Friday, September 17, 2010

Going Down or Going Up

Anyone who is familiar with the medical field is well aware of the hierarchy that exists for the typical doctor in training. It starts in medical school, when you are a lowly first-year, and culminates after you finish residency, when you are a polished doctor, an attending, defining your own terms.

During the first year of my emergency medicine residency, we were assigned a rotation of five to seven weeks in a very demanding surgical sub-specialty service. Lucky me. Not only was I assigned this rotation during December and January, the holiday months, but my specific time was seven weeks with this service.

Heart transplants, bypass surgeries, lung resections, and much more--all at my lucky finger tips. The main reason for our involvement in this rotation, as ER residents in-training, was to learn how to perform a chest-tube insertion. Simply, it involves cutting through the skin of your mid-lateral ribcage, through the muscle and cartilage layers between two ribs, and accessing the lung space. You then insert a hollow tube into this lung space, which when hooked to a low-pressure vacuum, evacuates blood or air, or both. Either of these (usually from a trauma) can collapse the lungs and cause respiratory distress, which can lead to cardiac distress, so quickly inserting this tube can be life-saving. This procedure, known medically as a tube thoracostomy, is one of the "musts" that anyone entering the emergency medicine field must learn.

Simply put, though, this rotation sucked. I can't put it in any nicer terms. I was tired and worn-out, depressed and miserable, from all the hours and extreme demands of this rotation. A typical day started between 4 and 5 a.m. and finished, if you weren't on call, around 6 or 7 p.m. I was on call every third day, which meant I worked a 36 hour shift that day. Over Christmas, it got even worse--I was on call every other day. This was genuine, hellish, character-building training back in the days when strict rules and regulations were just evolving.

The hierarchy was never more evident to me than during this rotation. I was a lowly emergency medicine intern on service with several medical students below me and a fellow surgical intern beside me. Ahead, a second-year internal medicine resident, a fourth-year surgical resident, and a "fellow," a graduated surgical resident pursuing several additional training years in a surgical sub-specialty. And, of course, our attending, who varied day-to-day. Eight of us made up the team.

Did I mention that this was a hard rotation?

The funny thing about medicine, though, is that, as a resident, an intern, or medical student, there is much more to be learned from a rotation than just the medical knowledge and patient care. I constantly stress this to our emergency medicine residents. Be alert. Absorb everything about a patient and their case. Be compassionate. And watch those teaching you, extracting the best and worst of those experiences to add or avoid in their own practicing. I credit myself for being the doctor I am from emulating my favorites attendings just as much as from learning how not to behave or practice from certain individuals in the medical field.

From all my experiences during these seven weeks, one negative experience prominently stands out. Unfortunately, it doesn't involve a patient but rather the attending of our team. It was Christmas Day, around 11 a.m., and I was on-call. After finishing morning rounds, the departing on-call team, the attending, and our oncoming on-call team were collectively going down an elevator to the main-entrance lobby. Our attending that day was a fiftyish, hard-working, intelligent physician who, quite honestly, was always quite impressed with himself. His people skills, though, were extremely lacking.

Despite everyone being either depressed or exhausted, a lot of effort by others was going into kissing our attending's ass--laughing at his jokes, hanging on his every word, schmoozing left and right. Someone eventually asked him what the rest of his Christmas Day plans were.

"Well," he answered, "unfortunately, all my kids came home for the holidays."

"That's a bad thing?" I blurted out, surprised by his answer. I would have done anything, anything at all, to have spent the day with my wife and my family.

"Yes," the attending replied, surprised by my question, "very bad, actually."

"May I ask exactly why it's bad, sir?" I asked, ignoring the glare of my senior resident. I knew she wanted me to shut up, but that wasn't happening. "Is it too many people in the house? Too much commotion? Something like that?"

"Hardly," he replied, laughing to himself and shaking his head. "My family aggravates me and, quite frankly, I don't enjoy their company." He could have stopped there but didn't. "My wife and I have four kids, two married, no grandchildren. I would love some grandkids, but my kids are too damn selfish for that."

He got momentarily lost in his thoughts before speaking again. "Let me give you all a little piece of advice. This job we do--make it the priority in your life. Don't get distracted with a spouse and kids if you can help it. Trust me, they only get in the way." I waited for him to laugh, to finish out his joke of a statement. No laugh ever came, though.

His words had silenced the elevator and still, he continued. "Now I have to go home and play nice with my wife and kids. Trust me, that's a much harder job than this, any day. If I had my choice, I'd avoid all of them and stay here for the day." The elevator bell rang as he finished speaking, the doors quickly opening to let the departing on-call team and the attending out. No last holiday wishes from any of them.

If only the attending had remained silent and lost in his thoughts, I wouldn't have had to pity this man and his ridiculous words. "Have a nice fricking Christmas," I mumbled to no-one in particular.

Here I was, an intern-- a low-life medical scum barely clinging to the bottom of the totem pole--wishing for nothing other than to be surrounded by the ones I cherished on that Christmas Day. And here was the attending-- a worshipped doctor high on his pedestal--wishing for anything but to be surrounded by his family on Christmas Day. Clearly, he was letting his life be defined only by his successful professional accomplishments. And he seemed to be okay with that. He didn't seem to be affected by his failures as a husband. As a father. As a friend. As a man. He probably didn't see it, even.

How sad. How very, very sad.

Although I learned a lot during this rotation, none of my gained medical knowledge came close to the perspective I gained going down that hospital elevator on that Christmas day. I was shown a clear example of what I did not, nor would ever, become. No textbook could have taught me that.

