discoveries magazine

Warning: Learning Curve Ahead

Being a beginner is tough — and there is no exception for doctors. It doesn’t matter how smart you are or how talented you feel, when you are new to a job, you will trip over a hurdle or two. Here, Cedars-Sinai’s stellar caregivers and investigators reveal lessons learned during their first days in medicine as well as surprising tales of the superstar mentors, savvy nurses, and idiosyncratic patients who helped along the way.

Doctor and Patient

Illustration: John Cuneo

Jeremy Falk, MD 
Associate Director, Lung Transplant Program

My first day of internship in the summer of 1998 was with a very busy heart failure service, and I was like a deer in headlights. Literally all the residents and fellows left for lunch and I was in the unit by myself when a patient had a cardiac arrest and went into ventricular tachycardia — a very fast heart rhythm that can be life-threatening. One of the possible interventions at the time was something called a precordial thump, which basically means that you strike the person’s chest and try to interrupt the rhythm. I had only read about this and didn’t really know what it meant. So I went into the patient’s room and very lightly tapped his chest. Of course, nothing happened. Then, after what seemed like an eternity but was probably about 30 seconds, a fellow came running from the other side of the room, made a fist, jumped, and slammed on the guy’s chest as hard as he could. Then I realized what a precordial thump was. And the patient was OK.

Ruchira Garg, MD
Director, Congenital Noninvasive Cardiology at the Guerin Family Congenital Heart Program in the Cedars-Sinai Heart Institute

One of my first overnight calls as a pediatric intern was to insert an IV into a patient. It was 2 a.m. when I got a call from a floor nurse about a 9-month-old infant with a complex genetic underlying disorder who’d had lots of IVs in the past but whose veins were difficult to access. The IV team had tried over and over to insert the IV but couldn’t. I said to my senior resident, “Why are they calling me when they do this all day? What can I do?” And my resident said, “Ruchi, you don’t know what you can do until you try it.” We looked at this patient very carefully, every arm and every leg, and I got the IV in on the first try. It was very empowering. That resident taught me that you never know what you can add to help a situation. You have to try.

Jaime Richardson, RN
Cancer Clinical Trial Navigator
Samuel Oschin Comprehensive Cancer Institute

When I was in nursing school, I did my labor and delivery rotation at a Jewish hospital (not Cedars-Sinai). My first patient was a young Orthodox woman. When she was in labor and bleeding, my nurse-instructor informed me that her husband couldn’t touch her, but he was still very close to her and talking her through the contractions. Pretty far into the labor, they wanted to pray in between contractions and requested to wash their hands. I ran outside and grabbed a bottle of Purell and then they explained to me, no, they needed a basin and warm water to wash their hands ceremonially. I felt like such a dummy! They probably were the same age or a little younger than I was, maybe in their mid-20s, and they giggled and were very sweet when I brought in the hand sanitizer. Then I provided what they needed and stepped out so they could pray. It was quite a lesson in cultural competency.

Bruce L. Gewertz, MD
Chair, Department of Surgery Vice President, Interventional Services Vice Dean, Academic Affairs Director, Division of Vascular Surgery Surgeon-in-Chief H & S Nichols Distinguished Chair in Surgery

The memory is still fresh in my mind more than 40 years later: I was a fourth-year surgical resident at the University of Michigan, shadowing an experienced endocrine surgeon named Norman Thompson. These were the days when you could smoke in the hospital, if you can believe it. He would walk into a patient’s room, pull up a chair, and start a cigarette. He’d spend the next several minutes chatting about a patient’s surgery, listening to her fears, and answering all of her questions. The patients were so grateful that he would commit like that — that he was really present and invested. Those conversations were an extraordinary lesson about the power of empathy and compassion.

