Medical Memoir - In Stitches One Girl's Opinion

Medical school memories came *flooding* back as I read Anthony Youn’s memoir, In Stitches.

Medical school was a time in my life where the details are sketchy because it was a blur of studying, isolation, anxiety, frustration…sprinkled with intermittent moments of fascination and joy. I can completely relate to his thoughts about pediatrics, “Little people, little dollah”, and being torn between life-style specialties and being a “real” doctor. I shared his dislike for the standardized patients and the weirdness that entire situation evokes in all of us.

My favorite aspect about this book is its honesty and authenticity. As I devoured the book chapter by chapter, I felt like I UNDERSTOOD Tony. I was able to peek into a life very similar, but very different from my own. His book was truthful, the language was clear, the humor and candidness kept me interested and I really felt like I traveled this journey with Tony. As I read the pages, I thought of my OWN similar experiences….and my reaction to them. And as I flipped the page….reading his words were like reading my own mind. It was quite amazing!

There were only two questions that stayed with me through-out the book: Why didn’t his family help him acquire better living conditions? And was he really a virgin until medical school? (implied, but not stated)

I will say that I feel like the first part of the book would appeal more to young men, with all the talk about girls, women, and overall “manning up.” Since women do not (typically) go through this, it’s all very foreign in an annoying kind of way (as a woman). I was much more interested in…all the rest. Thankfully there’s plenty of ‘all the rest’ and the book was thoroughly enjoyable.

I would LOVE to read a “part II” plastic surgery residency memoir. It really was *that* good!


Attendings who don't want to teach

Q: Now that I'm *officially* well into my intern year, I realize that some of our EM attendings are not interested in teaching (or otherwise interacting) with interns. As an intern, I'm offended. Is this acceptable behavior, and how should I handle it?

A: You're right, the attendings should be willing to work with ALL of their OWN residents (interns included). Its one thing to shun rotating residents/intern/students, but *your own* should be taken care of.

There are two different ways to look at this to help explain why SOME (i.e. not me, LOL) attendings avoid students/interns. The first way is to try and see their point of view.

Imagine you’re an attending:

When you go to work, you feel exposed (legally) because the residents are a liability. They don’t always know what to look for, what to tell you about, and how to treat the problem. Even if you, yourself, get up and go see/talk to the patient, you may miss something in your short interaction. And there are LOTS of patients. Actually, you feel overwhelmed at times because you’re responsible for the actions of others, although you don’t know what they’re doing/hearing/seeing. You have to ‘trust’ them…and that’s hard to do. And, you are just one person, and to have 2-4 people ‘presenting’ cases to you for 8-12 hours is just too hard. You can’t think, you don’t know who’s sick…and you can’t physically see everyone and do everything yourself.

And it’s even *worse* when an intern is working. BECAUSE they *really* don’t know what to look for, ask about, check or test for. And when they present to you, the story is often unclear, and you’re left sorta confused. The differential is too broad when the intern presents, and you either have to go see the patient yourself, or ask lots of detailed questions to the intern to get a better story. If the intern didn’t ask the important questions, you either have to send them back to get a better history and physical, OR you order tons of tests/studies to compensate.


10 month old baby is brought in my mom with a fever to 102.9 x 1 week. Intern presents it as a viral syndrome. Great, discharge, right? BUT they didn’t notice the dehydration and lethargy. They didn’t comment on the petechial rash. So, as an attending you can either:

1) get up and see the patient yourself as if he’s your own (this isn’t very practical if you have more than a couple of residents/interns to supervise or else the flow of the department will be very slow)

2) have the intern order more tests and studies to support the ultimate dispo (which isn’t really teaching, and isn’t really proper EM)

3) you can have a senior resident see the patient, and ‘advise’ the intern. That way, the likelihood of missing meningitis is lower if the senior resident signed off on the intern’s work.

Of the 3 – it’s easier to have the senior resident involved. Also, it’s logical because it allows the senior resident to see more, do more, supervise a bit, and begin managing an entire department. And as attending, you’re there just as back-up for the senior resident. It’s easier to teach the intern if the obvious nuances of the case have been discussed with the senior (at least from July – December). And it frees the attending up to work with the senior and students as well.

The attendings look forward to working with certain residents, just as much as residents like particular attendings. Typically attendings like residents who are confident, do appropriate work-ups, then come to them with their own thoughts about what’s going on, and what to do about it. Then the attending can talk to the resident as an educational ‘coach’ and (almost) colleague about the case. This is fun for attending.

