Chapter 64: Challenges

November 30, 1989, McKinley, Ohio

"You asked to see me, Lor?" I said from the door to her office on Thursday afternoon.

"I wanted to discuss your evaluations of your students."

I closed the door and sat down.

"Problems?"

"Red tape. Because of the situation with Krista Sandberg, Mr. Crowe asked to see the evaluations you wrote, and I want to go over them with you before I send them to him."

"As if I'd change a single word because of an attorney's input?"

"Don't get defensive, Mike," Doctor Gibbs said. "It's just about ensuring our i's are dotted, and our t's are crossed."

"Again, my evaluations speak for themselves, and the prose expresses my opinions accurately. It's not as if I used epithets or racially or sexually derogatory words or phrases!"

Doctor Gibbs sighed, "Can't anything be easy with you?"

"Apparently not," I replied. "Look, Krista and others have been assigned to me because they were clinically or attitudinally challenged in some way. I've helped most of them, with only Tim and Krista having negative outcomes. If my evaluations are such a concern, then don't assign me reclamation projects."

"Damn it, Mike!" Doctor Gibbs growled. "Will you just stop?!"

"If the bureaucrats and lawyers would stop, I wouldn't have any reason to respond this way. Next time you have a reclamation project, assign them to someone else."

"Mike..."

"All I've ever done is try to do what's right, try to do what's best for patients, and try to do what's best for medicine. And at every turn, some bureaucrat or lawyer or dinosaur gets in my way and slaps me down. I just want to be the best doctor I can be and provide the best possible care for my patients. I have ZERO time for bullshit. Zero. Everyone else seems to have infinite time for it while at the same time bemoaning a lack of resources to care for patients. And this conversation is bullshit, and you know it."

"What is it you think I should do?"

"Push back. Say what I said, but use whatever you feel are politically acceptable words."

"Why do you assume I didn't push back?"

"Because you would have led with that; you didn't, so you didn't."

"I did, but I was told to do this. And, despite your holier than thou act, YOU know the hospital has to protect itself from lawsuits and damage awards, otherwise there wouldn't BE a hospital. So, get off your damned high horse and CUT ME SOME FUCKING SLACK! Now, are you ready to go over these evaluations?"

"Sure," I said flatly.

"For fuck's sake, Mike!" Doctor Gibbs exclaimed in exasperation. "I didn't find anything that I felt needed to be changed. Why are you doubting yourself?"

"I'm not! I'm doubting the ability of the administration to be more concerned about medicine and medical training than covering their asses."

"Listen to yourself! Every single time you make a note on a chart beyond the vitals and orders, you're covering your ass! That's what all your notebooks are about. Yes, you portray it as improving patient care, but it could easily be seen as ass-covering. It all depends on which perspective you take.

"You're so anti-bureaucracy and so anti-administration, you can't see that what they're actually doing DOES improve the provision of medical care. Someone has to collect the taxes, someone has to run the business, and yes, the hospital IS a business; someone has to do all the bullshit that you sure as hell don't want to do!

"Even if we eliminated bullshit lawsuits and Federal bureaucracy, someone STILL has to pay the utility bills, staff the cafeteria, ensure the floors are mopped, order supplies, and on and on. What I don't get is why YOU don't understand that! You're the one who makes the point that medical care requires the concerted effort of doctors, nurses, medical students, nursing students, and clerks. SOMEONE has to do the scut. That's true on the business side too!

"So, bottom line, cut the attitude, face reality, and quit being an extreme idealist who looks down on anyone who doesn't live up to his own standards. Maybe THIS will get through your thick skull..."

She opened her desk drawer, pulled out a Bible, and opened to a page she had marked.

Judge not, that you be not judged. For with what judgment you judge, you will be judged; and with the measure you use, it will be measured back to you. And why do you look at the speck in your brother's eye, but do not consider the plank in your own eye? Or how can you say to your brother, 'Let me remove the speck from your eye'; and look, a plank is in your own eye? Hypocrite! First, remove the plank from your own eye, and then you will see clearly to remove the speck from your brother's eye.

