Sunday, July 29, 2007


Growing up means taking responsibility, learning your place in the world, and just occasionally, royally reaming out someone who deserves it.

But this isn't a post about nurses. You know I love you guys.

Or even med students. I was one once.

My program has a rather large array of personalities and capabilities. Most the people are pretty strong, even the ones I don't exactly click with. There is at least one notable exception.

Simon, as I'll call him, is a nice enough guy. Like all of us, his personality is not naturally that of the perfect physician, but unlike most of his classmates, he has not progressed very far down the path of mortifying these traits.

So yesterday, as he was the post-call intern, his job was presenting the new patients and giving a brief update on the old ones. Since this is the MICU, these patients are complicated, and need detailed notes discussing in depth, by system, the problems they have and what we are doing about them.

Rounds got off to a rocky start because (as my friend the senior resident told me) Simon had spent his night on call sleeping rather than working. So when he got up at 6am to round on six patients in the ICU before 8am, he was understandably far behind. He didn't know what had gone on during the night and had, despite the senior waking him up and directing him on what to do, gone back to sleep on several occasions before finishing his work. When I came in at 6:45 to see my one patient, I heard Simon asking his senior to help him with the note writing. He was rightfully rebuffed.

So notes were not finished before rounds. This makes rounding difficult, and what made it more painful (for Simon and the rest of us) was the fact that he had arbitrarily decided that some vital signs were not important on some patients. So, for instance, with one of his patients with acute renal failure and CHF requiring mechanical ventilation, he hadn't written down CVPs, and the blood pressures he had written down weren't the real range, they were what Simon felt were the "normal" ones of the night. Not cool. You can't just cherry pick data to make yourself look good, these are sick people.

There followed possibly the most painful rounding experience I've ever watched, one which demonstrated every mistake I've ever seen a third year med student make. Actually, I haven't ever seen a third year med student refer to his "Gay-dar" in assessing the patient's sexual orientation. Maybe you could get away with that, in the right crowd, with docs you knew and who understood your humor. Not the first day, when you've already floundered through twenty painful minutes.

This was painful, but I was mostly hoping it would be painful enough to make Simon realize his errors and maybe start slouching towards competence to be born. No such luck. Later that afternoon, about 3 hours after he was supposed to have left, I ran into Simon putting a note on a patient's chart. Unfortunately, this was a very short, 10-15 line note, nothing like the three pages you would expect on a complicated patient with decompensating respiratory effort.

So I called him out.

There followed a very tense, even toned conversation that was, nevertheless, my laying out in very clear language about 85% of what I figure is necessary to be a good doctor. I don't even remember all I said, but I do remember saying things like "this isn't about rules about notes you think are silly, this isn't about work hours, or personality, it is about taking care of patients. And if you don't realize that, you don't belong here. Internship is supposed to be hell, but you have to make it that way. If the pressure doesn't come from within you won't succeed." I added some choice things about needing to write notes, to consider every patient carefully by system because if you don't learn to come up with plans on your own, you'll never be able to. You'll always be an intern, and never a real doctor.

About halfway through this harangue, I realized that the entire nursing staff of that ICU pod, about 20 some odd people, were listening, mostly while pretending not to. I noticed the nurse taking care of the patient in question nodding his head in agreement. I am a bit ashamed to say I enjoyed the audience almost as much as the fact that I finally had an opportunity to maybe, just maybe, work for positive change in this guy's life, and more importantly, in the lives of his patients.

To his very, very great credit, Simon took this correction without offering an excuse for his behavior. He actually wrote a real note, and later, he paged me to thank me for the advice. I wasn't really sure what to say, except "you're welcome."

Heck, I could code in front of that guy some day. And it is nice to know, not just believe, that I have what it takes to give constructive correction. It is also nice to be the strong intern on the intensive care service.

30 hours without sleep? I'm still smiling.


Anonymous said...

What characteristics do you think are necessary to be a good doctor? And what is needed to be a good intern, that you've learned so far?

I'm graduating from med school this year and wondering what it takes.

Nathan said...

Thanks for dropping by. Here's a few points off the top of my head.

I would say, first off, that being a good intern requires hard work. You can't expect to sleep on call, and while you should definitely make time to eat, at time you'll miss that too. So number one, (besides the desire to take care of patients that presumably got you into medical school) is a work ethic.

The other thing you need is humility. You will make mistakes. You are the bottom rung on a very long ladder. You rank below the med students even, as an intern, because they aren't supposed to do scut work. That's your job. Recognize that position, and smile. And never, ever make excuses. If you mess up, take responsibility. You can't be a doctor with it.

Stay organized. This is tough, but it should be a priority. Get a binder and put sleeves in it capable of holding 5-10 pages each, and make each sleeve a patient file. In that you should have every scrap of information you can about them, organized where you can get it quickly. You need every lab, every vital sign, everything that you can find to better characterize the patient. Some people use clipboards, but whatever works for you, figure it out and be obsessive about it. In the same vein, keep a checklist, even if it's a blank sheet of paper, to write down everything the team decides on during rounds. Make to-do lists.

If you find yourself sitting without moving in the first few months of your intern year, you're probably doing something wrong. Work ahead, finishing paperwork, practicing your presentations, whatever you can. Remember your presentations are like first impressions, especially early in a rotation, and they can never been too polished.

Think for yourself. You need to learn to think independently about patients, and you need to be proposing treatment courses and option. You may be wrong, but propose away. (You will need to improve though, through the year) And you should have an explanation for every abnormal vital sign or lab value. Remember your basic physiology.

The last, which is what I think of when writing about Simon, is tougher to quantify. You really can't be clueless. You need to maintain a basal level of situational awareness. Getting along with people is part of this, but so is appropriate humor, basic social interactions, and patience with extreme frustration.

That's just some thoughts. Let me know if you have any other questions, and feel free to email.

Anonymous said...

wow, nathan, excellent advice. Very practical.

i'm thankful you had the guts to tell this intern the truth, and i'm also thankful he had the guts to take it. We can pray this makes a difference in his job, attitude, and life!


girlfriday said...

Nathan, I don't know you, but this is an excellent post.

I do wonder how you manage to read Doyle, Blake and Forester in between thirty-hour shifts. I am ashamed.

Alice said...

Nathan - Good for you, it sounds like you know what you need to be doing, and are on the way to getting it done. But 3 page notes, boy, I'm glad I'm not in medicine. ;)

Nathan said...

TMU - thanks, I try. But it mostly boils down to working hard, having good manners, and reading constantly. All of which have been beaten into me.

Girlfriday - thanks. The way I manage is by being single, actually, so it isn't for everyone. And hopefully it's not for me, forever.

Alice - Even surgeons write notes like that, in the SICU. Sometimes. I hope. :P