Opinion
A PIECE OF MY MIND Jeremy M. Blumberg, MD Division of Urology, Harbor-UCLA Medical Center; and Department of Urology, David Geffen School of Medicine at the University of California, Los Angeles.
Corresponding Author: Jeremy M. Blumberg, MD (jblumberg@mednet .ucla.edu). Section Editor: Roxanne K. Young, Associate Senior Editor. jama.com
Shepard’s Prayer When I accepted the faculty position offered by the chair of my department, he asked when I’d like to start. My fellowship would end on June 30, and so July 1 seemed like the logical choice—it was a Monday and everything else in the past 10 years of my life had started on that date. “I’ll start July 1.” Wouldn’t I want a little time off? A vacation, perhaps, with my wife and baby? I would. But the reality was that we had bills to start paying and no savings. I was in the common, but uncomfortable, position of being highly educated, thoroughly trained, and positively broke. Besides, I was ready. July 1 is when everything begins. But before July 1 would arrive, I’d have to finish my training; the last two weeks weren’t easy. I had been a urology resident for 6 years and a fellow in kidney transplantation for nearly 2. You get tired of being told where to place this stitch, stay in that plane, don’t put the clamp there. I’d participated in more than 200 kidney transplants, not to mention the previous 6 years of urologic procedures. It becomes irritating, the nitpicking, the micromanagement, the nanomanagement; what used to seem like good advice makes your blood boil. I imagine it’s the same for the finishing hematology-oncology fellow being told how to dose the chemotherapy for her patient with lung cancer, or the anesthesiology chief resident being reminded how to bring a patient back from surgical slumber. I was fighting a voice in my head wanting to shout, “I get it, I can do this, I’m ready!” I had become an angry, moody teenager again; my attending physicians became hovering parents. I was avoiding them. Did they notice my attitude problem? I knew I was being absurd, and at the age of 35 it felt utterly unnatural. I walked into the hospital on a scorching July morning, feeling renewed and invincible. The moment took me back to the day my mom had hugged me and cried as she left me alone in my college dorm room. I was starting my career. Real life. Autonomous. Independent. The first order of business would be to set up my office—forget the fact that I barely knew my way around the place and didn’t have an identification badge. For years my diplomas had been collecting dust, and my wife was undoubtedly fed up with my burgeoning home urology library. Now there would be a home for my credentials, indelible proof that I knew exactly what I was doing. I had been craving a place of my own, and while nothing was new or shiny in my office—the mahogany faux-wood paneling on the walls brilliantly evoked the 1970s—this was an upgrade from the exposed cubicle I’d used for the past 2 years. My hubris detumesced rapidly when I answered my first page. The transplant coordinator, someone I hadn’t even met yet, called to let me know we would be admit-
ting a woman for a kidney transplant. She was diabetic and had been on hemodialysis for nearly 12 years; a kidney was available from a slightly older donor, but the nephrologist felt this organ would be of great benefit to this woman. I had trained for this very moment, the time that I’d be the one ultimately responsible for what happened to this patient in the operating room. My patient. Sure, you feel responsible and connected to your patients as a resident and fellow, but the safety net is always deployed. There’s always an attending. We made preparations for the operation. I visited with the patient and her daughter in the dialysis unit. I explained the procedure and told them I hoped this would be the last time she’d be hooked up to that machine to which she was virtually a slave for more than a decade. She smiled and said, “Thank you, Doctor.” I’d rather she thank me after we finished the transplant. I just wanted it to go well. I persisted throughout the day that my residents dot their i’s and cross their t’s with regard to this case. What is her hemoglobin level? Did you speak to the nephrology team about the immunosuppression? When will the operating room be ready for us? Wait. Was I doing the nagging? The more than slightly irked expressions of my residents confirmed this. Their resentment was palpable. Just as soon as I had been liberated from people telling me what to do, now I was telling people what to do. I was surely in charge, but that only exacerbated my anxiety. At 6 PM the operation was bumped, delayed by a case of a gunshot wound to the abdomen. I sat in my office and as the night grew darker the hospital became quieter and more still. This wood-paneled crucible had no windows, but it was unquestionably night. I paced a bit and decided to walk outside for a while. I fixated on the billows of steam rising from the top of the hospital, the steam that emanates from every hospital, and at once the building itself became menacing—a glass and concrete