Making Decisions

“What do you want to give for sedation?” I stood there frozen, staring back at my attending as the question echoed off the walls. It was my first week in the medical intensive care unit (MICU), which happened to coincide with the first week of my internal medicine residency. I can only imagine what my facial expression revealed, but standing there in front of the code team, I had to come up with something. I recited a drug and dose that felt familiar from a midnight review of the intern handbook. “Go to the head of the bed and help him out,” said the attending, mercifully ignoring my answer and shifting attention to a senior resident who had also responded to the “code blue.” With assistance from the resident, we succeeded in securing the airway. Life began moving at normal speed again, aided by the directive to count slowly the seconds between squeezing in each breath. Off we rolled to the MICU. We arrived to find another senior resident preparing for a central line, having heard about the situation prior to our arrival. “What’s your name? Here, come help me.” I donned the sterile gown and tried to recall what I knew about central lines. “Where’s my line?” A new voice emanated from the bustling sea of scrubs. “We’ve got it,” said the resident calmly.

It was over quickly, but I remember it clearly. Now, working as an internist at a teaching hospital in Kenya, I’m no longer the trainee, and instead find myself asking the same questions my attendings were asking me. Beyond the language barriers, open wards, and cultural differences, the familiar rhythms of medical training remain: interns interview, examine, formulate, and present. We discuss our decisions and move to the next patient. Teaching in this environment is challenging. Interns have 3 months in internal medicine and manage a census well above what I encountered as a trainee. I do my best to support them, but the exhaustion inevitably creeps onto their faces as we trudge through our daily rounds. As they parry my inquiries about blood pressure, insulin dosing, and antibiotic selection, I look for opportunities to impart my knowledge on various subjects, while trying to maintain morale. Intermingled with my riveting tales of resistant hypertension and difficult-to-control blood glucose, a different kind of teaching opportunity frequently appears.

The phrases “we could” and “can consider” stand out to me in the case presentation like a premature ventricular contraction on telemetry. Sometimes this is a sign we should stop and deliberate, especially when there is no single solution or when the guidelines deviate from what the individual patient and family actually need. Other times, though, it can be an early warning sign of indecision, that discomfort all trainees eventually feel when faced with a complex choice about the health and well-being of a fellow human. In these moments I get to press pause and guide them through the decision-making process. “Those are great ideas, but what recommendations will you discuss with the family? How are you going to advise the nursing team?” The scenario is familiar: the rehearsed monotony of stable vitals and soft, nontender abdomens comes to a grinding halt with the grace of a record scratch. I see the intern’s eyes involuntarily widen, as their peers stifle nervous laughter. I’m witnessing the equivalent of a cognitive code blue, triggered by the R-on-T impact of the question, “So what are we going to do?”

As the young doctor takes a moment to deliberate, I recall challenges from my own time as a trainee. Midway through my own residency training I was paged about a sick patient overnight. I remember watching the green telemetry tracing race across the screen, cluing us in to the rising heart rate. The blood pressure was acceptable, so we requested a fluid challenge. I finished my shift and went home, but by midmorning the patient was in the MICU. The day team had evaluated the patient and determined the need to escalate care, and I suspect little had changed between our respective assessments. Sometime in the night, my fears of making the wrong choice paralyzed me. I was not missing any key piece of medical information, but rather was still forming a mechanism to make important decisions in the face of worsening illness. When I failed to act, I rendered useless all the resources I had at my disposal. I remember the embarrassment I felt afterwards, but I was fortunate to have teachers who modeled calm clinical reasoning and decision-making during my training. Over the years they guided me in my growth as a physician, and now it is my duty to do the same for these young doctors.

My intern regroups as the whir of life on the ward brings my focus back to the present, and the memories of my own training bring a renewed urgency to the present-day educational opportunity. I do my best to give them some space and time to commit to a differential diagnosis and a plan. As we discuss it, I hear myself reciting the same advice I heard as a trainee and now frequently utter, “You shouldn’t write ‘5 to 7’ on the antibiotic prescription,” and “Remember, metformin won’t fix today’s hyperglycemia.” We keep it lighthearted, and I slowly coax an actionable plan out of them. A few presentations later, they offer a complete plan spontaneously, testing the waters with their own differential diagnosis and the workup and treatment to follow. “Okay, that sounds good to me.” We round off the rough edges, and I throw in some pearls for style points, but something important has happened. This plan was their idea, and they will carry it out. They are empowered, and so is the patient and family. I can see their surprise and satisfaction as we move to the next bed without fanfare, having anticipated a speedbump that never materialized.

Over the coming weeks there will be times when they get overwhelmed and the whole process will seem to start over, but that’s why I’m there. Little by little, my role will shrink as my questions become more open-ended and less leading. They’ll become more independent, and over time they will care for patients from admission through recovery with little assistance. With a smile they will tell me the patient in bed 11 has recovered and is going home. They will revel in the victory and remember why they became a doctor. In those moments, so do I.