Wednesday, February 3, 2010

Reflections from a "Role Model" at Grady: The Accomplice

*names changed, minor identifying details changed

Grady Inpatient Service, early 2007

“11:41 a.m.!” I announced to my ward team while walking backwards. I spun on my heel and turned into the corridor leading to the emergency department. My long, brisk strides signaled urgency to all around. The team—made up of one senior resident, two interns and three medical students shuffled quickly to keep up. 

It had been a long morning of rounds, and we were finally approaching the bedside of the last of ten new patients admitted to our team on call the evening before. On our “post call” days, it was a struggle to get everything done. As the attending, it was my responsibility to see every patient with the team, seize teachable moments along the way, and finish in a manner timely enough to dismiss the house staff to the lunchtime teaching conference.

We were nearly three weeks into the month, and by now our team dynamic was relaxed and familiar. The learning environment was good—safe, collegial, and interactive. I worked hard to keep the group engaged, and to avoid the stagnant, endless rounds that I occasionally experienced as a trainee. I slowed my pace just long enough to scan the patient board in the ED for our patient’s initials and room number. 

“She’s in 208,” I spoke while pointing down the hall. The pack swiftly marched ahead; all of our eyes locked on room 208. As soon as we reached the room, like a well-oiled machine, everyone did their part. One intern stepped into the doorway and quickly murmured to the patient that we would be in shortly. Another industriously flitted about the nurses’ station searching for the hospital chart. 

Closing the door carefully, I pulled out a billing card and positioned my pen. Like clockwork, the team formed an arc around me as Evan, the third year medical student, stepped forward to begin his patient presentation.

I scanned the faces and body language of the group; the shifting feet, shoulder rolls, and quick glances at the clock made it clear to me that we needed to soon wrap up. I smiled and nodded in Evan's direction. He began speaking in a HIPAA-sensitive voice. 

“So last but not least, Ms. Harris is a thirty six year old African-American female who presented with a two hour history of chest pain after using crack cocaine.” 

He looked over at Mitchell, the senior resident, who let out an exasperated sigh. “She’s had two admissions this year for similar symptoms, and also has a history of hypertension and tobacco use. She’s nonadherant to her medications. Her chest pain started retrosternally and then radiated to her right arm. There was no associated. . . .”

Mitchell groaned and then interrupted. “Can I please just give you the Cliff Notes version? Basically, Dr. M, it’s just another crack-chest-pain. Totally not typical for cardiac causes, EKG was negative, enzymes negative, exam unremarkable, totally non-compliant and 100% uninterested in taking any of her meds other than crack.” Mitchell reached out and gave Evan a half-hearted pat on the shoulder. “Sorry, buddy, it’s getting really close to noon, and I’m sure Dr. M has reached her crack-chest-pain-limit for the day.” The group collectively released a nervous chuckle.

Wait. . what? 

A fine ripple of discontent ran through me—not the kind that mobilizes you to march on Washington, but just enough to make you take pause. I wasn’t sure what was worse—referring to this patient, this person as “just another crack-chest-pain” or the fact that I had created this climate that allowed my resident to do so. I searched myself for some poignant but quick statement that I could make as the attending to point out this faux pas to my learners, but came up with nothing.

“So do you want to pop in there together or would it be okay if you saw her alone?” Mitch made an exaggerated lean backward stretching out his back after a late evening on call and a long morning on rounds. I was still processing the “crack chest pain” statement. “Dr. Manning? Dr. M, you with me?” Startled, I sheepishly acknowledged that my mind had drifted, and agreed to reconvene with them later.

I began looking through Ms. Harris’ chart as the group prepared to leave, and overheard the team chatting amongst themselves. “Dude! What the heck is up with all of these crack-chest-pain admissions?” someone asked. Mitchell shook his head and snickered. “I know, right? It’s the blue plate special. Chest pain with a side of crack.” 

Again, the coalescent eruption of nervous giggles, and again my ripple of discontent.

“Hey, Dr. Manning,” Mitchell said with a mischievous grin,“I have an important suggestion for you to bring to the powers that be.” I braced myself for what I knew would be anything but. He playfully stood up and straightened the lapels on his lab coat whimsically. “We need a crack-team at this hospital.” 

The entire team exploded in laughter, some leaning over the nurses’ station, others slapping their legs. This only egged him on. “There could be a crack-pager, and somebody could be on crack-call in a crack-unit. Oh, and when they leave the hospital, they can all just follow up in the crack-clinic.” 

By this time, tears were rolling down his face, and others on the team could barely catch their breath. Their boisterous mirth continued down the hall as they waved goodbye and disappeared around the corner.

I stood there with the same nondescript expression that I had from the moment the first “crack comment” was made. It felt like I had just made a wrong turn down a dark alley and witnessed a mugging. Instead of leaping to the defense of the victim, I was paralyzed with uncertainty on how best to proceed. And by doing nothing, I felt like an accomplice.

When I entered the patient’s tiny room in the emergency department, she was leaned over the tray-table drawing a picture. The nasal cannulae initially given to her in triage was now perched atop her hair like clear rubber headband. She looked up at me and smiled. I returned the gesture, pulled up a chair, and sat beside her bed.

I learned that she was thirty-six, just like me, and that her family was originally from the south, just like my own. She told me about her 4 children, two sons and two daughters, none of which were in her custody. 

