Behind Closed Doors: When do the Training Wheels Come Off?

With apologies to T.S. Eliot, and the American taxpayer, April is not the “cruelest month.” That dubious distinction most certainly belongs to July, the month that newly minted interns and residents are loosed upon the populace. In the world of medical education July is the beginning of the fiscal year. Fresh out of medical school, or far less fresh out of internship, the first year of postgraduate medical training, new doctors begin the arduous process that will refine them into specialists in their given field.

Many patients I have taken care of over the years have asked me questions about this transition. Several have expressed fears about having operations in July, certain that they will be guinea pigs for some new anesthesiologist or surgeon. TV doctor shows like House, or Gray’s Anatomy do not assuage these fears. Quite the opposite, my family and friends can attest to the one sided shouting matches with the television I have had when some particularly obnoxious and stupid storyline has an intern shouting at a cowering patient, or even more unforgivably at a cringing nurse. (Note to prospective interns: if you shout at a patient, you will be fired. If you shout at a nurse, you will die. Or even worse, you will wish you were dead, as nurses can make an intern’s life unbelievably miserable. Imagine 3:00 AM calls every night to tell you that your patient needs to talk to you about their bowel movement.).

Interns and new residents in TV doctor shows are portrayed as having way too much power and knowledge for their level of training. Visualize a sexy Athena springing fully formed from the head of Zeus with a stethoscope draped casually around her neck. Now imagine a dumbed down Doogie Howser….naked. Yes, that’s more like it.

It takes a long time, and a lot of observing, reading, and being pimped, before a new doctor gets any significant responsibility. Sure there are apocryphal stories about the third-year medical student with his own medicine ward service at the V.A. hospital, or the new surgical intern with a textbook in one hand and a scalpel in the other, draining pus from a black tar shooter’s swollen arm at the county hospital. But for the most part, learning in medicine is an orderly process of graded responsibility. So to my patient, who nervously asks me if a doctor-in-training will be in charge of them, the answer is no. There may be a medical student scrubbed in and watching the surgery, or a first year surgery resident learning how to guide and focus the camera in a laparoscopic gall bladder removal and learning to suture the port incisions closed at the end of an operation, or a senior surgery resident operating under the watchful eye of the attending. There is no other way to learn than by doing; but this takes a long time, under the supervision of many highly experienced eyes and guiding hands.

As an anesthesiologist, I have always taken great exception to the portrayal of my chosen profession in the media. Next time you see a comic strip portraying the operating room,

Whoa! Watch where this thing lands…we’ll probably need it.

look for the anesthesiologist. Not there, eh? Nine times out of ten we are simply an IV and a machine with squiggly lines, or tanks with a mask attached.  Anesthesiologists are typically portrayed in movies as helpless bystanders in surgery “He’s flatlining…I’m losing him!!” as they look pleadingly at the surgeon to “do something, anything!” Believe me, unless the patient is bleeding to death on the table, the first thing the surgeon does in an unstable patient is fold their hands across their chest to remain sterile, and step away from the patient while the anesthesiologist scrambles to treat the arrhythmia, hypotension, or other metabolic crisis. Even when a patient is bleeding a lot and the surgeon works like hell to stanch it, it’s the anesthesiologist who transfuses blood cells, or plasma, or platelets, or a combination of all three to help stabilize the situation.

Despite these heroic efforts, the anesthesiologist is often portrayed as the bad guy in movies. Remember Richard Widmark in Coma? He was the evil doctor who masterminded the scheme to give healthy patients lethal doses of carbon monoxide during surgery to kill them and sell their organs on the black market. I saw this movie as a teenager, and aside from lusting after Genevieve Bujold who starred in it,  I wondered who in their right mind would want to be an anesthesiologist?  Well… as it turns out…me. My dad was an anesthesiologist who was decidedly not evil, so out of curiosity and a desire to see what his life was like, I took my first elective rotation in medical school in anesthesia, and I was hooked.

It’s a mystery as to what makes a person choose what to be, to make such eventful decisions at such a young age. For me, I like to think it was more my Dad and Genevieve than Richard Widmark.

Jeffrey L. Swisher, M.D.

San Francisco, CA