Not On My Body! The Dirty Secret of Surgical Training

It's the resident's responsibility the morning of surgery to check on the patient in the pre-operative area, make sure there's a current history & physical, make sure surgical consent has been signed, ensure the surgical site is marked, etc. It's often one of my favorite parts of the day. It puts a face to the person in front of you in the OR, humanizes them after the yellow iodine has been slapped on and the surgical drapes have been placed. Most of the time, it's the first time I'm meeting the patient and it reminds me of how important it is to be meticulous and thoughtful in the operating room. There's often some good-natured banter to soften the patient's nerves. I have a fairly consistent spiel I give when I first walk up.

"Good morning, I'm Dr. MedZag, one of the surgery residents. I'll be helping out with your surgery today."

Some small talk typically follows. I may explain to them what's going to happen during their surgery, or what to expect following it, or let the family know how long the operation is going to last. Many patients are curious about residency and what that actually means I am. I explain that it means I have completed medical school but this is part of my post-graduate training. A mentorship or discipleship, of sorts. I have a medical license but am not board certified. Many people ask how long it lasts. I explain that for the surgical fields, it's between 5 and 7 years, and many of us go on to do fellowships afterwards. "Oh wow, that's a long time!" is the common response. "Well, they don't let us go out and start operating on people without earning it first!" is my usual one liner. But occasionally, I get a bit of a skeptical eye from the patient, and I know what is coming next:

"But Dr. Very-Important-Attending is doing my surgery right?"

I still don't have a good way of answering this question. But I have a few canned responses I cycle through:
1. "Don't worry, Dr. Very-Important-Attending is the boss in the operating room."
2. "I will be assisting Dr. Very-Important-Attending in any way he/she feels necessary."
3. "My role is to help Dr. Very-Important-Attending as appropriate."
4. "Dr. Very-Important-Attending runs the show, simple as that."
5. "Yes, Dr. Very-Important-Attending will be calling all the shots."
6. Variations of above.

I admit that some of my responses are farther from the truth than others and I also acknowledge that I'm always intentionally vague. The fact is that as an intern, yes, for many operations I'm simply there to "assist where appropriate." But for some operations, I'm performing parts if not all of the surgery. This is how we move from "intern" to "junior resident" to "senior resident". You can't become skilled at operating without, well, operating.

But I often wondered what the patient would think if we were brutally honest and told them who would exactly being doing what in the operating room. And the general surgery department at Madigan Medical Center in Washington looked at just that:

It's a very though-provoking study, but there are a few particularly salient and dramatic points they found, with the last two being most interesting:
1. 91% of patients believed their care would be equivalent or better at a teaching institution.
2. 68% of patients perceived a personal benefit from participating in resident training, and 87% believed that their participation would benefit other patients.
3. Patients "overwhelmingly" preferred to be informed if a resident would be performing parts of their operation.
4. 94% of patients stated that they would consent to the involvement of a resident in their operation.
5. However, after being given specifics of the role of resident involvement, patient consent dropped to 32% if the resident was performing the operation with the attending assisting, and 20% if the resident was performing the operation with the attending observing.

The overall message: Patients recognize the importance of training the next generation of surgeons. They just don't want to be the ones being learned on.

There was a great study published in the Journal of the American College of Surgeons earlier this year:

They looked at over 600,000 surgeries at private and training hospitals, and what they found was both expected and surprising. There was a slightly higher rate of complications, but a slightly lower rate of death, when residents were involved in an operation. I find that a very interesting and telling statement. It acknowledges that yes, we are learning, and as such, we make more mistakes. But it also acknowledges that we care about our patients and their care, and I think the mortality benefit reflects the reality that at a teaching institution there are more doctors who care about you keeping their eye on you.

I struggle with this underbelly of my training. The reality is I am learning. But at some point in technical fields such as surgery, you must learn by doing. Even in my short time in residency, I have had complications as a result of things I have done in the operating room. Nothing life-threatening or dangerous, but complications nonetheless. Mistakes that a more experienced surgeon likely would not have made. The reality is that these mistakes follow me. I think about them daily. And I regret that a patient has suffered harm, however great or little, as a result of my actions. But I also recognize that they have imparted to me great lessons, and have made me a better surgeon as a result.

Like I said, I find answering the "but Dr. So-and-So will be doing my surgery, right?" question difficult. Do we accept the half truths that permeate such a conversation as a necessary evil for the greater good so that myself and other surgical trainees will be ready to serve society for the next 30-40 years? Or do we instead veer towards blunt honesty, acknowledging that at an 80% consent attrition rate it would take me 20 years instead of 5 to gain that necessary operations and experience to be a competent surgeon? Do we be completely honest with patients but focus on educating them on what "resident participation" means from a value standpoint? That seems to be the ideal scenario, but my inner pessimist tells me that no amount of patient education would make most people willing to be learned on.

