The Intern Blues (39 page)

When you start sniffing the patients, I think it's safe to say you've been an intern too long. I think it's time to get out of here!

Sunday, May 18, 1986

Well, I haven't recorded anything for over a week, and nothing much has happened. Working at University really isn't so bad if you like taking care of kids with diseases whose names you can't pronounce. It's not like the other hospitals; they actually hire people here to do some of the scut work we're normally expected to do. So workwise there just isn't that much to do. But you more than make up for it in aggravation.

This is definitely the weirdest place I've ever worked in! At all the other hospitals, you really know what the score is. The rules are simple: They try to pile as much shit on your head as they can until you collapse, at which point a chief resident comes along, pats you on the shoulder, and gives you the weekend off to recover. Here the work isn't that hard, but you always have the feeling that you're missing something. You don't have control over anything. There are always attendings around who are trying to do things without telling you, and the parents always know more about what's happening with their kids than we do. It's very frustrating.

Nobody wants their kids touched by an intern. The parents all want the private attending to come in and draw the blood or start the IV. That's pretty funny because most of these private attendings haven't started an IV on a kid in years. People always naturally expect the more senior people to be able to do everything better than the interns. I'll tell you, at this point in the year there are very few people who are better than the interns at starting IVs, doing spinal taps, drawing blood, doing any kind of scut. But the parents still want to know why the private attending isn't coming in to do the stuff. So even though there's lots of time to sit out in the sun, I think I'd rather be in the wasteland of Jonas Bronck.

Well, there's only a little over a week to go and I'll be out of here. And then there's only one more month of internship left. That's pretty unbelievable, but I'm finding the idea of me being a resident even more unbelievable. In a little over a month there is going to be a group of poor, innocent interns who are actually going to look up to me with respect. They're even going to think they can trust me! My God, what a frightening thought!

Wednesday, May 28, 1986, 8:30
P.M
.

Well, it looks like I made it. I just came home, which means I'm done with University Hospital. The rest of my internship consists of one measly month in the NICU at West Bronx. It'll be a cinch compared with last night.

I had the feeling last night that what was going on wasn't real. I figured this had to be a setup for
Candid Camera
. But nobody told me to smile, and no short, fat, bald guy came out and shook my hand. So I think it must have been real.

I was supposed to be on with Diane Rogers, but she called in sick and there was nobody to cover for her. So the chiefs asked if I would mind working on the ward by myself. Me mind covering a ward filled with twenty-five sick kids by myself? No, no way I'd mind it. I told them I looked forward to challenges just like this, that I welcomed just this type of adversity. In fact, I even told them I'd be happy to work every night next month by myself because that's the kind of guy I am. I don't think they realized I was being cynical, because somehow at around ten o'clock last evening I found myself rounding on the ward by myself. I even yelled at myself a couple of times for not following up on some scut I was supposed to do.

Anyway, everything was going fine, mostly because there hadn't been any admissions in a couple of days and the place was really quiet, but then at about four o'clock this morning I got a call from one of the neurology attendings, who told me he was sending in a kid with a brain tumor who had been in status epilepticus for about four hours. Status for four hours! I told him fine, I welcomed these kinds of patients, that I looked forward to challenges just like this, and that I'd be waiting for him. Then I calmly hung up the phone, ran for the staircase, and started moving in a downward direction. I was getting out of there; I might be crazy, but I'm no fool.

When I hit the third-floor landing, something weird happened. I got this sudden rush of guilt and I realized I'd have to go back. So I slowly climbed back up, told the nurse what was happening, and got ready.

The kid got there at about four-thirty. He was seizing, all right, there wasn't any doubt about it. I had no trouble figuring out he was seizing; what I had trouble figuring out was what I was going to do about it. So I called the neuro attending at home, and the first thing he did was yell at me for waking him up. I was expecting that; the first thing everybody does when you call them from University Hospital is yell at you. But then I asked him what I should do, and he said, “You've got a kid who's seizing. What the hell do you think you should do?”

