A 5 Gawande day

As you may already have guessed, I am a huge Atul Gawande fan. For those who don't know, Dr. Gawande is a surgeon in Mass Gen who is also the bestselling author of Better, Complications and The Checklist Manifesto. He is clearly brilliant but also manages to portray medicine in an accessible, realistic, yet somehow highly inspiring way. The title of this blog is actually taken from his book Better:
“Better is possible. It does not take genius. It takes diligence. It takes moral clarity. It takes ingenuity. And above all, it takes a willingness to try.” 

Over the last two grueling academic years of medical school, whenever I felt disheartened, or had lost sight of the reason I had chosen this life in the first place, I found myself rereading his books. They recreated for me this vision of medicine as not only a science, which being in class for multiple hours a day was already giving me a good sense of, but also as an art of healing, connection and bettering oneself. 

These days, after being out of the house from 5 am to about 8:30 at night, I hardly have time to put food in my mouth before crashing into bed, so I certainly don't have time to reread a book. (This thought both amuses and saddens me by turns.) However, I have gotten in the habit of referring to terrible, uninspiring days in a numerical scale of 1- 5 "Gawandes" based on how badly I needed to read one of his books. For example, a day when I sat in the call room for 6 hours, afraid to look bored despite wanting to tear my own hair out, was a 4 Gawande day. A day where I watched a good hearted nurse anesthetist sit with a scared 8 year old girl about to go in for surgery for far longer than duty asked of him, was a 0 or even negative Gawande day. 

But every so often, there are 5 Gawande days. These are mostly when someone who is supposed to be a role model epically fails in that regard and reveals him or herself as a doctor or human being I would sooner leave medicine than emulate. 

A few days ago, I watched my first surgeon meltdown. Thus far I had been lucky enough to be in the OR with surgeons who were either reasonable people, or crazy people who had not been challenged in my presence by anything going awry. These meltdowns are notorious amongst third year medical students (and I'm sure the rest of the OR team as well). Surgeons have a pretty terrible reputation for being tyrannical dictators of the OR who, on occasion, will simply lose their minds at one person or another. On those occasions, you pray to god that it isn't you that is the subject of their unchecked wrath. 

This surgeon is an interesting study. For the purposes of the story, I'll call her Dr. L. She's a tiny woman who is chummy with everyone, wildly egotistical, with a flash-flood temper that makes nurses tremble. In a lot of the qualities mentioned above, she reminds me of my dad. And paradoxically, I kinda like her. Not to mention that having spent my childhood dealing with napoleonic mood swings from an ebullient person friendly with everyone, I knew exactly how to interact with her and quickly established myself as "on her good side." 

The surgery we were doing was a fairly complex one, using the Da Vinci robot. (Look it up- it's as cool as it sounds.) Something had gone wrong with the screen and Dr. L's legendary temper was flaring. However, when a reasonable human being gets upset, especially in a workplace, it is as least somewhat constrained by the dictates of etiquette and normalcy. Not so in the OR.

I watched, amazed and more than a little terrified, as she unleashed a torrent of abuse on a random nurse, yelling multiple times, "Why are you here if you can't do anything??" She also would scream, "I am the surgeon!" over and over. When the nurse tried to speak up and defend herself, Dr. L would cut her off with, "I don't even want to talk about it anymore," and then continue to rant at her. Loudly. Eventually the nurse manager was brought in to try and rein in the situation. I honestly didn't know where to look. 

Strangely enough, later that week I was in another surgery with the Dr. L. and that very same nurse, and they were joking around in an indirect way about what had happened. I laughed along with them, but I knew what I had witnessed was not normal in the slightest. 

Honing my beatboxing skills

I can't pinpoint the moment when surgery went from something awe inspiring to something, to be  frank, rather boring. But it's happened at less than 3 weeks in, and I must admit, I'm screwed.

Today I stood in the OR for about a total of 8 hours, watching 2 surgeries. During that time, I did my kegels exercises (which seems appropriate on an obgyn rotation), silently beatboxed along with the heart rate monitor and surreptitiously did tendus (a ballet step) beneath the table.

Most people are amazed by the thought of surgery- slicing open a fellow human, tinkering with their insides and sewing them back together again, confident in your ability to heal. To be honest, I am too. I'm amazed by the idea of it. The step by step technique is what fails to inspire. Or at least, the watching of this technique.

To be honest, today wasn't the best example. There was absolutely no role for me in the surgery and with an attending, two residents and a scrub nurse crowded around the bed, basically no room for me as well. I edged my way in only to be repeatedly edged out. And while I could see a corner of the incision on my tippy toes, I really couldn't see much of anything for most of it. Thus the mind-numbing boredom.

That said, there is simply no describing the abject terror (and vague undercurrent of excitement) when someone puts a tool in your hand, even one as simple and harmless as the suction (which does exactly what is says to clear the field of view for the surgeon). That weird, self-doubting, jittery place you go to in your mind feels like adrenaline being poured into your bloodstream by the gallon. Do I suction now? Or will I only get in her way and make her angry? Have I waited too long? Is she angry already? By the time you have made a decision and began your bumbling attempt at suction, the surgeon has taken the suction from your hands to do it herself.

