Chapter Thirty-Six

January

We spent Christmas in Chicago, then drove back to Rochester on New Year’s Day in a blizzard. It was midnight before we finally arrived home. The car got stuck halfway up the driveway so I just left it there.

I was up early the next morning, anxious to get going. It was a special day. I was going to begin my final assignment at the Mayo Clinic: chief resident in Orthopedic Surgery. I would have my own service with my own patients. I would do all my own cases, and would have a junior resident assigned to me.

I should have been proud and thrilled. This was the culmination of everything I had worked for since I was a junior resident on Dr. Harding’s service three and a half years earlier. Unfortunately I took very little pleasure in being selected chief resident. I was no longer programmed for pleasure. I was programmed for achievement. Rather than spending a little time basking in the glory, I immediately moved on to planning my next achievement: becoming a good, no an excellent, chief resident. I began calculating what I should do and how I should do it.

I told Patti I was worried. Being chief resident was a big responsibility and I didn’t want to screw up. She brushed away my concerns. “You’re awesome,” she said. “You’ll do great.” Of course, if I wanted to be Emperor of Japan Patti would tell me I was awesome and I’d do great.

As I finished shaving I looked at Patti’s bathrobe, floppy slippers, and disheveled hair. “Lookin’ good,” I said.

She pushed the hair back from her face. “Feelin’ good,” she replied with a smile.

She bent over, picked up a rubber dinosaur, and stuffed it in the pocket of her bathrobe. As she wrapped the robe around her, I noticed it was getting a little tight—again. She was due with our fourth child in May.

“You can kiss that Planned Parenthood Man of the Year award good-bye now,” Bill Chapin had said when he heard the news.

“Unregulated animalistic breeding,” Patti’s liberated, older sister had said when she heard the news.

“Who cawes?” our son Patrick had said when he heard the news.

As I put on my L.L. Bean parka and Sorrel boots, I noticed the streets had been plowed, but a wall of snow now blocked my exit from the driveway. I wasn’t worried, though. I knew the old Battleship would get me through.

I called good-bye to the kids who were down in the basement destroying things. They came thundering up the stairs. Eileen said Mary Kate took her crayons. Mary Kate said Patrick hit her with a hockey stick. Patrick said Mary Kate was “a alien,” and he was going to “vapowize her.” Patti grabbed the hockey stick and said she would vaporize them all if they didn’t knock it off.

“Have a nice day, dear,” I said over the din as I zipped my coat and started out the door.

She stuck out her tongue at me. “Close the door, you big omadhaun,” she said. “We’re all going to get pneumonia. It’s freezing out.”

“Yeah,” Patrick said, “it’s fweezing out.”

“You big omadhaun!” Eileen giggled as I shut the door.

I crunched through the snow to the car, listening to everyone inside laughing. (“You called Dad an omadhaun!”) They were gathered in the living-room window, climbing all over each other, waving and pointing as I revved up the Battleship and sent it flying down the driveway, smashing through the wall of snow, and skidding into the snowbank on the opposite side of the street. I waved to the kids, gunned the engine, and fishtailed down the street.

Alan Harkins, the senior resident assigned to me, was waiting when I got to the doctors’ lounge at St. Mary’s. Alan was a quiet, studious guy who didn’t play hockey, didn’t play golf, drank wine instead of beer, and preferred The Amsterdam Concertgebouw to the Clancy Brothers. On the surface we didn’t have a lot in common. We did, however, share one important trait: we were both very serious about our work.

When we finished rounds I told Alan he could have Sunday off. I would make rounds by myself. He, of course, demurred, but I insisted.

“I’ll see you at seven Monday morning,” I said. “And I’ll be around all weekend, so call me if you have any problems.”

When Alan had gone I went to the residents’ lounge to check the bulletin board for practice opportunities. In six months my residency would be over. I needed to find a job. One good thing about being a resident at Mayo is that there is never a shortage of job offers: Seattle, Colorado, Chicago, Tampa, Dallas, Boston. I pretty much had my pick of places. It felt strange to be looking for a job. Even though I was now chief resident, I still felt as if I had just started, and now I was making plans to leave.

