Authors: Robert Marion
The Intern Blues (25 page)
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This month marks the halfway point in the interns' trip through this horrible year. The first half of internship officially ends on December 28, and I'm sure that on that night, as they lie in their beds trying to fall asleep, or sit in nurses' stations around the Bronx trying to finish yet another admission note, many of our interns will take a minute or two to reflect on what's happened to them since July 1 and try to work up enough enthusiasm to propel them through next June.
The pediatric department's annual holiday party was held on Wednesday night, December 18. Most of the interns managed to turn out. That's surprising when you consider that a third of them were supposed to be on call and another third were postcall and many of these guys probably hadn't slept in a couple of days. So the fact that so many were there was nice.
Just watching them, it was clear that something had changed since the last time this group had met at a prearranged site for a party. At the first orientation party, the interns had seemed isolated, nervous, and scared to death. Now, six months later, they were a strong, unified group. Tight bonds had formed among them from the mutual sharing of the good times and bad that have occurred over the past six months. On the dance floor, at the bar, sitting at the tables, there was a lot of backslapping, a lot of laughing, and a lot of inside jokes. These guys have built a strong support network for themselves; they're there to help each other out. That's exactly the way it should be at this point in the year.
Thinking back on it, these people have definitely changed. They've gone from being frightened, untrained, technically awkward but very concerned medical students to competent, overworked, and chronically overtired interns. It no longer takes them all night to start an IV or all morning to draw the routine bloods on their patients. They've become masters of scut; they've learned how to manage their time so that they no longer have to stay until eight or nine o'clock on the nights when they're not on call, as they did when the year first began. They've learned the shortcuts that are necessary to survive.
They're also beginning to feel comfortable being around critically ill patients. They no longer feel the impulse to run away as fast as they can when they hear that a three-year-old who's in the midst of a convulsion or a six-month-old with signs and symptoms of meningitis has appeared in the emergency room. They've started to be able to formulate a plan of management by themselves, not relying as much on the residents or attendings to tell them what to do and when to do it. And they're beginning to develop good instincts; they're now able to figure out which patient is truly critically ill and in need of immediate attention, and which patient is not so sick and can wait. But these skills are still in an embryonic state. It'll take a few more months before any of the interns feel confident enough to reject advice given by an attending physician. But one day that will happen. They'll suddenly realize they can do it all themselves.
That's how it was for me. I remember the night everything seemed to come together. It was the middle of March and I was working on the general pediatrics ward: the worst night of my internship. Starting in the afternoon, I had admitted patient after patient, each sicker than the last. By the next morning I had trouble remembering them all; there had been at least eight of them, with three sick enough to quality for admission to our hospital's ICU.
It was at about five-thirty in the morning when it suddenly hit me. The sun was coming up and I was finishing with my third ICU admission, a fourteen-year-old girl who was comatose and near death due to acute inflammation of her brain. She had been sick with chicken pox the week before and had now developed post-varicella encephalitis, a very rare, devastating, and often lethal complication. I had admitted her and done the entire workup by myself, including putting in an IV, drawing the bloodwork that I thought needed to be done, and performing a spinal tap. I had decided on a plan of management and had confirmed that plan with all the appropriate consulting services. And as I sat to do my admission history and physical, with the girl's vital signs finally stable, after this long and terrible night, I realized all of the sudden that I could actually do this stuff. I could be left without someone looking over my shoulder and the job would get done. And once I came to this conclusion, I knew for the first time all year that I would survive my internship.
But it wasn't until March that I reached this conclusion. It's only December now and, although Mark, Andy, and Amy have come a long way, they still have a long way to go.
Mark came to the Christmas party with Carole. They seemed to have fun, but Carole has to have a tough time at events like this: She has to feel like something of an outsider, not being involved in medicine and knowing few of the people. And Mark has to feel a little uneasy, trying to share the experience with his intern pals while at the same time making sure that Carole is enjoying herself. They spent most of the night off to the side by themselves.
