The Gaze

Preface: this post is not meant to answers any questions, only to pose them. One of the benefits of the Asheville program is the "extra" curriculum outside of the hospital and the clinic. This includes monthly meetings to discuss ethics. Here, we can draw on experiences and talk about some of the dilemmas we've wrestled with within ourselves, or issues we've seen our patients face. This is a safe environment where we can feel at ease and discuss these quandaries without faculty (only our ethics sensei joins our group of eight). We also meet with faculty and course directors each month at the Chocolate Lounge to indulge in a glass of wine or coffee and discuss some of the finer aspects of medicine. We can talk frankly with established physicians, and discover their perspectives on the parts of our science that are not so black and white.

Our last conversation evolved into how we, as physicians, talk about our patients. Not about how a doctor should talk to a patient, but about how a doctor talks about a patient when the patient isn't listening. Where are the boundaries? The bottom line is, "is it right that a physician's behavior changes when a patient or medical student is not in earshot?" Physicians are asked to perform a highly stressful job for incredibly long hours. Stress can be brought on by dealing with matters of life and death every single day. The seriousness of these situations necessitates coping mechanisms. So, is it okay to get on the phone and vent with one of your colleagues about a difficult patient in a perhaps less than cordial way? Or, to make light of a frustrating situation, so you can go back to work the next day and envelop yourself in the gravity of the day to day? If you are a model of patient care and integrity when you are aware of the "gaze" of society (http://en.wikipedia.org/wiki/Gaze), does it matter what you say behind a patient's back in the security of rounds, or in your own car/home/place of business? Is there a place for this type of coping in the hospital itself?

For a budding third year, filled with altruism and excitement, I haven't yet felt the strong need to "cope." I haven't had to deal with years of frustrating patients (and don't forget the wonderful ones, too!), so I can't comment with any real expertise. What will be my answers to these questions 15 years from now? Will I be jaded by long hours and deep frustrations? Or, will I be able to answer honestly from a view outside the box? I can see both sides of the coin though. How does one deal with a patient who is obese, diabetic, has cardiovascular disease, hypertension, etc. and will not take care of himself or herself even though the patient has the time and money? How does one cope with an 18 year old on her fourth child who refuses birth control? In the clinic, the answer is easy: you are professional, you are at your best, you do what is best for the patient. But when your patients leave the clinic and you realize they haven't left your psyche, what then?

I've seen it in EMS, and again here in the hospital. After a 600 pound patient requires an "Orca Lift" and needs eight firefighters to be extracted from a house and put on a stretcher, the race is on for jokes post call. Or, a man in the hospital is so overweight that the trocars cannot penetrate the abdomen because of so much excess tissue. Comments will be made, but when and where? And by whom? Weight isn't the only example, but it certainly seems to be a common topic for jest. Ask anyone who knows me; I try to employ a large amount of humor in everything that I do. There are few situations in life of which I don't make light. But, these situations beg the question: as long as your patient care is done in a professional manner, does the rest matter? Where are the boundaries?

Aren't the eyes and ears of the patient the most important? An interesting comment was made during our discussion about how often the attendings and residents tone down their comments when a medical student is present. Aware of our gaze, they don't want us to lose our sense of idealism. I ask myself the obvious question: if the language changes because of the presence of a patient or med student, is that language appropriate at all? My first instinct is to say "no," but that is certainly hypocritical. There are plenty of jokes that my inner circle of friends find humorous, but which I would never make to a stranger. Knowing my best friend's true beliefs allows for leniency for our more crude jokes. Since these aren't about patients are they okay? The same being equal, I would think not. Or, is it that the business of medicine is just too serious to joke about? I continue to struggle with this gray area.

As stated earlier, I don't have any answers at this point. I can only be aware of my own gaze. I am not so naive to think I will never participate in the comfort of patient banter, but hopefully I will continue to be aware of my words and their context. Just something to think about.


As you can see, each question begets more questions. My questions started with our ethics discussion, and I looked at the Ring of Gyges as a thought experiment: http://en.wikipedia.org/wiki/Ring_of_Gyges.

Residents and Retractors

It's time to let you in on a little secret... I haven't had a completely "normal" third year experience so far in Asheville. That begs the question, "What's normal?" In the first six weeks on Surgery, we worked one-on-one with attending surgeons, sometimes as their first assistant. We scrubbed, we questioned, we joked. Now this is blasphemy. This is not how things are supposed to be.

