Reflections of a Clinician-educator: Kimberly and the Giant Calipers

Grasshopper: This is an outrage! You are a disgrace to your Phylum, Order, Class, Genus and Species!

Centipede: Say it in English!

Grasshopper: YOU, sir, are an ASS!



from Roald Dahl's childrens' classic "James and the Giant Peach"

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I used to love the book "James and the Giant Peach." If you've never read it, it's this wonderfully trippy journey of the imagination written by British author, Roald Dahl (the same guy who came up with the Willy Wonka books and also the recent book-turned-movie "The Fantastic Mr. Fox".) Poor little James had a few traumatic and convoluted experiences, including getting lost inside of a giant cavernous peach. Despite this, he learned some great lessons there and met some great friends along the way (even if they were insects). Although I loved that book, I'm still not sure about Roald Dahl and what could have been going on with him when he came up with this tale but that's another story. . . .

Anyways, I like to think of medical school and residency training that way. Some parts of it can be downright terrifying, and despite this, you encounter a few people and experiences along the way that ultimately help mold you into an even better version of yourself. Sometimes it's intentional, other times it happens by accident. Either way, it's necessary.



Kimberly and the Giant Calipers

When I was in my internship, I was rotating on inpatient Cardiology with this really hard-core Socratic teaching cardiologist. Every morning we started the day at like 6:30 a.m. for a half-hour of teaching. Here's how it went down:

1. Dr. Socrates marches in and carrying a tray of slides holding pictures of what are quite possibly the world's most heinous EKG tracings.
2. Dr. Socrates sets up projector at very back of the room and then switches off lights. Ginormous image of world's most obscure EKG tracing now in wallpaper proportions over the entire wall. (No, not on a screen, but the size of the ENTIRE WALL.)
   
3. Us terrified interns sit at front of the room vacillating between feelings of nausea and near-fainting. At least one will actually vomit or lose some other bodily fluid.
   
4. Dr. Socrates perches glasses on his nose and walks toward our seats. Although he is only 5'4" max, his shadow is projected on the wall which makes him look like a big, scary monster that has just jumped out of a closet.
5. In his hands are these gigantic wooden calipers for EKG tracings that are, literally, the length of my arms.
   
6. Interns begin praying to whatever God they pray to that somehow, someway they don't faint, become incontinent, or make a complete fool out of themselves in some other way, or that if they do, that all of the others also do the same.
7. Some unlucky intern gets handed the giant calipers and told to go to the front of the wall.

the calipers: like these, but wooden and scarier

the projected image: like this, but an EKG and scarier

Early one morning, circa 1996

I'd been standing in front of the ginormous projected EKG, and had just measured every interval, and answered the initial basic line of questioning. It always started with basic questions, followed by a series of harder questions that felt like water torture. I swallowed hard and prayed for sphincter control.

Me: "This appears to be some kind of incomplete bundle branch block, sir. Left, that is." I wanted to be noncommital, yet smarter-sounding. I could feel myself getting woozy and diaphoretic. "Some kind of interventricular conduction defect, sir." Uh oh. Want to take it back immediately.

Dr. Socrates: (Big sigh) "Okay, so Dr. Draper. . . . .tell me, what are YOUR criteria for left anterior fascicular block?"

Okay, let me give you more on Dr. Socrates. He was from somewhere overseas and spoke with an unapologetically thick accent that seemed to emphasize all the things that you were doing wrong. He constantly looked exasperated with us, and still wasn't happy even when there was a budding cardiologist on the team (which there was that month.) He was so intimidating that during the first few sessions, even when you knew the answer, it fell out of your brain into a crack in the ground, never to be seen or heard from again.

Me: "My criteria?" I had no criteria.

Dr. Socrates: "THE criteria." Even worse.

Me: "Umm. . . a left axis deviation and. . . .ummmm"

Dr. Socrates: "and WHAT?" I could feel myself beginning to sweat. The giant calipers slipping out of my hands.

Me: "Is the QRS interval a little bit prolonged but not too prolonged, right?"

Dr. Socrates: "Is it?"

I look over at my other two co-interns like I'm on some kind of game show hoping they will start shouting out answers. Instead they are both quickly thumbing through their pocket notebooks hoping the spotlight wouldn't turn onto them. No help at all.

