A Few Things You Should Almost Never Say to People

"Are You NUTS?!"

When I told people I was going to embark on medical school with a ten-month-old in tow, I got various versions of, "Are you friggin' NUTS?!" in response. See, I think you should only ask that question of someone who's about to jump off one of these (visited today at the Lake Placid Olympic Ski Area):

"We Think Your Child Might Be Retarded." [sic]

When I was four or five my kindergarten teacher expressed some concern to my mother that I might be developmentally delayed. After premature birth at 32 weeks in the early '70's, this wasn't out of the question, but when my mom asked why she suspected a problem, the teacher reported that I couldn't seem to pay attention and often looked blank.

"What are you teaching them?"
"Oh, the shapes and colors-"

"She already knows those."

"How to count to ten-"

"She can count to a hundred."

"The ABC's..."

"She's been reading the New York Times to us for weeks. Look, is there anything else?"

I don't think the meeting ended too well. Just for documentation my mom brought me to Clark Air Base to get psychometrically evaluated by the Americans. Everything checked out reasonably well. She put me in a different school.

"You'll Never Amount to Anything."

Sometimes I think conventional measures of ability and the tendency to judge people based on personality do little justice to the capabilities and gifts people actually have. I came across a wonderful letter to Stanford pre-meds by Michael McCullough, M.D., that I wish were required reading for ALL high school, college, and med school students and teachers. In it he reminds us: "Albert Einstein, Bill Gates, Winston Churchill, Thomas Edison, and Mother Teresa all had something in common: they didn't do well in school. Take home point: Don't rely on a grade point average to prop up your sense of self." We so often define our worth by our successes; it's high time we redefined success!

My favorite example of the school-"failure"-yet-genius is the story of Australian make-up artist Ann Maree Hurley. She kept telling people when she was growing up that she was going to be a make-up artist, and the best response she ever got was, "That's nice, dear." She failed her last year of high school and struggled through Wodonga Catholic College. But she persevered with her true love and has now worked as a make-up artist on all three Pirates of the Caribbean films. To that I say, you go, girl.

Oboist Caroline Plamondon posted a story on the Oboe BBoard relating how her school band teacher discouraged her from trying the oboe, because she was "too shy," then later tried to persuade her mother not to allow her to audition for the Montreal Conservatoire and two other colleges: "He called my mom and told her it would be a good thing if she discouraged me from entering those schools, because I didn't have any chance of getting in, let alone becoming a professional musician. Well, I got in to the 3 schools, chose the Conservatoire, studied there for 6 years before changing schools to obtain my Master's degree." SO THERE! Way to go, Caroline Plamondon!

***

When I was applying for pediatric residencies (before my anesthesia days) the chairman of pediatrics told me that Children's Hospital in Boston would be a "reach" and I shouldn't bother. In many ways he was quite right and the advice was practical. A couple of years later, after I had fallen in love with anesthesiology and switched my career track, I couldn't help laughing at the whole episode when I found myself practicing medicine at, guess where, the O.R.'s at Children's Hospital. The only way to know if you can reach something is to stretch for it.

This was the same chairman who, during my internship, after listening to me explain the molecular mechanism of hyperkalemic periodic paralysis, asked me in front of a roomful of pediatric interns and residency applicants to draw a diagram of the mechanism on the board. After a split-second silence, I said, "Sure" and walked up to the board and drew it. Then I left that program and started my anesthesia career.

But that's when learning became grueling.

During my first year in anesthesia residency I took an early leave-of-absence to help my husband and children move to the Boston area, and the day I returned, with my "skill set" still nonexistent (how I hate that phrase), or embryonic at best after only two weeks on the job, the attending physician I was working with sniped at me all day with insults before finally saying, "Maybe you shouldn't be doing anesthesia." When I looked at him in disbelief that a teacher could be so un-helpful to a trainee, not to mention in pain at being disparaged all day, he just emphasized, "Yeah. Maybe you shouldn't."

His labeling of me haunted me in various ways throughout my training, and despite some genuine teachers, like my residency program director, who were willing to judge me for the good progress I made and the expertise I attained by the time our training ended, there were still those who didn't have the capacity to look past that prejudicial incident and my early struggles during that challenging first year. Thankfully they weren't able to discourage me from taking good care of my patients - from the Peruvian child at Children's who put his arms around my waist and thanked me the day after I had to intubate him awake with a fiberoptic device, to the elderly Korean gentleman who spoke no English but conveyed his thanks with a squeeze of my hand. It was in these unseen, uncredited moments that I felt I was truly a physician my program could be proud of.

