“A good leader inspires people to have confidence in the leader; a great leader inspires people to have confidence in themselves.”

Eleanor Roosevelt

By the third day of being the new surgery intern, I had figured out the computer system and was able to look up bloodwork on the patients without going through a twenty-minute struggle and three phone calls to computer support.  I still had not been able to get rid of Ms. Warren and her unending excruciating abdominal pain.  Just as Stuart predicted, she was the reason behind at least ten phone calls a day.  I saw that miserable girl about five times every day and listened to her demand that we “do something”.  She threatened to pull out her IV and leave on several occasions, but never did it.  She told me over and over again she wanted us to operate on her, despite the fact that she had absolutely no indication for surgery.  At one point, Jessie even persuaded her to stay just as she was about to storm out. Why, why, why would anyone do that?! we all groaned. I could have strangled them both. 

     After almost another week, I finally accomplished my task of getting rid of Ms. Warren.  I had been up all night on call and must have been particularly unpleasant with patients that morning, because she finally agreed she felt good enough to be discharged.  She was pretty sure she would be found dead at home later that same day, but since all the tests were normal, she was eating and having regular bowel movements, and we were refusing to operate on her, she decided to finally go home.  Relief washed over me when I watched her cross the lobby, pass through the front doors, and leave the building.  After many days of constant irritation, endless phone calls and trips to her room, countless scans, scopes, ultrasounds and x-rays, and thousands of dollars’ worth of narcotics, she was gone.  A small part of me still felt empathy towards her. Does she really believe she has something seriously wrong? How hard it must be to live your entire life convinced you have a terrible medical condition that no one else understands or can diagnose or treat. But I mostly felt relief, like a huge weight had been lifted from my shoulders. 

     Over many years, the hospital had grown into a U-shaped conglomeration, and in the middle was a gated parking lot.  Our call rooms were on the top floor of a separate little three-story building in this parking lot.  There were four little rooms with beds, a central lounge type area with a TV and coffee pot, and two bathrooms.  The décor was seventies inspired yellow and orange furniture with a greenish shag carpet.  During my first night on call, I had no major traumas, no sick ER patients, and only three admissions.  I had gotten the patient list updated correctly the next morning.  Stuart was gone, down at the University for two months, and Tad was so busy in the ICU that we weren’t relying on him for much help.  I knew where the operating room was, and how to get to radiology, medical records, and the ER using all the shortcuts.  I had also learned that the OR schedule posted for the day had no relationship with what actually went on throughout the day.  In the world of surgery things were just too unpredictable for a schedule.  I had gotten into a routine that included frequent walks through preop to try and keep up.  I had learned to prioritize things and work more efficiently, and things seemed to be coming along okay.  Unfortunately, things were not going so well for Shahid, one of the other new interns.

     Shahid had started out on orthopedics.  We all had to do two months on the orthopedic service as interns.  The intern still rotated in the general surgery call schedule at night, putting us on call every third night.  But the ortho rotation was without doubt one of the easier services to be on.  I had heard some grumblings of general discontent from the PA’s (Physician Assistants) about Shahid.  He definitely seemed to have that “I’m-the-doctor-so-everyone-needs-to-do-what-I-say” attitude.  Which I guess is okay if you are competent and know more about the subject than anyone else, but this was not the case with Shahid.  The PA’s had come to the Program Director as a group and asked him to speak to Shahid about this attitude, as it was starting to really annoy them, the whole orthopedic floor nursing staff, and the radiology techs.  Everyone thought it was just due to inexperience and were willing to give him the benefit of the doubt, at least for a while.  I felt a little sorry for him, but that sympathy did not last long.

     It was about ten til six in the morning, and I was waiting for Shahid to show up to tell me about the new patients on my list.  He had been the intern on call overnight, so I needed a brief report from him on everything that went on.  This was before the advent of widespread electronic health records, where everything automatically shows up on a nicely organized computerized system.  The intern on call had to manually add each patient’s name and information to the correct list we kept on the computer in the work room, then we printed out our lists.  The attendings were divided into teams, each with a resident team assigned to look after those attendings’ patients.  The list was a vital tool for rounding and managing the service.  It had the patients’ names, room number, diagnosis, and key details like date of surgery.  On morning rounds, we would discuss everything that needed to get done for the patient before afternoon rounds.  To the far right was a little blank space where we would write in our list of things to do.  Everyone had their own system of remembering everything that needed to get done.  I put little blank circles beside everything I wrote down, and as the day went on and I accomplished things, I checked off the circle. If I didn’t write it down on my list, I was doomed.  There was just too much to do to remember it all.  I don’t think there is any human capable of keeping track of everything that needed done on a busy surgery service.

