Culture of Medicine and Surgery (2): Malignant Trauma
Preface: I have written several views into my experience on Trauma and Acute Care Surgery, a rotation in which I spend the majority of my preliminary surgery year. The description that follows is the mildest of these. The underlying theme in all of the writings is that Trauma Surgery purposefully maintains a culture of malignancy, perhaps out of some warped fealty to a stern, militaristic tradition of the past century. This has been my experience while working in different hospitals and in talking with other Surgery/Surgery subspecialty residents. It is important to note that my description of trauma/acute care surgeons does not apply to all attending surgeons. At my institution, there are a few very intelligent, civil, and able trauma surgeons, but their general decency is often overshadowed by the bad actors, of whom there are not just a few.
09/15/2019
A few months ago, I made food deliveries for GrubHub. It was simple, honest work. A notification would pop up on my phone informing me where to be by a specific time, and I would follow through accordingly. I provided a basic service. I did not make or package the food. I transported it from one place to another. Interactions were concise: "Thank you...You're welcome...Hello...Goodbye." No politics or fuss. Just business. When gas was running low, I would make a stop to fill up. A paycheck was deposited weekly into my account.
Now, my paychecks deposit bi-weekly - a sign of progress. Maybe when I advance further in Surgery my pay will come monthly. One can only hope.
In this particular year of surgery residency, I spend most of my time on the Trauma and Acute Care Surgery service feeding the wants of capricious attending surgeons.
"Go see this [non-acute] patient now," one of them barks. I meekly assent and scatter off to my work. On the way, I receive an onslaught of high-acuity pages and deal with those first. An hour later, the attending calls: "Why have you not seen this patient?"
We are taught to provide no explanations (immediately dismissed as excuses) so as to project strength. I cannot say "multiple traumas came in, and I had to prioritize those first." That would look defensive, and the attending would yell more. (I don't enjoy being yelled at, especially for things outside my control. I prefer low-volume, congenial interactions that are respectful and well-mannered. I believe most people share my preferences.)
As patients and pages come in, my daily to-do list builds to overwhelming proportions, but the work gets done (I do it well). By the end of the day, nobody acknowledges you for deftly prioritizing and handling the most acute issues in an orderly fashion. They only remember the things you did not do for them at their immediate behest. And they do not let you forget it.
Through a system of negative feedback with lashings, you learn...what do you learn? It's not patient care. You learn how to feel nothing when suffering the heaving winds of the trauma surgeons' great boiling egos, that rage on and raze their subordinates into hapless submission. "I will make you mine by destroying you, and only then will you become my true servant. I will dole out beatings, and you will whimper accordingly. Patient care be damned: You will do what I say." (Note, for the literal-minded, like myself: Nobody says this, though they project it.)
In this setting, patient care occurs despite an environment of psychological tempest, a culture of unending fear. Off-service residents (non-general surgery; eg. Orthopedic Surgery, Plastic Surgery, Urology, Otolaryngology) rotating on Trauma as part of their educational curriculum sometimes receive worse abuse from attendings, in the form of verbal harassment that cuts to the resident's core ("I'm concerned about you becoming a surgeon.") or very poor evaluations that do not fairly reflect actual clinical performance. Most of the time, their individual program directors provide reassurance and ignore any feedback arising from an angry-sounding Trauma attending.
Such a description of Trauma certainly isn't original. To me (as well as some of my peers), the modifier 'trauma' refers to patients with trauma-related injuries as well as the crucible of panic and misery the resident undergoes when dealing with malicious attendings - i.e. the rotation itself is a source of psychological trauma.
I have no studies to show that a culture of fear, mockery, career derailment, sly defamation, and verbal abuse in a team creates psychologically and physically sicker team members, nor do I think such a study would ever be done within a Trauma Surgery division. However, it is known from the general management literature that a genuine culture of openness, directness, efficiency, and civility, without ill will or slander, generates higher output and returns - not to mention happier employees.
To perform such a study, or to just look at itself in a self-critical light, would require great humility on the part of a Trauma Surgery division. Nobody is holding his breath.
09/15/2019
A few months ago, I made food deliveries for GrubHub. It was simple, honest work. A notification would pop up on my phone informing me where to be by a specific time, and I would follow through accordingly. I provided a basic service. I did not make or package the food. I transported it from one place to another. Interactions were concise: "Thank you...You're welcome...Hello...Goodbye." No politics or fuss. Just business. When gas was running low, I would make a stop to fill up. A paycheck was deposited weekly into my account.
Now, my paychecks deposit bi-weekly - a sign of progress. Maybe when I advance further in Surgery my pay will come monthly. One can only hope.
In this particular year of surgery residency, I spend most of my time on the Trauma and Acute Care Surgery service feeding the wants of capricious attending surgeons.
"Go see this [non-acute] patient now," one of them barks. I meekly assent and scatter off to my work. On the way, I receive an onslaught of high-acuity pages and deal with those first. An hour later, the attending calls: "Why have you not seen this patient?"
We are taught to provide no explanations (immediately dismissed as excuses) so as to project strength. I cannot say "multiple traumas came in, and I had to prioritize those first." That would look defensive, and the attending would yell more. (I don't enjoy being yelled at, especially for things outside my control. I prefer low-volume, congenial interactions that are respectful and well-mannered. I believe most people share my preferences.)
As patients and pages come in, my daily to-do list builds to overwhelming proportions, but the work gets done (I do it well). By the end of the day, nobody acknowledges you for deftly prioritizing and handling the most acute issues in an orderly fashion. They only remember the things you did not do for them at their immediate behest. And they do not let you forget it.
Through a system of negative feedback with lashings, you learn...what do you learn? It's not patient care. You learn how to feel nothing when suffering the heaving winds of the trauma surgeons' great boiling egos, that rage on and raze their subordinates into hapless submission. "I will make you mine by destroying you, and only then will you become my true servant. I will dole out beatings, and you will whimper accordingly. Patient care be damned: You will do what I say." (Note, for the literal-minded, like myself: Nobody says this, though they project it.)
In this setting, patient care occurs despite an environment of psychological tempest, a culture of unending fear. Off-service residents (non-general surgery; eg. Orthopedic Surgery, Plastic Surgery, Urology, Otolaryngology) rotating on Trauma as part of their educational curriculum sometimes receive worse abuse from attendings, in the form of verbal harassment that cuts to the resident's core ("I'm concerned about you becoming a surgeon.") or very poor evaluations that do not fairly reflect actual clinical performance. Most of the time, their individual program directors provide reassurance and ignore any feedback arising from an angry-sounding Trauma attending.
Such a description of Trauma certainly isn't original. To me (as well as some of my peers), the modifier 'trauma' refers to patients with trauma-related injuries as well as the crucible of panic and misery the resident undergoes when dealing with malicious attendings - i.e. the rotation itself is a source of psychological trauma.
I have no studies to show that a culture of fear, mockery, career derailment, sly defamation, and verbal abuse in a team creates psychologically and physically sicker team members, nor do I think such a study would ever be done within a Trauma Surgery division. However, it is known from the general management literature that a genuine culture of openness, directness, efficiency, and civility, without ill will or slander, generates higher output and returns - not to mention happier employees.
To perform such a study, or to just look at itself in a self-critical light, would require great humility on the part of a Trauma Surgery division. Nobody is holding his breath.
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