“The problem with incompetence is its inability to recognize itself.”

Orrin Woodward, New York Times bestselling author

Nearly three weeks had passed, but I felt like I had been a surgery intern for about ten years.  Jed was getting used to me coming home late and had stopped asking me what time I thought I might get home.  I never had any estimate that turned out to even be close to accurate.  He had started work at the bookstore, so he had reasonable, predictable hours.  I started out calling home if it was getting late, but this seemed to cause more problems for me than it solved.  I would have a few little things left to do on my list, so I would call and say something like ”See you in about half an hour”, and end up home two hours later.  Something was bound to turn up that needed done.  By the time I finally got home, Jed was unhappy, I was tired, and we had the same discussion about how I couldn’t just leave at a specific time.  This wasn’t a job where I worked a shift and came home.  I stayed until everyone was tucked in and taken care of.  This was very hard to explain to someone outside the field, who couldn’t understand why I just didn’t turn over all the work to the intern on call for the night.

     I had one more week left on the Red team, then would switch over to Blue.  I was a little nervous about the switch.  I had the Red Team attendings all figured out.  Budros was quiet, meticulous, a perfectionist.  He was very consistent, both in and out of the OR.  A resident had to work hard to earn his trust, but once he trusted you, he would invest a great deal of time teaching.  His partner, Dr. Trevino, was the opposite.  He was loud, operated fast, and let residents do a lot of the surgery right from the beginning.  Their newest partner, Phil Adams, was a Dr. Jekyll/Mr. Hyde.  Out of the OR, he was funny, pleasant, a real cool guy.  Once in the OR, he became an uptight, nervous, tense idiot who would suffer a complete meltdown over the most insignificant details.  I had been retracting the abdominal wall while he was doing an appendectomy on a pretty big guy when my retractor slipped, and it caused him to rip the suture he was tying right through the appendiceal artery, so it bled.  It squirted for about six seconds, losing a tiny amount of blood.  He just re-grabbed it with a clamp and retied it, but he went completely berserk, like I had punctured the aorta or something.   Dr. Davol was an older surgeon, one who should have retired a year or two ago.  He didn’t see all that well, and had developed a tremor, but continued to do big cases.  For big cases, two residents always scrubbed with him, because he often couldn’t finish a case on his own.  The rumor was he could never retire because several divorce settlements had taken every penny he had ever saved up and he still had alimony payments to previous wives.  They made up the busiest part of the Red Team.

     I had heard that the Blue Team attendings were a bit more eccentric.  Shahid had been scheduled to come to the Red team but had so many problems on call that someone made the decision not to let him on a general surgery service just yet. He would be going over to urology, and Jack would take over my Red service.  Shahid needed a little more time on an easier service, taking care of less critical patients, before he was ready for the general surgery service.  This is how Dr. Kaczanek explained the schedule change to us, but the word in the OR was that the three busiest Red Team attendings had approached Sanders and told him they would not allow Shahid to take care of their patients.

“So I get screwed out of my easy month.  Damn him and all his bungled-up orders.  He probably is a genius, and his whole plan is to spend the year looking incompetent, so he never has to do any hard rotations,” Jack griped.  But unfortunately, no one believed Shahid was a genius.  We were beginning to wonder if he had an actual diagnosable learning disorder or personality disorder or some combination of the two.

     He made the big mistake, right around this time, of pissing off Kenna.  He had been on ortho about three and a half weeks and already had a lengthy list of complaints from the PA’s and nursing staff.  At least twice a week, someone was in the Surgery Department office voicing a complaint about something he did. He was condescending to the PA’s, who knew more about orthopedics than he did.  He wrote stupid orders on patients, then would not admit he made a mistake, and would argue with the nurses.  He was mean to the nurses, he didn’t get the correct paperwork done, he was behind on his medical records, the list went on and on.   

     The big problem started on a night on call, with Kenna as his senior back up.  He ended up seeing a patient in the ER that needed to be admitted for a possible bowel obstruction.  This was very routine, and shouldn’t have created any problem.  Instead of calling Kenna for this patient, Shahid had gone to the SICU and found Tad.  Tad told him to admit the patient and let Kenna know about it.  Tad didn’t go see the patient, he thought Shahid would call Kenna, and she would come see the patient and take care of it, as was the usual routine.  As it turns out, Shahid never called Kenna, but just admitted the patient.  He signed it out to Jack the next morning.  Shahid described the patient, who was an elderly man who had noticed blood with his bowel movements for about a month.  He then developed progressive abdominal pain and distention, and had not had a bowel movement or passed any gas for two days.  He had come into the ER around eleven pm, and surgery was consulted around eleven-forty-five.  Shahid reported that the guy’s CT scan showed a possible small bowel obstruction.  Jack, now accustomed to double checking all information obtained from Shahid, sent the medical students down to get the CT scan. 

