Residents can’t become surgeons unless they do surgery—and everyone knows it. But residents aren’t as proficient as attending surgeons—and everyone knows that, too. And yet at every training center in the United States residents do cases; and at every training center in the United States administrators continue to proclaim, “Patient care comes first.”
I was sitting in the front seat of Chris Pfeffer’s Olds drinking a Grain Belt. It was 11:45 P.M. Hockey had ended fifteen minutes earlier. Chris was a fourth-year ENT resident who had played college hockey at Harvard. He and I usually had a few beers together in the parking lot before heading home. The engine was running and the car was just starting to warm up. We were talking about residents doing surgery.
“I feel like a hypocrite,” I told him. “If I truly believed the system was wrong, I should have refused to do any cases these last four years. I should have insisted my attending do every case. Why didn’t I have the courage to admit that the attending was a better surgeon than I, and that the patient’s right to care was greater than my right to learn? Where were my scruples then? Hell, I did every case I could.”
“Me, too,” Chris said. “Still do.”
“You know what’s funny?” I said. “Now that I’m in my last year, I actually don’t do every case I can. I’ve already done so many hip and knee replacements that I don’t need to do any more. I let the younger guys do them.”
Chris took a long pull on his beer and laughed. “I get it,” he said. “As long as you don’t feel competent doing a case, you do it; but as soon as you get good at it, you turn it over to your junior resident.”
“Yeah, what a system. It guarantees that all cases are done by the least competent person—a kind of medical Peter Principle.”
“You think too much,” Chris said, yawning and tossing me another beer. “You and I don’t make the rules. We’re just a couple of fucking Zambonis riding up and down the ice. We go where we’re pointed. Someone else is at the controls.”
“That doesn’t mean it’s right.”
“Jesus, Mike, get off this ‘right’ stuff will you? Do you want to leave here after four years never having done a case?”
“Well, no.”
“Then shut the hell up. Leave it to BJ and the other big shots to figure out all this other shit. How can Chris Pfeffer and Mike Collins sort it all out? Hell, we have enough trouble trying to live on the two-fifty an hour they pay us.”
As I drove home that night I wondered if I was being too hard on myself. I turned cases over to my junior resident and taught him, just as my senior residents had turned cases over to and taught me. That was how we learned. But what continued to gnaw at me was the suspicion we ran a system good for us under the guise of being good for the patient.
“A little more anteversion. See how I’ve got the tibia pointing straight up and down? You want the femoral component to be angled just a bit more that way.”
I was guiding Alan through his first total hip replacement. He had watched me do several cases, and was familiar with the technique. I had gradually let him do more and more. But this was the first case I let him do it all, “skin to skin.”
He was nervous, and wanted my input at every step. That’s fine, I thought. I’d rather have someone too cautious than too cocky. When the femoral component was cemented in, Alan reduced the hip and put it through a range of motion. Then we set the leg on the Mayo stand and began to close. I could see the relief in Alan’s eyes. The hard stuff was over.
“Great job,” I told him.
“Very nice, Doctor,” Gladys the scrub nurse said.
“Gee, Alan, you must be good. Gladys never says that to me.”
“I do, too.”
“You do? Then does that mean you think I’m as good as Dr. Coventry?” Everyone knew she worshiped Dr. Coventry.
“Never!” she said immediately. “None of you are.” She slapped a hemostat into my hand.
“Not even Jack Manning?” I asked as I cauterized the bleeder.
“Phhht,” she said. “Dr. Manning.” She spat out his name, but it was all part of the game we played. She loved Jack, but she hated the way he teased her about how he was going to be the “next” Dr. Coventry.
The post-op X-ray looked great. I had the techs make an extra copy for Alan. Gladys, Nita the circulator, and I all signed it for him.
Alan and I had been working together for a month and things had been going well. I was at home changing the oil in the Battleship when Patti told me Alan was on the phone. We were on call that weekend. That meant Alan would initially handle any injuries or consults. He would call me if he needed help or advice.
