Wednesday, April 11, 2012

The Internship and Residency Chronicles: One thing leads to another.


A replica of the watch I wore for four years of residency.


"Why don't they do what you say?
Say what you mean
One thing leads to another
You told me something wrong, 
I know I listen too long but then
one thing leads to another."

~  from The Fixx "One Thing Leads to Another"


_____________________________________

Summer on the wards, 1998


"Hey! Who am I?"

Kevin, one of my co-residents, grabbed a stack of index cards and tucked them into the waistband of his pants just at the center of the small of his back. Then he playfully lifted up his left arm and began poking his index finger repeatedly onto the face of his watch. Everyone standing around the nurses' station erupted in laughter.

"Ha ha. Very funny," I replied with a playful scowl. I bent my stethoscope in half and attempted to swat his arm with it.

"That's classic Kim Draper on call, dude. Classic!"  Kevin threw his head back and cackled. Then he leaned on the counter with both elbows in front of me. "Patient cards in the back of her pants and that scary calculator watch. Dude! What is it with you and that calculator watch?"

The interns and medical students from both of our teams were scattered all around the nurses' station and work area writing notes and orders-- but weren't too busy to laugh at Kevin's observation. My scary calculator watch had become legendary amongst my fellow residents--especially because I had mastered the tiny buttons so precisely that could get to any calculation in lightning speed. I also stored an unusual amount of data inside of it. No, I wasn't making a fashion statement with it, but for the pre-app/pre-smartphone era, the thing was awfully practical.

I folded my arms and curled my lips. "Look here, Jay Leno. . . half of my time is spent taking care of kids so I need this sucker to be able to calculate doses." I proudly lifted my left wrist and gave a slow, smug nod at the super-geek-ified contraption fastened onto it. With a shrug I added, "You can hate on the big face Casio all you want but all I'm saying is that this scary calculator watch has saved some lives in the clutch. Lives, I say!"  Everyone laughed as I slammed my palms onto the desktop in the most exaggerated way ever.

"Does that thing . . .like. . . glow in the . . .dark?" One of Kevin's interns decided to get in on the fun.

"It glows and projects x-rays, prepares blood smears, and spins urine." I feigned a very serious expression while raising an eyebrow.

"You know the worst part? I saw two other Peds interns with those things on!"  Kevin said incredulously to his intern. He squinted his eyes, stared at my watch again and then shuddered. "Seriously, Kim? Least cool watch of all time."

I stacked my patient cards up on the counter and jammed them straight into my waistband at the lower back, nearly identical to the way Kevin had just mimicked. Next I slung my stethoscope over one shoulder and walked around from the nurses' station with my nose haughtily turned upward and my palm splayed out in front of me. "Talk to the hand, Kev! You know you want a big face Casio, dude!"

Just as we started to joke around some more, both of our pagers went off nearly simultaneously. We were both the senior residents taking call that day, and things were already hopping. Kev unclipped his pager from his scrubs and pushed a button to see the number. He held it toward me and shook his head. "Seriously? Somebody must have ticked off the ER gods. Sheesh! This is my third admission in one hour!"

I pointed the LED screen of my pager in his direction and offered a sympathetic nod. "Same here, man."

"Yeah, dude. . . but at least you have a computer strapped to your wrist to help you." Before I could come back with a witty retort, he was scurrying down the hall toward the elevator.

"Hater!" I called out behind him.

After I watched Kevin disappear around the corner, I turned my focus onto my team made up of three interns and two medical students. Lee, the most efficient and easygoing of my interns, was sitting directly beside Maya, one of the two medical students on our team. In front of him was an EKG that he was carefully reviewing with her. Emily-Ann and Aneesh, my other two interns, were writing what appeared to be progress notes or orders into open charts. The sound of my pager seemed to kick them both up a notch with an added sense of urgency.

 And then there was Camille.

