I Wasn't Sure Yet...

Cut to the Chase: General Surgery Survival Series — Post 27

The attending stops outside room 12 and asks what is going on with her.

You have a thought. It is about sixty percent built, and while you are working out whether sixty percent is enough to say out loud, somebody else answers and the group moves down the hall.

Forty minutes later you tell your co-intern in the stairwell what you had been thinking. You were close. Closer than what got said.

I wasn't sure yet.

That is true. It is also the reason nobody heard it.

Nobody taught you to hold it back. You worked that out inside a month, from watching. Saying a half-built thought out loud means being wrong in front of the person writing your evaluation, and sixty percent does not feel like it clears that bar.

It clears it. Nobody grades a third year on hit rate.

What gets noticed is whether the thought existed at all, and whether it arrived while anybody could still use it.

Start with what you saw across the bed, because you read it wrong.

Your senior did not know either. She had a shorter list than you, built out of forty patients who looked roughly like this one, so her narrowing came out as a sentence while yours was still a search.

When your senior narrows it in one sentence and you are still searching, that is a shorter list, not a better mind. She has seen forty patients who looked roughly like this one.

Here is the part that costs you.

The window where your observation is worth something is the window where you are unsure. By the time you can prove it, the finding is obvious, and obvious findings do not need you.

So say it early, and say it in a shape somebody can pick up. That takes two attachments and nothing else. What you would do next, and what would change your mind.

I don't know what this is yet. I would mark the edge of the redness with a pen and look again at four, and if it is past the line I want to open it.

There is no diagnosis anywhere in that. It is still the most useful thing said about the patient all morning.

Nobody minds that you did not know at nine. What gets asked about afterward is what you did between nine and eleven while you did not know.

The other failure is quieter, and it catches the better trainees. You name something reasonable, and the naming is what stops you checking whether it fits.

She's dry. She's just in pain.

Your first explanation is allowed to be provisional. It stops being provisional the moment it starts needing excuses.

You can also act a long time before you know. That is the piece nobody says out loud, so trainees spend the uncertain hours watching and ordering nothing, because ordering feels like claiming to know something.

In those hours, do the things you would not mind having been wrong about at eight the next morning. A second line while she is warm and still has veins worth finding. A type and screen the first time the word blood crosses your mind, not the first time you believe it.

You do not have to know what is wrong with someone to have blood in the fridge for them.

You also do not have to say it to the attending, which is where people get stuck, because the attending is the one asking.

Say it to your senior on the walk between rooms. A half-built thought handed one rung up gets tested for free, and if it holds, it reaches the table without you ever having been certain.

I say it out loud at the table myself, in front of people I am supposed to be teaching. Not out of modesty. I would rather be corrected at nine than at four.

The trainee I watch hardest is the one who has never said it. Sounding sure and being right are separate skills, and sounding sure develops first.

When somebody sounds finished, the room quietly stops checking their work.

Second year. A woman three days out from a gastrectomy who was quieter than she had been the day before.

Nothing on the flowsheet. Nothing I could have defended if anybody had pushed back on me.

I decided I would see her again after clinic, when I would have something. My chief found it about forty minutes later and started moving.

Then I said the worst sentence in surgery. I was actually wondering about that.

I meant it as a contribution. It was a thought I had saved until it cost me nothing to have had it.

Nobody said anything to me about it. Nobody needed to.

Say I don't know while the question is still open and somebody can use it. Said after the answer is in, it buys you nothing, and everybody in the room can hear that.

Some morning this year you are going to say it standing up, before you have earned it, in front of everybody.

Nothing will happen. Somebody will ask what you want to do about it, you will have an answer, and the group will move off down the hall.

The next one is easier. Not because you are any more sure. Because by then you know what the sentence actually costs.

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What to Read Next: Post 28, “The Complication That Was Yours.” Saying it in time does not always change the outcome. That one is about the morning after it didn't.