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.

On Seeing and Being Seen: a meditation on the social psychology of medical intervention

I thought Bill Clinton's graduation advice to make sure you really see the person next to you was good.

I thought the failure of people to notice Joshua Bell playing at the Lafayette Metro Station was bad.

But there's worse.

What's worse is people NOTICING something notable, but ignoring it.

And worst of all is when failure to see, or act on, a noticeable crisis costs a life. It was one of this week's buzz stories in the O.R.: the death of Edith Rodriguez.

Edith Isabel Rodriguez went to the E.R. at Martin Luther King, Jr. Hospital in L.A. - also known as King-Harbor and formerly known as King/Drew - doubled over with abdominal pain. According to the Associated Press, "It was at least her third visit to Martin Luther King Jr.-Harbor Hospital in as many days. 'You have already been seen, and there is nothing we can do,' a nurse told her.”

This kind of situation can put any doctor or nurse in a tough spot. A patient presenting with a history like this is usually either afflicted with an ill-defined medical problem, sometimes chronically, often more than one, and typically difficult to relieve completely, OR...the patient is in SERIOUS TROUBLE.

Jonathan Larson, composer of the famous Pulitzer Prize and Tony Award-winning musical Rent, got sent home when more than one emergency department failed to diagnose the cause of his chest pain and nausea: aortic dissection, which killed him the day before Rent opened.

Sometimes it can be a tough call, but I think when someone goes from abdominal pain to vomiting blood, it's usually a clue that something really BAD might be going on, depending on the nature of the vomitus and the amount of blood present, and I have to wonder what the thought process was in that emergency department. I admit I don't know all the details, and hindsight after someone codes and dies is certainly 20/20, so I am in no way trying to point the finger here. I'm just wondering, like everyone else, what happened, and how could it have happened?

Edith Rodriguez's story has by now been publicized widely in the media. The articles I saw were on MSN and the L.A. Times, but I was struck most by the CNN video on glumbert.com. It relates how Ms. Rodriguez lay on the floor vomiting blood, and somehow got help from NO ONE except a couple of individuals who tried to call 911 for an ambulance to take her to ANOTHER hospital. From the video and the articles I read, I've reconstructed part of the transcript of these calls here:

First call, 1:43 a.m.:
Caller: My wife is dying and the nurses don't want to help her.
Dispatcher: Okay, what do you mean she’s dying? What’s wrong with her?
Caller: She’s vomiting blood
Dispatcher: Okay, and why aren’t they helping her?
Caller: They’re watching her...uh...they're watching her there, and they’re just not doing anything. They’re just watching her.

Second call, from a different person, 1:51 a.m.:
Dispatcher: What’s your emergency?
Caller: It’s a lady on the ground here at the emergency room at Martin Luther King.
Dispatcher: Well, what do you want me to do for you, ma’am?
Caller: Send an ambulance out here to take her somewhere where she can get medical help.
Dispatcher: Okay, you’re at the hospital, ma’am, you have to contact them.
Caller: They have a problem, they won’t help her.
Dispatcher: Well, you know, they’re the medical professionals, okay? You’re already at the hospital. This line is for emergency purposes only. 911 is used for emergency purposes only.
Caller: This IS an emergency!
Dispatcher: It’s not an emergency. It is NOT an emergency, ma’am.
Caller: It is!
Dispatcher: It is not an emergency.
Caller: You have to see how they’re treating her.
Dispatcher: Okay, well, that’s not a criminal thing. You understand what I’m saying? We handle-
Caller: Excuse me, if this woman all out dies, what you mean there ain’t a criminal thing?

The call did not end well. The dispatcher insisted again that the situation was not an emergency and offered the caller a business number if she was displeased with what was going on. Just before 2 a.m. the caller said, "May God strike you too for acting the way you just acted." The dispatcher's reply: "No. Negative ma'am, you're the one." He has since received "written counseling" for the way he handled the call.

Edith Rodriguez was pronounced dead at 2:17 a.m.

Zev Yaroslavsky, LA County Supervisor, was flabbergasted at the security video of the incident. He said it was even worse than the audio tapes. “Not one person out of a couple of dozen, including citizens and staff and doctors and nurses…[They] didn’t lift a finger to help her. They just ignored her. Even the janitors who were cleaning up the vomit from around the woman who was on the floor did a very elegant job of cleaning up the vomit but didn’t do a thing to help her. It was just indescribable.”

