COMMENTARY

'Residents From Hell': Indignities and Outcomes in Medical Training

Ronald W. Pies, MD

Disclosures

December 12, 2019

Don, my resident, grabbed me by the collar and pushed me against the wall of the empty hospital corridor.

"What the hell were you thinking, Pies?" he growled, his breath hot against my face. "Did you not consider that Mr A could be septic?"

"I'm sorry, Don!" I said miserably, my heart knocking against my rib cage.

"Don't apologize to me! Apologize to Mr A! He could have died if I hadn't found your screw-up!"

"I know, I know, Don. It's just that—I assumed the systolic reading…"

"Damn it! How many times have I told you? Assumption is the mother of screw-up!"

Don used a coarser term than "screw-up." He never minced words or missed an opportunity to let me know what a pitiful excuse for a medical intern I was. He was one member of the duo I used to call "The Residents From Hell." Together, Don and Phil (not their real names) helped make my medical internship one of the most painful experiences of my entire life. Yet, despite the numerous psychic traumas they inflicted on me, these two skilled physicians also helped me become a better doctor.

I had entered my internship with a pretty high opinion of my medical knowledge. Having majored in biology at Cornell University and having earned "honors" in my internal medicine course, I had some basis for my delusion of grandeur. But I soon discovered, among many similar revelations, that knowing the physiology of sepsis is not the same as detecting it in an older patient. Mr A proved the point.

A thin, frail gentleman in his 70s, Mr A had been admitted to the medical unit with some vague symptoms the staff described, lazily, as "the dwindles"—a 10-lb weight loss over the past month, poor appetite, and a general sense of malaise. At the time of admission, no one had considered sepsis in the differential diagnosis. Mr A did not show any of the classic signs of sepsis, such as fever and chills, low body temperature, decreased urination, rapid breathing, or a low systolic blood pressure.

However, with that last finding, I made a potentially lethal assumption. I had checked Mr A's blood pressure while he was sitting on his bed, but I failed to check for an orthostatic drop in blood pressure. I assumed that a reading of about 105/70 mm Hg (as I recall) was an accurate reflection of the patient's hemodynamic state. But when Don checked Mr A's blood pressure when he was standing, the reading was an ominous 85/55 mm Hg—a huge drop, potentially signifying sepsis.

Emergency physician Justin Morgenstern, MD, has described the wide range of cognitive errors that lead doctors to make serious mistakes. Among them is ascertainment bias: we "see what we expect to see." For example, a disheveled, homeless man staggering into the emergency room, slurring his speech, is assumed to be "drunk" when he is actually hypoglycemic. When Mr A was admitted to our unit, I expected to see someone who was either depressed (I was, after all, heading into a career in psychiatry) or showing signs of a covert malignant tumor. I was not expecting to see someone in the early stages of sepsis. Morgenstern also describes "value bias," sometimes known as "affective error" and defined as "the tendency to convince yourself that what you want to be true is true, instead of less appealing alternatives."

Clinical depression was a diagnosis I probably "wanted to be true" because I was familiar with it and knew how to treat it. Sepsis, not so much. Whether we see what we expect to see or convince ourselves that what we want to be true is true, we are making unwarranted assumptions. And as Don was trying to teach me, assumptions can come with consequences.

I'd be lying if I said that I appreciated Don and Phil's tutelage at the time they were tormenting me. Far from it. Although they taught me to question my assumptions and avoid premature diagnostic closure, they also taught me, firsthand, the pain of humiliation and indignity. I still remember, on another occasion, standing outside my newly admitted patient's room, alongside my medical student, and Phil saying with icy composure, "Pies, don't kill this patient!" Maybe he thought he was being funny. Or maybe he was trying to goad me into being the kind of meticulous clinician we all want to be. But Phil's words left me feeling like an insect crushed beneath his heel. I recall that brain-searing insult with a wince, even now—over 40 years later.

That font of Jewish ethics, the Talmud, likens humiliating another human being to "spilling blood"—perhaps reflecting the fact that our faces tend to blanch when we experience public humiliation. And yet, as Friedrich Nietzsche once said, "Anything that doesn't kill me strengthens me." Although nothing can justify the deliberate humiliation of another human being, Phil and Don's "instruction" taught me to overcome my wounded feelings and get the job done. And their deplorable indignities taught me to aim higher in my own treatment of patients, colleagues, and students.

Yes, I learned from Don that "assumption is the mother of screw-up." That lesson has served me well, particularly when considering the differential diagnosis of a medically complicated patient. What looks at first like schizophrenia may ultimately turn out to be tertiary syphilis—the "Great Masquerader." What seems to be understandable grief or depression can turn out to be the early signs of pancreatic cancer.

However, the most valuable lesson I took from "The Residents From Hell" is to treat all persons—especially those with little power—with courtesy and dignity. To be sure: Diagnostic acumen is the foundation of good medical care. Don and Phil possessed that trait in abundance. Yet atop that foundation stands the House of Medicine—its essential constituents being respect, compassion, and kindness.

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