I'm supposed to show up in my cute little white coat that's stuffed full of books, notes, and pocket tools at 0400. I'm supposed to report only to residents, because the attending is to be awed and feared. He/she is the omnipotent, omniscient, omnipresent being who strides onto the floor confidently, a few inches off the ground. Eye contact must not be made, and it is proper to cower just a little bit in his/her sight. If true fear is not inspired, a good grovel should be thrown in every few hours. If groveling is not ergonomic, you just have to hope they catch you in solemn prayer (praying to their divine-ness, of course). When the attending asks you to present a patient, beware! You will be interrupted quickly, and dismissed even quicker. Your saving grace will be the resident physicians, who are the buffer zone between you and the attending. They are supposed to be terse, possibly flustered, and always running out of time. You, the medical student, are an added chore. Go put a Foley in 17. What?? You really don't know how to put a Foley Catheter in? Get someone else to teach you. I'm busy. Follow resident physicians like lemmings, and, even though they aren't attendings just yet, cower if appropriate. These are the horror stories we students heard from the class above us. Fresh meat, we are.

I must say with a sigh of relief that this is not how OB-GYN really is in Asheville! But I'm not going to lie; of all the rotations this year, this is the only one that gives me a bit of the shakes thinking about it. It's uncharted territory (especially for the young, nulliparous male). Yeah, I'm sure the residents get a kick out of some of my patient care suggestions and butchering of common medical abbreviations (apparently "R+R" means "resection and reanastomosis," not "remove and repair" - but close!), but I'm always pleasantly corrected later. Thus, the next morning I won't act such a fool in front of the omnipotent one on rounds. The residents always have time for me; they teach and don't appear flustered (at least not that I can tell). My chief even helped me horde numerous packets of needless 2.0 Vicryl, so I could tie two-handed knots over and over and over again. I think I picked it up quickly afterwards, but in the OR I'm sure it was like watching a 15 year old behind the wheel for the first time... you grit your teeth, and want to rip the wheel out of their clumsy hands, but you know it's their first time.... they need the practice. After a couple days of trial and error, I can now challenge my Eagle Scout Pops to a "knot-off." And the attendings? I may still have a little bit of healthy fear, and perhaps they do walk a few sonometers off the ground, but there's less grovelling, cowering, and praying than I expected. They don't even blink an eye when I "remove and repair" someone's small bowel. Actually, they've been downright great. It was a great week one, and I'm shaking just a little bit less.

I was also shocked when I made it through 6 weeks of Surgery without doing any serious "retracting." You see that bad boy up in the top left? Now that's a retractor. Med students are bottom of the totem pole in the medical community, so if we get to scrub in, we're supposed to be pulling on these cumbersome tools to hold the patient's skin back. The residents and attendings do all the cool stuff obviously, but most of the cases on Trauma and General Surgery didn't require any heavy lifting. We've been replaced by this tool called the "Bookwalter," which hovers over the patient's belly and secures multiple retractors at the same time (sorry, I can't grow hands either). But finally in Gynecology-Oncology, I got to do my due duty! I got to grab my Deavers and Army-Navies and pull up 'n away. Sure I had retracted here and there in Gen Surg, but now I got a chance to hold back skin flaps for hours and hours at a time (or that's what I'll tell my kids). Don't worry, Robert's ready to retract! And I am. I like being helpful in the OR if I can, and if I play by the rules... do we remember our rules?

Rule #1 - Don't Get in the Way; Rule #2 - Don't Touch the Mayo; Rule #3 - Don't Get in the Way, and Don't Touch the Mayo!

We're there to learn, but I also think that the patient always comes first. Pestering the attending into a fit of rage is not going to make the surgery go smoothly. Queries at the proper times, and struggling to pull back Goelets to help him/her visualize is going to make the attending happy. And believe me, a happy surgeon is a good thing. So I try to find a good balance between learning and helping (so long as I don't touch the Mayo, of course). We had a wonderful case this week that tested the hours I'm putting in the gym. A few minutes into retracting above the liver my left arm starting shaking as I flexed backward. It was a monster piece of metal, and for the life of me I can never remember it's name. But I know what she looks like, and we will do battle again...

This is our only taste of "real" medical education in our third year, but I'm glad for it. This gives us a chance to  better understand a few things: like how much we will know at different levels in our training, what the medical hierarchy is and how it works, and what our lives are going to be like as residents. We also get the opportunity to learn from physicians not far out from medical school; those who perhaps understand our inadequacies a bit better, having walked our shoes just a few years before. It is also an important reminder that the people make all the difference in a residency program. I can't stress this enough. If I'm going to be spending 80 hours a week with just a few colleagues, they better be pretty chill. Fortunately, Asheville attracts that kind of person, I think. We're lucky here.

Now, back to the OR to defeat my nemesis.