Camille was the other medical student on our team that month and she was. . . . . notoriously special.  Not special in a really good way, unfortunately, but special in the sense that oft times she'd say and do things that absolutely floored everyone around her.

Case in point: There was this one day that Dr. Olds, the Chairman of Medicine, came to join us on rounds (in that way that sometimes Chairs do) and he asked Maya and Camille if they'd like to go down to the micro lab to look at our patient's gram stain.

Now. When a Chairman asks you to go anywhere educationally-related as a student---even if it is to explore the components of toe jam under an electron microscope--there is one answer and one answer only.

"That would be great!"  (Or if you aren't the shmoozy type, "Yes, sir" or "Yes, ma'am" will suit you just fine.)

What was particularly egregious about this, though, was that our Chairman was an internationally recognized tropical Infectious Disease doctor with a wealth of knowledge and experience. A moment at his feet, especially if you were a student and especially if it involved something infection-related, was equal parts awesome and  hard to come by.

But on this day, Camille looked our Chair square in his seasoned, World Health Organization tropical ID nerd, big-boss eye and said with a wrinkle of her nose, "No, thanks."

SKKKRRRRRRRRRRRRRRTTT!!!!! Slam the freakin' brakes!!!

Yes. She really said that.

Not. Even. Kidding. The child had just told our Chairman "No, thanks" as if he'd offered her butter for a dinner roll or something! And I kid you not, she said this like it wasn't anything and went right back to reading the First Aid for the Boards book in front of her.

Dr. Olds didn't even flinch. He simply nodded and gave a terse smile which made me want to jump out of my chair and kick Camille squarely in the behind. (I know it's bad that I felt that way since that's technically violent, but it's true.) So off he went with Maya, who really did want to see that gram stain because she actually recognized what an honor it was to learn one on one from a master teacher and the freakin' Chairman of the whole department of Medicine.

Hello?

See, had that happened today, I would have immediately pulled Camille aside and gave her some swift feedback. But back then, I did what many residents did (and still sometimes do) -- I called one of my fellow residents and cracked jokes about the craziness of my medical student. My partner in crime that month was Kevin.

"She said WHAT?" he howled that day through hysterical laughter. I kept repeating the story over and over and he'd double over with every escalated version. And that was pretty much how that got dealt with. From that point forward it was understood that Camille was. . . . uhh. . . special.

"Got one for me?" Lee asked while looking up from the EKG that he was reviewing with Maya. He had already finished his morning work and was availing himself to another patient.

"Not sure yet," I replied while dialing the number back. "I'll let you know in a minute." Just then someone answered the phone in the emergency department. "Good morning. This is Kim Draper, 9B senior. I was paged?"

After being placed on hold, an ER resident friend of mine came back to tell me about the next patient being admitted to us. As she finished telling me about this middle-aged fellow with heart failure, she then added, "Don't kill me but I actually have another admission for you, too."

"Ingrid! Y'all are killing us!" I groaned.

"Dude, you should see it down here. It's mayhem, dude." (I have no idea why we insisted on all calling each other "dude.")

"I know, I know." I pulled a blank card from the stack tucked in my waistband. "Okay, I'm ready. Hit me."

So Ingrid then told me about this other patient who interestingly was also being admitted for a heart failure exacerbation. This wasn't a surprise; everyone knows that diagnoses often come in groups. This was obviously "heart failure day."

"Everyone is ignoring their low-salt diets and eating barbecue, I guess," Ingrid added at the end. "I've admitted four people today with volume overload. I'm not kidding."

"Crazy!" I responded while balancing the phone on my shoulder and sorting out my cards.  I flicked them out into stacks by intern like some sort of dealer preparing a hand of blackjack in Las Vegas. "Thanks, Ing. Anything else?"

"Naaah. Sorry, dude."

"No worries."

