The Things That Medical School Won't Teach You (10): [Good] Leadership

"Thrown under the Bus" by Jason Jones

My (Kenyan) medical internship was a treasure trove of experiences, and thus on this fine day we will be revisiting one of those many formative experiences.

So I'm in the Obs/Gyne department (little surprise), and it was one of our elective theater days (either Monday or Thursday if memory serves me right), and I was assisting a consultant as he performed a TAH (aka Total Abdominal Hysterectomy). We've gotten through the relevant set of procedures, cut what needs cutting, and tied off any bleeders that need to be tied off. All this was done with very little blood loss all around.

So, now comes the moment of truth. Patient has been adequately hydrated by the anaesthetists and it's time to make sure that the patient is able to produce urine. So the patient gets a dose of a diuretic (Lasix/Furosemide), and we keep our eyes on the catheter that's been shoved up their urethra waiting to see some magic happen. Unfortunately, after about 10 minutes of watching, nary a drop of urine has collected in the urine bag. Basically, my consultant ended up tying up the patient's ureters during the procedure - the most common complication your medical school teachers would warn you about concerning this procedure.

So, it's back to the drawing board, or the chopping block as luck would have it. We proceed to backtrack trying to figure out at which point the ureters have been tied, and undo the damage. What should have been a 1 - 2 hour procedure ended up being a 5 hour long procedure with not so much as a break taken in-between; however, we came out of it thinking that we had at least salvaged the situation.

We skip forward to her time in the ward, and it becomes painfully obvious that the patient still isn't out of the woods. Her urine still isn't making it through the catheter, but, it is now draining through the incision scar in her abdomen. On the one hand, we're glad that she won't be developing kidney failure; on the other hand, we still have a veritable mess and our patient's dressing and bedding keep being stained with urine.

Worst of all was my consultant's decision to go AWOL and leave me "holding the hot potato". Imagine having to explain that stuff to the patient and her exasperated relatives day in and day out. At this point, the consultant is only addressing the issue via phone conversations with me. Eventually, plans ended up being made to transfer her to a bigger hospital to address the issue, but then some haggling over the issue of footing the ambulance bill to get her there broke out and threatened to lengthen her stay at our hospital. I don't remember how things finally got sorted out, but eventually she left, and I had never been so glad to see a patient leave.

Medicine in its most classical form is learned through apprenticeship. Some teachers might go a bit overboard with the "See one, do one, teach one" approach to learning procedures, but at the end of the day you need to be learning the nitty-gritty from someone else. With that in mind, when you're starting out you benefit from having a good leader who can impart useful knowledge, teach you the complexities of patient care, and even act as a mentor. Some of these people will actually sway you towards choosing which field to specialize in if you come into the game unsure of which direction you feel called in.

However, as I was recently reminded by a friend of mine, a "God Complex" almost certainly seems to be associated with doctors. I did take some time to correct the misconception though; just like I had been reminded by my friend Javed (circa Wenzhou, 2007), people have multiple reasons for choosing to become doctors. The way he broke it down for me, there were basically about 10 reasons, but the more common ones (of the top of my head) are as follows:

1. Prestige
2. Feeling called to help in society
3. Prior interaction with medical professionals due to your own/relative's illness
4. Money
5. Following in a parent's footsteps.

If "Prestige" is someone's driving force, you shouldn't really be surprised if patients, colleagues and juniors end up being used like mere stepping stones. You've probably been in the presence of doctors who made you feel like they were only interacting with you for the purpose of making a pay cheque - unnecessary tests, needlessly excessive repeat appointments, excessive medication, aggressively scheduling you for surgical procedures, etc. If we are looking to put a dent in your wallet, or take advantage of your insurance, many are the ways that we could make that happen. Truthfully, any doctor worth their salt should be able to explain their reasoning and justification for everything they subject you to, and you can always seek a second opinion if you're not convinced.

Medical school does not endeavour to develop people's character. They might sneak in an Ethics class or two, but character formation is really up to the individual and those that you choose to mentor you. So when it comes to "God Complexes", that was probably the default baseline setting of the respective individual. They would have ended up being a difficult lout regardless of whether they had chosen Business, Engineering, Politics, Fashion or Teaching.   

