Standards of "I don't care."

2011 graduates Zwade M. and Andrew B., after matching at Harvard programs.

Zwade M. and Andrew B. are two of the most professional, respectful and altruistic young doctors I have ever met. Seriously. I met Andrew B. on his first day of medical school back in 2007, and I met Zwade M. very early in his second year of school.  I can tell you that from the moment I met both of them, they were ultra-gentlemenly, exquisitely thoughtful and unbelievably careful in every single one of their professional interactions.  Although several of us Grady doctors were involved in both of their medical educations, I am pretty sure that we can't take any credit for their excellent behaviors.

Check it. Unlike these two dudes, every now and then you encounter a learner in the hospital that makes you scratch your head and say, "Huh?"  Or better yet, makes you want to say, "You do realize I can hear you and see you, don't you?"

One of my friends and fellow Grady doctors was working with an intern recently who, for all intents and purposes, simply didn't give a damn. I mean a damn.  Now let me clarify:  This wasn't a situation where he was poking patients in the eyes or sedating folks so he could sleep. He was doing his work, and wasn't an assassin but. . . .as far as his interactions with my colleague, his supervising physician?  This dude might has well have given her the finger.

The guy showed up every day dressed like a slouch, and was totally unapologetic about it.  He walked off of her rounds, texted on his cell while she was talking, announced repeatedly that "he was just trying to get through the month," and even took the liberty to alert my friend repeatedly of the fact that he was going to be leaving at some oddly unappointed-by-her time.  It was crazy.  This was a whole new standard of "I don't care."

So this particular person was just rotating on Internal Medicine for the month, and had made it abundantly clear that doing so was a nasty little lump that he was being forced to take.  My colleague, who could quite possibly be one of the most caring, kind, empathic, thoughtful, humanistic, professional physicians I know, was really bothered by this. More than bothered. It hurt her feelings.

I'd like to think that I wouldn't have put up with this kind of behavior. I'd like to think that the reason that I haven't really been in a situation is an attestation of the handle I have on my teams. Ha. I'd like to think that. Instead, I've probably just been lucky.  

Another one of my fellow Grady doctors was dealing with a similar situation with a medical student--you know, that same perplexing don't-give-a-eff behavior that is so puzzling to the faculty member that they wonder if they've somehow become invisible.  This particular attending knew this learner well, and Lord knows had fought the good fight in trying to get the student on the straight and narrow. More than the first person, this person was also bothered. And maybe even a little bit hurt, too.

So what does all that mean?  Like, what does it mean when a learner simply tells a faculty member to "stick it" in no uncertain terms?  Does it mean that we have fallen short?  Does it mean that the person simply has no "home-training?" (As the Grady elders call it.) Is it just a sign of the times, where these young whippersnappers have just become more entitled?

Beyond Zwade M. and Andrew B., I know plenty of students and residents that are beyond professional. Jackie G., Alanna S., Francois R., Roger A., Roy A.. . . .the list goes on and on. Now that I think of it, there is this one second year student that I know quite well who is, in particular, professionalism personified.  She is an eager learner. She values medical education so much that the excitement oozes from every part of her being.  Her coat couldn't be whiter. Her posture couldn't be straighter. And as far as being bright-eyed and bushy-tailed? Fuggeddaboudit. This student has taken that to a whole 'nother level--and not in that brown nosey way, either. And you know what? This student was like that from the start.

That leaves me with the point of this random rambling:

Can we teach professionalism?

Here's the deal--as medical educators we are expected to help guide our learners toward professional behaviors. Yeah, yeah. . . .we serve as role models and such, but seriously, we are actually mandated to teach and evaluate the students and residents on their professionalism. They are supposed to be competent in the area of "professionalism" before they graduate, which gets hard, especially when they aren't, well, professional.

The Zwades and the Andrews of the world are easy. They show up in their white coats with their deferential behaviors, their pleases and their thank you's. They take notes while you teach and listen intently during rounds. They show up on time and pitch in to help others.  And with the flick of your wrist, you sing their professional praises on evaluations, feeling like you somehow can take a little credit for it knowing deep down that most of that has to do with what the Grady elders call "mama 'nem."

So what's a medical educator to do?  What do you do when someone just doesn't give a damn?

I am really asking because I am interested in your thoughts. I really want to know how folks suggest we go about doing this. Not just doctors, either. But people's mamas and you non-medical folk.  See, because you guys are the ones that will be lying in hospital beds when folks like that middle-finger-giving young doctor strolls in to write life saving orders in your chart.

Do we put them in time out?  Do we shrug it off and suggest that some are lost causes?  Do we pounce on top of them with a knee in their chest and a nasty snarl saying, "Don't make me put my foot in you. . ." Uhhhh, you get what I'm saying.  Like. . . I don't know. I really don't know.

Oh yeah, and I acknowledge that we could be the problem, too. Are we not firm enough? Are we sending the wrong message to the learners through our behaviors or is it that weak leadership manifests as the egregiously unprofessional behavior in those don't-give-a-damners? Is it a respect thing? Is it a . . .gulp. . . woman thing?  Like, would these same learners tell a man to stick it?  I hate to even go there, but neither of the aforementioned faculty were male.

Sigh.

So that's what's on my mind this morning. What y'all got to say about all this?

Culture Club.

"Do you really want to hurt me?

Do you really want to make me cry?

Do you really want to hurt me?

Do you really want to make me cry?"