Shervin Rabizadeh, MD, MBA
Director, Pediatric Inflammatory Bowel Disease Program

Director, Division of Pediatric Gastroenterology Medical Director, Children’s Health Center My residency was at Johns Hopkins, but sometimes we would go to a small community hospital to serve as residents on its pediatric floor and the baby nursery. On my first day there, an attending neonatologist gave the interns a 10-minute lecture on how to examine a little baby. We learned that if the heartbeat is more prominent on the right than the left, it might indicate issues such as a collapsed lung. But this is extremely rare. That very afternoon, I was examining a baby and I said to myself, “Wait a minute, this heartbeat is so much stronger on the right than the left.” I thought to myself, “Nah, come on. It must be a figment of my imagination, because this is so uncommon.” But my co-intern agreed with me. Nervously, we called the attending doctor and she said: “No way, no way. Fine, I’ll come over.” But she examined the baby and started to think we were right. We got an X-ray, and the kid did indeed have a collapsed lung, which we treated. Some things you just learn on the job right away.

Bradley T. Rosen, MD, MBA
Vice President, Physician Alignment and Care Transitions

Medical Director, ISP Hospitalist Service Medical Director, Supportive Care Medicine A code blue is when a patient has some kind of cardiopulmonary arrest or requires heroic intervention to save them. One day during my first month of internship, I was part of the code team, led by a third-year resident. This code went on for probably 30 minutes. We tried and tried to get the patient back, but eventually the resident “called” the code; we were no longer going to attempt resuscitation and the patient was pronounced dead. There is this uncomfortable moment in that situation when everything stops and you’re in the room with a newly dead person. Staff started filing out and I remember feeling very sad and confused. I walked up to the resident and asked, “What happened? Why did we stop?” He took time to pull the code team aside and we talked through the whole experience. I found that to be such a human moment. It stuck with me because it was a nice way to reflect upon the seriousness of the work we do — and how to cope with death and with moments when we can’t help someone. When I train interns now, I am still mindful of how new and terrifying everything is to them. I try to keep it light and be supportive at the same time.

Shelly Lu, MD
Director, Division of Digestive and Liver Diseases Women’s Guild Chair in Gastroenterology 

To survive as a physician-scientist doing basic research, you need to learn that getting rejected is par for the course. Eons ago, I submitted my very first paper and, of course, it got rejected. My mentor said, “You’ve written a paper; the work’s been done. One journal rejects you — another one will accept.” This is the “one door closes, another opens” philosophy. You have to think about how to overcome a disappointment and realize it might not even be a bad thing. For instance, I had a big grant rejected, so I repackaged it into two smaller ones and both got funded! And when something good happens, you can celebrate for a day or two and then come down to Earth. That’s how I try to coach my mentees. They need to develop a thick skin to do well in academia. But I also tell them not to become overconfident — you can’t know it all or do it all. I like people with humility.

Kelly Wright, MD
Minimally Invasive Gynecologic Surgeon Department of Obstetrics and Gynecology

When I was a resident on the labor floor at Massachusetts General Hospital, a woman came in at term with her fourth baby. The dad and their boys — who were 6, 4, and 2 — paraded in behind her. She was laboring really fast, and dad gently lined up the boys against the wall in order of height. The woman coughed and her water broke, and the baby kind of flew out on this big wave of fluid. The three boys looked at their baby sister and all said, “Yay!” and threw their hands up like the touchdown sign. They were so cute and happy, all lined up in a row. Even though I don’t do obstetrics anymore, that’s where the best memories come from. It’s not only the delivery, but also the chaos that can surround it and make it seem like a circus — but then something good happens, like a healthy baby being born. That’s one of the most positive things that can happen in medicine.

Nancy Sicotte, MD
Vice Chair, Education, Department of Neurology Director, Multiple Sclerosis Program Director, Neurology Residency Program

My first night on call as an intern, I was assigned to care for leukemia and lymphoma patients. You’re in the hospital by yourself, alone, and when you take a call, you’re responsible for people who are all very sick. I remember lying in the call room with the beeper on my chest, just waiting for it to go off and feeling terrified. One thing I did right, which I have passed on to my trainees, is that I made friends with the nurses, and they were wonderful. They knew much more than me, the green intern. I always tell the house staff, “Be respectful of the nurses and let them help you, because they want to help you.” Or, less politely, “Never piss off the nurses.” It’s a team sport.