     Shahid never mastered the list.  Throughout the entire year, he remained challenged by the concept of the list.  He had taken call and had added a few patients to our lists that he helped to admit overnight.  Dutifully, Jack and I printed our lists, got sign out from Shahid, and went up to the floor for rounds.  Zayed and I came to our first new patient, and he introduced the team.

“Hello, I am Dr. Zayed.  We all work with Dr. Budros, who will be in a little later…”.  Dr. Budros was listed, on the official list, as the patient’s attending physician. 

“Who’s Dr. Budros?” the patient interrupted, puzzled.  “Dr. Nayhan has done all my other surgeries.  I thought he was taking care of me.  That’s what they said last night!  I don’t want any new doctor.  I want my doctor!  Dr. Nayhan knows me, and that’s who I want!”  He was all riled up, thinking we had pulled a switch on him.

     Zayed went back out, looked at the admitting orders, and sure enough, the patient was admitted to the other service. 

He looked at me, because everything is the intern’s fault.

“Oh, I guess we put him on the wrong list.  Sorry, I‘ll fix it.”

“Fix it and go back and explain it to the patient.  You have to get this stuff right, we can’t be wasting time and getting patients ticked off.  Now that patient is going to complain to Nayhan about the residents, they always do.  And tell Kenna so she sees him.  Go, go right now,” he said, rather disgusted.

     I told Kenna and Jack, and they penciled him in on their list. But thanks to Shahid’s spectacular list mismanagement, they got hit even harder than we did that day. One of the worst blunders a resident can make in the eyes of the attending is to not know about a patient on the service. To be completely unaware that the patient even exists. 

Kenna had run into Dr. Moezzi a little later that morning.

“So what do you think of Mrs. Taylor?” Dr. Moezzi had asked.

Kenna paused, racking her brain for some recollection of a Mrs. Taylor.  She looked at her list.  No Mrs. Taylor.

Tentatively, she questioned, “Who’s Mrs. Taylor?”

     Dr. Adib Moezzi was famous for his temper tantrums.  He had been practicing at the hospital for about eighteen years.  He had finished his residency here, then joined and eventually took over the practice of one of his attendings.  He was the surgeon who screamed and yelled at people, threw things in the OR, and tried to bully and intimidate everyone.  He was about five feet two inches tall, and he had trouble intimidating some of the OR staff.  The ones who had been around forever and remembered him as a resident just didn’t take his tantrums seriously, which was a major source of irritation and profound frustration for him.  He was always trying to get someone fired. 

     Moezzi immediately went into one of his tantrums, outraged that this patient had been admitted twelve hours ago, and his residents had no clue.  He had no sense of empathy or understanding.  There was not a sympathetic, forgiving bone in the man’s body.

“When I was a resident, we managed forty or fifty patients, because everyone stayed.  If you had a hernia fixed, you stayed for a week.  We never lost patients.  How is it that you don’t know about this lady? Let me see your list.  Look at this, you have eighteen patients, and you can’t keep track of them?”  Then he was off to the program director to complain about the lax standards of today’s residents.

     As the saying goes, shit rolls down hill.  Kenna called Jack for an explanation, who said he was sorry, he hadn’t known about the patient either, he didn’t know what happened, but he would go see the patient and report back to her.  Then Kenna talked to Shahid, who was down on the ortho floor trying to convince some total hip replacement patient to get up and walk.  Shahid found it very frustrating that patients didn’t just blindly follow his instructions.  He was the doctor, after all.

     Shahid had thought he put the patient on the list, but somehow it must have been deleted.

“Did you sign the patient out to Jack?” she asked.

Well, no he hadn’t, because the patient wasn’t on the list, so he did not tell Jack about her at all.

“Okay, Shahid.  You forgot to put one patient on the list, and you put another one on the wrong list.  This is probably the simplest task that you need to accomplish all day.  You have to get this straight, we rely on that information.” She continued to point out all the ramifications of this error, expecting Shahid to say something about understanding this and that he would do better.

“Well, basically, it would not be correct to say I forgot the patient.  It was somehow deleted from the list, perhaps when Jack tried printing it,” he responded.

