Chapter 58: What do you want me to do?

December 2, 1988, McKinley, Ohio

"Doctor Javadi thinks you're a cowboy," Doctor Strong said with a slight smile.

"Permission to speak frankly?"

"Always, Mike, if we're in private."

"Doctor Javadi is chafing under the low-level hazing PGY1s receive and is champing at the bit for procedures in the cath lab or surgery."

"Something that has never bothered you."

I laughed, "Something that has always bothered me, I just don't let the Residents or Attendings know it! Ask Clarissa Saunders or Peter Baldwin, and they'll tell you about my griping at times!"

"Service with a smile, as they say?"

"Yes. I don't enjoy doing scut more than the next medical student, but I know it's a necessary part of training, and frankly, somebody has to do it. It makes sense to have the least skilled staff members do the scut, so long as it doesn't interfere with actual learning. That said, there are things to learn by doing scut, it's just we all want to do 'doctor stuff', and we're all champing at the bit for it.

"Anyway, in this case, as I said to Doctor Javadi, re-siting an IV is a nursing procedure, and I'm fully trained in inserting IVs. In the ED, I did it, and other procedures, without direct observation. We all know that's technically not allowed, but nobody follows that rule because otherwise doctors would be tied up watching medical students do routine procedures, which makes zero sense, especially in a busy ED."

"Out of curiosity," Doctor Strong said, "do you think that's true of all medical students?"

"It's true of those who have demonstrated their skills and knowledge, and who the Residents and Attendings trust."

"And does Doctor Javadi trust you?"

I saw his point immediately.

"She doesn't know me from Adam," I replied. "You and Doctor Getty do."

"And you hit her like a runaway freight train."

"I've found that being assertive is a primary trait for successful medical students."

"I don't disagree, but you might have given Doctor Javadi a full shift before you hit her with both barrels!"

"Besides my usual 'in-your-face' style, did I do anything wrong?"

"No. The policy in place for the nurses is because of an incident in June where a nurse didn't note an infiltrated IV on a chart. Doctor Getty put the rule in place to make a point. You were correct in that it didn't apply to you, and you updated and signed the chart. Angel performed the procedure because you spoke with authority and you knew what you were talking about. And no, she's not in any trouble, either, because you were speaking for Doctor Javadi."

"Advice?"

"Dial it back for doctors you've just met, especially PGY1s who often have a chip on their shoulder."

"Doctor Gibbs and others have worked to ensure I don't have one. I get lectured all the time!"

Doctor Strong laughed, "For a definition of 'lecture' that means 'friendly advice'! Has anyone ever spoken to you in a disciplinary way?"

"Not really. A few 'course corrections' but otherwise, just good advice."

"When you make your first major mistake, and you will make one, then you'll get a lecture! Or worse, have to stand up at an M & M and explain your actions and take the withering fire of Attendings and Residents looking to put you in your place, even if it's couched in a way to conform to the M & M 'no disparagement' rules."

"Advice on what to do about Doctor Javadi?"

"At this point, just continue and show her you know your stuff as a Fourth Year. For most students, I'd advise them to dial back the assertiveness a bit, but I don't want you to, and neither do Doctors Getty, Roth, or Gibbs. Just be smart about it."

"Will do."

"Any chance you can join us for golf on Thursday afternoon? You have it off."

I did, but I'd start a shift at midnight, and I'd need time to nap, but I could probably swing it, and the contact with the seven doctors who played in the two foursomes was valuable.

"I did promise I'd play when I had the time," I replied. "I just need to make arrangements for Rachel, which I can do."

"Good. We'll see you on the course at 1:00pm."

"OK. Do I need to worry about Doctor Javadi?"

"No. I discussed you with her, something I should have done before your first shift. And before I forget, thanks for the invitation to your wedding."

"You're welcome. Will you make it?"

"Yes. Obviously there are no scheduled procedures on New Year's Day, and Doctors Abbott and Javadi are the junior Residents, so they're stuck with covering the holidays. Doctor Bielski will be on call, as the junior Attending."

"OK."

"Oh, there is one more thing," Doctor Strong said. "A patient's wife visiting around 3:30am?"

"I judged it was in the best interest of the patient and his wife. Who ratted me out? The nursing supervisor?"

"Yes. Don't sweat it. She was just covering her butt. I'd have done exactly the same thing."

"Prognosis?"

"Not good. Severe ischemia and not a good candidate for transplant, if we could even get him a heart. You know the stats, right?"

"Around two thousand hearts are available for around half-a-million potential candidates. What is the contraindication?"

"Vascular disease in his neck. We'd have to send him to Cleveland Clinic because we can't do the procedure here. I'm not sure he'd survive the helicopter ride at this point. If he improves following the bypass, we'll re-evaluate for transplant, but as I said, it's not promising."

"Recovery, then ICU?"

"Yes."

"Did someone speak to his wife?"

"Doctor Getty and Doctor Edmonds."

Doctor Edmonds was a cardiothoracic surgical Attending I hadn't worked under.

"Out of curiosity..."