“Mike,” he said, “I’m in the ER. We’ve got a sixty-two-year-old lady with a mid-shaft femur fracture, an open Colles, a fracture-dislocation of the ankle, and a shitload of belly and head trauma.”
“Car crash?”
“No, attempted suicide. She jumped out a window.”
Suicide. We didn’t see much of that in Rochester. I asked if she was stable.
“Not really. Her pressure is sixty or so. The general surgeons are taking her to the OR now. They said we can do our part when they’re done.”
I told Alan I would be right there. I finished filling the Battleship with oil and drove to the ER. Alan introduced me to the family. The specter of suicide lay all over them. They were by turn embarrassed, apprehensive, angry, and hurt. Apparently she was an alcoholic and had brought more than her share of trouble to the family. I found it hard to tell if they were more upset that she attempted suicide or that she failed. They didn’t seem terribly interested in what her injuries were or what we were going to do about them.
It was almost 5:00 P.M. before the general surgeons finished exploring the belly. They removed her spleen and repaired her liver. It was ten by the time Alan and I had rodded her femur, plated her ankle, put a lag screw across her talus, and externally fixed her distal radius. We took her to the ICU where she promptly coded. She died an hour later.
I went out to break the news to the family. The waiting room was empty. They had all gone home.
What a waste, I thought. What a total waste.
I had worked so hard to put her back together. I wanted everything to be perfect. I made sure we got the correct rotation and length of the femur. I made sure we got an anatomic reduction of the lateral malleolus. I made sure we avoided devascularizing the talus. I made sure we put the ex-fix on the radius just right. Her post-op films looked great.
Yeah, I thought, she’ll have the best-looking X-rays in the morgue.
Sitting there alone in the doctors’ locker room, head bowed, hands in my lap, I found it all so pointless. I had used all my skill and training to fix a lady whose family didn’t care about her, who didn’t care about herself, and who only lived for one hour.
I tried to give myself the usual pep talk: you do the best you can. What happens after that is beyond your control. But pep talks weren’t working that night. It was one of those nights when everything seems absurd, when everything seems so laughably presumptuous. What difference would it have made if she had lived another day, another year, another decade? In the end nothing would change.
I’m an orthopod, I thought. I fix things. Big deal. Everything I fix winds up in a coffin anyway.
Chapter Thirty-Seven
March
As our fourth Minnesota winter dragged to a close, I was starting to feel comfortable as the chief resident. I loved having my own service. It was almost like being a real doctor. But being chief resident also meant being a little schizophrenic. The younger residents thought of me as an attending surgeon. They constantly came to me for advice, wondering how to treat this or repair that. But the attending surgeons still thought of me as a resident, a convenient place to dump things. As elsewhere in life, that brown stuff kept flowing downhill—and I had to be there to catch it all. Every goofy case, every undesirable consult, was shunted to the chief resident.
I was sitting at
breakfast one morning when Charlie Norrie sat down at our table. Charlie had been the junior resident with me on Antonio Romero’s service. He was a hardworking guy from Gary, Indiana, and a lifelong White Sox fan.
Charlie didn’t want to talk about the Sox today. “Mike,” he said, “I have a consult for you.”
Frank Wales, who was sitting next to me, clapped his hands. “A consult for the chief resident,” he said. “This’ll be good.”
“Screw off, Wales,” Bill Chapin said. “Quit trying to rain on Collins’s parade. Charlie’s consult is probably from the head of IBM who needs a total hip. Mike’ll do the hip and the guy will be so grateful he’ll buy Mike a plane ticket around the world. Isn’t that right, Charlie?”
Charlie frowned and said, “Well, no…not exactly.”
“Let’s hear it, Charlie,” I said.
He cleared his throat and looked at the notes in front of him. “The patient is a well-developed, well-nourished fifty-six-year-old white female librarian who presents with a chief complaint of—”
“Charlie, save the medical bullshit for the fleas. Just tell me what you’ve got.”
