A recent family practice journal article tested me on the phenomena of testicular torsion (a painful condition of mostly growing boys and adolescents where a testicle twists on itself and cuts off its own circulation). I have not thought of this condition for some time but remembered how central it was to my coming of age as a doctor.
While in medical school, surgical specialties held a kind of draw for me. I like working with my hands and I like my work to be clearly identified as having improved things. Surgery facilitates such desires. The surgical residencies were self-identified as brutal and long. They were also a bit confining with respect to the breadth of medical care they provided. In a sense, I wanted to do everything—I was of the Marcus Welby school of doctoring— and the surgical specialties would not deliver on that. Nonetheless, my interest in surgery was clear and remains with me.
One of the few times in my life to experience an academic oral examination was in surgery at UCLA. My examiner was unknown to me. He had an easy going manner and soon we were having a fairly normal interaction, where he would pose a question and I would explore the answer trying to show off any extra information or experience I might have. It was going really really well when he asked, “Tell me about pseudocysts.” I smiled and jumped in explaining and defining the anatomy. He smiled and nodded as we went. When we finished, I asked, “So, how did I do?” He responded, “Well, you did pretty well though you described a cystocoele when I asked about a pseudocyst.” The color drained from my face. “No worries, Ray, it is clear to me that you know your stuff and you enjoy it.” He did not however, ask me to consider a career in surgery as had my attending physician in the Urological clerkship.
My residency was at Natividad Medical Center in Salinas California—the county hospital. When on call as an intern, one pretty much was the “goffer” with respect to any problem on the hospital floors outside the ICU. I learned within a few months to dread certain nights because once every two weeks, a consulting urologist came to the hospital and performed surgery. This urologist was clumsy in speech, temperament, and to my disadvantage, surgical skill.
This doctor (we played often with appropriate names by specialty, so I will crown him, Dr. Seaman) commonly left an elderly man on the medical floor after prostate surgery with a urethral catheter that typically clotted off with blood around 2 AM. The bladder swole painfully. I had no special expertise in relieving the now overfilled bladder and in the spirit of, “see one, do one, teach one,” I was shown how to irrigate the clots free and suck them out with a giant syringe. The technique was, “plumbing 101” and frankly did not work well. My ego and heart both took a beating as delirious post operative very old men sensed the painful over-filled bladder that I attempted to drain. Not infrequently, I gave up and attempted to re insert a new catheter that given the recent surgery, was unpleasant for all concerned. This exercise predictably got me behind with other work, admissions, and preparing for the morning rounds.
My calls to Dr. Seaman if made in a timely manner (2:00 AM) were not well received. A form of hazing seemed the norm and I could imagine him in some surgical hospital having to do this work over and over as a surgical resident. He offered no pointers or suggestions to help.
This experience was new for me as at UCLA, a two week clinical rotation in urology found a world renowned surgeon of prostate cancer suggesting after I scrubbed in with him on a few cases that I should seriously take Urology as a chosen profession. His work was clean if not elegant and he was a fountain of education. His residents were wonderful doctors. I took this attention to heart but felt the specialty to be a bit confining despite the “hands on” benefits. So just a little over a year later, I was trying to reinvent the wheel with no back up in a very lonely rural county hospital.
The sloppiness of Dr. Seaman’s work was well known among fellow residents and the nursing staff. We were lucky to have a private urologist willing to work in the county hospital and so it would seem, it was the cost of doing business. There was one other urologist that took cases and this was a man whose origins were Thailand. Dr. Cockburn was wonderful with his surgical skill, good heart, and pleasant temperament. He could however, be a little silly; “Ah, Randy, the case you present is a classic example of a leaky tiki.” It was times like these that I re thought my leaving UCLA.
My second year found me assisting surgery of all types and this included urological cases. Most urological cases did not require my presence. Dr. Seaman however, hit the gold mine when the Republic of South Vietnam collapsed. We were near a large army base, Fort Ord, and many Vietnamese immigrants found their way to our community. I think Dr. Seamen met them on the tarmac after the airlift and convinced all the males, regardless of age, that they could not be real Americans unless they were circumcised. I assisted on many an adult circumcision that year. It was nothing short of criminal. If you question the pain of a circumcision for your newborn male child or grandchild, I would welcome your introduction to this surgery in adults and the follow up clinic visit for suture removal. I never knew that a penis could swell, ooze, bleed, and chafe as these poor SOB’s demonstrated the week after surgery. Dr. Seaman was oblivious to all that. It was business as usual and I am sure he collected fees from the MediCal system as renumeration for such procedures was not small.
