Dean Lao
Cell 2 Soul. 2007 Spring; 3(1):a9
On September 19, 2003, my classmates and I took part in our debutante entrance into the medical profession — the "White Coat" ceremony. First held at Columbia University's College of Physicians and Surgeons in 1993, this annual rite of passage is now practiced at the majority of U.S. medical schools. After being "coated" that glorious day, I remember raising my right hand and reciting the Hippocratic Oath. My proud father smiled as my mother furiously snapped photos, trying to capture the exact moment of my conversion from layman to future doctor. A senior physician told us: "Never see your patients merely as vessels for disease; instead, view them as human beings who are suffering and in need of care." His words resonated deeply within us; and we left the ceremony bright-eyed and idealistic, ready to change the world. If you had asked me then what medical specialty I was considering, I would have said without hesitation, "primary care."
Fast forward three years. Currently, I'm applying for residency training — in anesthesiology. Twelve of my classmates are applying to anesthesiology residencies as well. My interviewer (a hematologist-oncologist) said it best when he asked, "My God, isn't anyone interested primary care anymore?" What made me change my mind?
In our third year, my classmates and I discovered specialties that better fit our interests and abilities. Equally important, we were exposed to the realities of contemporary medical practice. Previously, I had thought that internal medicine consisted of diagnosing rare diseases and providing comprehensive care at the bedside. I never imagined that most of my time would be spent entering orders into a computer or arguing with laboratory personnel on the phone. I felt like Dilbert, minus the cubicle. Instead of examining patients with my resident, I would spend two hours of my day on "social work rounds," pleading with every social worker in vain attempts to "diurese" (discharge patients from) our service. Every morning, I listened to my resident complain that the previous team had stuck him with a "Zen rock garden" (patients who would never be discharged for medical or social reasons). From now on, he would assert, our team needed to focus its energy on "dispo" (discharging patients).
Rather than scheduling follow-up appointments for my patients, I would give them the clinic phone number, knowing that they would never call. Once, after admitting an elderly Hispanic woman with hyperkalemia, I immediately administered the necessary medications. As soon as her potassium level fell below 5.0, my resident told me to send her home. He was a good teacher, always willing to explain things and help me to expand my limited assessments and treatment plans. But he was downright nasty to nurses and social workers. Although proud of the fact that he got two nurses fired at the Bronx VA Hospital, he told me not to mention his name on social work rounds. Because the staff had rebelled against him, it was that much harder for us to get our work done and our patients out the door. Though I received an "Honors" mark for this rotation, and my resident called me his "savior," I certainly didn't do everything I could have done to help these patients. I wanted to send them home, so I could go home, too.
I suppose that, as an anesthesiologist, it is harder to short-change a patient. These days, lifestyle considerations and the thought of graduating in six months with $150,000 in educational loan debt have made a lot of my classmates take the ROAD more and more frequently traveled by. (ROAD is an acronym for the most popular residency programs: Radiology, Ophthalmology, Anesthesia, Dermatology.)
During my first two years of medical school, we had a weekly class called the "Art and Science of Medicine" (ASM). This was implemented to teach us history and physical examination skills and to provide us with regular patient contact. We also had seminars and small group discussions on medical ethics, end-of-life issues, surrogate decision making and "professionalism." (I still don't know exactly what professionalism is, but my instructor paraphrased Supreme Court Justice Potter Stewart's explanation of hard core pornography when he said, "I'm not going to attempt to define it, but I know it when I see it.") I relished interacting with patients during ASM, when I had two hours to spend with each one. Although my rambling, unfocused history taking and meager physical exam skills probably didn't instill confidence in my patients, I managed to find out that one of them worked as Italy's ambassador to the UN in the 1960s. Still, I failed to obtain the pertinent positives and negatives regarding his chest pain. Yes, third year was a rude awakening for me.
