Go Blue! (and Yellow)

Howdy,

Greetings again from a soggy Michigan. May so far has been distinctly cooler and wetter than April, though by the time I finish writing this post I'm sure the weather will have changed again. It varies a lot here depending on whether the wind is coming straight down from Canada, or straight up from the Gulf of Mexico. It seems those are the only 2 places that wind comes from.

We had really a really good storm last week, and even a tornado warning that flashed up on the TV. Exciting stuff - but no tornado, and we're all still in one piece. The boys' basketball net did get blown over though. Some in Oklahoma were not so lucky.

We went to a cool crab restaurant last week. Every now and again the restaurant would be magically transformed into a disco - lights and music would start, and all the waitresses would suddenly stop what they were doing and all start dancing in sync - all choreographed. At the end of the song they just carried on where they left off. Surreal! We've had lots of great meals out (and take-aways) including Italian, Mediterranean, Arabic, Sushi, Fondue and lots of pizza.

If lots of the operating lists are overrunning at work and we're likely to be there late the department orders in about 10 pizzas complete with cheese sticks, garlic bread, chicken wings, drinks and desserts. It keeps morale up and makes everyone feel appreciated - as well as being really tasty! (and probably really bad for you).

I did a 24 hour on-call on Saturday. 7am - 7am resident in the hospital. Work wise it wasn't much different to doing a typical on-call at home, although a few cases get done that would probably wait till the Monday at home. There's the usual familiar arguments from the surgeons about whose case deserves to go next - but the senior resident on-call holds the phone and usually does all the arguing. It surprised me how little trauma work there was (like fractured hips, etc). I don't know if it's because the population of Ann Arbor is very young, or if they all go somewhere else. We did some neuro cases, laparotomies, laparoscopies, a few trauma cases. By tea-time we had finished all the booked cases and we all got together and ordered a take away to be delivered. Yum - I could really put on weight here. At night I got lucky so I got to make good use of the on-call room.

It was a bit daunting at first going back to 24 hours on-call instead of shifts. My memories of 24 hours on-call from when I was a baby surgical house officer are not good, it obviously makes a big difference whether you're up all night or whether you have a few hours when you can sleep. After doing 9 years of shifts though I have to say that I hate night shifts with a passion. At least with a 24 hour on-call it's all over in 1 day, there are less frequent on-calls, and everyone has an incentive to get the work done in daytime hours, and there are proper on-call rooms to relax in. I think I get depressed when I have a run of night shifts coming up. They also interfere with training. Sadly because of EWTD there is no going back now in the UK. Some of the American residents have said to me they wish they could have our working hours and shift systems, but I really think that would be a bad move here.

There is a very different work ethic here on the whole. Everyone seems much more motivated and there is very little complaint of work to do. Every case is seen as an opportunity for training. The residency programme for anesthesiology is only 3 years (after 1 year intern - like a PRHO year), so they are generally keen to do as much as possible in that time - they fight each other off for opportunities to do lines, blocks, epidurals, etc. After their 3 years they are board certified (if they do the exams - which aren't compulsory!!!) - and they can work as an attending (consultant). Some do a year extra fellowship (eg in Pain / regional, cardiac, etc). Pain is a really popular specialty here.

A lot is expected from the residents from day one. They are given a lot of responsibility and can be left alone with difficult ASA 3/4 cases (sick patients). The learning curve at the start must be huge.

The new batch of residents start in July. Currently we have some newbies that will be starting in July shadowing the existing residents. They really are starting from scratch. Some know nothing about anaesthetics or physiology (eg how much oxygen is there in room air?!!) and have never before managed an airway. That does not stop them wanting to take on pretty difficult cases.

After a years training some think they know everything. I overheard a first year resident complaining the other day that they were not allowed to do a newborn paediatric cardiac case on their first paediatric module... Scary. They say a little knowledge is a dangerous thing.

The residents have this "can do" attitude to everything - which is great for many things, but it really can catch you out. I've learnt quickly never to ask them if they are happy to do a procedure. The answer is always yes. Saying "no - I'm not that confident, can you help me" would in their eyes be seen as a weakness. Instead I ask how many times have you done this? Often the answer is zero, but they wouldn't admit that unless you asked specifically. The third year residents on the other hand are usually pretty experienced, although I still find that their main weakness is over-confidence. They are always very confident, even when (just occasionally) not that competent. This is not just the anesthesiology residents. It applies to the surgeons, the nurse anaesthetists, in fact most people. This is not a criticism - it's just an observation. It is very much ingrained in the culture here. The culture along the lines of "Don't let anyone say you can't do something", or "Nothing is impossible, impossible is nothing", and other such sound bites. One of my favourite quotes I've seen was at the Henry Ford museum, from the great local hero himself:

"Whether you think you can or whether you think you can't, you're right."






You see it everywhere in different forms - TV adverts, posters, bumper stickers, T-shirts, self help books. They teach it in schools, in sports, business meetings, church. It is like the universal religion and dogma. It is a philosophy that everyone believes in, no matter what their politics or religion. I'm sure it is the reason why the USA is world leader in many things. It is probably why the USA won the space race and sent men to the moon. It is what inspired the Wright brothers, the Empire State building and so many other great achievements. On the flip side, it is also probably the reason they got into a mess in Iraq and with the recent economical disasters. But then failure is not seen as necessarily bad. It is "just another step to success". To quote Mr Wayne, "Why do we fall? So we learn to pick ourselves up".

I like this part of the culture here. In fact if there was just one thing that I wish I could take back and import to the UK - it is this self belief and willingness to try something. Not to fear failure so much that you don't even try. It fits very well with the ideology that everyone is responsible for their own successes - The true American Dream. The general optimism and positive attitude is infectious, and it keeps general morale up.

The disadvantage of this kind of attitude in medicine (especially anaesthetics) though is that you can easily get into deep water without knowing if you can swim yet. It is something I have learnt to be constantly vigilant for here. In fairness, the residents on the whole are mostly conscientious - I'm not saying they are cowboys, but there is a fine line between being confident and being rash. The residents don't appreciate it if we don't let them "try out something new" that they want to do, or take over a procedure when they are having difficulty. I have on occasion had to be very direct and assertive when things look like they are getting out of control. Balancing the training needs of the residents with what I think is within an appropriate safety margin for the patient has got to be the biggest challenge of this job so far. It goes without saying of course that safety always comes first.

I'm doing a lot of teaching with the residents, and now brand new interns. I'm also giving a lecture to the medical students next week, which hopefully will become a regular slot. It's a part of the job I really like.

This weekend we're going away for a break to Glen Arbor in the North of Michigan. It's supposed to be beautiful beaches there and quaint little towns. We're really looking forward to it, it will be our first overnight trip away from Ann Arbor. Will let you know how it goes next week.

All there is for me to say now is congrats to all in Blighty on your new blue and yellow government - coincidentally the university of Michigan colours. I wish I could sum up something enthusiastic to say about them but I'll just steal from the locals here and say "Go Blue (and Yellow)!" This of course can have more than one meaning depending on where you place the emphasis...


Till next time,

Remember -

"Only those who dare to fail greatly can ever achieve greatly" (Senator Kennedy)


Drake.