Chapter 61: I Taught Medical Students in the Wards

December 7, 1988, McKinley, Ohio

"That's your answer, then," I said.

"OK," John replied, "but what about observing? Isn't that how we learn?"

"It is, but that part is a mix of low-level hazing and the fact, if you'll pardon the expression, that shit rolls downhill. As the most junior doctor on the service, she is assigned to do all the consults, pre-op and post-op checks, and supervise lowly medical students doing the scut she doesn't want to do. In January, she'll get into the cath lab or into an OR and, so long as Doctor Getty trusts her, start assisting with some procedures. Remember, a Residency in Cardiology is eight years; nine if you include a Fellowship."

"Yours is that long, too, right? Because of the surgical component?"

"Yes. The best part is that I'll be in the ED for two years, and emergency medicine scut is doing actual procedures and being involved in just about everything that comes in the door. Surgical Resident scut is more like what Doctor Javadi is doing and lasts for a couple of years. Because I'll be a PGY3 when I start the surgical part of my Residency, I'll get to participate right away."

"So you basically skip most of the bullshit, then?"

"Yes, because of the way emergency medicine handles Residents. Internal Medicine is perfect for you because the skills involved doing scut on that service are exactly the skills you need to develop for private practice. For example, when you run labs, review them and compare them with the standards. The new machine actually prints the ranges on the form, while the old one doesn't. You should learn the ranges so you're able to discern high or low values simply from someone telling you a patient's stats.

"When you do your emergency medicine rotations, get as much suturing as possible, and you absolutely should do an emergency medicine Sub-I, a pediatrics Sub-I, and two internal medicine Sub-Is. The other two can be whatever you wish, but a second emergency medicine Sub-I would be useful, especially if you focus on walk-ins, because that's what you'll encounter in your day-to-day work. I'll be an ED Resident when you do those Sub-Is, and I'll do my best to ensure you get cases that will help you be the best physician possible."

"I know I said this before," John replied, "but you're like the only person who doesn't look down on me for choosing to be a GP."

"Well, from my perspective as a prospective trauma surgeon, the better trained you are and the better job you do, the fewer patients who show up with acute medical conditions! Of course, that means patients have to actually follow your instructions, and all I can say there is 'good luck'."

"Why?"

"One thing you'll learn in the ED, Internal Medicine, and Cardiology is that patients routinely fail to follow physicians' instructions. A common one is not completing a course of antibiotics because they feel better. I'm sure you remember a discussion about that in pharmacology class."

"The resistant strains of bacteria, right?"

"Yes. And many patients don't follow diet or exercise plans, continue to smoke, drink to excess, and generally ignore good health advice. That will likely be your frustration for your entire career. Mine will revolve around 'hold my beer'!"

John laughed, "I've heard some stories!"

"When do you have your emergency medicine rotation?"

"Last," he replied.

"Then we'll be together there at some point, most likely. It's my final Sub-I, then I have a one-month break before I start my Residency."

"Why the break?"

"You only start June 1st if you start at your local hospital. Otherwise, you start two to four weeks after you graduate. I asked to delay mine so my wife and I can take a delayed honeymoon trip."

"I suppose you can't get away in January."

"I arranged with Doctor Getty to have five days off, but any more than that would mean seeking an exception and waiver, and I already did that during Third Year."

"I have to say I've never been so shocked to hear something in my entire life. I know it's late, but my condolences."

"Thanks."

"What now?"

"Now I'm going to take a nap," I replied. "Return the charts and you can sack out and wait for the inevitable consult, or perhaps, if you're lucky, sleep until 5:00am when we need to do pre-op prep and pre-rounds."

We got up and headed for the on-call room, and I barely made it to the door before my pager went off showing a room in Oncology. I pressed the button to silence my pager and hurried towards the stairs, moving quickly up to the fourth floor and then hurrying down the corridor to the oncology ward, arriving just before Doctor Javadi.

"No code should have been called," a male Resident said. "She's DNR. Sorry if we woke you."