Writing this post, I realize that I never found out how that Christmas day turned out for this attending. I wonder if there were any family arguments? Did anyone drink too much? And what emotion saturated the dining room while this family ate their holiday meal? Anger? Silence? Am I too hopeful and naive to think that maybe there was a little happiness? I picture extreme silence, barring the silverware clinking the plates, with everyone maintaining their robotic and detached manners. I hope I am wrong.

This attending gets full credit for teaching me something valuable during that rotation. Climbing up the hierarchy of medicine did not mean that I would have to sink down the hierarchy of family and friends. I would never sacrifice one for the other.

Best Christmas present I got that year, for sure.

As always, big thanks for reading. I hope you all have a great weekend. See you next week...


ER's Mom said...

Yes. Oh, yes.

CeeCee said...

I'm one of those weird people that reads obituaries.
I'm always saddened by obits that are a full column long, and list the man's (always a man) accomplishments in life. It's always these extra long ones that never mention family. All it will say is "he is remembered by Suzie his wife and his three kids, Jane, Joe and John, their spouses and his 6 grandkids"

Unfortunately, your attending from that day will have that sort of obit. How sad for everyone involved.

I've read through your blog, and I imagine you were already knew what your priorities were about family before that night. :)

Pissed Off Patient said...
This comment has been removed by the author.
Pissed Off Patient said...

Oh wow. Very sad.

At least you have your priorities straight.


Cal said...

Some people really love their career and should stick to it. Choosing to have a family when you really do not want one just makes for a bunch of more miserable people. I know people whose work is their life, and while I do not understand it I certainly think that it is best for them to just not pretend and try to built a family.

Anonymous said...

I've been a hospital (ICU) pharmacist for 30+ years & in my role, I'm rarely seen. but I observe A LOT. In my rather limited experience, I've seen many physicians come & go all the way from the brand new attending to the sub-sub-subspecialist surgeon of much note & many years experience.

I have observed this phenomenon of becoming extraordinarly busy on holidays is inversely porportional to how well the physician "gets along well with others". He/she may not be aware of it since all the minions who work around him/her wear smiles, but we actually berate him/her as soon as he... walks out the ICU door.

My theory, as shared by my colleagues is that the family does not share the hero-worship the individual needs/thrives on. Thus, the physician is treated at home just as any other mother/father, husband/wife, while at work is treated as someone so special no other person can compare. This individual doesn't realize they too can be replaced when needed (recall - I've seen them come & go in 30 years. There is not just one sub-sub-specialist trained per year!).

Thus - there are arguments (yes...we hear them while physician is on the cell phone) over mundane things like picking up dry cleaning, kids, shoes, underwear, etc. On holidays, it becomes worse because a holiday meal & the days surrounding them require multiple helping hands & happy demeanors. Its difficult to become "just that extra set of hands to clear the table", when at work - those are the hands that save lives. Its a disconnect that is lost on the surgeon. He can't take his Dr hat off & become just a husband & father (that truly is the most important job there is).

We've all said - "get a life" at one time or another when this individual has berated us one time too many. I'm sure his family is used to his nastiness & would just as soon he stay at work - or the very least - get the child support check in on time!

Katie said...

This saddens me. His comments and unhappiness would lead me to believe his wife and children were/are discontented as well. What a horrible situation for all involved. I hope you were not the only one to learn such a valuable lesson that day.

Enjoy your weekend and spend some time with your kids and wife. :-)
<>< Katie

Have Myelin? said...

This post made me cry...but that's okay.

Karen said...

He must have been a real joy to have been around. His family was probably none too happy about him being home, either!

Empress Bee (of the High Sea) said...

you know doc, this post does not surprise me at all. i believe quite a lot of doctors feel this way, in fact i believe they go into medicine because of their ego and not their wish to help other people at all. they may be good doctors, most are i am sure. but i don't like them. i can spot one at twenty yards. that's one more reason i love dr. wacks. he loves his family. in fact two of them work with him. no ego problem at all, just good medicine. glad you are the same!

smiles, bee

merinz said...

How sad. But what goes around comes around. His family may not be around at some stage late in life when he really needs them.

Chrysalis Angel said...

Very sad.

Maha said...

Here's hoping that he was having an exceptionally horrible day and decided to vent but if not, I feel really sorry for him. When you get too old to do your job (and everyone does) you need your friends and family to carry on with your life. It's sad to see someone miss that fact, especially in health care when we see so many elderly patients making it through with the help of their family & friends.

Winking Doll said...

I agree with Cal @September 17, 2010 12:08 PM. Sadly, too many just get married due to societal/peer pressure. In Singapore case, there's also pressure from government policies that disadvantaged single citizens.

I am just so sorry for your attending's wife. Hopefully, she and their children have each other for support.

ER's Mom said...

FYI - today, the boy and I made snacks so we have something to eat during the big game.

The girl and I did matching manis-pedis. Lilac.

We ate supper as an "indoor picnic" as a change of pace.

You CAN be both a damn fine doc and's just very hard.

Anonymous said...

If his grown children are unpleasant and selfish, the really sad thing is that this doctor probably raised them to be that way. I am involved with a large Boy Scouting troop with several doctors' sons. Not all, but most are appallingly spoiled, overindulged rich kids who don't think they need to spend the time to master skills, go camping, or wear the uniform.

We reap what we sow.

Peter said...

I remember one particular young doctor who was working in ED at the same time as me, a very nice man indeed, who used my nursing admission notes to supplement his!

They were good going on some comments but I cringe everytime I think of this!

Mind you, I learnt heaps from him as well, especially how to keep your cool during busy times.

Take Care,

Confessions of a Mother, Lawyer & Crazy Woman said...

Your writing is so evocative, I can see the doctor, the elevator ...

As for his attitude, I saw that often in law was first and ONLY for so many ... one thing I very much disliked about the practice ...