"You're the worst goddamn resident I've ever had"

Robert Patterson, MD

CMAJ 1998;159:823-5

© 1998 Canadian Medical Association

• Evidence: Clinical teachers as humanistic caregivers and educators
• Editorial: Physician as humanist
• Letter: Bittersweet memories of residency
• Letter: Remember residency's good times too
• Letter: Respect matters

Because one of the themes of this issue is the role of clinical teachers and the ways they are perceived by clerks and residents, CMAJ asked general surgeon Robert Patterson to reflect on his experiences during residency training. It was an easier job for him than most because he maintained a journal throughout his 5 years of training. Some of his most vivid recollections are distilled here.

The thrill of being accepted into the program is being extinguished quickly by the reality of the workload. On my first day I am assigned 32 patients. I am expected to recite their histories and operations by memory the next morning. Many of my patients are recovering after routine cholecystectomies and hernia repairs, but other procedures are more complicated and easily confoundable. During morning rounds I state that a patient's colostomy is functioning well and then lift the sheets to reveal an intact abdomen. "It was there yesterday," I insist. "We all saw it." The medical students nod in agreement. The senior resident appears sceptical.

December 1990: orthopedics rotation

Two rather unproductive months. The mornings are spent holding retractors, the afternoons preparing patients for elective surgery the following day. On call I learn to read x-rays, but the senior resident handles all the cases. On one occasion there are not enough sandbags, so I spend an hour under the table holding a patient's leg in position. A senior resident shows me how to set a Colles' fracture and an attending physician lets me pin an ankle — that is the extent of my operative experience in orthopedic surgery. For the rest of the rotation I feel like the classic off-service scut monkey.

May 1991: pathology rotation

Finally time to sit and read. I am impressed by the pathologists' depth of knowledge and the effort they make to teach us — this is undoubtedly the most valuable off-service rotation, and there's no call for 2 months. That's a blessing, because I'm struggling with sleep deprivation. Even when I'm off call I need hours to fall asleep, and then I awaken nauseated, with a headache.

Several times I fall asleep at red lights while driving home after a night on call. Once I leave the hospital parking lot and find myself on a highway miles out of the city, with no idea how I got there. I roll down all the windows, play a Queen tape at full volume — no one can doze through Fat Bottomed Girls — and manage to make it home safely. I fall asleep on the stairs, on the way to my room.

August 1991: cardiovascular rotation

A 17-year-old male was stabbed in the chest and we take him to the OR for a suspected hemopericardium. A small blood clot sits on the heart, and the surgeon rubs it softly with a sponge. The heart erupts, spewing blood. The surgeon curses a blue streak, nurses fly about the room, the anesthetist pours in blood and vasopressors as fast as he can. It's all in vain — the patient bleeds to death on the table. Warm blood soaks through my gown, runs down my legs and fills my shoes. I throw away my socks, have a shower and then go through the rest of the day with bare feet inside my sneakers. Over 5 years I discard numerous pairs of socks and underwear that have been stained with blood, pus, feces or some combination thereof — the kind of stuff that just doesn't wash out.

January 1992: general surgery, take 2

I'm getting to do more cases. A 16-year-old girl is asleep on the table — we're about to remove her appendix. The surgeon hands me a pen, asks me to mark where I'm going to make the incision and then turns to chat with a nurse. In a fit of whimsy I draw a long squiggly line all over her abdomen. The surgeon turns around and his eyebrows arch. "Do you realize," he asks acridly, "that the ink is indelible? What am I going to tell the mother?"

I feel a bit foolish but bluff bravely: "No problem. It'll come off with an alcohol swab." It doesn't. I'm not sure how the conversation with the mother evolved, but I will never again use a patient for a doodle pad.

September 1992: a resident dies

A fellow resident is fatally stabbed by an intruder in his home. He dies in the same emergency room where he helped save so many lives. I had seen him just a couple of days ago, out biking with his kids. How can this be?

January 1993: a chance to unwind

The annual residents' weekend retreat is held in the mountains and for 3 days we are relieved of our clinical duties and unwind with a vengeance. We attend a few basic science lectures, go skiing, socialize over elegant dinners and play shinny on an outdoor rink, whooping and hollering like schoolchildren. The crisp air and mountain scenery contrast sharply with the dark and dingy hospital corridors. Sunday evening arrives too soon and, regretfully, we head back to the salt mines.

