Concept of 'Deep well' and 'Deconstruction'

          I am a senior resident in a medical institution of national reputation. There are some peculiar things about an ‘institution.’

          There is a halo of extraordinary brilliance surrounding every professor. Students all over the country look up to them as some wonder creatures, people who are considered supreme authority in their own specialty. Only the national toppers have an opportunity to learn in an institution. I have though about myself as an average student. I believe in hard work and bit of luck. I have nothing to do with supernatural brilliance. But in this premiere institution, I have seen more people with extraordinary capabilities than any school I have been to. I have been working here for some time and was confused about my own academic identity. There is always a gap between professors and residents, but yeah, there are exceptions.Recently I got an impression from two persons, which opened my eyes, the answer to why there be this incongruity between residents and professors.

         It was a usual morning seminar presentation. The resident was trying to present whatever he could gather on the power point with the ‘usual attitude’. The professor, also the head of department was getting irritated with the ‘bland’ presentation. He could not find a soul in the presentation. For him, it was another gimmick of lack of interest in the subject. He explained, ‘these three years are like gold mine for you. If you try to spend time with the patients and read your books, instead of sleeping and roaming around, you will go back with something useful. Other wise, you people will remain dumb all your life, and no one is going to teach you after these three years, nor you are going to make an attempt to learn’. He continued ‘Consultants are like deep well, you have to pass your bucket again and again to gather some knowledge, it is not going to rain for you. I have to see that you are interested and trying, then only I will respond. Some how it is your interest, that is reflected like a telepathy to us, that push us to teach you.’

         Well said… I was confused again, why is there a problem, if the consultants are this much interested in teaching, why are we not learning. Any way all those enthusiasm vanished as soon as that seminar finished. After two days, I was lying in the duty room, when two of my juniors were having a conversation. They were having the ‘resident talk’. But I liked the statement made by one of them. It felt so true. He said ‘ this institution has deconstructed me. If somebody tell me left main coronary is from middle cerebral artery, I will believe it.’

        I have also heard this phenomenon from other professors too. It is a ‘thing’ with the institution. They say ‘If you want to a ask question during clinical round, better it to be the freshly joined resident or the exam going resident. More chance of getting an answer based on knowledge and common sense is from the fresh resident. If you see the resident is blank like a white paper, sure it is a second year resident’.

        It is true. The institution has a process of deconstructing the resident. All the extra ordinary brilliant people surrounding the work place, prejudice and the round the clock- work schedule make the resident go blank. But, yeah most of them pull together themselves by the end of three years.

THE RED LINE

‘I want you to go through the charts and tell me when we started losing the baby.’ I nodded my head agreeing to that. I was emotionally blunt, didn’t have any true scientific curiosity. It was 9:30 am in the morning after a 24-hour shift in the cardiac infant ICU. A baby, who was admitted with us for last 20 days, had expired. He was operated for a complex congenital heart disease. The post-operative period was a gloomy long journey down the hill, but with occasional rays of hope.

Any one who has worked in neonatal or infant cardiac surgical ICUs will understand the feeling, which I had, without much explanation. Babies come to the ICU from the operation theater with labels: PFO present, Sternum open, Severe PAH etc. A quick look into the case sheet and preoperative notes will give a light into what the future looks like. But the surgeons face itself will give more information, which is not mentioned in the operative notes.

I have been working in this ICU for last two months. But the actual line, where we start losing the babies is still unclear. It is not a line; it is rather a zone, a zone that extends from state of recovery to state of deterioration. But one thing is for sure, Once you realize that you have crossed that zone and the baby has started losing, there is nothing much to do.

Provisional History

     A patient was admitted with pain and swelling in the left inguinal area. The casualty officer doubted it to be an irreducible hernia and got an ultrasound examination of the swelling. Ultrasonologist felt it to be an inguinal abscess, but did not want to rule out a grave possibility of irreducible hernia. He was taken to the Operation room for exploration of the swelling. On exploration it was found to be an abscess with abscess surrounded by indurated and inflamed tissue in the subcutaneous plane. Every thing was superficial to the External Oblique fascia.