I hung up the phone and looked up at Lee and Maya.  "Maya, how about I have you pick up this gentleman. Lee, you can take him with her." I handed the card to Maya. "Mr. Allen -- a fifty-seven year old man with shortness of breath who can't lay down flat since yesterday."  Maya perked up and nodded eagerly. Lee waved for her to follow him and they leaped straight into action.

Emily-Ann had already received two admissions that morning so she was off the hook--at least for the moment. Aneesh came beside me and positioned himself to take the next patient. Camille, on the other hand, continued to quietly read her First Aid for the Boards book in the swivel chair behind us.

"Emily-Ann, you'll be up next. Aneesh, you guys can pick up Mrs. McIntyre here," I said, stating the obvious. Emily-Ann nodded and kept writing in the chart and Aneesh reached for the note card with Mrs. McIntyre's information scrawled on it. "Lots of swelling, shortness of breath, and hasn't been compliant with her Lasix or her sodium restriction. Ingrid said her ejection fraction is only 20% and she's followed int he Cards clinic."

"Gotcha," Aneesh responded while jotting down information onto his own note card. He asked a couple more questions which folded us into a conversation about heart failure management. Half way through my response, I looked up and realized that Camille hadn't budged.

"Camille? Oh my bad, how about you come over and hear this, too, since Mrs. McIntyre is going to be your patient with Aneesh. She sounds like a great patient!"  I smiled tightly, clenched my jaw and told myself to assume the best of Camille. Yes, I was annoyed that she hadn't thought to get up and join us and of course, some part of my foot still wanted to kick her squarely in the caboose. Coaching myself to not show exactly how irritated I was, I took my card from Aneesh and extended it toward Camille like some sort of olive branch. "Here, you can just take my card with the info on it. I'll make a new one."

Camille didn't move. She looked up from her book and offered a quick, tightlipped smile. "No, thanks," she answered nonchalantly. "I'll just wait for the next one with Emily-Ann."

Wait, huh? 

I stared incredulously at Camille who had already returned to licking her finger tip and turning the pages of her study book. I laughed nervously. "Uhhhh. . . yeah. Camille, it wasn't really an optional suggestion. I want you to pick up Mrs. McIntyre."

She furrowed her brow at me in a way that I felt rather like she was blowing off what I was saying. Still holding the book on her lap with both hands, she gave that same dry smile. "It's okay, I can wait."

What the?

That's when she said one of the craziest things I have ever heard. "Look, I don't even want to do Internal Medicine. It's so . . . .redundant. The same things over and over again. Since I have to take an admission at least I can wait for something cooler to come in."

Whaaaaattt?

Aneesh widened his eyes in my direction and Emily-Ann froze while waiting on that chart. We all offered an obligatory pause, just to see if she was joking even though we knew full well that she wasn't.

"I bet Mrs. McIntyre thinks that she is cool." That was all I could think to say that didn't involve expletives. Plus, I wasn't as savvy with medical students as I am now.

Camille snorted and replied, "I bet she does. How 'bout I go down there and just tell her to not eat pork skins and take her Lasix? I can do that and be back up here in five minutes."

Oh my good golly Miss Molly! This child was dead serious. My mouth fell open as did those of my interns. Before I could even respond, my pager went off again. Camille returned to her book. I willed myself to not be as mad as I was starting to feel but it wasn't working. I focused on my pager and the call that had just come in.

It was the ER again, this time with a seventy year old gentleman with -- you guessed it -- shortness of breath. It wasn't clear if this was emphysema or heart failure or both. Camille listened to the exchange and didn't even bother to hide the eye roll she made as I hung up.

She cannot. Be. Serious. Take a deep breath. Deep breath.

Emily-Ann instinctively took the information from me and paused to see if I had anything to add. "He's in the ER on the B side," I told her.

"Anything else?" Emily-Ann queried.

