Good Medicine - Residency II
Copyright© 2025 by Michael Loucks
Chapter 53: Still a One-Hit Wonder
September 28, 1990, McKinley, Ohio
"How would you evaluate your training program so far?" Owen Roth asked at our team lunch on Friday.
"Overall, I'm happy," I replied.
"But..." Shelly Lindsay prompted.
She wasn't on the team, but had joined as she was my mentor.
"I'm not very good at sitting and waiting. Please don't get me wrong — the program is working exactly as designed and exactly as it should. I'd prefer to see more walk-in patients rather than sit in the lounge waiting for trauma or consults, but that's not my job. It's something I need to accept, just as I learned to accept that in nearly every case of an admission or a referral, I do not know the final outcome."
"You say 'should'," Owen observed, "but are there tweaks we can make?"
"I think the answer to that is 'always', but I think what I identified is a necessary effect of the position — I have to be available for trauma and MI patients, as well as for surgical consults. Patient care would suffer if I had to excuse myself in the middle of treating a walk-in.
"I'm positive that will happen at some point when the ED is slammed, and either Mary or I are seeing walk-ins that need more immediate attention than the assigned staff can provide due to patient loads, but we can't make that our normal operating procedure. It's like that at Cook County, even without a trauma surgery program.
"Perry Nielson has horror stories about walk-ins sitting in exam rooms for hours for something that should have taken twenty minutes because the treating physician was called away. That's the last thing I think we should encourage, which means Mary and I cannot, except in extremis, see walk-ins. And that means, for now, we'll have time where we sit and wait."
"What happened to the Mike I met three years ago?" Tom Dierks asked with a grin.
"He learned how medicine actually works, rather than how he wants it to work," I replied. "Trust me, I'm not done jousting with windmills by any stretch of anyone's imagination!"
All three surgeons laughed, and Lauren did her best not to.
"It's OK to laugh, Lauren," Shelly said to my student. "Mike is his own harshest critic, and he understands the nature of our laughter."
"Do you have any observations about the training program, Miss Peterson?" Owen asked.
"Me?" she inquired skeptically.
"You're an MS4, which means in eight months, you'll complete your eight years of training and be a doctor, so yes, you."
"I'm not quite sure how to judge Doctor Mike's training, but he's a good teacher."
"That is actually part of his evaluation," Doctor Lindsay observed. "What do you think of his role?"
"It's not for me," Lauren replied. "I prefer more orderly conditions."
"Cardiology, right?" Owen asked.
"Yes."
"Did Mike provide your evaluation?"
"Yesterday afternoon, after his lecture."
"I'll see it next week," Owen said, "but what did you write in the comments section?"
"Way to put her on the spot!" Tom Dierks interjected.
"I know Mike well enough that he already asked her that question once he'd provided her evaluation. Miss Peterson?"
"He did," Lauren said with a smile. "I wrote that he's an excellent teacher and mentor, and that he doesn't like rules."
All three of my fellow surgeons laughed.
"She has your number, Mike!" Shelly declared.
"No kidding," I chuckled.
"What I didn't write, because it wasn't appropriate, was that it's weird because he attends a church that has more complex rules than Calvinball!"
All of us laughed.
"I will point out that contra Calvinball, our rules NEVER change!" I chuckled.
That wasn't quite true, but close enough to not matter.
"All joking aside," Shelly said, "the rules Mike tends to object to are the ones that probably do need to be addressed, but the medical community and society are not ready to address them. He's not quite Cassandra, because we all know the points he raises are valid."
"So why not address them?" Lauren asked.
"I'll take that," I said. "It's a mix of inertia, tradition, and resistance to change, though the biggest reason is probably found in the idea that if something works, you don't change it lightly, even if it's not perfect. The system works, and actually works well, and radical change might well upset the entire applecart and leave a smoking ruin instead of an edifice."
"Talk about mixed metaphors!" Tom said, shaking his head.
"So sue me," I chuckled. "But the point is, we make slow, incremental changes; we have to make sure we don't destroy the village in an attempt to save it."