~ Culture Club

_____________________________________________________

When I was a resident, we weren't always so professional. In fact, oftentimes, we were downright unprofessional. I mean, we cared about our patients and did everything to keep them alive. But back then, pre-duty hours reform, we worked obscenely heinous hours. And on top of that, the whole "professionalism" and "humanism" movement hadn't quite hit yet. Every now and then, I remember some of the things I heard, said, or to which I didn't object--and I cringe. No--first, I shudder, and then I totally cringe.

Today, I am reflecting on knowing better and doing better.

There was a middle school kid who was emergently rushed into our Pediatric Intensive Care Unit during my PICU rotation as a second year Med/Peds resident. My team that month consisted of a third year Pediatrics senior resident, who took call with me. There was one other junior/senior team, and a nurse practitioner there that month, too. Supervising us all was our attending and a Pediatric Intensive Care Fellow.

This particular day, my team was the one on call, so we admitted that seventh grade boy.

What I remember is that he had deliberately drank a few swallows of Liquid Drano because he was mad at his mother. It unfortunately liquified his esophagus, and nearly killed him. It remains one of the most awful things I have ever seen in clinical practice.

My upper level and I cared for that child all month long. And he was so, so sick. Reconstructive surgeries. Setbacks. Total parenteral nutrition. Back to the OR. Infections. Adhesions. Back to the OR. It was terrible.

But now that I am older, I remember some other parts of that month and those times. If I close my eyes, I can even feel the culture we were in back then . . . .sigh. . . .and it wasn't always good. Humor was our pressure release valve, and we released pressure a lot that month.

Me as a second year, but this classmate, Ron C., is NOT the resident in the story!

After seeing and caring for that young man for so many days, we somehow lost our sensitivity chip. Completely. I wish I could say that I was the one who objected and that I could tell this story not as a "we" but as a "they". . . .but I can't.

It started with my senior resident. He had already been asked to be chief resident, and was considered a golden boy. I worshiped this guy, and everyone else on our team, including the attending and the fellow, thought he'd hung the moon. We were rounding one day. . . on like hospital day ten or something. . . and I can hear it like it was yesterday. We stopped in front of his room and my resident said,

"And now, for 'The Gutless Wonder.'"

My real, true recollection? Everyone laughed. Including our attending. Including me.

"No guts, no glory," my attending replied. Then he added, "Literally."

Everyone howled. Me included.

The fellow snickered and said, "Guess he won't be swallowing his pride for trying to get even with his mom!"


Bwwwahhhh haaaa!

I actually remember thinking it was cool that our attending could loosen up and poke fun with us. I thought he was the cat's pajamas for being so easygoing that he'd join in all of our (making) fun. Every day it was something new. And even he was in on it.

"How is Mr. Esophagush?" he asked one morning. Yes, the attending.

More laughter.

Every time I think of that month, I want to hang my head. How could we have been talking that way about someone who was literally on the brink of death? How could we stand in front of his mother, the mother who trusted us so much, and still say such things in her absence? How could our leaders have been talking that way?

It was terrible.

All month long, if a patient stayed with us long enough, at some point they became fair game for "witty" team jokes. Another one I continue to feel ashamed of:

"Are you down with hearing about our Downs baby?" my senior would ask each day.

(Insert collective laughter here--especially from the attending which, to a resident physician, is equivalent to high praise from a parent to a child.)

Wow.

Every single day, this is how he preceded his discussion of this sweet, sweet infant girl on our service who was hospitalized with congenital heart disease as a complication of Down Syndrome. And although I can't remember if I LOL'ed as second year in 1997 or simply looked amused--what I know for sure is that I didn't protest. At all. Not even internally I didn't protest. Even as an intern without a big voice, I could have screamed at the top of my lungs on the inside.

But I never did.

Shame on me. Even in 1997, shame on me . . . . . and shame on us all.

But especially our role models. Now that I am allegedly one myself, I bristle every time I imagine myself as that attending.

That was then, yes. But it was still foul. Real, real foul. . . . .even in 1990's pre-duty hours reform, it was foul. And it's foul to this day.

"Give me time. . . . .to realize my crime. . . ."   

~ Culture Club

Today I am reflecting on the power of culture. More than that, I am reflecting on the power of role models as drivers of the culture in our learning climates. I am so happy to be a clinician educator in an era that promotes feeling and acknowledging that being tired and overworked is no excuse for being unprofessional. I'd like to think that our culture has evolved to something more empathic than walking up to the bedside of a twelve year old with a chemically decimated esophagus and who is fighting for his life, closing the door so his mom can't hear and saying, "Gutcheck!" (Bah-dump-bump!)


What about now?

Do tired learners and faculty still lose their manners? I'd say, yes. Call me naive, but I'd say it's not as bad, though. At least now we are practicing in times where you wouldn't seem like a martian for raising a red flag when someone does take a complete detour from professional behavior.

Knowing better. . . . .

Referring to somebody's beloved child or loved one as "a Downs baby" is beyond offensive. It's hurtful and rude. Furthermore, many don't even realize that the proper term is "Down Syndrome" -- named for the late physician John Langdon Down--and even saying "Downs" with an 's' is not cool.

I now know for sure that just referring to the child by their name works just fine, thank you very much.

Sigh. To every single one of those patients. . . . I deeply apologize. I know it's over a decade late, but I do. I really do.

Nowadays, my "fun" references to my patients are things more like "F.P." for favorite patient or something like that. And while I do like having that relaxed camaraderie with my own students and residents just like my PICU attending did with us, now I know enough to not try to achieve it at my patient's expense.

***

"When you know better, you do better."

~ Maya Angelou

Do better, man.