L'Insegnamento Medico Alla Moda

In 1720 composer Benedetto Marcello (whose oboe concerto in C minor is a well-loved part of the accomplished oboist's repertoire) anonymously published a satirical pamphlet entitled Il teatro alla moda - Fashionable Theater. In it he criticizes contemporary trends in opera by constructing a handbook of sorts for various participants in opera production.

The pamphlet suggests that the modern composer should have no knowledge of proper music theory; that virtuosi should be illiterate and don't need to have good pronunciation or comprehension of the words they sing - the better to perform "ornaments, trills, appoggiature, very long cadences,"* etc.; that the modern Poet "should not have read and should never read the ancient Authors, Latin or Greek. And this is because the ancient Greeks or Latins have never read the moderns;" and the mothers of female singers should mouth the words with their daughters at every audition, prompt them with the appropriate ornaments and trills, and lop at least a decade off their virtuose's ages whenever asked.

I read some of Il teatro in the original Italian, and I have to say, it's pretty funny. But I'm sad that Marcello included a caricature of Vivaldi on the cover of the pamphlet, and that the pamphlet is in fact a response to, and harsh critique of, Vivaldi's style. Benedetto Marcello wrote such a lovely oboe concerto (as did his older brother, Alessandro Marcello); I hate to think such a talented composer might also have been a sneering jerk.

Yet I can't pass judgment, because of what I'm about to do.

I'm about to start...in quizzical memory of Benedetto Marcello...and with tongue firmly planted in cheek...

L'Insegnamento medico alla moda: Fashionable Medical Education, being a compendium of safe, easy, useful and necessary Advice given to attending physicians, residents, medical students of both sexes, premeds, spouses of the above, & other People belonging to the World of Medicine.

Some excerpts:

Medical Students, say a fond goodbye to your spouses, your children, your hobbies, your wallets (figuratively speaking), and your beds (quite literally). You will probably never see them again.

Residents, especially those engaged in surgery or anesthesiology, should have themselves permanently catheterized so as to be able to void bladder contents at appropriate times rather than waiting the requisite 6 or 8 or 10 or 12 hours for their cases to be done.

Female residents, please prepare and practice the sweet smile you're going to show daily to patients who address you as "Miss," "Nurse," or "Kid" despite the name tag on you that clearly says DOCTOR on it.

Attending physicians, be sure to expect your students to know everything there is to know about medicine prior to their having been taught any of it; expect them also to read your mind and know exactly what you want without your giving a lucid explanation or clear directions; never offer clear directions, or guidance of any kind, or if you do, do so grudgingly and with an air of exasperation or contempt; don't forget to contradict the attending physician who was teaching before you, so as to confuse your trainees utterly and make them appear incompetent to the next person; and finally, never, ever, ever, ever allow the on-call residents to sleep. Ever. And make sure they have to work like oxen the following day, especially if they are residents in cardiac surgery or neurosurgery.

Spouses should take a vow of long-suffering patience and self-sufficiency in addition to all that love, honor, and cherishing they promised before they realized what they were getting into.

Nurses in the recovery room or ICU, be sure to brow-beat the residents from the moment they drop off the patients to the moment they finally take their leave and run to the rest room or drinking fountain. Some exceptions apply...

Fellows and senior residents: lord it over any one less senior than you, fix the schedule so it favors you and nails everyone else, bad-mouth the attendings above you and the juniors below, and avoid doing work of any kind.

Heehee...I know, I am SOOOOOOOOO bad...but I'm not really this cynical, honestly. For the record, during my training I did know attendings who were good teachers and clinicians, nurses who were kind and helpful , surgeons in various subspecialties who were gracious and respectful, and senior residents and fellows who exemplified everything I hoped to become as a physician. But after all these years, a girl can take things a little less seriously, lighten up, and let off a little satirical steam, no? :-)

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*translations are from the wikipedia article about il teatro alla moda.

Who's Afraid of the Big, Bad...Resident?

