variation on a theme: romance of long hours

written post-call after a long ICU shift, which after I wrote it I realize is a reworking of some things I've written before

I used to work at a public health job, working for the city, with good benefits, and time to go to the gym before going home to make myself dinner. When I started talking about becoming a doctor, a lot of people said that was nuts, most of all some doctors who looked back on their experience bitterly. Others were more encouraging, and I chose medicine.

I have no idea what my life would have been like if I hadn't chosen medicine; but what I usually tell people is that although I've sometimes been exhausted or miserable or depressed or discouraged, I've almost never been bored. I hated being bored at work. Now I'm not bored.

But aside from medical training being totally absorbing, part of the dirty little secret of long work hours is that it is part of a romance that doctors and patients have with each other. Many of my patients look at me sympathetically and ask whether I ever go home, and even shake their heads over my working conditions. But many of them also seem to sort of appreciate the romantic idea that I'm some sort of insanely dedicated nut who cares only about helping people and has no life other than worrying about their telemetry alarms. I'm there all night, yes; but I'm there for them.

On the flip side, as I'm complaining to my friends with regular jobs, I'm also a little proud of myself for making a different choice. I joined the few and the proud; my life is full of drama and a sense of importance. In the dark early morning hours in my academic hospital, the halls begin sputtering with the energy of people working really hard to become who they are going to become. That's kind of beautiful, and I am proud to be a part of it. And, though usually I would only tell my mom this, I'm proud of myself. I'm proud of myself for choosing something tough. This is a common impulse: it is the basic idea of most military recruiting pitches, and it has worked to convince people to do difficult or even insane things for many generations before this one.

When I worked in a regular job, I felt that my life lacked significance or importance somehow, even though I was doing important work. That was because I lacked this sense of drama.

The sense of drama that draws doctors to our training--even as the conditions that make our training dramatic also sometimes make us bitter or depressed--is probably in the end a fiendish tool of The Man to make us work harder for cheaper, and like it.

It's also part of how doctors become self-justifying later; other people can just suck up whatever hardship they face, because we did. (As if a few years of earning an average American wage and working insane hours in preparation for joining the top tier of wage-earners and gaining inestimable social prestige is really a form of enduring suffering.)

Change won't occur until the rest of the society stops appreciating the beauty and the drama of the dedication that the medical training process represents, and starts viewing residents as participants in a high-stakes industrial process that must eliminate systemic sources of error. But the latter view is much less romantic, and much less beautiful.

For almost everyone involved, it is more emotionally satisfying and less safe to romanticize the difficulty of medical training. Perhaps this is not surprising: in many other parts of life, emotional appeal often wins out over sensible decisions. But that appeal is part of why doctors choose this life; and I think that the romance of the doctor as a special breed of person is part of what seduces patients of academic hospitals into accepting a system that is not always designed in their best interest.

Becoming a doctor requires imagining the obvious.

When I was in medical school, I worked hard; I was thoughtful about my patients; I got along well with most of the people I worked with. But my grades weren't as good as some of my colleagues' grades were. They were fine, but more often than I liked, I seemed to just miss the highest grade in my overall evaluations. Sometimes that was for blatantly unfair reasons, other times for reasons I understood perfectly. But most of the time, it was harder to tell why I'd just missed. I spent a lot of time thinking about how to improve, and asking people how I should be improving.

In the last part of medical school I was starting to get it. An ICU rotation gave me the biggest transition: I went from doing some of my worst clinical work (in that I was disorganized and confused in presentations and in my thinking about patients) to some of my best. A couple of other rotations towards the end of medical school also went well. Still, I wasn't sure exactly what had changed, and which of the things I'd done to try to improve had actually worked.

Now that I'm an intern, I still have a lot to learn. And I'm sure I'll still have many stumbles and falls ahead. But I feel more confident in a way that surprises me, but also explains a lot of my medical school experience. I recently realized that it took me until some point between getting my diploma and my 20th hour of internship to actually believe that I was going to be a doctor. In other words, until I became a doctor, there was some part of me that didn't understand that I was actually going to be one.

In fact, even during my first day on call the meaning of the job still hadn't 100% sunk in. I was just trying to keep up, to not do anything wrong, to keep my feet on the floor and my pulse within normal limits. Before I started, everyone told me to listen to the nurses, and especially with a bunch of ICU veterans like the nurses working with me, that seemed like great advice. Nurses were coming up to me and saying, "Mr T's pressure is dropping; I think we should give him a bolus of fluids." Great, I'd say. "Half a liter sound good to you?" I'd say, entering the order into the computer. "Mrs S's potassium is down," another would tell me; "Thanks, I'll order that now," I'd say, looking at the sliding scale to replete the potassium.

For most of that first day on call, this worked excellently. Our hospital's critical care nurses are excellent, my resident and attending were watching closely, and our patients did well.

At some point early in the morning, a nurse suggested another bolus of fluids on a patient. The patient had already had a fair amount of fluid through the day. I started worrying about what another half a liter was going to do to his lungs. "Actually, I'm hesitant to do that," I said to the nurse, explaining my reasoning. Together the nurse and I talked through an alternative plan, and I checked in with my resident. It was a tiny step, a tiny transformation, but I recognized it: actually, I was a doctor. The MD on my badge was more than some iconic token of my education.

