Qualifications of a “leech”

Rivers (and others) describe another aspect of medicine that is consistent with a biomedical healing ritual. Speaking further about the qualifications for a leech, Rivers says:

The most complete instruction in any branch of medical magical or medical religious art is of no avail to the people unless money has passed from himself to his instructor. This instruction and purchase, however, nearly always include both the production and cure of disease, where disease is ascribed to human agency in the power and knowledge to perform rights other than those of the curative nature where medicine is allied with religion. [2001[1924]:41]

Although he's talking about healing rituals in Melanesia, that same statement is a fairly accurate description of postgraduate medical education in the United States. Consider that Dr. Fields has

$240,000.00 of educational debt. I will provide further aspects of training a leech later.

Repeating what Rivers said, Evans-Pritchard states:

Magic must be bought like any other property, and the really significant part of initiation is the slow transference of knowledge about plants from teacher to pupil in exchange for a long string of fees. A teacher may show them casually to his pupil at any time when they were both out in the bush together, as on a hunting trip, or he may specially take him out for the purpose. Unless the medicines are bought with adequate fees there's a danger that they will lose their potency for the recipient during the transference, since their owner is dissatisfied and bears the purchaser ill will. [Pritchard 1976:97]

The modern-day version of that is a medical-surgical residency. There is a connection between hierarchy, experience, and competence among doctors.

Meyer Fortes also talks about training and its vital role in generating a healing ritual.

“But I have in mind more the fact that divination is often a specialized technique. The diviner may have to undergo training to become expert in it, or he may be selected for it by virtue of his talents for his psychological makeup. The diviner must be properly accredited, often by a public initiation after evidence of his acceptance by the occult agencies” (Fortes 1987:10).

Those passages describe the initiation and transfer of the systems of meaning that comprise diagnosis and therapeutics. This is as much a part of the healing ritual as any other. If Western biomedicine is a healing ritual, then my data should contain observations to verify this.

After all, society confers the privilege of pronouncing a diagnosis narrative to only those whose qualifications and credentials are recognized by others. This training not only qualifies the practitioner to proclaim a diagnosis but also is a vital aspect of the persuasion component of the healing ritual. Although a supportive function, it is a necessary function and intimately connected to the other narrative components of the ritual. It identifies an authoritative narrator.

Brian assesses the qualifications of his doctor

Brian intuitively understands that there is a connection between hierarchy, experience, and competence. This portion of his monologue highlights that concordance and affects how he navigates the healing ritual.

Well, I knew enough about what was going on to know that prostate surgery included urinary incontinence and sexual problems and things. I’m imagining I'm gonna run around with a diaper for the rest of my life and my sex life is just gone completely and is gonna stop from here on, and I'm gonna to be rendered pretty much unable to do any of that. I mean, that's – You jump to the extreme of what you've heard and know about.

Knowing that I was probably not thinking totally clearly, as the one who is trying to assimilate all of this. I know at one point I asked him, “Okay, how many surgeries of these do you do,” because I was – and I don't remember at what point we heard from this friend of ours, and it was probably at the point we knew we had it, but before we had decided where we were gonna go about this. So I know there were some questions about, “Okay, how many of these do you do?” And it was something like well 20 or 25 a year. And then we were comparing that with Dr. Stein, who did 30 a week or something like that. It was drastically different the number of these things that people did. And so that was also part of the discussion of where we were gonna have this done and how we were gonna do it.

The husband of a colleague of hers had been through similar things more advanced and more serious than what I was dealing with, and he had a very

positive experience at Connaught and referred me there. So I contacted Dr. Stein, who was the surgeon who had done the other guy's surgery and for seeking at least a second opinion and potentially to do the surgery. Well, he was very busy, and it was going to be very difficult to get in to see him. I think he was the head of the oncology department over there, and so getting to Dr. Stein was supposed to be rather difficult, and the first contact was, “Well, you know, would you be interested in having one of his students or one of his colleagues do that?”

And I said, “I really would like to have Dr. Stein do this,” and subsequently I was accepted as a patient of Dr. Stein and met with him at least once to go over that and then ultimately the surgery was scheduled.