"We just came on shift," Doctor Javadi said. "Need anything from us?"

"No. All the forms are properly countersigned."

"Who called the code?" Doctor Javadi asked.

"A nursing student; I'd rather they err that way than the other."

"Absolutely," Doctor Javadi agreed. "Let's go, Mike."

We left the room, and I accompanied her to the elevator.

"Does that happen often?" I asked Doctor Javadi.

"Once before, and nobody said the patient was DNR until after I brought him back with high-dose epi and compressions."

"Wonderful. What happened?"

"He coded again about three hours later. It was the middle of the night, so it wasn't as if the family was aware."

I hated the idea of not sharing full details about care, but what we could say to families was closely controlled by the hospital legal department. There had been pain and suffering suits for bringing someone back when they had a DNR order in other places, but so far, Moore Memorial hadn't had one of those.

"What's your save rate?" I asked.

"About what you'd expect — just under twenty percent."

We returned to Cardiology, and I went to the on-call room and climbed into the top bunk. I'd barely put my head on the pillow when a nurse came to get John for a consult in the ED. That meant I had the ward, but I could sleep until I was called, so I put on my soft eye mask and quickly fell asleep.

I managed to sleep all the way until just before 5:00am when Nurse Cathy woke me so that Felicity and I could do pre-rounds.

"Get any sleep?" I asked John, who was going off shift, when I saw him in the corridor.

"About ninety minutes total; we had three consults, conveniently spaced, so I only slept about thirty minutes in a stretch."

"Did you turn everything over to Felicity?"

"Yes. I went over all our notes from last night."

"Did she write anything down?"

"No."

"OK. See you at midnight tomorrow night."

He left, and I went into the lounge.

"Ready for pre-rounds?" I asked.

"Yes."

"First, check that all the labs are back, please."

"I know what to do," she replied.

"I'm sure you do, but that doesn't relieve me of the obligation to ask you to do it. I'm scheduled to observe an angio with Doctor Strong, so you'll need to be ready to present to Doctor Javadi. Now, please do as I asked."

I didn't see Felicity's face, because she'd walked past me to leave the lounge, but I could feel her roll her eyes. I resolved to simply do what Doctor Javadi, the other Residents, and the Attendings expected me to do, and that was ensure that Felicity, a Third Year, knew how to do chart summaries, knew how to prep for rounds, and knew how to prep patients for surgery.

Felicity returned five minutes later.

"All the labs were run."

"Did you bring the charts with you?"

"No."

Now I wanted to roll my eyes, but I didn't.

"The next thing we need to do for pre-rounds is chart summaries so you can present to Doctor Javadi. Go get all the charts and bring them here."

She huffed, turned, and left, and was back two minutes later.

"You could have told me," she declared.

"First, I said we needed to do pre-rounds, and this is part of it. Second, you told me you knew what to do. I'll give express, step-by-step instructions until I'm sure you do."

"Don't be a dick."

I wanted to retort and tell her not to be a whiney bitch. A different response was called for, as saying what I wanted to say would get me in serious trouble with Doctor Javadi, Doctor Strong, and Doctor Getty.

"It's not about being a jerk," I replied. "It's about you learning how Cardiology does things. Someone should have done the same thing for you in Internal Medicine and OB/GYN, though rounds in OB are different from those in Medicine or Cardiology. And Psych is very different. In any event, review each chart, make notes of conditions, vitals, recent atypical test results, and any overnight events. My advice is you write it down in a separate rounds notebook, as the summaries will change day-to-day and patients will change day-to-day. I use one that has loose-leaf sheets, which I replace every Friday. That allows me to refer back to previous days. I do not rely on memory."

"Not as smart as you pretend to be?" Felicity asked snidely.

"Wisdom, not intelligence," I replied. "I won't trust a patient's life with my memory about their specific situation. If I go to see someone, I review their chart first. Attendings do that because NOBODY has perfect memory. Wisdom comes in understanding our limitations and ensuring those don't impact the patients. Now, begin your summaries."

