May of 1973

It was May of 1973. I was a Chief Surgical Resident at the Montefiore Hospital and Medical Center in the Bronx, New York. In six weeks, I would complete five years of surgery training and be qualified to sit for Board Certification.

There were four color–coded surgical services at Montefiore. If my memory serves me correctly Red stood for Blood, Green stood for Money, Orange stood for Stool and Purple which stood for Imperial, as it was Dr. G’s service, who was the Chief of Surgery. The Head and Neck and Vascular services had no nickname unless “pain” was considered one. I was the Chief Resident on Purple, which was a difficult service to run, as it was the largest and most diverse service in the Surgical Department. It also included the entire full time faculty (many of whom were very senior and heavy hitters), the transplant service and the ward service. I had ten senior and junior residents working for me. In short, the Purple service posed quite a management problem, especially considering how many patients were in hospital at the same time on Purple. Furthermore, at this time—1973—Chief Surgical Residents were on call 24/7/365 and were totally responsible for their services. This was particularly so for the ward service where patients without their own surgeon or the ability to pay for one were admitted. This meant I was the surgeon for every ward patient with the only caveat that I had to notify the service attending of the day what my plans were especially if I wanted to take a patient to the operating room (OR). It was the obligation of the service attending to be in the OR at the time a ward patient (or service patient to use the more common appellation) was having a procedure.

I had been on Purple since the beginning of May and, to be honest, was getting tired and worn with these demands at the end of a brutal year. Still, the Purple service was under control as I had learned how to organize and not take “no” for an answer: at least from a fellow resident.

I was making rounds early one morning when the senior resident who had been on call the night before took me to see a man in his thirties who had been admitted through the emergency room (ER) with a diagnosis of appendicitis. This diagnosis had been made, as it usually was in 1973, with a minimum of laboratory work and no CAT scan, but with a good history and physical examination (including a rectal). This evaluation yielded an accuracy rate of approximately 85%–90%, which was totally acceptable. I reviewed the lab work and examined the patient. As far as I was concerned, it was a textbook case that required operative intervention within a reasonable number of hours. I tracked down the service attending (not always an easy task) personally before he started his operative schedule, as it was the best way to get cooperation while demonstrating the need for urgent action. In all fairness, Dr. S. came to see the patient without a problem. However, after examining the patient—somewhat superficially in my opinion—he told me that the patient probably had gastroenteritis and did not need surgical intervention. He left to go to the OR. My senior resident and I looked at each other in disbelief.

I had never been in a position where I had a patient whose well being and possibly his life was in my hands but had no way to care for him as I could not book him for the OR without a service attending. The structure of a surgical residency then somewhat resembled a medieval guild system with the residents at the bottom of the heap with little recourse once a guildsman had spoken. In general, nobody wanted to hear your complaints at any level of authority. Unfortunately, the system has not changed that much to date, as residents are still dependent on the attendings to actually do cases.

While I considered myself widely read in history and the humanities, I had...