Posted by I’ve been away from the blog for a while, working on fellowship applications and riding the wave of the ICU. Thank you for your patience, as ever.
As you might remember from my days as an intern, I used to love the ICU. That love is no longer: doing procedures to people whose fate is inevitable isn’t as much fun as it used to be, and I feel powerless in the face of a culture that doesn’t exactly embrace the avoidance of unnecessary intervention.
This most recent time in the ICU, I worked with an intern who seemed to me less eager than some to take on the burden of her responsibility. About three days into the rotation, she–let’s call her Dawanna–remarked to me with some irritation that “all I ever do is put in orders.”
“Yes,” I replied. “That’s kind of your job.”
Of course, that’s not her entire job–she is also meant to evaluate patients, make plans (or try to) for their care, and learn about their disease processes and our interventions. However, the intern is meant to be the first line for nursing concerns, and a large part of her job is therefore to write orders.
I was annoyed by her implication that this was a waste of her time, and that there was nothing to learn from this exercise. After all, I told her, when she is an upper level and her intern asks how to do things, how will she provide instruction if she hasn’t ever done those things, herself?
Only a year and a half ago, I was an intern. I remember feeling demoralized at the paperwork–especially that involved in discharging patients. But the lists of orders carried with them a certain amount of satisfaction in their doing. I felt like the engine that made the hospital run, writing hundreds of action verbs every day: admit, administer, place, remove, flush, drain, call. While others ruminated, I did.
I remember cursing at computers, printers, and occasionally, behind their backs, other people–but I never questioned whether the job was mine to do. I was astounded that Dawanna did.
One of the things Dawanna didn’t want to deal with was patient deaths. I know this because she remarked repeatedly that she hoped patients wouldn’t die while we were on call. In my irritation with her, I related this to her lack of enthusiasm: patient deaths require an exam for pronouncement of death and a small stack of paperwork, which can be time-consuming. Not wishing to hear more about her distaste for her job description, I did not inquire further.
Today, I woke up and started reading “Final Exam,” by Pauline Chen, a liver transplant surgeon. In it, Chen writes about the ways in which doctors are trained to deal with death, or not, and uses as illustration vivid tales from her own training. Early in the book, she captures quite beautifully what disturbs her most the first time she pronounces a patient dead:
I had insinuated my hand into that mysterious nexus of stars and fate and destiny, and I had reduced that great passing of life into an arbitrarily calculated moment in time.
Until I read this, it hadn’t occurred to me that in Dawanna’s anxiety over patient deaths was more than mere laziness–that there was fear of what it might mean and what it might feel like to be the pronouncer of a person’s passing.
Only a year and a half ago, I was an intern. I feared this, too.
In retrospect, I really should have asked what she dreaded about the pronouncement, and should’ve given her some space to talk about what it means when someone dies, or what it feels like to be present at a death. Even if it was just the paperwork she didn’t want to do, it would have been good for her to feel able to explore her feelings around other–especially senior–residents.
Who thought I’d ever feel guilty about not being touchy-feely enough?
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