"Nope. I'll be down shortly." I glanced over at Aneesh. "Hey, Aneesh? Go ahead and see Mrs. McIntyre and page me when you're done. I'm heading down to see Lee and Maya's patient and I'll catch up with you after that." I slid off of the chair and restacked my cards once more. Back they went to my waistband as I stuffed my feet into the clogs that had fallen on the floor in front of the chair. I could feel my blood boiling.

Be cool. Be cool. Be cool.

I yawned a very fake yawn and decided to remove myself from that situation.  Camille had infuriated me so badly that I couldn't even deal with her. So, in that instant, I decided that I would not. As I walked past her she whipped her head up from the book and looked puzzled. "Kim? What do you want me to do? Come with you or what?"

"Nope. Definitely not that."

She squinted one eye and sighed. "Uuuuhh, okaaaaay. . . .soooo. . . .what should I do now?"  Her response was laced with sarcasm and had this trivializing tone to it.  It pissed me off even more.

Calm down. Relax. Be cool, Kimberly.

"How about this? How about you go home and read your book. It would be far more comfortable for you and it's not like you want to do Medicine any way." Steam was steeping out of my ears.

"Excuse me?" Now she was serious.

"Go home. I'm serious. Nothing cool enough for you is likely to come in today, so leave. Go." I flicked my fingers toward the door in case my words didn't convey what I meant. And with that I walked down the hall before it got any uglier. I could feel my pulse quickening as I walked away. I didn't care what she did. I was there to take quality care of patients. Anybody who wasn't down with that could go somewhere, anywhere -- just away from me. It was like that old saying goes, "You ain't got to go home, but you got to get the hell up out of here!"

I guess she could tell that she had messed up at this point. By the time I reached the elevator and started aggressively pushing the button to go down to the ER, Camille had appeared beside me.

"Gosh! I'm sorry, okay? Fine, I'll go and see the heart failure lady with Aneesh. Where was she?" The way she said "sorry" was nasally and cynical. And the way she referred to Mrs. McIntyre as "the heart failure lady" took me somewhere out-of-body-ish.

That did it. I had tried to get away from her but this was the last straw.

"GO HOME. I mean it. LEAVE. GO." I felt my voice crackling a bit. "Take your book and your funky attitude to the coolest place you can find with the coolest people you know. I don't care WHAT you do. Just do it away from me. I really, really mean it. GO!" She stepped backward like she thought I was planning to hit her. And while I'm not a hitter or even the fighter type, I have to admit that I'm not fully sure that hadn't crossed my mind for a millisecond.

"Just because I am not all 'ooh aaahh' about Internal Medicine doesn't mean I'm a horrible person. I'm just honest unlike the rest of these medical students around here!"

"No, Camille, unlike the rest of the medical students around here, you're an asshole. An entitled, disrespectful little asshole." That boiling blood had now turned to vapor. The elevator seemed to open at the most dramatic time. "Now please. Get away from me. I'm dead serious. Get out of my sight--please." I took in a deep drag of air and swallowed hard.  She just stood there frozen and I cocked my head at her angrily. "Camille, move out of my way so that I can go and take care of my patients. The last thing I want is some ungrateful asshole around my patients."

I stepped past her hard and onto the lift. My eyes were stinging with angrily confusing tears and my head was hurting. Knowing that I was near tears made me even madder. I couldn't reel back my emotion; I felt like some kind of drunken person. I clenched my jaw and waited. The last thing I saw was her now crimson face as the doors closed.

In the silence I immediately began to think. And feel regret.

Wait. Did I just call my medical student an asshole repeatedly and send her home? Did I?

Indeed I had.

Immediately, I felt ashamed. I knew that Camille wasn't right, but I also knew that my response wasn't either. I tried to lose myself in patient care for the next few hours, but couldn't stop worrying about my inappropriate outburst. Eventually, I found a quiet bank of phones on one of the wards and called my attending physician, Dr. Blinkhorn.

He listened intently as I explained everything that had happened. And I'm not sure why, but I began to cry while I was telling the story. Unusually hard, actually.

