* * Anonymous Doc

Friday, March 11, 2011

I just yelled at a med student.

I don't yell at med students. I don't yell. Some people yell. There are a fair number of residents who yell. I've had some of those residents. I'm not saying I'm better or worse, I just don't have it in me. I don't like to be in a work environment where everyone is walking on eggshells. I don't want the people under me to hate me. I don't want to hate the people above me. I want things to be friendly and civil so that spending twelve hours a day here isn't torture. I've had very competent interns and med students who do good work, who make the job a lot easier, who are certainly better than I was at that point, and who I genuinely enjoy being around, despite the work. And I've had interns and med students who work slowly, or make mistakes, and the attending teaches and I teach and we make it work and try to figure out what's causing the problem. And there's no need to yell. Everyone's trying, yelling won't accomplish anything. Even my med student who was making dental appointments in the middle of the day and telling me he had to leave in the middle of a rapid response-- we had a conversation, I tried to explain he needs to take on more responsibility-- I didn't yell.

Until today.

I don't know if this guy is taking lessons from the patient's wife who I wrote about in the last post, or what-- because it's pretty much the same story, only worse because this is a soon-to-be-doctor.

We have a patient who's not eating-- can't eat. It's not useful to explain any details, but it's a malnourished patient who needs to be eating and can't eat, and we're trying to nourish her in other ways but she's rapidly destabilizing. We had to move her to the ICU. We happened to move her right as they were coming around with the dinner trays. We get her out of her room, and my med student turns to me and says:

"I could probably steal her fruit cup, right?"

Then, off my look: "What? Too soon?" he says.

And I grabbed him. Okay, I probably didn't actually grab him, but I made it clear that he should follow me. And I took him into the stairwell, because we don't have private spaces, because we're prisoners, forced to be here for what feels like days at a time.

"This patient might die."

"Oh, I was just trying to make a joke--"

"Yeah. This patient might die. Do you understand that? We just moved this patient to the ICU because this patient might die. This patient, who we are supposed to keep alive, might die. Today. She might die today. And you're making a joke about her fruit cup?"

"I'm sorry. I--"

"I don't care. There is nothing you can say to justify it."

And I left him in the stairwell to deal with himself. Look, I don't know if I'm a hypocrite. There are patients who say stupid things, there are patients who are frustrating to deal with, there are families that are frustrating to deal with, we all cope in different ways. I'm not one to talk, given this blog. We sit in the call room and talk about the patients, we sit in clinic and talk about the patients, stories get around, not everything that is said is appropriate. But hopefully there is a difference, and there's a line. Death is real. You come in and complain about a "new cough" you then say you've had for the past thirty-three years, making a joke about that in the call room is one thing. But you watch us wheel out a patient who's clinging to life and may not survive the day-- and then you want to make a joke about *that*? I hope there's a difference. I think there's a difference.


  1. I understand your point of view but I also slightly sympathize with the medical student. As a med student we are new to everything and are trying to fit in as best as we can. There are so many doctors that teach us, and each doctor has a different personality and sense of humor. As a medical student we try to pick up on these personalities and attempt to imitate it so that we fit the mold. It sounds like the student felt pretty bad after you addressed it. It sounds to me like he has probably been around some docs that have this sense of humor & he figured this is just how docs act. It is good that you addressed it because obviously not all docs have that type of attitude, & now the student might be able to express more of who they are. I wouldn't write the student off just yet, if the student continues the same behavior that is just his/her personality & sure you can not like them all you want. It sounds to me that won't be the case and the student would probably benefit greatly from having a doc like you mentor to student and show how the student can still be their self and make it in medicine.

  2. It's not ok to make jokes like that.

    I'm also a hypocrite. Right after a talk about lymphomas, and people dying from lymphomas, I joked with my friend who had some pretty swollen lymph nodes about his "lymphoma." He laughed, I laughed, and I walked away hitting a wall of shame as I realized how deeply inappropriate that was. Neither of us thought he had lymphoma, but I suppose it would be on his ddx. The talk had been pretty depressing and it was a way to blow of some steam.

    Gallows humor. I'm not sure when it's ok. I'm sure it's sometimes necessary. Never within earshot of patients, and as a student - probably not within earshot of your superiors. There's also a difference between Gallows humor and making light of death and people's lives. I'm not sure where this student fits in.

  3. You did the right thing: you stated clearly what the problem was, you didn't get personal, but said what needed to be said. You're absolutely right that a family member could have overheard. Jesus.

    Have I blown off steam? Sure, but as you said, there's a line between gallows humor and situations that are Not Funny under any circumstances.

    To anonymous above: it's pretty weak to attempt to "fit in" by making jokes in questionable taste. Just because some attendings and residents make jokes in poor taste doesn't make it's okay, or, worse, a behavior to be emulated. I learned that as a student, and you will, too. Grow up.

  4. chill! Everyone is dying get in line.

  5. To the first commenter - the "Anonymous" med student - I don't care if you work with doctors who use this inappropriate humor. That does NOT mean that you should, too. And if you decide to do so, you are being highly unprofessional.