My neurons turned on and I waited a couple of seconds for an answer to come out of my mouth. When it finally did, it was, “Give him an anticonvulsant?” The neurologist said, “Brilliant,” so I knew I was on the right track. I said, “Should I start a line, give him some Valium, and then load him with Dilantin?” He told me that that sounded like a wonderful idea, so that's what I did. I got the line in, I pushed the Valium, and the kid suddenly stopped seizing. It was great. By six-thirty I had him stabilized, lying in bed, sleeping, which was a lot more than I can say about myself.

This was pretty amazing. I have a lot of trouble believing I was capable of working by myself for a whole night and even admitting a seriously ill patient and not making any major screw-ups. I guess now that I've got pediatrics perfected, it's time to try another field. Maybe I'll become a heavyweight boxer.

Bob

MAY 1986

 

At the beginning of the month, Amy Horowitz told the chief residents that she was pregnant and needed to arrange maternity leave. Her announcement was met with the release of an explosion of venom aimed at her by the chief residents, who weren't about to give any special treatment to Amy just because she happened to be pregnant. This reaction of the chiefs produced the release of an equal explosion of venom from Amy, who, fed up with what she viewed as the chronically poor treatment she'd received all year long, decided to call the Committee of Interns and Residents to find out exactly what she was entitled to. The situation, which was escalating, was finally defused by Mike Miller, who managed to put Amy's ire to rest, at least for the time being.

The issue of maternity leave for house officers is a relatively new one. In the 1950s, residency training programs didn't have to worry about developing specific policies regarding leaves of absence for new mothers for two reasons: First, at that time, there were very few women in medicine; and second, many programs strictly prohibited house officers of either sex from being married. Over the past thirty-five years, however, this situation has changed dramatically: Today over 50 percent of the 105 house officers who make up our program are women, and the majority of these women are married. In recent years we've averaged about five new babies born to female house officers annually. As a result, a definite plan regarding maternity leave has been developed, with the intern or resident receiving about three months away from the hospital around the time of delivery.

The development of this plan has been met with mixed reactions from the house officers, both male and female. After all, if one person is given three months off, someone else is going to have to fill in for her. An attempt is always made to spread the coverage evenly, but often a few people wind up doing what they consider more than their fair share. This leads to resentment directed toward the person on maternity leave, resentment that may stay with her through the rest of her training.

But the problems that female doctors face are certainly not limited to these issues surrounding maternity leave. Discrimination against all women in medicine is rampant. Although the foundation of this discrimination is rooted in the past, when medicine was exclusively a male profession and when house officers were referred to as “the boys in white” and specialists such as ear, nose, and throat surgeons were called “ENT men,” the image lives on in the public's mind. It lives on mainly because the medical establishment, which at this time is composed of those “boys in white” of the 1940s and 1950s who have grown up and taken charge, perpetuates the myth. And so the acceptance of women as medical equals of men is a difficult goal to attain.

It's easy to see examples of discrimination. In our emergency rooms, any male who has contact with a patient is immediately referred to as “Doctor” by the patient's parents, regardless of whether he is a doctor, a nurse, a medical student, or a clerk. Any female, no matter how senior or expert, is automatically assumed to be a nurse. At the beginning of the year, the female interns take great effort to correct the parents; they explain that they've gone to medical school, have graduated, and are just as much doctors as any man; but as time passes and it becomes clear that these explanations are doing little to change the public's conception and actually are creating hostility between doctor and patient, the women try to ignore what they consider this slight, managing just to cringe a little and swallow hard a few times when it happens.

And patients often believe that women can't do as good a job as men when it comes to the technical aspects of medicine. I've seen it a hundred times: parents refusing to let the senior resident, who happens to be a woman, draw blood, do a spinal tap, or start an IV on their child, demanding that the male doctor in the next examining room, who happens to be an intern, try the procedure first.

But the patients clearly are not the only ones who discriminate against female doctors; it's also firmly entrenched in academic bureaucracy. Thus far, few women have achieved positions of authority at medical schools in the United States. As an example, only a handful of the chairmanships of pediatric departments, the specialty with the largest percentage of practitioners who are female, are held by women. Part of this is due to the fact that until recently there weren't many senior physicians who were female, but part is definitely because qualified women are frequently not offered a job when an equally qualified male candidate is available.

