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

Behind Closed Doors: Inside the Operating Room with Dr. Jeffrey Swisher

Welcome to my first post for PokitDok! Despite having a sister who is of one of the most prolific tech journalists on the net, I am a first time blogger. But bear with me, perhaps this is genetic, so I will give it my best shot. When Lisa Maki, my old college and Stanford Sierra Camp pal tracked me down after many years to invite me to be part of her new health/medical information venture “PokitDok”, I was intrigued. I also couldn’t get the image out of my mind of those little pastel colored sugar candy dots glued to the roll of three-inch wide ticker tape. I think they were called Candy Buttons, but I called them “Pocket Dots”. They were the perfect “pills” for playing doctor, and undoubtedly launched me on my career as a physician.

Lisa and I talked over the course of a long hike in the canyons of Mt. Tamalpais near my home in Marin. Our discussion ranged widely, and as is typical for Lisa, was engaging and insightful. We caught up on our respective lives and careers, our health issues that invariably ensue as you hit middle age, and our mutual fascination and frustration with the complexity, politics, and economics of health care delivery in our society.

I am an anesthesiologist who works in a large tertiary care hospital in San Francisco. My group of 53 physicians provides comprehensive anesthesia care for a wide variety of medical procedures and surgeries. From epidurals for relief of labor pain, to surgeries on tiny premature babies, to liver and heart transplants, and the whole range of surgeries and procedures in between, my practice is interwoven with the complex tapestry that is modern medical care. And believe me, “complex” is an understatement.

It is said that one should befriend a sharp accountant, a trustworthy mechanic, a relentless attorney, and a good butcher. I would add a well-trained anesthesiologist to that list. There are few doctors who are as present and responsible and as little known about as
anesthesiologists. Prior to your operation, we review your health history and current medical issues, as well as your medications and their various interactions. We perform a rapid and comprehensive physical exam, explain the myriad risks and benefits of the anesthetic procedure tailored specifically for you, then put you to sleep using powerful sedatives such as propofol, the “Michael Jackson” drug.

Or we can render parts of your body numb with local anesthetic drugs injected through precisely placed needles in your back, or arm, or leg. And then we stay right next to you for the entire duration of your procedure, watching you. We carefully monitor your vital signs, and oxygen, carbon dioxide, and anesthetic gas concentrations using complex machinery, tweaking here, and adjusting them as needed. We tally and replace fluids and blood loss. The latter surprises a lot of people. “You give blood during surgery?!” As opposed to whom, the blood fairy perhaps? We keep you stable, and alive, in a state of suspended animation while the surgeons do their job. Then we bring you back. Putting you to sleep is only a small part of what we do. It’s keeping you there and then getting you back—awake, safe sound and comfortable—that’s tricky.

What’s unique about anesthesiologists aside from our particular expertise, and good looks, is that we are always in the middle of things. We meet a lot of people, we listen a lot, and we have a lot of time to ponder. Operations are often long affairs involving a wide variety of folks: surgeons, nurses, scrub-techs, physician assistants, equipment reps, etc., all confined to the small space of the operating room. Conversations are lively, often about politics, economics, and the modern realities of medical care. We talk about Obamacare, death panels, HMO’s, PPO’s, mandated insurance, rising costs, decreased reimbursements, drug shortages, the list of new topics continues to grow.

So, exclusively on PokitDok, I will share with you medicine from the inside of this small room - conversations and stories accumulated over the years from encounters with my patients and my colleagues. Stories that highlight many of the issues we are all facing today with our new world of decisions and choices we must make about our health and our medical care.

Jeffrey L. Swisher, M.D.

San Francisco, CA