How long before I begin, before it starts, before I get in?

September 5, 2009 at 2:09 pm | Posted in Uncategorized | Leave a comment

This has been the strangest couple of weeks ever. First of all, last week I was assigned to clinic for nearly the entire week.

That’s why people go into surgery, you know.  For the clinic.  Because we all love talking to people all day instead of operating.  Especially talking to people whom someone other resident operated on, or will operate on, even though you’re the one they know and you did all the paperwork and dictation.

So needless to say, that was pretty much the opposite of fun.  But I did begin to develop a more efficient approach toward patients, which was certainly needed.  Basically, I spend about 5 minutes with a postop patient and do a very targeted exam to look at the surgical site, and assess for improvement in the symptoms that made us decide to operate.  Why?  Because postop visits can’t be billed separately, so we only need to collect data that’s relevant to our clinical decision-making.  It’s very liberating.

But the resident always has to be the one to do preop H&P’s, and see new consults.  Why?  From the cynical standpoint, it’s because no attending wants to spend the time it takes to gather the information required for a detailed enough note to bill at level 4 or 5.  From a non-cynical point of view, however, those are also the patients we can learn the most from.  In reality, it’s probably a little of both.

Also over the last couple of weeks, word has gotten around that one of the residents’ contracts is not going to be renewed after this year.   Apparently, everyone’s known this for like, a month already.  But we’re only two months into the academic year, so how did that resident’s contract get renewed for this year, only to have the non-renewal decision for next year happen so quickly afterward?

Interestingly, last year’s pre-residency fellow, who is now PGY-1, was promised advancement to PGY-4 in short order, due to his extensive prior experience in neurosurgery.  This seems appropriate to me, from what I know of his knowledge base and clinical judgment relative to the other residents in this program. But I had wondered how it would happen, and now I think I see how it might.  Though the other junior is acting like that spot is up for grabs, and we’re all in competition for it.

Frankly, I dislike the kind of traits that such competition reveals in people. I’d rather operate on the assumption that this decision has been made already, and that my goal is simply to function at as high a level as I can, without sandbagging someone else in the process.  Plus I’m still hoping that Gigantic Hospital will offer me their spot, and end all of this crap that I had no idea I was getting into.

Not that I wouldn’t still recommend this place to people applying.  The catchment area is huge, and demand still exceeds program capacity, so cases are going elsewhere that could potentially come here.  And as the number of attendings increases, they will.  Even though it’s pretty much a single-hospital program, the residents are spread thin and they work hard, which is good.  Research-wise, I wouldn’t get the training I’m looking for, but clinically it’s solid.

Chairman-wise, a number of big names have come through here.  Financial mismanagement is the #1 reason most of them are gone, I’m told.   Consequently, we’ve already had several conferences on how to dictate, document and bill for things in order to maximize reimbursement without committing fraud.  Fortunately UW general surgery also trains its residents well in this regard, so none of it was a huge shock.

With respect to the attendings, none of the programs I’ve encountered has such direct and unshielded interaction between junior residents and the attendings as a group.  Most programs I’ve seen limit it to rounding with a single attending at a time, and perhaps at most a weekly formal presentation.  Here you present the 3-8 patients you pre-rounded on that morning to all of them, as a group, daily.  And once or twice a week, when you’re post-call, you run that morning’s conference, and you present not only all the new patients, but also the ICU patients as well.  So it can easily become a feeding frenzy if you show any signs of weakness in your workup, plan, overnight decision-making, background reading or presentation.

Some of it is just a matter of learning (or re-learning) the gentle art of verbal self-defense, and how to deflect questions before they’re asked.  But you’re also expected to have done some reading and research about your patients overnight.  And most times, you can’t BS your way though it.  You also get no points for having read dutifully, but being brain-dead post-call and unable to recall the information on the spot.  Or for getting disoriented because the pictures you looked at in your reading are upside down with respect to the structures on the scan you’re being asked to point them out on.  On those occasions, you just kick yourself afterwards for looking like a bigger idiot than you actually are.

So, a strange thing happened this past week.  The reputedly least tolerant, most malignant attending at this program (who generally doesn’t even want to talk to junior residents until they become senior residents, and had kicked me out of his clinic the prior week for incompetence–he’s made others leave morning conference for the same offense, just so you know) actually sat me down last Monday and asked me what my plan was for learning neurosurgery this year. I don’t think he really expected me to have thought about it, but of course I had.

So I outlined it for him, including the fact that several of the books recommended to me thus far have proved to be very outdated or too shallow for the level of practice expected of me here, and what other resources I’ve found to use instead. He reiterated the fact that they love their current chief, and that I should solicit his advice on the subject (which I’d done weeks ago and been brushed off with the only most basic and self-evident of suggestions.  But since my plan up to that point was “clearly not working,” in this attending’s assessment, and it’s just socially tone-deaf to criticize any group’s golden child, I didn’t mention it.)

Anyway, the strange thing is, I find that I actually like this attending.  I appreciate the straight talk, and the lack of any agenda or other bullshit than simply knowing your stuff, being efficient and making good decisions.   I don’t mind high expectations and criticism aimed at making me a better neurosurgeon.

What I don’t like is this feeling that I’m a unwitting pawn in someone’s game, and that my future will be determined by what’s in their best interest, even if it doesn’t entirely serve mine.  I know better than to expect differently.  But nonetheless I hope.