Being stressed out about missing something because an unreliable resident (whether it’s because they’re ‘new’ or just ‘suck’) is telling you half-truths and cannot think for themselves…is miserable.


The second way to try and understand what’s going on is to realize that this has nothing to do with you, and everything to do with their own issues:

Imagine you’re an attending…and you’re a bit bitter about your job (for whatever reason). Really, you don’t want to work shifts, you’d rather get credit for shifts worked, while NOT doing any shifts. BUT, you’re not quite *important* enough for the department to allow you to engage in other scholarly activities…and since they NEED attendings to work shifts, you get more than your “fair share” (for your rank and experience), in your opinion. But you can’t quit, because you need your benefits and paycheck too bad. So you make due.

There are two types of doctors (those who actually are comfortable with themselves, their knowledge, and love to share and can readily admit when they are unsure of something....and there are those who pretend to know *everything* and don't want to answer questions because they feel threatened by the resident who's actively reading, and who, on any given day, may be better-read on a particular topic than the attending).

So let's say I'm the second type of attending -

I don't want to 'expose' myself as interns don't know much about 'the way things work' and instead of just 'going with it' they'll ask:

"why? why? why do we use this drug instead of that drug? why can't we just do the procedure this way like Rivers said? Tintinali's new edition said that we shouldn't use this study, that the new ultrasound technique is better..."

Whereas a senior would be more apt to 'just go with it' as per current local ED culture. And if the senior asks questions, it's more appropriate for the attending to follow-up their question with a 'reading assignment' to be presented the next shift. So the residents ‘learn’ to not ask questions.

So, in short: either this is their way of hiding the fact that they don’t know something….OR they’re acting out because they don’t want to be in the position they’re in….

Either way nothing to do with you.

My advice is: YOU SAY NOTHING! Go with the flow...and do not let the Eye of Sauron fall upon you. Stay below the radar right now. Learn, learn, learn. Shine on the inservice in February.

Next year...maybe say something if you're still so inclined (maybe). It's not worth the risk right now. If you're black-listed, you will have a horrible residency experience. Lots of former residents can attest to this fact.


Can I be cool with my nurses (and they cool with me)?

When I was a medical student, I was quite envious of the nurses.

It seemed like the nurses, from the RNs to the licensed practical nurses, had the best of everything. Their lounge was big. Their area well stocked with food and drinks. They were always having celebrations...for everyone...for everything. They made late-night Starbucks runs, and had food delivered to the hospital all the time. And even though they were courteous enough to offer me a latte (sometimes), it always felt weird to 'fraternize' with *them*. They, were them...and I was *us.* "You cannot trust 'them,'" I was told. "'They' will throw you under the bus first chance they get!"

So, for years, I had an awkward relationship with the nurses. If I needed them to do something...how do I ask? "Um, excuse me Nurse, did you see my order?" Or, "Ms, I mean, Nurse Smith...can you get room 1 a bedpan?" It just seemed like...I was asking them to do things...like I was in charge. But they are quick to let you know you're not in charge. But, you kinda are in charge. But you cannot 'remind' anyone that you are in charge...or else you belittle their contribution.

What gives?

Then I realized...as I advanced in my education/training...and as I spent more time as an attending...that good nurses are really there to help make your life easier. If they are not doing that...I would argue that perhaps they are not good nurses. And the thing is, I didn't realize this until I had an *awesome* nursing staff to support me!

In residency, the nurses were indeed a little cult...whose primary mission seemed to be to make your life as difficult as possible. Sorta like they were jealous of a young woman doctor...and resented having to take orders from her. They were not polite. They claimed they didn't know how to do much of anything. "Um, I couldn't start the IV on room 3...so I guess you'll have to come do a central line." Or, "we cannot get blood from Ms. Jones...so you'll have to do a femoral stick." Really?! Really, really! Either you're one sorry nurse...or you're just out to get me.

As you progress, it becomes less acceptable for the physician to perform nurse duties...while simultaneously performing doctor duties. Time becomes more valuable, whereby if the physician isn't seeing patients quickly...someone is losing lots of money (and it's usually someone "more important" in the hierarchy than the doctor). And that...is not tolerated. CEO losing money?! So support staff is hired so the physician can continuing 'bringing in the money.' And this extrapolates to nurses who enjoy (or at least don't mind) nursing.

