Chapter 54: Trouble Brewing

June 4, 1987, McKinley, Ohio

"I really should hit a bucket of balls first," I said to Doctor Roth as we left the clubhouse.

"Our tee time is set, so that won't work. I know you're rusty, and we'll make allowances."

"I'll do my best," I said.

"You're playing in your cassock?" Doctor Lindsay asked.

"Playing golf doesn't fit within the list of exceptions my bishop provided. Other than medical necessity or custom, the only exception I have is for playing in my band, because technically, clergy are prohibited from playing instruments of any kind or performing on stage in any capacity. Modern practice allows both, with the blessing of the bishop."

"That doesn't constrict your swing?"

"My wife made me several cassocks, including the one I'm wearing, that fit loosely enough to participate in sports like golf, touch football, or baseball."

"That's handmade?" Doctor Getty asked.

"Yes."

"Your wife is an expert seamstress! I can see the quality work on that garment rivals anything I've seen at a professional tailor shop!"

"I'll let her know you complimented her."

We approached the first tee, and after the Starter gave permission, we teed off, with Doctor Getty going first, Doctor Roth second, Doctor Lindsay third, and me last. My drive was sub-par, but I at least managed to keep it on the fairway, though only just.

"Doctor Lindsay," Doctor Roth said, "would you feel comfortable with Mike handling suction for our bowel resection on Monday?"

"That's not typical for a Third Year," she countered.

"That's not what I asked, Doctor," he said firmly.

"Based on his history and grades, if he were a Fourth Year, I would say 'yes'."

"Again, not what I asked."

"No."

"Justify that decision," Doctor Roth ordered.

"He has insufficient time in the OR, and there is no substitute for observation."

"What do you think, Ron?" Doctor Roth asked Doctor Getty.

"I think he's not my Clerk, that's what I think!"

"Would YOU allow it if he was?"

"I wouldn't have this conversation in front of the student," Doctor Getty replied.

"Would you excuse Residents from M & M so you could talk about them behind their backs?"

"That's different," Doctor Getty objected.

"What did Doctor Strong say about Mike at our conference before the new crop of Clerks began?"

"Come on, Owen," Doctor Getty protested.

"He said, and I'm quoting here, 'Mike is better qualified in cardiology than the two most recent PGY1s'. So why would we hold him back? Doctor Strong referred to the article 'On the Training of Cardiologists' by Doctor J. Willis Hurst, which Mike showed him. I take it you read that article? I certainly did."

"There is a reason we do things the way we do, Owen."

"I'm not suggesting he do bypass surgery!" Doctor Roth said. "I'm asking about allowing the top student at McKinley Medical School, who aced the MCAT and MLE, and who Doctor McKnight wrote 'has the best hand of any student in my twenty years of experience' with regard to dissection. So, tell me, Ron, why hold him back?"

"It's your call, Owen. And your ass if it goes wrong."

"Mike, what do you think?" Doctor Roth asked.

"May I ask a question before answering?"

"Sure."

"Did you speak to Doctor Mertens in the past few days?"

Doctor Roth laughed, "Busted."

"Busted?" Doctor Getty asked.

"Mike lodged the equivalent of a formal complaint about how his final Preceptorship was handled. That took guts, and he nailed it, even citing that journal article we referred to earlier."

We reached my ball, so the conversation stopped while I used a long iron to get the ball within pitching wedge distance of the green. I was probably going to take at least a five on the par four unless I pitched perfectly onto the green and sank the putt.

"What happened?" Doctor Lindsay asked.

"I was in a family medicine practice that took the 'observation' rules to the extreme. No questions, no interactions with patients, just stand or sit and watch and listen. I learned nothing during the entire time. Previous to that, I'd been at the McKinley Free Clinic where I was allowed to draw blood, take histories, and have direct patient interaction, within the bounds of the rules for students who haven't passed step 1 of the MLE. You know how much I worked with Doctor Strong, and Doctor Roth mentioned my pathology rotation. So, I went to Doctor Mertens to solve the problem for future students."

