Gunners

I have a friend in med school, and he is continually worried about gunners. He's started clinicals and doesn't want to be shown up or embarrassed on rounds. To me, it's quite amusing listening to students complain about gunners, because it's all perspective.

When I was on internal medicine as a student, there was another student on rotation who was always chipping in or talking about some obscure thing he'd been reading about. He knew MY patient's labs, just in case I didn't. It's not like he told me the lab values. He just got them so that if I should falter, he'd have them ready so that he could look good and I would look bad.

But looking back on my surgery rotation, I showed up earlier than everyone, did all my pre-rounding, and helped the interns with pre-rounding, and I volunteered for all the dull procedures. I wasn't trying to shine. In fact, I just wanted to do my time and be done with it, but because I put in the effort, I was always first in line. 'Hey, ifinding has scrubbed in on like five lap chole's this week. He should get to come in on the Whipple.'

I had no desire to do surgery. Scrubbing in on the Whipple was six hours of absolute torture. I wasn't trying to show off or make other students look bad. I just wanted to have a good experience. After the rotation, I found myself complaining about gunners, and one of my friends elbowed me, saying, 'Yah, takes one to know one!' I was shocked, but after a while, I saw it. I'm a gunner too. Being a gunner is all a matter of perspective. We're all gunners.

Choosing a specialty

Recently, I was talking to a 3rd year student, and he was trying to figure out what to do with his life. He was still a little lost, like most people in their 3rd year. Everything either seems fun or horrible. Everyone expects that moment of, 'This is what I want to do with the rest of my life!' but in reality, few of us get that moment. I can't tell you when I decided on internal medicine. I just did.

I tell most people that they should go with the pathology. Whatever diseases interest you are probably things that will continue to interest you, because the patients can't all be winners. This student told me that he wanted to do ER because he didn't want to see the same thing over and over. I was polite enough not to laugh in his face.

The truth is that every specialty has its bread and butter. For me, that's hypertension and diabetes. For the surgeon, it's gallbladders and appendices. And all specialties have their chronic patients. You can't choose a specialty aiming to avoid these chronic folks or to dodge the routine diseases. The only way to dodge that stuff is to go into a field without direct care: radiology, anesthesia, path...

When I was trying to decide, I posed a simple but profound question to myself: what is my staple diet? Sometimes I get a taste for Mexican, but I can eat rice every day for the rest of my life. And that's what choosing a specialty is like to me. What can I see again and again and always find satisfying? That's the specialty for me.

Hardass

I thought I put this up a while ago, but I guess not. Here we go. I wrote this like a year ago...

When I was a medical student, I worked with one senior resident, Dr Hardass. He really pushed us, and it was a really tough month. He did however teach us almost continuously, and he made us really excited about medicine. I couldn't say enough about the guy. He was what I wanted to become. I wanted to be that good, and that dedicated. He was the ideal senior resident. I wanted to do well to prove myself to him.

So, when I became a senior resident, I thought of him while working with medical students and interns. I was tough on my interns, and I held my interns to a high standard. Some complained, but others really responded to the tough love.

In the end however, I felt vindicated. Some of the students and interns thanked me. They were so happy to be held to a high standard. I would tell the students that they had it easy, and they challenged me. They took on bigger patient loads, wrote sharper notes. It was impressive.

It was my belief that I have to hold people to a high standard, not just acceptable but excellence. If you only ever expect passable effort, that's all you'll ever get. Holding people to excellence breeds excellent effort.

There are no exceptions, especially for myself. I set out to be like Dr Hardass, and I think I did a decent job getting there, and now I'm considered by a lot of students to be their favorite resident. It's an honor.

The weird thing about being a resident is that it's a chance to be a mentor, and that really is a sacred duty, because your actions are the basis for students' view of what being an excellent resident is.

One of my friends told me that I'm an exceptional leader because I listen to others, always try to do my best, and trust others to rise to the occasion. And those who've worked with me felt they should excel too, not just for the sake of excellence, but also because they didn't want to let me down. That's an awesome feeling.

Yeah, I'm a hardass, but that's DOCTOR Hardass to you.

It's all about trust

I completed the nomination forms for graduation awards for clinical faculty and students. The docs that I nominated were folks who I thought deserved it, but my votes for students were not exactly predictable. I would guess that none of the people I voted for have any chance at winning. At the onset, I tried to come up with a set of qualities and traits to rank people, but in the end, it really just boiled down to trust. Do I trust this person?

On my sub-I, I consulted an attending whom I'd worked with before. I told him about the patient, and he took my presentation at face value. He didn't have to. I'm a student. As an attending, it's his right to talk to my attending, or my senior resident, or even my intern. He doesn't have to take my word for it. But he trusted that I was giving him the whole picture, and that I would follow up on what he had said. And that's something.

