The Intern Blues (20 page)

Anyway, Saturday was pretty quiet. I got only two admissions the whole day, so I had a chance to spend the day sitting in the residents' room watching TV and eating mock-turkey sandwiches. It was good; I needed a chance to relax a little and figure out who all my patients actually were. And today was pretty quiet, too. So right now I've got most of this straightened out.

I spent yesterday in the city with Carole. We went to a matinee. We saw
Cats
. I fell asleep four times and Carole had to wake me up because my snoring was disturbing all the people around us. I don't think I missed much; from what I saw during the short period when I was conscious, it looked pretty lame. I can't figure out how they get people to wear those silly costumes eight times a week. I guess if they can get me to do the ridiculous stuff I do, they can get anybody to do anything!

Thursday, October 10, 1985

As if my life weren't bad enough, Hanson's back. I couldn't believe it! I got called down to the ER to pick up an admission last night and all I knew was it was supposed to be a six-month-old with diarrhea and dehydration. I got down there and there he was. There was no doubt about it. No other six-month-old I've ever seen has that characteristic putrid look about him. His mother had brought him to the ER, and of course she didn't recognize me. During the entire month he had made my life miserable on Infants', she had never once come to see him. All I knew about her was that she was a drug addict. When I realized she was his mother, I almost said, “Oh, I'm sorry, I didn't recognize you without the needle in your arm,” but I showed excellent restraint and tact and kept quiet. I'm getting really good at this patient-relations stuff. Anyway, poor little Hanson had been home maybe two weeks and had developed diarrhea again. I asked his mother why she didn't bring him back to Mount Scopus since, after all, all his records are there, and she said, “I don't like those doctors at Mount Scopus. They don't know nothing. They're all a pain in the ass.” I guess she came to Jonas Bronck because she wanted a second opinion. Very smart!

Anyway, I figured I should try to get some history on his last days at Mount Scopus, so today I got in touch with Jennifer Urzo, the intern who discharged him from Infants'. I said, “I just admitted Hanson,” and I could hear her groan. It's amazing how one tiny baby can cause such a uniform reaction from everybody who's come in contact with him. Jennifer told me this weird story about how she spent the entire month of September working really hard to get him straightened out. Not only did she work on getting him relatively healthy, she also arranged for a bunch of outpatient follow-up appointments, home visits by the VNS
[Visiting Nurse Service]
, social work involvement, the works. It sounded as if she genuinely liked the kid (there's no accounting for taste). When everything was arranged, Jennifer somehow got in touch with the mother and actually convinced her to come in and learn how to take care of the baby, which must have been a major miracle. The mother came a few times. Jennifer said she never felt really comfortable around her but that the nurses felt the mother knew what she was doing. So Jennifer told her she could take the baby home. She started going over all the appointments she had made and the mother said something about the fact that she was going to take the baby home and she'd keep most of the appointments but she sure as hell wasn't going to come back to see Jennifer because she didn't like her, she didn't think she was doing a good job with the baby. She said she didn't think she was a very good doctor. This obviously really hurt Jennifer. She even got tearful on the phone just talking to me about it.

Anyway, he seems to be doing okay now. I kept standing around his bed all night waiting for him to crump but he never did. He hasn't had any diarrhea since early this morning but we're still keeping him NPO. I started an IV last night. What thrilling memories that brought back! I'll tell you one thing: He may be a little bigger and two months older, but he still has shit for veins! I stuck him about a dozen times to get the line to stay in place. It felt so comfortable. Just me and him and a box of twenty-two-gauge plastic IV catheters.

While I had Jennifer on the phone, she told me what finally happened with Fenton, the kid on Infants' whose grandmother was crazy and was getting him admitted to all the hospitals in the area for GE reflux that he didn't really have. BCW took the grandmother to court, and Jennifer had to testify, since she was the discharging intern. The judge decided the grandmother needed psychiatric evaluation and ordered that the kid be placed into foster care until that was completed. So there's another happy ending.

Anyway, there's not much else going on right now. I'm going to sleep so I can be bright-eyed and bushy-tailed for call tomorrow.

Wednesday, October 23, 1985

Nothing much has been going on. The ward's been pretty quiet, thank God, and I've been getting sleep most nights when I've been on. The most notable thing that's been happening is that Carole and I have been talking a lot more about the future, which is starting to scare me to death. She wants to get married. I'm not so sure I do. I have to admit, she's been very good to me since I started this insanity. She's always been there when I've needed her, but marriage, that's a really big step.

I'll have to do a lot of thinking about this. Just as soon as I have enough time.

Bob

OCTOBER 1985

 

In October of my internship, my wife developed severe abdominal pains. She went to a physician who did an upper GI series and diagnosed a gastric ulcer. The doctor started her on Cimetidine, a drug that decreases the amount of acid produced by the stomach, gave her advice regarding her diet, and told her to take it easy. With time, the symptoms disappeared.