    As a student, your job isn't to "fit in," it's to learn. As a physician, your job will not be to fit in, it will be to do your damn job and do it well and with respect and reverence for the lives that will be in your hands. I certainly hope that you learn that before the beginning of your residency, or you won't be "fitting in" with many of your future patients. I suspect quite a few of them will dislike you... strongly.

    YOU, in fact, need to grow up and be your own person... not some lackey who modifies your affect based on who happens to be in the room. This implies to me that you lack the appropriate level of maturity needed to be a decent physician. I hope, for the sake of all of the human beings whose lives you intend to touch, that you mature quickly.

  6. I agree that the comment was completely inappropriate, and I think you responded perfectly, Dr. Anon. Still, I feel a little sorry for the med student. It is hard sometimes trying to figure out what to say and do, and unfortunately being able to fit in is really important to one's future success in life!! Sometimes in one's anxiety to do that, people say stupid things.

    On the other hand, it could totally be the case that this med student was just an insensitive douche. Don't be too hard on yourself. No matter what, the student learned something important because of you.

  7. OMDG: Under no circumstances is it acceptable to "fit in" by saying and doing things that are morally questionable. Wrong is wrong. If you think it's necessary for "future success in life", well, that's sad, and you will not improve the profession by joining it. In effect, you're saying it's more important to advance your career than to be a decent human being.

    The best doctors are both.

  8. I think labeling his comment as morally questionable is a bit of a stretch. I remember some rounds when I was starving, and a fruit cup sitting on the tray of a thousand-year-old patient who you *know* isn't going to eat...well, it can be tempting. Anyway, so he voiced it. If it was truly in ear-shot, then I agree it should have been gently dissuaded (I wouldn't have chewed him a new one, though). Not sure of this patient's circumstances, but lets face it: not all deaths are equally "tragic." We all know that half the ICU beds in any hospital are people who should've had DNRs. All this effort to get a 90-year-old patient to live long enough so he can get to his next hospital stay. So, in addition to gallows humor, it can be humor to diffuse some of the frustration--the seeming futility--related to the incredibly massive efforts that are made in medicine to protract (and frankly, distort) the dying process.

  9. When did we EVER get the idea to joke about death? It does NOT matter if a patient is 90 or 14, terminal or curable, death is a scary thing. Although it is inevitable, we, as doctors, have the responsibility to make the patients get healthy. It is not in our right to say that because a patient is 90, he or she deserves to die.

    You were not over-reacting. You did the right thing, bud. That was extremely inappropriate to say even if the patient was not in ear-shot. What if the patient had died? Would you still want his fruit cup? If it's more important to him to have a fruit cup than the fact that a person is getting worse, that someone is dying in front of him, then he would make for a terrible doctor.

    Your Faithful Follower

  10. Teufelhunden: Obviously, for reasons of HIPAA, Anonymous Doc couldn't share the particulars, but I really doubt this was a thousand-year-old patient. Since neither you nor I were there, I'm also going to give Anonymous Doc the benefit of the doubt re: the completely inappropriate nature of the comment, not the immature, insecure, thoughtless med student who made the comment. One would hope the student will learn from this encounter with his resident. If not, well, our profession is in serious trouble.

    More residents and attendings should speak up.

  11. Agree with Teufelhunden. Sure, the med student's comment was... insensitive, but I've been guilty of the same. Would you have flipped if this had been a hard-working MS3 who prerounded every day, knew his patients, wrote excellent notes, paid attention in conference, etc etc, and just said something stupid this one time? Probably not. Which doesn't make you wrong.

    Gray zones! They are hard.

    Anyway, I commend you for chewing the stud out in the stairwell. I always respect residents (and attendings) who discipline in private; there's no reason to make the whole floor your audience, ever.

  12. Clearly, medical schools are doing a bang-up job of selecting mature, compassionate individuals to become future doctors.

  13. Anon commenter above - What do you mean, when did we get the idea to joke about death? We joke all the time about things that are scary - BECAUSE THEY ARE SCARY. Humor is one way people deal with it.

    My father jokes frequently about how soon he might die - and he is in his mid-70s - and I asked him to please not do it around me, because it made me sad. But that doesn't mean humor is inappropriate for HIM.

    This particular joke was pretty stupid. Certainly you don't joke in front of a patient who is dying - unless you are joking with them, and it is clearly something they want/need to be dong. But you can't just cross off all dark humor ever, Anonymous commenter. You've been reading this blog too - surely you laughed at some of the predicaments described.

    Comedy and Tragedy go together and have for a long time. As it happens, this particular med student has a loose grasp of them both, but other people do it right, and we should probably encourage them. Things are pretty bleak without it.

  14. By the way, you might want to look at this post you wrote about a year ago...

  15. oh shit, that last guy was right:


    definitely dig the blog -- just found it today. but the "yelling" post was lame, man. jokes are jokes are jokes. death. rape. death and rape. anything and everything is fair game. and the whole "unprofessional" thing is overrated. treat and move one.