More Residency Regrets and Faux Enemies

Wellness

May 17

In my last newsletter, I delved into the tension between orthopedics and radiology in residency training and one of the transformative impacts of technology on the field. (If you missed it, you can read it here.)

Today I want to discuss a significant shift that occurred during the transition from resident to attending. This transition brings about various changes, and one of them stands out–the shift in perspective from “us vs them tribes” to being on a multidisciplinary team.

Besides the Ortho vs Rads dynamic, there was a prevalent mindset of orthopedics vs internal medicine, also present at my med school. Ortho always wanted the sicker patients to be managed by medicine while medicine felt they were being abused by Ortho (“Aren’t you doctors too?” was a common retort).

Ortho’s frustration stemmed from the fact that the sicker patients required continuous workup and care, and while the IM residents were out on the hospital floors all day, we were largely in the operating room (OR). We would return to the floor in the early evening to check out, only to find a long IM consult recommending labs and imagining, none of which were ordered much less completed. So the patient would now need to get the labs overnight and the studies the next day, only to find additional recommendations at the end of the next day.

Finally, one Ortho resident became so exasperated with this cycle that when called on an IM patient for a hip fracture, he wrote a long consult that they should take the patient to OR, perform a lateral approach to the hip, fix it with a plate and screws, and then perform X-rays for assessment. The intention was to highlight that our different skill sets could benefit the patient in different ways. Things did improve for a while following this stunt.

Similarly, in the OR it was Ortho vs Anesthesia. We had one attending, in particular, who always seemed to start his day with a loud outburst before settling into normal behavior. To shield ourselves, we would attempt to redirect his ire toward someone else, by informing him that Anesthesia wanted his patient to have a spinal rather than general, or that Anesthesia felt further workup was needed prior to surgery. On occasion, we would tell him that the Physical Plant said they couldn’t get the room temp down. (I apologize to the Anesthesia residents and attendings, but Physical Plant, you know what you did.)

This was such a normal experience that I didn't think much of how it had shaped my thinking during that time.

However, after being an attending for many years, I encountered a traveling nurse in the OR who had previously worked at a highly regarded training program. She would often begin complaining about Anesthesia as soon as I came into the room. I found this really odd. It was disconcerting to come into a room and immediately hear my colleague being denigrated by someone else who had just recently entered the environment.

That’s when it hit me. She was accustomed to the “us vs them” culture prevalent in training programs, where the surgical team viewed anesthesia as the “enemy”.

But in my non-academic hospital, everyone in that room was part of my team. The team works together to take the best possible care of the patient, no longer separated by specialty, role, or divisive barriers.

This change in perspective was also evident on the hospital floors. IM no longer viewed Ortho as adversaries constantly burdening them with patient handoffs. They recognized that since Ortho spent their days in the clinic or the operating room, they were better positioned to order and coordinate care for the sicker patients and had the best specialty training to do so. Conversely, Ortho recognized that IM excelled in caring for patients with complex medical needs and gladly addressed any orthopedic issues the patients had.

The dynamic between the teams had shifted to become specialty diverse and more collaborative, resulting in improved care for the patients. Equally important, the mentality of perceiving each other as enemies to be defended against was also eliminated.