     I was up on the floor waiting for Zayed when Kenna showed up to round with her team.  Jack mentioned the new patient, and that the students were bringing the CT scan up for them to see.  Kenna immediately freaked out.  She knew nothing about this patient.  Poor Jack had assumed she knew about him, since she had been on call. 

“How the hell does a patient get admitted to my service during the night when I am on call without my okay?!  Where did they come from?  This is not acceptable.  This is not acceptable,” she ranted as she quickly reviewed the chart. 

“He came through the ER,” she uttered with disgust. “There’s his H&P and orders.  God damn it, he never called me on this.  Get his ass up here right now.  Right now!  I don’t care if you have to drag him out of bed from across the street, get him here now.”  

     She wouldn’t even say his name, but we all knew who she meant.  Morning rounds came to a screeching halt while Jack paged Shahid to get him up to the floor for an explanation.  She quickly saw the patient and reviewed the CT while waiting for Shahid to arrive on the floor.  The patient actually had a complete colon obstruction evident on CT.  His proximal colon was hugely dilated, with what looked like a mass in the sigmoid colon.  His CT and story were pretty classic for an obstructing colon cancer.  He would have done better going to the OR right away.  So now Kenna was in the position of explaining to the attending why we admitted a patient with a complete colon obstruction without telling him, let the patient sit on the floor overnight deteriorating, and now wanted to rush the patient to the OR.  She was very, very unhappy.  Shahid had a peculiar way of digging himself deeper and deeper into his own grave in these situations.  He came up to the floor to talk to her and began by telling Kenna that she had no need to raise her voice, and that he would explain everything if she could just calm down. 

     For a moment, I thought she was going to rip his tongue right out of his mouth.  After a rather unpleasant lecture on the hierarchy of the residency program and pointing out that she was the senior resident and he was the intern, they moved back to the real issue.  I could see things were getting ugly, so I dispersed the medical students to collect vital signs and start some dressing changes.  Shahid explained that he had the situation under control, and he had run it by Tad, who had agreed they should admit the patient.

“Is Tad your senior resident?  Does anyone give a shit if Tad thinks you should admit the patient?  Is he here doing rounds to take care of this mess?” she snarled.

“There is no mess, the patient is fine,” he mumbled.

     The thing I liked about Kenna was that she very rarely got flustered or upset or emotionally unstable during her tirades.  She chose her words carefully and was usually completely correct in principle, though maybe more brutal than the rest of us would be.  She calmly instructed Jack to start rounds.  He was more than happy to leave the area. 

“This is going to occupy me for a while.”  She turned back to Shahid.

“What do you think is wrong with the patient?” she challenged.

“Well, basically he has a partial obstruction of his bowel that maybe will get better with basically conservative management.  He has an NG tube in…” he started to answer.

“Did you look at the CT scan?  He has a COMPLETE colon obstruction!  There is a mass sitting in his sigmoid colon with no air beyond it.  His colon is so dilated it’s about to burst.  This does not get better by itself.  It gets worse, then the colon ruptures, the patient gets septic and they die.  It is obvious enough that a first-year student could make the diagnosis, but even if you are so incompetent you are unable to interpret the scan, the radiologist’s reading is right there on the chart, you could have just read that.  He needs an operation, last night!”

“I had the situation controlled.  You didn’t need to be called, I discussed this with Tad,” he stammered.

     She leaned in close to him, her forehead brushing his, and informed him very bluntly that he would not be making decisions about when it was necessary to call her.  He was to always call the senior.

That’s when things got really, really bad.

“I know to call the senior, but I am accustomed to Zayed or Grant being on call.  I just really prefer to discuss cases with the male residents, and we did have this situation under control,” he said.

     Even if he felt that way, I couldn’t believe he was stupid enough to say it, and to Kenna of all people.  He may as well have pulled out a long sharp knife and plunged it directly into his own chest.  He was of Middle Eastern descent and had been raised and gone to medical school there, so he very well may not have been all that “accustomed” to having women in positions superior to him, but to come right out and make that statement was obviously an egregious error.