Fast forward to now. I have a great relationship with my nursing staff in general. Some of it is because my nurses are now there to support me (rather than antagonize me). Some of it is because it is the expectation that the nurses do nursing work. But a large part of the equation is me. I am more comfortable with myself, with my skills, and being a doctor. And because I am comfortable with me, and my role as leader...I am less...awkward. I am more willing to "fraternize with nurses because I realize that being friendly with nurses doesn't undermine me or my role. I see myself as team leader...but I give each member of my team the option to critically think and act without me micromanaging their decisions. I ask their opinion...and I don't feel like "they think I'm stupid" if I don't know something.

And in exchange, they bring their kids in to see me for impromptu doctor visits. They save me a piece of baby-shower cake. They "protect" me from the patients and their families (this is a post for a different day). They sneak me a Tylenol or a Reglan out of the Pyxis when I'm not feeling well. They catch my oversights...and they have my back.

Short story:

Last week I had to reduce a patellar dislocation. SUPER easy to do...but I'd never done one before. So, I gathered my nurse and my tech, and confessed. "Hey guys, we have to reduce this...and I've never done one. So I'm going to read up a bit, then we'll do it, okay?" Amazingly, they were even more excited to learn *with* me. We checked out emedicine. We watched a short video. Gave each other encouragement. And went in the room like we knew what we were doing. Like we did this sort of thing everyday. "Don't worry Mr. Johnson, this will be quick and over in less than 10 seconds" (hopefully). We exchanged glances...smiled a little bit. And did exactly what the doctor did in the video. For about 6 seconds, it didn't seem like it was going to work. But then we heard it. The "clunk" of the patella going back into place! We all exchanged glaces again...with big grins on our faces.

We walk out of the room, and into the back, giving each other hi-fives! WE did it!

How fun is that?! This is what makes emergency medicine a team sport.


Ideal job - 6 years out

One of my attendings once told me that it takes about 5 - 7 years for a new ER doctor to master the specialty. This was music to my ears, because I knew that I was *not* confident upon residency graduation to jump into this very stressful specialty. I needed to wade in...from the shallow end of the pool...slowly.

When I graduated, I did not look for jobs that required me to "roll up my sleeves" and do *real* emergency medicine. Contrary to what my colleagues seemed to believe, I realized that I was not quite ready to be a sole doctor in a small town ER, with no specialist support...trying to save lives. Emergency medicine is hard enough in a big city, at an academic institution, with every esoteric subspecialty at your beck and call. The real emergency medicine heroes are truly those docs who work out in Podunk, alone, and really have to do it all!!

So, my first job was at Kaiser. First in Southern California, then Northern California. Kaiser is a very "safe" emergency medicine job. All the patients are insured, they all have primary care physicians, and everything in the ER is protocoled. Oh yeah, and the patients cannot sue you! So if you follow the protocol, you're good. They have all the standard sub-specialists available, and the patients are not that sick. They receive no trauma, and many doctors are working at the same time. So you're not alone, nor are you overly concerned about being sued.

But Kaiser has many drawbacks...and for me was not my long term plan. What Kaiser offered me was...a transition from resident physician to attending physician (on the shallow end). After working at Kaiser, I felt a bit more confident. I actually carried some of their protocols with me, and those protocols allowed me to have "a plan" for patients in other institutions as soon as they presented.

Next, I practiced my wading skills by taking a job with a group who allowed me to work a bit slower at first, and hone my skills. See, the thing is, if you are "slow," you do not make enough money for the group to cover your hourly pay. This means that...the other doctors in the group are subsidizing you. Thankfully I found a wonderful group of docs in CEP to take me under their wing, and allow me to work at my own pace until I developed confidence and personal protocols. (CEP is a great group, but very site specific. Some sites are not willing to "deal with" new docs.) Also, CEP has many sites California, so being with them, I was able to "try" many different sites, and find one that worked for me.

It is common for ER docs to work at multiple sites - sometimes with multiple groups. After all, to have all of your eggs in one basket can be unsettling since we are all well aware of the inherent instability in group contracts and hospital adminstrators. But, working in multiple places allows the new doctor to realize characteristics that are pleasing to them, and those that are annoying.

I discovered that I am not a huge fan of working in hospitals where the clientele is "upper-class." The pay is better in these hospitals, but the patients are not as appreciative, and they are 'entitled' in a way that is really annoying to me. In comparison to rural or inner-city ERs, I find that the social issues in these rich suburbs are similar (such as drug addition, alcoholism, violence) but no one dares to acknowledge these issues lest we upset someone by even suggesting that these issues even exist in well-to-do communities.