These issues are important ones to think about, but ones I can't afford to think about too much right now. Because I'm an intern, and I have too much to learn and too much to practice. So tomorrow, I will be in the operating room. I'll cut skin with the knife, buzz blood vessels with the cautery, tie sutures. And I'll keep learning.

Warrior

He was young for his type of cancer - squamous cell carcinoma of the larynx. I can't remember if he was a smoker or not, I don't think it matters, because those little details tend to deceive us into judging whether a patient "deserves" their cancer or not, and no one deserves a diagnosis of cancer. His tumor fell into the "organ preservation" limb of treatment, and he underwent weeks of grueling radiation and chemotherapy with his wife steadfastly by his side. The first few scans came back clean, then a year or so after treatment - recurrence. The cancer would prove to be a formidable enemy.

"Salvage laryngectomy" is the term we use when our first treatment has failed for voice box cancer and the ultimate decision is to be more aggressive and wield cold steel and hot cautery against our opponent. I think in some ways the term is quite poignant. It implies a battle of sorts raging within the body - treatments and human will versus the scourge of the malignancy infiltrating the tissues. Poetic interruptions aside, it meant the patient lost his ability to speak when we removed his larynx in an attempt to also in turn remove the cancer. Once again, a period of reprieve and healing. He became artful in speaking with the electrolarynx, attacking this new challenge the way he had all other challenges before then. But once again, the cancer returned with a ferocity, infiltrating the skin around where his airway now exited from his neck.

"Peristomal recurrence" is the term we use when the cancer returns in such a location. In general, it is considered a very poor prognostic sign. The type of sign where all you have to do is utter the term and those knowledgable to the lingo simply nod their head sadly, understanding that you're implying the chance cure is essentially zero.

And so it went on, another round of chemotherapy. More radiation. More chemotherapy. Experimental regimens that were so new or different they weren't even clinical trials yet. He lost a lot of weight. Nausea. A tube was placed through his skin into his stomach. His tumor grew larger. He was hospitalized. His tumor grew larger. He had bleeding. He spent time in the ICU. His tumor grew larger. He had abdominal pain. That earned him a surgery, and more pain, only to find that the cancer had further metastasized. His tumor grew larger. He would spend the last few months of his life in the hospital, until one night he quietly passed.

The unfortunate fact is that half of head & neck cancer patients in an academic institution will succumb to their cancer. His story, however, struck a chord with me.

Our team was frustrated with his care. We had tried many times to lay out prognosis to him, to arrange end of life care, to make him comfortable. But he would always talk about the next round of treatment. He would always talk about the day when his cancer would be gone for good. In fact, up until the end, he talked quite a bit. About his favorite football team and the upcoming season. About his rec sports league and the joy he got from the competition. He struck he as the scrappy small guy you hated to compete against but always wanted on your team. Ultimately, he always equated palliative care with quitting no matter how how we tried to frame the conversation. We, the team of residents caring for him, had trouble with transferring our own opinions onto his life. We saw the last few months spent in the hospital as time wasted, unnecessary pain and suffering. (And wasted healthcare dollars if you work in Washington). Some would paint his case as a failure of our medical system to navigate end of life care. Every day as we passed through his room we were left with a dampening of our spirits, a daily reminder of our own mortality, and the futility of our care at times. He was the other, more real, 50% of head & neck cancer patients.

I think when it comes down to it, he derived value and meaning from the fight. And I think he measured the worth of his life in the end by how hard he fought. He was a warrior. He outlived prediction after prediction. 6 months to live. 3 months to live. 1 month to live. He tolerated an inhumane amount of painful and debilitating treatments. He demonstrated the tenacity of human will.

And ultimately, I can't help but admire his story. In the end, I think, it was a good death. A death befitting a warrior.

Worrywort

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.

*ahem*

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

Soon.

So are you going to be doing my surgery?

Residency is very different from medical school.

(Thanks, Captain Obvious.)

I had a flashback this week to our "orientation to the clinical years" just before beginning my third year of medical school. I remember the out-going third year trying to coach us on various things - like writing a good note, making a good presentation, etc. I remember asking "So, what does do you do as a third year?" He gave some answer involving "helping with floor work, updating the list, faxing for records, following up on labs, ad infinum", and I remember thinking by the end of is "Yeah... but what do you DO?". I ahd not tangible mental image of what my days would be like. As I discovered over the next few weeks, you can't really understand it until you have to do it.

I think the same goes for residency. Sure, you have a lot of interaction with residents as a student and you get a sense of their responsibilities and how a resident's day is structured. But you don't really understand until you have to do it. A few of the key differences I've found include:
1) There's way more things competing for your time than you have as a student. At any given time, this includes: managing patients on the floor, discharges, seeing patients in clinic, logging procedures, prepping for conferences or tumor board, teaching time, self-guided reading time, prepping for OR cases, didactics, preparing a presentation, practicing basic surgical skills, graded laparoscopic assignments, and maybe a research project or two. As a student, you also had some of these requirements, but if you skimped a bit someone may or may not notice, and no harm no foul. As a resident, if you don't do them, they don't get done, and someone always notices.