Also, it becomes difficult for female doctors to deal with nurses, the majority of whom also are women. A good intern has to be aggressive, but aggressiveness is not a trait that is viewed as acceptable in women. When a male doctor orders a nurse to perform a task for his patient, it is viewed positively; he is just carrying out his responsibility. When a woman is the one who requests that a nurse do something, she is regarded as “uppity” and a troublemaker. It's a bind that is difficult for the female house officer to resolve satisfactorily.

These issues present an enormous identity problem for the female intern. On the one hand, she's not getting equal treatment from her patients or from the nurses; on the other hand, she has few or sometimes no role models to guide her in her training. Very often this second problem is more serious than the first.

Take Amy's problem as an example. Amy has done an amazingly good job. She has worked for an entire year as an intern, fulfilling all or most of her responsibilities. But at the same time, she's also had to be a mother to Sarah, trying her hardest to fulfill the responsibilities of what clearly is a second important full-time job. She's done all of this without anyone pointing the way for her; there are few faculty members around who could share their experiences as an intern and a mother with her. And although she's had some help, mainly from her husband and her baby-sitter, she's found little support within the system. The chief residents never wanted to know how sick her daughter was or what family obligations she had; they weren't even happy or excited when Amy told them that she was pregnant; they only wanted to know that she'd be at the assigned place at the assigned time and that her job would get done.

And there are very few options open to female residents with children. The attitude is basically this: If you want to have a baby and you want to spend time with your baby, you should take a year or two off; if you want to work, you should put off childbearing until after residency training is completed. A happy medium—that is, working as a house officer halftime and spending the rest of the time as a mother—is at present available at very few hospitals.

Changes are occurring, but they're occurring slowly. Eventually the young women who are house officers today will move into positions of authority, and the concept of medicine as a private club for men will gradually fade away and ultimately die out. At that time, a more realistic attitude toward women in medicine will evolve. And innovations such as shared residencies with two or more people fulfilling the responsibilities of one house officer, day-care facilities within hospitals, suitable facilities to encourage breast feeding, and fair maternity leave policies, which today are considered radical and expensive luxuries, will become commonplace. But as of now, Amy and her sisters in medicine must bear a heavy load.

Andy

JUNE 1986

Tuesday, June 24, 1986, 5:15
P.M
.

My internship ends in three days. I'm moving back to Boston on the twenty-eighth. I can't believe this is finally going to be over so soon.

This has been a tremendously long year, in some ways feeling more like three separate years than just one. The first year stretched from when we started back in June to when I finished on Adolescents' at the end of September; that first period took me from the time when I was enthusiastic and up about medicine to the point where I reached my first real depression. The second year included University Hospital and my first three months at Jonas Bronck; this was the best time for me. I was “up” for a lot of it, I managed to get myself organized, I pulled some things together for the first time, and I really began to see that the experience was eventually going to turn me into a doctor; the time I spent on the east campus was the most optimistic period for me.

The last period, which has been the most difficult, took up about the past four or five months, from the time I first walked into the PICU until now. I've gone through hell these past five months; I became emotionally wrecked, much worse than I ever thought I could. It's affected every aspect of my life, including my relationship with Karen, which I've always thought was unshakable. There was a time earlier this month when things had gotten so bad that we were seriously considering splitting up. This last period of internship has turned me into a very selfish and self-centered person. Thank God I've gotten some insight into what's been happening. I think Karen and I have patched things up pretty well now, but it was very disturbing there for a while.

The hardest period of this year happened during the last half of May. I hit the big burnout. I really didn't give a shit about anything; all I wanted was to be left alone by everybody. This lasted through the first couple of weeks of this month. At one point about two weeks ago, our attending sat me down and said, “You know, Andy, when you go to that new institution, it's going to be very important for you to make a good impression during the first couple of weeks. Everyone is going to judge you for your entire stay there on how well you do at the very beginning. So snap out of this!” He realized I was just going through the motions, and it was nice of him to talk to me about it. I've pretty much recovered from that burnout now. I don't know how, maybe it was because of what the attending said to me or maybe I just kind of woke up and realized what was happening on my own, but now I can behave myself most of the time without cursing and being moody and driving everyone crazy.