October 1993: "Where the hell have you been?"

I'm working with a grumpy old surgeon who advises all residents to "get out of medicine while you still can, 'cause it sure ain't what it used to be." The night is busy. I'm following a case of intussusception with interest. I watch while the radiologist tries but fails to reduce the obstruction with a barium enema, so we're off to the OR. I look forward to learning the technique of milking out the telescoped bowel, avoiding an enterotomy. It is 2 am and while the surgeon snores on the couch I pace back and forth, impatiently waiting for the anesthetist to put the patient to sleep. Time drags as he struggles with a difficult airway.

Another problem strikes — my bowels. The irregular hours and rushed meals of residency give me frequent diarrhea, and it's that time again. When I come out of the washroom a few minutes later, the couch is empty. I walk into the OR and the surgeon explodes. "Where the hell have you been? Can't you see we're starting the case? You're the worst goddamn resident I've ever had."

The tirade continues for several minutes. The anesthetist and nurses are embarrassed for me and lower their heads or look away. The surgeon does the procedure himself, posturing himself to shield his work from my view. I arrive home an hour later and think how easy it would be to extinguish the pilot light on the furnace and lie down to a peaceful sleep. I go down to the basement but the furnace room doesn't have a door and I can't think of how to concentrate the gas fumes, so I trudge back upstairs. This is the only time in residency I contemplate harming myself. I realize later that my judgement was impaired by lack of sleep at the same time my self-esteem had been shattered by the surgeon's caustic comments. A dangerous combination.

January 1994: "So what are you doing after work?"

While putting in a central line at 4 am, I feel strongly attracted to the nurse who is assisting me. Since sleep deprivation has the same disinhibitory effects as a couple of stiff drinks, I decide to ask her out. She scribbles down her phone number on a paper towel, probably hoping I won't call. But I do.

August 1994: inflamed gallbladder, inflamed resident

I'm chief resident now and that means more paperwork and more challenging cases. I'm doing an acute gallbladder with a surgeon I don't see eye to eye with, and not just because of the difference in our heights. The gallbladder is extremely inflamed, and every time I touch it, it bleeds. This brings forth a barrage of criticism. "You're too rough! That's not the way to do it! Be more careful! Didn't you see that vein?"

Finally, disgusted by my technique, he crosses over to my side of the table. Having a case taken away is a grievous insult, a sure sign the attending physician lacks confidence in the resident. After elbowing me out of the way the surgeon gently grasps the gallbladder, which responds by oozing forth more blood. He looks surprised. "This gallbladder sure bleeds easily," he observes.

I exert all my self-control, bite down hard on my tongue and barely keep from shouting, "Well no shit!"

November 1994: "Can you try this?"

I am between cases when a surgeon calls me over to his room. "Can you try this?" he asks. "I'm getting really frustrated." I scrub in and note that exposure seems to be the problem. I ask the anesthetist to put the patient more head up, and insert another retractor to hold the bowel out of the way. Eventually I get the gallbladder out. "Thanks for the help," says the surgeon. Nothing more. Though not yet a peer, I feel I'm getting close.

January 1995: a resident dies, take 2

Another resident dies, this time from a drug overdose presumed to be accidental. Rumours soon circulate that needletracks have been found under his pants, where they wouldn't be seen. I worked with him numerous times and never suspected a thing — apparently no one else had either. He loved the sea and at his funeral a song plays over and over — Orinoco Flow (Sail Away) by Enya. We are all saddened by the tragic waste of a young life. I recall my own contemplated act of self-destruction and realize how foolish it would have been.

"Do you take this nurse . . ."

Eight weeks before my residency ends, I marry the nurse I met over a central line. The wedding guests are a tapestry of the past half-decade — friends, fellow residents and many of the surgeons who were my most influential mentors. They applaud our vows, share our joy and laugh at our nervous attempts to dance. Ahead lie the Royal College exams, fellowship training and my first job, but on this day all that matters is the friendship that draws us together.

Looking back

Was residency "worth it"? Reading my journals years later, I am struck by the number of negative experiences I recorded. I had forgotten how often I was depressed and how many times I was tempted to walk away.

Today, I wonder how many people actually did.

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