Sunday, August 16, 2009

Intimidation Based Learning

There have only been two occasions when I have wanted to give up medicine for good. The second was when I was in general practice and I went as far as getting a law school application but went into anaesthesia instead.

The first was during my internship.

I don't like internal medicine. I should elaborate. I enjoy the clinical problems, and much of the patient care aspect. I don't like the constantly having to justify why you did even the most minor thing to a staff person who was home asleep when you did it, I don't like the hours, I don't like the scut work and I don't like the placement problems. Therefore I really wasn't looking forward to my 8 week internal medicine rotation during my internship which to make matter worse took place in December- January (i.e. over Christmas).

At least I thought I had the foresight to pick a non-academic hospital to work in. In the internal match, I chose and got Camp Hill Hospital which was an old former veterans hospital in Halifax.

Camp Hill didn't have an emergency room. This should have been a godsend and indeed was during my surgery rotation at the same hospital. In medicine however we accepted emergency admissions from the large teaching hospital about a kilometer away. In theory there were 4 medicine services at the LTH and our hospital was the 5th which meant that we took every 5th emergency admission. It wasn't exactly like that however. The patients had to be stable enough to transfer by ambulance. This meant that we usually got elderly failure to thrive patients who became placement problems, and alcohol related problems. There was a tendency of the ER docs and the internal medicine residents at the LTH to lie bald-facedly about the condition of the patients they sent over.

We had a 4 bed ICU which was covered by the interns. This was a glorified CCU mostly made up of patients on medicine who had deteriorated after their admission, disasters from the surgical service and the odd patient from the LTH who was stable but needed to be monitored. We had three teaching wards which acted as services with two staff physicians on each ward, each of whom had their own house staff. When you were on call as an intern, you covered your own ward, were second call for the wards covered by medical students and you covered the ICU. The rule was, if you were the unfortunate who admitted the patient to ICU, you covered that patient for the duration of his ICU stay or life whichever was shorter. We also had residents. These unfortunately were either junior medical residents with a few months more training than us or second year family practice residents. At that time, you could go into general practice after your internship; we called the two year family practice residency "the internship for slow learners". Therefore having a second year "slow learner" as your back-up was not terribly reassuring.

Our little ICU was covered by two staff physicians. Each covered for a month. On weekends and holidays, a single physician covered all the ICUs in the city and went from hospital to hospital rounding. The first physician was Dr. Kookie . He may or may not have gone to medical school somewhere in the third world but had obtained a fellow-ship in Internal Medicine something I have since learned is not correlated with intelligence or good judgment. He also practised as gastroenterologist at our hospital. The second was Dale the Hut. Later in my internship, "The Return of the Jedi" came out and as I watched the movie, I had the odd feeling of deja vu on seeing Jabba the Hut. I later realized he reminded me of this doctor. Dale the Hut was fat and smoked stinky cigars back when you could smoke in hospitals. He had a really bad comb-over. He practised as a cardiologist although as I later learned, he only had a fellowship in internal medicine. He also had an untreated strabismus so it was difficult to know whether or not he was looking at you. (He may have had a grudge against doctors because his strabismus was missed and not treated which he took out on trainees). He was extremely dogmatic on just about everything.

The fact was as I learned later when as a resident I had to look after ICU patients, neither Dr. Kookie or Dale the Hut knew anything about looking after ICU patients. I suspect they were either covering ICU because they needed the extra money or because Camp Hill couldn't find anybody else. Unfortunately as I have learned, when you are uncomfortable with something, a good strategy is to make everybody feel uncomfortable too.

So if you were unfortunate to end up in our little ICU. You were looked after by an intern, backed up by a junior resident, with Dr. Kookie or Dale the Hut (who were idiots) as your staff physician. After hours the nurses would page you for problems. Occasionally they would go over your head and page the resident instead. If you didn't know what to do, you could phone Dr. Kookie or Dale the Hut and get yelled at on the phone, or you could do what you thought was best and get yelled at at rounds the next day.

The low point of every day was ICU rounds which started at 1100 to allow us to get our ward work done and to ensure that we would have no appetite for lunch. We would all sit at the desk with Drs. K or Hut and the intern responsible for the patient would present the case. This you learned had to be a detailed and organized present no matter how long the patient had been in hospital. If there had been changes over night, the on call intern had to describe what happened. I tend to be a bottom line person: this is what he has; this is why I think he has this; this is what I did and this is why I did it. That didn't cut it.

Dr. Kookie was merely clownishly incompetent and indecisive; once you accepted that you could survive rounds. With Dale the Hut, ICU rounds was a hour long ordeal of squirming in your seat, in pool of sweat under his strabismic gaze. One the big problems was that occasionally changes were made by the medicine resident who usually didn't attend rounds, or on weekends by the covering ICU staff who usually knew what he was doing and Dale the Hut inevitably disagreed with what somebody else had done but you now had to justify as if you have ordered the test or treatment.

