1979 found me in my first year’s work as an MD. I was an intern at the county hospital in Salinas, California. The foundational education at hospitals like UCLA and Cedars Sinai were just that—foundational—but they were without much fun or the pressure of being, “the one” taking care of business when no one else was around. As I had acquired my sea legs and experienced the class divisions found in a rural county hospital, some of the black humor first introduced in Los Angeles sparked a genuine reaction in my day to day. My good friend found a humorous diversion, a game called, Intern. Modeled like Monopoly, there were slots on each four sides of the board, each representing a hospital ward: Surgery, Neurology, Medicine, and OB-GYN. One rolled the dice, drew a card (It might have even been a Chance card) moved your figure around the board and the fates executed their answers. The goal of the game? One might suppose that curing all the patients on your ward might be a goal—maybe curing them before the other doctors did the same with their patients. That was not the winning strategy. The goal was to empty your ward. To do this, you could cure your patients, they could die, or you could find a reason to transfer them to another ward. This last choice proved to be the winning strategy.
Young idealistic residents within the first year of internship were reduced to black humor and winning a game by tricking the system into moving them on to be someone else’s problem.
With time I would come to look at this strategy as one taken on by the insurance industry.
I imagine trying to explain this game to modern residents. The black humor, I am sure they would get, but the mechanism of transfers? My understanding that there is gridlock in our modern hospitals and transfers are still a possible strategy, but one that is very hard to attain.
My work in the family practice residency complicated this cynical reading of what our work was. We did transfer patients between services or wards, but when we had such a transfer in our small county hospital, the patient went to a coworker—a fellow resident— and perhaps but not always, a friend. What might make your workload easier was something that might add to the workload of a friend.
One transfer occurred when I was on general surgery. The resident the year before me was on specialty surgery (ie he managed cases that had required a specialty intervention for example those who had had surgery on their neck, ears, throat, chest, or urological parts). One morning, we heard that overnight, a member of a motorcycle gang had been admitted having been shot point blank in the chest with a hand gun. He was admitted to the specialty service by the on- call resident but at the morning’s report, it became clear that the bullet had not pierced his heart, major vessels, or even his lung. The chest xray showed little markings of lead in the chest wall with the bullet itself, somewhere in his back. Dr. Hunt, the second year resident let me know he would transfer the patient to my care as no specialty intervention would be necessary. I was unsettled; the only work I could see was arranging for the discharge when I was sure he was stable, and interacting with the Sherrif’s department. I was babysitting. My attending surgeon however was wryly amused. We went to see the patient.
Motorcycle gang members lose some of their mojo lying in bed with a hospital gown. This guy had an engaging personality and he was on—and why not? He had been shot in a bar at point blank range, right where his heart should be and he was alive and quite happy to interact with us. We examined the entry wound, just to the left of his sternum and could find no exit wound. When listening to his lung sounds, I encountered a bulge just under the skin in his back. The surgeon smiled. “There’s your bullet.”
I put two and two together. “So the bullet entered at an angle and tracked under the skin and over the ribs until it came to rest in his back.”
“Yes…….”
“So what do we do?”
“If it were me,” the surgeon is grinning at me, “I would remove it under local.”
I suddenly realized the lazy Dr. Hunt and his transfer of care to me would allow me to do a procedure. I became a doctor to do procedures. I grinned back.
I reviewed the procedure and where it should be done with the surgeon. There was no need to use the operating room. Local anesthesia should be adequate for the job.
The patient took all this in stride. I came back in the afternoon and had him sit up in his bed; I cleaned and then anesthetized the area where I could feel the lump. I made a sharp incision and the bullet popping right out and into the stainless steel emesis basin. The surgeon had made a point of making sure I had a steel emesis basin ready to catch the bullet. The resulting noise was one of which Gary Cooper or Jimmie Steward would have approved.
The patient asked if he could see the bullet; I showed it to him. He asked if he could keep it. I understood the allure but no, the Sherrif’s department had a pretty clear claim to it. He accepted this with resignation.
One of my favorite cases of my first year came to me as a transfer.
That ethos of taking pride in doing the work and not transferring also required some work. New to Olympia, one Christmas, I had two admissions, both complicated. The first I finessed with help over the phone. The second was very complicated—-really really complicated. As I worked through the process that every admission entailed, the discussion points on this case were heard by one of the hospitalists who worked in the ICU. We did not know each other well but he, in a friendly manner, checked in with me and suggested that my partners in Seattle would really like to get their hands on this patient. My not wanting to bother anyone on Christmas suddenly looked silly and I was gratified by the response I got from the Oncology department in Seattle’s Group Health Hospital: “Send him right up!”
One of my least favorite cases early in my career was taken off my hands by a graceful and talented doctor.
I was and remain a very lucky doctor!
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