Signout

Kind of your job

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?

Comments

  1. #1 Comrade PhysioProf
    November 14, 2008

    Wonderful post, Dr. Signout!! BTW, I loved Chen’s book.

  2. #2 Heather
    November 14, 2008

    Any chance you could take another crack at that conversation?

    Have been missing you.

  3. #3 Signout
    November 14, 2008

    PP: Aw, thanks! I am loving her book, too. She makes very sensible points with great humility. I would submit to her scalpel any day.
    Also, in your screed about Rahm Emanuel, you neglect the fact that he is So Freaking Hawt. Could you please consider that before you blather about him any more?

    Heather! Absolutely.

  4. #4 bioephemera
    November 14, 2008

    Yay! Great to see you back! I’m catching up on blogs because I can’t get out of bed, and a new post from you is almost as good as antibiotics.

    Incidentally, I heard Rahm Emanuel was the inspiration for Josh Lyman, my unrequited West Wing crush. Good times.

  5. #5 Pup, MD
    November 14, 2008

    Even if it’s annoying, I don’t think you should ever judge someone on the fact that they find the utterly meaningless aspects of our job, well, meaningless. Yes, it has to be done, and yes, someone the least senior has to do it, but that doesn’t change the essential rationality of wondering why you’re doing something that sucks when you could presumably be somewhere else, doing something else.

    There’s probably more going on here, but simply complaining about stupid stuff may be the only reason most of us don’t hang ourselves in the bathroom at the end of every day.

  6. #6 Isis the Scientist
    November 15, 2008

    Lovely post, Signout, and a great reminder that we don’t all interpret every aspect of our job the same as our colleagues do.

  7. #7 storkdok
    November 15, 2008

    It’s funny, I never had any feelings of irritation or superiority when I was an intern doing the “scutwork”. It was simply the stuff that needed to be done, and I accepted it wholeheartedly as an intern. I knew it had to be done, so why waste time and energy on hating it? I also looked at it as an opportunity to talk to the patients and nurses and get to know them, since we couldn’t manage a social life outside of the hospital!

    I am glad you recognized her dread about pronouncement as something more than paperwork. One part of my residency I loved was the once a week the hospital chaplain/counselor/ethics professor would round with us. He was great at asking these probing questions and helping us to recognize our own individual feelings and how to approach situations and the individuality of patients on high risk OB or gyn oncology.

    Good luck with your Fellowship applications!

  8. #8 Bo
    November 19, 2008

    I used to hate deaths in the ICU, too. It may have stemmed from an unfortunate experience during my rookie days. Recently I worked in an LTAC and was gratified to see that I’d gotten more “comfortable” and thus felt more able to concentrate on being more empathetic with the patient and their family. Hopefully your colleague will keep growing in her position. (PS I’m just a nurse.)

  9. #9 Lisa b
    November 24, 2008

    hey Signout I’ve missed you and your touchy-feely posts.
    I think I made a similar comment on a previous post but again as the mom of a NICU baby I have to tell you that doctors who are able to calmly deal with end of life conversations are a treasure.

  10. #10 boya
    February 25, 2009

    Lovely post, Signout, and a great reminder that we don’t all interpret every aspect of our job the same as our colleagues do.

  11. #11 电磁铁
    November 3, 2009

    thanks for sharing.

  12. #12 FrmClub
    November 6, 2009

    its very nice

  13. #13 komik videolar
    November 15, 2009

    Any chance you could take another crack at that conversation
    Have been missing you.

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    November 18, 2009

    Any chance you could take another crack at that conversation?

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    November 22, 2009

    I am glad you recognized her dread about pronouncement as something more than paperwork. One part of my residency I loved was the once a week the hospital chaplain/counselor/ethics professor would round with us.

  16. #16 super payday
    December 30, 2009

    Even if it’s annoying, I don’t think you should ever judge someone on the fact that they find the utterly meaningless aspects of our job, well, meaningless. Yes, it has to be done, and yes, someone the least senior has to do it, but that doesn’t change the essential rationality of wondering why you’re doing something that sucks when you could presumably be somewhere else, doing something else.

  17. #17 film izle
    August 8, 2010

    Lovely post, Signout, and a great reminder that we don’t all interpret every aspect of our job the same as our colleagues do.

  18. #18 prefabrik ev fiyatları
    August 16, 2010

    Even if it’s annoying, I don’t think you should ever judge someone on the fact that they find the utterly meaningless aspects of our job

  19. #19 kabin
    August 20, 2010

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    October 6, 2010

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    November 9, 2010

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  22. #22 haber
    December 18, 2010

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    January 7, 2011

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  24. #24 traverten
    January 11, 2011

    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.

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    January 14, 2011

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    February 5, 2011

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    February 9, 2011

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  28. #28 otel rehberi
    February 15, 2011

    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.

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    February 23, 2011

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    April 6, 2011

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    May 4, 2011

    the face of a culture that doesn’t exactly embrace the avoidance of unnecessary intervention.

  34. #34 mobilya
    May 10, 2011

    I feel powerless in the face of a culture that doesn’t exactly embrace the avoidance of unnecessary intervention.

  35. #35 dunya rehberi
    May 21, 2011

    I feel powerless in the face of a culture that doesn’t exactly embrace the avoidance of unnecessary intervention.

  36. #36 sorgula sorgulama
    May 25, 2011

    I feel powerless in the face of a culture that doesn’t

  37. #37 yemek tarifi
    May 28, 2011

    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.

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    May 30, 2011

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  39. #39 konteyner
    June 1, 2011

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    July 2, 2011

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    November 20, 2011

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    November 21, 2011

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    January 21, 2012

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    May 4, 2012

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