The Intern Blues (41 page)

I thought when it was all over, I'd have all these great, profound thoughts about internship. I've been trying to think of something profound to say all day, but I can't come up with a single thing. Internship sucks, that's all there is to it. It just flat-out sucks. But hey, it's not my problem anymore. I'm no longer part of that lower class of humanity! I'm pretty sure that if you come to me in five years and ask me if I thought my internship was a good or a bad experience, I'll probably tell you it was bad but that there were a lot of good things about it. That's what happens to people when they stop being so depraved. Right now, I can assure you there is absolutely nothing good about internship. Nothing.

Well, that's not exactly true. I've worked with a whole bunch of nice people whom I never would have come to know had I not been here. And I had a lot of good times. And I had two wonderful vacations I'll remember for the rest of my life.

See, it's been over for only five hours, and already my mind is warping. Do you think there's any hope for me?

Bob

EPILOGUE

Wednesday, February 25, 1987

About seven months ago, on a sunny Wednesday morning near the end of last June, as Amy, Andy, and Mark were beginning to celebrate the end of their year of internship, I got into my car and drove up to Peter Anderson's house in Westchester County. At about eleven o'clock that morning I found myself sitting on the grass outside Dr. Anderson's front door and asking three scared-to-death interns-to-be what most worried them. My question was met by an intense silence that lasted for what seemed like minutes. Finally, one of the new interns, a guy named Anthony D'Aquila, meekly said, “The thing I'm most worried about is the night call. I just don't think I'm going to be able to survive a whole year of being on call every third night. I can't understand how you can be up all night every third night and still be able to function the next day.”

Slowly, the other two interns joined in, agreeing with Anthony. Then one of the others, a woman named Andrea Zisman, said that she was worried about what internship would do to her social life. She told us that she'd had a steady relationship with a guy for the past three years; he was a lawyer, and she was concerned that the life-style of an intern would completely destroy this long-term relationship.

We spent about an hour talking together in that group. As the time passed and as the list of anxieties I was recording on the piece of paper in front of me grew longer, I could feel at least some of the nervousness, some of the tension, gradually die away. By the time Mike Miller finally came to call us all to lunch, I had the sense that these three had made some progress; they were ready to begin the year.

I saved the anxiety list from that morning's group and brought it home with me. I compared it with the list that Andy, Mark, and Amy had generated exactly one year before. The lists were almost identical. Not in the same order, not in the same words, but the concerns, the issues, the worries all are universal. Although Andy, Mark, and Amy have moved on, we attendings are dealing with the same problems, counseling away the same anxieties, coping with the same fears in a new group of interns.

Nineteen months have passed now since the day in June 1985 when I asked Mark, Andy, and Amy if they would like to participate in this project by keeping a diary of their internship year. Today those three interns are more than halfway through their junior residency and more than 50 percent finished with their mandatory three-year period of training. And even those three interns with whom I sat at orientation in June 1986 have only four months left until they say farewell to internship. Like the interns who came before them and like the interns who will follow them, they're at present trapped in the depths of the February depression. But I've told them to take heart. The light for them is beginning to appear at the end of the tunnel.

A lot has happened to the public's conception of internship over the past year. Various cases of suspected medical malpractice caused in at least some small part by the fact that unsupervised, overtired, and overwhelmed interns had allegedly made errors in judgment at critical junctures in the management of patients have received a great deal of publicity. The effect of this media attention has been that the lay public's eyes finally have been forced open to the fact that young doctors are often required to work over a hundred hours a week in a system that's antiquated, unnatural, and unhealthy for both the patients and the physicians themselves.

The state of New York has looked into the issue of internship training. The New York State legislature has proposed placing limits on the number of hours a house officer is allowed to work. There are two mechanisms for doing this that are currently being studied. The first of these limits the total number of hours a house officer can work in a single week to eighty; the second limits the number of hours that a physician can work in a single day to twenty-four.

Limiting the number of hours that can be worked in a single day to twenty-four would mean that interns would never again have to work thirty-six-hour shifts; overnight call would be illegal. However, because the wards and emergency rooms have to be staffed twenty-four hours a day, additional house officers would have to be hired. Although the state of New York has announced that funds for these new physicians would be forthcoming, there is a real question whether adequate numbers of medical school graduates could be found to fill these new slots. If sufficient personnel could not be recruited, the new regulations would ensure that interns would wind up working six or possibly even seven days a week. In discussing this possibility with our house officers, almost all state that they would much rather work thirty-six hours at a stretch knowing that they'll have a day off rather than work shorter hours without a day away from the hospital.