To the teachers who actually TAUGHT, I send out a heartfelt thank you, for bringing me to this successful place:

Have You Hugged Your Anesthesiologist Today?

That’s it. I’ve had it. I’ve read yet another piece of writing that demonstrates a complete lack of understanding of what anesthesiology is and entails, and I need to vent.

So allow me to lower the mysterious drapes for a moment and let you into my world.

No one gets up one day and says, “I want to be an anesthesiologist when I grow up.” I wanted to be a ballerina, or a bookstore-café owner, or an artist of some kind – someone who was required to pay close attention to the world, take real notice of it, and take creative and compassionate action. But I am neither a ballerina nor a bookseller. I am an anesthesiologist.

Frequently people ask me a version of “What on earth made you choose that?” I try to explain that I love the way anatomy and physiology come alive moment-to-moment in daily practice. Or I try the concrete approach and admit that I actually enjoy placing intravenous lines and breathing tubes. The response I get is usually a glassy-eyed “Uh-huh” or, occasionally, a nose-wrinkling “Eew.” If the conversation progresses beyond “eew,” the more people talk to me about what they think I do – that is, if they think I actually do anything in the first place – the more bewildered I get over how difficult it is to convey to others an understanding of my work.

One time I visited a patient the day before her planned surgery. After I explained what she could expect, she exchanged a few words with her family in her native language. They clearly assumed I couldn’t understand them. An older woman instructed my patient not to bother asking me too many questions, saying, “She’s just an anesthesiologist; what do they know?”

After years of annoyance at many people’s assumptions that I was not a physician because of my gender or my young appearance, this remark – not the first I’d heard along those lines – made me take stock. I realized that not even other physicians understand what we anesthesiologists do, sitting back there in our little cockpits behind some blue drapes (“the blood/brain barrier”), periodically looking up at large machines but appearing otherwise idle. One doctor asked me once, “You have to take an oral exam? For anesthesia? Is there enough material in anesthesiology for an oral exam?” Considering the profound suffering the ordeal of the orals caused me, and causes many anesthesiologists, I felt like shaking the guy by the hair – except he didn’t have any. If other doctors don’t get it, how could I hope to find anything but murkiness and misunderstanding in the perceptions of non-doctors?

I did a little experiment. I constructed a detailed questionnaire about what kind of physician people would want to come to their rescue if they collapsed in a public place. No one wrote down that they would be glad if an anesthesiologist were around.

I figured out about four broad, wide-spread misconceptions about anesthesiologists:
-we are not doctors
-what we do is easy
-we don’t establish rapport with our patients
-if anything goes wrong, “it’s Anesthesia’s fault.”

Then I realized something else: because people have absolutely no idea what to imagine about our work, they decide to make stuff up. It’s amazing.

People react to the mysterious in one of three ways: with fear, with fabrication, or with efforts to deepen their understanding. The fear I see daily. The fabrication – well, let’s just say if I hear one more person declare that all I do is put people to sleep, then sit next to my anesthesia machine and—what? Daydream? Wait for the patient to wake up? Twiddle my thumbs?—that will be one person too many. But that is what people say.

I have heard more times than I can count, “Well, all you do is knock people out. How hard can that be?” My hairdresser asked me when we first met, “So, once you put the patient to sleep, do you leave the room since your job is done?” Excuse me? My job is done? Then who did he think was keeping the patient alive while the surgeon was mucking around with his vital organs and causing all sorts of dangerous disturbances to his vital signs? Who was going to make judgments about what was specifically appropriate for that patient’s particular brand of heart defect, or lung disease, or neurologic abnormality? And then there’s my personal favorite: “You mean, anesthesia for appendicitis is different from anesthesia for heart surgery?” Hmm. 1-inch abdominal incision versus sawing through a person's chest. Yes, it's different.

My husband once tried to mollify my irritation by pointing out that people just couldn’t be expected to know about anesthesia. “Do you know what a machinist does? Or a gaffer?” To which I replied, “Of course not. I have no idea. But I don’t assume that their jobs are easy, and I don’t presume that their work can be summed up by one simple task.” Even my lawyer husband had to admit I had a point. “Well,” he said, “what DO you do, and what do you want people to know about it?”

