Medicine From The Trenches

Experiences from medical school, residency and beyond.

Suicide

I have wanted to push this post out for many months. This is very difficult to write about because I am still so close to the raw emotions and feelings. I want my readers to understand how much many of us who take on the task of teaching others medicine care about our teaching and our students/trainees. This was very close to me and stays with me because the young person that I write about left behind two young sons and a young spouse who is somewhat adrift even today when I spoke with them.

I met this young resident physician when they entered the program where I teach. That first day when everyone met and introduced themselves as we all sat around a large oval table. The PGY-1s and the faculty members who would get to teach them and get to know them. The resident was full of hope and anticipation being so happy and grateful for a match into our program. Everyone was so hopeful even knowing that residency pushes one to limits physically and intellectually in the case of surgery. Many believe that the major test of medical school is the measure of a physician but residency is where practice begins and starts the foundation of what will be a life of practice and learning. While medical schools gets one ready for residency, the experience of managing patients and performing surgical cases first as surgeon junior and then as resident is the making of a surgeon.

This resident started out on a ward-intensive rotation under a chief resident who was a patient teacher and generally supportive of the junior residents and medical students who were on the service. All reports were good and the resident was progressing well-not superior but more than adequate. All PGY-1 residents need to sleep more, read more and get out of the hospital as much as they can. The faculty in our program work with the chiefs to make sure that the workload is challenging but not oppressive. I love to do patient care along with my residents because I love taking care of patients. On many weekend mornings, I round, write my own notes and inform the chief of what I have been doing so that the junior residents and medical students are not so burdened.

By the end of the first half of the first year, all of the new interns (PGY-1 residents) seemed to be getting into a groove. The major services: general surgery, colo-rectal surgery, minimally invasive surgery and surgical oncology, were humming along well. The specials: vascular, pediatric, thoracic, critical care, cardiac and plastics were well-covered with interesting cases and patients. It seemed like the year was going to roll along in that predictable manner so that we could all gather at the end and make fun of ourselves while sending the graduating chiefs off in appropriate fashion.  Mid-way through this year, one of the new interns started to unravel a bit. I was asked to do a bit of counseling and unloading. I am happy to play this part for the program.

It is a general fact that most interns will not ask for help when they are getting overwhelmed, especially in a surgical program. There is the code of the surgeon being tough and resilient, thriving under pressure and invincible. Some of my fellow attending physicians still subscribe to this code of conduct but I am having little of this. I love showing my vulnerable side, and often do,  because it enables me to show my strong side at the same time. Yes, I am a human being that is the same as my patients and those I train. I learned from a very wise surgeon colleague that I have to allow those who encounter tragedy and stress to decompress immediately and to keep decompressing. As a leader, I owe this to those who work with me in this profession.

The intern seemed to have a difficult time dealing with the night float where one has to shift rapidly to cover the incoming patients. On my call nights with this intern, I would generally cap their load so that some rest and learning could take place. I calculated the average for the past week and capped when that number was met. Anything over the cap, I admitted, worked up and handled with the chief resident. This generally didn’t amount to many patients but it created a sense of teamwork and accountability for all of us. I loved presenting new patients in morning rounds and having the chief question me (same as the interns) about management. This is a great experience for all of us and continues today.

Along with difficulties on the night float service, personal problems at home began to creep into the picture. The spouse was having an affair and the children were feeling the effects of the strained marriage. Being single, I am surely not equipped to counsel anyone on marital stresses but I did strongly encourage this resident to seek some outside counseling. I assured this young physician that I would be as supportive as possible in making sure that my colleagues understood the grave nature of the home front problems without betraying any confidences. I know of great love and feeling for another person and the loss of that person can be raw. I also know that every person deals with loss in different ways and that with the stresses of a surgical residency, seeking some marital counseling is probably a sound idea.

Three week later, this intern was still trying to balance work and family struggles. Things were unraveling and I suggested taking a leave of absence for the remainder of the year. When things can’t be worked out and work can’t be done, a leave of absence is often the best solution. This was arranged by the program director with an offer for this resident to attend teaching conferences and educational classes as much as possible. We offered a research position that had been left by another candidate so that this resident could have some income. We all offered support and fellowship but substance abuse came into the picture.