"Now, can we STOP with the bullshit?" Doctor Gibbs asked, closing the Bible and putting it back into the drawer.

"Fighting dirty, are we?" I asked.

"Hitting you where you live is good tactics, not fighting dirty."

"I smell a rat!" I said with a smile. "I'd like to see that Bible, please."

"Admitting nothing, what makes you smell a rat?"

"You don't go to church, and Bobby is Catholic, so any Bible you had at home would be either the New American Bible or the New Jerusalem Bible, and you quoted the New King James, which is the one the Orthodox Church uses. That means you consulted with either Ghost or Clarissa, and they gave you the correct version. My money is on Clarissa, but Ghost wouldn't surprise me."

"You are a ROYAL pain in the ass, Loucks!"

"Don't bring a knife to a gunfight! I concede that I had my back up and that bureaucracy annoys me. I shouldn't automatically take it out on you. I apologize."

"Accepted. But does that mean you'll coöperate?"

"I reserve the right to object in the future."

"Object away. Come in and bend my ear. But don't blame ME for the system, and absolutely don't take it out on me. Hell, you're Cutter's guy; give HIM both barrels starting in January! Now, let's discuss Nicole, Sophia, and Marv."

"Is there any concern at all?"

"You tell me. Anything I need to know?"

"You'd only ask that if you knew something. If I had to guess, you somehow know that Sophia and I dated casually and briefly during my Sophomore year at Taft. And that had NO effect on my evaluation of her. She's married to my best guy friend and has been for two years."

"Don't you think you should have disclosed that beforehand?"

"I didn't see the need. If we'd dated recently, then I could see it, but she's a friend and I had disclosed that I had an outside relationship with her."

"Friends is different from dating."

"It is. Friendship is more likely to create problems than a past dating relationship that ended amicably. What, pray tell, happens when Nora Mertens convinces five of the six members of the study group I'm mentoring to attend McKinley Medical School? Or when Jenny Leonard attends? Would it be fair to them to exclude me from training them because I mentored them beforehand? Or if someone I mentored as a Third Year who became friends with me is assigned to me?

"Or, what happens when an ED Resident takes a shine to a promising young student during his Preceptorship, then mentors and guides him during his Clerkship and multiple Sub-Is AND writes his evaluations? And recommends him for the Match after having dinner at his house, attending parties at his house, and inviting him for pizza in her apartment? You know darn well that NONE of those are considered ethical violations, so there is no need to belabor the fact that Sophia and I dated briefly when our close friendship is more important."

"Circumstances."

"Does anyone but you know the additional information?"

"I don't believe so."

"Then let it be. There is no way that Krista Sandberg is going to try to use that against me. I'm her best witness! And nobody can point to favoritism with Sophia. Her evaluation is accurate and was confirmed by Doctor Baxter and Doctor Billings."

"Are there any other potential landmines?"

"Sophia is not a landmine. There are no landmines. As I said in my deposition, I have not engaged in any inappropriate relationships during medical school or Residency. I'll extend that and say that I've never engaged in any inappropriate relationships as defined by my ethics or state law."

"Your ethics?"

"The hospital's ethical rules were no limit, as we've seen clearly demonstrated. Neither were the medical school rules, as we've also seen demonstrated. So yes, mine. I have friends, and yes, I have had sex with girls who were just friends. But never anyone subordinate to me or supervising me while I was in medical school."

"Interesting qualification."

"No comment. Please just drop the Sophia thing. There's zero risk to the hospital, and I'm positive the evaluation is unbiased and based solely on her work during her Sub-I."

"I don't disagree, but I'm positive you're aware of how it might be spun."

"Had it been after Elizaveta reposed, it would have been a different story, but it was seven years ago. And, as I said, someone could spin our relationship into false claims of favoritism."

"Given nobody has said anything, and you disclosed a friendship, I agree that's the way to handle it."

"Thanks. I'll deliver the reviews tomorrow."

"Go heal the sick."