mass ready to swallow me whole. I wandered back to that new office of mine and incurred a Dickensian experience—like Scrooge being visited by spirits. I couldn’t have known but the pictures I placed in my office earlier that day, the first day of my “real job,” would provide me with guidance to get through this July 1. The diplomas, plaques, and certificates meant precisely nothing to me at this hour. It was the people in my photographs that I had haphazardly hung on nails my predecessor neglected to remove who would speak to me this night. I had taken photos throughout my training with my surgical mentors, action shots in the operating room—it just seemed like a good thing to do, and they always made for good presents to my parents who were proud to see their son, the surgeon. JAMA October 23/30, 2013 Volume 310, Number 16
Downloaded From: http://jama.jamanetwork.com/ by a University of St. Andrews Library User on 05/18/2015
1675
Opinion A Piece of My Mind
First I concentrated on two 8 × 10s, one with each of my fellowship mentors as we performed transplants together. It was clear that I was doing the sewing, their eyes fixed intently on my hands. But if I could just imagine what either of them would do in any situation encountered on this night, I’d be OK. My patient would be OK. Next I looked at a photograph of myself with my closest and most important mentor from residency. We had always done the toughest operations together, operations no one else wanted to tackle. I’d be bold and courageous in the face of blood and whatever difficulties arose. I’d get the job done. Hanging above the doorway was a photo taken of me operating with a pediatric urologist. I could remember the case well, nearly 20 hours long. If there was one thing I had learned from this mentor it was that I could never leave the operating room until I was fully satisfied with the work I had done. Otherwise, I’d do it over and over until it was perfect. Finally, the operating room called, so I walked down the nowabandoned hall. As I turned off my phone the screensaver (a photo of my wife and 8-month-old daughter) flashed. I smiled and felt warm. It occurred to me that I needed to take care of this woman as I would want another physician to care for my loved ones. My patient was a daughter and a mother herself. I made my way to the scrub sink. I could see the residents draping the patient. As I washed my hands, my thoughts turned to my favorite movie, The Right Stuff, which details the early years of manned space flight and the Mercury astronauts. On May 5, 1961, Alan B. Shepard Jr sat in a tiny capsule atop a glorified stick of dynamite waiting to be the first American blasted into space. Just before ignition he purportedly said, “Dear Lord, please don’t let me f--- up.” Shepard returned to Earth safely, and these words came to be known as Shepard’s Prayer among his astronaut colleagues. Years later, Shepard, who was not particularly religious, set the record straight revealing that his exact words were “Don’t f--- up, Shepard.” I looked at myself in the mirror that hangs above most
scrub sinks and whispered Shepard’s Prayer, hoping that I, too, had the right stuff. This operating room was new to me; the nurses were friendly, but foreign. The instruments seemed familiar, but somehow felt different—was there just a barely palpable increase in tension in the muscles of my hand causing this effect? The patient’s blood vessels were hard, thickened from years of diabetes and dialysis. She bled more than usual when we reperfused the transplant kidney. It felt as if every last molecule of epinephrine had rushed out of my glands and nerves, squeezing my blood vessels and taunting my intestines to detonate. I breathed in hard through my nostrils and did what all those faces on my office wall would do. The kidney looked great, we closed the incision. She left the hospital a week later off dialysis. I didn’t f--- up. I walked to my car at 3 AM and gazed again at that steam billowing from the roof of the hospital—this time it seemed soothing: white plumes against an indigo sky. It occurred to me that this is indeed a place where I can help make people better. A living, breathing place that had endured at least 50 years of July 1’s and hundreds of fresh attending physicians like me. Take care of your diplomas—you’ll need them for hospital credentials. Take some pictures with your mentors, as quaint as it might seem. Hang up some shots of your loved ones. We are inextricably linked to those people who taught us to walk, to diagnose, to heal, and to love. The metamorphosis from trainee to attending is not easy; it brings more responsibility and novel anxieties. You have to become your own nagging voice in the back of your head, your own parent, your own attending. Keep those attendings with you, and look at your photographs often. The trainees you pester during their medical education might end up putting you on their office wall. If the photos don’t talk to you, pick up the phone—our mentors and former attendings, like parents, always love to hear from us. And, recite Shepard’s Prayer whenever needed.
Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
1676
JAMA October 23/30, 2013 Volume 310, Number 16
Downloaded From: http://jama.jamanetwork.com/ by a University of St. Andrews Library User on 05/18/2015
jama.com
A PIECE OF MY MIND Jeremy M. Blumberg, MD Division of Urology, Harbor-UCLA Medical Center; and Department of Urology, David Geffen School of Medicine at the University of California, Los Angeles.
Corresponding Author: Jeremy M. Blumberg, MD (jblumberg@mednet .ucla.edu). Section Editor: Roxanne K. Young, Associate Senior Editor. jama.com
Shepard’s Prayer When I accepted the faculty position offered by the chair of my department, he asked when I’d like to start. My fellowship would end on June 30, and so July 1 seemed like the logical choice—it was a Monday and everything else in the past 10 years of my life had started on that date. “I’ll start July 1.” Wouldn’t I want a little time off? A vacation, perhaps, with my wife and baby? I would. But the reality was that we had bills to start paying and no savings. I was in the common, but uncomfortable, position of being highly educated, thoroughly trained, and positively broke. Besides, I was ready. July 1 is when everything begins. But before July 1 would arrive, I’d have to finish my training; the last two weeks weren’t easy. I had been a urology resident for 6 years and a fellow in kidney transplantation for nearly 2. You get tired of being told where to place this stitch, stay in that plane, don’t put the clamp there. I’d participated in more than 200 kidney transplants, not to mention the previous 6 years of urologic procedures. It becomes irritating, the nitpicking, the micromanagement, the nanomanagement; what used to seem like good advice makes your blood boil. I imagine it’s the same for the finishing hematology-oncology fellow being told how to dose the chemotherapy for her patient with lung cancer, or the anesthesiology chief resident being reminded how to bring a patient back from surgical slumber. I was fighting a voice in my head wanting to shout, “I get it, I can do this, I’m ready!” I had become an angry, moody teenager again; my attending physicians became hovering parents. I was avoiding them. Did they notice my attitude problem? I knew I was being absurd, and at the age of 35 it felt utterly unnatural. I walked into the hospital on a scorching July morning, feeling renewed and invincible. The moment took me back to the day my mom had hugged me and cried as she left me alone in my college dorm room. I was starting my career. Real life. Autonomous. Independent. The first order of business would be to set up my office—forget the fact that I barely knew my way around the place and didn’t have an identification badge. For years my diplomas had been collecting dust, and my wife was undoubtedly fed up with my burgeoning home urology library. Now there would be a home for my credentials, indelible proof that I knew exactly what I was doing. I had been craving a place of my own, and while nothing was new or shiny in my office—the mahogany faux-wood paneling on the walls brilliantly evoked the 1970s—this was an upgrade from the exposed cubicle I’d used for the past 2 years. My hubris detumesced rapidly when I answered my first page. The transplant coordinator, someone I hadn’t even met yet, called to let me know we would be admit-
ting a woman for a kidney transplant. She was diabetic and had been on hemodialysis for nearly 12 years; a kidney was available from a slightly older donor, but the nephrologist felt this organ would be of great benefit to this woman. I had trained for this very moment, the time that I’d be the one ultimately responsible for what happened to this patient in the operating room. My patient. Sure, you feel responsible and connected to your patients as a resident and fellow, but the safety net is always deployed. There’s always an attending. We made preparations for the operation. I visited with the patient and her daughter in the dialysis unit. I explained the procedure and told them I hoped this would be the last time she’d be hooked up to that machine to which she was virtually a slave for more than a decade. She smiled and said, “Thank you, Doctor.” I’d rather she thank me after we finished the transplant. I just wanted it to go well. I persisted throughout the day that my residents dot their i’s and cross their t’s with regard to this case. What is her hemoglobin level? Did you speak to the nephrology team about the immunosuppression? When will the operating room be ready for us? Wait. Was I doing the nagging? The more than slightly irked expressions of my residents confirmed this. Their resentment was palpable. Just as soon as I had been liberated from people telling me what to do, now I was telling people what to do. I was surely in charge, but that only exacerbated my anxiety. At 6 PM the operation was bumped, delayed by a case of a gunshot wound to the abdomen. I sat in my office and as the night grew darker the hospital became quieter and more still. This wood-paneled crucible had no windows, but it was unquestionably night. I paced a bit and decided to walk outside for a while. I fixated on the billows of steam rising from the top of the hospital, the steam that emanates from every hospital, and at once the building itself became menacing—a glass and concrete mass