It’s a box in the top right hand side of the emergency chart, just beside the patient’s weight. I fill it in routinely, every time I’m seeing a patient in the pediatric emergency department. I systematically check the vital signs typed in at the triage desk, ask “Any allergies to medications?” and then “Are immunizations up to date?” I abbreviate it “ImmU2D” to save time. And each time I ask, my heart rate jumps for just a second, a guttural butterfly-in-stomach wave shoots through me, and I hold my breath while I await a response. “Yes, of course” most parents say, and I exhale, moving on to the next question.
Most parents. Not all. There’s a few, and I emphasize a few, who launch into a confident and slick diatribe when “Oh, we choose not to immunize” would do. It’s often dramatic, confrontational, and seems to have been practiced in the mirror over and over and over again. Of all the people I judge, I judge them the most: he who doth protest too much. I try not to show it, the actor in me rising to Oscar-worthy performances that say “I don’t hate you, but I don’t in the least agree with you, but I’m trying to hit my quota of 16 kids this shift, so let’s just assume you’ve already been made aware of how stupid you are and have elected to be stupid regardless.” I move on.
And that was it, I thought, until last night.
Now this isn’t a post about why vaccines are good. For the sake of completeness, the save lives, they don’t cause autism, and their utility in stamping out disease is based entirely on the concept of “herd immunity” – the idea that if two cows out of a hundred are susceptible to a disease, they can’t catch it from the 98 who are immune (since immune people don’t get the disease). It’s worth noting that some people – like babies and immunocompromised people – aren’t able to be immunized and thus depend on herd immunity for survival. If you like, Penn and Teller explain it better than I.
All of you have surely heard of the tragic death of Ezekiel Stephan, a 19-month old who died of bacterial meningitis after his parents, who are against vaccines, spent weeks caring for him with hot peppers, garlic, horseradish, and positive vibes, none of which kill Neisseria meningitidis.
This week, his parents were found guilty of “failing to provide the necessities of life,” a cop-out used by a Crown painfully aware that no jury would find well-intentioned (though stupid) parents guilty of murder. The maximum jail time is 5 years. This verdict, while better than an acquittal, angered me and, I suppose, made me extra-sensitive last night, 15 hours into my work day and still 3 hours from the end of my shift when I grabbed the next chart in the to-be-seen rack.
NOT IMMUNIZED, I wrote in large letters, circling it twice (out of anger, not emphasis) along the entire top of the chart. I started taking a history, and immediately felt my eyes rolling as the parent recalled a years-long-battle with an “assumed” diagnosis of a rare, transient disease. I could feel the sarcasm broadcasting from my body. I performed a cursory exam, and reported to the consulting pediatrician that this patient could be discharged and follow up with their unfortunate immunologist. I could not hide my contempt, and my boss went in to discharge the patient. She came out with a signed consent to administer blood products. To save you the medical jargon, I had missed something serious that required immediate (and significant) treatment.
Eight hours earlier I sat in a lecture about being compassionate. I made a comment about trying to be compassionate towards people I dislike. And yet, primed by the tragedy in Alberta and tired of the vindication antivaxxers wear on their smug faces, I let my own judgments of a parent affect the care of my patient – a child – who was an innocent bystander in this massacre of my clinical integrity.
I’ll spare you the root-cause-analysis and discussion of cognitive biases. Suffice to say, I could have performed better. I let my “negative countertransference” towards her affect my ability to care for her child.
I’m no where near being able to throw compassion towards antivaxxers. But I’m more aware of my own reactions to these idiots, and (I hope) more capable of helping their extra-vulnerable children, lest a kid like Ezekiel be fortunate enough to end up in the to-be-seen rack before it’s too late.
This post was originally going to be a carping vent about other people who’s out-of-context assumptions about my ability to manage my own time hold me back from reaching my full potential. But as I sat down on the patio at a Queen St West pub, cider in hand, the negativity drained right out of me (faster than I could drain my pint glass). So instead, this is a post about the people who enable me.
“When you die, the most important thing you will have done with your life is mentor other people.” – Al Craig (paraphrased)
I just finished an eight-hour meeting of the MedicAlert Board of Directors. This group of 12 women and men are responsible for strategic direction and governance of a Foundation who’s mission is to save lives by providing emergency personnel with critical information at the time of need. During our meeting we discussed what we were looking for in prospective board members, and it got me thinking.
Like MedicAlert, I have a board of directors. It is a group of diverse and intelligent people who all place my interests in high regard. They believe in me even when I don’t believe in myself. They are a diverse group of experts from various fields that directly or indirectly play a role in my professional and personal lives.