My thinking at the time and the reason for going to Dr. Stein was he had – at least I had become aware, and some of it was from the reference that got me there. And other sources, I don't recall. He had lots of surgical experience with the robotic surgery. He went out of his way to not just hack away at it and take whatever was left. His specialty was leaving as many of the nerves as possible and being very exact in how this was done, and he has developed a reputation for that and with some very good results. His whole focus was “We're gonna do this and leave you in absolutely the best shape we can to live a normal life from here on.” And so that aspect of it, of the outcomes, was pretty high in my looking for, you know – I wanted it to be a successful surgery, but my mission was I want it to be successful. And I want my full function of my body when I'm all done, and so the whole emphasis on – the whole reason for going to Dr. Stein was the – I'll say

“reputation,” but it was the focus of a lot of his research, and his practice was doing this surgery in as least harmful way as possible.

Embedded in this passage is the contemplation of incontinence and diapers, impotence, and a sex life that is just gone. Brian’s response is to seek out the best practitioner of the healing arts, the one that leaves as many of the nerves as possible and is very exact in doing it with the DaVinci robotic surgery technique.

Transference of knowledge from teacher to pupil

The inpatient urology rounding team consists of a chief resident, senior residents, the intern, and finally the medical students. A strict hierarchy is enforced, with the chief resident acting as proxy for the attending physicians for clinical management of the patients, supervising

the more junior residents. The chief resident also decides who gets to scrub in on what surgery.

The chief himself claims the difficult cases and the robotic cases; the others have to wait until they become senior enough or chief to have this opportunity. On the other extreme is the intern who does the repetitive, routine surgical cases, such as retrograde urograms and cystoscopies. In the following vignette, notice how strictly the hierarchy is enforced. The slight infraction is punished by comments about getting experience in the operating room and the ultimate insult to a resident, offering the first assistant position to a medical student.

Connaught Cancer Institute rents renovated floor space on the fifth floor of Hopewell Hospital. The accreditation for the urology residency is through Connaught, so they see most of their patients on this floor. However, they also see consultations on other floors of the interconnected hospitals. Rounds start at 6:30 a.m., so I tried to arrive slightly earlier. The medical students were already there and collecting data from the various computers as well as a perfunctory interview with each patient. Shortly after I arrived, Dr. Wright showed up and immediately went to the computer and started jotting down labs. The tall medical student was doing the identical procedure with a different computer, jotting down labs, both of them copying them onto a computer printout with the patients’

names. After Dr. Pinder arrived, he started whispering with Dr. Wright. Shortly thereafter Dr. Wright says, “What we have here?” The medical student started presenting patient after patient to Dr. Pinder. He reported symptoms, lab results, temperature and vital signs,⁷² including input and output.⁷³

At 6:48 a.m., Dr. Fields joined the group. Dr. Pinder said, “Dr. Fields just wants to show up and operate while I take care of patients. At least he wants to go to OR now, so that's a little bit of progress.” Rounds continued without comment.

Dr. Fields took one of the portable computers on the small tabletop and pushed it around down the hallway and into each individual patient room. He was constantly staring at the computer and typing throughout the walk, the discussion, and the patient interviews. I was able to get a very close look at the computer that Dr. Fields was using. I was able to ascertain that it was actually progress notes that he was generating directly onto the computer program.

While in a room with a patient, Dr. Pinder asked, “Are you passing any gas?”

The patient replied, “Why do you say that?” There was no response from Dr. Pinder. Dr. Pinder put gloves on and examined one patient’s wound while asking “Any nausea or vomiting?” after finding out the patient had not yet passed gas. Instead, Dr. Pinder started examining the incision and asked, “Any pain?”

72 Vital signs include blood pressure, pulse or heart rate, temperature, respiratory or breathing rate, and “pain”.

73 Measures of fluids going into the body and fluids coming out of the body, recorded in the nursing notes section of the chart.

The only response was “Arrghr-rrghh!” Even while the patient was moaning, Dr.

Pinder said, “Incision looks good. We started TPN yesterday.”⁷⁴ The patient asked, “Can the drain come out?”

Dr. Pinder said, “Yeah, there's not a lot draining. The incisions look good.

Your urine looks good too [even though it was bloody red]. You have a low-grade fever,” which seemed to surprise the patient. Dr. Pinder continued, “The most important thing is to use this device,” referring to the incentives spirometer. “You should get up and walk around, and perhaps you can get the urinary catheter out today and maybe even possibly go home.” As everyone left the room, Dr. Fields pushed the computer on wheels outside the room.