ready to swallow me whole. I wandered back to that new office of mine and incurred a Dickensian experience—like Scrooge being visited by spirits. I couldn’t have known but the pictures I placed in my office earlier that day, the first day of my “real job,” would provide me with guidance to get through this July 1. The diplomas, plaques, and certificates meant precisely nothing to me at this hour. It was the people in my photographs that I had haphazardly hung on nails my predecessor neglected to remove who would speak to me this night. I had taken photos throughout my training with my surgical mentors, action shots in the operating room—it just seemed like a good thing to do, and they always made for good presents to my parents who were proud to see their son, the surgeon. JAMA October 23/30, 2013 Volume 310, Number 16
Downloaded From: http://jama.jamanetwork.com/ by a University of St. Andrews Library User on 05/18/2015
1675
Opinion A Piece of My Mind
First I concentrated on two 8 × 10s, one with each of my fellowship mentors as we performed transplants together. It was clear that I was doing the sewing, their eyes fixed intently on my hands. But if I could just imagine what either of them would do in any situation encountered on this night, I’d be OK. My patient would be OK. Next I looked at a photograph of myself with my closest and most important mentor from residency. We had always done the toughest operations together, operations no one else wanted to tackle. I’d be bold and courageous in the face of blood and whatever difficulties arose. I’d get the job done. Hanging above the doorway was a photo taken of me operating with a pediatric urologist. I could remember the case well, nearly 20 hours long. If there was one thing I had learned from this mentor it was that I could never leave the operating room until I was fully satisfied with the work I had done. Otherwise, I’d do it over and over until it was perfect. Finally, the operating room called, so I walked down the nowabandoned hall. As I turned off my phone the screensaver (a photo of my wife and 8-month-old daughter) flashed. I smiled and felt warm. It occurred to me that I needed to take care of this woman as I would want another physician to care for my loved ones. My patient was a daughter and a mother herself. I made my way to the scrub sink. I could see the residents draping the patient. As I washed my hands, my thoughts turned to my favorite movie, The Right Stuff, which details the early years of manned space flight and the Mercury astronauts. On May 5, 1961, Alan B. Shepard Jr sat in a tiny capsule atop a glorified stick of dynamite waiting to be the first American blasted into space. Just before ignition he purportedly said, “Dear Lord, please don’t let me f--- up.” Shepard returned to Earth safely, and these words came to be known as Shepard’s Prayer among his astronaut colleagues. Years later, Shepard, who was not particularly religious, set the record straight revealing that his exact words were “Don’t f--- up, Shepard.” I looked at myself in the mirror that hangs above most
scrub sinks and whispered Shepard’s Prayer, hoping that I, too, had the right stuff. This operating room was new to me; the nurses were friendly, but foreign. The instruments seemed familiar, but somehow felt different—was there just a barely palpable increase in tension in the muscles of my hand causing this effect? The patient’s blood vessels were hard, thickened from years of diabetes and dialysis. She bled more than usual when we reperfused the transplant kidney. It felt as if every last molecule of epinephrine had rushed out of my glands and nerves, squeezing my blood vessels and taunting my intestines to detonate. I breathed in hard through my nostrils and did what all those faces on my office wall would do. The kidney looked great, we closed the incision. She left the hospital a week later off dialysis. I didn’t f--- up. I walked to my car at 3 AM and gazed again at that steam billowing from the roof of the hospital—this time it seemed soothing: white plumes against an indigo sky. It occurred to me that this is indeed a place where I can help make people better. A living, breathing place that had endured at least 50 years of July 1’s and hundreds of fresh attending physicians like me. Take care of your diplomas—you’ll need them for hospital credentials. Take some pictures with your mentors, as quaint as it might seem. Hang up some shots of your loved ones. We are inextricably linked to those people who taught us to walk, to diagnose, to heal, and to love. The metamorphosis from trainee to attending is not easy; it brings more responsibility and novel anxieties. You have to become your own nagging voice in the back of your head, your own parent, your own attending. Keep those attendings with you, and look at your photographs often. The trainees you pester during their medical education might end up putting you on their office wall. If the photos don’t talk to you, pick up the phone—our mentors and former attendings, like parents, always love to hear from us. And, recite Shepard’s Prayer whenever needed.
Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
1676
JAMA October 23/30, 2013 Volume 310, Number 16
Downloaded From: http://jama.jamanetwork.com/ by a University of St. Andrews Library User on 05/18/2015
jama.com