And every once in a while, you do something right. In a surgery a few days ago, we were performing a hysterectomy, slowing clamping, cutting and tying off the blood supply to the uterus so we could remove it. Having finished one side of a large, fibroid-distorted uterus, the surgeon flipped it over to continue the other side. "There's something bleeding on my side," I croaked out, having not spoken for a matter of hours. "Really?" she replied, flipping it back over. On the other side, an artery was rhythmically spurting, having in that short period of time already filled the cavity beneath it with blood. She quickly clamped the artery and tied it off. After the flurry of activity, she looked up from the pelvis and stared me straight in the eyes. "That was good," she said, "that was very good."
Maybe I love surgery.

Introductions are in order

I realize I may have jumped into things rather quickly.
I apologize and will now take some time to introduce myself:

I'm a newly minted third year medical student at a large east coast medical school. I love medicine and am full of excitement, hope and determination when looking at my future.

I'm currently rotating on my obgyn rotation at a major hospital and am daily being buoyed up and dragged down by the medicine I see there. I never thought blogging would be for me, but after reading Hyperbole and a Half (if you haven't read it, stop reading this drivel and go read it), I realized it can be a combination of catharsis and prose. And I need the catharsis. Boy, do I.

I don't consider myself naive in the slightest. Some would even call me mildly jaded. And yet I still find things I witness at the hospital shocking and sometimes soul crushing. Residents who've stopped trying to be good physicians and are now simply trying to escape beratement by their superiors. Patients in the OR being ignored in the bustle, who are trying so hard to be brave but can't help but let a few silent tears slip out before they are put under anesthesia in that cold, sterile and frankly terrifying room.

Not everything is that bad. Today I was told by a grateful patient that I had "sweet eyes" and I "would make such a kind doctor." I also witness some amazing feats of endurance surgery where all the staff in the room give their all until late into the night so that the patient has a shot of coming out cancer free.

I need to get these emotions out of my mind and heart and onto the page. I only hope you bear with me on this roller coaster journey that seems set to be fraught with intense highs and lows.

A life vs a grade

In the brief time that I have been a third year medical student, I have seen things that shock, amuse, excite, infuriate and amaze me- just some of a myriad of emotions. 

At times the situations that a third year medical student is put in are extremely frustrating. While I can gladly suffer the indignities of being ignored or treated as a dullard, knowing full well that everything is temporary and this is one step of many toward my goal, I can’t abide seeing patients get substandard care.

Earlier last week, a woman came in for oncologic surgery, having had multiple forms of cancer in her life. Reading through her chart, I realized this had to be a genetic syndrome, because it was simply too many cancers at too young an age to be mere coincidence. In fact, this seemed to me to be a textbook case of Li-Fraumeni Syndrome, a mutation in the p53 tumor suppressor gene that leads to multiple cancers. I suggested this to my residents, who had never heard of this syndrome, but after some explaining on my part, agreed that it was a likely conclusion.

That night, I went home and read up on the syndrome and found the patient fit the diagnostic criteria to a T. The next morning, I came back with the article and information and presented it to my residents, as well as the attending. They all agreed that this was a good observation on my part and that the patient had Li-Fraumeni Syndrome. However, when we rounded on the patients that day, no one said a word to her about her condition. Not a single word. Confused, I brought it up with the residents after we left her room. “Aren’t you going to tell her?” I asked. “Eh,” said the resident. I was stunned. But let me explain: Li-Fraumeni Syndrome is autosomal dominant; it was likely that one, if not both of her sons had inherited it.  In fact, one of her sons had already had leukemia, one of the cancers included in this syndrome. Li-Fraumeni Syndrome makes its sufferers extremely susceptible to DNA damage by radiation and it’s very important for these patients not to have or to have very few X-rays or CT-scans, not to mention they should not receive radiation treatment for their multiple cancers. This woman needed to know her condition. She needed genetic counseling, she and her sons needed to understand what was happening to them to prevent further damage and lastly, she deserved some answers to the mysteries of her health. To take it even further, she should be offered some time with a social worker, since the syndrome would be a very heavy psychological burden, and this woman had been through a lot of trying times in her life.

After struggling with shock and disappointment, I raised the issue two more times with the resident. Seeing that he was getting annoyed, I dropped the issue. I desperately wanted to tell her myself but was reluctant, knowing the consequences would be a verbal evisceration and a bad evaluation. So I didn’t. And as time went on and she was discharged, it seemed too late to do anything.

Each time I think back on this, I realize I should have told her anyway. This patient needed better care than these residents were willing to give her. The bare minimum of medicine that they were providing was simply not enough. Even as a third year doing the first week of rotations I could see that. And what is a lousy evaluation in the face of a person’s life?