by Robin Cook
Noah’s eyes roamed around the unit. He saw that each cubicle had a nurse, some more than one, and all were busy. The patients were all totally bedridden, many with respirators as the only sign of life. For Noah, the fact that there were no doctors present was revealing and reassuring. “Looks like you have things wonderfully under control,” he said. The other reason nurses liked Noah was because he was appreciative of their role and the work they did. Noah often asserted that the nurses did nine-tenths of the work in the hospital and that residents were there merely to help.
“It has been a better night than usual,” Carol said.
“Any problems that I should know about?” Noah asked. He redirected his attention to the unit supervisor. He was surprised that she was staring at him.
“I don’t think so,” Carol said. “Let me ask you a question: How is it your white coat always looks so clean and pressed?”
“I change it often,” Noah said with a laugh.
“Why, exactly?”
“I think patients appreciate it. I know I would if I were a patient.”
“Curious,” Carol said. She shrugged. “Maybe you are right.”
“You’ll be getting several new surgical residents today,” Noah said.
“Don’t remind me.”
For nurses, July 1 was often a difficult time, especially in intensive-care units, where there was a steep learning curve for first-year residents. For a week or two the critical-care nurses joked that they had to direct almost the same amount of attention to the residents as they did to the patients to make sure the residents didn’t do anything untoward.
“Let me know if there are any problems,” Noah said.
Carol merely laughed. There would be problems. There always were.
“I mean any problems above and beyond the usual,” Noah added.
In the unit, Noah had two of his own patients whom he had operated on, both disaster cases that had had surgery at community hospitals and that had to be redone. Both patients had been airlifted in dire straits into the BMH and were now on respirators. Noah spoke with the nurses taking care of each one, checked the patients themselves briefly, particularly their sutured incisions and their drains, and then glanced at their SICU charts that hung off the ends of their gurneylike beds. Noah did all this in minutes but with attention to detail to be sure he wasn’t missing anything. While he was in the second cubicle, residents assigned to the SICU began arriving; their faces reflected their fatigue.
In terms of residents, the SICU was a kind of miniature United Nations. Critical Care had evolved into a specialty of its own, with its own residency program. At the same time, it was felt appropriate to continue to rotate junior surgical residents through the unit to gain the experience that it could provide. It was the same with anesthesia. What this meant for Noah was that a certain amount of diplomacy was necessary, as he technically did not have power over critical-care residents or anesthesia residents.
Lorraine Stetson and Dorothy Klim were the two surgical residents who had been assigned to the ICU for the previous month, and seeing Noah, they immediately came in to join him. Although the number of female surgical residents had climbed dramatically over the last ten years, it was rare for both ICU surgical residents on the same rotation to be female. Lorraine was a first-year resident who had miraculously transformed overnight into a second-year junior resident, thanks to it being July 1. Likewise, Dorothy was now a third-year senior resident. Noah got along well with both women, although Dorothy often made him feel uncomfortable. He didn’t know exactly why but assumed it had something to do with her appearance. In his mind, she looked more like a movie actress playing a role than a real surgical resident, even though he admitted such a thought was sexist.
“I’m sorry we were not here when you came in,” Dorothy said.
“Why?” Noah said. “Everything is copacetic here, and SICU rounds don’t start until six.”
“Still, I think we should have been available when you arrived.”
“No problem. It doesn’t matter. What matters is that you will be passing the baton to a brand-new first-year resident by the name of Lynn Pierce. Also to Ted Aronson, whom you obviously know. I want you to let me know if there are any problems whatsoever, particularly with Miss Pierce.” For first-year residents, starting off in the ICU before getting their feet wet in the program was often stressful for everyone.
“We met Lynn Pierce last night at the Change Party,” Lorraine said. “I think it is going to be fine. She’s actually excited about being thrown into the deep end of the pool. Those were her exact words. She thinks she lucked out.”
The famed Change Party was a yearly surgical department event held at the nearby Boston Marriott Long Wharf hotel on the evening of June 30, no matter what day of the week it occurred. The party’s main purpose was to send off the fifth-year residents with a fun-filled event that included a number of irreverent homemade videos, generally mocking the attending staff of BMH but in actuality celebrating them and the institution. As a command performance, Noah had attended the celebration, as he had previous Change Parties, but such gatherings weren’t his cup of tea. To be sociable and try to relax, he’d had several drinks, which had made him feel less than top-notch this morning.
Although the Change Party was to acknowledge the residents who were leaving, it was also secondarily an opportunity to welcome the twenty-four first-year residents who were about to join the BMH family. Only eight of the twenty-four were categorical residents, meaning they were expected to stay for all five years of surgical training. The other sixteen were planning on finishing only a year or two of surgical training before going on to various surgical subspecialties, such as orthopedics or neurosurgery.
