As a senior fellow, one is blessed to have a light call schedule compared with that of our younger peers. Having paid our dues during residency and fellowship, we get the privilege of picking our call schedules and are required to cover just 4 weekends for the whole year.

With 3 call weekends left on my schedule, it was smooth sailing. I was scheduled for the weekend of September 8, 2017, which looked to be a warm but unremarkable Miami weekend. I would be rounding on the patients, taking in new consults, and covering for colleagues who were taking the weekend of. There was some talk and background noise that Hurricane Irma, brewing in the Atlantic Ocean, might make its way to Miami in the coming days. After all, it was hurricane season, and that’s a weekly story, nothing to worry about—or so I thought.

I have had my share of calamities during my medical training. I spent a month at a military hospital during wartime in Lebanon, was stuck at Memorial Sloan Kettering Cancer Center in New York City throughout Hurricane Sandy, and was the weekend on-call fellow during the blizzard of 2015, also in New York City. I figured I had enough “when I was your age” stories to tell younger physicians 20 years from now.

Irma had other plans. As the week progressed and the e-mail frequency increased, I soon found out that the hurricane would be making landfall during my call weekend. The emergency plan was basically for the house staff and attending physicians to pack and head to the hospital on Saturday morning, with no expectations of leaving before getting the green light from the hospital leadership. Every patient who didn’t need to be hospitalized over the weekend had to be discharged as soon as possible. All noncurative chemotherapy was put on hold until further notice. This was obviously not the first rodeo for our hospital.

After my fair share of lamenting my fate (a little dramatic here), I was on my way for my 3-day lockdown. When I arrived at the hospital, I found it barricaded as though ready for the apocalypse. No door or window was left uncovered. Only a few entrances were open; they would be locked down at noon that day.

Despite the warnings, it was sunny and beautiful outside— the calm before the storm. I walked in, expecting chaos, but it was business as usual for the nursing staff and hospital operations. Everyone was in a good mood and ready to go. I found a place to sleep and created my own area, which I split with my attending physician. I had enough snacks for 3 days. They were gone in 3 hours&mdash;stress eating, I guess. Soon after, the hospital was on lockdown. No one could get in or out, wind speeds started picking up, and the only way to know what was happening outside was by watching the TV screens in the hallways and patient rooms. It began.

Cabin fever hit hard. I was isolated from the outside world, with no natural light and no cell phone reception. Going for a walk meant pacing the hallways and visiting patients on the other side of the hospital. No one—neither us nor the patients&mdash; could really sleep or eat well. We were more concerned with the goings on outside, and then for ourselves inside. Patients asked me more about what I thought would happen to their loved ones than about what was happening with their treatment and disease. That’s not uncommon with people who have cancer; despite having to fight the hardest fight of their life, they always feel that they have to take care of those around them. I never get used to their show of strength, and even though I cannot know where or how they get it, I admire it and accept it.

I spent more time than usual with patients, because time was the only thing I had plenty of at that point. We briefly discussed their treatment and complaints for the day, and then they always moved on to telling me stories about their last hurricane and how bravely they prepared for it and got through it—how they rebuilt what was lost better than ever. We would end the conversation by comparing their cancer with the hurricane and how they would get through that, too.

In my downtime, I tried without success to study. I just had to follow the path of that big spiral in the sky. On TV, online, on my phone…I never knew there were so many weather apps out there!

After 3 days and 2 sleepless nights with no sunlight to go by, no window to peak through, my body and mind started losing track of time. It’s hard to explain, but I soon became disoriented: 3 PM felt like 3 AM and vice versa—not a good feeling.

And then, at the nurses’ station, we received an email saying that it was safe to go outside—the worst of the storm had passed. We were advised that some roads would not be accessible because of broken trees and downed power lines, but I didn’t read that part. All I wanted was to get out. As I walked through the exit, I could see the first signs of the aftermath&mdash; massive trees ripped by their roots lying in the middle of the street, which would require lots of manpower and machinery to budge. Nature’s wrath is scary.

After I walked around a bit, watching as people started to clean and fix what was broken or lost, I went back to check on patients before my relief coverage took over. One of my patients with leukemia asked me when I was going home. “In an hour or 2, I hope,” I replied. She said she was happy that I finally would get some rest in my own bed. “You deserve it. And go shave—you look better without a beard!” she said.

My drive home was a slow one, although the streets of Miami were eerily calm. Not too many people were outside or even around, because most of the city had been evacuated. Some streets were either flooded or so strewn with debris that I had to change routes. Electricity was out in some areas and phone reception was spotty at best, but all in all, I thought, we dodged a bullet. All I cared about was a warm shower and few good hours of sleep. I made it home.

The next morning, I woke up to a phone call from the hospital— I had overslept. I dressed hastily and headed back to work. Just another day on the job. No glory or fame. Life of a doctor, I guess… As doctors, we are committed to certain things that most people do not even consider. We work at night, we work during holidays, we work on weekends, we work after hours, we work before hours, we work when everyone else evacuates to safety. We also leave behind our families, our loved ones, and our children to fulfll our duty to strangers, hoping that those we love will take care of themselves. It’s unfair, one might say, and it raises a lot of questions about the work that we do&mdash;questions such as “Why shouldn’t I be able to evacuate with my family?” and “Why should I be separated from my loved ones when it matters the most, to go take care of others?” It’s exhausting and makes you age quicker, plagued by guilt trips every time you think about it.

At the end of the day, that’s what makes our lives as doctors unique and, dare I say, brave. We fght for our patients and for their well-being every single day, rain or shine, hurricane or war. We do it not because we are forced to; we do it without questioning. We never ask if we should do it, for that’s a fait accompli; we ask what the best way to do it is.

