Chapter 51: Medical Coat and Tie

September 4, 1990, McKinley, Ohio

"I see you found a way out of playing golf with us," Owen Roth said with a sly smile when I was summoned to his office late on Tuesday morning.

"That was not the intent," I replied. "But given we're so close to the end of the season and I haven't touched a club in well over a year, I didn't feel it made sense to try to play maybe twice before it's too cold to play."

"Reasonable," he said. "I do want you to teach, so I'll forgive the transgression!"

"Thanks, I think!"

He laughed, "In all seriousness, Mike, you're an excellent teacher, and I believe the students will learn quite a bit from you. Of course, you may give the other professors at the medical school heartburn with your, pardon the expression, unorthodox approach to medicine."

I chuckled, "About the only thing you could accuse me of being unorthodox about, given basically everything else I do is expressly Orthodox, with a capital 'O'. What schedule?"

"Nora asked for alternate Thursdays between now and the end of March, but not the weeks before and after Christmas. I agreed, though obviously you have to agree."

"I do. Starting when?"

"Next Thursday."

"That works for me."

"On Monday, you're assigned to my team. You'll have opportunities to cut, though I have to try to make them somewhat equal. We'll try to give you the appys and any other emergency cases where I think you're up for acting as second surgeon. Most of the routine stuff will go to Tom Dierks. Next year, as a PGY3, you'll be scheduled as second surgeon."

"Thank you."

"I'd like you to follow the surgical dress code, please."

I smiled, "It's actually logical because otherwise I'd end up using six or eight sets of scrubs, rather than three or possibly four. In the ED, it helps me stand out as a surgeon, and people in the ED actually expect physicians in scrubs, despite Dutch Wernher's opinion."

"Your views are starting to spread, and, to be honest, I agree that in most treatment situations, not only do scrubs make sense, but most people expect them. Where they don't is consultations with surgeons and cardiologists. I expect that to change, too, given society is becoming less and less formal ... Doctor Mike!"

I chuckled, "I get all the 'formal' I need in a church setting! In any event, medical coat and tie."

"Good. Has Leland Crowe given you any idea of when you'll be called and how long your testimony will take?"

"On the former, I'm his first witness, so when I'll be called depends on how long the prosecution takes. He expects his direct examination to take about four hours of testimony, but clock time could run longer if there are objections or breaks. He can only guess about cross-examination, but he believes they won't actually spend much time on any topics except my exam versus Paul Lincoln's and the indications of malignant hyperthermia during surgery. May I speak bluntly?"

Owen laughed, "The next time YOU embroider will be the first! Go on."

"I'm reasonably certain I'm going to sink the hospital because the Webbers' attorneys will elicit testimony that indicates we ignored the signs of malignant hyperthermia. We didn't, but the fact that I ordered the cold packs is devastating."

"Yes, but it was the correct thing to do. Please do NOT allow anything the Webbers' attorneys say to cause you to not act proactively. And that's probably all we should say about the case."

"One other thing — I'm sure you've realized Paul Lincoln is cannon fodder; he knows it, too."

"And here is where the adversarial system breaks down, and the system used by some countries, where an independent panel reviews the case and pays out according to a set schedule, is very attractive."

"We also need a better way of weeding out bad doctors," I replied. "We do a good job during clinical rotations, but we do miss some."

"We do, and that's an important part of your job, just as it is mine. See you bright and early on Monday!"

I left his office and went to the cafeteria to have an early lunch, as I had clocked out, so to speak, for thirty minutes. When I returned to the ED, there were no cases for us to handle, so I sent Lauren to have her lunch.

"How does it work next week?" she asked when she returned from lunch.

"Unless Doctor Roth says otherwise, you'll scrub in. Mostly, you'll observe, but I'll do my best to get you an opportunity to hold a retractor or suction. That's the limit of what you can do as an MS4, and remember, I'm third surgeon on anything other than appys and emergency cases where Doctor Roth believes I am qualified to assist as second surgeon."

