The Secret Language of Doctors

by Brian Goldman

  The 2011 survey for the American College of Physician Executives found that 27 percent of male physicians had been disruptive—and so had 23 percent of their female counterparts. The presence of women physicians in growing numbers may reduce the number of difficult colleagues as well as disruptive acts, but not nearly as much as some have hoped.

  An unfortunate byproduct of the emergence of women in traditionally male areas of medicine (general surgery, orthopedics and neurosurgery) is abusive behaviour toward female trainees. In his article, Krizek gave a chilling example: a senior surgeon waved a suction device in the face of a female medical student and announced that “he was going to stick the sucker so far up her ass that it would suck out her brains, if she had any.”

  Krizek’s article was published back in 2002. But abuse and disrespect towards women are apparently alive and well today. “We will talk about residents ‘having hypervaginosis,’” says a former senior resident in general surgery. Hypervaginosis is pure slang. Vaginosis is a clinical term for an infection of the vagina. The prefix hyper– means “excessive.” I asked my informant to define hypervaginosis. “Forgive me, but they’re a big pussy,” he replied.

  I asked him what would it take for a resident to get a reputation for hypervaginosis.

  “Complaining, [especially] to someone outside the hierarchy or chain of command,” said the young doctor. “We have a resident who all of us have had issues with because she frequently complains about something to the program director rather than her senior resident or chief resident or someone basically in that chain. We like to think of ourselves as being very hierarchical; even as a chief resident, I would very seldom go to the chairman of the department with a problem.

  “Going outside of that gives you a reputation as whining, as being very complaining, as having a lot to complain about and not respecting that some things aren’t badness. Not expecting that, you are going to have some problems because it’s residency and it’s surgery and it can be very difficult.”

  I asked who came up with the term hypervaginosis.

  “I have no idea,” he said. The former chief resident said he did his medical school at a college in another state. He was sure he had not heard hypervaginosis until he started his residency in general surgery.

  And what does author Dr. Stephen Bergman think about the slang term and its meaning? “I think that’s despicable,” he says. “It’s saying you’re whining because you’re a woman. You know, a pussy is a sort of weak, whining woman. I’ll put it this way. From all my years in the pre-women’s movement and the women’s movement, I have seen the tremendous destruction that kind of shit does. You just don’t do that. We would never have done that. Ever.”

  Disruptive or abusive behaviour has a serious effect on hospital culture. Norman Reynolds wrote that it “demoralizes members of the hospital staff, leads to lawsuits by co-workers, and can create a hostile work environment.”

  It also affects the safety of patients. The 2008 Sentinel Event Alert by the Joint Commission said: “Intimidating and disruptive behaviors can foster medical errors, contribute to poor patient satisfaction and to preventable adverse outcomes, increase the cost of care, and cause qualified clinicians, administrators and managers to seek new positions in more professional environments.” Beginning in January 2009, the Joint Commission required hospitals to develop zero tolerance for such behaviors.

  In his article, Dr. Norman Reynolds concluded that preventing disruptive behaviour is better than having to deal with it on the job. He recommended screening job seekers for prior unprofessional behaviour. More controversially, he explored the possibility of looking for worrisome patterns in applicants to medical school.

  Good luck with that. It’s easy to make new rules to discourage disruptive doctors; much harder to change the culture that bred them. It turns out that disruptive doctors often bring lots of paying patients into the hospital. The 2008 Sentinel Event Alert said that hospital staff perceive that revenue-generating doctors are “let off the hook” for bad behaviour; nearly 40 percent of physician executives surveyed in 2004 agreed that “physicians in my organization who generate high amounts of revenue are treated more leniently when it comes to behaviour problems than those who bring in less revenue.”

  You’ll know the problem is ebbing when doctors and nurses stop inventing slang to talk down their colleagues. So far, that hasn’t happened.