I don’t think of myself as a doctor whose function is to induce sleep. My primary function is to resuscitate those who need resuscitating. Yes, about 1% of what we do does involve calculating the appropriate dose of the appropriate drug, drawing it up into a syringe, and injecting it into the veins of people who would like to avoid feeling pain or hearing unfamiliar noises during surgery. But I spend most of my energy making sure that I can bring them back. Designing an anesthetic is a thoughtful act. My resuscitation of my patients often begins the night before I meet them, when I am going over safety plans in my head.

Most of my training, in fact, was focused on becoming an expert at resuscitation in its various forms – reviving patients who were dead or near death; intubating those who could not breathe; rehydrating the dehydrated; unparalyzing those I had paralyzed chemically for surgical purposes; awakening the unconscious with judicious use of anesthetic drugs and gases; creating pain relief and anti-nausea regimens for the afflicted; and making sure failing heads, hearts, or lungs functioned well enough to ensure survival of a given surgical procedure.

Late in my training, I realized our level of expertise when I asked a resident in a different specialty – one whose members also take pride in their resuscitation skills – how many intubations she had done after two years. I was expecting to hear perhaps half of my quota of about 1200. “I’ve logged about 84,” she replied. And this was the physician-type people wanted nearby if they collapsed in a public place and needed a breathing tube to stay alive.

Anesthesia affects consciousness, blood pressure, heart rate, respiration, and a whole host of other body processes. If I am not there to watch over you, that first injection can harm you. And that’s just the first step. I should be breathing for you if you stop (and you will), administering fluids when your surgeon nicks a “bleeder,” and giving you the medications you need to wake up safely and comfortably. This can mean a lot of scurrying around, checking, and readjusting within the confines of my “cockpit.” Is the IV running too fast? Is the machine blowing in enough air with each breath? How’s the urine output? Oh, they’re closing – should I turn the gas down now, or will he take a while? Is that heart rate a little too high for his aortic or mitral valve problem? Did I give the drug to slow it down? Let me dive down under the drape to make sure his eyes are still protected…This is all behind-the-scenes, largely unacknowledged work, but it makes even the tiniest task a meaningful act, and I love that about my job.

And that’s just in the O.R.

I've written elsewhere about my E.R. and I.C.U. intubations, but I haven’t even addressed the expertise anesthesiologists bring to laboring women, not only in placing and ensuring the safety of epidurals for labor and spinals for C-section at any given moment, day or night, but also in caring for mothers when childbirth becomes dangerous. On occasion help is needed for an alarmingly sluggish newborn, and yes, we are useful for that too. The code that made my heart beat the fastest was when “Anesthesia, Stat” was paged overhead to the labor and delivery suite and I realized the person coding wasn’t one of the moms, but rather a minutes-old newborn. The family practice attending physician handed over the laryngoscope he was holding, and I intubated the baby so we could bring her oxygen saturation back up to liveable.

Many people have assumed that their limited understanding of our profession reflects a limited scope of medical practice on our part. Assumptions can be unfortunate, but I prefer to focus on the things that keep me coming back to the O.R. despite people’s colossal lack of awareness about what I try to do for them. I know what you’re thinking: it’s gotta be the paycheck, right? Never mind that childcare costs and six-digit educational loans eat up half of it. Sure, the pay is good, but it’s good because of what we are capable of doing for people, and the amount of sweat and tears it took to acquire and prove those capabilities. This is not a job you can commit to just for the pay and be truly happy. It’s too hard.

Nor can anesthesiologists be motivated simply by glamour and prestige – there’s too much ignorance about anesthesiology to allow for either. For me, real job satisfaction has to rest on tenacity, self-respect, humility, kindness, and happiness with the work itself. The big pay-off, in my mind, lies in my relationships with my patients, whom I may meet only briefly but during intensely significant moments in their lives, when they may need the most comfort. All the scientific gobbledygook that goes into the practice of anesthesiology has a chance to get sifted and transformed into a true human connection, into resuscitation that goes well beyond the needs of the body.

It’s my hope that someday, when a person collapses in the bookstore-café that I don’t own, or in the opera house in which I’m not dancing (or playing the oboe!), and an anesthesiologist responds, it will be common knowledge that the professional responding to the situation is providing expert care in the truest sense of the phrase.