Shepherds and Hirelings

Which will you be?

It’s 6:00 PM, and I just barely finished my last progress note for the day that should have been signed ten hours ago. I have discharged three patients, accepted two ICU transfers, assisted with two cases in the OR, helped in clinic for an hour, responded to a code, and wrote orders for the emergent trauma patient. I am completely exhausted, but by some miracle everything is tied up and ready for sign out. My night float coverage steps through the door at exactly 6:00 pm and before I can sign over my pager, one last message comes through the airways: “Patient’s family is here and wants to talk about the plan.” I inwardly (and outwardly) groan. My mind runs through all of the things I had planned to do with my “early” evening: go for a run, get dinner with friends (or maybe even just eat dinner), go to bed early, etc.. I’ve stayed late every other day this week. Maybe I can just pass this page off to the night person.

However, a certain scripture echoes in my head during this twilight hour of sign out. In John 10 verses 11-14 we read:  “I am the good shepherd: the good shepherd giveth his life for the sheep. But he that is an hireling, and not the shepherd, whose own the sheep are not, seeth the wolf coming, and leaveth the sheep, and fleeth: and the wolf catcheth them, and scattereth the sheep. The hireling fleeth, because he is an hireling, and careth not for the sheep. I am the good shepherd, and know my sheep, and am known of mine.”

One of my co-interns is consistently known as a great intern.  A chief resident told me he was so grateful to have this intern on his service because he knew he could count on him to truly care about the patients, even to calling the patients’ families every day to give them updates (something typically unheard of on our busy surgical services). I personally witnessed his commitment as I worked alongside him one weekend. We were each covering two services and doing the jobs that four people are assigned to during the week. His services were particularly large, and so he had been granted a "float PA" to help. He gave her a few of the patients, and even though she insisted, he kept all of the ones he had cared for throughout the week. Although it resulted in a heavier workload, he said they were his patients and he wanted to see their care through. As he worked tirelessly that day, he truly emulated the role of the shepherd.  

Why is it so easy to become like the hireling? With the eighty-hour work week and more frequent sign outs, it is easy to lose the feeling of having stewardship over patients. My first time on night float, I quickly developed a sense of "day team" issues-i.e. cleaning up orders, updating patients on imaging or lab results, and reconciling medications. After all, I was covering twice as many patients as my day-time counterparts. Wasn’t my role just to put out the fires? It was a constant struggle for me to determine my level of responsibility. On the flip side, when I was on day shifts it was tempting to pass tasks off to the night team.

I will never forget the patient in the fluffy blue bathrobe who taught me the importance of stewardship.*  I cared for her over the course of a month, although she had been in the hospital for much longer. She was sick, and had suffered many complications from her disease.  She was stuck in hospital, although there was not much we could do for her. I felt uncomfortable going to see her each day since we had nothing to offer.  I spent the least amount of time in her room possible so I could check her off my rounding list and then rush around to care for the other patients. The other trainees on the team were also frustrated by her lack of progress and talked with our attending to see if we could transfer her to another service. However, our attending insisted we continue to care for her. This was confusing to me, until one of the more senior residents explained that our attending had been caring for this patient for nearly a decade.  He knew her before her surgery, before she was sick.  The resident explained to me that as trainees, we only saw this patient for a few weeks and did not have the full perspective of who this patient was and what her journey had been.  Our attending was invested in this patient and would not abandon her. This conversation adjusted my approach to this patient, and I began to spend more time with her and have a few meaningful interactions before the end of my rotation.

About a month later, I responded to a code in the hospital.  Amidst the quickly growing crowd outside a patient room, I caught a glimpse of a blue bathrobe. My heart sunk. “Does anyone know this patient?” yelled the resident leading the code. I pushed my way towards him and quickly told him everything I knew. I got in line for chest compressions and thought how in this moment, I owed her everything I had. I wanted to be a shepherd to her, even if I had not always been before. As more people came to help, a nurse asked if anyone had thought to call her family. I stepped away and called her husband and told him to hurry to the hospital.

I am grateful for my co-intern and the other residents and attendings who have shown me by example to look beyond the sign-out emails, patient lists, and check boxes to see the actual patients and families who are living through these diseases and trials. As much as I dread being in the hospital over a weekend or holiday, I have learned that my patients dread it even more. Now when I stay an extra hour to speak with a family of a delirious patient or take the time to just talk with a patient about what his or her life is like outside of the hospital, I take off the leash of a hireling and pick up the staff of a shepherd.

 *Patient details and identifiers have been changed for confidentiality purposes.

Written by AirwayBreathingChurch