74 TPN is Total Parenteral Nutrition—all nutrition provided through an IV and not the gastrointestinal system.

Figure 19. Computer on wheels—almost ubiquitous in inpatient settings.

Once we were outside the room and back the hallway, Dr. Fields said to Dr. Pinder, “This is the first time in my entire residency that I've been late; it's been 14 months and this is the first time. You showed up two minutes before I did.”

Dr. Pinder said, “It doesn't matter what time I show up.”

Dr. Fields replied, “I was hoping you wouldn't chew me out on rounds."

The conversation drifted to “What’s the case today?” Then someone said,

“There are four cases tomorrow.” Dr. Wright turned toward the medical students saying, “You might be the first assistant on one of the surgeries.” The entire time the residents were discussing surgeries and surgical techniques. One of the senior residents used hand gestures in three-dimensional space to demonstrate anatomy and surgical techniques. He did this multiple times. Once, when they were arguing about a specific procedure, one of the residents demonstrated a reported technique from the literature and performed the entire operation in three-dimensional space with his hands to show the others.

The constant conversation and gesturing about surgical techniques was always part of the daily discourse in the life of a resident. They are learning their craft – surgical skills. They also have to learn cognitive skills. On Friday mornings, there is a conference at the residency office attended by a couple of attending physicians and the residents, followed by an unstructured learning session for residents led by the chief resident. The typical format for this would be to review board questions from a board exam preparation book.

The pretense for the meeting was to study. They asked questions from a textbook. They would intersperse clinical case discussions with test questions and socializing:

In contrast to the admiration and banter with their own faculty, they discussed the strengths and weaknesses of private attending physicians with an almost mocking perspective. They said things like, “He went crazy on me” Or asked a particular community attending, "How do you do a hydrocoele?"⁷⁵

The attending replied, “I open the scrotum. I take it out.” The resident was aghast that he didn't have any particular procedure and was unfamiliar with a

75 Hydrocele is a cyst on the spermatic cord,; when very large it can cause discomfort, the reason tor surgically remove it.

particular named procedure that Dr. Patel uses. When the resident questioned the community attending, he reportedly said, “I don't know what you're talking about."

In addition to sharing surgical techniques and medical management knowledge, the topic discussed the most was the amount of surgical experience each of them had, and how they could get more experience. A junior resident said,

“I beat him by an hour [arriving at the hospital], so I did the surgery and I was actually leaving by the time the senior resident got there.” Another resident prostatectomy before they diagnose the lung cancer.”⁷⁶ The residents talked about a retroperitoneal varicocele⁷⁷ repair and the senior residents said, “What's the plan for that case? I plan on scrubbing, but if one of you guys wanted to do it, I'll walk you through it.”

“He let you do on those?”

The senior resident said, “Those guys [at an affiliated hospital] are open surgeons, so they are more comfortable letting you do things that are open, because they know that they can get you out of trouble. They are less comfortable letting us use the robot. That's totally different with Dr. Jeffries.” They talked about the different robotic surgeries each resident had done and the senior resident said, “The Cowboys are in town, and that's never going to happen again.” He was referring to the episode where one of the junior residents did more robotic surgeries than one of the senior residents. “That was selfish of them. You're still third in line. Just remember that.”

This desire for surgical experience is understandable. It is the only way to achieve competence. On a different occasion, I overheard Dr. Jeffries telling the residents that he would be happy to confront the private attending physicians if they weren’t allowing the residents to get enough experience. Because robotic surgery is relatively new, patients seek experienced surgeons. This measure of experience both creates the hierarchy and the hierarchy ensures that each resident is trained properly. Consider the socialization process of the more junior residents:

76 STAT refers to immediate; prostatectomy is surgical removal of the prostate gland. In this case, the residents were joking about how to get more surgical experience. If lung cancer was diagnosed, the patient would not be eligible for a prostatectomy.

77 Retroperitoneal refers to anatomical structures behind, “retro” the abdominal cavity, which is covered with a membrane called the peritoneum. Varicocele refers to “varicose veins” or engorged veins in the scrotum.