I was pretty surprised when Beth told me about her ulcer. After all, I was the one with the stressful life-style; I was the one who wasn't getting enough sleep, who was taking care of critically ill patients and trying to cope with their families. All she was doing was working in her laboratory, the same as she had done for the previous three years.

Looking back on it now, it's clear that Beth's life at that time had become as stressful as mine. First, because I was in Boston and she was in New York, she had become a regular weekend passenger on the Eastern shuttle. Beth was terrified of flying, and these weekly excursions were rapidly taking their toll on her mental health. Second, upon finally reaching Boston after each of these hair-raising flights, she was finding that I, once a sensitive and loving human being, had been turned into a melancholy, self-centered wretch. She seriously questioned, at least to herself, whether this “new” me was a permanent change or whether it was just a temporary interruption in our relationship. And finally, she was worried about her work; it wasn't going as well as it should. She was expending so much energy worrying about me and our relationship that she just couldn't concentrate on what was happening in the lab. At the time, I didn't understand any of this. That's because I, like most interns, couldn't see past my own problems.

It's not surprising that Beth's ulcer first appeared in October. It's during October that internship begins to take its toll on everyone. To the intern, it's the start of the winter doldrums: The thrill of being a doctor is gone (that usually occurs back in July), the “newness” of the on-call routine has worn thin, and exhaustion has begun to set in; in addition, the intern realizes there's no end in sight.

October also is usually the time when interns lose all contact with friends and relatives. I clearly remember the routine that became established at about this time in my own life. I'd come home after shopping to pick up a pizza, take off all my clothes, climb into bed, and watch reruns of
The Odd Couple
and
The Brady Bunch
while wolfing down dinner. Then, by about eight-thirty or nine, I'd turn out the lights and quickly fall asleep. Unless forced, I would not leave my house; I didn't go out to movies or to dinner with friends or even to the supermarket to buy food. I didn't have the strength, and I didn't have the interest. I just wanted to be left alone.

Andy Baron is taking to internship just like I did. When I visited him on the ward at University Hospital early in the month, he said he couldn't talk to me. Figuring he meant he was too busy to take a break, I suggested we go out for dinner, and he said, “No, you don't understand. I can't talk to you, and I don't know if I'll ever be able to talk to you again. If I think about what's happening to me, I'll start to cry, and once I start crying, I don't think I'll be able to stop.”

“So you don't think you ever want to talk to me again?” I asked.

“I'm not sure,” he replied, and I could see tears starting to well up in his eyes. “For now, I just want to be left alone. I don't want to have to talk or think about anything.”

I told Andy how much he reminded me of myself. I told him about my pizza and
Odd Couple
routine. He smiled at this and said it hadn't gotten that bad for him yet (he said his TV was broken).

To people like Andy, Mark, and Amy, who have long-term relationships, October can be a frightening time for loved ones. Because of the appearance of this first wave of depression, interns become introspective, largely ignoring everyone else; all an intern is concerned about is his or her ability to get enough sleep, enough to eat, and to find some kind of happiness without expending too much physical or emotional energy. And like Beth, this is a time when spouses begin to wonder what the future is going to hold.

That's certainly the case with Carole, Mark Greenberg's significant other. She and Mark have had a relationship that's gone on for years and weathered all sorts of storms. And now, four months into his internship, she finds that Mark has no time for her. He falls asleep whenever they go anywhere together; he talks about nothing but life on the wards while taking no interest in her work or her problems. Carole is looking for some answers: She wants to know if the change she's seen in Mark is permanent or temporary; she wants to know what effect all this will have on her life; and she wants to know if she and Mark will wind up getting married or not. Unfortunately, at the present time, Mark is in no condition to give her these answers.

Amy seems to be handling her life outside of work better than any of the other interns. From what she tells me, her relationship with Larry has not been adversely affected by her internship. I think there are two reasons for this. First, Larry is an exceptional guy; he's very patient and understanding, and he loves to spend time with his daughter, which is pretty important, since he's Sarah's primary caretaker most nights and weekend days. Second, Amy is reacting differently than everyone else; she understands that she can't come home, sit in front of the TV, and tune out life, because she has a second job that's even more important than being an intern: She has to come home and be a functioning and loving mother. So far, Amy and Larry seem to be holding things together.

But even their relationship has clearly been stressed. Amy told me about an argument she and Larry had concerning Amy's yelling at their baby-sitter. She said they almost never argue, but this one had occurred after a particularly bad night on call because Amy was overtired. So even for them, some small cracks have begun to appear in their ironclad marriage.

October also is a pretty hard month for the house officers who don't have “significant others.” During the middle of this month, I went to the Recovery Room, a bar across the street from Mount Scopus, with some of the senior residents. Ben King told me he was a little upset because he was planning to go to his ex-girlfriend's wedding this weekend. He and this woman broke up last year after a long-term relationship because she just couldn't take it anymore. She didn't like the idea of spending every night alone. “Even when I was there,” Ben told me, “I was only about half there.”