I have interacted with many doctors in my time who were very humble and willing to show me the ropes. My most vivid memory was working with Dr. Onkunya who showed me how to perform an excision of a breast fibroadenoma when I told him I had never performed one before. It was my first day in the Casualty, and one of my initial interactions with Dr. Onkunya, and I really didn't know what to expect. Fortunately, he was so concise and precise about the whole thing, and encouraging as he tutored me such that I was able to flawlessly replicate his technique and perform the next one on my own, and eventually teach the technique to others.

Unfortunately, I have also interacted with a lot of doctors that are a disservice to the profession. Some doctors merely see the practice of medicine as a power play and a chance to browbeat you into submission. You'd think you were in a boot camp, and they were drill sergeants. These doctors are usually short-tempered, prone to chastising and insulting you at the drop of a hat. Learning from them is also a task as they can opt to show you up in public (among your colleagues during ward rounds), and without remedying your ignorance, simply tell you to go read a book. Seems like their amount of bravado is inversely proportional to their actual skill. These doctors encourage you to basically hide your imperfection and basically "fake it till you make it", which, in light of rampant medical errors and malpractice, is about the worst thing you could ever do. Even at a basic level, doctors are tasked with repairing/fixing the human body and its processes after things have obviously gone awry; and we are expected to do it to such an extent - whether by surgery or drugs, physical therapy, etc - that the verisimilitude would approach that of a normal functioning body. You can't really fathom how much things can go wrong until you have to "undo" the work of one of your colleagues. This could range from poorly placed implants, poorly sutured wounds, erroneous drug prescriptions, missed diagnoses and misdiagnoses, etc.

A good practitioner will teach you to own up to your mistakes early, and to fix them as soon as possible; if that entails getting help, then get the aforementioned help; in retrospect, my Obs-Gyn consultant did just that - I just wish he had had the guts to actually talk to the aggrieved family face-to-face. A poor practitioner, however, is likely to be averse to admitting fault and/or blame others or systems for their failings. When that happens, you best be prepared to have yourself thrown under the bus for someone else's follies. I remember so vividly being tossed under the bus by my Director of Medical Services last year for something that was obviously a systemic issue that stemmed from poor management practices at the hospital, one of which they immediately course-corrected after this particular misfortune. (I cannot divulge any further information because that specific case might be undergoing some active litigation). If you haven't been thrown under the bus a couple of times in your career, then you've probably had a hallowed existence...like a unicorn. Since it is such a common evil, you should make it a point to cover yourself accordingly:

1. Document, document, document!  (Rule of thumb: if it isn't written down, assume it wasn't done!)
2. Be careful about anything that you end up signing
3. Be careful about being sent to witness a post-mortem. If litigation ensues (and court cases can last a really long period - years), you will find yourself sitting in court because of just one case.
4. Don't assume that the hospital has your back during a court case. It would be great to assume that this great community of individuals that you spend so much time with is your family, but such sentiment can turn in a minute. Distinguish yourself as a consummate professional, but always remember, "it's everyone for him/herself and God for everybody!" 

On a more positive note, remember that the vast majority of doctors actually joined the service for more philanthropic reasons. In a world this crazy, there are still good people trying to make things work; and the best of them can teach all these skill and experiences, and can inspire a whole host of people in the process.

As a parting shot, I remember that during my pre-internship at Kenyatta National Hospital (KNH), an Obs-Gyn consultant was walking though the maternity ward, and he was giving this rousing speech in order to let people know what was up. Can't remember most of it, but this little snippet (paraphrased) stuck in my mind,

"We are here to do a job. If you do not know what needs to be done, kindly make yourself known to us so that you can be taught what that involves; but if you feel like you don't need to know, then keep yourself out of our way so that we can still do effective work"

Very blunt and straight to the point! This hallowed profession demands that we always propel it forward, and check ourselves if our egos or other shortcomings are an impediment to its practise. We should remember that we are called upon to lead, as much as to be led. Therefore, invest yourself in learning to lead as much as you hit the books to improve your skills; and always remain teachable - the effort will never be wasted.

God Bless.