Thursday, August 4, 2011

Introduction to Clinical Mediocrity

“Oh well.” The nurse midwife shrugged her shoulders and went on to see the next patient. I had to get out of there. I wasn’t proud of wanting to leave, because maybe I could have helped things if I had stayed longer. But with frustration stewing just beneath my smiling exterior, I felt like it was time to go. And it was time to go. I was only scheduled to be at the clinic until noon, and it was now a quarter past one.
“Can you please fill out my evaluation before I leave?” The midwife nodded, took a look at my form, and then made me read off each category, noting which grades I should check off for my performance. The print was too small, she said. I did it with a smile. “Grab some of my super-juice on the way out” she hollered from a patient’s room after we were done. I filled my cup with the green concoction that she had purchased from a health food store, took a few sips, and tossed the rest in a trash bin on my way out of the hospital.
“Oh well” is something you say when your milk expires. It is appropriate for lost pens and broken vending machines. “Oh well” is not something you say to a nurse after she goes sprinting out of clinic and hospital in hopes of delivering to a patient the prescription you forgot to write. There is nothing dismissive about providing substandard care. I wanted to trash "oh well" like I had trashed the super-juice.
For the most part, third year is exhilarating. You come home exhausted because you’ve emptied yourself into new experiences. You deliver your first baby, you perform your first Pap smear, and you see 19 cm tumors being dissected out of people’s bellies. The most frustrating thing about third year, therefore, isn’t the sleep debt you quickly accumulate, or taking call on weekends, or even the time you spend studying for exams on top of it all. I think the most depressing part is that long hours spent in the hospital will eventually bring you right up against the darker underbelly of medicine. The inevitable truth is that we will all see patients—people who lean on us—being mistreated, mismanaged, or sometimes even blatantly misled. I wasn’t exhausted when I came home from the clinic that day. I was furious.
I had spent the morning at an obstetrics clinic working with a certified nurse midwife and her team of two nurses doing routine check-ups on pregnant women. “You will be helping me with the computer today,” she told me after I introduced myself. I gave her an eager nod, “alright, sounds good.” It was only my second day on the new LAC computer charting system, and the electronic procedures were all foreign to me. But you learn that as a third-year student, the right answer is always “of course I’ll do that” or “yeah, that sounds good.” So I watched as the midwife saw her first patient while indicating to me which icons to click, what things to type, how to create and file new notes—stuff like that. Then she entrusted me with the charting.
Even as I settled into my role, I quickly realized some things were being overlooked. After interviewing one of our first patients, the midwife insisted that I include in my note, “no vaginal bleeding, leakage of fluid, or uterine contractions. Positive fetal movements.” This is a pretty standard review for all pregnant women—except in this particular interview she asked none of those questions. In my most pleasant tone, I piped, “Oh, did we ask the patient these questions?” The midwife looked at me incredulously, and replied “don’t you think she would have told us if she had any of those?” I nodded and kept my lips tight. Maybe the midwife’s assessment was fair. Maybe not. You learn early on in medicine never to assume, and I didn’t feel comfortable making even these seemingly small assumptions. I know enough to know that this is how you get in trouble. So my frustrations began to mount.
After we saw a few more patients, she began asking me to include in every chart that “patient was counseled on preterm labor precautions.” It would have been appropriate except that no such counseling occurred. I started growing uncomfortable with some of this. As a medical student, you are often so busy trying to learn the culture and practice of each rotation, you sometimes lack the time and insight to raise valid questions. And even if your wits catch up with you, your position at the bottom of the totem pole sometimes precludes you from wielding a voice. So you learn to choose your battles wisely—especially if they involve engaging a superior who is expected to evaluate you. In retrospect, I regret not asking the midwife to clarify what she meant by preterm labor precautions. Somehow, in the heat of learning a new computer system and working in a new environment, my wits just never caught up with me. Or maybe they were being drowned out by my own frustration.
Things got worse when a Chinese couple came into our clinic toward the end of the morning. They spoke Mandarin and I was excited to be able to communicate fluently with them. The midwife dove into the exam while asking the husband a few questions, because his English was marginally better than his pregnant wife’s.  I started translating and taking my own history on the side, taking joy in answering a few of their simpler questions in Chinese. As I flipped through the patient’s electronic chart, I saw stated in previous records that there was a prior complaint of green vaginal discharge. I turned to the midwife and asked if a pelvic exam would be appropriate to which she simply replied “well, she was given antibiotics last time so she should be okay.” No exam. No repeat culture. Not even a few questions regarding whether the patient was still having symptoms. Instead, the couple was ushered out of the room, and I was left to finish the charting. After a few moments the midwife poked her head back into our room. “Are you ready for the next patient?” I was ready to leave.
The next patient turned out to be the lady for whom the midwife forgot to prescribe antibiotics. The positive urinalysis results were lying on the desk beside the patients chart, and we somehow missed it. The nurse ran to the bus-stop and returned with the prescription still in hand. “Oh well.” I can’t remember exactly how I felt as I left the clinic that day, because my head was spinning a bit. I do know that my thoughts never mirrored the midwife’s flippant “oh well.”
It’s clear me that providing adequate care for our patients comes with a multitude of challenges. New computer systems. Large patient loads. Limited time. I knew this when I signed up for medicine. I also understand that at some point, I will surely do worse than forget to write a prescription. We train ourselves to avoid mistakes, but hopefully, we also train to own up to the ones we do make. I entered medicine because I felt it was a humane endeavor. But it’s also a human endeavor. It is not empty of error or devoid of tragedy. Even as such, my feeling is that we can always do better than “oh well.”


  1. Jay, you couldn't have said this more perfectly. I find myself constantly appalled at how so many things get overlooked because our superiors don't take the time to look/ask/investigate further. It gets awkward because you don't want to question their authority, but we're supposed to be there for our patients and advocate for them. It definitely is frustrating, but we just got to make mental notes not to repeat those mistakes in our own practice.

  2. "I wanted to trash "oh well" like I had trashed the super-juice."

    I love this quote. And I love this post.

  3. I concur. The most frustrating part of the exhilarating 3rd year is the loss of sense of control. It happened to me so acutely (overnight really). I'm glad you are able to write what I feel since I can't seem to say it all myself.

    But, the best part has been finding practitioners OPPOSITE what you characterize in this post. Even after 30 years some people keep their mojo and so will you.

  4. The midwife's lack of integrity is overwhelming. Those are grounds for termination in most jobs, including mine. I wouldn't even label that mediocrity - that's downright deceitful. She is trying to cover her ass with her lies. I'm appalled. Of course, if I was the husband of one of those patients, I probably wouldn't even think twice to doubt the treatment, and that's frightening.

  5. Thanks for letting me know this happens.


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