Dr. Santell's Rounds #1: Make Time For Breakfast

The first time I met Dr. Santell I was a fourth-year medical student arriving for my first day of a rural family practice elective. I'd been told to show up at 7:30am in the main conference room to attend the Morning Report. When I arrived, the room was empty, so I took a moment to decide where to sit. There were about ten 6-foot long rectangular tables lined up in rows of two, each with three seats. I didn't want to sit in the front row like a geek, but I also didn't want to creep around in the back and look like a slacker on my first day, so I sat in the first chair in the second row, closest to the door.

Morning Report was an institution at this hospital, where I went on to do my residency. Because the residents ran all the services in the hospital--Medicine, Peds, OB, ICU, Surgery--the different services did not meet individually. Instead, the daytime residents finished pre-rounding at 7:30 to meet with the Night Float or post-call residents at the Morning Report. The conference room was next door to the cafeteria, so everyone picked up breakfast and ate it while the night team presented cases.

Tradition required a resident to stand in front of the room and present their case aloud. You could refer to your notes but senior residents were expected to do away with the notes and set a good example. During the week, one of the faculty members attended every Morning Report and made notes on all the presentations, because Night Float was a formal rotation and your feedback depended partly on how well you conducted yourself during the Morning Report. Interns tended to make long, stammering case presentations but R3s rattled theirs off like auctioneers. R3s were also in charge of hanging X-rays for the day teams to look at. The relatively well-rested R2 presented a brief educational talk two or three times per week, depending on the patient load and how many cases had to be presented each morning.

That first morning, I settled myself at the end of the second row and waited for everyone to show up. I felt awkward sitting there, the way you do when you're the new kid on the block and don't know where you fit in yet. Later, by the end of my third year, the inside of that conference room was more like home than the apartment I rented several blocks away. I'd eaten more meals there than I did at home the entire three years of residency, and passed many tense moments defending or apologizing for my decision-making in the cruel light of morning after difficult nights on call. But I didn't know any of that the first time I attended Morning Report. It was all still a great mystery to me.

I was sitting stiffly at the end of the second row when Dr. Santell entered. He was dressed, as I learned he always was, in blue hospital scrubs and a blue OR cover gown. He held a cafeteria tray on which his breakfast was balanced, and when he saw me he stopped in the doorway. I remember a slight hesitation, a brief pause while he stood there and took in my presence. Then he nodded to me, walked around to the next table and sat in the row behind my seat.

He dug into his scrambled eggs and took a few silent bites. When I looked up at the clock, he cleared his throat and asked, "Are you a student?"

"Yes I am," I said, and introduced myself.

"Third year?" he asked.

"No, fourth. I'm on an elective."

"Well, that's good," he said and tucked back into his breakfast.

I didn't know it at the time, but this was a lot of small talk for Dr. Santell. He wasn't the kind of man who talked just to make conversation. He only spoke when he had something to say, and maybe for that reason his smallest utterance conveyed volumes.

The residents began arriving and Morning Report progressed uneventfully. Afterward, I went to Labor & Delivery where I was rounding with some of the residents. One woman, an R3, kept looking at me as if she had something to say but was debating whether to do so or not.

Finally, she took the plunge. "You know," she began, "Well, you couldn't have known, but the chair you sat in this morning is Dr. Santell's."

"What?" I asked. Remember I was new to this hospital, and her demeanor was so odd about the whole thing.

"Second row, end nearest the door," she continued. "That's where Dr. Santell sits. He always sits there." She sounded embarrassed and quite insistent at the same time.

I laughed. I had to, the whole thing was ridiculous. "I thought he looked at me strangely," I said. "But he was very nice about it, he didn't say anything but he did look at me funny." We all laughed at that, but I could tell I thought it was funnier than the R3 did.  Dr. Santell had this effect on people; he inspired universal respect but some people never got over their awe of him. People like me--irreverent, goofy people--got over it and made him laugh.

Morning Report was a tradition at our residency but, like most traditions, it had its critics. Some people-- faculty and residents alike--thought it was too business-like, rushing through all the admissions from the night before without much chance to discuss the cases, unless the night had been relatively quiet. Residents ended up resenting Morning Report for disrupting the flow of morning rounds. Night Float residents found it particularly agonizing because it represented one last hurdle before they could go home to bed. At various times, people suggested eliminating Morning Report, or changing the format to discuss a single interesting case in depth. These changes never happened while I was there, mainly because no one could come up with a better way to sign out between night shift and day shift. Peds and Surgery didn't care much one way or the other--they could figure out what happened the night before from the handwritten H&Ps on the chart or by grabbing the night resident before rounds to ask what happened. Medicine and ICU attendings wanted to keep Morning Report. Especially Dr. Santell.

Dr. Santell showed up to Morning Report every morning, day in and day out, fifty weeks per year. His presence was the necessary catalyst for the tradition to continue. As a resident, you knew he'd be there in the morning, and you wanted to know what he thought about the new patients arriving in the hospital. The best way was to listen to what he said--and what he didn't say--at Morning Report. If he disagreed with the way the night team handled a case, he said so. If he agreed, he didn't say anything. It was always a relief when a perplexing case commanded mere silence from Dr. Santell. If he thought you did a good job, he nodded at you. That was gratifying.

Then there were the mistakes residents made that were due to inattention, laziness, taking bad advice, or forgetting what Dr. Santell already taught us. These were not often big mistakes, when it came to patient outcome, but they were big transgressions in Dr. Santell's eyes. If you ordered a diagnostic test at 10pm but hadn't checked for the results by the time of the Morning Report, it was worse than mere ignorance, it was laziness or inappropriate self-assurance, and you had to be taken down a notch or two. Dr. Santell wasn't above criticizing you in front of your peers, but that wasn't all that bad. The worst was when a resident's error was willfully careless or lazy. On those rare occasions, Dr. Santell said nothing. He looked at the resident, the looked down at his hands, and shook his head, as if he couldn't believe what he was hearing. That was the worst. It was like a knife through my heart, seeing him shake his head like that, even if I wasn't the one who made the mistake (and believe, me, I avoided these mistakes like the plague).

Whenever discussion turned to eliminating or changing the format of Morning Report, I'd go and talk to Dr. Santell about standing up for tradition. We needed to keep Morning Report going, I insisted. Residents learned a lot more than they realized from presenting their cases, hearing criticism and defending their decisions. When were they going to learn these skills if we eliminated Morning Report?

I asked Dr. Santell this rhetorical question once. I don't know what kind of answer I expected--an passionate agreement, I suppose, or some biting criticism about the people who wanted to eliminate the old tradition. Instead, he listened to me rant and shrugged. "Well," he said, "We all need to eat breakfast."

Since his death, I hear Morning Report has changed, but not as much as you'd expect. Once a week, case presentations are set aside and a single case is examined in detail. The internal medicine and ICU attendings still show up, and the residents are still eating breakfast in the conference room that seemed so full of possibilities the first time I met Dr. Santell. I don't know who sits at the end of the second row, near the door. I can't imagine anyone sitting there. I like to think that chair is left deliberately empty, they way the prophet Elijah's chair is left empty on Passover, because you have to leave a space open for the divine to enter your life.

Comments

[Theresa]

Elizabeth--Realized when I woke up this morning I meant Passover but typed Rosh Hashanah. My error. I didn't know the chair was kept open for a bris as well.

[Alex]

Great post !

[Elizabeth]

Um, there is no chair open for Eliahu on Rosh Hashanah--the chair is open at a (boy) baby's bris.