During the course of the evening and despite generally feeling like a fish out of water, as he always did in large social situations, Noah tried to introduce himself to a few of the incoming surgical residents, a couple of whom he had met when they had come for their interviews before being accepted. One of them was Lynn Pierce, and he had been impressed with her, although she’d had a similar effect on him as Dorothy, making him wonder if physical attractiveness was now a criterion for the program.
“Are you going to stay for SICU rounds?” Dorothy asked.
“No,” Noah said. “Seems there is no need, and I have a lot on my plate before the welcoming ceremony this morning. And you guys are planning on attending, right? Remember, everyone is expected to show up.”
“We wouldn’t miss it for the world,” Dorothy said with a smile. “That is, unless the roof falls in here in the SICU.”
“Don’t count on it,” Noah said. “Be there!”
The welcoming ceremony was as preordained as the Change Party but a lot less fun. It was supposed to welcome the first-year residents, but Noah saw it more as an opportunity for the departmental bigwigs to hear themselves bloviate. Over the years he had come to understand that there was always a lot of posturing and jockeying going on in the front office of top academic surgical programs, and the surgery department at the BMH was no exception. Competition was the name of the game in medical academia, particularly in the surgical arena, and it never stopped. Luckily, Noah considered himself good at it.
As had been the case for the last four welcoming ceremonies he had attended, Noah was not looking forward to it. The first one had been different because he had been eager to start his residency. He had been so eager that he had found most of that June five years ago to be almost intolerable. The days had seemed to drag by from medical school graduation until July 1, despite his having been busy finding the Revere Street apartment and setting it up with Leslie.
From Noah’s perspective, this year’s welcoming ceremony was going to be more trying than usual. He was not going to be allowed to sit passively and persevere as he had the previous four years. As the new super chief resident, he was going to be asked by Dr. Carmen Her
nandez, the chief of surgery, to say a few words. Unfortunately, this wouldn’t happen until after the chief and then Dr. Edward Cantor, the surgical residency program director, had exhausted everyone with long, boring speeches about the history and importance of general surgery and the BMH in the development of modern medicine. Noah knew that by the time he was introduced, the audience would be close to comatose.
Of course, Noah understood it made sense for him to address the group, since he was the new residents’ day-to-day boss. The structure of the surgical residency program was as simple as it was medieval. The first-year residents were the serfs, or, according to in-house parlance, the “grunts,” Noah their liege lord, Hernandez the king. Each year the residents ascended the rigid ladder, with increased perks and responsibilities.
Noah had never been fond of public speaking, particularly in a formal setting. He was fine if not brilliant in informal settings, such as on surgical rounds, considering his command of the medical literature to back up any point he was trying to make. The reason public speaking bothered him stemmed from his competitive quest for academic excellence, which he thought was put at risk in such a circumstance. He always had the fear that his mind might go temporarily blank or he’d inadvertently say something outlandish. It wasn’t necessarily a rational fear but real nonetheless, similar to his fear of social engagements like the Change Party. To make matters worse, he had been so busy preparing to assume the role of super chief that he hadn’t planned his remarks. He was going to have to improvise, which only increased the likelihood he’d say something inappropriate in front of the surgical hierarchy.
Leaving the SICU well before 6:00 A.M., Noah took an elevator up to general surgery on the eighth floor. Work rounds with junior and senior residents weren’t scheduled until 6:30, giving Noah time to check in with the night-call senior resident, Bert Shriver, a solid, dependable resident. Like everyone else, Bert had risen in stature overnight, if only in name. He was now a fifth-year chief resident. He gave Noah a quick rundown of the night. There had been two surgeries, both appendectomies that had come in through the ER, and the patients were doing fine. With all the surgical inpatients, there had been no problems whatsoever. There had been one consult from the internal medicine floor to do a cut-down on a patient who needed an IV but had no superficial veins.
“You’ll be at the welcoming ceremony, right?” Noah asked. As the new super chief, he was now responsible for no-shows.
“Wouldn’t miss it for all the tea in China,” Bert said with a grin. “Can’t wait to hear whatever pearls you have conjured up.”
Noah gave him the finger and an exaggerated dirty look.
Still with time to spare before general work rounds would begin, Noah used the phone in the nurses’ station to call the OR to see if anything had been scheduled behind his back. He had checked the evening before, prior to the Change Party, and had been told no surgeries would be scheduled until 10:30 A.M. His concern was that if surgeries had been scheduled overnight, which needed resident helping hands, it would be up to him to supply them. He was happy to learn that no cases had been added. For once, word had apparently gotten out so that the entire surgical department knew about the welcoming ceremony. Noah was pleased on one hand and a bit more nervous on the other. The implication that the ceremony might be even better attended than usual added to his anxiety about speaking.
