What follows is a special edition of the Central Intelligence Agency (CIA)’s Simple Sabotage Field Manual, reissued with the needs and opportunities of the American intern and/or resident in mind.

It is issued not to any individual resident but to a class of workers who share a common, untenable situation: extensive training, complete institutional dependence, and wages that could be readily matched or exceeded by entry-level positions at a variety of regional fast casual and convenience franchises such as Chick-fil-A and Buc-ees.

The techniques described herein are calibrated to preserve and protect, at all costs, the mission of patient care as our highest calling, while pursuing, with equal dedication, simple acts intended to cause delay, interference, or in the best cases genuine financial consequence to the bureaucratic machinery by which resident labor is converted into institutional wealth.

Proffered within is a collection of professionally defensible behaviors — each compliant, each documented, each nefarious in its own way.

It will not be distributed. It does not exist. You have already read it.

ORGANIZING PRINCIPLES

Sabotage, in the classic formulation, takes three forms: physical destruction, process interference, and morale degradation.

This manual concerns itself primarily with process interference — the introduction of friction, delay, and revenue loss into systems that depend on your frictionless, uncompensated cooperation to function.

Effective sabotage shares several characteristics:

• It is deniable. Every technique in this manual has a legitimate professional justification. Thoroughness. Caution. Documentation. Pride in one’s work.
• It is scalable. One resident undercoding is lost in the noise. Twenty residents undercoding is a red number or a downward trend on a finance spreadsheet somewhere.
• It is directed. This manual concerns the hospital system and its administrative machinery. It does not concern your colleagues, your co-residents, or your patients.

A note on alignment: residents are not each other’s adversaries. The techniques in this manual are directed exclusively upward and outward — toward the institutions, systems, and individuals who have determined that your time, your labor, and your expertise are available at a discount. Your co-residents are your colleagues. Treat them as such.

When you recognize a fellow saboteur operating in your vicinity, do not acknowledge directly. Simply note the technique, appreciate the craftsmanship, and if appropriate, collaborate.

Learn where the compliance lines are. Then stand precisely one step behind them. A note missing one review-of-systems item is a documentation oversight. A department where notes are consistently denied reimbursement is a billing problem that someone will eventually need to correct.

STRATEGIC DIS-DOCUMENTATION

While our forefathers envisioned progress notes as a sacred tool for interprofessional communication, today they are largely an exercise in futility: a word salad of clinical terms and auto-pulled data tables designed to maximize perceived level of service for billing purposes without regard for whether any real clinical information is being relayed. Besides, if a nurse or a consultant has a question, it’s always easier for them to just call you at 3 am when they think of it because their time is much much more valuable than yours.

Given this state of affairs, it is in the interest of our cause to optimize progress notes along a different set of parameters: to minimize both the time it takes for a resident to complete a progress note while at the same time minimizing the extent to which that piece of documentation can be monetized.

Your typical resident has become expert in the various turns of phrase that create the appearance of clinical action where in fact there is none (see appendix for illustrative examples), and with a one-time expenditure of effort, can create a near-universal, reusable note of “progress” that acknowledges that a patient has been at least visualized with the eyeballs of the resident and noted to be alive and in control of some number of limbs, and that a plan of care is ongoing, but nothing more.

This variety of documentation that satisfies requirements, reduces billable material, all while freeing the resident’s time is an excellent strategy for sabotage.

KARMIC CONTACT MANAGEMENT

The resident who has survived more than a few months of training has accumulated, through no fault of their own, a contact list of considerable length and dubious character. Attendings, consultants, charge nurses, administrators, and various other parties have made themselves known, often at inconvenient hours, and often with requests calibrated entirely to their own convenience and not yours.

It would be a shame to let this institutional knowledge go to waste.

A contact management system worthy of the name does more than store phone numbers. It stores context. The resident is encouraged to develop a personal notation system that captures the nature of past interactions with any given contact, such that future interactions may be calibrated accordingly. The specific notation system is a matter of personal preference, but should of course be encoded to minimize any risk of detection. For example, if you might say, colloquially, that you have “beef” with someone, perhaps an emoji of a steak can serve as an effective reminder both to you, and to anyone else you may pass along that contact to. In a similar fashion. This system should be maintained diligently and, where appropriate, transferred to incoming residents at the conclusion of your training. The institutional memory of a residency program is one of its most valuable and least documented assets. Be the change.

A note on proportionality: this system does not advocate for the withdrawal of competent clinical care. It advocates for the withdrawal of enthusiasm, alacrity, and the above-and-beyond that you were never contractually required to provide in the first place.

REAPPROPRIATION OF INSTITUTIONAL SUPPLIES

Compensation, as our nation’s healthcare system likes to remind us, can come in many forms: money is a small part of it, but residents also receive verbal expressions of appreciation, bulletin boards throughout the hospital celebrating their existence up to once per year, “free” pizza, strength of character forged through hardship, and online quizzes which provide a fun diversion as long as they are completed in a timely fashion.

Compensation can also take the form of useful items for daily living that are conveniently available to residents throughout the hospital. While they may not be packaged or labeled as they would be at a traditional retail establishment, with a little of that trademark resident ingenuity, you will find many valuable pieces of your compensation in the various closets and cabinets throughout the hospital.

