The Student Prints

I like med-student blogs. They remind me of the excitement, the frustration, foreboding, and fun of those times. More than that, from the quality of the writing and the depth of the thoughts expressed, it gives me hope that when I'm sick there may still be doctors out there interested in taking care of me in the way I'd have taken care of them. On the other hand, some of what I read is disturbing.

It's a predictable pattern: someone writes about her/his surgery rotation, and -- if not perfectly word-for-word -- certain statements will be made, and an inevitable array of comments will follow. The cast of characters is always the same: the asshole resident, the overbearing and brutish professor, the student who hates everything about it, sometimes with one or two who love it (and whose motives and sanity will likely be challenged.) Rarely, there might be a supportive resident or two. The behaviors described recur time and again. Berating, humiliation; a senior attending who not only treats the students and residents like shit, but his patients as well. The author, and the commenters, in the most vituperative and unforgiving of terms, validate their owns similar experiences and roundly condemn the surgeons and their method of teaching.

Keep your fingers off the keypads for a minute, kids: I'm with you. The reason this is disturbing is that it's true, and I hate hearing it. By far the worst thing to read -- and I've read it in commentary by patients as well -- is the description of a doctor (any doctor, but particularly a surgeon, because they seem to be the most frequent offenders, in these fora, anyway) being disrespectful and uncaring toward a patient. For that, there's no excuse, ever. And whereas I don't think for a minute that it's limited to academe, I believe -- from observation -- that such behavior is more common within the ivory walls than outside. Maybe it's tenure; maybe it's the academic rat-race; or maybe it's slop-over from the anti-Socratic method of discourse that's become embedded in surgery training like dogshit in a Doc Martens.

The operative phrase is "shit runs downhill." Profs dump on the chief resident, who dumps on the senior resident, who dumps.... But it needn't be like that. I wasn't like that.

In training, as I worked up the ladder, I was a good and patient teacher (or so I'm saying!) I had interns and junior residents over for dinner; I made jokes on rounds, and pitched in on the scutwork. I relished showing technique and explaining reasons for things. I rarely -- if ever -- grilled, and when I did, it was to get somewhere rather than to debase. It can be done. I don't recall chewing someone out, ever. But when I became a real doc, bearing all the responsibility myself, some things changed. I NEVER treated my patients with anything less than respect and empathy. But I know I could be hard on the nursing staff, and even referring docs, when I thought something had been done less perfectly than I demanded of myself. Believe it or don't, I was much harder on me than on anyone else if anything diverged from my view of excellence, but I make no excuse (OK, I do: it was based on hyper-perfectionism and not arrogance): things can be said in less off-putting ways. (In fact, in my second incarnation, after brief retirement and time to relax and reflect, as a surgical hospitalist I had an entirely different attitude. Nurses who'd known me before said they'd never seen me so happy. I think it partly had to do with sleep. And, yeah: being old and beat up enough to let some things go.) But there's a point here.

Not everyone will buy it without offense, yet it's true: surgery is the court of last resort. A surgeon is judge, jury, and -- God forbid -- executioner. Every other doctor can punt, and they do. Often. A surgeon can't, especially in the OR. And so, whereas it needn't be as punitive and degrading as it is in some places, surgery training will always be long, and hard, and demanding. I accepted a certain amount of misery when I went through it (and worked hours far more brutal than now) because I felt urgency and necessity. I thought then, and still do, that surgery training does more than the others to inculcate a sense of responsibility, the knowing of one's limits, and a commitment to perfection; and it must, because there are no hiding places in an operating room. If some students are put off by it, it's not entirely a bad thing. They will, and should, make another choice.