 

Although I was eager to begin my work as chief resident, there was one thing that bothered me. It is traditional that the chief resident let his resident do a lot of surgery. Only jerks hog all their cases. I knew Alan expected me to turn over a lot of my cases to him, but this was going to be hard for me. Hell, I had just started getting comfortable doing cases myself, and now I had to let a less-experienced resident do them—in my name? If Alan screwed up, it was my reputation that was on the line. It was my patient who would be harmed. I didn’t know if I was ready for that.

The issue of residents doing cases had come to a head in our department the year before when Bill Chapin was on Don Ashford’s service. Ashford was new on staff and was still insecure about letting residents do cases. His residents rarely got to do any surgery. Bill didn’t like it, and never one to back down from anything, he took his complaints to BJ Burke, insisting that something be done.

“Either this is a training program, or it’s not,” Bill insisted. “And if it is, then residents have to operate.”

Ashford took the moral high ground, insisting that “patient care” came first, and that “our mission to provide proper patient care takes precedence over our mission to train residents.”

Ashford had pressed the right button and he knew it. Everyone at the Clinic paid lip service to the notion that patient care came first, even though everyone knew that wasn’t always true. It was one of those uncomfortable truths easier to ignore than to acknowledge.

The patient did not always come first—especially in the surgical specialties. If the Mayo Clinic’s primary concern was patient care, then how could they ever let a resident do a case? The resident is virtually never a better surgeon than the attending surgeon. Now that I was chief resident I was pretty good at doing most orthopedic operations. But I never for a moment thought I was better than Antonio Romero or Tom Hale or Mark Coventry. So how could the Clinic justify letting me do cases when everyone knew I wasn’t as good as those guys? And how could I justify letting Alan do cases when I knew he wasn’t as good as I was?

Residents can’t become surgeons unless they do surgery—and everyone knows it. But residents aren’t as proficient as attending surgeons—and everyone knows that, too. And yet at every training center in the United States residents do cases; and at every training center in the United States administrators continue to proclaim, “Patient care comes first.”

 

I was sitting in the front seat of Chris Pfeffer’s Olds drinking a Grain Belt. It was 11:45 P.M. Hockey had ended fifteen minutes earlier. Chris was a fourth-year ENT resident who had played college hockey at Harvard. He and I usually had a few beers together in the parking lot before heading home. The engine was running and the car was just starting to warm up. We were talking about residents doing surgery.

“I feel like a hypocrite,” I told him. “If I truly believed the system was wrong, I should have refused to do any cases these last four years. I should have insisted my attending do every case. Why didn’t I have the courage to admit that the attending was a better surgeon than I, and that the patient’s right to care was greater than my right to learn? Where were my scruples then? Hell, I did every case I could.”

“Me, too,” Chris said. “Still do.”

“You know what’s funny?” I said. “Now that I’m in my last year, I actually don’t do every case I can. I’ve already done so many hip and knee replacements that I don’t need to do any more. I let the younger guys do them.”

Chris took a long pull on his beer and laughed. “I get it,” he said. “As long as you don’t feel competent doing a case, you do it; but as soon as you get good at it, you turn it over to your junior resident.”

“Yeah, what a system. It guarantees that all cases are done by the least competent person—a kind of medical Peter Principle.”

“You think too much,” Chris said, yawning and tossing me another beer. “You and I don’t make the rules. We’re just a couple of fucking Zambonis riding up and down the ice. We go where we’re pointed. Someone else is at the controls.”

“That doesn’t mean it’s right.”

“Jesus, Mike, get off this ‘right’ stuff will you? Do you want to leave here after four years never having done a case?”

“Well, no.”

“Then shut the hell up. Leave it to BJ and the other big shots to figure out all this other shit. How can Chris Pfeffer and Mike Collins sort it all out? Hell, we have enough trouble trying to live on the two-fifty an hour they pay us.”