Over the past week or so I've started listening to some of the tapes I made back at the beginning of the year, and I noticed something: It seems like I remember the bad things much more vividly than I remember the good. I've forgotten a lot of the good things, the successes, the patients who have walked out of the hospital and have said, “Thank you” and have shaken my hand. Those people have been crowded out of my memory by all the ones who died or who did poorly, the ones who wound up breaking my heart.

Internship is supposed to be an important educational experience, but I'm still not sure what I've learned. One thing I've accomplished this year is I've managed to develop my own personal style as a doctor. I've turned out to be more compulsive than I thought I would be. I've gotten very efficient; I'm more able to decide what's important and what's not than I was a year ago, when I don't think I really knew how to prioritize at all. And probably a year from now, I'll look back and realize how little I know about what's important right now. I also think I somehow managed to retain my sense of humanity and my sanity among the inhumane environment of the hospital and the insanity of everything we do and the craziness of the Bronx. Thinking about it like this, I guess I really did pick up a lot this year.

But I definitely don't feel ready to be a second-year resident yet. I don't feel ready for that next step, that sudden acquisition of great responsibility where I'm the one who has to make the decisions and oversee the interns. I've gotten pretty good at doing what I've been called on to do as an intern. I have my own opinion now about how things should be done, but I don't argue much if I disagree with the residents or the attendings. They've got their jobs to do and I've got mine.

The other day we got new medical students. Brand-new, green, third-years, who've never been on a ward before. Our resident took great pains to explain carefully everything that was happening to these guys, like what a FIB is and what tests were done in a CBC. I was bored to tears.

We were all on our best behavior during rounds, but as rounds were ending, the other interns all tried to impress the students with how jaded and how cynical they had become. I stood there for a while as this discussion began and I just thought, Listen to all this bullshit! After a few minutes I couldn't take it anymore; I didn't want to be a part of this scene. So I just walked off. This kind of thing, trying to impress these poor third-year students, gets old really fast.

But I had fun with my stud
[student]
the rest of the day. I caught him in the library reading at about noon and I said, “Give me a break! What are you going to do, put on a nice clean shirt and tie every morning and spend the entire day sitting in the library reading textbooks? You're not going to get anything out of sitting in the library.” So I forced him to get up and follow me around. I showed him some of the ropes. This afternoon I asked him to write a progress note on one of the patients he picked up and he wrote one of the worst notes I've seen in my entire life. It's so funny. He had absolutely no idea what was expected of him or what was supposed to be written in the chart. It kills me because he seems to be so bright and eager to work, but he just doesn't understand how to do anything yet. So tomorrow I'm going to have to really start to teach him things from scratch. But it's so hard to try to get my mind back to where a beginning third-year student is. I just can't put myself in his place.

Friday, June 27, 1986, 8:00
P.M
.

My friend Ellen always used to talk about the need to process what was happening to all of us. She told me recently that it wasn't until the last few months of internship that she's been able at least to start to fit some of the pieces together and begin to understand what had happened inside her. I guess I've been able to do that only a tiny bit so far. I'm still standing too close to things to have any real insight. There's a lot of my internship I haven't talked about on these tapes. There have been things that were just too painful to go into; they would have been too damaging to bring up at the time, and now I've forgotten a lot of the details. But they've had their effect on me.

I'd like to think that overall this has been a good year, but I can't. It has been good in the professional sense. I was transformed from a medical student into a doctor. I've learned a great deal about patient management and how to think on my feet while half asleep. I think internship did all that extremely well. Thank you, Schweitzer Peds Department. All of you helped me make that transition.

Internship was also good in providing the battlelike atmosphere that brought me close to a bunch of strangers, my fellow interns, and very close to a few people to whom I'll forever have a bond, no matter how infrequently we communicate, no matter how physically far apart we drift. In all other respects, though, my internship was a draining, dehumanizing, destructive experience. It's almost like we started out in July smelling of cologne and perfume, and dressed in freshly laundered formal evening clothes, well-mannered and even-tempered with warmth in our hearts and great expectations, but by the end of the year we had become tattered, unshaven, smelly, cynical, snarling survivors of a long and somewhat meaningless struggle with ourselves and the rest of the world.