But limiting the number of hours an intern can work to eighty a week seems like a viable option. This would essentially outlaw the every-third-night call schedule, replacing it with a more human every-fourth-night scheme.

These reforms are long overdue. But the changes will take time to establish and to institute. So for the time being, at least, internship and residency proceed as they always have.

 

 

Early on the morning of June 29, 1986,
I drove to the Bronx and stood out in a drizzle as two enormous guys loaded all of Andy Baron's possessions into an Avis rental truck. Andy, Karen, and I stood out there during the hour it took to get everything loaded, getting soaked by the rain. We didn't say much to each other. I knew there were a lot of things going on inside Andy's head, but apparently he didn't want to let either Karen or me in on them. So we just stood there, getting wetter, and silently watched Andy's furniture disappear into the truck.

The two guys were finished by about ten. Andy paid them, and then he and Karen got ready to climb into the truck. Before he got behind the wheel, I put out my hand. Still in silence, Andy came toward me and gave me a bear hug. After a few seconds he released his grip, turned, and climbed into the cab of the truck. A minute later I watched as the truck disappeared down Gun Hill Road, heading east toward the entrance to I-95 and his junior residency at Children's Hospital in Boston.

I've kept up with Andy since that day, speaking with him and Karen by phone a couple of times a month. In some ways, this year has been like a second internship for Andy: He's had to prove himself all over again, he's had to make a whole new group of friends and learn the ins and outs of an entirely new system. Everything about his new program is different from Schweitzer: The patients are mostly private and are referred to the hospital because of the special expertise of members of the faculty. The diseases they have are, for the most part, less common. (“We've got zebras here,” Andy told me. “No horses, just zebras.”) And the ancillary services are worlds better than ours. It took some period of adjustment, but now Andy is feeling comfortable. Before he left, he had some concern that he would be ill-equipped to work at Children's, that his knowledge and skills after a year of training here in the Bronx would leave him wanting when compared with those of the house officers in Boston. He's told me that that fear has turned out to be unfounded. He feels that he knows as much as if not more than the other junior residents in the program.

Recently, most of Andy's thoughts have been taken up with the future. Specifically, he can't figure out what the hell he's going to do after he finishes his senior year. He's jumped from wanting more than anything to get some subspecialty training so he can know a great deal about one particular area of medicine that very few other people know about, to wanting to be a good primary-care pediatrician, serving the needs of a large number of children and their families. In our most recent conversations, Andy's been leaning back toward specializing. His current favorite area is nephrology. Maybe someday he'll come back to Schweitzer to take care of all the kids at the University Hospital with chronic renal failure.

While in deep sleep during the early-morning hours of Wednesday, November 12, 1986, after nearly two weeks of maternity leave, Amy Horowitz spontaneously ruptured her amniotic membranes and immediately went into labor. Larry, awakened by the rush of warm amniotic fluid that engulfed the bed, immediately jumped up and started to get dressed. They briskly walked the two blocks from their apartment to University Hospital, stopping a few times along the way when the contractions came. Amy was admitted to the labor and delivery suite in active labor. She delivered her second child, a perfectly formed, beautiful boy, just before eight o'clock in the morning. Amy and her son, who was named Eric, stayed in the hospital for three days and were then discharged to home, to spend the next six weeks together until Amy had to return to work.

I spoke with Amy last week. She told me that she can't believe how quiet and well-behaved Eric is. Apparently he never fusses, he rarely cries, and he demands almost no attention. A typical second child! Amy also told me that Sarah loves her baby brother and wants to help with his care whenever possible. “Her biggest goal in life right now is to carry the baby around,” Amy said. “But since she weighs about twenty-five pounds and Eric already weighs about twelve pounds, it doesn't look like that's ever going to be possible.”

