The Road through Residency:


It's a scary thing when people look directly at you when someone is dying. While the face can lie about its emotions, the neck never can. The pulsating carotid bulge, the contraction of the sternocleidomastoid, cannot be calmed in a moment of fear. Many years ago, when I worked in the emergency room as a technician, even the most seasoned attending physicians, with their poker faces practiced over a lifetime of medicine, were betrayed by this muscular tightening of the neck.

One of the greatest modern physicians, Sir William Osler himself, described the quality of resolve in the face of great and certain adversity, which he considered essential to the modern physician, as imperturbability. In his address Aequanimitas (a Latin conjunction meaning "even mind"), he relates, "Imperturbability means coolness and presence of mind under all circumstances… immobility, impassiveness, or, to use an old and expressive word, phlegm."

A few hours into the first of many call nights I will experience as a resident, the pager on my hip goes off and a voice comes over the address system: "Code blue, room…" I've had anxious dreams exactly like this for months, but this time, the situation is undeniably real. Flying up the stairs and into the room, I try to take control over a situation that actually seems fairly stable without my intervention. I don't necessarily feel overwhelmed. I follow the algorithm that has been beaten into my mind. I try to think out of the box, I examine, I watch, and I analyze. There really is nothing more I can do. The chest compressions are sustaining an excellent femoral pulse. The carotid pulse bounds with each push into the chest. The rhythm on the monitor jumps and falls. The cycle continues: shock, drug, shock, drug. It's almost like a dance, where each step is delineated. An anti-arrythmic drug here, a dose of magnesium there. Suddenly, I realize that I'm no longer treating the patient. I'm treating the family outside the doorway.

Osler wasn't a cold, aloof physician bent upon making robots out of medical students. The "firmness and courage" essential for physicians should never come, he insisted, at the cost of "hardening 'the human heart by which we live.'" Nowadays, physicians seem to fear our patients more than a failure of our own courage. We are much more worried about harming the patient than afraid that some disease will take them from us. Writing down an order for medication or treatment has a sense of finality to it. There is no going back.

"Do everything you have to," the patient's son tells me. I take his words to heart and assure him we are doing all we can. I wouldn't look so confident in my response if my senior resident weren't standing behind me. When you're being pushed to the edge of your comfort, it's nice to have someone back you up. I return to the scene, still filled with a deep-seated fear that I'm forgetting something, that I may do something wrong, in the incorrect order, or without some vital piece of information. But there's no time to stop and second-guess. I keep watching the monitor, my fingers on the femoral pulse, repeating the algorithm in my mind like a prayer.

The truth is that physicians make mistakes. We're only human. No matter how many checks and balances exist in the hospital system, errors will seep in. At the end of the day, you have to accept this, or you'll never be able to keep out the fear that can freeze you in your tracks. I suppose the mistakes we make, we can ultimately live with, as long as they are in good faith. These are the mistakes made from ignorance beyond medical knowledge, from the excessive complexity of a situation, not because we faltered in our resolve.

In his farewell address, Osler admitted, "I have made mistakes, but they have been mistakes of the head, not of the heart. I can truly say, and I take upon myself to witness, that in my sojourn among you: 'I have loved no darkness / Sophisticated no truth / Nursed no delusion / Allowed no fear.'"

At the beginning of what I hope will be a long and fulfilling career as a physician, I can only hope I will someday be able to look back and say the same.