As I drove home that night I wondered if I was being too hard on myself. I turned cases over to my junior resident and taught him, just as my senior residents had turned cases over to and taught me. That was how we learned. But what continued to gnaw at me was the suspicion we ran a system good for us under the guise of being good for the patient.

“A little more anteversion. See how I’ve got the tibia pointing straight up and down? You want the femoral component to be angled just a bit more that way.”

I was guiding Alan through his first total hip replacement. He had watched me do several cases, and was familiar with the technique. I had gradually let him do more and more. But this was the first case I let him do it all, “skin to skin.”

He was nervous, and wanted my input at every step. That’s fine, I thought. I’d rather have someone too cautious than too cocky. When the femoral component was cemented in, Alan reduced the hip and put it through a range of motion. Then we set the leg on the Mayo stand and began to close. I could see the relief in Alan’s eyes. The hard stuff was over.

“Great job,” I told him.

“Very nice, Doctor,” Gladys the scrub nurse said.

“Gee, Alan, you must be good. Gladys never says that to me.”

“I do, too.”

“You do? Then does that mean you think I’m as good as Dr. Coventry?” Everyone knew she worshiped Dr. Coventry.

“Never!” she said immediately. “None of you are.” She slapped a hemostat into my hand.

“Not even Jack Manning?” I asked as I cauterized the bleeder.

“Phhht,” she said. “Dr. Manning.” She spat out his name, but it was all part of the game we played. She loved Jack, but she hated the way he teased her about how he was going to be the “next” Dr. Coventry.

The post-op X-ray looked great. I had the techs make an extra copy for Alan. Gladys, Nita the circulator, and I all signed it for him.

 

Alan and I had been working together for a month and things had been going well. I was at home changing the oil in the Battleship when Patti told me Alan was on the phone. We were on call that weekend. That meant Alan would initially handle any injuries or consults. He would call me if he needed help or advice.

“Mike,” he said, “I’m in the ER. We’ve got a sixty-two-year-old lady with a mid-shaft femur fracture, an open Colles, a fracture-dislocation of the ankle, and a shitload of belly and head trauma.”

“Car crash?”

“No, attempted suicide. She jumped out a window.”

Suicide. We didn’t see much of that in Rochester. I asked if she was stable.

“Not really. Her pressure is sixty or so. The general surgeons are taking her to the OR now. They said we can do our part when they’re done.”

I told Alan I would be right there. I finished filling the Battleship with oil and drove to the ER. Alan introduced me to the family. The specter of suicide lay all over them. They were by turn embarrassed, apprehensive, angry, and hurt. Apparently she was an alcoholic and had brought more than her share of trouble to the family. I found it hard to tell if they were more upset that she attempted suicide or that she failed. They didn’t seem terribly interested in what her injuries were or what we were going to do about them.

It was almost 5:00 P.M. before the general surgeons finished exploring the belly. They removed her spleen and repaired her liver. It was ten by the time Alan and I had rodded her femur, plated her ankle, put a lag screw across her talus, and externally fixed her distal radius. We took her to the ICU where she promptly coded. She died an hour later.

I went out to break the news to the family. The waiting room was empty. They had all gone home.

What a waste, I thought. What a total waste.

I had worked so hard to put her back together. I wanted everything to be perfect. I made sure we got the correct rotation and length of the femur. I made sure we got an anatomic reduction of the lateral malleolus. I made sure we avoided devascularizing the talus. I made sure we put the ex-fix on the radius just right. Her post-op films looked great.

Yeah, I thought, she’ll have the best-looking X-rays in the morgue.

Sitting there alone in the doctors’ locker room, head bowed, hands in my lap, I found it all so pointless. I had used all my skill and training to fix a lady whose family didn’t care about her, who didn’t care about herself, and who only lived for one hour.

I tried to give myself the usual pep talk: you do the best you can. What happens after that is beyond your control. But pep talks weren’t working that night. It was one of those nights when everything seems absurd, when everything seems so laughably presumptuous. What difference would it have made if she had lived another day, another year, another decade? In the end nothing would change.

I’m an orthopod, I thought. I fix things. Big deal. Everything I fix winds up in a coffin anyway.