I read a student blog the other day. The writer said she hadn't read up on the operation in which she'd be participating, and was taken to task by the operating surgeon. With relish, evidently. Her post was followed by lots of comments deriding the attending in particular and all surgeons in general. There was an echoing chorus of animus: they're dehumanizing, bunch of egomaniacs, surgeons are terrorists. But along with the cringe of embarrassment for being associated with the evident scum of the earth, there was a twinge of an opposite thought: if I were to show up to an operation unprepared, someone might die, or be maimed forever. I'd hope that people who choose to become surgeons are the sort that don't need reminding, and are, in fact, the kind that wouldn't show up unprepared in the first place. But in training, some do. And they don't last. If they don't respond to whatever method the attendings or the senior residents bring to bear to point out and correct their failing, they get tossed. As they should. And, as someone who might some day lie on a table in the most vulnerable position you'll ever be in, aren't you glad to know that?

Dead Man Wasting

Even as I questioned the value of dog labs, I wonder still more about the most hallowed and time-honored tradition of medical school: the dissection of cadavers to which all first-year students are subjected. Because the bodies have been knowingly donated, it's not really an ethical issue, except to the extent that those who've made the gift might have a more exalted view of its value than is accurate. And before I say my piece, I must admit it's just one opinion, from a ways back. I'd hope more recent, and current, students might chime in and set me straight, if that's what is called for.

I'd guess we've all seen classic paintings, like Rembrandt's "The Anatomy Lesson." We've heard of grave-robbers hired on the sly to supply medical schools, of Michelangelo becoming one himself to facilitate his artistry; and we know the extent to which these dissections have been carried out, more or less in the exact way, for centuries. So in pushing yourself through the portal into the anatomy lab, you feel as if you're entering a space hallowed by history; taking up a challenge and a charge handed down by people willing to risk their freedom to advance science. Maybe more than anything I can think of, you're stepping into the past. Unlike, say, those who re-enact wars, or who sail on resurrected galleons, this is more than play. It's not make-believe. This is becoming what was, experiencing exactly (sort of) what the pioneers of our field felt, and did. In a couple of important ways, though, it's also a great deal less.

Much as I might have liked to be wearing the flowing clothes, the fuzzy collars and broad hats of Rembrandt's vision, it was rubber gloves and plastic aprons. If I'd imagined being in the thrall of a master lecturer and demonstrator, it was in fact a bunch of clueless students trying to follow written instructions, wrestling alone and together with their conflicted thoughts, working out who'd do what, with a lab assistant sometimes wandering by. (Was that a smirk on his face?) As far from life-like as they could be, the tissues reeked of formalin, and were leathery and hard, belying and opacifying the mystery they held. Or had held. And they were greasy. There's not much to be gained from the process of finding one's way through, by dissecting such unnatural material, spending lots of time getting there and often missing a turn. To the extent that there's knowledge to be revealed, in a preserved cadaver it's in the arriving there, not in the travelling. And marvelous and awesome as is living anatomy, what's revealed in a cadaver is a wooden shadow; as removed from real as a dried and pressed flower is from a bloom.

There was a need to acknowledge the gift this person had made, and there was a desire to turn away from it. To look at the face; simultaneously to absorb and to erase. Tightened, tanned, transmogrified, the body had already been dehumanized more than our dissection would do; still, in making the first strokes of the knife, there's an inward voice saying, "Sorry... sorry... sorry."

Is it like removing the sword from the stone? There's a sense in which this feels like a rite of passage, a symbolic qualification for being allowed to learn the long-guarded secrets. If you faint, if nausea overtakes you, if you can't get past the sense of transgression, you ought not be here. So it seems. Does it harden you? Or soften you up? For most, it's the first encounter with a real live dead body. There's fear of how you'll react, of embarrassing yourself. Some students have ceremonies of thanks to the person who gave their gift. Whom's it for? Is it being actual sensitive, or see-me-sensitive? To the extent that this dissection is ritual, we respond with ritual. We dance with the corpse, and it dances with us. So it raises a question: is it necessary?