Since her return from maternity leave, Amy has worked very hard and seems to have a serious, no-nonsense attitude about her responsibilities. And her reputation has changed with this apparent change in attitude. I was talking with Eric Keyes and Enid Bolger, two of the chief residents, about Amy last week. Amy was in the emergency room and had just called up to tell them about an adolescent with DKA
[diabetic ketoacidosis]
whom she apparently had managed superbly. Enid said, “I never worry when Amy's down in the emergency room. She's got a good sense about things. She knows what to do, and when she's in the ER, I know I don't have to worry.” Amy's becoming a mother for the second time has apparently caused her to do a great deal of growing.

And what of Mark Greenberg? Of all the people in the internship group, he's probably the one least changed by his transition to junior residency. He's still making everybody laugh. But he has become a leader, which is what a good resident needs to be.

There is another thing that has changed in Mark's life. In July, a few of the house officers were invited to Mike Miller's summer house on Candlewood Lake in Connecticut. Because of Mark's childhood friendship with Mike, he and Carole were invited to come. In the afternoon, Carole and Mark got into Mike's rowboat and rowed out into the middle of the lake. When they stopped, Mark reached into his pocket and pulled out a jewelry box. From the box, he produced a ring. And then he asked Carole to marry him. Old cynical Mark, proposing marriage in probably the most romantic way possible. Carole accepted the ring. They plan to be married this coming summer.

What is there left to say? My own internship was the hardest, most devastating year of my life. It's been eight and a half years since I finished that year, and some of the pain, the anger, the exhaustion, and the anguish is still with me. I don't think my experience, or the experiences of Andy, Amy, and Mark, are unique. Everybody who lives through an internship is forever changed by the experience. The intern learns about medicine and the human body; he or she truly becomes a physician. But in the process, through the wearing down of the intern's spirit, that person also loses something he or she has carried, some innocence, some humanness, some fundamental respect. The question is, Is it all worth it?

Afterword

January, 2001

“Is it all worth it?” A little less than fifteen years have passed since I wrote those words ending the manuscript of
The Intern Blues
. Even though by that time nearly a year had passed since Andy, Mark, and Amy had finished their internships, each was still engrossed in residency training; the experience was still too close, both temporally and emotionally, for them to be able to offer a valid response to my question. But now, with the perspective of time, of more than ten years since the completion of their training, they should be able to look back and offer some insight. So, when my friends at HarperCollins informed me that they wanted to put out a new edition of
The Intern Blues
, I began to search for the three ex-interns. In addition to getting an answer to the question I'd posed a decade and a half ago, I wanted to see what had happened in their lives since then.

 

Near the end of the epilogue
to
The Intern Blues
, I stood in the rain, watching the truck Andy Baron had rented disappear down Gun Hill Road. With Andy driving and his girlfriend, Karen, sitting in the truck's passenger seat, they were hauling Andy's stuff from his apartment in the Bronx to their new place near Children's Hospital in Boston, the facility at which Andy would soon begin his junior residency year. Although I did keep in contact with Andy via periodic telephone calls for the first year or so, we lost contact soon after and had not spoken since.

Finding Andy was quite easy: I simply searched for him on yahoo.com. Typing his name into the search engine, I immediately found him listed among the faculty of the Division of Neonatology on the website of the Department of Pediatrics at Boston University School of Medicine. After calling the main office, I was given the number of the Neonatal Intensive Care Unit at Wellesley Medical Center, a community hospital affiliated with Boston University, in which—at least according to the secretary—Andy worked. I dialed the number, and within a minute, he was on the line. To say the least, Andy was surprised to hear from me.

We spent a few minutes catching up. After driving that truck down Gun Hill Road, Andy got on I-95 North and headed for Boston, where, as expected, he spent two years completing his residency at Boston Children's. Then, feeling wiped after the long, arduous process of residency training, he took a job working in a local pediatric practice, seeing patients three days a week. “After my residency, I felt . . . I don't know . . . ‘used up' is probably the best way to describe it,” he told me. “I needed to replenish myself. I didn't have any direction, I didn't really have a plan about what I wanted to do with the rest of my life. I knew I didn't want to do general pediatrics forever, but the job gave me a chance to clear my head and think about the future.”

Andy got married during this period—to Karen, who was then doing her residency training in psychiatry—and they remain married (“happily married” in Andy's words) to this day.