"And you're just going to sit and watch?"

"No, I'm going to do my own, and we can compare. The goal is for you to look good when you present to Doctor Javadi, so she's prepared for rounds."

"And she can't do this?"

"She'll select charts to read thoroughly based on your review. That's why we point out anything new or atypical. A stable patient needs very little time on rounds. One with worsening conditions or a complicated case needs more time. And before you ask, it has nothing to do with laziness and everything to do with efficiency. It's not a good use of Doctor Javadi's time to check labs and ensure charts are updated with recent vitals. That's our role because what we can do is limited."

"Hah! You have no limits."

"I'll stand to the side and watch the angio. Nobody is foolish enough to allow me to touch a patient in the cath lab except to help move them to the procedure table. Look, you can fight me or learn from me; it's your call. If you can't learn from me, then go tell Doctor Javadi and ask for a new shift."

"Yeah, right, like that's a good career move."

"Learn or don't," I replied. "That's one hundred percent on you."

A third mediocre evaluation, which she was on track to receive, would result in a tough conversation with her advisor, and serious questions would be asked and a remediation plan developed. From there, things could only get worse for her unless she lost the attitude and got her act together. She would not be the first to wash out due to poor clinical skills, but she still had a chance to succeed, if only she took it.

There was another way to look at the situation, and that was that there was a disconnect between how Felicity learned and how I taught, or that she simply didn't like me and that was interfering with her learning. The problem with that was two-fold. First, it was incumbent on me to figure out how to teach her, and second, she had to understand that she wasn't going to like everyone from whom she needed to learn. I could do something about the first thing, but only she could do something about the second thing.

As Felicity reviewed each chart, she made notes in a small notebook she had taken from her purse, then handed me the chart to make my own notes. We finished all eleven charts, and I asked Felicity to present the patients. She did a credible job, though her bad attitude clearly showed through.

"OK," I said. "Let's go prep Mr. Evans for his bypass. Once we do that, you can present the information to Doctor Javadi. Have you prepped a patient for a bypass?"

"No."

"Then just observe today, and you'll do the next one. It is fairly straightforward."

We left the lounge and went to Mr. Evans' room. His surgery was scheduled for 6:00am, which meant waking him to check his vitals, shave his chest hair and his upper leg, and get final pre-surgery labs. A nursing student, Mary, drew the blood and took the tubes to the lab for 'stat' analysis, I shaved Mr. Evans' chest and leg, then attached fresh EKG pads. The anesthesiology Resident and Doctor Getty arrived at the same time, spoke with Mr. Evans, and then pre-surgery sedation was administered. Once that was complete, I called for an orderly, and we moved Mr. Evans to the OR.

Once Mr. Evans was in the OR, Felicity went to find Doctor Javadi for pre-rounds, and I went to Mr. Carmichael's room to prep him for his angio. In his case, it was a matter of shaving just the inside of his thigh where the catheter would be inserted. The labs from the night before were sufficient, as he wouldn't be under a general. I had just finished when Doctor Schroeder, an Attending, and Doctor Strong came into the room.

They verified everything was in order, then left to change into scrubs while I waited on anesthesiology to administer the sedation. That happened about five minutes later, and I called for an orderly to bring Mr. Carmichael to the cath lab. Once he was situated on the procedure table, the nurses began hooking up the monitoring equipment, and I went to the scrub room. Five minutes later, I was in the cath lab, standing in the usual place for a student who was observing.

After a routine procedure, I helped an orderly return Mr. Carmichael to his room, as he didn't need to go to Recovery, and then went to see Doctor Javadi to see if there was anything I needed to do before rounds at 10:00am. She asked me to come into the Resident's office and shut the door.

"It won't surprise you that Felicity complained about you being condescending." Doctor Javadi said.

"First, may I ask how she did in presenting the summaries to you?"

"About what I would expect from a Third Year on her first clinical rotation."