      After the surgery the house surgeon asked the operating surgeon, “Sir, I have written the history for obstructed hernia, shall I change it to the history for inguinal abscess?”

PS: History: patient had an insect bite at the area of inguinal canal 3 days back. He developed severe pain and swelling following the bite. He never had any swelling in the inguinal area previously.

The important lesson

         Communication is the center pillar of a successful surgical practice. Long years in medical school and hospital practice make surgeons accustomed to the blood and pus. It is easy to explain the possible complications of a disease to a medical student. But only a surgeon can understand the chance of collateral damages associated with a surgery in a difficult situation.

        Some days ago my professor was called in to gynecology operating room. They had opened a patient for a large ovarian cyst. The patient had history of four abdominal surgeries. The gynecologist made a rent in the rectum while separating the adhesions in the pelvis. There was bowel contents were released to the peritoneal cavity. Considering the nature of injury and comorbidities, my professor advised a covering colostomy after repairing the rent. Now the difficult part was to get things explained to the relatives. They will never understand how difficult it is, to operate in an abdomen with adhesions; they will never realize how easy it is, to get bowel injury while separating adhesions, even with utmost care. But my professor handled the situation very smartly. He met the relatives and explained them, that the tumor was adhered to the rectum. The options left were to leave the part of tumor or remove the tumor completely with a part of rectum, for which a covering colostomy is required. The relatives were happy to agree to do the colostomy.

         This incident is a story about my professor in medical school. He did a thyroid surgery; unfortunately the recurrent laryngeal nerve got damaged on one side. He could identify it on the table itself. He went to the relatives and explained about the patient condition. He said “I was in a difficult situation during the surgery, I had to choose between the life and voice of the patient. I asked God. He told me, life is more important than voice. So I had to do it that way. So patient may have some change in the voice, but thank Him for giving back the life.”

Revelations

         I started working as a teacher in the department of surgery at a private medical institution in my home state. A month has passed and I understood two things, relevant to situations, which I never encountered previously. First thing is related to my views about teaching in medical profession. Second thing is about hospitality and patient communication in a private setup.

          Regarding teaching as a profession, this short period has opened my eyes wide. The difficult part of teaching is not transferring the ideas, but maintaining discipline and motivating. Sometime before, I had written, that education is about making people capable of thinking at a higher level.  I developed this clarity about my profession only after some years after entering college. It is very difficult to make a young man or woman open up their mind. They remain unfocussed even after repeated advices. Taking classes for the undergraduates is very easy. I know what I am teaching. I have the experience of treating patients. I know how to conduct a good session on any topic related to my practice. But guiding the students to think out of the box, or motivating the house surgeons to go to the bottom of a treatment plan, is a herculean task. Teaching is easy, but educating is not easy. That is the feature, which keep some teachers apart from the rest. It also requires being strict with the rules. Students and house surgeons are in the constant process of thinking how to avoid responsibilities and how to disappear from the duties. The capability to motivate the students, the capability to make the students think of their own; It’s like starting a campfire from damp wood. Until it gets going by its own, one has to struggle a lot. I now realize why teaching is considered as one of the greatest professions in the human civilization.

           Second revelation was about the hospitality, while practicing in a private setup, where the patients pay for the treatment by themselves. Except for a short period as a casualty medical officer, I had always worked in government run hospitals. I had developed a reasonably good communication skill and I considered myself good at explaining about diagnosis and treatment plans to the patients and relatives. I remember most of the patients were happy with my communication. But there used to be some patients, mostly patient relatives who are unsatisfied with the logistics or discontent with the functioning pattern of the hospital facilities or staff. In such situations, I used to defend the hospital and staff pointing out how good we cared for the patient regarding the disease management. But in a private hospital a whole new realm is added to a doctor’s practice- hospitality. Now sometimes, I have to keep my pride away and talk like a customer relations manager in a showroom. I have to make them feel like; the staff in a hotel or some kind of tourist center treats them. We are not supposed to fight with them. We are not supposed to make them correct. Only thing we can do is to make them happy, make them feel they are served right and decide what they want. Now I am working on it.