"Low man on the totem pole in the OR; I assisted Doctor Lindsay in harvesting while Doctor Edmonds and Doctor Getty performed the graft. To answer your next question, I've done a number of angiograms and angioplasties, basically on my own. You know how it works."

"I do. You have, what, four more years as a Resident?"

"Yes. Next year I'll study under Doctor Edmonds, and once I've done that, then I'll be able to do a bypass procedure as soon as Doctor Getty thinks I'm ready. You're in the same boat with eight or nine years of Residency."

"Eight plus a Fellowship."

"Same here; it's actually three more plus a Fellowship."

"Is there a Cardiology Fellowship here?" I asked.

"One was proposed for 1990 and is working its way through the system. Hopefully, I have the inside track, but you know doctors from outside the hospital will apply. I'm sure you're aware that there are other candidates for the trauma surgery slot."

"I actually asked when I had my interview."

"Of course you did!" he said with a knowing smile. "Anyway, that's all I had."

"Thanks, Doctor Strong."

I left his office and returned to the lounge, but Felicity wasn't there. I picked up my textbook to read until I was needed, or it was time for lunch. Just before lunch, Felicity returned from a consult on a rule-out MI, but it had turned out to be chest pains with a normal EKG and no elevated cardiac enzymes, so the patient was referred to his GP and advised to see a cardiologist.

Felicity and I had lunch together, then did afternoon pre-rounds, followed by rounds. I found it strange that she was busier than I was, but that was mostly because there were no scheduled procedures, and the norm was to take Third Years on consults, leaving Fourth Years responsible for the ward. Monday would be different, as there were four scheduled procedures, which would mean prep and aftercare, which very much fell on Fourth Years. Of course, that didn't help me, because I'd be in Pittsburgh interviewing.

The treatment of Fourth Years led directly to the treatment of PGY1s, and was why Doctor Javadi was relegated to consults and patient care, rather than assisting procedures. In a way, she wasn't all that different from me, in that she did not yet have a medical license and she was, like a medical student, working on the license of the supervising Attending. What I could do was limited by law, as I didn't have an MD, but her limits were imposed by Doctor Getty and the Medical Director.

All of that was one more reason for emergency medicine to be the best specialty in my mind. Even when I was a Third Year, I saw patients, performed procedures, and had more or less acted like a doctor. The downside of my training program would be going from the ED to surgery, where, for the most part, I wouldn't be doing procedures, though Doctor Roth had expressed his intent to treat me the way he would a PGY2 surgeon, rather than a surgical Intern. That had been his impetus for me to do the pathology Sub-I.

"Are you going to the M & M?" I asked Felicity when we completed rounds.

"I've never been."

"You should come along. We're given permission to go, and the most junior Resident covers the ward, which in this case is Doctor Javadi. She'll page us if she needs us, and of course, I might be paged for a code. In addition to the M & M, you should attend the lectures if they are of any interest. There aren't any in December, but they resume after the first of the year."

"I thought those were only for doctors."

"No, nurses, medical students, and technicians are also invited, in addition to doctors. Basically, anyone on the medical staff or medical support staff is invited. Let's let Doctor Javadi know we're going."

Once we'd seen Doctor Javadi, we headed for the auditorium for the M & M, with the main case being the mysterious death under anesthesia that Doctor McKnight and I had investigated. The tox screen had been negative, but there had been traces of metabolites of amphetamines. The patient had declared use of pseudoephedrine in the days before his surgery, though not within twenty-four hours, which would explain those trace metabolites.

Based on the patient's clinical history, the negative trauma tox screen, and investigation by the police, Doctor McKnight had concluded the patient had not used illicit drugs before his surgery, and had been truthful about taking an OTC medication containing pseudoephedrine. That left the death a complete mystery, something that was rare in a relatively young person in their thirties, but which did happen. The final determination was 'death due to unknown causes; no foul play'.

Doctor McKnight, Doctor Cutter, and Doctor Blake fielded a barrage of questions, all of which had satisfactory answers, save the most important one — why did an otherwise healthy thirty-seven-year-old with a benign tumor on his adrenal gland die during routine laparoscopic surgery.

"You assisted on that autopsy?" Felicity asked.

"Yes. I did a pathology Sub-I at the suggestion of Doctor Roth because it's about the only way a medical student will touch a surgical instrument."

"You seem to do things very differently from everyone else."

"I have strong opinions about how medicine ought to be practiced and how medical students ought to be trained. I've voiced my opinions, and I've been smacked down a few times, but I've also found sympathetic ears."

"Isn't it risky to rock the boat?"

"Yes, but my mentors are very good at pulling back on the reins to keep me from bolting. But if nobody speaks up, nothing will change. Everyone in my study group pushes the edges of the envelope because there are things we simply can't abide — racism, sexism, and ass-covering."

"What about favoritism?"

"That too," I replied, certain of what she'd say next.

"Says the guy who has the reputation as the teacher's pet!"

"I've earned the advantages I have," I countered. "Being first in my class and scoring in the 99th percentile on my exams, earning positive evaluations, and demonstrating my skills, abilities, and knowledge has earned me the trust of doctors, and that is the source of any advantage I have with them. Add to that my positive attitude and my unwavering dedication both to medicine and to practicing in my community, and it should be obvious that I'm not receiving special favors for any reason other than having earned them."