“It’s a lady with an infected knee.”
I groaned.
“For the sixth time.”
Chapin and Wales were nudging each other, snickering. Frank slapped me on the back and said, “Ain’t this the dad-gumdest, most perfect chief resident’s case in the history of the Mayo Clinic?”
I was used to strange consults. I began telling Bill and Frank about a consult I had seen the month before on a man with shoulder pain. The routine at Mayo is for the junior resident on call to see the consult the night it comes in. He presents it to the chief resident who sees it the next day.
It turned out, though, that the gentleman with shoulder pain was a bigshot lawyer from Philadelphia who wanted everything, and wanted it immediately. As soon as he was admitted to the hospital he started complaining. His room sucked. The hospital sucked. The nurses sucked. They brought him his dinner and (surprise!) it sucked, too, so he dumped it on the floor.
Finally the nurses couldn’t put up with him for another minute. Annie Cheevers paged me. She said the man had refused to let the junior resident come in the room. “Please,” Annie said, “could you see him tonight? I’m afraid he may hurt someone—and if not, someone here may hurt him.” Annie had done me a lot of favors over the years so I told her I would come right over.
It was about ten o’clock when I got to St. Mary’s. His Eminence was sitting on the edge of his bed, fully dressed. He had refused to put on a hospital gown. He was tapping his foot on the floor, looking at his Rolex. I didn’t even get a chance to introduce myself before he said he’d been waiting for three hours and what the hell did I mean keeping him waiting so long?
I apologized and told him consults usually weren’t seen until the next day. When I introduced myself as the chief resident, he was outraged. He didn’t want “some piece-of-shit resident.” He wanted the chairman of the department. There was nothing I would have liked more than to call Big John Harding at home and tell him to come in. Or better yet, BJ Burke. I would have given anything to see what BJ would say to this gentleman.
I began to take a history but the man wouldn’t answer my questions. He got up and began pacing around the room. He said his shoulder had been hurting for over a month. He was tired of it. It felt like Son of Sam was sticking giant daggers in his shoulder every minute of every day.
“Do you understand what I am saying, Doctor?” he said.
I was trying to remember who Son of Sam was. I knew he didn’t work for Mother Teresa but I couldn’t remember if he was a murderer, or someone from Nixon’s cabinet, or who the hell he was.
Suddenly the patient strode across the room, slammed his hand down on my left shoulder, and began digging his fingernails into my skin. “Do you feel that, Doctor Whatever-your-name-is? Well, that is what I am living with every minute of every day, and I want it taken care of. Now!”
Pain shot through my shoulder as he continued digging his nails deeper. His jaw jutted out, only three feet from my clenched right fist. In a setting other than a hospital room I might have responded differently. But retaining my professional decorum, I yanked his hand off my shoulder, got to my feet, and stared him down.
“I am going to leave now,” I said slowly, “but before I leave I am going to instruct the nurses to treat you with courtesy and respect. I expect you to treat everyone in this hospital in exactly the same manner.”
I went out to the nurses’ station where Annie Cheevers had a cup of coffee and some chocolate-chip cookies waiting for me. “Annie,” I said, “after what I’ve been through I need a bottle of Valium.” Annie thanked me and then told me to be sure I ordered the world’s strongest sleeping pill for him.
At this point Frank Wales interrupted my story. “That’s it,” he said, slamming his palm on the table. “That’s more than any man can be expected to take. It’s obvious what that feller needed was TPW.”
We all looked at him. “What?”
“It’s an old Wyoming folk remedy. We used to use it at home on recalcitrant cases.”
“What is it?”
“TPW,” he said, slowly nodding his head. “Therapeutic Pistol-Whipping. Nothing too drastic. You just lay the barrel of your six-shooter up against the side of that man’s head. Not hard enough to kill him. That would be TPE, Therapeutic Pistol Euthanasia. Too much paperwork after that one. TPW is plenty.