One member of my Board once said something that I will never forget. We were at his retirement party at a yacht club and it was all very fancy. He stood up, thanked the crowd, and offered a reflection on his industrious 40 year career of saving lives, transforming systems, making scientific discoveries, and managing a half-billion dollar organization. These accomplishments, he said, were very nice. But the most rewarding part of his curriculum vitae wasn’t his war stories from the medical trenches, his political wins, or his list of publications. It was watching his mentees succeed.
Yep. His legacy, he sincerely believes, is evidenced in those he mentored.
As one of those mentees, I felt incredible privilege to have access to his wisdom, insight and investment and horribly responsible for my future endeavours lest I should let him down.
If my Board, which is spread around the globe in at least half a dozen time zones, were to meet in person, he would surely be the Chair.
Who? My Board is fluid, but most of the people on it have known me for a decade or two. They know who I am. They know what I am. And they know what I can do. Most importantly, they place my interests above their own, every time they give me advice. They make up most of the very short list of people I trust completely.
Why? My mentors challenge me to articulate my crazy ideas. They expose weaknesses that could lead to disaster and make connections that lead to brilliance. Sometimes this puts a brakes on my plans, and other times it accelerates my path. In a few instances, it has completely revolutionized my life, putting me on a path I never would have found on my own.
How? My mentors encourage me when I’m down, pat me on the back when I succeed, scold me when I’m insincere. They keep me honest, demand integrity and never let me forget where I came from.
Sometimes my mentors disagree with each other, but they never force me to pick favourites; I have the autonomy to accept, reject or modify their wishes so that I can choose my own path. If that path ends in disaster, they are right there to help me execute a U-turn, or pave a new way forward.
Life is complicated. My Board guides me through the ups, downs and in-betweens. I am eternally grateful to them for what can only be described as unconditional love. They care. Today’s interactions in the Board meeting opened my eyes to the importance of having a smart, diverse team of deeply committed experts behind you. I understand what my mentor meant that night at the yacht club when he confidently preached that the most important thing you can do with your life is mentor other people.
As I move through my career, I do my best to mentor others using the examples taught to me by my Board. Those a big shoes to fill, but thanks to them I am on solid footing.
I’ve read nearly every Zombie survival guide out there, and can quite confidently state that when (not if) the Zombies arrive, arms grabbing and mouths gnawing, I will survive. While their dogged determination and sheer numbers have overwhelmed numerous B-rate celebrities in film after film, I have sorted out an algorithm of sorts, a protocol, to survive.
This protocol, the Zombie Apocalypse Protocol for Survival (ZAPS), is secret. I’m sorry – it’s nothing personal, but as you must know from 28 Days Later, displays of compassion during a Zombie Apocalypse will get you killed. I suppose you’re likely to come back from the dead as a human-eating Zombie, if that’s any consolation. Ok, fine, I’ll give you the basic components. You can try to fill in the blanks, and some of you (Brodie Nolan) are qualified to critique and collaborate on improving it.
AN ABBREVIATED GUIDE TO SURVIVING THE ZOMBIE APOCALYPSE
First, there is preparation.
Third, rapid response, which has four prongs:
1) Alert others as circumstances allow
2) Evacuate if possible, else:
3) Hide (for there are good hiding spots and bad).
4) Fight (neuroanatomic disruption is the key)
And finally: Die heroically *in a fashion that excludes becoming a Zombie
*optional, depending on Zombie species.
How To Kill A Resident
With equal preparation to ZAPS, one could learn how to kill a resident. Residents are not Zombies, though if you stared into the eyes of a Resident post-call, you might mistake him or her for a creature from Resident Evil. Residents are, I feel the need to remind some of my Staff Consultants, humans. We have weaknesses, feelings, and insecurities. But since Residents are unlikely to attack you outside of the safety of their dreams, we could use their weaknesses to actually help residents live better, learn better, and be better.
There are four general ways you can kill a resident, none of which involve physical disruption of the central nervous system:
Disengage them Undermine their confidence
Judge them to be incapable Allow venomous commentary
And so, I present to you How to Kill A Resident, in the hopes that you will help inoculate us from these pitfalls of Mother Medicine and make us as invincible as the Zombies that will one day kill us all. Well, most of us.
How to Kill A Resident #1: DISENGAGE THE RESIDENT
Don’t listen to what a resident is saying.Teach the resident something they don’t want to be taught.