     She looked at him blankly for a minute, as if trying to digest what she had just heard.  She asked for clarification, not quite believing what she had heard. 

“I know you have your opinions about things, but I feel this patient was well taken care of and it was not necessary to wake you up.  I am simply more comfortable with having supervision from physicians that are not of your particular gender, and I am usually on with Zayed or Grant, so it has not been any problem.  I am sure we can continue to work together…” that’s all he got out.  I think he realized Kenna would not really find this explanation satisfactory, but he seemed to think he might be able to get away with it by using that strange, indirect phrasing “not of your particular gender”.  Like she might not recognize the fact she had just had her competence and intelligence questioned because she was a woman.

     Kenna momentarily forgot about the colon obstruction and let loose a tirade so venomous that the entire nurses’ station cleared.  Even the housekeeping staff backed quietly down the hall.  She was a good six inches taller than him, and stood about a foot away, towering over him, like a lioness about to devour its prey.  I shrank back into the wall, trying to act like I was still going through my charts, not quite sure what to do.  Do I slip out?  Do I stay and keep looking through my charts, like nothing is going on?  Where the hell was Z, so I could go round?  Once she got on a roll she just kept going.  And it undoubtedly made for very interesting listening.  Later I would need to give a detailed account to Jack and Stuart anyway.  Even though he was down at the University, I knew Stuart would hear about this somehow and page me within the hour.  So I settled in to become a spectator to this merciless slaughter, at least until Zayed showed up and we started rounds.

“You know what?” she started.  “I don’t give a fuck what you are comfortable with or accustomed to.  You are an intern, and you are going to call me every time you see any patient when you are on with me.  Not only are you going to call me, you are going to give a detailed report, and you better have every fucking detail right, and you are going to do exactly what I tell you to do!  You think I am going to let some intern from some back ass country tell me I can’t supervise him because I am a woman?  Are you stupider than we all think?!  Do you realize you are in America?  Do you see any women around here, cowering in subservience, walking ten feet behind the men?  Look around you!”  She continued along that line for what seemed like an excruciatingly long time.

     Shahid tried to utter some sort of response, which was futile at this point.  Beads of sweat collected on his forehead, and he kept nervously clearing his throat.

“And it’s not like you are even marginally competent.  You have done nothing but screw up since the day you started, and you dare to even think I am not fit to tell you how to take care of patients?  This is unbelievable.  Truly unbelievable.  Do you have any clue how bad you screwed up?  This man needed an operation last night, and you still just don’t get it.  This guy may die because you screwed up, you didn’t make the right diagnosis and you don’t have any fucking idea what this guy needs.  You really don’t get it.”

     I spotted Zayed coming around the corner and met him by the first room.

“Oh, my God,” he shook his head, hearing the commotion from the nurses station.  “What’s he done now?”

     I brought him up to date on the situation, and he chuckled. 

“He told Kenna he wouldn’t call her because she is a female?  Oh, my God, he likely won’t survive this.  Look how mad she is.”  He shook his head and chuckled again.  “That was not a smart move.”

     We did our rounds, pretty much able to overhear most of what went on between Shahid and Kenna.   We finished our patients and sat down to write the progress notes, and they were still there.  Shahid looked like a beaten puppy, and Kenna appeared to be at a point of complete frustration, almost at a loss as to what else to say.  The conversation finally ended with Kenna declaring that she had no more time to waste trying to educate an incurable moron and dismissing him.  He left the floor, not making eye contact with anyone.  Kenna picked up the phone and dialed Dr. Moezzi at home.  Of all the attendings, it had to be his patient.  He was always completely unreasonable. 

“Hi, Dr. Moezzi, sorry to call you so early, but we have a little problem,” she started.  “We have a guy who probably needs to go to the OR sooner rather than later.”

     She presented the patient, stating that he had come in and it looked like he had a mass obstructing the sigmoid colon.  She was very vague about when he came in, and said she would get him to pre-op holding.