Zuri Murrell, MD
Clinical Chief, Division of Colorectal Surgery Director, Colorectal Cancer Center of Excellence

My residency is where I met my friend and mentor, Dr. Michael Stamos, who is the reason I went into colorectal surgery. He was a hard-ass — no pun intended. In training, we do morbidity and mortality conferences, where we discuss the results of our procedures. Dr. Stamos would make grown men and women cry by drilling them in front of everyone about why they did what they did in surgery. I’m not scared of much, but I was deathly afraid of him. I told myself: “I’m never going to cry in front of him!” I studied and over-studied, even when I was dog-tired, and he never got me. My fear of being embarrassed motivated me to become a well-read and learned doctor. To this day, before going into surgery, I have a ritual. I look through my notes and visualize the procedure. He instilled that in me — no matter how many times you’ve done it, you’ve never done it on this person. Every single person is different, and you have to treat them that way.

Mark Pimentel, MD
Director, Medically Associated Science and Technology (MAST) Program Department of Medicine

When you’re a medical resident and it’s 3 a.m. and you’re called for the first time to pronounce someone deceased, you have a spiritual moment. You realize that 20 minutes before, a spirit and a soul were there. For me, this occurred with an 80-year-old gentleman. Until you become a doctor, you’re generally not the first person in the room at the time of death. These things are hard to witness, but they are also peaceful. You wonder what their life was about and where they are going, because you don’t know. That’s what we think about as doctors: life and death — and improving life.

Beth Karlan, MD
Director, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology Director, Gilda Radner Hereditary Cancer Program Director, Women's Cancer Program, Samuel Oschin Comprehensive Cancer Institute Board of Governors Chair in Gynecologic Oncology

I met one of my most cherished girlfriends and colleagues during my first days as an intern. It was at Yale New Haven Hospital, where I had come after Harvard. She already had been a medical student at Yale, so during orientation, she leaned over to give me advice about living in New Haven to help me get situated. It was serendipitous that she happened to be sitting behind me. That was the start of a lifelong friendship. We’ve provided support and camaraderie for one another for more than 35 years through training, self-doubts, challenging cases, raising children, changing jobs, and navigating life’s many hurdles — including solving the problems of work-life balance. She now works in New Hampshire. We don’t see each other often because of our busy schedules and the 3,000 miles that separate us, but we continue to speak at least once a week and provide a sounding board and ongoing support and friendship.

Rex Chung, MD
Director, Surgical Simulation Laboratory

Here at Cedars-Sinai, interns and residents get to train in the Women’s Guild Simulation Center for Advanced Clinical Skills, which replicates a real clinical environment but with mannequins for patients. As a young intern at Loma Linda University Medical Center in 2006, I didn’t have the luxury of a state-of-the-art simulation center and my first day was so memorable, I try to forget it. I had a cardiac code on day one, and let’s put it this way: Things didn’t go right. Training on a mannequin would have been great. The first week for an intern is very stressful. There’s a huge learning curve. Simulation training at least breaks the ice and puts in your mind the kinds of things that could happen. Interns can go home, study, know to expect these situations, and be more prepared.

Robert Baloh, MD, PhD
Director, Neuromuscular Medicine Director, Center for Neural Science and Medicine Ben Winters Chair in Regenerative Medicine

In your first days of residency, you’re expected to know a lot, but you don’t. How do you both take care of patients as well as continue learning? It’s the first time you’re not in school and, until that moment, every day of your life has been regimented and your success reflected in the usual metrics of test scores. When you get to residency, you realize, “My gosh, how will I evaluate whether I’m OK?” And honestly, I have to say that question persists throughout your life as a physician. I worry about people who are convinced they’ve got it all figured out. The nature of medicine and science, which are highly interconnected, is that they are uncertain and constantly changing. As you go on through your career, you continue to learn, and, at some point, you realize this is never going to end — and that’s OK.

