Chest Pain Relieved by Antacids: My Last Night as a Resident

 From the 7/9/2021 newsletter

Director’s Corner

 

 

Chest Pain Relieved by Antacids: My Last Night as a Resident

 

 

Adina Kalet, MD MPH

 

 

 

In this Transformational Times devoted to transitions Dr. Kalet recalls the final night of her residency at Bellevue Hospital in New York City …

 

 

The astute intern standing next to me, noticing the beads of sweat forming on my forehead and my clenched fist rubbing my breastbone, walked to the medicine locker, grabbed a little blue bottle of antacid and handed it to me. “If this works, I won’t have to admit you on your last night on call as a resident!” he said cheerfully.

 

I slugged the chalky, mint flavored substance and almost immediately felt the chest pain—which I hadn’t even fully noticed until then—resolve. “Thanks,” I said, “You’re gonna be a great resident in a few hours!” I glanced at my watch. 4:00 a.m. on June 30. My last day as a house officer.

 

 

“4344 Stat!!” the crackling voice of the Bellevue Hospital operator cried from one of two cigarette box size beepers hanging off the waist band of my white pants.  This dedicated “code beeper” was calling me to the emergency room where, luckily, I already was standing, ready to help my colleagues who were conducting a cardiac resuscitation on the patient in the “slot.”  This was not the cause of my heartburn. I loved this part. I was trained to do this, my movements were smooth and assured, the decision-making was practiced and honed. I felt competent and proud of my colleagues as we surrounded this patient, a man brought in by ambulance from Pennsylvania Station awake and alert, experiencing substernal chest pain and shortness of breath, who now needed us to save his life. And save his life we most likely would. This was quintessential doctoring, one patient at a time. 

 

My heartburn was a result of the other beeper. The “medical consult” beeper was insisting, with the exact same urgency, that I call “bed board” (the office that managed the 400 adult beds in the hospital) and 17 West and 16 East and the Surgical ICU all at the same time. I added the call back numbers to the pink sheet on my clipboard. I made eye contact with the senior resident running the code to signal I was there if he needed me and picked up the wall phone.

 

This part of the job made my stomach acid churn. After a year of med consult call, all of us senior residents had mastered—but did not have a positive attitude about—what we called the “hotel management” or “traffic cop” aspects of the job. We disliked assigning admitted patients to medical teams and working with the hospital administrator (“bed board”) and nursing leadership to assign beds to those patients. It was a hard and thankless three-dimensional chess game. I didn’t feel particularly good at or prepared for these logic puzzles. But I engaged because it was my job on the team that night. 

 

There was also the “consultation” part of the job, which sounds like an opportunity to engage in erudite conversation with residents on other services about how to best care for patients, but that wasn’t how things worked. The attending physicians did that part. Most often, we residents engaged in tense discussions demanding to transfer patients from their service to ours or vice versa. Too often, we debated whose “job” it was to adjust antibiotics or blood pressure medications. I would argue that any physician could handle this simple task with a little advice from us, but they would argue that their job was complete, and the patient now belonged on our team. We would argue where the patient with ominous abdominal pain should be monitored; our team contending that the physicians who could provide definitive surgical therapy would be best positioned to manage the patient, while they argued that until an intervention was needed, the patient should stay with us. On and on. Over and over.

 

Senior residents developed reputations as being a “wall”—staving off patient transfers by playing expert, impenetrable defense, or being a “sieve”—easily persuaded to accept the transfer. I won’t tell you which reputation I had, except to hint that I did accept transfers to our service only when it was obvious that a patient would be best cared for on our team. This was a judgment call, and I trusted both team to do right by the patient.

 

It was also true that I didn’t have the courage or tenacity to insist that other teams handle problems outside of their comfort zones. I have since gotten over that.

 

Physician professional identity formation, in those days, was in a very tribal stage of development. We worked on teams and, as teams, we defended our boundaries. As soon-to-be attending physicians, our main developmental challenge was to balance team loyalty and identity with a much more subtle discernment about “what is best for the patient.” These situations were very complex; a single correct answer was unlikely. Beyond the formidable technical aspects of our disciplines, we attempted to discern what was really, wholistically best for each patient right now and under these circumstances. Without realizing it at the time, we were developing the practical wisdom needed to thrive as a physician for a lifetime.

 

This critical learning process literally gave me chest pain.

 

Eventually the new consult resident, in a fresh scrub shirt and white pants, came by to take over the beepers. She listened carefully to my recitation, jotting down the names, locations, and vital facts about the consults still to be seen and for those who needed follow up. We reviewed the remaining “bed board” issues. I asked her to check on the freshly resuscitated patient; finding him a hospital bed was a priority. The resident had been at our class’s graduation ceremony the week before, so she knew of my plans for a year abroad for medical education research and my ensuing fellowship. She wished me luck.

 

I found myself wistful and sentimental about her very first med consult shift and envious of her freshness and eagerness to do right and good. I hoped she would develop the wisdom needed to navigate the complexities in the best interests of our patients, without spending much time seriously considering being either a wall or a sieve. But we didn’t have any time to discuss this, both beepers were already sounding.

 

I cleared out my locker and packed up the remaining books, toiletries, and other odds and ends. Gathering up fresh beeper batteries and few single dose bottles of antacid I had pilfered from the nurse’s station, I left them on the table in the on-call room. Someone would need them sooner rather than later.

 

 

 

Adina Kalet, MD MPH is the Director of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education and holder of the Stephen and Shelagh Roell Endowed Chair at the Medical College of Wisconsin.