Andy didn't show up at the party until after nine. He had gotten out of the hospital late after a busy night on call, and he had stopped at home to take a shower and change his clothes before coming over. He was wearing a bolo string tie, had his hair slicked back, and was wearing a pair of horn-rimmed glasses that he hadn't worn since sixth grade. The effect of all of this was that he looked as if he were on his way to a costume party.
Andy immediately joined in with a group of eight other interns who stayed together through the rest of the evening. This group is composed of the interns who had either started the year alone, without “significant others,” or, like Andy, with significant others who lived outside the New York area. These people have supported each other through the first half of the year, and they have formed very tight, close friendships.
The interns in this group have little to worry about. They may not each be feeling great right now, or be extremely happy about the prospects for the rest of the year, but they know they've got each other and they know that no matter what happens, the others will be there to help them through any bad times.
At the Christmas party, the house officers traditionally put on a skit. This year, the senior residents presented a little play about what life must have been like in the Jonas Bronck ER back in the “Days of the Giants,” the phrase facetiously used to describe the times when the current attendings were doing their training. The myth about the “Days of the Giants” goes something like this: “Back when we were interns, we worked much harder than they do today. We were on call every other night, and we loved it. And when a tough case was admitted, we fought to be able to take care of that patient. We wanted to impress our chief with how good we were.”
In the skit, senior residents were Alan Cozza, Mike Miller, Alan Morris, and Peter Anderson. They ran around a pretend emergency room trying to prove how
macho
each was. They got into arguments and ultimately fistfights about who would admit the critically ill patient (played by another senior resident) who was brought in by ambulance.
But the residents also went on to depict what actually occurred once those Giants got those really tough cases: They didn't know what the hell to do with them. Because the reality of the situation is that back in the “Days of the Giants,” there wasn't a tenth of the technological advances that are commonplace today. In fact, pretty much all the Giants could really do was fight over the patients; there was very little that could be done to cure many of the problems presented. The skit ended with a very bitter and melancholy song about the life of the residents.
The other attendings and I all left the party early; that's also become traditional. The latter part of the Christmas party belongs to the house staff, a time for them to let loose without having to worry about being judged by their bosses standing off in the corners. The morning after, there were a lot of exhausted but happy interns running around the Bronx. They've got six months to go. In many ways, these last six months are much tougher than the first six.
Sunday, January 19, 1986, 1:00
A.M
.
I started my vacation, as planned, in Portland
[Maine]
with Karen and her family. We were there for Christmas. I ate like it was going out of style, I vegged out and slept a lot, and I got to know Karen's family a little better. Three days never went so fast.
After leaving Portland, we went back to Boston but we only stayed overnight. We had originally planned to go to New Orleans, but we went to California instead. We decided not to go to New Orleans because we saw in the newspaper that it was forty-five degrees and rainy down there and we heard that one of the big college football teams was going to be in town for a bowl game and there were going to be millions of crazed football fans running all over the place. So we spent a week out in Santa Barbara instead. We stayed at Karen's sister Kathy's house. Kathy was still out in Portland with Karen's parents. My brother and his wife, Debbie, and Karen and I shared this little bungalow with a porch in the backyard where you could sit and look out and see the Pacific Ocean in the distance. It was very quiet, very beautiful, and warm. We did a lot of walking that week; we walked on the beach and in the hills and around town. It was really a good kind of meditative thing to be doing. I had a chance to look back and think about what had happened to me over the past six months, what this internship had done to me. We watched a million movies on Kathy's VCR, just one after the next. I slept a lot, and that was very good, too, just having the chance to catch up on some of the sleep I've missed. And I balanced my checkbook, which I hadn't done in six months. I brought all the stuff out with me because I knew I wouldn't do it otherwise. And I felt like my life was a little more back in order again.