"This is her third," I observed. "While OB is different, the procedures in Cardiology are almost identical to those in Internal Medicine, so she should be better. She claims to know what she needs to do, but it seems obvious to me that she does not. I'm not sure what to do at this point, and I'm concerned I'm not the best teacher for her."

"Undoubtedly," Doctor Javadi replied. "But as was explained to me when I had a serious dislike for a Resident during my very first rotation, which was pediatrics, that is not an excuse. I am sure you've run into someone who you disliked, or who had a style that clashed with yours. What did you do?"

"Found a way to work with them, which mostly meant me sucking it up and dealing with it."

"Which is what Felicity needs to do."

"I don't disagree, but I wonder if she might do better with someone else teaching her."

"Given the schedule, how would you propose to do that?"

"Is this where I say that's your problem, not mine?" I asked lightly.

"If you want to do only scut for the next fifty-four days!" Doctor Javadi replied.

"Not to be a smart ass, but isn't that what I'm already doing?"

Doctor Javadi laughed, "Unfortunately, that threat really only works against Residents, except in the ED, where you can be prevented from doing procedures if your Resident wants to punish you."

"Felicity is going to be a disaster in the ED," I replied. "Do you know when she has that rotation?"

Doctor Javadi smiled slyly, "Guess."

I groaned, "April, right?"

"Yes. And Mike, I know I'm a PGY1, but one of the lessons here is that you have to be able to teach anyone."

"I agree; but that requires a student willing to learn. She hasn't shown that to me, and in fact, actively rejects my input. To be blunt, she doesn't like me, for whatever reason. Actually, I'd say she despises me, or perhaps it's better to say she despises the way I'm treated. But to me, that reflects on her, because instead of taking full advantage, which she could, she's whining and complaining."

"Have you had any interaction with her before you started this rotation?"

"No. I generally don't go to medical school events, and I haven't seen her at M & M conferences or on the wards. Well, I may have seen her, but I had no interaction with her."

"I think I'm going to call her advisor and see what I can find out."

"Mind if I ask to whom she's assigned?"

"Doctor Mertens."

"Same as me," I replied. "That could be good or bad. How do you want me to proceed?"

"Keep doing what you're doing, and let me speak with Doctor Mertens and with Doctor Strong and Doctor Getty. You aren't the only one who questions her clinical skills, as witnessed by her mediocre evaluations."

I wondered how she and Clarissa got along, and I'd have to ask when Clarissa relieved me at midnight.

"OK. I'm going to go grab a quick breakfast before rounds."

"See you in fifteen."

I left the office and quickly made my way to the cafeteria, taking the stairs so I didn't waste time waiting for the elevator. I bought a bagel with cream cheese, a bowl of fruit, and a bottle of grapefruit juice and took them back upstairs with me so that in the event I was paged or called, I could simply respond and return to my breakfast afterwards. I hoped to finish eating before I had to join the team for morning rounds, but there were no guarantees.

I ate without incident, saying my morning prayers silently as I ate, then joined the rest of the team for rounds. Rounds were routine, with nothing special to note. Mr. Evans was in recovery and being attended by the surgical team, Mr. Carmichael was showing improvement after his angioplasty, and Mr. Jacobsen was ready for his angioplasty, which would happen after lunch.

The afternoon was routine, the second angioplasty had gone off without a hitch, and Mr. Evans was returned to the ward from recovery. Doctor Javadi had spoken to Felicity, and she seemed to pay attention to the things I showed her, but her responses were cold and her stares icy. During the times we weren't busy, I either read medical journals or visited patients, while Felicity, unsurprisingly, read a novel.

I was tempted to point out that during my Preceptorships and Clerkships, I'd read relevant journals and sought out Residents for additional training. The fact that she wasn't doing that spoke volumes. She might manage to skate through medical school, but she wanted a specialty that had very few Residency slots, by comparison with internal medicine, emergency medicine, or even surgery. Oncology was an exceedingly tough Match, and with mediocre evaluations, she wasn't going to make any hospital's list.