September 18, 2011


There was this one moment I remember vividly from when I was a third year medical student. I had been working with one specific doctor all week in clinic, and we were talking about an interesting patient we had seen the day before.

"I worried about her all night," the attending said.

I remember reflecting on that line later that night. I remember it so vividly because I didn't worry about her at all. I went home that night, did some reading, mucked around on the internet, and had a blissful night's sleep. And I wondered why. Was it because I didn't understand the complexity of her case? Or was it, I really worried, because I didn't care about my patients enough?

That continued throughout the rest of medical school. I felt like I connected well with patients during the day. Empathized with them. Felt concern for them. But when I went home, I could unplug from that. And always in the background was this vague gnawing feeling tha maybe I didn't care enough.

From the other side, I can see it was because you are so well protected as a student. Sure, you dabble in independence. One night as a fourth year student we were being hammered on call. The resident was busy with our 8th trauma ICU admission of the night and a big case just got out of the operating room. The resident sent me to evaluate the patient and come back and tell me "stable or spiraling" (i.e. is this a patient I need to see now, or in an hour when the traumas are done). I remember the anxiety of that moment standing in the ICU room alone with the patient - looking at monitors, drains, and drips and trying to get the overall gestalt of the situation. But by the end of the night, the resident had come and seen the patient, and had agreed with my assessment. I went home and had a worry-free nights sleep.

In some ways, moving from student to resident is like being a sheltered teenager that suddenly graduates high school and moves away to college, thrown into a crazy world where dangerous things lurk around the corner.

I worry about my patients now.

The patient I just operated on with post-op tachycardia and EKG changes. I do an assessment, order labs, look at her old EKG, and make the determination that her heart rate is secondary to pain and she ends up going home. I worry that she is doing OK, and I didn't miss her heart attack.

The patient whose feeding tube comes out prior to discharge. I place a new one, order the xray, and see it isn't comfortably into the stomach. Go, advance the tube, and re-order the scan. Somehow the patient gets discharged before he follow-up x-ray is taken, and I worry all night that the tube is in the right place.

The patient with shortness of breath after an operation where you SHOULD feel some shortness of breath, and I worry that her symptoms are covering up something more insidious.

There's a few things that I mull over about this newfound worrywort quality of mine:
1. I wonder if it is because I don't want to "get caught" doing something "wrong." I think that may be part of it, because all of us in medicine tend to have a perfectionistic quality. And I recognize that, as a person who didn't really get "into trouble" as a child growing up, I retain some of that quality in adulthood even now as a resident where I don't want to be in "trouble."
2. That being said, most of my focus is on my patients. The worst thoughts I have are of my patient at home, suffering, because of something I did or something I missed. So I think my worry comes from a good place, because my focus is on keeping my patients well.
3. I'm learning that its good to have worry. It keeps you vigilant. But you have to be able to turn it off. You have to be able to trust your colleagues to handle issues for you. You have to be comfortable with uncertainty and trust that if things begin to go downhill, the patient will let you know.
4. I'm also learning that perfection is a noble and good goal but not an attainable reality. You will make mistakes. There are mechanisms in place to pick up on mistakes. And, to use a cheap sports analogy, you have to forget about the botched play and get ready for the next one.

I think back to those days of medical school when I worried that I didn't worry enough and I smile. It's always fun to reflect on your own naïveté.

Big Boy Pants

Intern year is a weird limbo of sorts. In some ways, you're still like a medical student(+). Your activities consist some days mostly of carrying out other peoples orders throughout the day. The things you do handle independently are mostly algorithmic. Manage this patient's pain regimen. Work up this patient's chest pain. Evaluate this patient's shortness of breath. Put in this patient's admission orders. Anything beyond that, you are generally encouraged to page up the food chain to residents above you (or discouraged from handling these things on your own, depending on how you look at it).

But the other day I had to put on my big boy pants.

Due to a combination of the chief resident being out of town, one of our residents being post call, and the last one being in the OR all day, I was gifted with the responsibility of handling the otolaryngology consult pager for the day. The ENT consult pager is an interesting beast. Most of the time, our consults are something very benign and not particularly time-sensitive. The little old lady with an incidental mass found on imaging when she presented with stroke symptoms. The level 3 trauma with the mandible fracture. The cheek laceration in the motor vehicle accident. But the consult pager is also a terrifying thing, because it is also the emergent airway pager. These are very rare, but present. So every time the pager goes off your heart rate jumps a couple clicks.

Luckily, I escaped without an airway emergencies. However, I did pick up an emergency department consult later in the afternoon. It was supposed to be a curbside consult. "We have a patient with sinusitis and I was wondering whats the best imaging test to order." I ask to hear more about the patient, and there was enough concerning bits about the story I say "you know, we should probably formally consult and lay eyes on this patient." Go to evaluate the patient. Run the story by the chief on call, who is already home for the day. Get the imaging ordered. Read through the images with the chief, and decide the patient has to go to the OR. Immediately. Staff with the attending on call. Get the case booked, talk to the ED resident, explain the findings to the patient, answer questions, get the consent.

As the patient is being wheeled into the OR, the chief and attending still have not shown up, and I realize... I'm the only person who has physically seen this patient.

The necessary powers show up. The attending sits at the computer checking email and the chief ends up taking me through the case in its entirety. Whether it was luck or whatever may be, I end up being right, the operation was appropriate, and everything goes smoothly. With the case complete, I put in the admission orders and go and talk to the family.

When I finally get home later that evening, I think back on the whole sequence of events. It was a fairly straightforward consult. But I was the one who decided we needed to formally consult. I was the one who saw the patient, took the history, performed the physical exam, performed the endoscopy, and ordered the imaging. I was the one who talked to the patient about the findings, talked about the implications, obtained consent, booked the operation, performed the surgery, and talked to the family afterwards. From the patient's perspective, and from the family's, I was the only person they had seen and talked to. I was their doctor.

That was a profound feeling.

I know that is the endpoint for residency, to be able to independently evaluate and treat patients who come under you care. And I know that my chief and attending had my back, and if it wasn't something straightforward, they would have been there to see things over in person. But for someone still so green at all of this, it was a refreshing (and, in some ways, terrifying) experience to be the point person for everything.

The patient did great and went home the next day. I saw him on morning rounds, staffed with the attending by phone, and put in his discharge orders. He is scheduled to follow-up with the attending surgeon in two weeks for post-operative care. And part of me wonders what he will think when he shows up for his appointment and my attending, a person he never met, opens the door to the exam room.

I think I'll try to be there.

September 15, 2011


I am alive. I am loving residency. I have lots to write about.