Today was supposedly the worst day this year to have to go to the hospital. July 1 is typically the first day of the training year for all residents and medical students across the United States, though there are a few programs that start their year in the last week of June. I imagine that most people who know this and have a negative attitude about medical trainees look upon hospital admissions in the month of July with a mixture of dread and disdain.

There have been various writings, from The Underwear Drawer, a blog by anesthesia resident and talented humorist Michelle Au, to an article in The New Yorker by Atul Gawande, about doctors who, with some guilt over the hypocrisy of it, request the most senior person available to attend to their loved ones. I've had a different response. Yes, I want the best care for my family, always, and of course I wouldn't want my young children to be poked endlessly by novices who couldn't get a blood draw or an IV. But when I was an intern and someone asked me where I would take my children if they needed medical care, I immediately named the hospital where I was training, even though I knew residents did all the legwork. I knew my colleagues at the time, and I knew they were unswervingly meticulous about evaluating their patients thoroughly and competently.

And when I was an anesthesia resident and needed to bring my son to the E.R. at Children's for stitches, the senior pediatric resident there, who knew I was an anesthesia resident, asked me if I wanted the attending physician to do the stitches, to which I replied, "No way, I want you to do it." I knew he had been doing procedures day in, day out for the last three years while his attending physician looked on, made suggestions, and signed the chart. So in some sense I was doing the same thing Drs. Au and Gawande wrote about doing, and asking for the most experienced, competent clinician to take care of my son. But I didn't automatically decide that the pediatric E.R. resident was inadequate to the task, like so many people do, a priori.

Having been on both sides of things, I think residents are misunderstood and too little respected. Residents are M.D.'s - doctors - which means they have more knowledge than the average citizen about medical matters. Their education as residents is for acquiring sound judgment and comfort with procedures in a particular specialty - the kind of judgment that can only come from experience. Fellows are those who undertake a subspecialty after completing residency in a specialty. Attendings (short for attending physicians) are done with training.

Someone commenting on Dr. Au's blog compared being approached by residents to being "accosted by idiots." I could go on for a long time about people who make sweeping generalizations about groups (i.e., prejudiced people), but suffice it to say, I found this statement completely offensive in its attitude and content, and unfair to the many resident physicians in this country who provide outstanding care for their patients.

Of course no one wants to be a pin cushion for people learning to start IV's the first week of July, and right now the only way to learn is to practice. As a resident I did let my students start IVs on me, and I wasn't mean or whiny when they missed. The path to perfection is woefully through many hills and valleys of imperfection. And people forget, it's not always a problem with the person performing the procedure. I've seen cardiac anesthesiologists struggle with IVs after decades of doing them expertly. Some people do have terrible, terrible veins. Just like airways. Even the best laryngoscopist encounters that pulse-increasing, difficult airway once in a while.

Personally, and I've written this before, I think simulators are the way to go for certain elements in medical education, like procedures and group dynamics. Repetitive action by muscles makes those muscles and muscle-brain connections more capable. Ask any musician. Of course, in medicine there has to be a STUDY to prove something even that obvious, and those studies exist. They show, of course, that simulation of procedures increases competence at performing those procedures. What a shocker. (Kind of like that study that showed that sleep deprivation - a recognized form of torture, I might add - diminishes the quality of care provided by the sleep-deprived clinician {typically, an exhausted resident}. Like, DUH.) The one simulator I've been dissatisfied with is the intubating mannikin. Intubating that thing is NOT like intubating a human being at ALL.

Sometimes I play a game in my head that involves finishing the sentence: "There are two types of people in the world..." By now I have a long list, which I may post some time, but tonight my mental entry is, There are two types of people in the world: those who respond to students with understanding and patience, and those who respond to them with frustration or contempt. The former probably make better teachers, at least from the students' perspective, in terms of "making connections" with or "reaching" students. I've found that the medical world is littered with many examples of the latter - perhaps because responding the first way takes some genuine humility and a spirit poised for compassion. But there's hope - after all, it's called the practice of medicine.