I had so many questions leaving home the day of the hurricane, not knowing what I would return to, but I never questioned whether or not I should be at the hospital. It was my duty. I could say that doctors have a military-level commitment to their duty toward their patients. That makes us proud! At the end of the day, I made a diference for the fathers, mothers, brothers, sisters, cousins...everyone I took care of during the hurricane. Who knows, maybe I had a role in saving a life or two.

I hope that I don’t keep attracting disaster situations on my weekend call days. I am happy to pass the torch, but if I end up in another hurricane, I can say that I’ve seen enough to be ready!

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Simon Abi Aad, MD, discusses caring for patients during Hurricane Irma.

Our Patients' Care Comes First, Even During Natural Disasters

Medicine requires by far the longest "schooling" of any career. By the time we finally become independent practice—eligible physicians, we are already in our mid-30s and have almost never had the opportunity to make an unsupervised decision on a patient’s care plan. The day that comes will be scary for most of us, because we are conditioned to always double-check with the boss, to be under someone’s wing. Suddenly we are the boss, with all the responsibility and liability that come with it. Until that day, we will always have several attending supervisors, some with whom we will work often and others with whom we may not even cross paths.

That’s the part of training no one tells you about: "managing up." I first heard this term during my 2-year career in the pharmaceutical industry, between medical school and residency. It was a mandatory training for new hires. A whole weekend was spent teaching me how to manage the different challenges I would face with the different types of personalities that might end up being my managers. Despite all the evidence- and science-based methods out there, nothing can fully prepare you to work one-on-one with so many people of different personalities and from different cultural and personal backgrounds.

At first, they don’t know you, they don’t trust you, and they almost never believe a word you say. With time, this cold start to your fellowship slowly changes—or not, depending on whom you are working with and the reputation you build. Attendings talk with each other, so expect your performance when working with one of them to be shared with the others. It’s human nature; accept it.

4. Render Caesar the Things that are Caesar's

The following is my approach to managing up, based on nothing but my own humble experience.

Find out about the person with whom you are about to work. I’m not talking about what they published last month or where they worked before they started at your hospital. Ask how they like to round. What are their pet peeves? Avoid doing that “one thing” certain to anger them early on.

The best thing you can do, regardless of whether you are alone or supervised, is to be on top of your game. Know everything about the patient, and I mean everything. Saying “normal” doesn’t cut it (I tried it; doesn’t work)—know the values. Sometimes a small detail of no relevance to you or your plan may be more important to your attending than the disease itself. Always have the numbers ready, regardless of whether you think they matter, and know what other services are involved in care, why they are used, and what they do for the patient. With time, as trust builds, your attending will ask for less information, so you will have more time to focus on the important stuff.

This is one of the hardest skills to learn, and I do not believe it can ever be mastered completely. Observe your attending and try to understand their baseline personality, current mood, anxieties (let’s be honest—we all have them), cultural background, and interests. You might have a hard time with a certain type of personality and get along beautifully with another, but at least try to understand how your attending thinks and reacts to a certain situation. Figure out if you are caught in a domino effect: Your attending is under pressure and consequently puts you under pressure. This will help you navigate rough days when you are not on the same page or one of you is not in your usual mood.

Most of the time you will agree with your supervisors, but sometimes you won’t. Most of the time they will be right, but sometimes they won’t. Most attendings will listen to you to see where you are going with your thinking, then nicely shut you down with data you never knew existed, because you either don’t know enough yet or didn’t attend ASH or ASCO last weekend. Inevitably, you will meet the attending who is set in the old ways, refusing to accept any suggestion that does not conform to their modus operandi. If it will not make much difference at the end of the day, let it go. I have yet to see any fellow win that battle (the “show me the data” approach almost never works, even if you do show the data). If you believe patient care and well-being are at stake, kindly suggest a tumor board presentation or ask an expert in the field to weigh in.

Notice I say “thrive.” Independence in training, as discussed above, is not possible. The next best thing is to get as close to it as possible. How? It took me quite some time to figure this out, but what worked best for me was to study hard to be as good as my attending. I found that this gave me independence of thought and streamlined my life. My presentations became more organized, more focused, and packaged with a solid plan. The results were fascinating: no more endless questioning, triple-checking, and looking at charts together. We simply discussed fine-tuning the plan and moved on to the next patient. Pseudoindependence…close enough. With this approach, you spend time learning the things you cannot find in books instead of having your attending teach you the basics that you didn’t read.

One of my chief residents told me once that we, as doctors, are the most compassionate people to our patients but the cruelest people to each other. I guess any physician can understand or relate to that statement. It doesn’t have to be that way; just remind yourself of why you and your attending are rounding on a sunny Sunday afternoon. Remind yourself that you are here to help patients as best you can and learn from each other. We all come from different walks of life and experiences, and it is always fascinating to discover what can be learned from an attending who has been doing this for years, before we even knew what cancer was.

At the end of the day, we need to remember that, as physicians, we all are overworked and strive every day to give our patients the best care in a new healthcare order that seems more concerned about saving money than saving lives. I was blessed to work with great attendings and not-so-great attendings. I learned from all of them, either what to do or not to do. The bottom line: Never take it personally, don’t sweat the small stuff, and remember—it’s temporary!

Simon Abi aad, MD, gives advice on how to navigate the professional side of a fellowship, including how to build relationships with your colleagues and supervisors.

Simon Abi aad, MD

Articles

Our Patients' Care Comes First, Even During Natural Disasters

Oncology Fellow Relationships and Challenges