The journey from timid trainee to clinical leader is rarely a smooth one, and authority does not come easily to all. Lessons learnt from inevitable missteps can be as useful as the positive accumulation of knowledge and skills. By looking back at formative moments in a fourteen year career I have tracked the evolution of my own authority…and in doing so I have recognised that near the end of the path lies a trap, and it is called arrogance.
As a Senior House Officer, in conversation with my Registrar.
Registrar: “And you think the bronchospasm is what, pulmonary eosinophilia, due to migration of parasites? Why doesn’t he just have asthma?”
Me: “It’s just…this patient has made no improvement after five days. We’re getting nowhere. His renal function is off. Either an unusual infection, or something else…perhaps autoimmune, vasculitic. Shall I ask the rheumatologists to see him?”
R: “He’s a bit dry, that’s all. Speed up the fluids and his kidneys will turn around. The prednisone will kick in soon. Don’t worry.”
Next day – a SHO detains me in the corridor
SHO: “I hear your man was transferred to intensive care.”
Me: “I’ve seen him. Blew a pupil, dropped his conscious level. I don’t understand, it doesn’t add up.”
SHO: “But you’ve heard what the diagnosis is?”
Me: “No. Not yet. Tell me.”
SHO: “Churg-Strauss syndrome. Classic presentation. ICU called the rheumatologists in. But he’s pretty far gone now, on dialysis…they’re starting cyclophosphamide this afternoon. You look shocked.”
A few years later, with some specialised knowledge under my belt, I felt confident in challenging error where I saw it developing…
In the intensive care unit, a Specialist Trainee greets me.
ST: “Thanks for coming down. Her liver is fine but her ammonia is off the scale. Very odd. Epileptic, but the EEG says she’s not in status. CT scan is normal”
Me: “Does she take valproate? An overdose would explain it – it interrupts the urea cycle.”
ST: “Yes. We figured that. But she hasn’t woken up on the filter. Have you got any ideas?”
Me: “I’ve had a look at her. She has signs of raised intracranial pressure. Clonus, sluggish pupils. She’s at risk of coning. At the moment you have no handle on the pressure, nor how aggressively to treat it. She needs a bolt.”
ST: “An intracranial pressure monitor? Really?”
Me: “Yes, the neurosurgeons will put one in if you call them.”
Later that day
Me: “Did the neurosurgeons come down?”
ST: “No. We didn’t think it would add much.”
Me: “But it would…you have no idea what’s going on in her skull.”
ST: “But the treatment would be the same anyway. And besides, there’s no evidence of a survival advantage…”
Me: “Evidence is lacking, you’re right. But this situation is rare, the trials will never be done. Look, you asked for my advice, and I’ve given it to you.”
ST: “We’re not convinced…it’s a risky intervention…”
How far do I take this? I’m convinced it’s the right thing to do. How hard should I fight for what (I think) I know is the right decision?
Me: “This woman is at huge risk of brain death, and without quantitative assessment of the pressure you cannot treat her appropriately. If the pressure is persistently high after mannitol you’ll need to try indomethacin, consider a thiopentone induced coma, cool her right down. Where’s your
consultant? Who do I need to convince to make this happen? You clearly don’t have the experience in this unit to make the right decision.”
But I did not say that. I figured – it’s their decision, their responsibility in the end. I gave an opinion, one of many probably, and they must assess the pro’s and con’s before making the call. They may have a better understanding of the whole situation. So I said,
“I’ll review her first thing tomorrow. That will be 24 hours since she presented. If there are persistent features of raised pressure I think you’ll have to do it. Ask the neurosurgeons for their advice. You have mine.”
She never woke up. No-one can be sure what difference the bolt would have made.
Two years later I found myself arguing over a patient whose heart had stopped.
Me: “Another cycle, and then I think we’ll stop. There’s been no electrical activity since we started…all agree?”
The cardiology Registrar enters the cubicle pushing a portable echocardiography machine.
Cardiology Registrar: “I’m just going to take a look, see if there’s any ventricular activity.”
Me: “We’re just about to call it. She’s dead, unfortunately. We’ve been going for 20 minutes in asystole.”
CR: “You haven’t excluded all reversible causes yet. What about tamponade?”
Me: “There’s no reason to suspect tamponade, no instrumentation, anticoagulation, no electrical activity on the monitor…”
CR: “It will only take a couple of minutes. My consultant will want to know before you stop resuscitation.”
Me: “What! No! I’m running this arrest, we’ve given four shots of adrenaline, and the line is flat. She is dead. I’m not going to have this woman subjected to another 10 minutes of CPR while you do an echo and go and call your consultant.”
CR: “It’s protocol on the cardiology ward.”
Nurse: “That’s two minutes.”
Me: “Okay, what’s the rhythm…asystole, not compatible with a pulse. Let’s stop. Stop compressions.”
CR: “I’m calling my consultant.”
Me: “Do so. At no point in the life support algorithm does it mention echocardiograms and phone calls to consultants. We’re stopping.”
I walked away, emboldened by the challenge. Assuming authority in this situation had come easily. I felt that I had risen to the challenge, and proved my seniority.
Two weeks into my job as a consultant I conducted a ward round. A new patient, with alcoholic cirrhosis, had been transferred to the ward. My SHO presented him.
“He’s been triggering all night, low blood pressure. Down to 80 systolic.”
“He’s septic you said.”
“Yes, spontaneous bacterial peritonitis, confirmed.”
“He’s passing urine, he looks alert. Lactate’s normal. Give him more time, he should skate through without needing vasopressors.”
Later that day my SHO found me in endoscopy.
“He’s not picking up. We’ll need to adjust the alarm parameters if we don’t want to be bleeped about his BP every thirty minutes.”
what cirrhotics do, run low BPs, dilated circulations, even without sepsis. A bit more filling, another couple of days of antibiotics and he should turn around.”
Next morning she came to my office; the registrar was away.
“I’m worried. Sodium’s down, BP is still poor. And he’s got a rash, all over his trunk. It’s blue.”
“But he’s talking, reading the paper, walking to the toilet. I passed him on the ward this morning. I’m not too concerned about him.”
“But he’s just not right…”
A brief stab of annoyance interrupted my continued reassurances – yes, we’re all worried about him, but get on with it!
On the third morning I was called to the ICU. My patient lay dying, his skin mottled, a cardiac output monitor confirming that his heart was barely functioning. He had been displaying signs of severe alcoholic cardiomyopathy from day one, and I had missed it. My SHO had never seen a case before, but she had sensed it, the wrongness…just as I had sensed that there must be an alternative diagnosis in the man with asthma. I didn’t hear her, because I was sure I knew more.
The only doctor we can observe over an entire career is the one we see in the mirror every morning. We must reflect on our own experiences to truly understand how we have evolved – and why. When the patient with Churg-Strauss syndrome was admitted I was no more than a wallflower during medical arguments. Now, if I am sure of myself, and if after reasoned argument I wish to ensure that the wrong decision is not made, I may display intransigence and will ultimately pull rank. For after all, I am right more often than I am wrong, and my senior position should ensure that what I say goes. Shouldn’t it?
Having reflected on some of the steps that led from a questioning but silent observer to a physician with the power to insist, I am reminded that the evolution of authority does not end with the progression to consultant rank. Only open mindedness, the ability to admit mistakes (to oneself if not to ones juniors), and the realization that learning occurs in both directions can prevent the sheen of hard earned authority from deteriorating into a impermeable hide of arrogance.