"You certainly have the ego to be a surgeon."

"While it might seem that way, all I did was counter the implication of what you said — that somehow I hadn't earned my position."

"And your father-in-law being on the Board of Directors has nothing to do with it, of course."

"It doesn't. If you have a formal complaint, take it to Doctor Getty. If not, then I'll ask you to not spread scurrilous rumors, because I won't tolerate it."

"Right, I'm going to go against the guy who has the entire freaking hospital in his pocket!"

"For the sake of argument, let's take what you said as true, even though I know it to be false. You have a limited set of choices. You can complain to Doctor Getty. You can ignore me. You can learn from me. Those are your options. Well, you could continue to talk about me behind my back, but if I get wind of it, I will be forced to respond, and that will not go well for you. You have to decide if you want to learn or not. It's your call."

"You don't have to be a jerk about it!"

"Says the person who accused me of having an undeserved position. Look, I've been directed to teach you, and I will, no matter what you think of me. Whether you learn anything or not is up to you. I've already shared some of my practices that my study group and I developed. Use them or don't. I'm going back to the ward."

I walked a bit quicker than usual, and took the stairs rather than the elevator, and when I arrived in Cardiology, I went to the Resident's office, where I found Doctor Strong with Doctor Javadi.

"Do you have a minute?" I asked Doctor Strong.

"Come in. Is this something you need to say privately?"

"Actually, I'd prefer that because I want some advice."

Doctor Javadi got up and left the office, closing the door behind her. Once she was gone, I related the conversation I'd had with Felicity to Doctor Strong and asked for his opinion.

"First, I'm assuming your reporting in this matter is as accurate as your reporting for medical matters. You spoke to her the way a Resident would have, which is both positive and negative. Positive in the sense that I believe what you said needed to be said, based on my reading of Felicity's previous evaluations; negative in the sense that you aren't a Resident.

"As a Fourth Year, your communications with Third Years should be collegial, not confrontational. You need to leave the confrontational style to the Residents. The substance of what you said was fine, but the manner in which it was delivered was not. That's an important lesson to learn, Mike. As a Resident, your communication with other Residents should never be confrontational, that's the job of the Attending.

"It's OK to challenge each other, but it needs to be done in a positive, rather than negative, way. In this situation, her criticism caused you to get your back up, and true to your reputation, you let your righteous indignation color your response. And while I get that it bugged you, ultimately, it's meaningless because we, and I mean the Residents and Attendings, all know you as deserving of the treatment you're being given.

"Don't let another student's or another doctor's petty jealousies cause you to behave in a way that might cause you to lose your position and your privileges. I know you're becoming somewhat impatient after seven-and-a-half years of education. You can see the finish line from where you're standing; just be patient, complete your rotations, Match, graduate, and then you'll have achieved the goal of being a doctor you've had since fourth grade. Don't stumble with the brass ring in reach!"

What Doctor Strong was saying was eerily familiar, and if I simply changed the context to church, he was saying much the same things that Father Nicholas and Bishop JOHN had said.

"I've heard something similar from my priest and bishop on spiritual matters," I admitted.

"Why am I not surprised?" Doctor Strong asked with a wry smile. "It's your personality, Mike. You just need to tune it to the situation in which you find yourself. There will be times for you to exhibit that attitude; this was not one of them."

"Should I apologize?"

"You tell me. Will it do more harm or good?"

I considered for a moment before answering.

"That's a good question, because apologizing might make it easier for her to accept instruction, but it might also be a tacit admission she's correct."

"So what if it is?"

I nodded, "I'll apologize to her."

"Make it a teaching moment, Mike."

"I will."

"On Monday, I'll get you into the cath lab with me."

"I have a Match interview on Monday, so Tuesday?"

"Sorry, I forgot. Tuesday, then."

"How do we handle codes in that case?"

"You won't be participating in the surgery, so you'll have to leave for the code. That said, you cajoled Doctor Javadi into allowing you to run the next code, so if you complain about having to answer a code page, I'll make sure you do nothing but Third Year scut for the next two months!"

"Me? Complain? Never!"

"Uh-huh," Doctor Strong said flatly, but then smiled. "Remember, we've all had situations like this, and some of us have had worse. Don't take this as a beating, but more of a gentle course correction. You're going to make an excellent physician, Mike. We just need to sand off the rough edges."

"I appreciate the guidance."

"You're on until midnight, right?"

"Yes, with Doctor Javadi and Felicity. Clarissa Saunders relieves me."

"OK. I'm off at 6:00pm and back Monday morning at 6:00am. Is there anything else you need?"

"No. Thanks."

"You're welcome. And Mike? This wasn't a lecture!"

I laughed, got up, and left the office. I left and walked back to the lounge, but Felicity wasn't there. Most likely she was either talking to Doctor Javadi or on a consult, so I sat down with my cardiology textbook to continue my refresher course. About fifteen minutes later, Nurse Cathy came to the door of the lounge.