“Do you have kids?” she asked me earnestly. I responded by showing her a picture of my two sons on my cell phone, and again we shared a smile. A boyfriend had suggested she try crack cocaine when she was only twenty one years old, and she “got hooked from the jump.” I eventually came to the history of present illness, followed by a physical examination, which yielded very little. 

Methodically, I explained that she didn’t have a heart attack, and she could probably be discharged from the hospital today with plans to follow up in our primary care clinic. “That sounds good, doc,” she said, again flashing the same dingy grin.

My eyes rested on the sketch that sat before her. “Do you mind if I look at this?” I asked. She nodded in acknowledgment, as I inspected the carefully penciled drawing of a mother holding a baby. The intense love between mother and child was captured beautifully; from the glistening eyes to the details of the mother’s embrace. “Wow. This is awesome,” I uttered aloud, completely sincere. 

“Yeah,” she spoke softly, “I always loved drawing pictures.” 

I reflected on my own interests, and quietly replied, “Me, too.” Yet another thing we had in common. I enveloped her right hand in both my hands, encouraged her to keep drawing and to keep her appointments, and told her it was wonderful meeting her. I meant that.

Later that afternoon, I met up with my team to solidify the plans on our patients. 

“Anything earth-shattering when you saw Harris?” Mitch asked lightly. I stared at her name on the billing card, as the team waited respectfully in the pregnant pause.

I looked up from the card and gave the team a half-smile. An unexplained tension mounted in the room; I chose my words carefully. “Miss Darlene Harris is originally from Demopolis, Alabama. She has four kids—two boys and two girls—Dwayne, DeRon, Denise, and DeShon. ‘D’ is for her grandmother’s name, Dorinda. Her grandma raised her since both her parents struggled with health problems and alcohol." I looked up for a moment at the group, some shifted nervously in their chairs while others just sat-- mummified and quiet. I cleared my throat and went on. "She loves to draw, and wow, y'all . . .she’s really good. She was only twenty-one when she got addicted to crack, and she wishes she wasn't. Oh yeah, and I also learned she’s the same age as me, thirty-six.” 

I could see her smiling face, warm and genuine. I felt an unexpected wave of emotion pushing against the backs of my eyes. I swallowed hard and willed myself to keep my composure. 

“So yeah. . .I guess what I learned was kind of earth-shattering for me. I guess I learned that she isn’t just another crack chest pain.” I scanned the faces of my learners, earnest and thoughtful. I suddenly felt my face grow warm with shame and dropped my head, identical to that of my children when they’ve knowingly done something wrong.  

Had I? Had I done something wrong?

In this moment, I had the undivided attention of my team, just as I had many, many times that month. That told me my answer. As the attending, it was I who had set the tone for that team. The foundation for what was acceptable and what wasn’t had been laid by me, and brick by brick, whatever I did or didn’t do, or any indifference I'd shown had sent a mighty message. 

It wasn't like I had this egregiously unprofessional resident that month. He was a good resident, really, but somehow, some way as their role model, I'd dropped my guard and allowed things to go awry. . . . as was clearly evident in his comfort in delivering that stand up "crack" routine. 

I studied my chicken scratch notes on her billing card again, shook my head and sighed. “We’re taking care of real people, y’all. I’m sorry for not slowing down more to help us remember that. I promise to do better. . . .yeah. . .I really do. . . let’s just all try to do better, okay?” When I looked up, the first thing I noticed was one of the medical students, silently crying.  

Yeah, man. . . .you've got to do better.


Medical school and residency training is an exhausting, confusing, and curious existence. I still remember those days of admitting ten sick patients all with self-induced medical emergencies, and participating in those unflattering resident conversations over Chinese takeout in the middle of the night. As trainees, we'd find ourselves looking to those huddled beside us in the trenches to join in the co-misery. . . .and to help offset the heaviness of it all. Let's laugh about it, you tell yourself. It's funny, man, admit it, you say. And maybe when you're still a learner. . . . perhaps it is. . . .and just maybe you can convince yourself that this is one of the only ways to cope. Right? 

But what I've learned over time is that at some point, that stops working. . . .and it starts with that first time you see someone junior to you do or say something exactly like you. . . .just because they learned it from you. That's when it hits you-- Oh sh@%! I'm a role model! And each time, it's like a bucket of cold water in the face, and it's up to you to decide if and how you'll respond to the jolt.

When I saw that student crying at the end of our discussion that day, it affirmed my response to that morning's "jolt": I promised myself that I would never be an accomplice to another Grady "patient mugging" again.


  1. Hi Dr. Manning, I just wanted to drop you a line to say thanks for writing this blog. I stumbled upon it last fall and have been subscribed since then. As someone who's considering med school, I find it really enjoyable. It's fun, insightful, and always entertaining. Just thought I'd to let you know that the time and effort you put into it is much appreciated. Thanks!
    -Mitchell Roth

  2. Hi Kim,
    I am touched by this my own years at Grady, (and other hospitals) I sometimes found it difficult to remember that the patient and the disease are two different entities. This was an elegant and lovely reminder of that simple fact.
    David Martin

  3. i was deeple touched by this blog...its just a reminder to be true to ourselves and our profession - the lost ART of medicine. Thank you Dr Manning for sharing your inspiring thoughts with us. We are lucky to have you at Grady!


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