Me: "Um, yeah, it's . . . uh. . .short. I mean, yes sir, it is prolonged."

Dr. Socrates: "How prolonged?"

Me: "Umm. . .prolonged a little bit but still less than 0.12?"

Dr. Socrates: "And? I'm waiting." Wait, did he just roll his eyes at me?

AND that was the extent of what I knew about THE criteria. That is, that was all I would be able to recall under those circumstances. I mean, all I really knew is that it wasn't a left bundle branch block, which I'd determined after using the giant calipers. I knew that somewhere in there there was some rule about right bundle branch block, but I wouldn't dare utter it while standing in the big shadow box. I shifted from side to side on my feet, hoping this would end. Instead he sat at the back of the room like Michael Douglas on "A Chorus Line" bellowing scary questions out without the least bit of sympathy. I was sure I was going to be sick (or lose sphincter control.)

Like Michael Douglas at the back of that dark theater, but darker and scarier

Dr. Socrates: (sighs in the most exaggerated way ever) "You interns don't know NAAAH-THING. Don't they teach you NAAAAH-THING? How do you not KNOW the criteria for a left anterior hemiblock?"

Me: speechless but thinking, I might partially know, but the chances of me being able to tell a screaming, 5 foot madman with white spit flying from his mouth are slim to none.

Dr. Socrates: "Look at the inferior leads!" He grabs the calipers from me and heads to the front of the room. He stomps his foot. "LOOK! Don't you see those Q waves? You can't call this a left anterior fascicular block in the face of an old inferior myocardial infarction! Come ON! This is KEEEED STOFF!"

But it wasn't kid stuff. It was new stuff. To me and to the other two interns rotating with me that month. I wanted to become more proficient at EKG reading, but this was terrifying. And so, for an entire month, we withstood the giant calipers until eventually something happened. We kept getting challenged. We went home and studied. We tried harder. At some point, we started getting the answers right. And when we did, he just asked harder questions until we somehow got those, too.

By the end of the month, we realized that hearing him say, "Don't you interns know NAAAAH-THING???" was really a term of endearment, and that his other winner--"Help! Help! THAAAT is what this poor man will be saying while you interns try to ASSASSINATE him by not knowing NAAAAH-THING." --was his way of saying, you have to know this not just for tests but for patients. On the last day of the rotation, I gave him a big hug and even wrote him a thank you card. Crazy as it sounds, that rotation turned out to be one of my most favorite months of residency (despite the PTSD it cause me for complex EKG reading.)

13 years later, I can truly say that I remember that attending with warm nostalgia instead of nausea. While I can't say that I personally endorse his colorful method of teaching, what I can say is that now I do appreciate his dedication and passion to our medical education. Now that I'm a clinician-educator, I know what must have gone into gathering all of those EKG tracings and getting them onto kodakchrome slides. I recognize how committed he had to be to meet us every single morning at 6:30 a.m. before rounds, all while still being responsible for the entire service of patients and probably countless other things. I can now see how, deep down, he had high expectations of us and for us, and though he wasn't so touchy-feely about it, he really cared. And in the end, I'm thankful for it.

Kind of like James and the giant peach. He started out lost and surrounded by scary things. With time, those things became more familiar and less daunting, and even downright enjoyable. Though somewhat traumatic along the journey, he was better for it. The struggle was worth it, and yes, necessary. That attending may not have been warm and fuzzy like a peach, but at least he wasn't apathetic. When it's all said and done, I'll take spunk over apathy any day.

So now, I let my learners get lost in the giant peach just a little bit. . . .never at the expense of patient safety, of course--but enough for them to struggle and learn. I take the best of Dr. Socrates, and soften it with my own style. Like him, I expect them to do well, to learn with experience, and to try. And also like him, I do my best to back it up with instruction, time, and passion. Even if their journey into the core of the peach gets a little rough, I know it's necessary, and that they'll be better for it.

***

At the end of "James and the Giant Peach", James makes a home of the peach pit which turns out to be an oasis in the middle of New York's Central Park. Those insects end up being his very best lifelong friends--and they all live happily ever after. :)