Chapter 63: Like Mother, Like Daughter

December 12, 1988, McKinley, Ohio

"Hi, Mr. Perkins," I said, coming into his room early on Monday afternoon after visiting Rachel at lunch. "We're here to prep you for the helicopter flight to Columbus. We need to change your EKG pads and hook up a portable monitor."

"Did they find a heart?" he asked.

"Not as of ten minutes ago," I replied. "I believe Doctor Strong explained that by moving you now, it'll save hours when a compatible donor heart is found."

"He did."

I shut off the EKG monitor, then removed the ten electrodes and pads, replacing them with five pads for the portable monitor. Once they were in place, I removed the pulse oximeter and automatic blood pressure cuff, then hooked up the portable EKG machine. A nurse came in to put on compression stockings, both to keep his feet warm and to improve circulation, as well as guard against clotting.

"The orderlies will be along in about five minutes," I said. "Nurse Mary will stay with you until then, and I'll see you on the chopper."

"OK," he replied.

Felicity and I left the room, and I turned towards the elevators, which would take us to the ED, rather than towards the lounge.

"Let's get suited up, I said.

"Suited up?"

"You're flying along," I replied. "This is your first trainee flight. Make four more, and you can be certified as a flight surgeon once you're a Resident."

"No way!" she exclaimed. "How?"

"I asked. Now, let's go."

"Wait! YOU asked?"

"Yes. We can discuss it later if you want, but right now we need to get downstairs, get our flight jackets and helmets, and get up to the roof."

We rode the elevator down to the ED, and I led Felicity to the closet where the jackets and helmets were kept.

"Put on a blue 'Trainee' jacket, and I suspect the smallest helmet, but make sure it fits snugly. Let the cords dangle over your left shoulder."

I quickly put on a large red jacket and helmet, while Felicity put on a small blue version of each.

"Helmet not too tight?" I asked.

"No, it's fine."

"Then let's go."

"Who's covering for us?"

"Maryam. That's why she showed up earlier."

"Why didn't you tell me until now?"

"Because things could have changed. Doctor Getty and Doctor Strong were not disposed to allow this."

"So you used your influence?" she asked.

"You can take off the gear and stay here if you don't like it," I suggested.

"Never mind! Forget I said that."

"Wise decision," I replied.

We rode the elevator up to the roof where the helicopter was waiting, blades turning. A minute later, Doctor Strong arrived wearing a red 'Flight Surgeon' jacket, and a few seconds later, the orderly, nurse, and Doctor Pace came out of the transport elevator with the patient.

With help from the co-pilot, Doctor Strong, Felicity, and I got Mr. Perkins into the helicopter. Once he was situated, I plugged in my headset and showed Felicity how to plug in hers.

"Comms check!" the pilot said.

"Loud and clear," Doctor Strong replied.

I responded the same way and prompted Felicity to do the same.

"Hayes County Air Ambulance departing Moore Memorial Hospital for Ohio State University," the co-pilot announced as the helicopter lifted off the roof.

The flight, as with the previous two, was completely uneventful, and once again, I stared at the monitors all the way to Columbus and napped on the way back. When we arrived back, we all went to the ED and returned our helmets and jackets, Doctor Strong signed our procedure books, then we all returned to Cardiology.

"Have fun?" Maryam asked with a smile when I met her in the corridor.

"I watched the monitor on the way there and slept on the way back. I might have looked out the window once, as we landed."

"That is such a 'Mike' thing to do! OK if I head home?"

"Yes. Thanks for the three hours. Anything of note?"

"I sat in the lounge with my cardiology journals for the entire time!"

She gave me a chaste hug, then left, and I went into the lounge.

"Will you explain why?" Felicity asked.

"Because you admitted that you didn't know where to put the EKG leads, then copied the diagrams from my notebook. That showed me you wanted to learn, so I suggested to Doctor Strong that we make a gesture to show you what's possible."

"What do you mean?"

"Earn the trust of the Residents and Attendings, and you'll have the same opportunities I and other members of my study group have. They aren't unearned privileges, they are earned opportunities. I am not saying you have to like me, but for at least the rest of December, and I'll wager heavily on January, you're stuck with me. And that may well be true next year as well, if you do an emergency medicine Sub-I, which is typical for nearly every medical student, because I'll be a Resident.

"Given that, my advice, if you'll take it, is to set aside whatever grievance it is you have with me. If you can't, then tell me what the real problem is, and if there's anything I can do to help resolve it, I'll give it proper consideration. What I'm trying to say is that I can help you, and I want to help you. I will absolutely admit this isn't pure altruism, as much as I'd like to say that it is, because it's my job to teach you, and I'll be evaluated on how well I've done that."

"The real problem?"

"Maybe I'm wrong, but I don't believe that the problem is the opportunities I've been given. My gut tells me it's something else. But I'm neither omniscient nor psychic, and I don't know you well enough to even hazard a guess. I do know a few things about you, but it's all third hand, which makes it unreliable."

"What do you know?"