After a blissful week of anesthesiology, where I became a passive learner shooting the breeze behind the curtain, I started my surgery clerkship at an urban hospital in the world's most diverse zip code city. At the start of morning rounds on the first day, my chief resident told me: "This team is going to run with or without you — try to keep up." Then off he ran, literally and figuratively. Afterwards, he wouldn't give us medical students opportunities to present our own patients. Then he used to scream at us for not sounding polished during rounds with the attending physicians. Clearly, he didn't like me. While preparing a patient for a cholecystectomy, he snapped at me. "Dude, surgery is all about doing stuff! Why don't you do something while you're in the OR?" The next day during an appendectomy, when I tried to hand him a retractor, he said: "Don't ever touch anything unless I tell you!" This behavior continued for three weeks. I was so stressed out that I had an extensive exacerbation of my eczema. I couldn't believe it — I was actually "allergic" to general surgery! In his defense, my chief resident was under duress as well. We had nearly 20 patients on our service at any given time, and he was interviewing for a colorectal fellowship. I doubt that he saw his wife during daylight hours. Even his colleagues told us: "When S. was an intern, he was so laid back and funny — always cracking jokes. But over the years he's become such a hard-ass!" He would address his patients: "Hey, where's your pain?" and tell them, "Hoy, a la casa!" Although technically a skilled surgeon, it seemed like he only cared about removing diseased organs. He never stepped back to ponder what an amazing thing he was doing — he was literally saving lives every day. He never let that joy seep into his soul. I suppose that he was too busy taking out his frustrations on me. On my last day, he found his newest victim — a surgical intern from China. The last thing I remember him saying to this intern was: "Do you think this is funny? This is fucking incompetent." I was glad to leave. I have no interest in pursuing a career in general surgery, because I don't want to end up like S.
Yet I have had the pleasure of working with many bright, compassionate house officers — people I want to emulate as a physician and as a human being. During my inpatient medicine rotation, I was assigned to the HIV and oncology service. Many of our AIDS patients were living on the edge — homeless, IV drug users, not on HAART, with very little insight into their disease. I remember buying one patient an ice cream sandwich in order to induce him to undergo a high resolution CT scan to evaluate a lesion in his lung, only to have him request eggs and sausage the next day. When I said no, he spat at me and signed out against medical advice. Another diabetic AIDS patient repeatedly screamed: "I want sugar for my coffee!" at the Nurses' station until we called Security. They sedated him with "Vitamin H" (haloperidol). None of this bothered Andrew, my resident. He had a smile on his face each morning and kept his cool no matter how his patients acted. One morning, when my patient, a very sick man with AIDS, died, Andrew sat down with me and asked if I wanted to talk about it. He reassured me that there was nothing I could have done to save my patient. He didn't blame his patients for their illnesses, even though many were self-inflicted. He felt that, as a physician, it was not his role to punish them for their indiscretions. I admired the way he treated the staff — nurses, phlebotomists, transport personnel. He ruled by friendship, not fear. People are much more likely to do work for those they like. When I am an intern next year, I will continue to think: "What would Andrew do?"
The transition from medical school to residency is daunting. It's strange to think that my first real job will be one of the most grueling out there — mentally, physically and emotionally demanding. Those residents responsible for teaching us should keep in mind that we medical students are always observing them and trying to emulate them. Resident and attending physician behaviors and attitudes influence students at all levels. The use of teaching staff as role models for professional behavior has long been an informal part of medical training. I believe it is more important than the first two years of medical school. Negative role models during the clinical years of medical school contribute greatly to a loss of idealism and an overall sense of bitterness towards the profession and patients alike. These attitudes turn medical students away from certain fields toward more "benign" lifestyle-oriented specialties. The most sought after careers in medicine are not necessarily those associated with a holistic, patient-centered approach.
References
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Wright SM, Kern DE, et al. "Attributes of Excellent Attending-Physician Role Models." N Engl J Med 1998;339:1986-93.