"Where are you?" he asked.

"On 10B," I quietly answered.

"Wait there. I'll come to you," he instructed me.

Less than five minutes later, my attending arrived and walked with me over to one of the patient waiting rooms.

"I'm glad you called me, Kim," he said as an icebreaker.

"Sir, I don't even know if she went home. I was just. . .so. . .so mad at her. For being so disrespectful, you know? And when she disrespected Dr. Olds it was. . . I don't know . . .funny to me. But today the way she disrespected our patients--especially the one I tried to give her---it just . . .took me someplace else." I plunged my hand into my hair and pressed my lips together. Now my eyes were mounting with tears again and my face was growing hot.

"What time did you go home yesterday?" Dr. Blinkhorn asked.

I shrugged my shoulders.

"You seem tired."

Like a toddler, his "tired" accusation upset me even more. Those tears pushed straight out onto my lashes again. "I'm not tired, sir. I'm mad."  To offset my emotion, I reached into my waistband and nervously thumbed through my patient cards.

He nodded in concession and backed off of that.

I shook my head and then added,"You know? I don't even want her here if she doesn't want to be here, Dr. B. I mean it."

Dr. Blinkhorn looked over at me wisely and placed his hand on my shoulder. "Kim, you know what I know about you? I  know that you are a leader. And as a leader you have to lead all kinds of people. All kinds. Some will follow your lead willingly, others will not. But a good leader leads them all."

I wiped my face hard with the heel of my hand and stared back at him intently.

"Your job is to make them want to do what they don't want to do. You can't let them see you losing your cool like that. You can't." He paused for emphasis. Then he went on. "You also have to pay attention to yourself. Make sure you aren't so tired that your fuse is short. The same way you take care of these patients, Kim, you have to take care of your team and especially yourself. You have to."

That's when it dawned on me that I had never really thought about it that way. I always thought my job was to take care of patients and patients only. But my team and . . .myself? That had never even occurred to me.

I thought that being patient-centered was all that was necessary. I even had a scary calculator watch to calculate things for my patients. To double check drips and dosages and to quickly pull up numbers to expedite things for them, my patients. I kept meticulous track of every one of my patients with that giant deck of index cards and color-coded every last one of them with a highlighter, too. Because, for my patients, the love was in the details.

But my team? And me? This wasn't even an afterthought--it wasn't a thought at all. Our job was to come in and care for these patients with all of our might. Period. End of story.

Yes, my student was rude and disrespectful. But then, so was I.  I was also tired and overworked and overstretched. When she finally broke the camel's back, I lit straight into her like a bat out of hell. One bad thing had led to another. And this wasn't effective leadership at all.

Suddenly I deeply wished to fix this but realized I may have missed my opportunity. "I sent her home, sir. I told her . . to leave."

"Now come on, Kim. Do you really think she left at 10:30 AM on a call day? I ran into her crying near an elevator."

Eeek. 

"So you already knew what happened?" I pressed feeling even more ashamed.

"Somewhat. And I did talk to her about professionalism and my own concerns. It's only fair to tell you the same."

I nodded hard while still watching him. "Yes, sir."

"Your goal as a leader isn't to make her cry. It's to get her do do the right thing. Yelling at her and calling her an asshole probably won't achieve that, you know?"

"I know."

"All that does is make the issue snowball into bigger issues. Go and talk to her. And say what you mean. Like a leader, Kim." He kept his eyes focused in on my own. "And then, go and get you some rest if you can."

Later that afternoon, I found Camille and talked to her. I apologized for calling her names and explained how I felt. I shared with her how frustrated I had felt and how disappointed I was in her for the several things that I'd witnessed that month. Then I told her how disappointed I was in myself for snapping like that.

"Seeing how upset you were kind of woke me up," she said. "I guess it made me realize how offensive I'd been."

"Yeah, but I still shouldn't have gotten so upset. I'm sorry."