In my view, there's only so much -- not much -- that you can get from working with stiffened sinews and pickled pieces. The anatomy I really needed, the relevant relationships I began to understand as a surgeon, I got in the operating room. Or in the basement: I participated in autopsies of unpreserved bodies, and the ones on patients of mine were infinitely more emotional -- and instructive and useful and important -- than that work as a first-year student. The sequence seems wrong: if such dissection is to be done, it ought to be by those more knowledgable and honed. Absent context, it can become clutter. Cardiologists need to have the experience of holding a heart in their hands (and to see one beating in the operating room); how much more meaningful to do it later in the process. As students, it's like a White House document dump: too much information, no hooks on which to hang it. Even books, with their diagrams and plastic overlays provide more understanding once you figure out what it is you need to know. And now, of course, 3-D imaging and computer programs allow interactive and highly effective work.

At the time I went there, my medical school was the leader of a revolution; it broke the timeless tradition of curricular structure. For ever, it had been anatomy, physiology, pathology, pharmacology, lined up in sequence and out of sense. Where I went, they'd just rearranged into teaching by system: cardiovascular, for example, including the anatomy, physiology, pathology, organized in ways to make it meaningful. So the old-fashion dissections were out of synch, and therefore out of use to a much larger extent than at other schools. We did, in other words, much less in the cadaver lab than our contemporaries. In hearing of that, at first I worried that I'd come out unprepared, anatomologically. It was almost embarrassing to reveal to college friends at other med schools how little time I'd spent doing the dissections and taking the tests that they and our forebears had done. But it's clear to me now my time was better spent. And whereas I do think all doctors need a working understanding of the anatomy of all systems, it needn't be -- and in fact isn't -- those first-year dissections which provide it. I'd go so far as to say that, other than imparting a sense of having walked over the same coals as everyone else, the first-year cadaver lab is over-rated and under-important.

Bag Man

There's a recent post by Orac about the "'swag" given to docs by drug companies at medical meetings. It reminds me that when I was in med school, my class was -- far as I know -- the first ever to refuse the personalized black bags traditionally given to students by Eli Lilly Company. I was of two minds.

My consciousness was a little late in the raising. It hadn't yet occurred to me back then that there were issues with taking goodies from those guys. We were also in the midst of the Vietnam war, and my class was active in protests. I attended a meeting in which a moratorium on classes was being planned, for the purpose of war protest, and the dean -- a bullet-headed guy much admired by all -- burst in and, in his most gravelly of the graveliest of voices said "What we need is a moratorium on bullshit." So it was a transitional time; but things were beginning to dawn on me. (By graduation, I was one of only a few wearing a "peace-sign" armbands at the ceremony. Ironically, I'm pretty sure the only member of my class to serve in Vietnam was me. And I'm glad I did.)

I'm proud to say that when I went into practice I was -- until there evolved a like-minded clinic-wide policy -- one of the very few in a large clinic to refuse to see drug reps; nor did I -- despite the attraction of great restaurants and a the occasional gratuity -- attend dog and pony shows put on in the name of some new drug or another. (Truth: I went to one, and felt dirty.) But back then, I wanted the damn bag.

"Right on," I said, gritted teeth hidden behind a powerless pasted smile, signing on to the class-wide refusal. Fuck The Man. But I wanted the damn bag. I'd worked hard; med school was a goal sought and achieved, getting the MD sheepskin in one hand and a black bag engraved with "Sidney Schwab, MD" in the other was something I'd envisioned for a long time. Screw activism. Gimme the bag. In the end, of course, I didn't take it. There was always my grandmother...

During my internship there was a company hawking a very long IV catheter, to be inserted in the arm (a theoretically safer route than some others) and threaded far, to where it could be used to measure central venous pressure, or to provide high-calorie intravenous feedings. Today such tubes are routine, and work well. Then, there were problems with the first iterations: inflamed veins were nearly universal. At our weekly conferences, complications were regularly reported. But the rep.... the rep.... She was a beauty. We were (excepting the one female in my group) a bunch of overworked and underpleasured guys. Her blond hair, her sweet smell. Her lovely form, those welcoming, eager br.... (Sorry. My wife reads these posts...) Suffice it to say that whatever the latest problem, she had a way of sidling up and explaining it away and talking us into using the catheter again. And again. And oh yes, oh yesss, again. Standards? Yeah, I have 'em. But don't we all have a price?...