"The working theory of the person who spoke to a friend of mine who spoke to me is that academics were always easy for you, and suddenly, nobody cares about your grades or your ability to take tests or write lab reports. The only thing they care about is your clinical skills, which are limited, mostly because you're a Third Year.

"I know I said I couldn't hazard a guess, but now I think I will. You, like most medical students and PGY1s, think scut is beneath you, and you resent it. But the thing is, right now, you and I are mostly only qualified for what you consider scut. I think the difference is that I see those tasks as necessary, and understand the pecking order. I've called it low-level hazing, and it is.

"As I've discussed with my study group and others, the doctors are in an elite club we want to join, and they've made the rules. We have to live by them, or they won't let us into their club. And that's even true about PGY1s and some PGY2s. If we want to be invited into the club, we don't have a choice. I do everything assigned without complaining and with a smile. Why? Because we have to pay our dues. Doctor Javadi is paying her dues, and despite being an MD, hasn't set foot in a procedure room or an OR."

"But you have! Why?"

"It's a different situation. As a Sub-Intern, I'm supposed to be exposed to those things so I can decide on a specialty. And yes, I was invited in as a Third Year, because I was at the top of my class, and I complied with the training program."

"But you were allowed to invent your own Residency!"

"I cribbed it from another doctor," I said. "And everyone here knows that it wasn't my work. What it came down to was a surgical Attending trying to convince me to do a surgical Residency when I had my mind made up on emergency medicine. Trauma surgery is up-and-coming, and it allowed me to, in effect, split the difference."

"But why did they want you so badly that they'd do that?"

"First, it's the right thing for patient care, or it wouldn't have happened. Second, again, I'm number one in my class, I do as I'm told, I study more than most, I read medical journals, I review procedures before they're done, and on and on. If I simply assumed my good grades would get me ahead, I'd be exactly where you are. Well, minus whatever your grievance is."

"It's not you, personally," Felicity replied.

I wondered if part of it was the anti-female bias in medicine, which, while it was beginning to change, had a very long way to go. Male surgeons still outnumbered female surgeons by five to one, even at Moore Memorial, where Doctor Roth was a strong proponent of eliminating that disparity.

The problem was, the anti-female bias was so pervasive that many women didn't even consider surgery, cardiology, neurology, or similar challenging specialties, instead focusing on family medicine, pediatrics, and gynecology. Part of that was they were steered in that direction by men, and part of it was simply not wanting to put up with the pervasive misogyny of some services.

For whatever reason, Moore Memorial had a larger number of women Residents than was typical for a hospital, and McKinley Medical School had more enrolled female students than a typical medical school. That meant that as bad as things were here, they were worse in many other places, though often the bias was hidden and subtle, rather than overt. Nobody put up 'No girls allowed' signs on the doors, but that didn't mean many male doctors didn't have that attitude.

"I have a sympathetic ear," I replied. "But if you'd prefer a female ear, Fran Fredricks or Maryam Khouri would be good choices. Fran is the President of the Student Organization, so if the problem is related to the school in any way, she'd be a good choice. But that's up to you, obviously. The only thing necessary is for you to allow me to teach you the little bit I know."

"OK to be blunt without you becoming upset?" Felicity asked.

"I'm not upset and haven't been upset with you. Concerned? Certainly. Frustrated? Absolutely. Upset? Not at all. The short answer is 'yes'."

"Why be self-deprecating? You know a lot!"

"I'm paraphrasing what Plato attributed to Socrates — 'I am the wisest man alive, for I know one thing, and that is that I know nothing'. That basically sums up what Doctor Getty said about knowing that I know just enough to get into trouble. Think about the quote on Doctor Getty's wall, and what that means for the way medicine is taught."

"You're talking academics versus practical training, right?"

"Yes. If you think about it, we have it exactly backwards. Six years of academics, if you include your undergraduate degree, and two years of practical training. But that's not the end of it, either, as a Residency is actually more practical training. In my mind, it would be better to ditch the undergraduate degree for two years of intensive academics followed by two years of practical training, and then Residency.

"Honestly, I won't use most of what I learned in academic classes in my day-to-day job as a physician. You've seen the reports from the new machine in the lab, which prints the reference levels for each test right on the form. It's really only a step or two from there for a computer to spit out a list of differential diagnoses to consider based on those reports."

"So just let the computers decide what to do?" Felicity asked.

"No, not at all. But let computers do what they're good at — storing and collating information, and doing calculations quickly. My one concern is that it would make physicians lazy, and they'd rely on the computer for diagnoses, and I don't think it will ever be that simple, except for diseases where there is a specific marker.

"But even then, you know there is always the potential for masked illnesses, and I don't know if there's a way to program a computer to handle that. What I'm getting at is that, with everything you've learned, you are not qualified to be a doctor. Neither am I, but the state of Ohio, in its wisdom, says I will be in May. That's when the real training starts, and it lasts for eight or nine years. Oncology is four, right?"

"Yes."

"In Europe, at least in some places, you go straight to medical school from the equivalent of High School, and they do a total of four years of academics and two of practical training before Residency. I used to champion that, but now I've come to the conclusion that it's backwards, just as ours is backwards, and that's based on Doctor Osler's statements. The man invented Residency, so I think he might know of what he speaks!"