Words, tone and body (or eye!) language should be listened to. If I am glazing over, staring off into the distance, or mesmerized by an environmental services worker’s mop movement, please stop teaching me how to work up cutaneous T-cell lymphoma. I DON’T CARE. Even if you think I should care, I don’t. So, either find an angle to get me to care or move on.
How do you find an angle? Treat me like an emergency resident, no matter what rotation I’m on. Find something that I need to know. Start your lesson with “here’s something that emerg docs get wrong all the time” or “let me tell you about a tragedy that could have been prevented”. No offence to consultants in internal medicine or surgery, but you don’t know what the Royal College expects me to prioritize in my Oral Board in 2020. What is important to you may not be important to me. Let’s work together to make my off-service rotation result in my development as an emergency specialist.
How To Kill a Resident #2: ASSUME THE RESIDENT IS INCAPABLE
Use the Law of Averages to think you know a Resident’s needs.Lose patience and take over too soon.
Whenever I ask to do a procedure, I am asked “What PGY level are you?” My numeric response will determine if I am given what at the time seems to be the penultimate privilege in medical education (when in reality it is your job to supervise and guide me until I am competent in procedures). We all come from different backgrounds and through interest, chance or luck have different capabilities and experiences.
I suggest preceptors rephrase “What year are you in” to a more specific question: “how many times have you done this independently in the past? or “what step do you often have trouble with when doing this procedure?” It’s also totally fair to see if I have done my homework – “What are the contraindications to performing lumbar puncture” is a totally fair question if I ask you to let me stick a needle in someone’s spine.
Now that you’ve decided to give me a chance, I need you to be patient. Running through my checklist and fumbling with equipment takes time. It might even take another tray or pair of gloves if I break sterility. Help me prepare for success; I appreciate that screwing up is type of experiential learning, and I think it has value in simulators, but guiding me to success and following up afterwards with pearls and pitfalls is my preferred way to teach and be taught in a clinical environment.
How To Kill A Resident #3: UNDERMINE A RESIDENT’S (FRAGILE) CONFIDENCE
Dear Non-ER Consultant: I am a new, junior emergency resident. I am not as smart as you, and I know it. Rather than show off your knowledge, show off your teaching skills. Find my level. Help me raise it a notch. Don’t start with “what’s the FiO2 of room air” and move on to “interpret this blood gas.” If I don’t know something, I am to blame. But the system has also let me get this far without filling that gap. Let’s be practical: fill the gap to accomplish the goal of “me not screwing up again.” This is also known as “teaching.”
During laparoscopic surgery, you can yell at me for not being able to direct the camera at the Ligament of Treitz (“Did you even go to medical school?”) or you can recognize my limitations and feelings (“Julie, can you take over for Blair? He’s very nice, but they don’t do much laparoscopic surgery in the ER, and I need an experienced camera operator during this critical phase of surgery.”)
A short guide to telling me to kick it up a notch:
My colleagues and MedEd heroes may disagree with this next part, but I think it has served me well as a preceptor of paramedics and as a learner. Save your below-the-belt punches for the end of the day. If my fragile confidence is shattered mid-shift, I might as well call it a day. Teach me what you can, and then sit me down before we part ways. “Blair, for someone who has been on this rotation for three weeks, you seemed to drop the ball quite a few times today. Is there anything you want to chat about?” is a fair way to call me out on poor performance while offering assistance. If I am below the mean, I appreciate being told “I’ve had a few other emerg residents recently, I would have expected your anatomy knowledge to have been stronger.” If I need a kick in the ass, kick me. Be obvious, be quick, and do it once. Please avoid the balls. I’ll do the rest. I am my own worst critic.
How to Kill A Resident #4: ALLOW VENOMOUS COMMENTARY
Allow trash-talking of residentsGive feedback badly
It sounds obvious, but we can forget the basics of humanity when we are working in health care. We are not perfect, but we all want to provide perfect care to every person who we interact with.
We are all learning (and will continue to do so until we retire). We all struggle. We all believe certain dogma that may, or may not, be kind of, or not at all, true. We are all inspired by our love of medicine. So we do not put people down. We seek solutions to our challenges, we reflect on ourselves, and encourage others to reflect on themselves. We feedback to each other, we feed back to ourselves.
Feedback is mandatory if we wish to fulfill our central purpose: to deliver perfect care to people in need. Please give me feedback. It can be positive feedback, or it can be negative feedback. It can be filtered, refined, or blunt. I love it all. But please give it in a constructive manner with one objective in mind: to influence my practice so that I can be an excellent physician.