At the end of the week, we were all very sad to go home. Karen and I were still enjoying each other's company a lot. We went back to Boston, where it was frigid and bitter cold. I had a few more days there. I saw a couple of old friends, and then Karen and I packed up all our stuff and got ready to come back to New York. Karen has come out to stay for two whole months. She's doing a subinternship in psychiatry in Westchester.
I came back from vacation relaxed and happy, and I was hoping my mellowness would carry me along for a couple of weeks, at least into February, when I'm scheduled to be in the ICU. The depressing thing is that the pace of being back in the ER, the aggravations of being an intern, the frustrations that come with taking care of patients all mounted very rapidly, and it took only a couple of days before I felt like I'd never left. And it's kind of a drag. I mean, here I am, only back for a week and a half, and already I'm feeling aggravated.
Most of the patients I've been seeing have been really abnormal children, really abnormal! During OPD, I spend two out of five weekdays in clinic, and that's what's killing me! All the kids I follow now seem to be abnormal; I've picked up tons of patients who've been discarded by other doctors. I've got kids with MR-CP
[mental retardation, cerebral palsy]
, kids with seizures, kids with weird syndromes, psychotic adolescents I picked up while on the ward; you name it, I've got one of them in my clinic. I seem to have no straightforward, healthy children at all.
And in the ER, well, we do see relatively normal kids there, but it's such a bad situation. The parents are exhausted, they're frustrated, they've had to wait no less than forty-five minutes before they're seen; most of the time they have to wait a couple of hours. Half of your interactions with parents in the ER are not very good. I try so hard to make things go off well, but it's so hard. By the time they get to see you, the parents are so aggravated that you get aggravated. It's just a vicious cycle.
There were a couple of bad things in the ER today. I had one kid who came in and got worse right in front of my eyes. We wound up nearly coding him. And then we had a kid with 20 percent second-degree burns to the perineum
[the diaper region]
that didn't look very nice. How do you think those got there? It was another abuse case, of course.
Then a thirteen-year-old stab victim came in. The stories are always the same with stab victims: They say they were just going to the store to get their grandmother some ice cream or something like that when somebody out of the clear blue came up to them and stuck a knife into their chest; they're always innocent. This kid wasn't really that bad. And he was about the worst we had today. I didn't have to do any pelvics. So that made it a pretty good day.
I used to get upset about doing pelvics, but I really don't care about them that much anymore. They really aren't so bad as long as you've got a kid who isn't going to be hysterical. That's about one out of every five kids. I'm not wild about doing the other hysterical four, but one of those will be only semihysterical, and only one of the other three will be completely off the wall. But you really can't blame them; most of them are twelve years old and they've never had a pelvic before, and then they find out they're pregnant. Uhh, God forbid! Anyway, it happens all the time. And sexual abuse, you knowâwhat can I say?
We had this attending on today who was driving me up a wall! She was so indecisive, I wish I'd never asked her anything! I think she made more trouble for me than anything else. But I kind of liked her, she was really very nice, and she actually gave me a little off-the-cuff talk on pharyngitis that was very good. But every other time I asked her for help, she just wound up making everything very confusing.
I'm getting to the point where I don't want to bother with the attending, I just want to ask other residents for advice. The attendings usually wind up mucking you up, unless they're really good, and that isn't too often. I'm realizing that it's best just to listen to their advice as a suggestion and then do whatever you want to do. Shit, it's my name that goes on the bottom of the ER sheet, not theirs!
[Although the attending is supposed to be supervising the care of all patients in the ER, the house officer is the one who signs the chart at the completion of the patient's care
.] I'm the one who's really responsible!
I really can't complain about anything tonight. First, I got home at a great hour. I mean, I left that emergency room at twelve-thirty. That's almost unbelievable! And I have the next two days off because Monday is Martin Luther King's birthday and all the clinics are closed. Hallelujah! What will I do with myself with all this spare time? Sleep, probably.
Sunday, January 19, 1986, 11:30
A.M
.
