Lakeside Medical Musings

And What Difference Does That Make?

I think my despair probably peaked in the winter of 1981.  I had survived my internship year, and now I felt I could confidently handle most of the medical problems I encountered in the hospital. I was proud of the skills I had developed through that grueling year, but  I had also begun to see the 80-110 hour-work weeks as more of a badge of honor than as something to actively resent.  But being an Internal Medicine resident at Parkland Memorial Hospital was a game the residents, ultimately, could not win. It was us against, well, everyone else: the attendings, the hospital administrators, the nurses, and all the other residents who weren’t “our” residents.  I felt exhausted, unappreciated, and mentally abused, but I wasn’t alone with those feelings of despair. Misery loves company, and I did have my thirty-eight fellow first-year IM residents for that. Our attendings subscribed to the principles of the Socratic Method in teaching us, but by this time, this lofty academic theory had deteriorated into something closer to pure fraternity-row hazing. Being a resident was stressful enough on its own, as we we were making life and death decisions without the life-long experience that would make this process easier later on, but knowing we would also be second-guessed, ridiculed, criticized, and harassed no matter what decisions we made put an enormous emotional strain on each of us.  As interns, we had survived (barely) the weekly noon meeting with our revered but terrifying Chairman of the Department of Medicine, the notorious Donald Seldin.  At these meetings, Dr. Seldin would randomly pluck one resident’s patient’s chart from a tabletop pile of medical records for public review and degradation.  The anxiety that crept over each of us in the seconds before we found out if it was one of our patient’s charts Dr. Seldin now held in his hands was palpable.  His high-pitched, deeply Brooklyn-accented voice screaming, “Does your mother know you are trying to kill this patient? What were you thinking?” still has the uncanny ability to pierce right through my night’s sleep.  His occasional hurling of a chart out the 10th floor window in disgust was humiliating and demoralizing, something that never happened to me, thank God, but the fear of its possibility haunts me to this day. My fellow residents at Parkland were some of the brightest people I have ever met in my life.  Everyone who trained at Parkland had graduated at the top of their medical school classes and excelled clinically.  Many of my former fellow residents are now Chairmen of Departments of Medicine, Cardiology or Nephrology at some of the finest medical schools and hospitals in the country. But the emotional hazing during our training was unrelenting and an equal opportunity demoralizer. The abuse was not directed at me, in particular; it was directed at all of us, in equal measure.  Joseph Heller’s famous anti-war novel, Catch-22, published in 1961, was my favorite novel at that time for reasons that are obvious:

“They’re trying to kill me,” Yossarian told him calmly.
“No one’s trying to kill you,” Clevinger cried.
“Then why are they shooting at me?” Yossarian asked.
“They’re shooting at everyone,” Clevinger answered. “They’re trying to kill everyone.”
“And what difference does that make?”

To mix references, my other favorite literary absurdist, Kurt Vonnegut, said it best:  “And so it goes.”

Everyone had a different way of coping with living under this constant state of attack, like Londoners during the Blitz.  Some drank, and some drank a lot.  Some became clinically depressed and resorted to antidepressants for relief.  And some of us, me included, turned to outright hostility and tried in the smallest, pettiest ways to get back at THEM.  Here are some of the amusing — and ultimately pointless — antics that made me feel like I had some control over my out-of-control life that make me look back now and laugh at how silly they really were.

While most of our medical training revolved around in-hospital work, each resident also had one half- day each week of clinic duty. The clinic was not set up like the office your physician has today.  We didn’t have desks or even cubicles; there was just a row of long Formica-topped tables lined up against a row of windows that looked out onto an outside wall of another wing of the hospital. The chairs were not comfortable “doctor’s office” chairs but hard wooden school chairs. Behind the residents’ backs were the exam rooms, a row of doors in this long, long room.  The interior of each exam room had two doorways on opposite facing walls, one that opened just behind our chairs and one that opened into the massive waiting room. Each resident was expected to see eight to ten patients in the half day of clinic, but I always scheduled as many patients as I could, sometimes as many as twenty in a day, in an act of outright hostility and rebellion. Working harder doesn’t sound like an act of hostility, does it? Aaaaah, but under the right circumstances, it is!

Two nurses and six residents worked on the afternoons I was assigned to clinic.  While the nurses in the hospital were understaffed and worked exceedingly hard, the nurses in the clinic always had time for a chat with each other with a cup of coffee in hand, and I resented that they were able to work at that pace. One would think that having more patients per resident would make life harder on the staff at the clinic, but I couldn’t see how it did.  I had no idea what the nurses in the clinic actually did to keep busy.  While a patient waited in the waiting room, a secretary delivered a chart to my table.  I took the chart and reviewed it.  I then walked through the empty exam room behind me and opened the door to the waiting room.  “Mr. Smith.  Mr. John Smith,” I would announce, and then I’d wait as Mr. Smith slowly made his way from his chair to my exam room.  I would  help him get undressed and into his patient gown and then take and record his vital signs. It was only then that I proceeded to do the actual physician work by taking the patient’s history and performing a physical examination.  I wrote up my office notes in his medical record, and then I returned the chart to the front desk. Now you need to empathetically put yourself into my hostile, depressed, exhausted (from the unrelenting hospital work hours of all the other days of my week) state of mind.  What the hell did the nurses do in the clinic, besides put up with all of us exhausted and angry residents, of course?  I had no idea what physical work they did, which was what made us residents so angry. We got so little help in doing our job.  Even when we were taking care of patients in the hospital, the amount of support we received was minimal.  We almost always drew the blood on our patients, started our own IV lines, transported our patients to and from radiology: all support staff tasks everywhere except for residents at Parkland Hospital. Why didn’t the hospital hire phlebotomists, orderlies, and enough nurses to assist residents in caring for our patients?  Why couldn’t we get help from anyone?  Why were they trying to kill me?