The general pediatric practice eventually grew to bore Andy. He worked there for a total of two years, then took another part-time job, this one doing shift work as a hospitalist
[essentially a glorified resident]
in a neonatal intensive care unit. “I always liked working in the NICU,” he told me. “There was always something exciting going on. I even liked it during residency, but back then it was mostly unpleasant because of the hours they forced us to put in. But when you're working shifts, you can decide how much you want to work and how much you want to screw around. I played with my schedule until I had what I thought was the perfect mix.”

Andy liked working in the NICU so much (and was so good at it) that he decided to obtain formal training in the specialty, a step that would ultimately allow him to become a board-certified neonatologist. So four years after completing his residency, he returned to Boston Children's as a neonatal fellow. “Those were three pretty grueling years,” he explained. “Each of my fellowship years was easily as hard as internship.”

Following completion of his fellowship, Andy passed the boards in neonatology and took the job he currently holds, director of the nursery at Wellesley Medical Center. “It's a small unit. We have only eight beds. Most of the time it's manageable. But on those days when we're really busy, it's hard to get out of here at night.” He also continues to work only half-time, splitting coverage with two other part-time neonatologists. “When Karen and I first started thinking about having kids, we decided we didn't want them to be cared for by nannies or grandparents or anyone other than ourselves. So we agreed that we'd each work part-time and spend the rest of the time caring for the kids.” The Barons have two boys, currently seven and three years old. “It's worked out really well for us. Don't get me wrong, it hasn't always been easy. We've had to make some sacrifices. Believe me, we could be making a lot more money if we both worked full-time. But we're comfortable, and how much money do we need? This way, Karen and I both have lives. I have time to paint and draw, things I used to love to do during high school and college but never had time for once I started medical school. And I'm able to watch my kids grow up. That's worth a lot more to me than having a ton of money.”

I asked Andy to look back and consider what effect his internship had on him. He thought about the question for a while before answering. “You change so much during your training,” he replied. “You see such awful stuff, it has to have a permanent effect on the way you look at the world. But you change a lot as you get older, anyway, whether you do an internship or not. So I don't think I can blame internship or residency for any big epiphany that occurred to me.

“The biggest change in my life happened when my first son was born,” he added. “Having kids definitely changes you; they change your perspective on patients, on their families, everything. I began to talk to my patients' parents a lot differently after having my own child. I had a better understanding of what was important to them, and what wasn't so important. Having a child definitely had more of an effect on how I deal with patients than anything that happened during my internship.”

And was it all worth it? Again, Andy considered the question for a few seconds before answering. “I'd say yes,” he finally replied. “I like what I do; I like being a neonatologist, and being able to set my hours and live the kind of life I live. None of this would have been possible had I not done an internship. There might be better ways of doing it, better methods of training young doctors, but all in all, it was a means to an end. I made it through and here I am. But there's another question you should ask me, Bob.”

“What's that?”

“Would I want my sons to become doctors?”

“Well, would you?”

“No. But it has nothing to do with my training. It has to do with insurance. The insurance industry has made medicine completely crazy. If you had told me when I was an intern about what I'd wind up having to do to get insurance companies to pay for what I think my patients need, I'd have told you that you were nuts. HMOs and the rest of the insurance industry have made the practice of medicine horrible, and I wouldn't want my boys to have to go through this.”

We talked for a little while longer, but Andy had to get back to work. I wished him well, told him to give Karen and his kids a kiss for me, and we hung up.

 

 

Mark Greenberg was a little harder to locate:
In contrast to Andy, he does not have a presence on the Internet. In order to find him, I sniffed around our department's alumni records and came upon a letter of recommendation written by Peter Anderson (our chairman and the man whose lawn was the site of the original meeting between Andy, Mark, Amy, and me) and addressed to a hospital in central New Jersey to which Mark had applied for admitting privileges. Calling information in that town, I was given Mark's office number. I hesitated before dialing the number.

I hesitated because Mark and I had not parted on exactly the best of terms. It took me more than a year to transcribe and edit the audio-diaries of the three interns that formed the basis of
The Intern Blues
. As I completed that work, I sent each of the by-then senior residents a copy of his or her transcript. A few days after sending his out, I got a call from Mark. “You can't publish this crap,” he yelled at me over the phone. “I never said any of this stuff.”