"A far cry from your attitude as an MS1," Shelly said. "You were a radical bomb thrower!"
"I'll leave the 'throw everything but the kitchen sink at it' approach to Medicine and Oncology! I prefer the precision of the scalpel. I have learned, Doctor Lindsay."
"Obviously!" she said with a smile. "But if I can't yank your chain, who can?"
"My wife, Doctor Saunders, Doctor Mary, my bishop, my daughter, my sister, my sister-in-law, my mom..."
Everyone laughed again.
"In all seriousness, Mike, is there anything you would change?"
"Seeing that Tom has a sandwich and chips, and therefore did not pick up a knife or fork, more opportunities in surgery."
"You performed an appendectomy as a PGY1!" Tom protested. "I couldn't even DREAM of doing that!"
"Me either," Shelly agreed.
"Owen did ask," I said with a grin. "As I was reminded many times, and as I remind my students, each of us is responsible for our training, and if we don't advocate for ourselves, who will?"
"On that, how did your lecture go yesterday?" Owen asked.
"I took them through two of my shifts from Hell to give them a picture of what it can be like. They looked like deer caught in the headlights."
"I have to say that's one thing that wasn't true for you," Shelly observed. "You were either completely ready for it or hid it well."
"I hid it pretty well," I said. "There are some things you simply don't forget."
"Your first burn victim?" Tom asked.
"Yes. Those are absolutely the worst, and that includes car-versus-train accidents. Of course, emotionally, the worst is telling a parent their child has died. I don't think I'll ever not be emotional about those, at least inwardly."
"If you weren't, you wouldn't be human," Owen said. "Lauren, what do you have next?"
"Cardiology."
"Mike, who do you have on Monday?"
"Kelly Atkins," I replied. "I know her from her Clerkship in the ED last December. She intends to Match for surgery. She's competent."
"That's damning in your book!" Tom declared.
"I've actually changed my evaluation criteria," I said. "Except for truly exceptional MS3s, saying they're 'competent' means they're following the program, and I'll reserve judgment until they're MS4s."
"Interesting," Tom observed. "Lauren, were you satisfied with your evaluation?"
"Yes. Doctor Mike provided good feedback along the way, so there were no surprises, and the comments were helpful and constructive. If you're wondering about why he didn't mark 'select for Match', it's because I made it clear I'm only interviewing in Arizona, where my family is. I hope to Match in Phoenix, but Tucson or Mesa would be fine."
We finished our lunches, and as we didn't have an afternoon surgery, I went to the ED to see Mary Anderson and found her in the lounge.
"Hey, stranger!" Mary exclaimed.
"I saw you last Thursday evening," I replied with a grin.
"And before these new shifts, we spent at least twelve hours a day together, six days a week! That was more time than you spent with anyone else!"
"True. How are things this week?"
"The usual mix of MVAs, MIs, and 'hold my beer and watch this' antics! How about you?"
"I've been allowed to close a few times this week. I told you about the resection and close on the emergency splenectomy I did last week. Another eight months, and I'll be able to scrub in officially as second surgeon."
"Think I'll get chances next year?"
"I'm positive you will," I replied. "And we'll have a third trauma surgeon who will take the night shift so you and I can alternate weeks in the ED and OR."
"Swapping days and nights gets old REALLY fast!" Mary declared. "But I knew the drill going in."
"Hi, Mike!" Ellie exclaimed. "Mary, EMS three minutes out with an MVA."
Mary and her student headed for the ambulance bay, and Lauren and I made our way back to the surgical lounge.
"It was weird the way everyone was talking at lunch," she said.
"I'm used to it; they've done that to me for the last few years. You handled yourself well, and I could tell Doctor Roth was disappointed that you're not trying to Match here."
"I like the hospital, but other than classmates, all my friends and family are in Arizona."
"Fundamentally, the same reason I chose this medical school and this hospital. The only way I would have wanted to Match at another hospital would have been if Rutherford Regional Hospital was a teaching hospital, which it isn't."
"I take it that's closer to where you grew up?"
