the day i became a cynic

i don't know how you keep your soul in this business. maybe it grows back after residency. or maybe you can afford to buy a new one with your attending-level wages. whatever the case, i have found myself rapidly spiraling down the dark tunnel of bitchy intern.

so determined to stay "nice," i began the year all smiles and acquiescence. i was polite and friendly to everyone, never interrupted, went to see every patient the nurses called me for. when an order didn't get followed, or a mistake was made, i had the patience of Job. no temper tantrums here. and what did all this nice-intern attitude get me?


i firmly believe(d) that you catch more flies with honey than with vinegar--the nicer i was to all the nurses, techs, consultants, med students... the nicer they'd be to me. but i will tell you, that was not the case. instead, my agreeable nature got me about twelve times as much work. i should have realized what a stupid adage that is. i mean, who the heck wants to catch flies, anyway?

the nicer i was to the techs, the more they pushed my patients to the back of the line for x-rays and ultrasounds (one told me, "i knew you wouldn't yell, dr. midwife, so i put dr. meenypant's patient first). the more accommodating i was with the nurses, the more bullsh** pages i got at 4 am. "dr. midwife, this patient never got consented for blood. can you come up and do it?" i once made the EGREGIOUS mistake of discharging two patients for the day gyn team (chief calls me: oh dr. midwife, could you please please please do me this teensy favor...) turns out the patients had incredibly complex hospital stays requiring dozens of phone calls to arrange follow-up care, and yesterday i was unpleasantly surprised to discover that i will have the honor of dictating the charts of these two patients (in whose care i never even participated) simply because my name is all over the discharges. how convenient for my chief. and now i get asked to do it all the time.

last friday i arrived to find hours of work left over from the day gyn and gyn-onc teams (discharges, post-op notes, lab follow-ups) and this even before i got a single page for my "on call." and then, then there was the straw that broke this camel's back. i had to write a post-op note on this patient, but i found no record of the urine output (a very big deal in post-op patients, it gives us an idea of the patient's hemodynamic stability).

me: where can i find this patient's urine output?
RN, not even looking up: i don't do that. ask the PCT (patient care tech).
me: where can i find the PCT?
RN: out there. (waving with her hand as she doesn't even make eye contact).

me, wandering around: are you the PCT?
PCT: yes.
me: where can i find room 12's urine output?
PCT: i just got here. you'll have to go ask the nurse.

me: the PCT says you got debriefed, and she doesn't have the vitals.
RN: well go ask her again. i don't have them.

me, finally getting really really pissed off: no, i need you to stop checking your email, and find this patient's urine output.
RN, grumpily looking at the vitals sheet: i don't see it here.
me, sarcasm getting the best of me: really. i told you that 5 minutes ago. any idea where i can find it?
RN: if it's not here, it probably didn't get recorded.

extensive discussion with PCT and RN leads to conclusion that if urine output did get recorded, no one knows where it is. currently, the patient is 8 hours post-op, with less than 50 cc of urine in the foley bag, which is NOT GOOD. this is where i lose it.

me, in the hall, to the RN and PCT: it is UNACCEPTABLE to have a post-op patient with no urine output recorded. do you see this order? it says: RECORD URINE OUTPUT. not only is it unacceptable for it to have not been done, it is unacceptable for no one to have noticed that it was not done for EIGHT HOURS. now i have a patient who may or may not be oliguric, complaining of abdominal pain. could be normal post-op pain. could be ureteral obstruction. but there is no way to know, now is there?

i didn't exactly yell, but it's the loudest my voice has been since starting residency. i was pissed, and for once, other people knew about it. but i was amazed at the results it produced. RN and PCT suddenly sprang into action, apologizing and measuring urine and offering to search high and low for lost vitals sheets. it was a sobering moment, because i realized that maybe, just maybe my perfect plan to be so nice that everyone loves and respects me wasn't working. being nice has given people the idea that i can be dumped on and walked all over. over the next few days i was more curt on the phone. still polite, but more cut-to-the-chase "what do you want?" i refused to see a consult before the medicine resident did her own pelvic exam (i don't consult cardiology for my cardiovascular exam, now do i?) i told other residents to do their own discharges and post-op notes. i stopped feeling guilty for not answering pages on my way to the bathroom. it feels good to stand up for myself, even a little bit.

in a way, i'm sad that i have to leave that last shred of idealism behind. until i figure out how to be both firm and nice, i'm going to err on the side of firmness, because i can't keep up with nice intern's workload.

and so it has come down to this.

if anyone out there has any suggestions, any magic formulas for being friendly without getting stepped on, please pass them along. i'd like to resurrect nice glorified midwife, maybe for second year.


At 9:10 PM, Anonymous Anonymous said...

I've found that it's easiest for me to be, when necessary, firm but fair to my cohorts--fair to myself and fair to others. The others, in your case, weren't being fair (to you and your pts), so you had to be firm at that moment at least.

It doesn't mean that you're suddenly mean--just clear on your expectations.

Nice blog; I'll keep reading. Thanks.

At 10:10 PM, Blogger incidental findings said...