Also, in these richer suburban ERs, everything is micromanaged. See, when things are 'perfect' at a facility, administrative hospital staff has to somehow 'justify their jobs' so they *create* problems to "fix." Sometimes these "problems" include...improving upon 99th percentile positive patient satisfaction scores ("let's have the doctors escort the patients to their cars to get that last percentile!") Or, "lets do away with triaging altogether, and promise patients we'll see them within 10 minutes of their ED arrival." Both are bad ideas...

In the inner-city, or out in Podunk, no one has the time or energy to micromanage. There are so many REAL issues for an already overwhelmed admin staff...that every idea is designed to help everyone be more efficient and decrease bad outcomes, period. It is understood that 100% patient satisfaction is not possible, or compatible with running an ER. It is understood that we are all doing the best we can, with what we have, and there is no need to "sell" a well functioning ER to a community. It will sell its self. When "customer service" interferes with the ability of the ER staff to perform their duties...ultimately everyone suffers. Unhappy staff that have better options, leave. Patients who are really sick are not recognized (as everyone caters to our "customers") and good medicine is not practiced as we try to appease every flight of idea a "customer" may have regarding their own care - even if they are wrong!

But I digress.

There are many variables that contribute to an ER docs job satisfaction. Money is a part of the equation. But more than money, is the work environment in total.

  • Can I get a patient admitted, or is each admission request World War III?
  • Will a surgeon or a cardiologist come in to see a sick patient on Sunday afternoon...or will that patient code and die overnight because they refused to see them?
  • Will the laboratory run blood samples timely, or are they constantly "lost" or otherwise "insufficient"?
  • Are the patients appreciative, or are they demanding you be their drug supplier?
  • Is ER group more focused on pleasing hospital administration and patients, then getting "buy-in" from the physician members and practicing sound medicine?
  • Are the ER group members more interested in making as much money as possible apiece than actually staffing the ER safely?
  • Is the culture of the group to "cover" and switch shifts with each other to accommodate changes in life events, or is finding coverage impossible?
  • Do you get to leave on time...or is it necessary to constantly stay late because of inefficiencies in hospital staff...or colleagues who are unwilling to take a sign-out?
  • How many nights, weekends, holidays do I have to work...and how are they divided?
  • Is the schedule maker respectful of physicians, or are they just pawns who are "in charge of the pencils?"
  • Are my schedule requests acknowledged?
  • How far in advance does the schedule come out?
  • How many patients am I expected to see per hour?
  • Are there mid-levels available?
  • Is the hospital so close to my house that I bump into patients in the grocery store - and does that bother me?
  • What are the nurses like? Do they play well with others...or is everyday a battle?
  • Does the hospital allow you to eat in the cafeteria for free? - this is actually a bigger deal than you might think!
  • Parking, and call-room access (to take a nap after a long overnight shift before attempted to drive home in rush hour traffic) also demonstrates to physicians their value, and shows appreciation by the hospital admin for the services you're providing at 2am!
  • Are you going to be alone in the hospital at times (running ICU codes, delivering babies and such) in addition to managing your ED - and how do you feel about that?
  • How long are the shifts? 12 hours? 7 hours?
  • How are patient complaints handled? Are you guilty until you prove your innocence? Is every frivolous dissatisfied patient's letter taken seriously? Sometimes, a complaint does not need to be passed on. Sometimes, a patient will write a letter, and a polite response can be given, because their gripe is clearly not with inappropriate medical treatment.

And these are just a few of the questions that came to my mind in the moment! And each of these issues contributes to physician happiness with a group, and at a site. Getting with "your type of people" is a process of trial and error. And after a few different experiences, I realize that my personality fits best in groups who are a bit more authentic in their practice and in their lives. And this...this attribute tends to be more often present in 'non-rich' communities. I feel more like a real doctor, making a real difference in communities that represent where I came from.

So now, I'm happy working in Podunk, with my lovely nurses...and appreciative patients. I am now on the deep end, swimming without undue fear as an ER doctor 6 years out of residency. As I developed my confidence, I was able to trust my staff more, and rely on them without feeling judged or inadequate (which is huge). I am the only doc in the entire hospital at times (much of the time)...and am responsible for any acute issues that arise. My consultants are fantastic (and NICE), they don't bitch and complain about working...and transfers are not very complicated or time-consuming. I get to eat in the cafeteria for free...and it is not too close to my home where the bank teller recognizes me as the doctor who treated her daughter 2 weeks ago (that was uncomfortable)!

Most docs do not expect perfection in a job...but there are certainly some that are closer to our personal ideal than others.

Finally, (I think) I've found my ideal ER doctor job :)