With her writhing on the floor in pain, vomiting blood, and her loved ones begging for help, how could someone NOT have assessed the need for some intervention? If nothing else, isn't that what emergency departments DO?

Now, I know about the Bystander Effect. I've heard of Darley and Latané's social psychology experiments demonstrating the failure of people to help others in a crisis if other people are also present. I've read about the terrifying case of Kitty Genovese, who was stabbed, raped, and killed over the course of half an hour even though 38 witnesses heard her desperate cries. I've even been a cautious bystander myself.

When I was walking back to my hotel from dinner with an anesthesiologist friend of mine (we were in D.C. about to take our oral boards, actually), we noticed a pair of human legs protruding from the bottom of the potted plant decorating the entrance of her hotel. We came upon a man passed out on the sidewalk, his head and neck cocked to a rather concerning angle. There was already someone palpating the carotid for a pulse (correctly, we observed), and we didn't want to contribute to a "too many cooks spoil the soup" situation, so we lingered in case our help was needed but stood quietly in the background. I did go into the lobby and try to get the hotel management to bring out any first aid or medical equipment they might have had, but they just stared at me blankly and said 911 had already been called. I insisted that someone go and retrieve the stuff anyway, and one of the employees went, but I didn't see him again. Anyway, the paramedics arrived and packed the guy up, and my friend and I saw that they needed no interference from us. But I should hope we would both have asserted ourselves immediately if the situation had really called for it.

What bothers me about the Edith Rodriguez case is that I could easily have been one of the bystanders in that hospital lobby and contributed to her death, although I can't say for sure what my reaction would have been without knowing all the details of the actual situation. We all want to think we would have been the different ones, the types who would have said "no" to the authority figure in the Milgram experiment and refused to apply the electric shocks to the subject, the types who would have called for help in Darley and Latané's experiment when the stranger started seizing. We all imagine we would have bent down in concern toward Edith Rodriguez and at least tried to figure out what was going on, if not offer actual assistance. I think I would have done this, I hope I would have...but I also think deep down we all know that it's easy for ANYONE to be swept into the middle of an inert crowd and stay there dumbly looking on.

Edith Rodriguez's brother, Eddie Sanchez, made this poignant comment on the glumbert video: “You go there to get help, and nothing happens, like…You get ignored like if you’re nobody.” How many times have I failed to SEE my patients, or unwittingly treated them as if they were "nobody?" I cringe to think that I may have done the very same, albeit without the fatal consequences. Or, even if I paid adequate attention to a patient, what if I made the wrong judgment about how to manage the patient's problem, out of a reluctance to admit, "Yes, we have a disaster, and it's right in front of our eyes?"

I pray every day for the ability and courage to make the right calls. A couple of weeks ago our friend who's a flight attendant was describing a flight during which a passenger was found doubled-over in his seat. She announced the need for a physician and said it took a long time for one to come forward. I understand that - the daunting sense of responsibility often competes with the desire to serve and relieve suffering. As it turns out, the physician who did examine the man also told our friend that the captain had to land the plane immediately because the man was in acute heart failure. I think that was a very brave doctor in there. That's a heck of a call to make, diverting a flight filled with passengers to save one life on the suspicion of a life-threatening condition NOT confirmed by the technological aids we get so used to relying on in hospitals. I spiritually bow my forehead to the ground in respect and admiration and pray I never have to make a call like that. Although, what's worse - being wrong about the heart failure, and causing an inconvenience, or being right but lacking the confidence to make the move, thus costing a life? I guess the answer's pretty unambiguous.

I've alluded to the training we got in our medical simulator during residency. I am not allowed to comment specifically on our training scenarios or on people's actions within them, but I think I can make some general remarks on the experience. While the medical aspects of those scenarios were useful, I think a key element in teaching crisis management of any kind is a rehearsal and discussion of group behavioral dynamics. We did bring up and discuss issues like those raised by the Edith Rodriguez story. What makes us blind to another's needs? What makes us ignore data that's right in front of us, or help that's offered? How can we best structure a group's interactions so that efforts to provide help are focused and organized?

One take-home message I valued was that there should always be an "event manager" - one who's NOT involved in DOING tasks, but rather is WATCHING everything that's going on, processing it, and determining what steps are needed next. But of course, in the real world, this role separation is difficult, and often it's not possible to delegate. Or, people are reluctant to step forward to claim the role.