December 1, 1989, McKinley, Ohio

"Did you turn in your evaluation at the medical school?" I asked Nicole when we met on Friday morning.

"Yesterday after my shift."

"You're the first to receive an evaluation from me with the new forms and the new grading system. As you know, we switched from 1–5 to 1–9 for our grading system to provide a bit more granularity. A grade of 1–3 is 'Below Expected Performance', a grade of 4–6 is 'Expected Performance', and a grade of 7–9 is 'Above Expected Performance'. The grading criteria have changed as well, with specific descriptions of each evaluation provided to the reviewing physician. Did you have any questions about the evaluation forms?"

"No."

"I'll cover the numbers, and you can read the prose at your leisure. Overall, you were professional, respectful, proactive, and honest. I found no deficiencies in your professionalism. Those aren't scored numerically on the form, but if they were, 3 out of 3 across the board. Any questions?"

"I believe this is where it serves my best interest to say nothing!" Nicole declared.

I chuckled, "A lesson I should learn one of these days! For the four 'Patient Care' items, you received 6s for History Taking, Physical Exam, and Medical Decision Making, and a 7 in Clinical Reasoning. That leads to an above-average score. Questions?"

"How do I get all the scores in the highest range?"

"You can read the prose, plus review the evaluation criteria, but the short version is you have to be much better than the average student. According to the evaluation manual, scores above 6 are to be used sparingly. Remember, too, with these new forms, there is an overall grade, which is what will be reported. We'll get to that at the end. OK?"

"Yes."

"You received an 8 in Medical Knowledge and an 8 in Learning Skills. Your medical knowledge is above average for students at your stage of clinical rotations, and you ask all the right questions and make a serious effort to learn. Questions?"

"No."

"For the 'Communication Skills' category, you scored 6s on your communication with patient and their families as well as charts and notes. You scored 7 on oral presentation of cases. Questions?"

"No."

"And finally, you scored 8 on teamwork, yielding an overall score of 7, which is above average and in the 'exceeds expectations' range. Is there anything with which you disagree?"

"This isn't disagreement or a complaint, but is it possible for anyone to earn a 9 on the scale?"

"Officially, yes, but we were discouraged from assigning a 9 unless the student is so head-and-shoulders above every other student in that category."

"Would YOU have earned 9s?"

I chuckled, "I have no idea, but anything 7 or above is equivalent to a 5 on the old scale, given the criteria. The new system allows for more nuance than the old one. In any event, you did outstanding work and absolutely deserved an 'exceeds expectations' overall rating."

"What is reported with my transcript?"

"The overall score for each rotation. In this case, it will be seven of nine, with the text 'exceeded expectations'."

"Great! Thanks."

"Any feedback you want to provide for me?" I asked.

"Do you get to see the individual evaluations?"

"No. If there's a shortcoming identified, it will be communicated to Doctor Roth. Otherwise, I'll see my overall rating in early June when classes move up. Is there anything you want to say?"

"Other than you're a great teacher, and you gave me plenty of opportunity, no."

"I wish you the best on your next rotations, and I'll see you for your emergency medicine Sub-I!"

We left the consultation room and, together with Sophia, handled four walk-ins before it was time for Sophia's review. As I had with Nicole, I reviewed her scores, all of which were in the 'exceeds expectation' range, and she did receive a single 9 for Medical Knowledge. Her overall grade was an 8, though the guidelines had been fairly clear that those should be as rare as snow in July.

"You did excellent work, Sophia. Anything you want to ask or add?"

"Just that having been graded with the old system and received 5s across the board, it feels like a letdown."

I nodded, "I would have felt the same way, but I actually prefer the finer granularity, which allows me to distinguish between students, and the narrower categories, which allow for more effective evaluations. No other Fourth Year received an 8 as their overall rating for their emergency medicine Sub-I this rotation. You're still on track to graduate first in your class!"

"Yes, but now I can't have perfect scores in my rotations!" she groused.

"Remember, according to Doctor Mertens, any grade of 7 or above is equivalent to a 5 using the old system. The 8 and 9 are basically the checkmark on the old form."

