Rounds in a teaching hospital take different forms, but in addition to taking care of patients, the purpose is to demonstrate and learn.  Sometimes the experience is enthralling and truly enlightening, and sometimes it’s tedious and awkward.  The balance often depends on the approach of the attending.

After we walked around the hospital to see a few patients, we decided to head to the conference room to finish our rounds.  It hadn’t been a good morning.  Our attending had been critisizing the residents on their note-writing skills, unrealistic differential diagnoses, untimely completion of tasks, etc.  He was upset by a patient who took a downturn, later to find out he suspected it was his order for a beta-blocker that sent her into cardiogenic shock…worsened kidney function, ischemic bowel, respiratory failure, and so on.  I wish I could say this event was the only reason he cut the interns with such belittling precision, carving out descriptors like “apathetic” and “ignorant” across their foreheads, but it wasn’t.  This was his usual game, at least in the early days of each week-long tour on the inpatient service.  Usually by Thursday or Friday, he’d give himself permission to be gracious.

I have a pretty good relationship with this particular attending, at least that’s what he wants to believe.  No matter how much he protests, I’m older and more experienced at acute care internal medicine than him.  I don’t mean that I have all his knowledge (although I have the pharmacy-equivalent of training). I don’t pretend to be an expert in diagnosis or physical findings or significance of subjective evidence, but he pretends to be an expert in pharmacology, and on rare occasions he turns to me to confirm that his micro-teaching is correct.  It’s when he doesn’t defer to me, in those moments when he confuses his arrogance for competence, that he often relays inaccurate information. 

He explains to the team how on another patient because she stopped dialysis a month ago, her serum levels of digoxin increased causing her current bradycardia.  Well, actually, no, that’s not it.  Digoxin is not removed by dialysis.  That part of her history is unconnected.  Or how fentanyl is a partial opioid agonist, and that is the reason it’s not a good sedative in intubated elderly patients.  Sorry, it’s a pure agonist, and one doesn’t have anything to do with the other.

How am I supposed to correct these inaccuracies when it’s very possible that my forehead is next?  I imagine my carvings would be “insubordinate” and “irrelevant.”  Picking my battles and picking the right time is always key.  Today most certainly would not be the day.

Today was, in fact, the day.

While walking across the hospital out of the ICU, he offered his elbow to engage in a little Wizard of Oz reenactment, sans yellow brick road.  We talked. We discussed alternative etiologies to our dying patient.  We bonded a little, as he respected me enough to ask my opinion and consider my responses.  Truth is, he knows my strengths, those beyond the scope of the typical pharmacist, those that come with a love of learning and analyzing.  Training.  And experience.

I took that moment in the hallway, away from the others to engage in what I wanted to be an edifying conversation.  “Did you know that fentanyl is not a partial/mixed agonist?”  I continued, hoping that additional information might knock the misconception loose, “It doesn’t have a ceiling analgesic dose.  Partial agonists do.”

He listened, cocked his head, and murmured, “Why did I think that?  What was I thinking of?  Hmmm…”

Then his phone rang.  And that was the end of our micro-lesson.  

Rounds continued a few minutes later around a table. The brief moments of serenity and humanity in the hallway had dissipated.  The repetitive clicking of his pen as the intern presented a clunky assessment and plan for her patient further revealed the mercurial essence of this man.  He was waiting to wield his cutting words while distracting everyone from the intern’s presentation. At that moment, my heart dropped in disappointment at this display.  I think we were all done learning for the day. 

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