Getting Along At the V.A. Hospital

For simplicity the pronoun “his” will be used generically, but “his/her” may be substituted at will. Getting along is a complex subject because it is so vague and means different things to different people. To one, it is getting out alive, to another doing a good job.

Several things affecting the topic will be discussed in a somewhat disorganized way.

• General clinic patient avoidance-mainly for seniors.
  
  
  • Get stuck in traffic
    
    
  • Schedule post-op visits in A.M. instead of P.M.
    
    
  • When nagged by Dr. Taterka, known affectionately as “Dr. T.”, whine that when you were a second year the seniors never saw general clinic patients. He has been seen to be close to tears when confronted like that.
    
    
  • When you are doing a “to-follow” case go to the O.R. as soon as the case is called for. You are then certain of 45-60 minutes of peace and quiet, because when the case is summoned, there are still left 40 minutes of surgery to which must be added about 25 minutes of room preparation time. This can spare you from seeing 2 or 3 clinic patients.
    
    
  • As the surgeon, prolong the last part of the operation by replacing sutures and breaking them as you tie, stop and aspirate a tiny shred of cortex if you see one. With practice 30 minutes can easily be added. This is called ophthalmologists “meticulous” surgery. Combined with the pre-op waste of time a skilled resident may get through the entire morning without seeing even 1 general clinic patient.
    
    
  • The opportunity to continue this strategy is enhanced in general anesthesia cases because it is easy to hide in the recovery area, while writing meticulous orders. Actually, compared to being in the clinic it is quite pleasant there.
    
    
  • Do not waste the opportunity to relax when Dr. T. is distracted by medical students, an ex-fighter pilot, Dr. Breinin, or one of his meetings. Because a senior's surgical experience is vary dependent on his clinic activity, there is the danger that the above strategies may be carried too far by a resident. For instance, we have had senior residents with the ability to disappear when you are alone with them on an elevator. These, of course, are where disappearing attendings come from.
    
    
• An extremely important topic is the execution of V.A. documents. The V.A. is uncompromising about certain things. Empty boxes on forms are forbidden. Examples of forms are: “C. & P.” (compensation and pension), drug studies, and particularly prosthetic request. The concern is with emptiness rather with either accuracy or relevance. It is considered poetic justice to refund any request containing an empty box. Perhaps 50% of the center work force is devoted to the generation of the boxes or checking to see if they are filled out. It turns out that they are more successful than the fillers outers. If one's job is to pay attention to the boxes it is easy to understand their disappointment when the box is ignored. Here is what gets the box people angrier than anything. When in a C & P exam you say if you wait and do such and such a test, you can avoid guessing. The use of the word “guess” is not entirely fair because it exaggerates the degrees of improbability. Obviously, the value of the guess is related to one's experience. This does not have to be carried so far that it inhibits the imperative to guess. There is unanimous agreement on what is demanded of you. Guess today. In the event that it is your opinion that there is, required medical follow-up, so advise. All the good will you will have established by fast guessing can be undone by failure to sign the forms on the designated place. This has the same effect as an empty box. The fact that your efforts may have been in vain because the record will be lost must not influence you. What must influence you is that Dr. T. is going to have to sign the form for you. Getting him mad is not such a big deal because he'll forget why. It is better not to ask him for a letter of recommendation before he forgets. What is a big deal is getting those of his superiors angry who have to approve our equipment requests. This is one of the worst things you can do besides upsetting Dr. Breinin or Dr. Noble. They have outstanding memories.
  
  
• For a variety of reasons do not even try to win an argument with the Chief of Staff or Operating Room Supervisor, mainly because you can not. Winning an argument with a patient or being unable to resist a clever one-liner can complicate your life. At this center are patients who are in constant contact with Congress about their treatment. That this is sometimes a manifestation of a functional disorder is not interesting to Congress. One of the things administrators and Section Chiefs hate even worse than empty boxes is having to respond to letters from congress about mistreatment of patients.

In spite of our constitution a complaint is either assumed to be true or confirmation of the doctor's character defect, particularly if he is a surgeon. It is the existence of the complaint, rather than its content that is important. The previous sentence implies that there is not excessive pre-occupation with metaphysical concepts such as, “fair” “due process”, or “too busy”.

One does not have to play the fool, but be tolerant and remember that many veterans made great sacrifices and deserve special consideration. In any case, it is our society which decides on veteran's prerogatives.

Over the years Ophthalmology has acquired a deserved reputation for good work and professionalism. It is much easier to destroy such a reputation than generate it.

Since you will benefit from good will towards the eye service, it is fair that you help to maintain it. In the end one does not need an excuse or performing one's job well.

What follows are some miscellaneous comments:

This is very important. From time to time it is necessary to arrange or test or procedures on a patients for which payment is necessary. An example might be chemosurgery at Universiy Hospital , an E.M.G. at Bellevue or a fee for Corneal donor material. Here is what is needed, everytime: Approval from Section Chief, Chief of Surgery and Chief of Staff. This will be coordinates in the Surgical Office.

In general senior house staff have the responsibility for manpower assignments. Before leaving for the day one should be released by a senior, if he can be found.

Immediate response to calls from the V.A. Emergency Room and admitting is expected. The patient must be seen there. In other words, he is not to meet you at Bellevue . Be familiar with the several layers of back up that is available if needed.

Sometimes patients arrive at the wrong time. This may be caused by negligence by them or because they were told the wrong time by the hospital. Our first reaction must not be immediate rejection of the patient because we are harried, tired, or something else. It is rather to understand the circumstances and to try to develop a solution. Sometimes it is reasonable and humane to reschedule the visit and sometimes it is not. For instance, a severely disabled 75 year old veteran driven a long distance by a member of his family cannot arbitrarily be sent away, regardless of how one feels. It would be correct to conclude that anyone who did this should probably not be a physician. It must be accepted that in general patients should not be punished for break downs in our system. We are usually able to resolve such situations in a reasonable way. If one thinks about it, it will be recognized that surgical training is full of ethical compromises. Almost all are to the advantage of the surgical trainee, but there's no law that says their has to be so.