Guest Blog: ToMAYto, ToMAHto

I work with with thirty-three different attendings. Who want patients managed, needles held, stitches thrown, lacerations repaired, knots tied thirty-three different ways. It was part of the learning curve, at first, learning which attending liked what, remembering who to call about different problems and learning to not be upset when I didn't remember who preferred what. And now, I'm starting to develop what I like. Many attendings have offered me pearls, on patient management and surgical skills, and I'm starting to develop a framework of what I want to do, what I think works well. And this is even more frustrating, because then I end up with someone new, who doesn't like the way I am doing something, and makes me do it a way that doesn't feel natural, or right. And really, no one is very wrong, but it means I am never right. It's like how some people say "toMAYto" and some say "toMAHto." No one is actually right, and everyone insists that they are. Here are some examples: Yesterday in the OR, an attending showed me a way to reload my needle without touching it with my fingers. Use the pickups, inch it out, and regrasp it in a way that it was ready to throw the next stitch. Better technique, he explained, it would allow me to avoid needlesticks and was a more sophisticated surgical technique. I practice, and look forward to my next c-section, where I can practice it again on a real patient. I start, expecting the attending to be impressed or at least not say anything, but she yanks the needle out of my hand and shows me how to do it....exactly like I used to. I pick up the needle, reload it using my fingers, and silently curse this frustration. An attending that puts me on the stool in front of the mother. She does this under the assumption that this is a good position for me to deliver the baby, but I have figured out the real reason. She puts me on the stool, then waits for the crucial moment when the baby is about the deliver, then rolls me out of the way and delivers the baby herself. Antibiotics. Some give antibiotics for GBS+ mothers at the beginning of inductions, and some only when they are actively laboring. The downside to the first option is a mother can receive fifteen doses of a medication that burns their veins and is unnecessary for that long. Alternatively, a mother can labor quickly and not get enough of a dose in and end up with a baby in observation in the NICU for 48 hours. So, I started to ask each attending, when would you like the pencillin started? They couldn't believe I was asking this, like I didn't know. Then, I would ask with one option offered, would you like this when they are in active labor? Some people then thought I was correct, and some thought I was an idiot. So, no matter what I think or what I would do, I look stupid at least half of the time, just trying to please everyone. I am fairly ambidextrous, and can operate either right or left-handed. Some think this makes me versatile, and encourage maintaining both. Others yell at me to pick a side and stick with it. Now I don't know which side to stand on. Likewise, I can clamp and cut cords after delivery lefthanded. Usually I hold the baby in my right arm, tucking baby's feet under the crook of my elbow, and clamp and cut lefthanded. I don't know why I do this. It just feels right, to hold the baby securely in my more dominant arm, and use my left hand for the instruments. But, attendings sometimes ask me if I'm right or left handed, and when I tell them right-handed but better with fine motor skills with my left (due to violin training, I think), they frustratedly instruct me that I should only be managing scissors around a newborn with my dominant hand. Again, I'm not sure which that is. There are probably infinite variations on how to do one surgery, one delivery, and that's what I'm learning. Even though I've never had a bad surgical outcome, somehow I am always wrong with how I do it. I'm trying to take the best of everyone's suggestions (ie yelled orders), and compile it into my own technique, but starting to realize that it will be awhile before I can really employ what I think is best. And I can't say I wouldn't be the same later, after a career's worth of doing what I decided is best...I'd probably want to hand my hard-earned knowledge along too. But it's frustrating now. I think I'll go sit down on the roll-ey stool and practice reloading my needle. Dr. Anne KennardMedelita Guest Blogger: Dr. Anne Kennard. Anne is an OB/GYN resident in Phoenix. She has kept a collection of writings about medicine/becoming a doctor since her second year of medical school, and we're honored to welcome her as a guest blogger for Medelita.

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