  * * *

  With slang terms like cowboy and flea, it’s easy to get the sense that surgeons, internists, ER doctors and everyone else have nothing in common. Envy and jealousy over money, power and influence are the things that divide us. Still, if there’s one thing that binds us together, it’s those powerful, life-changing traumatic occurrences to which each of us must bear witness. As you’ll see, we have slang for those too.

  13. Horrendomas

  One of the first bits of argot I learned when I was a resident is the made-up word horrendoma. Take horrendous and tack on –oma, the medical suffix for tumour. Pseudodictionary.com defines a horrendoma as “denoting an unusually bad or complicated medical condition.”

  Every profession, every job, every business has a slang word for those times when everything goes wrong. Many call it a snafu, the sarcastic military expression that means “situation normal: all fucked up.” The fact that your life might be on the line adds more than a bit of tension to the mix—and makes the stories my colleagues share all the more spine-tingling.

  Dr. Jay Ross, an anesthesiologist, has another name for horrendoma. “When there is an emergency happening and everything seems to be spinning a little out of control, and there’s not really a sense of what’s going on, we call it a clusterfuck.”

  The phrase comes from the old adage that anesthesiology is “98 percent boredom and 2 percent sheer terror.” Anesthesiologists are responsible not only for delivering anesthesia in the operating room but also for keeping patients safe during surgery. The hallmark of that job is what we call securing the airway. That means intubating (placing an endotracheal tube past the larynx and into the trachea), followed by putting the patient on a ventilator. Any number of obstacles—arthritic neck, congenitally tiny jaw, large tongue, floppy uvula, stiff epiglottis, to name a few—can stand in the anesthesiologist’s way.

  Clusterfuck is a reminder that no matter how well they plan their work, one day a patient will arrive whose airway puts all of the anesthesiologist’s training to the test. That’s what happened to Jay Ross during a night on call as a staff anesthesiologist.

  Ross was called in the middle of the night to the intensive care unit for a patient with bleeding esophageal varices, extremely dilated veins in the lower part of the esophagus. These are most commonly associated with cirrhosis of the liver. The problem with varices is that they can cause massive bleeding in the esophagus, which can cause the patient to go into shock. I’ve seen a patient nearly bleed to death in minutes. That’s bad enough, but the bleeding can be so brisk that it blocks the airway and threatens to suffocate the patient. Ross was called to the ICU that night to secure the man’s airway because the ICU doctors hadn’t been able to.

  “They couldn’t intubate this bleeding person, and now they were calling me,” says Ross. When he opened the patient’s mouth, all he saw was blood pouring out like a fountain.

  “Oh my god, this guy was just spewing blood nonstop,” Ross recalls. “I was having a hard time seeing the vocal cords so I could pass an endotracheal tube to protect his airway. I remember trying every trick in the book. I even got someone to press down on the chest and I looked for the air bubbles through the blood to try to put the tube in.”

  Ross tried one assistive device after another—every toy, as he called them, available to him. Each failed, and the patient’s throat kept filling up with blood. Eventually, Ross was able to provide the patient with some oxygen and buy time for a final attempt to save him by using a device called a laryngeal
mask airway.

  “I know we were certainly pushing blood into his lungs, but there was no choice,” says Ross, who summoned a surgeon to make a hole in the middle of the patient’s trachea called a cricothyroidotomy and pass a breathing tube through the hole. “You could almost feel this audible sigh. You could see the lungs rising. To give credit to the surgeon, I didn’t secure the airway, the surgeon did.”

  Unfortunately, it was all for naught. The patient continued to bleed and went into irreversible shock; he died several hours later in the ICU. “Coming back later and hearing that he’d died was just frustrating,” says Ross. “You put all this energy into trying to save this person’s life, and it was all for naught. Really.”

  What happened to Ross was a clusterfuck because anything that could go wrong did.

