Alpha Docs (11 page)

It's the Monday after Christmas, and I am starting my second rotation of cardiac intensive care, this time at Johns Hopkins Hospital downtown. I will be working through New Year's, which is best described as a hospital's “wacky time,” when all the people who somehow staved off every kind of malady to get through Christmas can hold back no more and the onslaught descends. The CICU is packed.

Day one and this rotation is a sharp contrast to the last one. Every bed in the unit is full; every patient is critically ill; several are in heart failure or shock, requiring high-powered IV medications to support their blood pressure. Some patients are contradictions—too young to be so fragile but barely clinging to life, while others are aging miracles, still breathing despite all odds. I've gone from dark rooms filled with computers into the full glare of intensive patient care.

The CICU at Johns Hopkins is a “horseshoe” of glass-walled rooms around the nurses' station, so that the staff can see all the patients at all times. Just like the CICU at Bayview, every one of these cases is presurgical or nonsurgical, ranging from heart attacks, decompensated heart failure, cardiogenic shock (when the heart's pump inefficiency has deteriorated to pump failure), and a variety of dangerous or malignant arrhythmias. Some patients can get out of bed and walk their attachments—a combination of IVs, tubes, wires, monitors, and encumbrances—to the bathroom, or sit up, read the paper, and talk on the phone or to visitors. Other patients lie fully sedated, attached to a mechanical ventilator that breathes for them, while their IVs provide a steady, wide-ranging stream of medications to support their blood pressure. We can monitor all of these patients from the pod in the middle of the horseshoe, on flat screens displaying EKGs, patient names, heart rates, and other vital signs. Audio alarms sound when any patient's readings deviate from the norm (due to anything from an EKG lead that falls off to actual cardiac arrest). All this information is gleaned without stepping into a patient's room, all without human interaction…for better or worse.

As with every rotation, there's virtually no orientation or introduction. We get there and do it. My team assembles first thing that morning—the attending, Dr. Chester, a senior professor of cardiology; the Fellow (me); and a team of residents, usually three first-year interns and three junior or senior residents. Together, we'll round on the CICU patients and take care of them day and night for the next two weeks. From 8:00 a.m. until midday, the team moves like a herd down the hall, stands outside each room, and reviews each patient's history and status. There is a highly structured format for presenting a patient anywhere in the hospital—in the ICU, on the general medicine floor, or in obstetrics or pediatrics. It starts with an HPI (history of present illness), one or two rambling, paragraph-long sentences, encompassing all that is meaningful about the patient right now—not all illnesses ever, tangential incidents, or unrelated symptoms…and no conclusions yet.

We're here to learn, to teach, and to treat, which takes longer than just treating. The priority is always the patient, not the students or the teachers, but the residents need the chance to learn on their own. Rounding has to strike a delicate balance between the academic side of medicine and proper patient care.

What attendings and Fellows look for are “crisp” presentations, which can be surprisingly hard to define. There are no clear-cut criteria, but a presentation should be short and pithy without omitting anything critical. You can do a good job in ten minutes or a bad job in thirty. An excellent presentation is not unlike what U.S. Supreme Court Justice Potter Stewart said about pornography: You know it when you see it.

The art of rounds lies in the interruptions and the critiques the attendings and Fellows make. A good interruption prompts the resident to expand on a point because it's a salient issue, while cutting in on a presentation and saying “Whoa! You're jumping to conclusions pretty fast” is not only bad form, but incredibly discouraging for a resident. I first learned this on the receiving end, noting that while some Fellows and attendings could deftly interrupt a presentation, others would let the resident wander off course before finally flashing the “T” time-out sign and guiding the resident back to the issue at hand. Hopefully, these experiences will come in handy now that I'm the one doing the interrupting.

The first patient we see is Ms. Jentzen, a sixty-seven-year-old woman who came in two days ago with an ST segment elevation myocardial infarction (MI)—a serious form of heart attack. She had a stent put in, but still needs IV dopamine to maintain her blood pressure. The resident presents the relevant questions of the case: Why is this happening? How long should we continue this course? What's the long-term outlook? It's a good presentation, fifteen minutes, relevant data, and a clear treatment plan, a routine case for the unit. I listen and critique. The attending listens and critiques my critique.

The next patient, a Mr. Orlando, requires a full presentation because he was admitted in the last twenty-four hours. A typical rundown goes through the patient's symptoms, tests, history, other illnesses and conditions, previous visits, medications, family patterns, in order to provide a total physical assessment of the patient. Mr. Orlando also came in with a heart attack, but he is currently sicker than Ms. Jentzen, and thus his case is more complicated.

Dr. Chester, Starbucks grande in her hand, is on one side of the nervous resident who is reviewing the chart. I'm on the other side, peeking at the resident's notes, while two other residents cluster in to learn how to, or how not to, give a presentation. The resident begins, “This is Mr. Orlando, who came in last night with a myocardial infarction because he smokes heavily and is diabetic, has high blood pressure, and was experiencing chest pain.” As he goes on, “…but he's doing better now. We started him on a beta-blocker…,” I know his presentation is heading down a rathole.

I've observed enough of these presentations to know that the most dangerous thing you can do is draw conclusions too fast. If you're a venerated teacher or practitioner, you can do your own version of the format, but if you're a resident, you stick to the book. Or the attending or Fellow will cut you off at the knees. And this resident is doing the unforgivable: He's presuming an accurate diagnosis before getting through the objective data, a critical error. Like a game-show host, the attending, Dr. Chester, zaps him, but her version is a withering scowl: “Doctor, we would prefer to have the facts first and make our assessments afterward.”

