Let’s face it, residency is no picnic. A combination of on the job training and trial by fire, no physician who has gone through it and survived will ever forget the experience. The emotions run from jubilation to sheer terror. It is inevitable that some of the people you interact with will leave a lasting impression. In the case of the resident, it is the attending physicians that fulfill the role of the teachers.
In my case, two attendings come to mind, let’s call them Dr. O and Dr. K. I first worked with both during my first year when assigned to the hospital in our system that did almost all of the pediatric orthopedics. There was an ER for mild trauma, but 75 percent of the elective surgery was pediatric. We routinely handled everything from club feet to hip dysplasia to scoliosis. Since this was inner city hospital with a large Hispanic population, we saw a lot of pathology. Working in the busy clinics it almost became a necessity for the residents to learn Spanish.
Dr. O was a 6′ 6″ hulk of a man who was the son of a poor immigrant and in private practice for many years. Working his entire life to put himself through school and build a practice on his own he would pull no punches with his opinions or his temper. George S. Patton comes to mind. I was never quite sure of Dr. K’s background, but he had been hired by the department chairman just two years prior because he completed a pediatric orthopedic fellowship. To put it bluntly, politics played a very important part in the hierarchy of the surgical department, and Dr. K knew this well. Dr. O, on the other hand, could care less.
When a resident wished to do to case from the clinic, they would present the case during grand rounds. To those who are not familiar with it, grand rounds is where the resident presents a case in front of the entire department. The resident is then grilled as to their knowledge of the case, treatment options and the justification for surgery. Both Dr. O’s and Dr. K’s styles were very different. Dr. O would ask a few straightforward questions and gave a very direct opinion as to whether or not he agreed surgery was justified. Dr. K, on the other hand, would keep asking more and more questions that appeared to have the sole purpose of just watching the residents squirm. It was very intimidating, especially to a first-year resident, but it had one bright spot. If the questioning got to out of hand, Dr. O would step in and demand to know why Dr. K was prolonging the questioning, especially when he felt the resident made an excellent case. I have to admit that it was a pleasure to hear Dr. O say to Dr. K more than once, “You don’t know what the hell you are talking about,” and watch Dr. K’s face turn red.
If Dr. O agreed that the case warranted surgery, he would meet with the family once before in the clinic. He would see them once more immediately prior to surgery and once or twice after. He was short and precise, explaining what the condition was, the need for the surgery, and what exactly would be done. No high marks for bedside manner but you knew exactly what to expect. I would best describe the family’s reaction as scared but reassured. Dr. K, on the other hand, would start out by saying something like, “I am so sorry this has happened to you,” and then went into a long explanation of the disease and treatment options, something the residents had already done. He was very non-committal regarding the surgery and appeared to only half agree to do it. I would best describe the family’s reaction as confused.
The differences extended into the O.R. Dr. O would come to O.R. into and immediately take over. One of the least kept secrets was the fact that he was having a long standing affair with one of the head nurses and watching them interact was a riot because she was more than his match. Dr. K came in quietly and just started working. After that, the contrasts could not be more different. Dr. Os cases ran with the precision of a fine Swiss watch whether he was doing a complex scoliosis case or a joint replacement. Dr. K’s cases were less precise.
But what has stuck in my mind the most was how they both interacted with the residents. A resident can memorize absolutely everything about a case but until you are there actually working you cannot say you are a surgeon. It was the norm for a resident to sometimes get lost and confused. Both surgeons would start out by saying something like, “What the hell are you doing?” The difference was that Dr. K would continue to belittle you even long after the case that made its way up the political hierarchy. If you answered Dr. O that you had no idea what to do he would kick you out of the room. However, if you demonstrated that you at least tried to prepare by studying the anatomy and procedure, he would say, “OK, you know what to do. You just have not done it yet,” and proceed to help you. I would continue to use some of Dr. Os tricks my entire career. Suffice it to say, there is no need to tell you about the differences in the long-term patient outcomes between Dr. O and Dr. K.
I will leave it up to you to guess which surgeon was more popular with the residents and which was more popular with the political hierarchy. Years later, I heard that Dr. O retired with distinction and managed to outlive every member of that hierarchy. The sad part is these days the Dr. Os likely would not survive. The Dr. Ks also do not survive but they last longer because political skills seem to be valued above all else whether in the form of compliance to a hospital protocol or the ability to get high marks on a patient evaluation.
All I know is that if I or a member of my family ever needs surgery I will take a Dr. O every time.
Thomas D. Guastavino is an orthopedic surgeon.
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