"That's better than being assigned to a PGY1 or normal PGY2 who doesn't get into the OR at all!"

"Did you just call me abnormal?" I asked.

"Is this where if I were a doctor, I'd say, 'If the shoe fits'?"

"There is that," I chuckled. "In any event, we'll scrub in for at least one scheduled surgery a day, and as many as three, plus any emergency surgeries."

"Do I have to do anything for prep?"

"Review each of the surgeries the night before because either Doctor Ross or I will ask you questions. You should know the patient's condition, all vitals, all medications, the steps of the procedure, the risks associated with the procedure, the possible outcomes, recovery time, and post-operative care. Being able to answer those questions is what will get you a chance to hold a retractor or suction."

"OK. I didn't get into the OR very often during my Clerkship, but I did assist with prepping patients. What about Mondays?"

"You can check on Friday, but to be safe, call in on Sunday evening around 7:00pm. The Charge Nurse will let you know if there are any changes."

"Mike?" Ellie said from the door to the lounge. "EMS three minutes out with a possible MI. Doctor Jackson is catching it."

"We'll be right there!"

Thirty minutes later, we returned to the lounge after Cardiology accepted the STEMI patient.

"You're treated more like an Attending than a Resident," Lauren observed.

"Part of that is the function of my role — to provide surgical consults and perform emergency procedures. Any surgical Resident who came down for a consult would be treated more or less the same way — it's simply a function of how the services interact. The other part of it goes directly to what I said before about studying everything about a patient and procedure — demonstrate your knowledge, and when given the opportunity, your skills. If you do that, you'll be given more opportunities and have a bit more leeway without running literally everything by an Attending. It's all about trust."

"Do you trust me?" Lauren asked.

"For the things I ask you to do, yes, I do. For other things, it's a moment-by-moment judgment call. The thing is, as we discussed, there are limited procedures or tasks I'm able to assign you."

"You didn't have a trauma surgeon to train you, right?"

"Correct. The Residents who covered the ED trained me on the procedures; reluctantly in some cases."

"Why was that?"

"A mix of wanting to do the procedures themselves, and thinking I was too new. It's a different training program, and for now, at least, is unlike any other."

"For now?"

"There's a tug-of-war between the ED and Surgery as to whom trauma surgeons will report, as well as the best approach to training them. There's also no specific Board certification, so there is no national training standard. That will happen, and it may look significantly different from our current program."

The afternoon saw a moderate number of patients, but nothing exceptional, and I managed to have dinner with Clarissa.

"You're looking at the newest Associate Professor of Medicine," I said once we sat down.

Clarissa rolled her eyes, "Literally everything falls into your lap, Petrovich!"

"Because hard work and determination have nothing to do with success, right?" I asked with an arched eyebrow.

"You know I'm yanking your chain! What are you teaching?"

"A Practice of Medicine seminar on Thursdays when I'm assigned to surgery. I'll be teaching about emergency medicine, but I'll include other material as well."

"Nobody goes to those Thursday seminars!"

"They've made some of them mandatory starting this school year."

"That would not have gone over well with our group, at least during First Year."

"To be pedantic, if the sessions had been required, we'd have worked around them. But it's also the case we figured out we didn't need to study quite as much as we thought at first, and mellowed a bit once we finished anatomy."

"That's true, but there's no way we would have thought that at the beginning. We were using every second possible."

"Sure, but again, that would have reduced the possible study time, but in the end, not as much as we reduced it ourselves, even during First Year."

"Arguing with you is like beating my head into a wall!"

"Because it feels good when you stop?" I asked with a smirk. "Unlike certain other activities."

"Your French girl seems to be keeping you happy," Clarissa said with a smirk.

"Very! How are things with Tessa?"

"They're good. We're thinking about two years from now for a baby; starting the treatments, I mean. Well, unless the French girl has changed her mind about the direct method!"

"That's about as likely as me becoming a member of Faith Bible!"