"About ten minutes from the house I lived in from birth to age eighteen. It's about forty-five minutes west of here."
"I, for one, am glad you're here because you're easily the best teacher, bar none."
"Thanks."
October 1, 1990, McKinley, Ohio
When I arrived at the hospital just before 5:00am on Monday morning, Kelly Atkins was waiting for me at the Nurses' Station.
"Morning," I said. "Do you have your pager?"
"Yes," Kelly replied. "I just got it from Nurse Mary."
"Then let's change into scrubs. We're in the ED this week."
"Just this week?"
"We're alternating weeks between the ED and surgery; in the ED, we'll only handle EMS transports and surgical consults unless they're slammed. That's the new protocol. We'll scrub in as part of Doctor Roth's team on the alternate weeks."
We went into the locker room to change, and I had my first indication of possible trouble. Kelly had been flirtatious, and nothing Sophia had said to her had changed her behavior or her obvious desire to sleep with me. As she changed, I caught out of the corner of my eye that she was wearing sheer thong panties and a sheer bra. Nearly every female doctor wore plain white cotton underthings, and most medical students followed that pattern.
"When do I get to wear red?" Kelly asked.
"Once you're a Resident," I said. "All students wear light blue."
I tied on my surgical cap, then closed and locked my locker.
"Ready?" I asked.
"For anything!" Kelly said, invitingly.
I considered whether I should say something, but decided to simply not respond. If she didn't get the hint, then I'd say something, with either Shelly or Mary as witnesses. I had the rules on my side, but the last thing I wanted to do was report her to the medical school. Hopefully, she'd finally take the hint and drop it.
"Hi, Mary!" I said coming into the ED.
"Hi, Mike! I'm out of here!"
She left, and I erased her name from the board and wrote in mine, then went into the lounge.
"Do you have your procedure book?" I asked Kelly.
She handed it to me, and I reviewed her first two Sub-Is — Cardiology and Internal Medicine. She had the appropriate number of procedures, and there was nothing to indicate any trouble.
"Have you decided on a specialty?" I asked.
"Endocrinology," she replied. "I plan to interview here, plus in Akron, Columbus, Cleveland, and Toledo."
"I recall you wanting surgery."
"It's interesting, but I prefer more patient interaction, and endocrinology is a much shorter Residency. Add in less competition, and it makes sense."
"OK. Going back to your choice of locations — you're from Akron, right?"
"Yes."
"Is that where you plan to Match?"
"I'm not sure about my first choice; I want to wait to interview to decide."
"That makes sense."
"We're not allowed to see walk-ins?"
"We are, but given I need to be available for surgical consults, it doesn't make sense. Students are no longer allowed to assess patients without direct supervision, so if I had to walk out, you'd have to stop."
"What happened?"
"Nothing specific of which I'm aware; it's Dutch Wernher's ED, so he makes the rules."
"Morning, Mike!" Nurse Jacqui said from the door to the lounge. "EMS four minutes out with an MI. You're assisting Doctor Schmidt."
"Thanks, Jacqui; Kelly, let's go."
We made our way to the ambulance bay, grabbing gowns, gloves, and goggles on the way.
"Morning, Karl," I said to Doctor Schmidt.
"Hi, Mike!"
"Just let me know what you need me to do."
I knew the outcome the minute Roy gave the bullet, as I saw a fireman performing CPR on a morbidly obese man in his late fifties. Twenty minutes later, Karl and I agreed it was hopeless and called Isabella to pronounce the patient, and then Karl and I informed his wife of the outcome. It was a routine occurrence, and one that was easily preventable in most cases by diet and exercise.
"Why do people not take care of themselves?" Kelly asked.
"Human nature," I replied. "In general, we're not very good at assessing risk, and the further out the risk, the worse we are at assessing it. We also, for the most part, do not face our own mortality, and are confident we will be alive tomorrow, and the younger we are, the more prone we are to believe we will, in effect, live forever. And even if we do consider those things, dopamine is a powerful motivator, and easily overrides critical thinking."