“What stuff are you talking about?” I asked, a little surprised by his reaction.

“All this stuff,” Mark continued yelling. “Almost everything you have coming out of my mouth. Like here, during February, when I was in the NICU. You wrote, ‘And then we walked around and he showed us these so-called patients. My God, those things weren't patients; they couldn't have been human; they weren't anything more than small pockets of pus and protoplasm! These things would have to quadruple their weight in order to be classified as patients. Right now, they're nothing more than tiny portions of buzzard food.' Bob, I never would have referred to preemies as ‘small packets of pus and protoplasm' or ‘tiny portions of buzzard food!' ”

“You don't remember saying those thing?” I asked, surprised.

“I never said them!” he answered. “How could I remember saying them if I never said them?”

“You don't remember your internship very well, do you Mark?”

“I remember it fine,” he replied. “I agree that things were rough for most of the year. But no matter how bad things got, I always showed respect for my patients. I'm sure of that.”

“Mark, I hate to burst your bubble, but not only did you say those things, I've got you saying them on tape. Would you like me to play them back to you?”

“You can't have them on tape, because I never said them,” he reiterated, more angry this time. “If you have someone saying that stuff on tape, then it must have been one of the other interns, because it couldn't have possibly been me.”

We argued on like that for a while. Finally, I agreed to let Mark “fix” at least some of what he believed was wrong with his portion of the book. I used his edited transcript to revise the final manuscript, but he still wasn't happy with the finished product. In the final eighteen months of his training, that unhappiness colored our relationship. So I was less than sure that Mark would react positively to my voice on the phone.

I called his office at about eleven o'clock on a Monday morning in late January, and when he picked up the phone, I was afraid my worst fears would be realized. “I can't talk now,” he said bluntly when I told him who it was and why I was calling. “It's crazy here. Can I call you back sometime after our office closes?” I gave Mark my home number, never expecting to hear from him again.

But I was wrong; he called me that night. “Sorry about not being able to talk with you earlier in the day, but it's been really nuts,” he explained, sounding neither angry nor put-out. “It's flu season here in beautiful New Jersey, and it appears as if everyone with a pulse and a respiratory rate is sick. I was on call this weekend, and I saw seventy patients on Saturday and fifty more on Sunday. A hundred and twenty patients in one weekend! By myself! Can you believe that? It's a new office record. In recognition, I'm planning on having the shoes I was wearing bronzed so we can display them in our practice's trophy case. So, sorry I blew you off this morning, but I think it'll work out better this way.”

“I thought you were still pissed off about the way you were portrayed in the book,” I said.

“Was I pissed off about that?” he asked. “I don't remember. I really don't remember much about my residency. Except that I hated it as much as anybody can hate anything, and that I'd never want to do it again. Outside of that, I don't remember the people, the places, the patients, or much of anything else.”

“You don't remember making me rewrite your sections?” I asked.

“The only thing I remember about it is I was afraid people would recognize me and give me a hard time. Remember, I had to go out and look for a job. I thought people in practice were all going to know I was Mark Greenberg in
The Intern Blues
, and who would want to hire someone who talked about patients the way that guy did? As it turned out, it wasn't an issue; I don't think anyone had even heard of the book. Looking back, I might have been a little crazy at the time.”

I silently agreed. “So what have you been doing since the late eighties?” I asked.

“Well, as soon as I finished residency, I started working at this practice,” he replied. “I joined in July of 1988, and I've been working here ever since. I've been here for nearly thirteen years, I've been a partner for ten, and I only have eleven more years until I retire.”

“Until you retire?” I repeated. “You've thought about when you're going to retire?”

“Sure I know when I'm going to retire. I plan everything. When I started here, I told them I was going to work until I turned 55. The group was fine with that; they all agree with it.”

“Why 55?” I asked.

“You've obviously never been in practice,” he replied. “You can't do this kind of work forever. Did you hear what I said before? I saw one hundred and twenty patients over the weekend. One hundred and twenty! By myself! And that doesn't count doing rounds at the hospital and speaking on the phone to the mother of every one of our patients who didn't come into the office. You can't do all that—the hospital, the office visits, the phone calls night and day—when you're 60 years old. Pediatric practice is for young people. And so I'm going to stop when I turn 55.”