Later, as I realized that I understood some of the physiology and basic science of another one of my patient's problems, and that my patient's nurse did not understand it in the way I understood it, I realized that those years of medical school did teach me something. It's not that her education and experience and observations didn't add up to anything. But it added up to something different. Patients are safer and better-served when nurses tell doctors when their medical interventions will cause unforeseen harm, and when they are partners in the conversation about what might be done next. But that doesn't mean that doctors, even new ones, can get away with just relying on the nurse to keep the patient well.

All of this is pretty obvious to an outsider, and probably to most medical students too. But now I realize that I hadn't ever 100% believed that I would become a doctor. That belief, I see now, is a big part of the intangible confidence that some of my colleagues with better grades had. It's part of how they looked like future doctors instead of current medical students. And when I at least mostly believed that I was responsible for being a doctor--as in my ICU rotation, and a couple of others--I did well.

Now I'm a doctor. And I actually believe it. As soon as I started believing it, I became a better doctor, in an instant.

Now, looking back and recalling that a medical student will, 98-99% of the time, graduate and become a doctor, I've been thinking about what part of me wasn't registering the obvious likelihood that I would also soon become a doctor. Some of the answer comes from who I was before medical school. The people who love me the most have always had great faith in me, and believed that I was capable of many things, but I don't think that when I was in my teens and up to my mid-twenties that anyone who knew me well would have predicted what I'm doing now. I thought of myself as an artistic person, and a political person, but not as a scientific person, nor as a person who would ever become such a normal thing. Willie Nelson instructed, "Mamas don't let your babies grow up to be cowboys"--instead, he sings, "make 'em be doctors and lawyers and such." I never thought I'd be a cowboy, but I didn't think I'd be one of those and-suches either.

Many of my classmates come from medical families. They believed they'd become doctors because the job and the social identity seemed natural to them. They might have resisted it when they were younger, in order to walk their own paths and not their parents', but when they returned to the path of medical training, the terrain was familiar. The medical students who didn't come from medical families often spent their lives, since they were children, working towards the goal of becoming a doctor. I think that many of these classmates, in both categories, always believed in their future as doctors, as soon as they walked into the hospital. They started to become doctors well before they were qualified to earn a medical license. That's actually sensible. You're 66% a doctor at some point in the third year of medical school; at that point you are really more a doctor than not.

When I look back and see the ways I was improving in the last part of medical school, I see that I was becoming a doctor, that the 85% doctor I already had become was directing my actions, even if my consciousness was still too aware of the 15% doctor that I was not.

It seems easier to imagine becoming an excellent and experienced doctor (which, nearly by definition, I am not) than it was to imagine becoming a doctor at all. The next part of my training will require more work, more cognitive strain, and a steeper learning curve than medical school ever asked of me. But in terms of how I see myself, and how I've had to change how I see myself, the hardest part might have just ended.

Fear really is the mindkiller

ACLS training today. That's Advanced Cardiac Life Support--it's where you learn how to shout "Clear!" and deliver a shock; or, "One milligram of epinephrine!" Just like TV. (Except, you shouldn't shout.)

I passed the written part of the exam with 100% of the questions correct (not a super hard test, and my result was shared by many present, but still, it was satisfying). Then we went downstairs to do what the American Heart Association calls "Megacodes" which inspired some of us earlier in the day to keep saying "Megacode!" at random times during breaks. (Well, mainly me, actually. But I'm sure that others wanted to.) The megacode involved standing with a mannequin and a bag-mask and a defibrillator; while an instructor ran us through a basic simulation of cardiac or respiratory emergencies.

I was the first to volunteer to be a team leader, and it was brutal: I couldn't remember whether the pathway we were on led to adenosine or atropine. The sonic similarities of the two drug names caused me to merge these two drugs, which are not at all used for the same things. In the larger sense, I did the right thing in that I knew I was in doubt and asked my team members--who said, no, it's not adenosine. And though I was then able to say, "OK, right, atropine 0.5 mg IV"--still, I was miserable at the end.

The schedule isn't actually out yet, but I have reason to think I'll be starting in the ICU next Saturday. If it's true, that means I'll be on the code team starting within the first three days of internship. As long as my resident answers the code page as fast as I do, I'll be fine: I'll take orders, bag-mask, do compressions. We'll sprint down staircases in our scrubs, and as long as my resident is running right there beside me, I feel more or less ready. Excited, even.

But if the resident is in the bathroom? Doesn't hear the code page? Is dealing with some other emergency? It's unlikely, but I fear being, for even a minute or two, the only MD in the room. Because we are the ones with prescribing capability, we end up being the people who call for drugs. And therefore, the MDs generally become the team leaders. Even, it seems, when my ACLS instructors who work as respiratory therapists or nurses are also on the team. (I wanted to ask, "Seriously, you started working as a respiratory therapist when I was two years old, and I'm one of the oldest interns in the place, and I'm the one who's supposed to run the code?" But it didn't seem like the right time or place for that conversation; I'll save it for a night in the ICU when there is time and quiet.) Thankfully, asking for help is encouraged. As long as there are other people there--and if the code cart and the drugs that freak me out are also there, that means that someone else will also be there--I will be OK.