"Didn't his Residents actually live at the hospital?" Felicity asked.

"That's where the name comes from, and he intended it to be a near monastic experience. Anyway, the point I'm trying to make is that everything you did before you stepped into the wards in June was about a set of boxes you had to check to prove you were intelligent enough to be a physician, at least according to the current selection and training methods."

"And you really believe you don't know anything?"

"I certainly don't know much, and I think Plato's point is well taken. Do you know the story of Socrates and the Oracle of Delphi?"

"That's about wisdom being the knowledge that you aren't wise?"

"To me, it's more of a warning against thinking you're the smartest person in the room because there is always somebody smarter. That applies to all forms of intelligence and all skills and abilities. But it's also limited by discipline. Let's say, for the sake of argument, you're the smartest person in the room. Could you, for example, wire a house for electricity? Rebuild an engine? Design a spacecraft that would take us to Mars?"

"Only that third one is about intelligence!" Felicity protested.

I shook my head, "No, they all are. You think that book learning is superior. Let me ask you this. What's your current salary?"

"Zero, obviously."

"And how much will you make as a PGY1?"

"Around $22,000 a year, I believe."

"My friend, an electrician, is younger than we are, and makes more than that as an apprentice. Neither of us could do his job. I don't know the first thing about wiring an electrical outlet. But then again, I don't know the first thing about oncology beyond the short module we had during Second Year. How much do YOU know about treating cancer?"

"Not much," Felicity admitted. "I'll learn during my Sub-Internshi ... shit."

"You acknowledge then that your way isn't working?"

"Obviously," Felicity said ruefully. "Your way seems to work, given you and your study group are all in the top ten in your class."

Nadine wasn't, but she was close, at fourteenth. It was unlikely she'd move up from there, but she had improved her class rank significantly since joining our group.

"A lot of it has to do with attitude," I replied.

"I could use some serious attitude adjustment after these long shifts."

"I teetotal," I replied.

"Isn't that an adjective? I as in 'I am teetotal'?"

I shrugged, "I have no idea. I've only ever actually seen the word in writing a few times, and heard it a few times. But there's a long tradition in English of turning everything into a verb! It's called anthimeria, and a good example is when we say someone is 'schooled' or a book is 'shelved'. We also turn verbs into nouns, and so on. And there are examples in Shakespeare, so it's not new."

"How did you know that?"

"One of the many tidbits taught by an English teacher in High School who also taught current events. He's responsible for almost all the useless trivia I know! But back to 'teetotal', you are undoubtedly right, but English is a moving target if there ever was one! All one has to do is read Shakespeare to see how much it's changed."

"The trivia wasn't useless in this case because I both learned something, and you made a point. As for Shakespeare, I never got into it. I prefer modern mystery novels."

"About that," I said. "You might consider reading The Lancet, JAMA, or whatever the oncology journal is. One thing I discovered in doing that is that what we were taught in class is anywhere from five to ten years behind the latest advancements. In most cases, that won't matter too much, because we only need generalized knowledge about most things. One of the main things I'll do in emergency medicine after stabilizing a patient is assess which specialist a patient needs and call for a consult."

"Why does it seem so easy for you?" Felicity asked.

"'Seem' is correct, because it's an illusion. The illusion is created by a dedication to learning, copious note taking, and unending study. You've seen me pull a deck of notecards from my pocket, right?"

"Yes."

"I take a random sample from a larger deck that I've built with everything I've learned to date. I review them every chance I get. And that goes back to the basic vocabulary we learned the first week of First Year. I know that might sound contradictory, as does reading textbooks and medical journals, but it's not. The journals are to keep apace with developments; the textbooks are for refreshers, or to learn about a specific service or procedure because no matter how smart you are, you can't remember literally everything about everything, even in medicine, let alone life."

"You have a rep for having an eidetic memory."

"Another illusion crafted by constant study and repetition. You have to also learn to compartmentalize. I couldn't tell you everything I learned during my OB rotation a year ago, because it was a year ago, and only some parts of it are relevant to my specialty. I do have notebooks where I could look it up, or textbooks, but when I hit some of those things on my flashcards, I don't remember. That's not a problem, because I don't need to.

"Think about this — oncology isn't a required rotation, nor is it a suggested elective for anyone who is not going into oncology, or, to a lesser extent, surgery or internal medicine. But I'll never do a cancer resection except perhaps as part of my training, and won't ever do one as part of my job. Nor will I diagnose cancer. I'll see markers and call you because I won't know, in fact, I can't know, much about oncology. There simply isn't room in my brain or any spare synapses."

"That is not what was implied in class, especially in anatomy," Felicity observed.

"You remember what they said you needed to do to pass the stages of the MLE, right?"

"You need two months to prepare for Step 1, two weeks to prepare for Step 2, and a number 2 pencil to prepare for Step 3."

"Think about that and what that means."

"Academics are used to weed out people early on, but become less important."

"Exactly," I replied. "And what's the biggest component of our boards?"

"The oral exam, which is almost all diagnostic and treatment based. Why has nobody told me any of this?"