Signout is hospital slang for the transfer of information between patient care teams. It is also the name of this blog, which represents one of the less dysfunctional ways in which Dr. Signout copes with her participation in a U.S. medical residency program.
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?
Medicine & Health
Comments
Wonderful post, Dr. Signout!! BTW, I loved Chen's book.
Posted by: Comrade PhysioProf | November 14, 2008 5:03 PM
Any chance you could take another crack at that conversation?
Have been missing you.
Posted by: Heather | November 14, 2008 5:21 PM
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.
Posted by: Signout | November 14, 2008 8:16 PM
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.
Posted by: bioephemera | November 14, 2008 8:23 PM
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.
Posted by: Pup, MD | November 14, 2008 11:01 PM
Lovely post, Signout, and a great reminder that we don't all interpret every aspect of our job the same as our colleagues do.
Posted by: Isis the Scientist | November 15, 2008 9:44 AM
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!
Posted by: storkdok | November 15, 2008 4:33 PM
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.)
Posted by: Bo | November 19, 2008 1:36 PM
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.
Posted by: Lisa b | November 24, 2008 9:47 PM
Lovely post, Signout, and a great reminder that we don't all interpret every aspect of our job the same as our colleagues do.
Posted by: boya | February 25, 2009 2:21 PM
thanks for sharing.
Posted by: 电磁铁 | November 3, 2009 2:08 AM
its very nice
Posted by: FrmClub | November 6, 2009 10:06 PM
Any chance you could take another crack at that conversation
Have been missing you.
Posted by: komik videolar | November 15, 2009 6:21 AM
Any chance you could take another crack at that conversation?
Have been missing you.
Posted by: sex sohbet | November 18, 2009 2:58 PM
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.
Posted by: replica rolex | November 22, 2009 3:41 AM
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.
Posted by: super payday | December 30, 2009 5:15 AM
Lovely post, Signout, and a great reminder that we don't all interpret every aspect of our job the same as our colleagues do.
Posted by: film izle | August 8, 2010 3:32 PM
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
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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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I feel powerless in the face of a culture that doesn't
Posted by: sorgula sorgulama | May 25, 2011 2:27 AM
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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