  An ear, nose and throat (ENT) surgeon who does facial plastic surgery in the Pacific Northwest calls that sort of thing a Humpty Dumpty for the nursery rhyme guy they couldn’t put together again. He remembers the first time he heard the phrase. “It was actually an orthopedic surgery and I was an intern,” says the ENT surgeon. “It was a pelvic fracture. When they are simple, you just put one plate or one rod through the bone. When you have some high-velocity, high-energy impact, the bones will just shatter. When I got woken up to go to the operating room, my senior resident said, ‘We’ve got a Humpty Dumpty we have to go fix.’ I remember that vividly, because I thought it was kind of smart and not so derogatory. It just kind of illustrated to me what we had to go do. There was a goal of rehabilitation there. That’s why I don’t get turned off by that phrase.”

  Every physician I know has a horrendoma memory or two that keep him or her awake at night. If you have lots of them, your colleagues might begin to refer to you as a black cloud or a shit magnet.

  But here’s the thing. As physicians, none of this is supposed to affect us. And we have a venerable physician named Sir William Osler to thank for that. Osler, one of the founders of modern medicine, first made a name for himself at McGill University in Montreal before heading to the United States. At The Johns Hopkins Hospital in Baltimore, Maryland, Osler became that pre-eminent institution’s first professor of medicine—one of the four founding professors of the hospital. Osler created the first residency-training program for graduate physicians.

  Among Osler’s lasting contributions is a legacy of essays intended to impart his wisdom to the physicians of tomorrow. Aequanimitas is Osler’s most famous essay; it admonishes MDs to maintain an attitude of unflappability that he referred to as “imperturbability.”

  Wrote Osler: “Imperturbability means coolness and presence of mind under all circumstances, calmness amid storm, clearness of judgment in moments of grave peril, immobility, impassiveness, or, to use an old and expressive word, phlegm…. Even under the most serious circumstances, the physician or surgeon who … shows in his face the slightest alteration, expressive of anxiety or fear, has not his medullary centres under the highest control, and is liable to disaster at any moment.”

  Simply put, Osler admonished generations of physicians—including me—never to let patients and their families see us sweat. Today, we call it detachment. But the concept is the same. “There is a long-standing tension in the physician’s role,” Dr. Jodi Halpern, a psychiatrist and philosopher, wrote in an article published in 2003 in the Journal of General Internal Medicine. “On the one hand, doctors strive for detachment to reliably care for all patients, regardless of their personal feelings. Yet patients want genuine empathy from doctors, and doctors want to provide it.”

  Finding the balance between emotional detachment and concern for the patient is the great challenge of modern medicine. Osler lived at a time when disease was the main cause of death, and death was accepted as part of life, even in infancy and childbirth. Today, people are more likely to die in violent circumstances—everything from horrific car crashes to child abuse; these leave their mark on the survivors and on the healers. Such experiences are daily occurrences for modern physicians and surgeons. You would have to be a fool to think they leave no emotional scars.

  I strongly doubt Sir William Osler used, much less invented, medical slang to describe the sad and horrible things that happen to patients that he witnessed as part of his job. But we do. And I would argue that in a perverse, unintended sort of way, we have Osler to thank for it.

  My first horrendoma happened when I was asked for the first time to pronounce a person dead in the ER—a story I told in my book The Night Shift. A woman had left the psychiatric hospital where she was a patient, walked to the nearest subway station, and leaped in front of an approaching train.

  As I approached her body, I realized in horror that her face was pointing at the ceiling, yet her torso was pointing down toward the floor. The speeding subway train had decapitated the woman; the paramedics had arranged her head above her neck to make her appear more human—but they had ignored a rather important anatomical detail.

  I kept my Oslerian composure long enough to complete the formalities. It was only after I left the room and retreated to the emergency physicians’ office that I could allow myself a moment to fall to my knees—giddy, nauseous and sick at heart from the experience. It was weeks before I could close my eyes without seeing the woman’s absurdly placid face.

  For nearly twenty years, I was angry with the paramedics who had me pronounce the woman without pulling me aside and telling me what I was about to witness. But, more recently, I began to feel bad for them. Did anybody warn them what they would find when they retrieved her body from the tracks?