"I'm sorry, too."

Then she told me all about the month she'd experienced before ours where she'd been ignored by her resident, attending and interns. She described how her resident scutted her all about and seemed disinterested in her or any other student on the team. This was a sharp contrast to her month on the Ob/Gyn service where every member of the team worked hard to include the students.

"It seemed like you already had an opinion of me early on," she said. "Like you were mad at me or something. I guess I felt mad, too."

I thought about that for a few seconds and realized that she was right. I had talked about her like a dog behind her back to Kevin not even two days before. Described her with words like "ridiculous" and "ultra-entitled." And never once had it occurred to me to sit her down and explore why or even discuss any of this with her.

"Camille, let's try to start over. There's still a few weeks left."

And she agreed and promised to have a better attitude. I believed her.


Today I am reflecting on all of the working parts that make team-based patient care work. The things we use to keep track of our patients, their medication doses and their progress. . . .how the work is distributed. . . but especially the team. That day, I learned one of the most valuable lessons of my career. I learned that the most effective leaders--especially in medicine--are able to take the most excellent care of their patients because they also take care of their team and themselves.

They listen. They pay attention. They reflect. And they make the necessary adjustments. All of this has to be done with careful intention.

Falling apart and hollering? Uhhhh, not so helpful.

By the end of that month, our team was a well-oiled machine. The interns and everyone else treated Camille kindly--and I know this is because they saw how I was now treating her. And even though I didn't change her mind about a future in Internal Medicine, I can honestly say that by paying closer attention to myself, I was more able to bring out the best in her. I truly was.

She even went out and bought herself a big face Casio watch just like mine and wore it faithfully. (Okay, maybe that part is an exaggeration, but it sure would have been a nice way to end the story, right?)

Yeah.

It's more than ten years later I've grown up quite a bit. I no longer wear that scary calculator watch. Nor do I stuff index cards into my waistband. You know what else? I also don't spend more time talking about my learners to other people than I do talking to them. That's proven to be far more effective.

But the biggest difference? Now, before I focus on anyone else, I take care of myself. And that has proven to be one of the most effective leadership lessons of all.


“What makes leadership is the ability to get people to do 
what they don’t want to do and like it.” 

— Harry Truman



"Not the cry, but the flight of a wild duck, leads the flock to fly and follow.” 

– Proverb

***
Happy Hump Day.

Now playing on my mental iPod. . .


*with the exception of my Chair and attending, all other names were changed.


9 comments:

  1. You never, ever fail to give me something to think about, to ponder. Thanks.

    ReplyDelete
  2. This was a great post! I have to ask. What ever happened to Camille? Do you know where she is now?

    ReplyDelete
  3. Sister Moon -- You always do the same for me.

    Anon -- No, I don't know where she is now. Of course her real name isn't Camille, but I do know that she went into Ob/Gyn and had a much better attitude for the rest of that month. I do wonder about her sometimes.

    Bumble Bee -- Thanks for reading, sis.

    Kristin -- 'preciate you as always.

    ReplyDelete
  4. A.Maz.Ing.

    No matter what, you always provide words of insight and wisdom. From where I am sitting, a current sr resident (veterinarian), your words ring true. Thanks for this.

    ReplyDelete
  5. Your words are powerful. In anything we do where we are involved in relationships, we have to take care of ourselves first in order to be our best. It sure sounds like you have come quite a long ways from the Camille days. You already answered this above but I too wondered if that was her real name :). It is touching that a big important doctor like you would tell us this whole story even though it involved going to your supervisor and admitting that you did not feel good about the way you handled the person reporting to you. You are so real, it's nice. Joanne

    ReplyDelete
  6. I still don't like her. So there.

    ReplyDelete
  7. What wonderful lessons...This is one of my favorite posts of yours.(well, maybe it's kind of like with the kids, each one really is my favorite!)

    Lena

    ReplyDelete

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