We reached the other doctors' lies, and they all had good second shots, with Doctor Getty reaching the green, with the possibility of a birdie.

"What Mike hasn't said is that I promised him that he'd be able to participate more than a typical Third Year if he made surgery his first Clerkship. He's kept his part of the bargain."

"You're likely to upset all the Fourth Years and PGY1s," Doctor Lindsay said.

"If I had a dollar for every hurt feeling of a medical student or Intern, I could give away my services and still live a comfortable life!"

"You're going to hear about it from the other surgeons and Attendings in other departments," Doctor Getty said.

"It sounds as if you've already made your decision," Doctor Lindsay said.

"Which doesn't preclude confirming it with other doctors. We're going to give Mike the opportunity to show his stuff."

"What about Doctor Taylor and Doctor Young?"

Doctor Young was the other PGY1 on our service, whom I had met earlier in the day.

"He's a big boy," Doctor Roth said. "He'll get his chances. He's been on my service for four days. I had Mike for eight weeks before, so, in a sense, he's a known commodity. I've seen nothing about Doctor Taylor or Doctor Young that gives me pause, and you need to tell me what he's ready for."

I was very happy that the conversation shifted away from me at that point, and I was able to mostly enjoy what turned out to be a mediocre round of golf, where I managed two bogies on my best holes. When we finished, everyone changed into street clothes and I changed into one of my more form-fitting cassocks.

"Let me buy you a Coke," Doctor Roth said. "I know your teetotal."

"OK. What's your approach?"

"I'll have a beer on occasion after a round of golf, so long as I have eight hours before I have to be at the hospital. At conferences, when I'm not going to be operating, I'll have a bourbon or two, and wine with dinner. But I didn't touch a drop during my last two years of medical school and my first three years of Residency."

We went to the bar and Doctor Roth ordered a beer for himself and a Coke for me.

"Comments?" he asked.

"It was a bit uncomfortable, but nothing like what an M & M will be if things go south with a patient."

"A good insight. I felt it was important to leak what I was doing. I'll get some grief about it, but you hit the nail on the head in your written complaint to Doctor Mertens. The thing that stood out was your statement that you were not trying to upend the system, but to fix things in your little corner. That is exactly how change is done in the medical community. Somebody takes a stand, does something differently, other people see it, and it spreads. That's how Preceptorships came here. Doctor Nelson, the former Medical Director of the hospital, read about the innovative program in Indianapolis and brought it here."

"I interviewed there," I said.

"I know. I read your entire file last week, starting with your application. As Ron said, it's my butt on the line, so I looked at everything to find any weakness; anything a critic could throw back in my face if something went wrong, or, as you heard, before something could go wrong. I'll get pushback because I'm doing something differently."

"You want me to be a surgeon that badly?" I asked.

"At least as badly as Loretta wants you in the ER!"

"How upset would you be if I split the difference?"

"Dual track? Similar to the program Doctor Al Barton created in Indianapolis and is implementing in Chicago?"

"Yes. I know it hasn't been done here, and I'd need your endorsement along with Doctor Gibbs', and the Chief Attendings and Medical Director."

"You're going to design your own program?"

"I figured I'd take a cue from the program in Indianapolis. It's two years in the ER, a year of general surgery, another year in the ER, then three years in surgery, or something similar."

"I could probably endorse that, so long as you were officially on the surgical service and covered the ER. That would actually help both services, because with two or three Residents trained that way, we wouldn't need to cover the ER on call the way we do now. And it would improve patient care if someone licensed to do basic surgical procedures was in the ER full-time. I want you to write it up."

"Write it up?"

"A proposal. We'll have to create a new Resident slot jointly managed by the ER and Surgical Service. I'll get you the proposal we used when we created the dedicated emergency medicine positions six years ago."

"You want ME to write it?"

"If you can't defend it, you can't do it. You have a year to get it done before the Residency Committee. I'll provide guidance as you need it, and I'm sure Loretta will as well."