I don’t know how substance use began but I noticed the smell of alcohol during one of our educational conferences. I immediately asked the resident to leave because the smell of alcohol can’t be on any physician who is in a clinical area without exception. I was deeply disappointed but asked to chat the next day when possible. The resident never contacted me. Later an admission for overdose of opioids (deemed accidental) along with alcohol. I rushed to the emergency department to find the resident semiconscious and unable to communicate. Clearly, as I spoke with them later, I emphasized the need to spend some extended time in counseling but I could sense a drift away. The shame of losing a training license and a residency position was more stress and deeper into a despair that I was not equipped to handle. I begged this fellow human being to reach out for the sake of the family and children.

Medicine and medical school into residency and practice attracts a person who becomes comfortable with work toward long-term goals. One has to have a high degree of comfort with the long term process because the journey is long. Along the journey goes the family and friends but the resident is the common factor. I know that my colleagues who have families are happiest when they spend as much time as possible with those families. One of my colleagues always says that he can’t understand where my recharging takes place (my spirituality, my adventures and my sheer wonder of all things as I go through this life). This experience rattled my entire experience with medicine and still does.

When this resident committed suicide, I plunged into a depression that only my faith could keep me going. I prayed myself to put one foot in front of the other one so that I could get out of the door of my house in the morning.  I know intellectually that I couldn’t force another adult human being into making better choices but I still can’t fathom leaving behind precious children. It is my firm belief that children can weather the disintegration of a marriage if the spouses involved are dedicated to raising them. I also believe that children only want your time and unconditional love (my experience with my nephews). In honor to this resident who felt so much pain and was unable to get the help needed, I listen intently to my trainees. In honor of this resident, I search intently for any shred of hopelessness in my colleagues, residents and students. In honor of this resident who was kind to their patients and to others, I strive to be kind to others. In honor of this resident, I try to learn the lessons of life and to be thankful for life.

30 June, 2015 Posted by | general surgery residency, intern, residency | , | 19 Comments

The Gift of Study

Introduction

Many who read this blog will begin their studies of medicine in a few short weeks while others will move into new roles perhaps with more responsibility and duties. I wanted to take a few lines to write about moving into your new roles be they medical student, intern (PGY-1), resident or attending physician.

Preparation

A mentor from my first days of medical school, actually during orientation, said in his soft southern accent, “Now go out and grab a copy of The New England Journal of Medicine and read it from cover to cover.” “You won’t understand it at first but keep reading it and studying the words of medicine.” Little did he know that he had just added more fodder to my constant journal reading and now had stoked a fire so huge that I could have been consumed in the flames, so to speak. As I look back now, years from those words and others that have shaped my current practice. Listen to those little bits and pieces of wisdom from people who will enter your medical education early on.

For those of you who will begin the study of medicine, your preparation is to open your mind, your ears and to consider the privilege of what you are to undertake. Yes, you will be “sipping from that fire hose of facts and materials” to be mastered but you have been given the gift of being able to study those facts and materials. You may want to allow yourself from time to time to marvel in what you will learn from the application of science to the practice of medicine. In short, take a moment to breath and enjoy the process.

For those who move “up in rank”, take a moment to look back on the things that you have studied. Every time one encounters a familiar concept, there will be new insight. For example, my intern year was spent learning the craft of patient care preoperative, intraoperatively and postoperative. As the weeks went by, I became expert, perhaps efficient in being able handling patient admissions to the hospital post-surgery, from the emergency department or from the clinic. Additionally, I learned to anticipate and manage the needs of those inpatients from their first moments under my care to their discharge from my care. My insight at this point was how my studies of symptoms and signs coupled with science now allowed me to care for my patients and see how amazing the human body and human spirit can be.

On my first rotation, as my learning curve was steepest, I felt as overwhelmed as I felt in my first week of medical school when biochemistry, anatomy and microbiology came flooding at me in torrents. At this point, it seemed that the work of history and physical exam with admission orders, checking tests/studies, checking wounds and discharge summaries would consume me but one week in, I was thriving and looking for every chance to get into the operating room in addition to my ward duties. I could take that moment to appreciate interaction with patients, nursing staff and get to scrub surgical cases. I was “basking in the glow of bright lights while playing with cold steel, “as one of my professors would say.