Surgery: In Review

After a quick 6 weeks, I am moving on from Surgery into the world of Obstetrics and Gynecology (OB-GYN). It is a tearful farewell, as I put hernias and fasciotomies behind me, but by this time next week I might have caught my own baby (there will be a detailed play-by-play when/if I do some serious baby-catching).

I did very much enjoy my time in the operating room (OR) over the past month and a half, though. One of the very few disadvantages of this longitudinal program is only having 6 weeks on Surgery instead of 8 or 12 weeks. My compatriots back in Chapel Hill and Charlotte have a solid two months, but from my understanding, we pack in more hands-on training during our shorter clerkship. When I asked one of my friends from another medical school how he found Surgery and working in the OR, he replied: "Oh, I had a blast. As the medical student, I watched the intern, who was watching the resident, who was watching the fellow, who was watching the attending perform surgery on the patient! I got very good at watching." This is probably a gross exaggeration, but the nice thing about our Surgery block is the ability to work one-on-one with attendings. A number of the services have surgical physician assistants (PAs) on all cases, but that didn't stop me from being "first assist" on quite a few operations. After practicing my suturing on pig's feet, dish towels, and bananas (bananas, by the way, are a horrible excuse for fake human skin), I had the opportunity to sew in tons of cases. I can vertical mattress, horizontal mattress, subcutic, and simply interrupt. I stapled, two-handed knotted, retracted with "Army-Navies," pulled on "Weitlaners," and cauterized with "Bovies." I saw a spleen get taken out ("splenectomy"), a clavicle get plated, and a stomach get wrapped around an esophagus to prevent acid-reflux and reduce a hernia (a "Nissen"). Overall, it's hard to complain.

I'm not surprised that a lot of athletes fall in love with Surgery (as did I). Each case is its own match/meet/game/(insert generic name for sporting event here). It's the ultimate team sport. Each person in the OR plays his or her own very important role, and of course we're all wearing the same blue uniform (mask, googles, hat):

• There's the "scrub tech," who is in charge of the massive number of tools, towels, knives, needles, sutures, machinery, etc. Needle driver? Boom. It's in your hand. DeBakey? Forceps? 10 Blade? Just open your palm and say the magic word. As a medical student, you just get out of the scrub's way. Don't touch the Mayo, and don't try to hand off instruments. You're ass will be grass.
• The "rep" helps the scrub tech if it's a very complicated case with new tools. The rep is from the surgical instrument company, and knows the product inside and out to help in a pinch. But, just like a defenseman in lacrosse, he or she can't cross mid line (lax players please correct me if I'm getting this rule wrong). A rep is forbidden to hand anything to the scrub tech, only the "circulating nurse" can (every sport has their own arcane rules). 
• The "circulator" is master organizer, charting the progress of the surgery, grabbing anything not in the room in an emergency, and is usually in charge of the general ambiance of the room (i.e., the iPod). 
• The "anesthetist" constantly monitors the patient, basically making sure the patient doesn't wake up during the match. The players are constantly being tagged in and out, or "subbed," for shift breaks to stay fresh. The new line comes in, and no one misses a beat. 
• The surgeon and the PA run the offense. The surgeon is the ultimate captain. The surgeon leads the team, directing the troops to victory. When it goes well, the surgeon takes the accolades; when it goes wrong, it's the surgeon's fault. But it really is a "team" in the OR: every person is critical to patient care and success. Surgery is re-living your sports career over and over (including the 5am wake-ups, yuck). Oh, and if needed, a nurse might come in late to be a "closer," both in the metaphorical and literal sense: the nurse will actually close the incisions on the patient to end the match.

And then of course you have the random med student slowing everyone down...

As a medical student, it's all about the little victories. Did I go an entire surgery without getting in anyone's way? (Harder than it may seem). Did I suction at the appropriate time without being asked? Did I not get scolded? Did the attending not have to adjust the way I was holding the laparoscopic camera? You won't get praise for doing any of these properly, only corrected when you mess up. And, thus at night, I dream of the perfect case...

I was scrubbed in first, ready and waiting for the attending to glide into the OR and prep the patient in the desired fashion. No one asked me to move out of the way because I stood in the corner expectantly, then moved to the azure blue field and placed my hands neatly next to the Mayo. I did what I was told, answered all queries immediately and effectively. I drove the camera expertly throughout the case, drawing back during every irrigation and cleaning the scope on the liver when needed. I "followed" without being prompted on every fascial suture. I was then left alone to close the abdomen, which was done beautifully with nylon and steri-strips. The anesthetist didn't even need to give more laughing gas to get us through the final stretch. I was the perfect medical student: polite, crisp, undaunted... and never in the way.