Robert Reznik, MD
Cedars-Sinai’s First Radiation Oncology Resident

I was the first resident in Radiation Oncology at Cedars-Sinai in 2013. When I started, I shared a small 10x10-foot office with two medical physicists. Physicians and physicists rely on each other for patient care, and I learned a lot being in close quarters with them. Physicists are key players on the radiation oncology team, ensuring that radiation therapy is delivered safely and accurately. Early in my first year of residency, we were treating a pediatric patient for a brain tumor. The child was 5 years old, and we anticipated he might live another 80-plus years, so we had to carefully consider the side effects of the radiation. The attending physician and I consulted with the medical physicists to determine the best way of delivering the treatment while minimizing the effect of radiation on his brain. Every patient really is unique, so you have to work with the whole team to individualize care and ensure the plan is the most effective it can be, with the minimum harm.

Shlomo Melmed, MD
Executive Vice President, Academic Affairs Dean of the Medical Faculty Helene A. and Philip E. Hixon Distinguished Chair in Investigative Medicine

I was an intern in an incredibly busy, overwhelming internal medicine training program. It was 2 a.m. on my first night on service when I was called to see a patient in extremis. When I got the call, I woke up and ran. I was on my own; it was just the nurse and me. The patient was a 96-year-old woman with advanced breast cancer, and she was, essentially, dead with no pulse and a flat EKG. The right thing to do was to certify her death, but I didn’t want to do it. I intubated her and she started breathing again. The next morning, my resident was angry. It wasn’t a medical error, but it was an ethical error, a judgment error. The truth is, I was so inexperienced, I didn’t even think to do it differently. This was a hurtful lesson on how life should end with dignity and comfort.

Mark Goodarzi, MD, PhD
Director, Endocrinology, Diabetes & Metabolism Director, Endocrine Genetics Laboratory

I was a first-year endocrine fellow at UCLA. My attending physician said that, when you’re managing a patient, there isn’t always one right answer. You may have a complicated case. You decide on one course of treatment; someone else might approach the case completely differently. But, in the end, what matters is that the patient gets better. If the steps you offer make sense, are justifiable, and based on good knowledge, go for it. It’s important to be open-minded and tolerant in this business. Medicine is not a great place for ego. It can create conflict if someone’s rigid.

Eric Ley, MD
Director, Surgical Intensive Care Unit Director, Surgical Care Fellowship Program

My first night on call, I was up all night and scared to do the wrong thing. I had a patient who was in distress and I thought he was having a heart attack. I called the resident, and he quickly diagnosed him with a PE [pulmonary embolism] — not a heart attack — got the imaging ordered, and started the patient on the right therapeutic treatment. The next day, I was almost regarded as a hero, even though I guessed the wrong diagnosis. But because I had a very caring and thoughtful resident, I was able to call him and figure it out. Good communication will never be replaced by computers and robots. You absolutely have to build teams. Sometimes that starts at the bedside: You need to make the patient feel comfortable communicating. Interns, fellows, nurses, respiratory therapists, pharmacists, and custodians in the ICU — communication includes all of them.

Moise Danielpour, MD
Director, Pediatric Neurosurgery Program Medical Director, Center for Pediatric Neurosciences Vera and Paul Guerin Family Chair in Pediatric Neurosurgery

When I was chief resident at Northwestern Memorial Hospital, the chair of the Department of Neurological Surgery was Dr. Hunt Batjer, an incredible surgeon and incredible man. One day, we were doing a very complex case: a young woman with a giant brain aneurysm. I was scrubbing in when the aneurysm suddenly ruptured and the operative field was filled with blood. Dr. Batjer and I put temporary clips on the arteries to stop the bleeding, cut out the calcified dome of the aneurysm, and completely reconstructed the parent vessel. All of this was done in 18 minutes. That’s like scoring four touchdowns in a row in the Super Bowl without the other team scoring a single point. The patient suffered no neurological deficits. From that experience, I learned what it takes to be the master of your craft. I have been fortunate to learn from many mentors, all giants in their field and amazing surgeons, teachers, and human beings. That is part of the reason I am so committed to teaching our residents who will be the next generation of great surgeons.