When I look back, one of my gifts on those first rotations was being assigned as the intern to the chief resident that everyone had whispered being the most difficult in our ranks. I came to appreciate my chief, the only person that I know who is as compulsive and anal as myself when it comes to the practice of surgery, is that I actually found that I could “get down there and nail things” faster than he could after three weeks. He made me stronger, faster, more efficient and more comprehensive. This allowed more time for me to obtain operating time which is why I became a surgeon in the first place. What other surgery interns avoided, I happily sought out. I was also the recipient of more valuable study advice from my chief, “Force yourself to read at least 30 minutes every day, more if you can, and at least 2 hours on the weekends.” There again is that gift of study. I stuffed my pockets with articles, pages from my textbooks and the surgical atlas. Even if I was exhausted, I had something to read or study in the back pocket of my scrub pants.

Performance

Back to my professor of surgical critical care: “Surgeons are not made, they are forged” was one of his favorite quotes to me. I thrived in the forge of residency because I didn’t look at study and learning while performing medical/surgical care as being in some sort of purgatory or prison. I was getting the opportunity to build a solid foundation of knowledge and skill that I would use for the rest of my life. I learned through being forged that I could solve problems and touch a multitude of fellow human beings in ways that others would never appreciate.

My professor would later say at my graduation that I never complained or said that I was tired when he knew that I was the oldest resident in the ranks. (I had attended medical school after graduate school). He said that he found that somewhat remarkable because as he had aged, he felt entitled to complain more and accept less mediocrity. He said that I was a person who accepted everyone as I found them without agenda. (Still one of the most interesting comments that I have heard about myself).

Under the scrutiny of my mentor in residency who like my first chief, was known for having a very challenging personality, read malignant here, I learned the clarity and performance of surgical skill. My mentor (faculty adviser), taught me to waste no movement in honing surgical skills. He loved that I studied as I learned and assimilated what I was taught in craft and theory. Again, back to those study skills.

Little did he know, I cut the spines from my surgical texts, punched holes in the pages so the they would fit in a ring and were more portable than the entire text (Sabiston’s Textbook of Surgery). My best memories of my faculty adviser are of him folded in a lounge chair in the surgical lounge with his Danskos next to his feet grilling me on how to handle this complication and what would happen next as this was more valuable than gold for me.

Even today, the residents, medical students and physician assistant students appreciate my high expectations of them in terms of work and study. I do not subscribe to the practice of berating as a means of teaching but go back to my very tough first chief resident and my faculty mentor in residency who generously gave of themselves to guide me towards performance at the highest level. I don’t have the difficult personality traits that were characteristic of many of my fellow surgeons but I have high expectations of those who have been assigned to me for instruction.

Practice

The gift of the study, and later practice, of medicine (if you are fortunate) is still one of the most divinely mystical and satisfying acts of a lifetime. Even if you are beginning your studies and are not enjoying much patient interaction, try to cultivate a love and appreciation for the gift of study. Those studies will allow mental efficiency which can lead to some of the most intimate and spiritual gifts from one human to another. Appreciate those gifts without complaint because many others will never have the privilege of enjoying them as you have them now.

26 June, 2015 Posted by | academics, medicine, practice of medicine | | 4 Comments

For Father’s Day

I want to share this post by a gifted physician, husband and father who writes about his father. This post which can be found here: A Father’s Story is an honor to a father from a son who is a father. For me, this wonderful post reminded me of my father who was a physician and my first and best mentor. Please enjoy this post and honor your father on this upcoming Father’s Day.

19 June, 2015 Posted by | practice of medicine | | 2 Comments

And there she sits…

I was called for consult on a patient in the “memory care” section of the long-term care facility affiliated with our health system. My partners hate to consult on patients in this facility and tend to “leave” these consults for me to work up because they just don’t care to do them, read, they say that I work with them best. For me, leaving the “mother ship” is a welcome time at the beginning of my day to drive over and see the patient in their surroundings as the first part of my work-up. You might ask why the patient isn’t transported to my clinic to save time for me but if the problem isn’t particularly emergent, I go to visit the patient and I am happy to do so.

 
She sat there in a wheelchair in the dayroom surrounded by other residents who were in various stages of behavior from a chair-bound woman who had removed most of her clothing while shouting to anyone who walked near her to a gentleman who sat in a chair by the window looking out at the bright sunshine reflected off the rich green leaves of the plants outside. I would have loved 5 minutes in that window for my sanity. She was surrounded by about 25 people some ambulatory and some sitting to watch the large television in the corner. As I called her by name, she looked first at my bright red suit and then at my small white chihuahua that I often take with me to this facility. This little white fluffy dog with alert tan ears and a bright red collar often provides comfort and serenity to patients while I perform an exam.