“Whatever, Shahid. It can’t happen again, okay,” she responded in an increasingly irritated manner.

“Yes, I will talk to Jack about being more careful about deleting things from the list.”

“No,” she cut him off.  “I am talking to YOU about getting the list right.  Just get it right, it’s not that difficult.”  She walked away before he could get in anything else.

     Surgery interns and residents generally did not try to make excuses and blame other residents or colleagues for errors.  There was an understanding that a resident had a scope of responsibilities, and that resident was accountable for any and all mistakes within that scope.  Kenna’s responsibility was to run the service, so when Moezzi chewed her out for not knowing about the patient, she took the beating and didn’t offer lame excuses that it was the intern’s fault.  She took responsibility, knowing she would find out why and fix the problem.  Jack was supposed to have a correct updated list, so he didn’t immediately whine that it had to be Shahid’s fault, though he knew it probably was, because this was not the first time we had found patients that Shahid had not told us about.  You couldn’t take these reprimands personally, you just needed to suck it up and fix the problem.  Period.  No whining, no excuses, no blaming everyone else.  If attendings were mad about something, the chiefs generally took the blame for the senior’s or intern’s error, then appropriately and privately found the responsible senior resident and whipped them into shape.  The seniors then hammered the appropriate intern, and everyone learned about responsibility and supervision.   

     The chief resident is the top of the resident chain of command.  By the time a resident became chief, they had earned the right to operate nearly independently, challenge the attendings’ decisions, have their opinion asked, possibly even respected. 

     Ann Coleman, my chief, was the first woman to ever be accepted at this program.  General surgery still remained a male-dominated field, but this program was rather late in admitting women.  The year she started her internship was 1988, and by that time the idea of women as surgeons was widely accepted.  Early on, women could be accomplished surgeons but had to hide their identity.  Dr. James Barry was an acclaimed Army surgeon, serving in the Napoleonic War then practicing up until his death in 1865.  At burial, “he” was found to be a woman!  In 1849, Elizabeth Blackwell became the first women to graduate from medical school in the United States.  In 1913, the American College of Surgeons had one female member.  By 1949, there were five board certified female surgeons in the country.  In the seventies, medical schools saw a huge increase in the number of women applicants, and they made up about twenty percent of graduates.  Today, women make up fifty-two percent of medical students, and dominate the fields of family practice, pediatrics, and some of the internal medicine specialties.  Within surgery, men still far out-number women.  But some of the surgical sub-specialties, like obstetrics and gynecology, now are predominantly female.  Out of about 102,000 practicing surgeons in the United States, there are about 4000 females, but the percentage goes up dramatically in the younger population. 

     However, even during my internship, there continued to be programs here and there with no women surgeons on faculty.  At St. Mary’s Hospital, they had one female attending general surgeon, and she left very shortly after I started, so all my mentors here were men.  Yale had some female attending surgeons.  Female residents tend to be drawn to programs with a strong female mentorship, so that may be why it wasn’t until 1988 that Ann Coleman became the first female resident at St. Mary’s.  She was the ideal woman for this, because she was smart, technically good in the operating room, even-tempered, reasonable, and very, very competent.  She grew to be very well liked and respected by the attending staff, alleviating any fears of women “invading” the program.  Most of the women in the program were strong, so by the time I came along, the whole sexist/gender thing wasn’t such an issue.  We graduated two chief residents per year, and Marcos Smith was my other chief.    He was also very competent and knowledgeable, overall, a good chief resident.  He had been born and raised in South Africa and had a great accent.  He was going into a plastic surgery fellowship the next year.    

     Both the chiefs turned out to be really good at appropriately shielding the juniors from the wrath of the surgery attendings, or even the chiefs of other services or the medical attendings who were mad at us for one thing or another.  It was a system that had definite advantages for the junior level residents. Residents spent long, long hours together.  It was comforting to know that the people you were spending the majority of your time with would cover for you and help you out.  It fostered a sense of trust between residents, when you didn’t have to worry that everyone was going to run and tattle to the attendings for every little mistake you made.  And as interns, everyone made their share of mistakes.

     Early in my first month, I had written admitting orders for a patient in the middle of the night, including the routine “as needed” orders so the nurses wouldn’t call me every twenty minutes needing something.  As one of the “as needed” orders, I had written for Demerol for pain control, to be administered as an intramuscular shot.  This would have been perfectly fine, except the patient also happened to be on coumadin, a blood thinner, because of her chronic atrial fibrillation.  Ann, Zayed, the medical students and I had been standing in the nurses station on the floor when Dr. Budros approached us, obviously irritated. 