So, Dr. Seaman’s judgement by my third year of residency had been called to question on many occasions. I learned from some of the older staff doctors that he used to be much better, but a stroke which occurred in the setting of a tennis game took him down several notches, and no, he had never been quite the same.
I had a young man come to the Emergency Room one night and the Emergency Room Doctor rightly sorted that this boy had a torsed testicle. As a consequence, there was pain, swelling, nausea, and vomiting. Movement of the legs was painful. One has to consider infection as an alternative cause but in this boy’s case, it was pretty clear that he did not have an STD. The treatment of such cases is time-honored and not controversial. One has to do a surgical reversal of the torsion and then “tack down” the testicle to prevent a recurrence. It has to be done relatively quickly (a few hours) to be successful. I got his paperwork in order and called Dr. Seaman, who was on call. He answered the phone and it was clear that he was at a party; there were clinking glasses, multiple voices competing for attention, and over all that, I gave a succinct absolutely clear presentation that left no room for second guessing. “OK,” he said, “Get him on the schedule for tomorrow morning.”
I was stunned. “I don’t understand; he will lose his testicle if we wait that long. Do you doubt the diagnosis?”
I don’t recall his response but he was clear that he would operate the next day. I decided that our communication was flawed and that he did not have confidence in me. I decided to rely on an objective irrefutable test. I ordered a Doppler ultrasound of the testicle. This would require an ambulance ride to the private hospital as that was the only place in Salinas where there was equipment to perform the test. The boy had to be accompanied by a doctor and the intern agreed to do this. Three hours later, (it was now around midnight) I called Dr. Seaman with the results of the test that showed no blood flow to the testicle.
“This does not change anything; we will operate in the morning.” No slurring. No sense that he was impaired. It occurred to me that if pressed to come in, he might suggest the kid was losing his testicle regardless.
We operated between 8:00 and 9:00 AM. By this time in my career, I had seen gangrene—mostly in extremities, but as he sliced open the scrotum, it was like a serving of black caviar: black lumpy dead testicle. I was silent and I was furious.
The boy, as boys tend to do, healed quickly and was out of the hospital with little fuss or bother. The parents were thankful that, “that was all it was.” They undoubtedly had cancer on their minds. My fury grew.
There are certain identified personality traits. I score high in the one labeled, “agreeableness.” I strayed from my comfort zone with this case. I wrote a letter to the board of directors of the hospital. I no longer recall if I got advice about this course which for a resident, had a potential downside. I know I would have discussed it with the staff surgeons and know they had no influence over Dr. Seaman and in fact, needed Dr. Seaman to flesh out the coverage we provided the population of patients unable to access the private hospital. Filled with moral indignation and knowing I had a good reputation with the hospital staff, I thought I might have influence by making this case known to the Board.
I got on with my work.
Months later, I got a short formal letter letting me know my efforts were appreciated. They would not/could not comment on the outcome of their investigation-that was confidential. The same week, Dr. Cockburn took me aside. “You know Randy, I would really rather that you had not written that letter.” He would not tell me why. “If you ever encounter a case like that again, even if I am not on duty, you give me a call, OK?”
That was easy and my agreeableness got back into its lane. Only later would I ask, “What if you are not around? If the hospital will not act on this case (Dr. Seaman continued to take call for us), what act would trip an action?”
With the passage of years, I remain troubled by the very real problem we all have with a clear sense of right and wrong or of competence and incompetence while juggling the needs of an institution, organization, or family that is woefully under-resourced. What is the tripwire for no longer accommodating a wrong or incompetent action? If the authorities with responsibility won’t act, how can an individual work the issue?
Dr. Seaman undoubtedly ended his career on his terms; as I think back on the medical society in Salinas I trained in, it seemed like the wild west. Returning for a reunion many years later, things looked much more normal. And yet, even in my community, there have been impaired doctors behaving badly. I wish the majority of doctors and nurses I have known were less conflict averse in reporting bad behavior. I wish I had more faith that the regulatory agency had its head on straight when evaluating such complaints. Mostly I have seen successes with this process and to this point have appreciated their work (Washington State Medical Commission). Usually, it takes a personal grudge to “go there” and register a formal complaint as was my case above. Many examples of repeated bad behavior or practice don’t rise to the level of a Commission action; consider for example, if I had complained about the unnecessary circumcision of Vietnamese immigrants. It is hard to believe the Commission could or would have acted on that complaint as it was based on my value judgement. I would have been tilting at windmills. What might have been more meaningful if I had considered it was taking the complaint to the California version of our medical commission ie outside the county hospital’s administration. That would have been a very hard thing to do for a doctor in training.
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