The extra mile

Ryan Meili

Early one prairie winter morning, my cell phone woke me by rattling on my bedside table. It was a concerned Dr Laura Davis on the line. We’d been up late with Cheryl, a patient I had followed throughout her prenatal care. She’d delivered just a few hours earlier. The delivery had been, from our point of view at least, an easy one: 10 minutes of pushing and out came a healthy baby boy. Cheryl had a mild second degree tear that I repaired under Dr Davis’s tutelage. Things were going well, everyone was in good spirits; Dr Davis even pulled out the old chestnut about the perineum healing if both sides are in the same room.

We examined the newborn. He passed meconium all over me as I checked his testicles (a pretty reasonable response if you ask me). A few minutes later Cheryl delivered the placenta without incident. A few clots followed it and her uterus seemed quite firm. We congratulated her and stepped out to the nursing station to do the paperwork. GreatApgar score, minimal bloodloss: a job welldone.

A nurse came out shortly after to tell us that Cheryl had lost some more blood. We went back into the room and examined her. After expressing a few clots from a boggy uterus, we decided to start an oxytocin drip. This seemed to do the trick, as the bleeding decreased and her uterus contracted more tightly.

Satisfied with this response, we left her in the capable hands of the nurses at about 10 PM. In the parking lot I let my car warm up while I dusted off the windshield. I looked around and smiled at the old buildings and the gently falling snow, warmed by a sense of vocation.

Fifteen minutes later I was opening the garage door at home when my phone rang. It was Laura. Cheryl was still bleeding; the oxytocin hadn’t worked. I turned around and headed back to the hospital. The nurses had given her a dose of misoprostol, a prostaglandin analogue, to try to encourage contraction. When we examined her, her uterus was boggy again despite the misoprostol; each time her abdomen was massaged a kidney basin–full of clots would come out. We called for cross-matched blood and consulted obstetrics.

The obstetrician on call arrived and put me on the spot in a way only specialist attendings can. I fumbled through the story of the evening and Cheryl’s past medical history, somehow managing not to mention her 8-cm uterine fibroid until the very end. Thinking back, I honestly can’t recall if we’d already decided that was the source of the bleeding or if I only realized it with the look of recognition on the obstetrician’s face. In any case it was obvious to him, and he got to work. An intramuscular dose of carboprost tromethamine, a more potent prostaglandin analogue, seemed to work well in stemming the bleeding, but we started a transfusion to make up for what had already been lost. The obstetrician, who was in-house, said he’d follow her for the night and sent us home. This time I made it to my bed and fell asleep instantly at 1 AM.

When the rattling phone awoke me at 6 AM I was groggy. I’m a big fan of sleep and am reluctantly brought out of it. Dr Davis said she was on the way to the hospital. Cheryl had continued to bleed through the night despite the obstetrician’s best efforts, and they had decided a hysterectomy was the best course of action. This was her second child, and she was in her early 30s, so this was less tragic than it could have been, but still a dramatic turn of events. Laura told me that an obstetrics resident and another gynecologist were joining the obstetrician to help with the operation and that, while she was going in to help out and see Cheryl, there was really no need for me to be there. From my position in my warm bed, this made immediate sense, and I told her I’d see her in clinic at 9 AM.

My head hit the pillow and bounced. There was no way I was going to be able to get back to sleep with Cheryl in the operating room. I got up, dressed, shovelled 6 inches of fresh snow out from in front of my garage door, and sped across the river. At the hospital I checked in with Cheryl and Dr Davis about the night’s events, gave Cheryl some words of encouragement, then scrubbed in as a less-than-essential third assist. We followed Cheryl on the ward over the rest of the day. She needed another transfusion but generally did well, and managed to adjust to the thought of the hysterectomy and all the implications thereof.

The aspect of this story I want to focus on is the pillow that couldn’t hold my head. I’m not suggesting for a moment that I’m a particularly dedicated resident. Far from it. There are many instances when, aware that I’m irrelevant, I will abstain from going the extra mile. So what was different this time? Well, as the saying goes, “It’s all about relationship.” Having seen Cheryl throughout her pregnancy, I’d gotten to know her and care about her on a personal level. That morning in the operating room, I wasn’t needed for any practical reason, but it felt right to be there and it meant a lot to her that I came. Dr Davis also played an important role in motivating me; she’s a respected mentor with a friendly, collegial style, the type of teacher who is engagingly enthusiastic. So as I write about these events months later, the emotional connection to the experience makes the details easy to recall and gives the clinical and professional lessons resonance.

Clearly residents have an obligation to provide care within the parameters of their clinical duties and the expectations of particular rotations. That said, the experience of providing care is greatly augmented when some sort of connection is established. That’s when you get residents really diving into their learning: poring over charts, reading voraciously around their cases, pestering the attendings to get those lingering consults done. The question is: Why does that happen, and how can it happen more? The fact of the matter is, the experience is far rarer than I had hoped on entering medicine, and I don’t think I’m the only one who feels that way.

Some might protest and suggest that with our workload we’re far too busy to establish a substantial number of personal connections and that no one has the emotional reserve to truly empathize with so many people. I see it the other way around: I don’t have the emotional reserve to have endless shallow interactions. The better I know the patient, the more I care and the more I feel as though I’m doing what I need to be doing. That recharges me; “moving the meat” exhausts me.

So what can be done about this? What can be done to increase the frequency of meaningful interactions? Can residency programs be designed to promote deeper interpersonal connections and more longitudinal exposure to patients? Can a spirit of engaged mentorship be encouraged and cultivated in faculty (as opposed to the all-too-persistent poles of intimidation and disinterest)? Or is it to be left in the hands of chance and the individual initiative of residents? Systemic efforts at improving quality of care through guidelines and monitoring are important, but it is personality and dedication that make it an honour to practise and a pleasure to serve. How do we foster that aspect of the profession? For the benefit of patients like Cheryl and residents like me, we should find out. Whether family medicine will be a fun job with great results for patients, or the fast lane to burnout, will depend on it.