Attendings have the liberty of avoiding scut work in house, but they have to trust that the residents will get it done, and rely on the work of the residents to base all of their clinical decisions. That's a lot of trust. Some attendings don't trust the residents or students at all. I know several attendings who repeat the entire comprehensive physical exam on every patient they see. Some check all the labs themselves, not trusting that the numbers we've written in our notes.

Everything after trust can be worked on. You can teach a person knowledge and judgment and clinical skill. You can't teach someone to be trustworthy. And that's why I didn't vote for some of my classmates. When the rubber hits the road, I just don't trust that they'd get the job done.

As an example, on my sub-I, there were a couple personal emergencies, and as a result, I was the only person on my service. No senior. No interns. I had to work with an intern pulled from another service to emergency cover. As we rounded, it became plainly obvious that the lists for the patients were not up to date, and we were paralyzed because we were spending all our time figuring out what medications our patients were on. The 3rd year students are supposed to keep those lists up to date, but they hadn't been keeping up.

After rounds, I had a talk with my students. I was nice. I said that it's important for them to keep their patients' lists up to date to avoid what happened. And from that day, I watched the list. There's truly no better, objective measure of a medical student than asking him to do the most trivial task on a daily basis.

When someone follows through on that, you know that you've got a winner. Because that student has shown the desire to earn your trust. And if someone can be trusted with minor things, than perhaps he can be trusted with greater things. And when a student doesn't follow through on something as simple as updating a list, that tells you something too. If someone can't be trusted to do something as trivial as update a list, how can he be trusted with something major, like the lives of his patients?

One of my students, my gunner, she was great. I could ask her to do something, and I knew that she would do it. She called people. She got old records. She tracked down a patient's baseline creatinine. She got the name of a patient's psychiatrist, of all things. She's a 3rd year, and she's got a ways to go with history taking and that stuff, but you can learn that crap. You can't learn being trustworthy. If I was a resident, I'd take her as my intern any day of the week and twice on Sundays. If we were picking teams, she'd be my first pick.

My slacker, it got to the point where I just couldn't trust her to get the basic stuff done: writing notes, updating the list, checking the labs, stuff like that. I had to ask her every day if she even saw her patients. I blame myself to some extent. I should've corrected this behavior from the get-go. But the heart of the matter is simply that I couldn't trust her.

So I'm glad that some of my classmates are going into fields without direct patient care or are far removed from internal medicine. I'd rather work with people I trust. And that's how I voted for the graduation awards. Despite all the flourish and prose written to encompass the awards, to me it boiled down to this: who would I trust to care for me? And when presented with that question, the answers were quite simple.

Medicine treats disease. We do not 'help' anyone.

The ICU is not for me. I know that now. There's something so... unsatisfying about taking care of a patient for only a few days, and then turfing that patient to another service. One of my patients made it out of the ICU, despite our best efforts, and I can't help but wonder what will come of him. It's like another patient I have from last month. He's still in house, and I keep meaning to visit him, but I don't have the time. I wish I could see him. I feel like I should. And that's how I know I'm meant for primary care. Because the thought that I'm not going to follow a patient is sad.

On the slacking front, it's become next to impossible to slack. I'm trying to slack, but there is just so much work to do. I'm only following two patients, but it adds up with other patients. Find this lab. Write this order. Do this. It's making the interns' lives a little easier to have another set of eyes and ears to catch the little stuff that slips through, but this rotation is one of the busiest I've ever done.

And I know you're saying to yourself, it's the ICU, man, what did you expect? Well, honestly, I expected that I'd get to be a medical student again. Instead, this rotation is far more like a subinternship than my actual subinternship.

I keep seeing attendings that I've worked with before. Uniformly, I get the comment that I'll make an excellent resident and that they hope I stay. Y'know, everyone tells me that I'll be a great resident, but I know me. The aspect of medicine that I excel at is just the work. I work hard. That's all. I think I know less than most. I just try to keep at it. I try to move things along.

We had a lecture about goal-oriented care, and I thought it was pretty stupid, because it's something I think about every day. We do all these things to patients, and half the time, I question who we're really treating: the patient or ourselves. In the end, I applied to medical school thinking that I'd get to help people, but most of the time, we don't help too much. It's mostly trying to hold back the tide. And the only rewarding part of that is knowing that at least you tried.

I had a patient who was put into Hospice care, and I was glad. Glad that we avoided putting in a PEG tube, putting in a trach, and doing all those things that make me hate medicine every day. I had always thought that the role of medicine was to help people. It's only now that I understand that the role of medicine is not to help people but to treat disease, and that is not the same, not by a longshot.