Then it's my turn. While the attending is a teacher for the entire team, my role is to be a teacher for the residents, and right now, my job is to help the resident without undermining or contradicting the attending. I nudge the resident: “Please review the EKG, the echo, and the enzyme results.”

The resident rifles through his papers, which, given the silence, seems to take an eternity. The other residents are collectively holding their breath. Finally, the resident delivers the sequenced facts as he should have—the symptoms, the EKG, the blood work, and so forth—and the attending lets him off the hook, though not without a parting shot of sarcasm: “Thank you. We cannot assume a patient arrived in the ER with a sign over him announcing that he's had a heart attack and that his diabetes and smoking were to blame. The information you've now provided gives us a clearer picture of the situation.”

What should have been a ten-minute presentation became a forty-minute case study. But the presenting resident (and the other residents) absorbed the lesson of presenting a spectrum of facts, not presumptions. Truth is the analysis you arrive at…if the facts are right.

The conclusion, as expected, is that the patient had a mild heart attack. He's scheduled for a cardiac catheterization to see if further interventions, such as a stent implant or bypass surgery, are warranted. His blood levels are checked to monitor effects his diabetes might have had. In the meantime, he's put on additional heart meds, and his vital signs and blood work will be watched carefully. These conclusions are not dissimilar to those of the resident, but the means by which they are reached are as important as the end.

Afterward, I walk the presenting resident down the hall to commiserate. “We've all been there. Don't worry about it. Nobody died.” He nods and thanks me, but I can tell he feels awful.

The attending was rough on him, but she had to be. Her responsibility is to turn residents into good doctors. She doesn't want to send doctors into the world who cut corners or do their job wrong, because a doctor's error can mean a patient's death. Do you tread lightly with students out of sensitivity to feelings, or do you have tough standards that may bruise feelings? Hurt feelings will recover. Patients may not. And Dr. Chester isn't really mean. I've witnessed mean. One attending, after a bad presentation, said to the resident, “Doctor, now that you've leapfrogged over the facts and somehow divined the diagnosis, we can assume this patient is miraculously cured, and we can move on to the next patient so you can perform your magic again….”

But I've also worked with doctors who could skillfully and subtly nudge residents back on track. “So…did the patient describe what the chest pain felt like—its intensity, location, duration?” “Can you tell us how the tests did or did not support your observations?”

During the rotation, during rounds, my conscious goal is to emulate and practice that method—“an iron fist in a velvet glove.” In addition to the second- and third-year residents, there are interns or first years, and I want to show the younger ones how it's done so they won't have to relearn it later. Out of empathy, I find myself erring on the side of the velvet glove. If residents say something a little off, I raise an eyebrow or try a time-out signal to get them back on script. If the resident says something just plain wrong, I stage-whisper, “Hmm, I don't know.” If that doesn't work: “Whoa. Slow down!” The art of interrupting—like being a good doctor—is about knowing when to listen, and when to act.

As week two begins, my interrupting skills are put to the test with three very different residents and a different attending. The attending, Dr. Herbert, has a background in economics and a fascination with technology, and he has a reputation as a fanatic for detail. Many residents, and even some Fellows, find him intimidating. During presentations, he will seize on a hint of incompetence, and he can make even outstanding residents wilt. Nothing annoys him more than lazy doctoring or disorganized thinking. He wants things done right, and he'll grill a resident like a homicide detective if necessary. As a result, some of the residents and Fellows think the right way always means his way. I don't agree. Dr. Herbert is obsessed with advocating for the best care, and has no tolerance for doctors he feels aren't equally obsessed. And when a resident veers off course, Dr. Herbert will bring the process to a halt. He will deconstruct a case for an hour until he's convinced that the resident understands not just that he or she made a mistake, but why and how not to do so in the future.

To get the full, fair picture of Dr. Herbert as a non-ogre, you only have to look at his bulletin board. There are pictures of him, his wife, four kids, and their grandmother, flanked by oversized Berts, Ernies, and Big Bird characters at Busch Gardens or elsewhere on their annual theme park trips. Despite his obsession with medical care, he is very much a human, caring person.

The other evidence of this is that as brutal as Dr. Herbert can be, ripping a resident a new orifice one moment, he can ease a patient's anxiety the next. He can even employ gentle humor, a rare feat in the somber CICU. He's been known to ask, in a very bad French accent, how a patient is enjoying the hospital's “haute cuisine” or to squint at his or her IV tube and say it's time for an oil change. This is the same dedicated but complicated attending who strikes terror in residents, which doesn't always make their work better, but which makes my job of training each of them challenging.

And when it comes to training, there are two basic truths:

Every night, I am faced with my end-of-day decision: How long do I stay? Most nights I go home around 7:00 or 8:00 p.m. if I feel comfortable there's a solid plan in place for each patient. But if my pager beeps at 2:00 a.m., I may head back in. There's an adrenalin-like excitement to these moments—a life hangs in the balance—but since I have to return to the hospital at 8:00 a.m., the days can run into one another. Some nights, even before I leave, I know I'll be back. It depends on many things, including the degree to which I feel I can trust the resident on call.

Of the three residents I'm working with, two have good instincts, and can tell when to say “I don't know.” Counterintuitively, in medicine, asking for help never makes you look dumb and almost always makes you look wise.

The first resident is a charismatic second-year, a rising-star cardiologist who is so calm, confident, and decisive that he is more or less functioning as the senior resident in the ICU. He's naturally charming, stars in the resident talent skits, and though relatively new to Hopkins, he's become a fixture, the popular kid who is also smart, easy to like, even with a slightly cowboyish nature, meaning he trusts his hunches—right or wrong.