Give me feedback with the intent of hurting my feelings, undermining my confidence, or disabling my curiosity, and you will be attempting to extinguish the burning fire that gets me out of bed each morning. Without that fire, I will be, by definition, burnt out.
Burn me out, and you will have killed a resident.
What do you think of my ideas? Please like, comment, share, tweet or use your rotary phone to dial your friends and tell them the URL of this page.
Feeling burnt out? Feel free to get in touch with me, the Doc Help Line 1800-851-6606, or check out this post here: Thoughts: On being less sad
For all intents and purposes, I am 24 hours away from finishing my internship. For those of you lucky enough to have never done an internship, it can be succinctly described as this:
Imagine running through a forest fire, trying to save as many rabbits and deer as you can, through acrid black smoke, without any idea where the oft-rumoured safe meadow of competence is.
Maybe that is a wee bit dramatic. Since the end of August last year, I have been assigned to work as a junior doctor in various departments of various hospitals doing various tasks that I know next to nothing about. Now, it is true that I am a doctor, but I am not a specialist. It is true that I am experienced in emergency situations, but I am not much of a discharge planner. It is true that I am a good communicator, but I am no social worker. Yet, as an intern, I must be all of those things (at three o’clock in the morning).
Emergency residents rotate through various specialties in their first year of residency. We tell ourselves we do this because other specialties have important things to teach us that will prepare us for a life in the trenches that is an emergency department; we will see post-operative complications following bowel resections, overdoses of psychiatric medications, extraordinarily complicated airways, sick neonates weighed in grams (not kilograms), broken bones exposed to air, and women who may or may not be in labour but are certainly in a heck of a lot of pain.
But the second reason (or perhaps it’s the first, and all that other stuff is the second) we do this is to “staff” services. Hospitals rely on junior doctors to consult patients in the emergency department, care for patients on the wards, discharge patients to make space, and coordinate community care, follow ups, and tests. We also provide night coverage to a hospital otherwise desert of physicians. Working up to 80 hours a week (or, as my dear friend on the surgery recently confided in me, 140 hours), we often work 24, 26 or 30 hours in a row with little to no sleep, running from ward to ward putting out fires.
That sounds crazy. Placing someone who is not a surgeon in a surgery ward to assess sudden drops in hemoglobin, or someone who is not an internist adjusting electrolytes levels, sounds very crazy indeed. However, I must say, the last 8 months has been one of the most fun times of my life. Scary, also. And stressful. But so much fun.
Thanks to WIFI, iPhones and really smart nurses, the junior doctors I work with deliver exceptional, if not confident, care 24/7. We’re pretty crafty people, and unfamiliar with a disease or procedure or situation as we may be, we are trained to find the answer, consult each other, consult our bosses (who we wake up when we are really unsure of what to do) and figure it all out. And in doing that, we learn.
Now, I’m not saying this is the best way to teach me how to be an emergency physician, or the best way to provide care to hospitalized people, but it’s the system we have, and I think it works pretty well. We can, and must, do better, and I’ll write about how another time. But on this, the eve of my finishing internship, I just wanted to express how much fun it has been, and how much I have developed and matured as a physician.
Sure, there was that morning I was so tired I didn’t notice I put moisturizer in my hair until I had slathered my face with hair gel.
There was that time I’m 100% sure I was 99% responsible for someone dying. That time I was yelled at by a family member, and uncharacteristically yelled back. Times of gloom, sadness and tears.
But then, there were all of the other times. The time I picked up on an anastomotic leak at 3am. The time I influenced “flipping the plan” towards palliation for an elderly man who had the ultimate altered sensorium. The time I laughed so hard with a patient I snorted, and then they snorted at my snort, and then their neighbour, separated by a curtain, began snorting at snorts.
And then yesterday, when a nurse overheard I was heading back to the ER and offered me a make-shift going-away card.
Residency is hard. But when I look back on the last year where I played trauma team leader, paediatrician, obstetrician, anesthesiologist, internist, and general surgeon, I wouldn’t give it back for the world. There are many pejorative words we use to describe the first year of residency. But if I had to sum it up with just one, that would would be FUN.
In Part 2, I’ll discuss some of the ups and downs in more details, share a few stories I probably shouldn’t, and try to give you a good sense of the life of a resident doctor.
In Part 3, I’ll speak to the privilege of caring for people in a large, tertiary care hospital, and the wonderful people who make the monstrosity that is a Hospital function.