Some are obvious. For example, the traditional hospital milk carton is approximately 230 ccs. Take 16 of them, and you have a gallon of milk conveniently pre-packaged into serving sizes.

Are you a wearer of contact lenses? Saline flushes can serve as an effective and surprisingly convenient contact lens solution. And once they are empty, can become useful take-home dispensers for any flowable substance available in a larger format at the hospital, from lotions and soaps to ketchup and mustard.

Specimen cups can be repurposed for storage of small items or even spices in your home kitchen. And nothing is better for setting the mood at home than lighting a candle with a battery-powered bovie electrocautery, and then removing the batteries so that you can power your home smoke detector.

Cleaning supplies, personal care products, foodstuffs, linens, and even occasional electronics and appliances should all be considered part of your comprehensive compensation package. Show your gratitude by making frequent, creative, and liberal use of these benefits.

A note on signage: you may notice signs particularly in nutrition rooms claiming that foodstuffs are intended for patients only. These signs are typically in impermanent forms such as printer paper with tape or a laminated bit of card stock. As such, they can be readily relocated.

EQUIPMENT MAINTENANCE

Hospitals are, of course, committed in principle to providing staff with equipment that meets minimum standards for its intended function. In practice, however, the gap between this aspiration and reality is considerable, and nowhere more so than in the shared spaces where residents spend the majority of their working lives: workrooms, call rooms, procedure carts, and operating rooms that have seen better decades.

The difficulty, from an administrative standpoint, is one of visibility. A computer that is merely slow, a pair of scissors that are merely dull, an otoscope that is merely dim — these items exist in a purgatory of dysfunction from which they are unlikely to be rescued, because their failure mode is not obvious enough to trigger a work order. They will be reached for in good faith by the next person who needs them, and they will fail at a moment of inconvenience, and then they will be returned to the drawer.

The resident can help.

A computer with several keys gently removed is a computer that will not be used under the impression that it works. In this sense, the resident who has liberated a few keycaps from a malfunctioning workstation keyboard–perhaps the F, the M, and the L–has performed an act not of sabotage but of quality improvement. A QI intervention, if you will, that has made invisible dysfunction visible and initiated the corrective action chain that hospital administration always intended to have in place.

Similarly, a pair of surgical scissors discovered to be dull mid-case should not be returned to circulation. They should be retired. Visibly. A scissor that is bent is a scissor that no one will reach for in error. You did not break the scissors. The scissors were already broken. You simply made the invisible visible.

A note on scope: nothing in this section applies to equipment involved in direct patient care that is currently in use or immediately accessible for emergency purposes. We are saboteurs, not monsters.

ACCESS AND WAYFINDING

The hospital is a building of considerable complexity, and access to its various supply closets, medication rooms, equipment cabinets, and storage areas is governed by a system of codes, badges, and keys that, at varying levels of sophistication, are intended to provide the appearance of security and/or monitoring of the movements of humans and other objects through the system.

These codes are institutional knowledge. They are learned through experience, passed along informally, and almost never written down in any official capacity, and as a result, can create particular frustration for residents attempting to provide patient care to a patient on an unfamiliar corridor in the middle of the night.

In the interest of operational continuity, residents are encouraged to document access codes in locations that are simultaneously discreet and discoverable by colleagues who need them. The doorframe of the relevant closet, written in small print, has historically proven effective. While eye level would be most convenient, these notations are best placed slightly lower, on the right side, for discretion and consistency.

PATIENT EDUCATION AND ADVOCACY: THE EXPANDED CURRICULUM

The healthcare system is incredibly complex, particularly when it comes to payment. It is not uncommon for patients to inquire about what a certain diagnostic test or even their hospital stay will cost, and while residents are not equipped to provide answers to these specific questions, they are well positioned to ensure patients have access to the information and tools they need to advocate for themselves.

The resident who takes a few additional minutes to ensure patients are actually aware of their right to, for example, an itemized bill for their hospital stay. They should certainly be aware that every hospital has a free service, variably called “patient services,” or “patient experience,” that provides additional guidance and support to a patient facing challenges related to their stay.

The Joint Commission’s complaint hotline (1-800-994-6610) is also a useful resource for particular complaints related to facilities, staffing, and billing.

On the matter of institutional finances: nonprofit hospitals are required by law to file Form 990s with the IRS, which are public record and available at ProPublica’s Nonprofit Explorer.

These documents contain, among other things, executive compensation. A resident who has familiarized themselves with this information and can relay it accurately to a patient who has asked, sincerely, why their care is so expensive, is simply being honest. This is encouraged.

Finally: the resident who finds themselves passing through a waiting room, a cafeteria, or a patient lounge in the quieter hours of the night may occasionally notice that these spaces, populated during the day, are briefly and usefully empty. Educational materials placed in these spaces have a way of persisting. A note on what a hospital CEO earns relative to other hospital employees, for example, may make for interesting reading material. This is simply public information, thoughtfully curated, strategically distributed.

APPENDIX A: GLOSSARY OF USEFUL PHRASES

A reference guide to clinical documentation language. For use in notes, sign-outs, and any context requiring the appearance of specificity and professionalism where in fact none is present.