Wednesday, August 06, 2008


on a recent post greg p made the comment "this is a strange system of teaching over there. all stick, no carrot." this is true. those who have followed my blog will see that i don't have too many fond memories of my training. truth be told, most of us became punch drunk and developed certain survival tactics. most of these i look back on with regret. but at the time it was the way of things.

we could do very little when we took beatings from our own seniors (except resign which quite a few did) but when attacked by other departments often all that pent up fury would come pouring out.

i was in the boss' firm. i was the most senior registrar in the final phase of training. it was our call day which was also our clinic day. fortunately i had an orthopod rotating with me so we divided to be able to handle everything. i did the clinic and he handled casualties, only phoning me every now and then for advice. at a stage he phoned about two patients. one had obstructive jaundice. the other clinically had cholecystitis. i told him to organize a sonar for both of them and continued wading through the patients in the clinic.

at about four in the afternoon my phone rang for about the ten thousandth time that day. however this one was unique.
"hello." my standard answer.
"who are you?" the voice said. interesting question. i considered asking him who he was looking for, but, being on call i thought i'd better be polite.
"it's dr bongi speaking. how can i help?"
"what are you?" ok, i thought. at least now i know i'm dealing with someone looking for a fight. polite is no longer needed.
"what are you?" i retorted. he let rip.
"i am a registrar in radiology and i want to know why you've sent two patients now for sonar!" his apparent complaint was that the sonars hadn't been organized with him and had apparently just turned up. the house doctor, on the instruction of the rotating orthopod had written my name on the request form. the fact that he didn't recognize my name told me that he was very junior. the fact that he decided to pick a fight with a surgeon told me that he was a fool. i considered going to sonar and sorting him out but decided i wanted to make sure my team had done nothing wrong before thumping someone unnecessarily. also to take a bit of time would allow me to calm down to a rage and maybe react with more circumspection.

by the time i had spoken to my team and ascertained that the fault did not lie with us (the house doctor had phoned sonar and organized the sonars with the head. she had left before relaying this information to her junior) he had gone home. later that night i stopped by radiology and chatted to the call guy. i had a good relationship with almost all of them. i relayed my story, asking who this aggressive guy was. they only knew there was a new registrar in the department who had only started that month. i decided to confront him the next day.

the next day, after the post call rounds, i went to sonar and asked to see him. the head heard i was there and came to me. the guy i was looking for was conveniently not there. i discussed the incident with the head of sonar, ending the conversation with two statements. this sort of thing was not acceptable and i would be expecting an apology from him. no apology came.

not too long thereafter i was on call again. we sent a patient to scan. when the scan came back i called my students around to teach them how to read a ct scan. after going through the ct, one student told me i had missed some free air in the abdomen.
"rubbish!" i said. "there is no free air in this abdomen." he then presented the radiology report which clearly stated there was free air in the abdomen. i was amazed. i went through the scan carefully but i just couldn't see what the report said was there. then i read the name of the radiologist. it was my friend from sonar. i smiled.

i phoned the radiology department and asked to speak to him. i introduced myself and then told him that i had a query about his report. i asked him to explain it to me in person. he invited me down to radiology. i said that i required him to come up to the surgeon's tea room. he said he'd be there in a half an hour.

when he arrived i had an x-ray viewing box set up. all my students were still with me to watch the show. when the radiologist came in i showed him his report and asked him to show me the air. when he showed me what he thought was the free air i admit i felt a bit sorry for him. he was clearly so junior he couldn't read a scan properly. without saying a word i pointed out on the scan why that was not free air and could easily be identified as lung in the thorax by simply following it out onto other images. he apologized for the mistake. still i said nothing. he owed me an apology for something else still. the students were snickering in the background at the fact that a surgeon read a ct better than a radiologist. he looked sheepish and left.

when i look back i'm not proud of my behaviour. and this is probably not the best first post dealing with the constant fights we had with other departments. but the actual point of this post has to do with our general frame of mind in those days. unfortunately it was not good and we were not the most loved people in the hospital.


rlbates said...

That picture is so appropriate to this post. By the way, did I say congrats for your blog post award. If not, then congrats!

Vijay said...

Knowing your preference for reading your own scans, I sort of expected that you wouldn't have nice things to say about radiologists ;)
In this instance, I agree with your assessment of the radiology registrar's stupidity. Not for the incorrect report of pneumoperitoneum, but for picking a fight over scans sent from the casualty. An error in reporting is acceptable, but to show anger towards the surgeon / ER doc for sending you a scan is inexcusable. I have felt bad and angry about many emergency scans that could've been avoided, but I never confronted anyone about those. Always at the back of my mind runs the possible scenario of a delayed diagnosis & treatment because of delayed investigation. Delaying a radiological investigation in order not to irritate the duty radiologist is probably the worst possible thing that could happen to a patient.

Vijay said...

Congrats on the blog post award. Well deserved.

Greg P said...

Almost without exception, those who impressed me most as they reached higher levels in their departments were those who became more gentle with their colleagues, more understanding, and more helpful.

We have our run-ins with radiologists too. They don't understand why I don't want to get a verbal 5 to 10 minute description of "what a scan shows", especially when they don't seem interested in the clinical question I had when I ordered it.
It's rare that you can understand what a scan shows by hearing/reading the report. You really have to be looking at the images while you read it, while you're hearing the description. I can acknowledge that there are things they can teach me about the interpretations, but there are things I can teach them about the clinical importance of what they see, and maybe point out some things they don't.

Anonymous said...

Actually, I think you handled that really well. There were some senior surgery residents (registrars) were I went to medical school that would absolutely rip you a new one for something like this.

I think inter-department bickering and turf-wars are a problem at every training institution, but as greg p put it is most impressive when the senior resident is able to control a situation with a firm, but calm hand without escalating tensions ...yet not giving up to much ground.

Bongi said...

anonymous, thanks for the compliment.

important to remember that when a surgeon threatens to rip you a new one, he actually can.

the reason that i said this is maybe not a good start to the inter-departmental wars is because this was not worth it. sometimes one must fight for the good of the patient, especially in a place like kalafong. this was not one of those times.

Anonymous said...

I have always tried to be an optimist and not react to misbehaviour, be it unadulterated aggression or stupidity, since there are often underlying reasons for it and rarely personal. I am sure I have misbehaved similarly on occassion and mainly regretted it. I feel remaining as cool headed as possible gives me a better shot at getting results, and patients, at the end of the day are whom we're there for. When I avoid personal attacks I will hopefully not 'close' someone's ears for good. Future talks may be more fruitful and that way the discussion doesn't end up in a downward spiral down the loo! BTW, I should say that I am an anaesthetist though this should not mean I have distanced myself from fighting for the patient's interests, quite the contrary.

I have loved reading your blogs and they paint vivid images of Mpumalanga. Thanks, long may they continue!

Ladyk73 said...

Is this training process there still so ...aggressive?

Or has the horrible hazing stop?

walt dandy said...

Part of training, I've noticed, is learning how to navigate all the very fragile egos in the hospital (sometimes including, I have to admit, my own). If you put constantly tired, stressed out, strong-willed individuals in a large and constantly noisy environment sparks tend to fly every now and then. My most regrettable event to date involved a resident from another service who paged me at 2am when I wasn't on call to ask to transfer a brain dead patient to our service. That question could easily have waited 3 hours until I was in the hospital rounding. I swore at him, which is not something I can recall doing before.

make mine trauma said...

Bongi, congratulations on a well deserved award.