Monday, August 27, 2012

The Marked Man

The New York Times' Pauline Chen recently wrote about the bullying in medical training. She described a study out of the UCLA School of Medicine where medical students complained about being verbally abused, slapped, and racially taunted. The researchers expressed dismay at their findings despite all attempts at elevating medical education. I'm quite surprised too. Most medical students I know are quite coddled, if not spoiled, during their clerkships. If they don't finish seeing their patients before rounds, no worries; the intern is supposed to do it anyway. If they're bored with an operation, they can easily make up an excuse about a meeting that they must attend to. And heaven forbid if they should have to stay after 5:00 PM or work weekends. There are all sorts of rules for protecting medical students from the real rigors of being a resident and attending.

In reality, the real bullying and abuse occurs at the residency level. If these medical students are complaining about their treatments now, wait until they hit residency. Then they'll understand what physical and verbal abuse really means. Though I've previously addressed the abuse I took as a surgical resident, I think I can point to one particular incident that marked the beginning of the end for my unsuccessful surgery training.

It was coming towards the end of my surgical internship. By then I'd become pretty comfortable with the work and had been praised by many nurses and staff for my work ethic. One weekend night while on call, I was paged by a nurse to come evaluate a patient's foot. The patient had just had a vascular bypass during the day and now the nurse was having difficulty finding a pulse. I went to see the patient though I was only cross covering for the vascular service and didn't know the patient that well. Sure enough, the foot felt cold and I too couldn't find a pulse. I quickly notified the second year resident about the findings. She agreed and said she'd take care of it. This was around 2:00 AM so I went to bed after that, exhausted as usual. The next morning, I told the vascular intern about what happened overnight. We rounded on our own patients then I went home to be with my family who had flown in from out of town during one of my rare weekends off.

We were out for most of the day. When I came back, my answering machine was blinking furiously at me. I pushed the button to hear who had called me. Out came the angriest message from the vascular chief resident. It was laced with all sorts of expletives and threats. He kept yelling I was such a screw up and how I almost allowed his patient to die and how I was a complete moron. That's the sanitized version. Unfortunately the machine was sitting in the living room where my whole family heard the message. I must have turned pale as a ghost since they all asked anxiously if I was okay. I quickly tried to contact my chief and the vascular chief but nobody called me back.

By the next day, I got the whole story on that patient. The patient's graft had clotted off and he nearly lost his leg. All the blame was being pinned on me as I was the intern on call. I thought this was extremely unfair as I had notified my resident about it, and even documented it in the chart. But what I didn't understand was that the second year resident had already notified the program that she was quitting surgery and starting radiology residency in a couple of months. So she got a pass while I as a categorical surgery intern was supposed to be more responsible than a second year surgery dropout.

That week's M&M Conference was a total nightmare. My case was supposed to be the highlight of the hour. Though the entire surgery program was supposed to be there, the second year resident, who would have been my backup, decided she wasn't going to attend M&M since she was leaving soon enough. So I was left to try to defend my decisions in front of the entire staff. Needless to say, it did not go well. One after another it was "What were you thinking?" or "Why didn't you?" or "Didn't you know?" The humiliation didn't ever seem to end.

But what was worse was that I was now a marked man. In residency there are always the golden or chosen residents and the marked residents. The golden residents could sever a carotid and everything would be forgiven. The unfortunate targeted residents could get a skin dehiscence and he'd be raked over the coals for why the wound got infected, why he chose that particular suture, why he didn't treat it earlier. I had seen this happen to other surgery residents and it was always painful to watch them getting flagellated up in the front of the room every week while the golden residents were always given a pass for much more egregious errors in treatment. I though this was extremely unfair but that was how the system functioned. Now I was one of the marked men. As if surgery residency wasn't hard enough as it is, now everything was ten times worse, with every decision second guessed and analyzed. Every complication was amplified and torn apart on a weekly basis.

I believe that night was truly the end of my surgery training. Once you are marked for failure by the staff, there is very little that one can do to change their minds. As an anesthesiology attending, I have seen that this preconceived notion about who are good residents still exist with surgeons. So if these medical students are already complaining about their abuses in medical school, they ain't seen nothing yet.


  1. All true. But it certainly happens in anesthesiology residency as well. Probably in all residencies.

  2. Have you ever considered another profession? ..... Maybe there's a reason you did..

  3. Medical school is shit. Residency is shit.

    Doctors are shit.

  4. I saw this Marked Man scenario played out in medical school.
    It happens to a lesser extent during 3rd year clerkships with subjective evaluations. Students receive higher clerkship grades just for being cute and/or congenial. In 4th year and Residency, patient care responsibility and stakes are higher. Aggressive colleagues use power intimidation, bullying, and magnify your errors 1000 times while ignoring the same errors by same or higher level residents.
    Here’s my analysis of it happens and how to protect yourself.
    (1) Every social group has aggressive individuals who can be vicious bullies who have charisma to build social capital, but they will tap their social capital in a moment’s notice to bully and destroy their victims when their aggressive instincts are triggered. The key is that they follow extremely strict rules written and unwritten.
    (2) If you break their one of their written or unwritten social rules or other rules, those extremely aggressive individuals will viciously attack without consideration of mercy. As soon as they leave the room, they will begin to tap their social capital to deliver more violence with the hopes of failure or dismissal from the program. They will also start to collect a portfolio of things you have ‘done wrong’ as the days go by; innocent things which be portrayed in the worst possible light They might turn vicious after just 1 repeated infraction of their social rule, or just 1 or 2 observations of your being different than the norm. However, initially they will greet you with a bright smile and charm. Just be aware of the other side of that smile.
    How to protect yourself
    (1) Make it a point to figure out the social rules of your program (written and unwritten). Example, people who know the rules quietly how would x , y and z be accomplished before launching out. If you find yourself being bullied and verbally abused, just realize that it is due to some unwritten social rule you broke. Or some presentation of being different from their norm and expectations.
    (2) If anyone starts to verbally abuse, bully you or use power intimidation, figure out the social rule you may have violated. It is critical to get a conference meeting with them and authority FAST. Bullying builds momentum. Like cancer, if you catch it early you can stop it. If there is already metastasis, meaning IF they have already engaged their social network against you, and IF they have already collected a couple BS anecdotal stories to attack you with in a meeting, then it’s a harder battle. You have to catch it early when they still have ONLY ONE or TWO thing to say about you – not after they have collected 5-10 BS items. Like the law in the jungle the dominant lion is not going to kill the little lion if some deference is shown. But vicious people do not necessarily respond to apologies and deference. The purpose of your conference meeting is to clarify in front of the higher ups. Bullies Hate Meetings. Bullying work much better when they can work privately in on a day by day basis and they have no intention of stopping they only escalate, recruit social networks and make a game of it. Avoid the snow ball.
    (3) If people often do not fancy you, and you are typically a lightning rod for controversy, research how to becoming more congenial. and put special focus on quiet excellence. With emphasis on the word quiet.