The key is not niceness, but to make yourself a person to the other people, and not simply "on call resident."

For example, all the time I get from nurses that know me, "Oh I'm sorry to bother you Dr. Ifinding..." because they know me and don't want to bug me with crap.

I try to be nice, but I am also a doctor first. I was cleaning up some stuff and the nurse pushed me away. "No one's paying you extra to do my job too Dr. Ifinding."

At 11:44 PM, Anonymous ruralobgyn said...

You handled the issue of urine output well. You stuck to the main issue--what is her urine output? and stayed away from judgmental statements about how the nurse chose to spend her time. Plus you appealed to her better side by pointing out that the patient could be in trouble and that the urine output was essential to knowing whether the pt was ok. So once again you did good. As for the discharge summaries and other scut, you just have to squawk loudly when you are treated unfairly. You know it, the chief knows it. Not to say you can't do a favor now and then, but make sure the giftee realizes this is a special favor, not something you're going to do routinely, and that she owes you! Maybe you'll get that vacation day you need when the next call schedule comes out. You haven't lost your idealism, you are just finding out the hard way how the world works.
Amazing that you have energy to do your blog! I hope you continue the blog AND keep taking good care of your patients. Urine output is key.

At 4:13 PM, Blogger The MSILF said...

This is one of the hardest lessons there is. It's so hard to go against all the years of manners and your basic nature. But we all gotta do it sometime.

I enjoyed reading this - I get that washing over feeling of dread when I know I'm going to have to confront someone on something. Glad I'm not the only one.

At 8:38 AM, Blogger Intelinurse2B said...

Good advice in those comments. I personally can not imagine not giving a doc eye contact and dismissively waving a doc in the direction of a PCT. Wow! That was rude.

At 2:09 PM, Anonymous Alice said...

Standing up for yourself, and making sure that you have the energy to do your primary responsibilities is not mean. There has to be a way to firmly but non-rudely tell people they can't take advantage of you. I hope I can find it when I get to your level.

At 11:25 AM, Anonymous Anonymous said...

Maybe "nice" and "not nice" aren't the benchmarks you should be looking at. "Reasonable" and "unreasonable" may be better ways for us physicians to gauge our behavior. I don't want to ever be known as the "unreasonable" doctor who just likes to scream at staff as a way to manage my own personality disorder. However, when faced with "unreasonable" patient care, a little righteous indignation is often required to protect the patient.

PS--Did you write your order on the "Physician Orders" sheet, or the "Suggestion" Sheet? :)

At 10:53 PM, Anonymous the evil resident said...

What you are experiencing is pretty consistent with hazing^H^H^H^H^H^H internship. Almost all of these things go away dramatically once you finish PGY-1 year. It's actually quite miraculous.

Some suggestions in the mean time:

1. Disappear whenever you can. Don't hang out where anyone can find you. Take at least a minute before answering pages—this will prevent the dreaded busy signal, and if they really need something more urgent, they will just call a code anyway.

2. Whenever you find yourself doing someone else's work, make sure they know what a huge favor your doing for them, and never let it go—bring it up through all the years of your residency, even if they eventually pay you back. That'll make them think twice about dumping work on you. With regards to allied health professionals (RNs and RTs, for example), sometimes it helps to be able to quote hospital policy chapter and verse, specifically, the part that delineates their duties.

3. Use your hospital's quality assurance system extensively and report each and every error. In the example of your urine output experience, an order wasn't carried out, and it had the potential of adversely affecting patient care. You may feel that you don't want to get anyone into trouble, but it has to be documented, and fact is, things will be much worse for you if you don't log it, and something bad does happen.

4. Never be afraid to throw around guilt trips—subtly remind others that they aren't working for you, they're working for the patient, and that what you're interested in is taking care of the patient, not fighting a turf war.

5. Sometimes you just have to take the hit, in the interest of patient care (but again, keep a strict accounting and let people know there will be a reckoning) In the example of the GYN consult from the medicine service, you really don't want an IM doc doing a pelvic exam. We don't know how to do them and will likely piss off/traumatize the patient, and we will not find anything useful to you, and you will end up having to do another one anyway, and by now the patient will be freaked out. As a counter-example, while theoretically surgeons should know how to manage fluids and antibiotics and insulin and pressors, sometimes the IM doc just has to accept the turf and keep the patient from being killed.

Good luck. Most interns hit the "wall" about 6 months into this mess (and sometimes earlier) and you'll feel that you don't want to do this any more, but then things seem to get better.

At 1:01 AM, Blogger ozdocblog said...

A great blog and takes me back to my intern years. Not sure about elsewhere but unfortunately in Australia the answer to too many queries to nurses about a patient was one of the following: "Sorry, I'm an agency nurse". "Sorry, I know we paged you and you've walked a mile to get here, but the nurse who knows about Mrs S is at tea". Or the one that didnt ever really make sense to me, "I've been on days off".
Why this means when you're back from days off you shouldn't know about your patients was always a mystery to me.
On the other hand, on many other occasions, a nurse has rescued me from disaster.


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