Still, mixing up the drugs when I was suddenly on the spot and feeling nervous was scary. That in turn made me upset and worried enough that I started having a hard time concentrating on the next cases and on what the instructor was telling us after I was done. I actually said to myself: "I will not fear. Fear is the mindkiller" in my internal Kyle Maclachlan voiceover voice, and with that, I was able to force myself back to the present, to the work in front of me.

Also I went around and talked to a couple of people to see if I could find a way to do some simulator sessions before internship starts. I want to pound on some mannequins, and see if that helps.

"Found Down": HMS/HSDM Commencement speech

"Each of these stories become more subtle and often more difficult versions of the same question: when we see suffering, do we look away, or go towards it?"
Photo: rescue staging area after Hurricane Katrina.


...More to write about graduation soon (it was yesterday, June 7). First, here's the speech I gave at the commencement ceremony of the Harvard Medical School and Harvard School of Dental Medicine.

I’m going to start with a story. It starts when a man falls down on the sidewalk. He might be drunk, or he might not. He might be unconscious because he fell, or he might have fallen because he became unconscious. Hopefully sooner than later, someone realizes that he has fallen down.

The call to 911 comes from the first person to realize this and to care. Next comes the ambulance crew, and even the cars that get out of the way when the siren goes on. As the story continues, there are triage nurses and doctors, x-ray technicians and respiratory therapists. Maybe the man found down has a strange rash, goes to cardiac cath, or needs a CT scan; maybe he has blood in one of his eyes, or a shattered bone. There will be more to the story, but this is its essence: a person falls, and in small and large ways, a huge network of people begins to pick him up again.

Today, we step into a new role within this network. But we have already been part of this group of people: those who go to the man found down, and try to help him up.

We can’t be too romantic about this story. Almost as soon as the man’s story begins, promises and demands of money start moving through the wires underneath the sidewalk onto which he fell, perhaps even before he has been picked up off of it. But today is not about that part of the story. Today is about what we do because of who we are, and not just who we are paid to be.

Each of us will encounter different versions of this story in our work. A child is frightened of her father. A veteran is overwhelmed with anxiety inside an MRI machine. And a family is just down the hall, waiting to hear the news of an operation, and someone must tell them that the operation went badly. Hundreds and maybe thousands of stories like this are unfolding at this moment, right outside this tent, in the hospital and clinic buildings all around us. And each of these stories become more subtle and often more difficult versions of the same question: when we see suffering, do we look away, or go towards it?

We’ll have to answer this question day after day. I once heard an ICU nurse in an urban hospital say, “All of our patients have the same chief complaint: found down.” July’s novelty and excitement will be followed by February’s bleak repetition. Just about any hospital has many people found down for reasons that are easy to diagnose, but can seem impossible to solve.

To respond to this sometimes relentless suffering, we’ll have to push back against huge impersonal systems, even when those systems beat us back again and again. And we’ll sometimes have to forgive terrible human frailty even as that frailty pushes us to our limits of forgiveness. And so nearly all of us will succumb to frustration and even cynicism from time to time. This is nothing to be ashamed of, as long as we don’t wallow in it, and as long as we don’t mistake bitterness for truth. We are graduating from medical school, not saint school.

Nonetheless, we can hope to meet the basic moral standard of looking towards suffering instead of away from it. In clinics and hospitals, in our personal lives, and in research and policy, we’ll constantly face this moral challenge. Even the best of us will often fail it. But that should not stop us from continuing to try.

When we do reach this standard, we have one final important task: to avoid congratulating ourselves too vigorously for our own forms of benevolence. Sentimentality about our special virtue as doctors can be as dangerous as cynicism, because it causes us to forget that we are joining something much larger.

Our medical training means that we will bring our expertise, our intellectual curiosity, our readiness to work hard. We can be justifiably proud of ourselves for what we have already accomplished, and we know for sure that the people in the audience today are already proud of us.

But today we also join others—paramedics, nurses, social workers—and dentists—and many others who spend their lives responding to suffering. In the few blocks around us, there are thousands of people like this. And even more importantly, there are many other people who are not healthcare workers, but just caring people who also see suffering and find ways to respond. I came to medical school because of people like this—people who responded to the crisis of the AIDS epidemic in San Francisco, people who taught me about courage in the face of disaster.

In small or large ways, most of us have probably come to sit here today partly because of people like this, people who taught us how to behave in the face of suffering: teachers, friends, family. They have usually taught us by example, often because they cared for us when we were suffering. Some of those people are here today. They have seen us fall; in one way or another, they have found us down and helped us up, sometimes many times. As we graduate, we honor their acts of faith in us. Today we mark a moment in which their gifts to us have come to fruition. Now, we will join them in helping those who are found down.