Which fed right into Kelly's comment to Sophia that 'all doctors cheat' — dopamine was a strong driver towards behavior that generated pleasure, and given the long hours and stress, and the availability of willing partners who had the same long hours and stress, it wasn't really a surprise.
"They didn't cover that in endocrinology."
I was fairly certain they did, but, as with everything else, medical students were trying to drink from a firehose, and it was impossible to retain everything; even retaining most of it had required significant study, and that was still the case.
"There is quite a bit of material that is, in effect, glossed over with only a brief mention. That's OK because medical school classroom work is meant to be a broad overview with a focus on anatomy and organ systems. That is the core knowledge every physician needs. Clerkships are an introduction to the main areas of specialization, and Sub-Internships build on that knowledge.
"The key thing to remember is that as you progress, you narrow your focus more and more, and the only way to learn things outside your specialty is through your own initiative to read and study. I believe I mentioned the flashcard system my study group developed — I still review my flashcards because it's the only way to retain the knowledge outside my focus on trauma surgery. And all of that is why we call for consults for anything that is outside our area of expertise."
"You can read EKGs like a cardiologist."
I chuckled, "No, actually, I can't. I can read EKGs in a way necessary to treat a patient in the ED suffering from arrhythmia. Yes, I know some indicators, but mostly we're working with a 5-lead, so there is limited information. For me, reading a 12-lead is spotty — I can identify some of the more common conditions, but by no means anything like what even a PGY1 in cardiology could identify. As I've noted many times — medicine is highly specialized, and what you know outside your specialty is limited."
"I still think you know a lot outside your specialty, and more than the average doctor."
"If so, it's only because I study more."
"Pretty much everyone here thinks you're the best doctor in the hospital."
"And yet, I have patients die."
"If you mean like that obese man who was just brought in, nobody could have saved him, right?"
"That's true, which means being the best doctor doesn't mean I'm a god, or anything close to it. It's also the case that I couldn't properly treat a cancer patient, perform angioplasty, or perform neurosurgery, and I'll never be qualified to do those things. If I wanted to be, I'd have to give up trauma surgery."
"Sure, but that doesn't mean you aren't awesome."
"Ask my eldest daughter about that in about ten or eleven years!" I chuckled.
"Isn't that normal, though? I mean, my dad got all weird when I started dating."
"I bet you thought he was awesome before that, and you probably do now."
"Yes."
"Mike?" Nate said from the door to the lounge. "EMS five minutes out with multi-victim MVA. Ghost requested a surgeon, and you're the lucky winner!"
I chuckled, "We'll be right there. Kelly, let's go."
We put on gowns, gloves, and goggles and joined Karl, Letitia, Ghost, Becky, Kellie, and five medical students.
"Hi, Mike. Karl and I will take the first patient, you and Letitia the second. I'll call you if I need a consult."
"Got it. Letitia, what's your plan?"
"You take the airway; if a Foley is necessary, your student should do it."
"Got it."
In the end, the patients weren't severely injured, as both had been wearing seatbelts. Other than bumps and bruises, the only injury was a broken wrist for the driver, likely as a result of airbag deployment. Once the driver's wrist was splinted, both were cleared to be released, as they had no neural deficits.
That was the pattern for the entire day — none of the patients delivered to us by EMS needed surgery, and other than one intubation, I had no procedures. Mary arrived just before 5:00pm, and Kelly and I went upstairs. She had another two hours on her shift, so she went to the lounge, and I went to the locker room to shower and dress. Once I was dressed, I left the hospital and headed home to my wife and daughters.
October 4, 1990, McKinley, Ohio
"How are things going, Petrovich?" Clarissa asked when we met for lunch on Thursday before my lecture at the medical school.
"Pretty good. It's been a slow week, though, with only one emergency surgery, but I couldn't scrub in. How about you?"
"Similar — just routine cases. How's your hot-to-trot student?"
"Keeping it in check, though it's blatantly obvious what she wants. Fortunately, her shift is two hours longer than mine, so that isn't a potential problem."
"I'm curious..." Clarissa smirked.
"You know me; I don't think that way. I could always keep my libido in check when I wanted to."
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