“Of course you also could have tried PPW—Prophylactic Pistol-Whipping. You don’t wait for the little worm to start whining. You just walk into the room and lay him out with the barrel of your .45. Then see if Mr. Bigshot isn’t a little more respectful when he comes to.”
“TPW,” I said, nodding thoughtfully and rubbing my chin. “Do you think it’s covered under most insurance plans? Maybe I could try it this morning.”
I thanked Frank for his advice, and went off to see my consult. Jane Satkamp was a pleasant lady in her late forties. She had contracted polio at an early age, and had been left with a withered left leg. She had some sort of antiquated metal brace that looked like it was made of cast iron and rhinoceros leather. The brace continually rubbed the side of her knee, leaving a raw, draining sore. Just looking at the purulent, dripping mess made me queasy. Jane insisted on wearing the brace because she couldn’t walk without it. In addition to the infection, Jane had post-polio syndrome that was slowly and inexorably stealing her strength.
“Couldn’t you just use a wheelchair for a few weeks to give this thing a chance to heal?” I asked.
“No,” she said, “I couldn’t. I seem to be getting weaker and weaker. I’m afraid if I ever stop walking I will never walk again.”
Jane and I hit it off right away. She was extremely well read, and we always found a little time each day to discuss some book or author we both admired. I made the mistake one day of mentioning Louis L’Amour, and from then on she continually teased me about my degeneration into “escapist, male-fantasy fiction.”
Jane was one of the few patients I ever called by her first name. I had always felt that using a patient’s first name was too familiar, that it presumed too much on the part of the surgeon. (“I am Dr. Smith, but you are Alice.”) Ms. Satkamp would have none of it, however. “I insist that you call me Jane,” she said. “I feel old enough as it is without having someone in his thirties call me Ms. Satkamp.”
I did what I could for Jane. I fought with the Mayo Clinic brace shop about fixing her brace. They had never seen anything like it. It was so old they were afraid it would break if they tried to adjust it. They made her a new one but she didn’t like it. She said it didn’t support her leg the right way. She went back to the old one.
I told Jane I was going to have to take her to the operating room to debride her wound. On the night before her surgery I asked her if she had a husband or child who might want to speak to me.
She gave me a perplexed look; surprised I woul
d ask such a naive question. “I’m not married,” she said.
We were both embarrassed, not by what she had said, but by what her words and tone of voice had implied: “I’m not married. I’m a cripple. Who would have me?”
I could have told her she was talking nonsense. I could have chided her for making such a remark. But, sadly, I knew what she meant. We live in a world preoccupied with appearance. Jane had resigned herself to that fact.
Despite her deformity, Jane was a very pretty woman, and was obviously intelligent and personable. Yes, she had a bad leg, but why, I wondered, is that such a big deal? What fool would reject a woman simply because her left leg didn’t look like her right one? Jane was worth twenty symmetrically legged women. But men couldn’t get past her withered leg.
I considered how poorly served men are by the Darwinian impulse that drives them to grovel before vacuous, self-absorbed beauties, whose attraction lies not in what they are, but in what they represent.
In my short medical career I had treated many people who had been stricken with a severe illness or deformity at a young age. Few of them had ever married. Life, it seemed, had been doubly unfair to them. Not only were they victims of a terrible disease, but they were also deprived of the solace and comfort of love.
At home that night I told Patti how wrong it all seemed. I had been thinking about my childhood, and I cringed with shame when I recalled how I used to mimic the lurching gate of the spastic, and the thick, guttural speech of the retarded. Later, in high school, my thoughtless cruelty “improved” to a careless disregard. I made the crippled disappear. I saw right through them. I could enter a room and not even let their existence register in my consciousness. They just weren’t there. Flushed with youth and strength, I had made the subconscious determination that these people, like cocker spaniels and geraniums, inhabited a lower plane of existence, and did not merit my attention.
“Why do those who look different have such a hard time finding love, or even tolerance, from the rest of us?” I asked aloud.
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