2) As a student, you try to know everything about your patients. As a resident, you need to know everything about your patients. There's redundancy in teams to help mitigate this, but there's always the possibility that you may be the only person to follow-up on a lab or check a vital during the day. And that may end up being critical to the patient. It requires a great deal of focus throughout the day to remember to follow-up on things when there's a myriad of other issues continually competing for your focus and attempting to distract you.

3) As a student, you study a lot, but your primary motivation is often your grade. Sure, you convince yourself to read sometimes because "you need to know this for the future" but that often becomes much less of a motivator than impressing those that will evaluate you or an upcoming shelf exam. You also jump around every month, so you reading often will be a sample platter rather than a 4 course meal. As a resident, you read because you need to know the information. Not just because its expected of you, but for the good of your patients. Reading is more intensive on given topics and can feel more exhausting - I feel like I need to hang on to everything that passes in front of me because it is all important, and I feel like there's so much to learn and retain and I want to tackle it all at once.

4) Your skills explode by sheer repetition. As a student, you develop certain skillsets, but the next month you're on to a new discipline and most things you learned pertinent to a specific field fade away. As a resident, the skills you need to learn how to do are the things you are doing every day, and you do them over and over again.

5) The attendings really do rely on you. There was talk at my medical school that a good student is always "value added" on a service. As a resident, you are "value needed."

I think it all comes down to a switch in the manner of your responsibility. As a student, you try to take on as much responsibility as possible. But a lot of it is faux-responsibility (both for medicolegal and practical reasons). As a resident, you continually accrue more and more responsibility over the care of your patient.

I was in clinic the other day with a pleasant patient. I went through a lot of the things I had practiced in medical school - took a history, did a physical exam, developed a plan, went and presented the patient to the attending. The attending came and whirled through the room, checked a few things, talked to the patient about surgery, then left me with the patient to consent them for the procedure.

As I shook his hand as he walked out the door he asked, genuinely: "So are you going to be doing my surgery?"

I think that encapsulates the big switch that occurs in residency. You turn from purely a student into a provider of care. Over the coming years, I will read about the patient's condition, I will learn how to do his surgery, I will learn how to manage patients like him post-operatively. And I will do it not just to provide care, but the best care possible for that patient. Residency is about living that mantra.

Residency, huh?

First of all, apologies for leaving the blog hanging in the wind like a bad M. Night Shyamalan cliffhanger for the past 3 months. You may (or may not) have noticed I dusted off some of the things around here and updated the header to note than I am no longer a short-coat-wearing, deer-in-headlights, hopelessly-clueless medical student. Since our last interaction, dear reader, I have shed the shackles of medical school, packed up all of my "stuff", drove 2,353 miles across the country, and settled down in a small city with a very big medical center where I have spent the last week preparing to be a long-coat-wearing, deer-in-headlights, hopelessly-clueless... intern.

Progress.

I debated for a long time what the fate of this little corner of the interweb would be when I would be forced to stop writing about medical school. For a long time, I was content to let it ride on out into obscurity like many medical student blogs before me. Less time during residency (especially a surgical residency), the changing face of medical social media, and increasingly stringent institutional policies would all stack up and make it easier to just stop writing altogether.

But a few things changed my mind. First, I remembered a conversation I had with a good friend of mine who is in a *wink* elite *nudge* branch of the military. During our conversation, we talked about unique and stressful experiences and how it is important to take time to reflect on those experiences to learn and grow from them. I know myself well enough to know that unless I'm writing it on this blog, I won't take the time to write it at all (I don't know what that says about me as a person... but moving on). Secondly, as I nostalgically romped through the end of medical school, I decided to go back and read this whole damn blog in its entirety. Reading posts was like reliving experiences all over again, and I was surprised by how much of those memories had already began to seep away into the dark recesses of my brain. Finally, during a conversation with one of my new co-interns, I discovered that he both read my blog and liked it, despite the fact that we never interacted on the interview trail and hailed from states on different ends of the continental time zone. I was reminded about the common thread of the medical student experience and how many comments in the past have remarked "I'm glad you're writing about this." These things have led me to the conclusion that:

Remembering the process is important.

Over the 4 rapid years of medical school, this blog has evolved from something analogous to a teenage chick flick, to a place for me wax sophomoric about my "difficult" life, to a place to reflect on the incredibly powerful moments laced into and around my chosen profession. But what this blog is is far less important than the purpose is serves... to remember the process.

So I plan to keep on writing. I have no idea how this space will change, only that it will change along with me. Hard to believe over 60,000 of you have been here to this point, but hopefully a few of you stick around for the next chapter. Because tomorrow I'll put on a long white coat for the first time, walk into the hospital, and get to be Dr. MedZag. And I'm sure it'll be a process.