"I suppose it's wrong to bitch about it, given I had the highest score!"

"You know I'd have bitched about it!" I declared. "There is one thing I do want to mention, and this is unofficial between friends, OK?"

"Of course."

"Doctor Gibbs discovered, somehow, that you and I dated when you were a Freshman at Taft and asked me about it."

"Because she thought you were biased?"

"She doesn't, but she was concerned about how it might play out if someone else accused me of favoritism because we were involved. As I pointed out to her, I disclosed our prior friendship and nothing in the guidelines applies to anything that occurred before entering medical school."

"Everyone is freaked out because Krista Sandberg has a legitimate claim against the hospital and King from Medicine."

"That is the bottom line, and, honestly, despite me going off on Doctor Gibbs about it, it shows they're finally starting to take the subject seriously. You know how bad things are, and this will improve them, even if it's uncomfortable at times."

"The next doctor who hits on me is going to find himself on the receiving end of a complaint."

"May I make a suggestion?"

"Of course."

"Give a firm 'no' that cannot be legitimately misinterpreted as playing hard to get and complain after the second time."

"I suppose that does make sense," Sophia agreed. "Tell them to get lost, and if they don't take 'no' for an answer, then complain."

"Exactly. And that goes for female doctors, too."

Sophia laughed, "I'm about as interested in that as you were in Lee!"

"So not!" I chuckled. "Do you have your interviews scheduled?"

"Yes. Five hospitals in the Bay Area — three in San Francisco, one in San Jose, and one in Berkeley. Of course, I want UC San Francisco, but any of the hospitals will be OK. Will you write a letter of recommendation for the Match?"

"At the risk of incurring the wrath of the OBs and surgeons here, yes, of course!"

"Thanks!"

We left the consultation room and treated an even dozen patients before lunch. After lunch, I stopped in to check on Nancy, then met with Marv to have his review. I explained everything as I had to Nicole and Sophia, then moved on to the details. His overall score was a six, which was above average and at the high end of 'meets expectations'.

"All done?" Clarissa asked when Marv and I came out of the consultation room.

"Yes. Sadly, that also means tomorrow is your last day in the ED. And with you doing a Free Clinic shift on Thursdays, starting tomorrow, we have even less opportunity to see each other."

"We can try for dinner on Monday and Tuesday and lunch on Saturday because we won't be on the same service."

"Sounds good."

December 4, 1989, McKinley, Ohio

On Monday, I had found my new medical students, Jenny Brown, a Fourth Year, and Kelly Atkins, Sophia's flirty friend, who was a Third Year. At noon, when Jenny went off, John Abercrombie would come on.

"Good morning," I said. "May I see your procedure books?"

Both of them had entries appropriate for their station — the fourth rotation of their respective years. I'd reviewed their evaluations on Friday, and both had received average or above-average evaluations for each rotation.

"It's sink or swim time," I said. "Your emergency medicine Clerkship or Sub-I will be the most difficult of all your clinical rotations. This is where you prove you're qualified to be a physician. A sub-standard evaluation will make Matching with a good program difficult, if not impossible. Jenny, get the first chart in the walk-in rack, perform an H&P, then call me when you're ready to present. Kelly, observe, because you'll do one later today."

"Without you there?" Jenny asked.

"Without me there. I'll validate your findings, but this will be your first patient, and you'll suggest a course of treatment. Hop to it!"

"Right away, Doctor Mike!" she exclaimed.

They left, and I went to see Ghost, who was the senior doctor in the ED until 10:00am.

"I take it you turned your students loose on an unsuspecting patient?" he asked.

I nodded, "Baptism by fire, as they say, though it's not as if I sent them to receive an EMS run!"

"That might be a bit much! Your theory on how to teach is interesting. Not many Residents would throw newbies into the deep end this way."

"More like the kiddie pool," I chuckled. "I checked the charts before I went to see them and the first chart in the rack appears to be a severe ankle sprain from jogging. If they kill THAT patient, the patient wasn't going to survive if you and I were there with them!"