"She's not going to be happy."

"Make her happy. You made the argument to me, now make it to her."

"Sure, after you called 'dibs' on the position!"

He laughed, "It would end up that way, anyway, because your license would include surgery, which means you have to be supervised by the Chief of Surgery. One thing you need to consider, and that's a Fellowship. Most likely you'll need to do that somewhere besides Moore Memorial Hospital, because our Surgical Fellowships are limited to cardiology at this point, and there are no Fellowships in emergency medicine here.

"A Fellowship is not strictly required, and you might have trouble finding a one in your dual-track specialty, but that's eight years away, and a lot will change. Emergency Medicine only became a truly recognized specialty in '79 with the formation of the American Board of Emergency Medicine."

"I remember how it was, at least fictionally, from Emergency."

"That wasn't far off, really. Our ER here was covered by Surgery and Internal Medicine, with other departments providing occasional backup. Pediatrics usually had someone in the ER, but not always. Our first dedicated Attending in Emergency Medicine was hired in 1981, the year you started college. His staff was all seconded from Internal Medicine for the first two years. Then things began to change to what we have now. That's why I want you to review that proposal. It's recent and successful.

"If you want it, you're going to have to make it happen. Marshal your arguments, find allies, determine who is going to oppose the proposal, feel them out for their arguments, then counter them in your proposal. And be prepared for a hell of a fight. If you're as good as you appear to be, it'll happen."

"A test?" I asked.

"Yes. Everything you do, as of last Monday, is a test. Everything. Getting out of bed in the morning. Brushing your teeth. Making love to your wife. Chasing labs. Taking histories. Interactions with other students, Residents, Attendings, nurses, orderlies, lab techs, and families of patients. ANY of those things can trip you up and cause you to flame out. Mistakes are going to happen; it's how you deal with those mistakes that will answer the question — is Michael Peter Loucks worthy of the title 'Doctor'."

June 5, 1987, McKinley, Ohio

"I can't leave you unsupervised for two minutes, Petrovich!" Clarissa laughed, shaking her head.

"I didn't DO anything, Lissa!" I protested. "Well, other than what any medical student is supposed to do!"

"And yet..." she smirked as we closed our lockers.

"On the plus side, I get to design my own Residency program."

"Assuming a bunch of doctors who hate change approve a major change."

"I'll just turn on my charm!" I declared as we walked to the nurses' station to gather the necessary charts for pre-rounds.

"Be careful with THAT, Petrovich! That got you into all kinds of trouble at Taft!"

"No risk there, Lissa. I know that was Doctor Mercer's big concern, but honestly, I don't see it. I'm energized by challenges. If there's a risk, it would actually come from boredom."

We joined the rest of the team in the lounge to go over the charts, and I made notes in my 'patient' notebook, which I had decided to keep separate from my surgery notebook. That way, the surgery notebook only had procedure notes, and would serve as a pocket reference. The patient notes were transient, and once a patient was discharged, mostly of little importance. I also had a third notebook in the pocket of my medical coat for interesting or abnormal cases.

Each of the three teams only had one surgery scheduled for the day, as the afternoon was occupied by 'Grand Rounds' and a lecture. There were four patients who were to be discharged, provided there was nothing wrong with their overnight labs or morning vitals, and five patients who were recovering and would be discharged over the next few days.

Doctor Roth was performing a carotid endarterectomy, and I'd memorized the procedure the night before, as was my usual practice, as well as consulting my textbooks on the contraindications and risks. During rounds, I was called on to give the list of potential complications.

"Stroke, which occurs in up to 5% of patients, with the risks for symptomatic patients being about double that of asymptomatic patients. Mr. Becker is symptomatic. Cranial nerve damage is possible, though unlikely. There are also the usual complications of any surgery — bleeding, infection, and post-operative pain. Care needs to be taken during the surgery to minimize the risk of cerebral hyper-perfusion syndrome."

"Very good," Doctor Roth said.