  Morgan Jones Phillips, one of the most passionate and articulate paramedics I’ve ever met, knows more about such horrendous incidents than I would ever want to know.

  “How many jumpers have I done?” Phillips asks. “I’ve probably done ten in eight years. We have something called Code Five; it means that they’re obviously dead in a way that means you should not try to help them.”

  Phillips says Code Five means the paramedics do not have to begin life-saving procedures such as CPR and defibrillation. It usually has one of several outcomes—each a horrendoma. There may be a body with no pulse to feel and obvious signs of death such as rigor mortis, dependent lividity (a blue or purple discoloration in the body where blood has settled), or a rotting appearance and smell of putrefaction. The body may be burned beyond recognition.

  A Code Five also refers to instances that are almost too horrific to describe. The body might be split in two across the torso. Or, like the woman I pronounced dead in the ER, the victim may have been decapitated. Phillips remembers a victim like that—a story he describes as an Ugly Code Five.

  “He was actually quite a thoughtful guy,” Phillips says with a tinge of detached sarcasm, marvelling at the pains the jumper took not to be an inconvenience. “He had gone into the subway at the end of the night, at closing time. He hid at the end of the platform and waited for the night car that drives through the stations to collect the garbage. Just before the car entered the station, he jumped down off the platform, stuck his head out and rested his neck across the tracks, and the train ran over his head.

  “In situations like that, the patient is the poor guy who’s driving the garbage car. The driver shouldn’t, but he’s going to feel like he’s killed him and is going to have to deal with that. In that situation, he becomes our patient.”

  For paramedics like Phillips, the most disturbing on-the-job memories are those in which the victim—while undeniably dead—looks unharmed. Such victims do not meet the strict criteria for a Code Five, which means paramedics must attempt to rescue them, even though it’s obvious they are dead. Phillips recalls one such man, also a subway suicide.

  “We had to do everything, but he was under a subway train,” Phillips recalls. “My partner and I crawled under the car, feeling terrified. Then we got him out from under it. And when we tried to move him, it was obvious that every bone wa
s broken. He wasn’t even bleeding. We picked him up by the arms and legs, but there were no bones to speak of at all. Everything was just sort of crushed.”

  Despite the fact the man did not meet the tight requirements of a Code Five, Phillips said he and his partner contacted authorities and received permission to pronounce the man dead in the field. To Phillips, the most disturbing part of the story was that the man appeared well enough to get up and walk away, despite the horrific way he’d met his death.

  How paramedics like Phillips cope with horrendomas like these is a matter of great concern. Studies have shown that paramedics have a much higher prevalence of post-traumatic stress disorder (PTSD) than the general population. PTSD is a severe anxiety disorder that sometimes occurs following a psychological trauma. The trauma can be a threat to your own life or your witnessing of a threat to someone else’s life. It can lead to chronic anxiety, depression, substance abuse, marital breakup, loss of employment and suicide. Although Emergency Medicine Services have implemented programs aimed at early recognition and treatment for paramedics, the culture of paramedicine often promotes a pattern of denial among working paramedics—perhaps yet another of Osler’s legacies.

  Some paramedics like to talk about traumatic calls, but most, like Phillips, prefer to keep those memories to themselves.

  “I’m sort of a suppress-and-move-on kind of guy,” he says. “I’m not saying it’s healthy or correct, but I don’t even really talk to my wife about the bad calls.”

  * * *

  You never hear physicians talking about PTSD unless it’s about a patient with the problem. The thing is, we’re just as susceptible, yet we don’t believe it can happen to us. But consider this: what surgeons and ER docs see every day would probably cause PTSD in most people. Unlike paramedics, doctors like me seldom have to scoop up dead bodies. But we do have our moments when we encounter cadavers as part of our medical studies and later as part of our work. And, earlier in the history of medical education, dissecting a cadaver in anatomy class and the first autopsy were often made into highly ritualized experiences for budding physicians.