Noah next went around to check in on his three private patients whom he had operated on. He thought it important for him to visit each at least twice a day to have direct, personal, face-to-face contact. Though he would see them again on work rounds, that was different, as it would be with the whole resident team. Noah had never been a patient himself, but he was sure that if he were, he’d want to have a few private moments with his doctor every day. His attitude about the importance of communication was one of the many reasons he was so popular.
Two of the three patients were still asleep when Noah entered their rooms, and Noah had to wake them up. During his first couple years as a surgical resident, Noah would not wake patients, thinking he was doing them a favor by letting them sleep. A dressing-down by a patient made him change his mind. Patients truly valued the personal, one-on-one time.
All three patients were doing fine, with one scheduled for discharge that afternoon. Noah spent a little more time with him to let him know what he could and could not do. He also assured him that he would see Noah and not another resident in the clinic for follow-up. The man had been a patient of the BMH for years and knew the ropes. Sometimes when residents rotated onto different services they didn’t get to follow patients they had taken care of on previous rotations. Noah had always made sure that didn’t happen to him. It was one of the benefits of the sheer number of hours Noah spent in the hospital, which married residents with families simply couldn’t do. Noah was never bothered by this added effort; in fact, he thought the opportunity gave him a leg up.
Work rounds went especially smoothly for a number of reasons, primarily because there were no problem cases that needed extended discussion as to future course of action. Another reason was that it was Saturday, when it was rare for attending surgeons to show up and try to turn work rounds into a variation of chief-of-service rounds, whose goal was teaching or at least pontificating. Work rounds, by definition, were a time to merely review the chief complaint, what had been done so far, and what was going to be done that day or in the near future, and then move on to the next patient.
The final reason the work rounds proceeded apace that morning was that the junior residents who did the actual presenting were now all second-year residents and knew the ropes. Presenting cases was a learned skill, which all had mastered, except for Mark Donaldson, who was obviously either not prepared or, worse yet, had somehow failed over the year to grasp an appropriate sense of what was important and what was not. Noah spared him the embarrassment of calling him out on the spot, which had been a typical pedagogical surgical-rounds teaching method honed by some attendings to the level of torture. Noah had hated it when he was a junior resident, even though it had rarely been directed at him. Nonetheless, Noah had vowed never to do it as he rose up the ladder. With the belief that persuasion was a far better teaching method than ridicule, he planned to take Mark aside at some appropriate time, probably later that day, and have a heart-to-heart discussion.
Since it was Saturday and there were to be no chief-of-service rounds, Noah had a bit of free time. The welcoming ceremony wouldn’t commence until 8:30 and it was now 7:00. After reminding all the other residents about attending the welcoming ceremony and after entering his progress notes on his three patients in the electronic medical record, or EMR, Noah took the elevator down to administration on the third floor.
In sharp contrast with the rest of the hospital, which operated on a 24/7 basis, the administration area was all but deserted on a Saturday morning.
Noah’s destination was the surgical residency program office, which was at the far end of a carpeted hall where all the graduate medical education offices of the various specialties were located. When he got to his office door he fished out the lone key he had in his pocket. It had been dutifully handed over to him a few days ago by Dr. Claire Thomas, the outgoing super chief responsible for shattering a few significant glass ceilings. She had been the first African American woman to be the BMH surgical super chief and was, as of that very day, the first African American woman on the BMH surgical faculty. Noah knew she was going to be a hard act to follow, as everyone liked and respected her, including Dr. Mason. She had never been chastised in front of the Residency Advisory Board by the program director, Dr. Cantor.
Using the key, Noah opened the door. He stepped over the threshold and closed the door behind him. For a moment, he just stood there and surveyed the room. There were five desks. One was for Marjorie O’Conner, the surgical residency program manager. She ran the show from a bureaucratic standpoint. Another smaller desk was for the
coordinator, Shirley Berensen. Her area of concentration dealt with managing the complicated evaluation requirements to make sure the program retained its accreditation and residents reached appropriate milestones. Another desk was for Candy Wong, also a coordinator, who oversaw the equally complicated issue of resident duty hours and the on-call schedule. Miss Wong had been the person whose attention Noah had spent so much effort avoiding after he had been threatened with dismissal for violating duty hours when he was a junior resident. For Noah, there was a certain irony that now he would be working closely with her.
There were two more desks, both smaller than the coordinators’. One was for the secretary, Gail Yeager, and the other for Noah. Looking at them, Noah had to smile. The irony here was that he and the secretary were probably going to be the busiest people in the surgical residency program and yet had the least impressive real estate. But the worst part, from Noah’s perspective, was not the size of his desk, which had no significance to him, but rather that his desk was completely out in the open, meaning there was no privacy whatsoever except after hours and on weekends. For something like the conversation he needed to have with Mark Donaldson, the venue was completely inappropriate. For such situations, Noah was going to be forced to improvise.