 
She sat there looking at my little dog who climbed into her lap and began the obligatory dog greeting. “Do I see a smile?” I said in a cheery voice. “I came to see you because you might need to have minor surgery on your arm”. “I thought we might get to know each other here rather than you coming to my minor surgery clinic with all of the hustle and bustle”, I said. She looked at my dog who by now had curled up in her lap. She didn’t say a word but didn’t appear to be frightened or even nervous by the dog.

 
The nursing assistant came over to let me know that my patient doesn’t talk and that she doesn’t understand what I am saying to her. “You should talk to her son and the nurse if you want to know anything” she said. “I said that I am doing fine and that I will speak with everyone but thanked her for letting me know. My patient sat looking at my red skirt as I sat in a chair across from her; still holding the chihuahua. (Being little and cute has some advantages that I will never know). “I just want to meet you and speak with you because I try to get to know my patients before surgery, if that is OK”.

 
My patient moved her hand to stroke the dog who was now dozing with her chin on my patient’s other forearm (the area that had the lesion). I looked at the arm that she kept so still as not to disturb the sleeping dog. She gently stroked the dog with her other arm as I examined the area of concern quietly leaning in as close as possible. She reached out to touch the material of my bright red suit and my arm. Still, she looked at the dog and not at me but put her finger to her lips in a manner to tell me to be quiet because the dog was sleeping.
“Now, I lay me down to sleep, I pray to the Lord, my soul to keep”, she said in a very soft voice. “I repeated softly with her. “If I should die before I wake, I pray to the Lord, my soul to take”. She still stroked the sleeping dog and a tear ran down her cheek. I completed my exam and moved my chair next to her as we both stroked the chihuahua. I can slow down my day, enjoy the bright sunshine and green leaves while my patient enjoys the company of a small dog.

 
I sat there for about 20 minutes thinking of who this very quiet but very kind woman might be and how best to treat her and keep the stress of the potential procedure to a minimum. When I see patients in the office/clinic who have come for workup for minor surgery, I generally complete the exam and information setting in 20 minutes but when I do a house call in the long term care facility, I like to take as much time as I need to get as much information about my patient as I feel is necessary. If this one patient takes my full morning, then that’s how much time she and I need.
My practice partners prefer to have a root canal done rather than visit the long term care facility. One of them remarked that if he slowed down for these type of patients, he would probably stop practicing. Another said that visiting the nursing home was just uncomfortable for him and that he didn’t want to be reminded of getting old as if entering this type of facility would speed up his aging process. Another partner said that he didn’t want to think about losing his mind and that these types of patients do this to him. “You are a woman and you do better with that stuff”, he said as I picked up the consult package on my desk.

 
I find their reactions interesting and somewhat distressing at the same time. Yes, they are admitting that they have a bias for treating older patients and I applaud them for recognizing that they are biased. Recognition of bias is a great way to overcome a bias if that is your goal. I am distressed because they attribute my being female to my having some extra ability to see the dignity and spirit in all of my patients (No, I am not a saint, I just feel privileged to be able to do surgery and see the wonder in all humans). Things like vomit and eye surgery are problematic for me but not my patients regardless of age, location or ability to communicate with me.

 
When I went back for follow-up post-surgery, I took my flute and played one of my favorite Bach Inventions (I seem to be able to remember those). My patient gravitates toward my dog, my music, my prayers and my brightly colored dresses that I often wear (when I can get out of green scrubs and a white coat, I do so). She longs for colors, sounds and the touch and interaction with others. As her wound heals, she has said few words but radiates the spirit and dignity of being a human being.

 
My partners may be right in that I am better at that “stuff” because that “stuff” is the “stuff” of my humanness. I have to bring that humanness to my practice even though a majority of my practice is procedures and acute. For me, being able to slow down and take the time to interact with patients who have lost some of their ability to communicate in a conventional manner is something that I enjoy and treasure. This is a gift from medicine to me and I treasure it.

17 June, 2015 Posted by | practice of medicine, surgery | | 3 Comments