How did I react to all this?  I did everything I could to even the score.  I occupied by mind by trying to figure out every petty little thing I could do to make as many people’s lives as miserable as mine was. I found out that in the clinic, it was the nurses, not the physicians, who administered all the immunizations.  So during flu season, I made sure every single one of my twenty patients had orders for the flu shot. In the spring and summer, I ordered tetanus, diptheria and pneumonia vaccines.  While this was medically appropriate, it was usually not done in this clinic.  This was a strategy that would benefit the patients while making the nurses put down their coffee and join the Crazy-and-Hateful Train that the residents already rode. And I was punching their tickets. Ha!

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“Doctor of Medicine to the loading dock!” blared the loudspeaker in the ED.  “Doctor of Medicine to the loading dock!”  I dreaded the sound of this particular call, as it meant only one thing: there was a body in an ambulance or a hearse in the loading dock of the emergency room, a person who had died either at home or in a nursing home.  The Doctor of Medicine, me, was summoned to “pronounce” the patient dead before the body could be brought to the funeral home.  The resident on duty, me, learned nothing from this service, and it often caused me to miss something relevant or helpful in the ER, so it eventually roused my ever-present ire. I wonder how much the funeral homes charge for the pronouncement of death and my signature on the death certificate? It could be $100, I thought.  Why aren’t we residents getting this money?  I knew that we couldn’t be paid directly, as we were salaried employees of the hospital, but the funeral homes could throw us a party, couldn’t they? They could do something for us poor working stiffs, right?  I was certain, as I always was back then, that I was right, and I suddenly refused to answer any more  summons to pronounce, and I instructed my interns to do the same.  Needless to say, that didn’t go over very well with my superiors.  I was quickly reprimanded—once again—and told to straighten up and fly right, and I was also informed that the funeral home did not charge for the pronouncement.  Foiled again!  Okay, I was wrong on that count, but I wasn’t giving up and giving in. On to The Alamo!

I went to my attending physician and told him in the most Eddie Haskell-ish (Leave It To Beaver, for you young’uns) voice I could summon, “Sir, I am sorry, but I cannot, in good conscience, continue to pronounce bodies on the loading dock. I do not  have an individual Texas License to Practice Medicine.  I have only the institutional license that allows me to practice medicine within the hospital.  These bodies are, technically and actually, not in the hospital.  They are on the loading dock, and I don’t want to get in trouble with the State authorities.  Now, if you would like to check these people into the Emergency Room, I would be happy to pronounce them there.”  I was barely able to contain my smirk.

This, too, did not go over well, but I held my ground, and because I was, technically, correct, I offered a compromise.  “Why is it that only the Doctors of Medicine have to go to the loading dock to pronounce patients?  Why not the surgeons, the OBs, the pediatricians, as well?  These physicians are all present in the ER, and each one of them is more than capable of pronouncing a person.  What do you think, SIR?”  He didn’t immediately fire me for insubordination, and he didn’t outright dismiss my claim, so I was happy, and I was actually asked, as opposed to ordered,  if I would continue to pronounce while the hospital powers researched the issue. Frankly, just being “asked,” for once, to do something was a win, in my muddled brain. I derived an inordinate amount of pleasure from my “stick it up your ass” attitude, even though I knew that nothing good would come of it.  Little victories can take on an outsized importance in a war that you are losing badly, but I did feel a sense of accomplishment and a little bit at ease from the results of that day’s skirmish.

About a week later, my attending physician came back to me and said he had looked into my request, discussed it with the other ER attendings, and they had made a new policy.  The surgeons would alternate with the Medicine physicians in pronouncing bodies on the loading dock.  I was both shocked and elated.  While this victory probably doesn’t seem like much to an outsider, it was one of my proudest accomplishments during my years in training.  I had made a little difference, and I had gotten a little something for my fellow Medicine residents and interns. “They’re shooting at everyone,” Clevinger said, in Catch-22. And while it wasn’t much, in this one small moment, I got to shoot back.

 

2 thoughts on “And What Difference Does That Make?

  1. John Post author

    I agree not all learning is comfortable and if “hazing” just occurred during our noon conference I think we all would have done just fine. But this teaching style was utilized in morning report which was a daily meeting with the residents, and attending rounds which was a 2-4 hour daily session with interns and residents. Add this onto: an 80-100 hour work week; other than 2 weeks of vacation there was not 1 day of the rest of the year that we did not come to work; and that this went on for 3 years. You can see how this would be different from boot camp.

    So yes I learned quite a lot during this time and, educationally, I couldn’t have learned more in this period of time. But emotionally it was crippling for many, many residents and it affected our lives for years to come.

  2. Lexi Phillips

    John I appreciate the musings in your blog. I wonder something about the teardown of your personality in the weekly noon meeting whether this was about making you a bulletproof physician? Rock steady in your opinions and able to counter under duress? Having gone through boot camp for the Marine Corps this is the first thing that occurs to me…but you probably already though of that. …not all learning is comfortable?

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