I was just lying in bed here thinking about how no one tells you, really, how to be an intern. They tell you what to do, when to do it, how much to do it with, and how you're not doing it fast enough, but no one tells you really how to be an intern. For instance, where do you draw the line between your own decisions and those of your superiors? Over the past few months I've come to feel comfortable with making decisions; I can deal with a lot of issues on my own now. But when the attending tells you to do something and you don't think it's exactly the right thing to do, what are you supposed to do? After all, it's your name that's on the paper, not the attending's. A lot of times it seems like the attendings don't really fully understand the case, and they make snap decisions with only a half or a three-quarter understanding, and you're the one who's supposed to carry out their orders. So what it all comes down to is, you have to decide for yourself. You're not a medical student anymore, you're really a doctor, even though you barely know how to function as one. That's what no one can tell you. It's something I can barely tell you myself.
The other night I examined a little three-year-old girl who came in with a vaginal discharge. The history wasn't suspicious at all, and there were only a couple of very, very subtle things on the physical exam aside from the vaginal discharge, but the first thing you're supposed to think of in a case like that is sexual abuse. And that's exactly what went through my mind.
But I found myself getting talked out of reporting the case to the BCW because it wasn't all that clear-cut. The attending argued that the discharge could have been caused by something other than sexual abuse. I had to agree. And I felt really pressured by the attending and the social worker, people who have had years and years more experience than I, just to let it pass, to sign it out as nonspecific vaginitis rather than sexual abuse. We talked about it for a long time, and they told me to think about what reporting it would do to the family; the child would be removed and placed in a foster home. The parents would be labeled as criminals, whether anything really happened or not. It might be years before these people's lives would return to normal. And with all that pressure, I decided to go along with them.
Now I'm regretting it. I've been thinking about this kid ever since. The attending told me to be sure to follow the girl carefully. But let's say this was a case of abuse: What if they don't come back for their follow-up appointment? What can I do then? And, of course, I called the bacteriology lab at Jonas Bronck today and was told that they have no record of receiving the GC
[GC: gonococcus, the bacteria that cause gonorrhea]
cultures. Great! I'll keep looking for them; I'm sure they'll turn up sooner or later. I hope to God the messenger didn't throw them down the elevator shaft or something like that. But if they don't show up and we never find the cultures, what can I do? And what'll happen if this girl comes back dead next week because whoever molested her decides to whack her over the head with a hammer? It'll be my fault, because I listened to the attending and the social worker rather than doing what I thought was the right thing.
This feeling I have, that I have to start making up my own mind and not relying on other people, it's really something that can't be taught beforehand. I'm just realizing it myself, and I've been doing this for six months now.
I got on the elevator in the DTC building
[the clinic building at Mount Scopus]
the other day and the elevator stopped at one of the adult floors. This middle-aged man came on with these two middle-aged women, and he said something like, “All they see when they look at you is dollar signs.” Then he said, “Look at their mistakes. They fill the graveyard. They don't give a damn. All they care about is money. I don't trust doctors one damn bit anymore.” This guy was standing three inches from me! And I was really biting my tongue. I felt like saying, “Look, there are some bad apples out there who suck, who are only in it for money, and who don't give a shit about people. But most of us really do care about our patients.”
I don't know, I find myself feeling defensive about organized medicine and at the same time being more disillusioned about it than ever. I do look at the mistakes that are made and the horrible outcomes that result, and yes, our mistakes do end up in the graveyard, but they dot them, they don't fill them.
Well, I've gotten a little off the subject. Anyway, I don't think there's any way that people can be taught about what it's like to be in the uncomfortable position of having to start to use their own mind but having very little to base decisions on. There's just no way anybody could have prepared us for this transition from the little puppy dogs who do everything the attending tells us to independent doctors who wind up being very uncomfortable with some of the decisions we have to make. I'm constantly feeling as if I've got a green belt in karate, that I know enough to kick someone but I might break my own foot doing it.