Dr. Groopman Discovers the Swamp

 December 15

On a sweltering morning in June, 1976, Jerome Groopman, a newly graduated MD, put on his starched white coat, placed a stethoscope in his black bag, and reported for duty.  At the time, he wasn’t fully aware that he was entering a swamp.  He soon found out!

He had spent the previous four years of medical school becoming a doctor, which included endless hours in the classroom studying anatomy, physiology, pharmacology and pathology from textbooks and manuals, and more endless hours “playing doctor:”  learning how to take a patient’s history, how to do a physical examination; and how to think about making diagnoses of their illness.  Until this July morning, however, he never had complete responsibility for the well-being of a patient.

This is not to say that his years in the classroom were easy or simple.  “Throughout those…years of medical school,” writes Groopman, “I was an intense, driven student, gripped by the belief that I had to learn every fact and detail so I might one day take responsibility for a patient’s life.”

Each day, he later wrote,

I sat in the front row in the lecture hall and hardly moved my head, nearly catatonic with concentration…determined to retain everything. I scribbled copious notes during the lectures and after bedside rounds. Each night I copied those notes onto index cards that I arranged on my desk according to subject. On weekends I would try to memorize them. My goal was to store an encyclopedia in my mind, so that when I met a patient, I could open the mental book and find the correct diagnosis and treatment.

His learning experiences during those intense and difficult years, while different in many ways, were alike in that the questions he pondered over and problems he struggled with almost always ended with a correct answer or a right solution.

Now, on the first day of his internship  at the Massachusetts General Hospital, he began the “real thing.” As he described it, it was “The end of play-acting as a doctor and the start of being a real one.” He was about to see real patients with real illnesses.

As he stood before the door of one his new patients, Groopman was beginning a major transition in his professional life:  He was leaving  the high, hard ground of academic preparation and entering the swamp-like environment of clinical practice.  Before knocking on the door of the patient in room 632, Groopman touched his left jacket pocket and felt the pack of index cards from medical school.  The cards,  he told himself, “would provide the ballast to keep me afloat alone.”

Groopman had studied the medical records of the patient in room 632 and learned that his name was William Morgan, a 66 year-old African-American man with a history of  hypertension.  He knocked on the door and heard “come in” from inside the room.

Groopman opened the door and said “Good evening Mr. Morgan, I am Doctor Groopman, your new intern.”

“First day, huh?” said Mr. Morgan with a grin.

After a few moments of pleasant small talk, Groopman was saying goodbye when suddenly, with no warning, “Mr. Morgan shot upright in bed.  His eyes widened.  His jaw fell slack.  His chest began to heave violently.”

“What’s wrong, Mr. Morgan?”  Groopman shouted.

“He shook his head, unable to speak, desperately taking in breaths.”

Groopman was paralyzed with shock and fear.  He was unable to think.  The encyclopedia of knowledge he had so laboriously constructed had vanished.  “My palms became moist,” he wrote, “my throat dry.  I couldn’t move.  My feet were fixed to the floor.”  When for the first time Groopman was faced with a crisis – a life or death situation – he had no idea what to do.

Suddenly he heard a deep voice behind him.  “This man seems be in distress.”

The voice was that of John Burnside, an experienced cardiologist who happened to be passing the door and heard the commotion inside.  Deftly, with no hesitation, he reached into Groopman’s pocket, took out the stethoscope, placed it over Morgan’s heart, listened for a few seconds, then handed it to Groopman.  “Here. Listen.”

“I heard something that sounded like a spigot opened full blast,” wrote Groopman,” then closed for a moment, and opened again, the pattern repeated over and over.”   In his training, he had listened to hundreds of hearts beating in hundreds of chests and had never heard anything like this.  It made absolutely no sense to him.

But Burnside knew:  “This gentleman just tore through his aortic valve.  He needs the service of a cardiac surgeon.  Pronto.”

While Burnside stayed with Morgan, Groopman raced to find a nurse.  Within minutes he returned with the duty nurse who had the resuscitation cart in tow.  Other nurses arrived.  Then the cardiac surgery resident appeared, and together they rushed Morgan to the OR.

Later, after the crisis was over, Groopman sat in a daze.  “The event seemed surreal,” wrote.  “I was enjoying a first conversation with one of my patients, then, like an earthquake, Mr. Morgan’s sudden upheaval, then the deus ex machina of Dr. Burnside.  I felt the weight of  the cards in my pocket.  Straight A’s when I was a student, play – acting.  Now, in the real world, I gave myself an F.”

Doing a” Groopman”

At one time or another, Groopman’s experience is one we all share when we attempt to apply the knowledge and skills we learn in the classroom to the real world:  Straight A’s (or at least good grades) in the classroom and F’s when we try to put into practice what we have learned.   Most of our preparation for doing difficult and complicated work is done on the high, hard ground of theory and textbook where we find answers in the back of the book and are taught solutions that others have already discovered.  Even when part of our preparation includes occasional visits to the swamp to see what it’s like, we usually just dip our toes in, never going in all the way.   It is only after we have “graduated” that we are fully responsible for doing Real Work.

The first times we face complicated, messy situations for which we have responsibility in situations that are important and that demand that someone take immediate action,  we often end up doing a “Groopman:”  Stuck in place,  “feet fixed to the floor, palms moist, throat dry, paralyzed with shock and fear.”

Doing a “Burnside”

All of us will spend time in our lives on both the high, hard, ground and in the swamps.  Almost all  of our classroom education prepares us to work and live on the high ground;  rarely are we prepared for what awaits us in the swamp.  Success in the swamp – acting with confidence and competence as we grapple with wicked problems – requires us to learn how to do a “Burnside:”  Show up in the middle of the storm fully present and alert with a calm and confident manner; get down into the mud and muck;  begin the process of figuring out what is happening; recruit and enlist others to work with us;  formulate an idea of the problem; then move, taking appropriate action to deal with the newly defined situation.

Becoming a Swamp Master 

It is clear from Groopman’s account that Burnside was a “Swamp Master:”  He knew where to start, how to make sense of what was happening, and what to do when he defined the problem. If he had been wrong in his first diagnosis, he would have tried something else, and then something else after that.  Burnside’s sudden and unexpected appearance with his calm, purposeful response to Mr. Morgan’s crisis can give us confidence that it is possible to not only  survive in the swamp,  but to do Good Work there, and even to flourish.

In a world full of wicked problems, our challenge is to become a Swamp Master!

Becoming a “swamp master” means,  at a minimum, the following: Understanding the differences between high ground and swamp; becoming reasonably comfortable amid the  muck and the chaos and the “hurly- burly” of the swamp; being fully aware that different rules apply; possessing the skills of gathering information about the “mess;”  making sense of it in order to determine the nature of the problem;  having the ability to involve others in collaborative work;  identifying and defining “a problem;”  giving it a name;  working with others to put together an action plan; then going to work to make a difference.

While there are different degrees of “Swampness,” all the way from mild encounters to major crises, any journey toward becoming a Swamp Master will require one to pass through these stages of  learning:

 Survival;

Muddling Through;

Coping;  

Managing;

Flourishing.

It is not an easy road.  Not everyone who takes it is successful.  Many people find themselves stuck in one stage or another, most often the stage of  Muddling Through.

What’s more, the road to becoming a Swamp Master is one that has no end.  Each time we enter a new “swamp” situation, we find ourselves back at Survival Mode, starting over.  There are, however, insights, approaches and skills that we can learn along the way and then take with us as we struggle, skills and insights that will provide us with huge advantages as we make our moves from Surviving to Flourishing.  We can learn to become Swamp Masters!