“No, we aren’t in the ER, we are up on the floor,” she responded to his question.  A pained expression overtook her face.  She had been hoping to remain vague about the time of the admission, and the fact that he had been sitting on the floor all night going into renal failure and getting more hypotensive and acidotic as the hours went by.  But Moezzi was going to persist with the questions.   She went on to explain that he had been admitted early last night, but no one had really addressed the fact that he had an obstruction and was not making adequate amounts of urine and had all the signs of a patient becoming septic from a colon obstruction.

     She held the phone away from her ear, and I could hear Moezzi bellowing from where I sat.  He was undoubtedly giving her a lecture about knowing the patients on the service and not slacking off and being irresponsible.  She finished up with him, wrote orders on the chart to get him ready for surgery, and paged Marcos, the chief resident on the service, to let him know this case would be going first.  She would get the same lecture about responsibility for the patients and needing to always know what was going on with the service from Marcos.  It would likely not be quite as unpleasant.  At the first possible opportunity, Moezzi would find Marcos and go on about how this never happened when he was the chief on a service, and he would talk to him about running a tighter ship and doing a better job of teaching and managing the junior residents.  Eventually, Moezzi would end up in Sanders or Kaczanek’s office, complaining that the residents were trying to kill patients again.  Then we were all in for a refresher lecture on responsibility.  The cascade was in motion, there was no stopping it. 

     Zayed gave Kenna a supportive pat on the back as we left.

“C’mon, Moezzi is happiest when he has something to be pissed off about.  He’ll get over it,” Zayed consoled her.

“Z, I really think I may kill him.  Actually kill him.  It’s the right thing to do, to protect society from his incompetence.  I still think he doesn’t see that he did anything wrong,” she responded.     

“It’s not worth going to jail.  He’s a prelim, he’ll be gone in 11 more months,” he said as we headed down the stairwell, leaving her to take her next beating from Marcos.

Moezzi got over it fairly quickly, as he always did. It helped that the patient ended up doing well. The next time Shahid was on call, there were only a few minor mishaps—small issues Jack and I managed to fix before the seniors noticed. As usual, Shahid did not seem to understand that it was in his best interest to keep a low profile for a while and avoid creating more problems. The following week, he put the final nail in his own coffin.

     Kenna had been at home for about an hour, and it was about eight pm.  She heard a knock on her door.  She opened that door and there stood Dr. Shahid Hasani, with a textbook in his hand.

She stared at him a moment, a little stunned to see him.  She knew he lived in the same building.  The hospital owned the apartment building across the street, and several of the residents lived there, because they could get such a good deal on rent.  It was close and cheap, so worked out well. 

“Shahid, is there something I can do for you?” she finally asked.

He paused, then asked if she wanted to have coffee and study. 

(“Like we were little college freshmen on a study date or something.  Like I hadn’t just told him he was a worthless moron less than five days ago,” she exclaimed as she told me the story later, laughing hysterically.)

He stood there silently, waiting for an answer.

Her answer was another question.

“Shahid, how did you know what apartment I live in?”

“Well, basically, I knew you did live here, as many of us do, and I saw you coming across the parking lot the other day, so I just came out and saw that the elevator stopped one floor above me, and as it turns out, I live directly below you.  My apartment is 614, and you are 714,” he explained.

(“It was just creepy.  He actually stalked me, watching me from his window, watching the elevator go up, then running up the stairwell and peeking out to see which apartment I went into.  It’s just unbelievable.  As if it’s not enough that I be tortured daily at the hospital, but now he lives underneath me, listening to every step I take.  Oh my God, he probably knows when I am taking a shower,” she shuddered as she related the details.)

Kenna made no response to Shahid, and he again inquired about the coffee and studying.

“No, no.  I really don’t study with other people,” she said.

He waited a minute, as if he was expecting to be invited in.

“So, I’ll see you at the hospital, Shahid,” she prodded.  No response.

“Goodbye, I’m closing my door now.  That’s your clue to go back downstairs, and not come back,” she said bluntly.

“Okay, well if you ever want to have coffee or something, I’m right below you,” he stated as she was closing the door in his face.

“Carol, what is wrong with him?  I thought he was maybe just having some trouble because he’s a new intern, that maybe he would improve a little, but he is totally clueless.  Not just about surgery and medicine, but about life in general.  He really has something very wrong with him,” she said with an expression of bewilderment.  “It was all just so absurd that it’s funny.  All I can do is laugh, because it’s just so ridiculous.”

     She was convinced from this point on that Shahid lacked the capacity to understand reasonable thought, but she never stopped trying to pound it into his head.