     He paused, looked at the team, then focused on Ann, blurting out, “Have you seen Mrs. Elden’s right butt cheek recently?”

     Ann let out a sigh.  “Yes, yes I have.”

     What the hell are they talking about? I thought.

“Where is the nurse taking care of her?  That was just a stupid thing to do…”

     Ann gently interrupted him, “I’ve addressed this with the nurse, she was following an order, and I’ve ensured the order is off the chart.  It won’t happen again.”

He was clearly mad.  “Who wrote the order?  Why would someone write an order for an intramuscular medication?”

“All the orders are my responsibility,” she replied flatly.

     Dr. Budros was flustered for just a moment, then turned to the rest of us.

“You are lucky you have such a good chief.  She knows I won’t take her head off because she’s a good surgeon and I like her.  And I know damn well she didn’t write that order.  She is not that stupid.  She just saved someone’s butt,” he glared at us.  Then he softened up a bit. 

“I expect the appropriate person will be… educated,” he said to Ann.

“It’s already done,” she assured him.  He left the floor.

She turned to me.  “Dr. Sawmiller,” she started.  Whenever a chief or senior addressed you as Dr. so-and-so, instead of just using your first name, you knew you were in trouble.  It was the equivalent of your mother using your full name, as in “Carol Joanne Carson, why is there broken glass all over the floor?!!”

“Dr. Sawmiller, I would like for you, on rounds, to closely examine the butt of Mrs. Elden.  And I would like for you to remember what an intramuscular shot can do to someone who is anti-coagulated.”

     Shit, I thought.  Oh, shit.  Sometimes, antibiotics increased the effects of Coumadin, a blood thinner.  Elden had been put on antibiotics at admission.  One had to be very cautious about bleeding in anyone on Coumadin and antibiotics.  Mrs. Elden’s level had been too high this morning, so I had actually held her Coumadin dose today, thinking I was pretty darn smart.  But I did not stop the intramuscular shot.

     On rounds, I asked Mrs. Elden to turn to her side and lifted the sheet.  She had a big, ugly, black and purple hematoma the size of a dinner plate on her left buttock.  I gently examined it, and it was firm and tender. 

“Is that pretty sore?” I asked.

“It sure is,” she said.   “That damn shot bruised me something terrible.”

     If a needle happens to stir up a little bleeding from the muscle, it usually just stops.  But with someone on a blood thinner, it may not clot.  It just bleeds and bleeds, collecting in the muscle and fat, until it has bled enough that eventually the pressure of all that trapped blood finally stops the bleeding.  This resulted in a huge painful hematoma for this patient.  After that, I never forgot that intramuscular shots don’t go well with Coumadin.  The patient had a reminder for about twelve weeks, as that big hematoma slowly resolved.  And I also learned an important lesson about leadership and responsibility.  Ann had completely covered for me, protected me from the wrath of the attending.  She easily could have told him I wrote the order.  After that, I felt a sense of loyalty to her and bent over backwards to try to keep her service running smoothly.  Years later, as a chief resident and an attending, or in leadership positions in the military, I always tried to follow that example.  The best leaders in any field take responsibility for their team, rather than trying to place blame for mistakes.  I learned that humiliation and blame have no place on a team committed to its mission.  Among all the officers I served under in the military, the ones I respected most lived by that principle. They constantly led by example, inspiring the people under them to pursue excellence in their daily work.  I have known surgeons, officers in the Navy, coaches and businessmen who never seemed to learn this, and they are always disrespected, sometimes held in contempt, by those who work for them.  Ann expected that we would follow her lead, learn from our mistakes and then provide that same type of leadership as we progressed through the program.   

     Doctors tend to remain protective of other doctors, which is great in a training environment.  The disadvantage to this whole concept, though, is the great difficulty surgeons have in reporting on colleagues who are actually dangerous to patients.  We become so accustomed to protecting one another in the early stages of our training, when it is necessary and makes sense, that later it becomes extremely difficult to abandon that deeply entrenched sense of loyalty to ones’ colleagues.  I guess that’s why there will always be malpractice lawyers and lawsuits and legislation to police and regulate physicians.  We’ve never done a great job of it ourselves.