Clarissa was asked the same information for her team's patient, who was having a cholecystectomy, and answered correctly as well. Doctor Young was tripped up on a question about the post-surgical treatment of a prostatectomy which had been done the previous day for cancer. I made a mental note to look up post-surgical treatments for cancer patients, though I suspected it would depend on the type of cancer, its extent, and the success of the surgery.

The surgery was routine, with no difficulties encountered, and once we finished, we went to the lounge to relax until lunch, which we ate together as was the usual team practice, then spent an hour preparing for 'Grand Rounds', which actually weren't done by walking from patient to patient, but were done in the lecture hall normally used for M & Ms. All patients in all wards and on all services were presented, though most only received cursory attention.

There were very few interesting cases, which according to Doctor Lindsay was the norm, but it was interesting to hear the breadth of cases, as well as watch the PGY1s make the presentations and be grilled on those few interesting cases. When 'Grand Rounds' ended, Clarissa and I went to get coffee, then returned for the lecture for Third Year medical students.

The lecture was on general hospital procedures, much of which I had picked up during my Preceptorships. Without that innovation, all the material would have been new, and this entire week would have been much more difficult. It confirmed what Doctor William Osler had said, as well as the journal entry I'd read. Books were OK, but they paled to being in the hospital or an active clinic or private practice.

We were allowed to leave for the day once the lecture was complete, but I sought out Doctor Lindsay.

"Would you go over the techniques for suctioning?" I asked.

"I wondered if you would ask, or rely on your textbooks."

"Experience is a much better teacher than any book," I said. "I can learn the rules of baseball from a book, but playing is much more than just following the rules."

"Let's go take a look at the machine," she said.

We went to the OR, and she explained the various parts of the machine and how to operate it, though, under normal circumstances, a circulating nurse would operate the controls while the doctor or medical student performed the suctioning. The main guidance was about proper settings on the machine, which involved decisions about volume versus strength, and how the machine was used to clear blockages in drains, to clear artificial airways, nasogastric tubes, and surgical fields. I made notes, and when I felt comfortable that I was prepared for Monday, I thanked her and headed home.

"How was your day?" I asked Elizaveta after she greeted me.

"Good. I spent the morning with Serafima and Alyssa, and the afternoon with Maria Petrov, Miloslava Sokolov, and Matushka Natalya at church. I answered the phones and straightened the offices while they cleaned the nave. How was your day?"

"Another good day, where I got to draw blood, do pre-op workups, and observe a surgery. We also had a lecture on hospital procedures."

"Have you given more thought to the proposal?"

"Doctor Roth left a copy of the proposal for dedicated emergency medicine specialists, and I was thinking I might call Doctor Al Barton in Chicago. He's developing a similar program in Chicago after he implemented one in Indianapolis. I suspect the medical student I met during my interview is in Residency at Indiana or maybe in Chicago with Doctor Barton, because her plan was to follow something similar to what I want to do."

"What did Clarissa say?"

"What do you think Clarissa said?" I chuckled. "That every time she leaves me unsupervised, I find a way to get into some kind of predicament!"

"A common problem for all boys!" Elizaveta teased.

"I'm a man," I corrected.

"Uh-huh," she replied skeptically. "A boy in a more developed body, maybe."

"I love you too, Kitten. Are you feeling up to going out tonight?"

"Yes. I went back to sleep after you left. Are YOU feeling up to it?"

"I am. Being at the hospital, especially in surgery or interacting with patients, energizes me. As I said to Clarissa, my frustrations are born out of boredom. This Clerkship will be anything but boring!"

"Do you know what movie the gang wants to see?" Elizaveta asked.

"The Untouchables was basically a unanimous choice, and I agree."

"Then go put on your cassock, and we'll go. The royal blue one, please."

"Yes, Kitten," I said with a robotic voice. "I hear and obey!"

She stuck her tongue out at me, and I was tempted to ask if that was an offer, but we could always do that later, and I didn't want to be late for dinner and mess up the plans for the evening.