in the most vulnerable position you'll ever be in, aren't you glad to know that?