This is a long digression to how I almost gave up medicine.

As the 8 week rotation went Christmas, we were given 4 days off out of the 8 days over Christmas and New Years. I worked 1 in 2 over Christmas and then had 4 days off. The last night I worked I was lucky enough to admit a patient to ICU. She was a 90+ year old lady who was still relatively with it. She had presented to the LTH ER with left arm pain and got a cardiogram which showed she was in complete heart block. The rest of her cardiac work-up was normal and she was transferred to our hospital for monitoring. I admitted her and went home the next morning. I thought she would only be in ICU for a few days; I couldn't imagine anybody putting a pacemaker in an otherwise assymptomatic 90 year old.

One of my coping mechanisms is that I usually completely forget about what I have done at work as soon as or before I get home. When I returned on January 2, I had completely forgotten that lady. I got in a little late and spent the morning catching up on what had happened to the ward patients while I was away. At 1055, the ICU nurses phoned me to ask me if I realized that I still had a patient in ICU, that I was going to have to present to Dale the Hut in 5 minutes?

Dropping everything I did, I ran (or walked fast, I never run) over to ICU. During the Christmas break, the ICUs were covered by city wide ICU staffmen, a different one every day. Somewhere along the line someone had decided to put a temporary pacemaker in the my LOL. The temporary pacemaker was giving her PVCs and someone else had started her on lidocaine. There was a paucity of progress notes explaining the rationale for any of this. She was booked for a permanent pacer later that day.

When my turn on the hot seat came up, I presented the case in my disorganized fashion. Dale the Hut was not impressed. When I said she had a temporary pacer, his response was "Why?". I mumbled something about how I didn't personally think she had needed one either but that I was not working that day. He also didn't like the lidocaine. I gave the same response. This precipitated a lecture on just because I had been away for 4 days didn't absolve me of responsibility for the patient's care.

I was on call that night. Our patient went over to another hospital to have the permanent pacer put in. (Even though Dale the Hut hated the pacemaker, he was not about to kibosh it). Someone at the other hospital stopped the lidocaine infusion, a permanent pacer was put in and the temporary pacer was left in to be removed the next day. When she came back to our hospital, she was not on lidocaine, I elected not to re-start it and she had no PVCs during the night.

1100 came and it was my turn on the hot seat. I presented the case in slightly more organized fashion at which point the Hut asked me why the lidocaine was stopped. I said it had been stopped at the other hospital. Why wasn't it restarted, asked the Hut. I said she wasn't having PVCs anymore so I didn't restart it. "Why was she having PVCs in the first place" asked the Hut. Because of the temporary pacer, I replied. "And is the temporary pacer still in?" asked the Hut.

I had been up for most of the preceding 28 hours and I was losing this interrogation badly. I decided to punt and I shrugged in a "yes I should have done that but no harm no foul" manner. This precipitated the worst temper tantrum I have witnessed in 30 years as a student/intern/resident/staff. "Get that smirk off your face", yelled the Hut. Because of his strabismus my first impulse was that he was yelling at one of the other interns who was taking too much pleasure in my discomfort. "And stop shrugging" That was when I realized he was yelling at me. He went on to yell about how we were the worst, stupidest, laziest, most incompetent interns ever, that the standard of care over the past few weeks had been terrible and this had to change.

At that time just to confirm his point, one of the four patients in the ICU arrested. After failing to resuscitate that patient and finishing rounds, he stormed out taking the two residents with him for a little talk.

As I said, I don't like internal medicine, but I am a professional and I do take pride in my work and am my own worst critic and looking back over 25 years to the incident I don't think there was anything wrong with MY management of this patient. Later that afternoon, the two residents called all the interns for a meeting in which they told us that basically Dr. McMahon is very dogmatic (true), he has a bad temper (true) but he is a good clinician (false) and you can learn a lot from him (false). I suggested that maybe if we actually got some formal teaching on looking after ICU patients we might actually be able to look after them in more praise-worthy way but neither resident thought that was practical. I thought but didn't say that maybe the Hut should be told that we are all actually fairly intelligent and hard-working interns who don't deserve to be yelled at.

I got home at 7 o'clock that night (after admitting another ICU patient because it was "my turn"), opened several bottles of beer and ordered pizza. I was so depressed, I had spent my first Xmas away from home, it was a drizzly grey Halifax winter etc etc. I seriously wondered if I really was even a marginally competent doctor, and whether I would be able to survive the remaining 4 weeks of internal medicine not mention my internship. But I got up the next day, went into work, survived internal medicine and sailed thru my intership. I never saw my evaluation for internal medicine; I assume it wasn't too hot.

Nowadays, there wouldn't be any question. I would have headed straight for the Dean's office and Dale the Hut would have been off for anger management courses.

For a few years, every time we got a Dal grad, I asked them about Dale the Hut but nobody seemed to remember him so I assume shortly after I left, his clinical teaching career ended. Pity.

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