What else did I learn? Orthopedists put in a lot of screws. They give new meaning to "drill, baby, drill!" Lots of plates, lots of screws, lots of drilling (and I got to drill!). For the general surgeon, pooping and passing gas ("flatus") is more important than anything... for the patient, that is. The SHELF exam was impossible; studying any more for it wouldn't have helped. And I think I might want to do Surgery.

So yeah, I learned a lot. Drill, baby, drill.

Dan "the Man" White

In most interviews, you end up talking about yourself, but I prefer to talk about Dan White. It's name dropping, I know, and it's shameful. But I do it anyway. I was particularly shameless during my interviews at Asheville. A few interviewers remarked about how they would have a tough time this year picking a class because all the candidates were so stellar. This is where I quickly interjected, "Yes! Like my friend Dan White. Have you talked to him yet?? Dan White? Well, yes. Did you know he was a stone mason?!? Like, an actual stone mason, and he has the beard to prove it. Yes, he carved stones. Stones, I tell you! Just look at his man-hands." Followed by, "You should accept me into your program because I know Dan White." That's what I wanted to say, but I refrained, because I think my love for him was already rather conspicuous. Dan and I met during Medicine and Society our first year in med school, and it's been a long courtship every since...

You see, Daniel James (and his partner in crime, Julia Brant - blog post to come about her loveliness later) is one of those people who has done everything. Everything. No, really, I mean everything. I might say, "Hey, do y'all want to go to Olive Garden tonight?" And Dan says, "You know, I used to be a dishwasher at Olive Garden, and let me tell you about the time I walked out on them because..." Or, I might complain about how long it's taking the pizza delivery man to get here, and Dan pipes in, "You know, Robby, when I delivered pizza for Stefano's in Knoxville..." You name it, he's done it. Odd jobs include: sandwich maker, kitchen grunt, dishwasher, cashier at White's Grocery (no relation, but great fun), post-office sorter, barista, pizza delivery man, bartender, physics tutor, and, of course, stone mason. I learned about this last profession on the drive to our Asheville interviews, and that's why I couldn't let it go (but, by the way, it seemed to work - I clinged to Daniel throughout the interviews, and look where I am now... jackpot).

Dan's laundry list of professions doesn't just extend to the weird and interesting. I gravitated immediately to Dan because of his immense perspective. A true out-of-stater and Summa Cum Laude graduate of the University of Tennessee - Knoxville, Dan spent from 2005 to 2007 in Can Tho, Vietnam, teaching American Culture and Listening and Speaking English to English majors at Can Tho University as a teaching fellow. But he didn't just teach and travel. He started a non-profit organization called the "Can Tho Youth Empowerment Project" which developed an English and computer curriculum for a local orphanage. Then, he continued this work back in Charlottesville, Virginia (yes, he has been forgiven for living in Cavalier land), as integration coordinator for the International Rescue Committee for refugee assistance. He used his recently acquired language skills to help families new to the United States find employment, access affordable housing and higher education, and attain financial literacy. He continued his work in medical school, creating and developing a health outreach program for refugee families (aided by med students and MPHs), which developed into an Albert Schweitzer Fellowship here at UNC.

The list continues, but let it suffice to say that Dan's done everything. He's a Family Medicine Scholar, which is one of the many reasons he came out here to the Asheville program (hopefully by the end of this medical year, I'll have blogged about all 7 of the other peeps in our class). I was uber-excited when I found out that I would have the opportunity to come out here and badger Dan for at least one more year of medical school. This is because Dan is my ultimate person to bounce "life" ideas off of. Whenever I get cynical or get caught up in some political conundrum, Dan is the man I go to. He has the perspective and patience to deal with me. As someone who's lived in a lot of people's shoes, he can say, "Robby, you're being an idiot," but in a way that makes me feel all warm and tingly inside. He's the type of guy who makes one think about people and problems in a different way, giving the ole noggin' a kick start. He always finds the good in everyone and everything. For me, the best Dan-isms start with, "You know, kind of the way I like to think about this is..." and then I know that I'm about to hear something profound. His wisdom is only exceeded by his modesty. I'm sure I will get a call after he reads this blog saying I was over the top (which although I usually am, is not true today).

As our dinners in Chapel Hill with Dan, Jules, and the other So. Villers became few and far between during Boards study, I felt that my medical education was diminished. Fortunately, we can delve into my ethical quandaries for at least one more year (much to Julia's chagrin). And once we have fully picked apart every aspect of a very serious problem, Dan the man will pepper in a "that's what she said," and we're all back to real world.

Dan the man, aka "the compassionate stone mason," and friend who got me into the Asheville program through flagrant name-dropping.