Usually, the only other single people unattached house officers come in contact with are other single house officers. There's almost no time for them to hang around places where nonmedical single people congregate, and during what little time is available, there is a great deal of pressure to “succeed.” But most potential partners, like Ben's old girlfriend, don't want to put up with the bizarre hours interns and residents are forced to keep. So it becomes almost impossible to develop any kind of meaningful relationship that will last through training. For the men, this is just a major irritation; they figure things will straighten themselves out after their internship and residency ends. But for the women, it's a lot more terrifying: They say they can actually hear those proverbial biological clocks ticking away inside their ovaries, and as time passes, they tend to become more and more fixated on finding Mr. Right.

So the overall effect of all this is that a great many interns and residents feel depressed. This internal turmoil can have far-reaching effects, causing the person to decide to make major changes in his or her life. Some interns decide to leave medicine; some (very few) decide to leave life by committing suicide; others decide to leave their program. This last seems to be happening with Andy.

On the evening of October 14, our phone rang almost as soon as I got home from work. It was Andy; he said he needed to see me right away; it was important, and he couldn't talk about it over the phone. He asked if I could come down to the Bronx immediately.

I was worried. I knew Andy had been depressed, and I also knew that anything was possible. So without losing a minute, I got into my car and headed back to the Bronx.

Andy lives on the twentieth floor of the Mount Scopus apartment tower. He has a studio apartment with a terrific view. From the balcony, looking east, you can see parts of the Bronx, City Island, Long Island Sound, and, in the distance, the lights of Long Island and Westchester County. After showing me around, Andy sat me down and said, “I guess you're wondering what's going on.” After I told him that was an understatement, he continued: “You have to promise not to tell what I'm going to say to anybody else, not even your wife. It's very secret and I could be extremely damaged if word leaked out.”

After we negotiated a little and I finally promised, he told me: “I've been offered a job at another program.”

I must admit it was kind of a letdown. I was expecting something juicier, something like he was having an affair with one of the other interns or possibly even with one of his ex-patients on Adolescents. He went on with the story; he told me that before this year had started he had talked with the director of Pediatrics at Boston Children's, the program he had originally ranked first on his match list last year, and had asked him about the possibility of coming back to Boston as a junior resident next year. The director had told him that no jobs were available at that time, but if one were to open up, Andy would be No. 1 on the list. Then yesterday the guy had called, had told him one of the interns was planning to leave and that Andy could have the position if he still wanted it.

Andy told me he was feeling very conflicted. There were a lot of things to think about. First, in spite of everything that's happened, he thinks our program is good and he's made some close friends; he feels bad about the prospect of leaving. Next, Karen is applying to some of the more impressive New York psychiatric residency programs and has a better than even chance of getting in.

“So stay,” I said.

“It's not that easy,” he replied. “My family's all in Boston. And I know I'll get a good education at the other program. And Karen and I are planning on settling in Boston. We want to have a family; staying in New York will just delay that.”

I told him it sounded like a tough decision but that it wasn't a bad situation to be in; I mean, he's going to win either way. I told him I'd definitely be sorry if he decided to leave.

We talked for about an hour and a half. Of course, nothing was resolved. I'm not sure what's going to happen to Andy, but if I had to bet, I'd bet on his going back to Boston. There's simply more to draw him there at this point than there is to keep him here.

 

 

Every October,
all the attendings who have contact with the house staff meet to discuss the internship group. This meeting serves two purposes: First, it identifies those people who are or may soon be having trouble so that some form of intervention can be planned; second, the meeting allows us to come up with some idea of who will be returning the following year and, more importantly, who will be leaving.

It's rare that all the interns come back as residents. Two members of each year's incoming group are accepted with the understanding from the very beginning that they'll be leaving for residencies in psychiatry, radiology, or other specialties in which a year of pediatric or internal medicine training is mandatory. A few more, people like Andy Baron, decide to change programs for personal reasons. So during this meeting, Mike Miller tried to get a head count of prospective junior residents.

The meeting this year was interesting. Mark Greenberg and Andy Baron were both viewed as very good. Andy, in fact, is considered by most people to be outstanding, an excellent candidate for one of the program's four chief resident positions. Since he had sworn me to secrecy, I didn't mention a word about his job offer in Boston.

The intern about whom there was the most discussion was Amy. She's apparently made more than a couple of enemies among the attendings. In addition to her problem in the emergency room back in July, she tends to do a lot of little things that get people upset, such as leaving the hospital early; complaining frequently and loudly; and criticizing other house officers, such as Barry Bresnan. I spoke up for her; I said I thought a lot of her complaints were justified and that she shouldn't be condemned for voicing them.

It was ultimately decided that Mike Miller would have a talk with Amy and explain the concerns that had been raised at the meeting. It wasn't thought that anything needed to be done, that her work was certainly good enough to justify being offered a position for the following year. I don't know how Amy is going to respond to this criticism, especially since I'm sure she won't think it's warranted. After all, I don't think it's warranted either; I think she should be commended for doing as good a job as she's done, considering all the pressure on her. And I'm going to tell her that.