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Fall 2010

Better Than the First Grade

Lessons learned after a year as Assistant Chief of Service

By: Daniel Munoz, M.D.
Date: October 1, 2010


Better than First Grade
Illustration by Sherrill Cooper

Many doctors, like other high-octane knowledge-based professionals, tend to seek it out. A steady stream of new lessons. The richness of novel experience. The chance to wake up, go to work, and encounter variety. In short, the chance to learn something new every day, often unpredictably. (And, oh by the way, the chance to make a living while doing so.)

For 365 days and nights ending on July 1, I had the privilege of serving as one of the four Assistant Chiefs of Service for the Department of Medicine. In doing so, I assumed ultimate medical responsibility for around 1,400 medical inpatients over the course of the year, all while shepherding a team of internal medicine residents through the diagnostic and therapeutic battlefields of illness in all forms.

Not since the first grade taught me the skills of reading, addition, subtraction, and kickball have I learned so much in one year. As with many chapters in the story of medical training, only in hindsight have I begun to appreciate the depth of lessons learned. Now, after a month of routine exercise, beers on Tuesdays, the occasional afternoon nap, and regular sessions with the Sunday New York Times, I can confidently say: Sleep and separation are essential ingredients in this recipe for reflection.

So in no particular order, here is a selection of the lessons this year taught and reinforced:

It turns out that 2 a.m. is an oddly peaceful time. Driving across the deserted city gives you the impression that the rest of the world is asleep. As you near my house, it also gives you the impression that the whole world has parked in Federal Hill for the night.

Much of what we do in medicine is reactive. It’s firefighting. We fix dangerously high or low blood sugars in a diabetic patient. We sedate and thereby protect patients from the most violent forms of alcohol withdrawal. We help patients with uncontrolled, symptomatic hypertension return to a medication regimen that makes sense. We dialyze patients with end-stage kidney disease who have missed their outpatient sessions and are thus drowning in their body’s excess fluid. Preventing these fires is the real heroics, the unrecognized, underappreciated work of primary care doctors who are stretched too thin and paid too little for their efforts in averting such crises in the first place.

After we put out these fires and patch patients up in the hospital, we too often send them back out to the same set of clinical and social circumstances that conspired to get them into trouble in the first place. There is no prescription for family support, for insight into the underpinnings of a patient’s own illness, for steady employment, for safe street corners, or for hope. Clinical patchwork is the start of our society’s moral obligation to the sick, but cannot be accepted as sufficient.

Oreo cookies and Lorna Doone shortbreads (the dinner of champions) are freely available in the Osler 5 pantry, down the hall from the nursing station. But you need to know both the door code and the secret location of the pantry key, both of which I will share for the right price.

Much of medicine is algorithmic. But some is not. When algorithms fail or don’t apply, the most important ingredients are time, thought, and empathy. The latter two require ample portions of the first. And efficiency and expediency can hurt, rather than help. Often, the most valuable clinical information about a patient is uncovered only after the investment of time. Time tells patients you care. Time tells them you have an intellectual and emotional stake in the outcome. Time helps both patient and doctor when medicine is powerless to change the outcome. And I assure you that time is reimbursed, just not in ways that are reflected in financial balance sheets.

An angry email or text-page written in response to a perceived professional slight or clinical injustice should be kept in your “Drafts” folder overnight. If what you wrote still makes sense in the morning, send it. If it doesn’t, you instantly cash in on restraint.

There is nothing that compares to working alongside a committed, passionate group of young people. Osler residents invariably teach you more than you teach them. Along the way, there should be room for laughter, safety for risk-taking, and support for tears. It is an enormously satisfying form of professional parenting, complete with all the hokey analogies that follow (scraped knees can be instructive, allowance grows with good behavior, and, no matter what, Mom or Dad always has your back). And by the end, it indeed feels like family. The toughest part is that upon completion of the academic year, Mom or Dad moves out of the house, and most of the kids get to stay. Empty nest in reverse.

Finally, the Royal Farms store in Federal Hill is open all night. It’s a friendly place, with Sandy usually working the cashier. But don’t get the chicken fingers after 2 a.m. *