Living Columns & Blogs

Our Lives: What my training didn’t teach

By Elizabeth Dreesen


My surgery residents keep disappearing. Don’t worry, though. They haven’t been abducted by aliens. And as far as I know, they’re not abandoning general surgery for online gambling careers. Instead, they’re regularly disappearing into classrooms.

The senior residents have a class in leadership and advocacy. The junior residents have a conference on quality improvement in health care. They all go to a daylong seminar called Resident as Teacher, in which they learn how to teach both students and each other. And each week, they have a lecture series on general surgical topics. Over a two-year cycle, they’ll review everything from hemorrhoid to thyroid. Plus some medical economics is thrown in along with ethics and medical-legal issues.

Classes like these are relatively new in surgical training, and I sometimes get grumpy when the residents disappear, missing the opportunity to see more patients or do an operation. How will they become surgeons, I grumble to myself, if they’re not here with me operating?

Back in the Stone Age, when I was a resident, there were no classes on our calendars. The only formal teaching we had was about how to actually do surgery. Even that teaching wasn’t always all that formal. Mostly it involved doing operations with supervising attending surgeons. If we were doing well, the attending surgeons were supportive and helped us do as much as we could do. If we were clumsy or slow, they heaved exasperated sighs laden with disappointment. Or they yelled at us. Or they got annoyed and took the knife away and did the operation themselves.

When we weren’t operating, we were seeing patients, and they were our true teachers. They were numerous and dependable. They could be counted on to show up. One patient after another, one operation after another.

It’s hard to argue that surgical patients shouldn’t be the focus of surgical residency. Still, my old-school education – one patient after another – left me with some remarkable gaps. When I went into private practice, I knew nothing about many things that really mattered to my patients. I didn’t know the difference between Medicare and Medicaid, or what Medicare did and didn’t cover. I didn’t know how much common medicines cost, though I’d prescribed them for years.

Plus, I had no idea how a hospital or a practice actually worked – how doctors earned and lost hospital privileges, how hospitals and doctors actually made money. As a newly graduated surgeon, I didn’t get paid for my first operation, because I hadn’t gotten authorization for the surgery from the patient’s insurance company. Sure, I knew a lot about surgery, but I’d never heard of pre-authorization.

In my first years of practice, I learned a ton of things I hadn’t known before. Some of it was even surgical. Most of it, though, was not.

I learned that you have to be disabled for a year in order to qualify for disability. And if you were dying fast, like one of my breast cancer patients, you’d be dead before you’d get a dime. I learned Medicare patients spend more out-of-pocket money to see a psychiatrist than a surgeon. So my patient who shot herself could afford to see me for wound care, but not a psychiatrist for the mental illness that caused the wound.

When I became the surgeon for our county’s group homes, I learned that having a psychiatric diagnosis like schizophrenia or bipolar disease didn’t mean that you couldn’t sign consent or make decisions for yourself. And I learned that many poor people can’t really read or write, and that filling out simple forms is an embarrassing and daunting task for them. Most hospital forms are pitched at a fourth-grade level, I learned, for exactly this reason.

When I was a resident, admitting and operating and discharging patients, I didn’t learn any of this. Other people knew it, though – lawyers and social workers, administrators and billers. We surgery residents were busy learning to operate, which was no small matter.

It’s clear that patient care is best learned, as I learned it, from doctors and patients. But what I learned after residency is that actually taking care of patients means more than daily patient care. It means advocating for people, helping them navigate a system of immeasurable complexity. You probably need special classes to learn how to do all of that. And if that’s what it takes, I’ll stop grousing when the residents get whisked off to class. Maybe I’ll even start going myself.