My heart goes out to Edith Rodriguez's loved ones. We in the medical profession failed them, egregiously. The only personal offering I can make at this point is a commitment not to rest smugly in the position of critic and judge, thinking, "Well, I would have seen her there, and I would have done something. I'm not blind." Sure I am. Or can be. And it makes me think twice about an old, familiar New Testament quote from a blunt, rather ticked-off Jesus:

Jesus said, "If you were blind, you would not be guilty of sin; but since you say, 'We see,' your sin remains." (John 9:41)

All I can honestly say is I would LIKE to think I would have treated the situation differently. But I cannot say that I would surely have been immune to group blindness or inertia. I think we need to learn to acknowledge our blind spots and make a promise to all patients, "We don't always see well, but we will always work to see better. Always."

Pie It's Not; or, Two Steps Forward, One Step Back

Why, oh why, just when we seem to be making progress, do we suddenly BOMB?

Yesterday's oboe lesson was so WEAK. I don't know what happened. I've been practicing DAILY. Scales, long tones, method book, and, dare I say it, "repertoire," embryonic though the latter may be. Practices have been going ok, with only a few bumps in the road due to fatigue, lack of technique, lack of know-how, what-have-you. Yesterday I was not fatigued. I was not nervous. I was having fun. 'My teacher was good-natured and laid back, as usual. And I just BOMBED. Couldn't even get through D major. Tone was horrible. Took 10 minutes of back-tracking and re-warming-up to regain my "sound." I was totally inconsistent. I kept making mistakes. I sputtered. What is UP with that?

I have a neurobiological theory, of course. I think when we learn a new skill and begin to practice it, our brains start rearranging little functions and electrical discharge patterns. Neurons adjust to new bursts of neurotransmitter, new connections. But I think there's a shifty phase when they're not quite comfortable with their new assignments. In the building process, with the "scaffolding still up" and some exposed parts here and there, I think some misfirings occur, and we have one of those dreaded bad days that supposedly everybody has. [Speaking of building: even during last week's barn-raising there was a major snafu that needed some re-working to resolve: the center post was actually off-center, so one of the major spans came up short!] I think eventually the activity patterns become established and coordinated, more orchestral, and the brain itself acquires new architectural elements, like a cathedral with a new wing. I guess I need to remember that every work-in-progress has to pass through major imperfections & ups & downs to get to a "more perfect" place.

If only it really were easy as pie. My family is very appreciative of my apple pie. My son calls it "Paradise Pie" because he says eating it is like being in paradise. When he was asked in school last November to write down instructions for how to make a turkey dinner, he wrote on his paper, "My family doesn't like turkey. We have ham and chicken at Thanksgiving." So his teacher asked him to make a list of instructions for any Thanksgiving dish, and he wrote,

How to Make a Pie.
Get 7 apples.
Bake a pie.
Eat it.

Love it! Wish I could apply that to music: pick up oboe, blow through reed, play music. Simple, right? If only!

And it's not like I can use an "oboe simulator" to learn. In medicine some of the best learning experiences I had were at our residency program's medical simulator. We could practice managing some pretty hair-raising scenarios and social psychology quandaries in the sim. I think it's the wave of the future for medical education and crisis management training. But to make music, I can't imagine there being an effective equivalent. The only way to be a musician is to keep TRYING to be a musician. I get so embarrassed when loving family members call me a "musician" - I feel so unworthy of the word right now!

Tonight I could only practice for a short time because it was close to the kids' bedtime by the time I got started. My son came up the stairs because he heard my scales. I said sheepishly, apologetically, that I wasn't that good. Like the supportive son that he is, he said, "I think you are, and you practice every day, so that makes you good." Sweet boy! My daughter soon joined us, and likewise said encouraging things that had more to do with her affection for her mother than her mother's abilities, but hey, no complaints here.

At the end of yesterday's lesson I asked Kyoko to play a portion of the Raymonda adagio I love, which I had transcribed clumsily onto some music paper a couple of nights before. I don't think I've ever heard it sound so beautiful. Wow. She has the perfect, rich tone and gentle vibrato for the piece. It sounded so gorgeous I could barely breathe. *Sigh* Something to aspire to...