Dishonorable Discharge

I have seen so many things already as a third year. I have watched a patient stroke out. I've seen five hundred pounds of naked flesh strewn over an operating table. I've seen hernias and livers and even beating, human hearts. I've had patients vomit on my shoes. I've performed pelvic exams and I've examined penises. I've dressed wounds so repulsive that I've had to hold my breath. I've inserted catheters and foleys. I've watched a patient struggle in her four-point restraints.

Most of the time, I don't let it faze me. I just think to myself, it's my job. These brutal hours, the constant vigilance, the pressure. I am awed by what my interns, residents and attendings are capable of, the knowledge they have accumulated, the grace with which they act. And every single day, I think to myself- I want to be just like them.

They call it "the hidden curriculum," but really it's the social curriculum of the hospital, the behaviors that you observe while you are on the wards and then unwittingly add to your own Patient Interaction Repertoire. If you're lucky, you gain good things: the way my Chief always says good morning when she walks into a patient's room during rounds. Or the way my attending always says, "Please" even when he's angry with the scrub nurse. My resident who apologizes to the patients when his stethoscope is cold. I want to be able to whistle a birdcall so that I can tell my pediatric patients there's a robin in their ears. One of my interns knew a patient so well that he brought her white bread with butter and chocolate milk- it's the only thing she'll eat when she's in sickle crisis. These are the kinds of interactions I want to absorb, to dissolve into my skin so that they stay with me forever, so that they shape my life.

But sadly, the hidden curriculum can also work the other way. In an article in NEJM (http://www.nejm.org/doi/full/10.1056/NEJMp1100674), the author writes that fourth years are startlingly less empathetic than third years, and interns? Forget it. They are in their own little circle of hell and can't be bothered with anything other than the admission-management-discharge dance. (Okay, that's not fair, I've met many interns whose hearts are in it.) But to be honest, I have seen many doctors who are apathetic, cold, even vulgar, towards their patients.

While I was on the Transplant Service, we had a patient, Mrs. B, who was coming in for a fistula ligation (a fistula is an abnormal connection between an artery and a vein, and are created so that patients with kidney failure can receive dialysis). Dr. S, a small man who reminded me of my father, was her surgeon. Unfortunately, the morning of the operation, he canceled it because the fistula had become infected. Even with my amateur eyes I could tell that the fistula was red, swollen, and angry. It was radiating heat.

But Mrs. B needed dialysis and the resident on call decided to go ahead and use that infected fistula as access even though Dr. S had specifically said not to. About a half hour into dialysis, Mrs. B went limp and became unresponsive and the team galvanized into action, a stroke code was called, and every effort was made to help Mrs. B regain consciousness. But she never did.

She was intubated, and was transferred to the MICU. A CT scan of her brain showed a massive stroke at the back of her head. No one believed she would wake up, but neither was she clinically braindead- she still had some primitive reflexes intact and could breathe spontaneously when challenged. That's when she became a problem, a waste of space, a bed that could have been given to another, more "saveable" patient.

What irked me is that no one would take ownership of what happened. The transplant team, the medicine team- everyone just said, oh, she was old and probably septic already, she had a stroke, it happens. I don't know if the use of the infected fistula was involved with the stroke, but according to Occam's Razor (which doctors love to preach about), it probably was. Instead of accepting that a mistake was made, people started blaming the family- complaining that they were taking too long to make a decision about signing the DNR papers. The nurses and attendings started referring to Mrs. B as "the vegetable." One day, during morning rounds, we were checking her chart and realized she hadn't been getting any of her TPN (total parenteral nutrition- liquid food through her veins) and when we checked, we found that her IV fluids were draining onto the floor, not into her vessels. I had never been so furious in my life. I wanted to shake everyone, throw a fit, and shout, "What if this was your mother?"

When Mrs. B finally died a week later, in the middle of the night on a Thursday, no one even thought to mention it to us students. We only realized she had passed away when we asked about her at morning rounds on Friday and our attending shrugged and said, "Game over."

I wish I could purge experiences like these from my system, smooth that wrinkle from my brain and forget it ever happened. That not-so-hidden curriculum does, inevitably, affect you. By the end, I felt almost like a hardened veteran of the wards even though everyone told me I was "too sweet" to be a surgeon, that I belonged in a "softer" specialty. But accepting pain and mistakes is a part of being a doctor, no matter what kind you are. And frankly, I don't care what I grow up to be, as long as I am remembered by a student for knowing that my patient liked chocolate milk and not because I likened a patient's life and death to a video game.