The Intern Blues (7 page)

So Elizabeth told her he couldn't leave yet, that tests were still pending and that, for the sake of the child's health, he'd have to stay at least one more night. Then the mother started yelling that if her baby was fine, the only thing that could happen to him in the hospital is that he could get sick, which was actually a good point, and she picked the kid up and started moving toward the elevator.

At that point, we all moved in. Someone called security stat
[immediately],
and within a minute a phalanx of Mount Scopus's finest emerged from the elevator bank and we had a standoff. The mother held on to the kid tight and shouted, “I don't want my baby in this fucking hospital!” at the top of her lungs, which went a long way to put most of the other parents on the floor at ease. Next she yelled, “I know what's best for my own fucking kid! If he's fine, I'm taking him home! Just try to stop me!”

Attendings, house staff, administrators, and more security guards started to show up. The mother and her boyfriend got madder and madder. The boyfriend finally said, “We're taking the kid out of here! If you don't like it, you might as well shoot us in the back, 'cause we're going!” The kid was screaming at the top of his lungs while this was going on.

The whole thing lasted about a half hour. It ended when an administrator, obviously someone who had majored in psychology and guerrilla warfare in administrator school, showed up and firmly told them that maybe they'd like to talk the whole thing over in the conference room. For some reason, the mother agreed and she, the baby, and the boyfriend headed off with him. I think our suspicions about the parents were correct. The BCW
[Bureau of Child Welfare, the state agency charged with investigating child abuse]
probably will be interested in doing an investigation.

I've nodded off to sleep three times while recording this. I think it's time to stop.

Wednesday, July 17, 1985

I'm a little more coherent tonight, I think. Nothing much is happening. Elizabeth's patient whose parents tried to kidnap him got sent home by Social Service last Friday. In their infinite wisdom, they cleared the family in two days. I've got a bad feeling about this family. I hope I'm wrong.

My patient with nephrotic syndrome is doing much better. Most of the swelling is gone, and he doesn't look so much like Buddha anymore. Those steroids are amazing! We're going to send him home in a few days; renal will follow him as an out-patient. They say his prognosis is excellent. The mother asked me if all this means he's not allergic to trees. I told her I thought it probably would be a good idea not to go back to that LMD anymore.

Last night was pretty easy. I got four hours of sleep, and that's been pretty much the pattern on Children's. I guess I did kind of luck out when they switched me from 6A. Those guys have been getting killed. As far as I know, none of them have gotten any sleep on any night they've been on call.

Wednesday, July 24, 1985

I'm about ready to die. I thought I was bad that night earlier in the month when I was up all night, but this is ten times worse. I haven't gotten any sleep for the past two nights, and I'm pretty worried about my grandmother.

I haven't mentioned my grandmother yet. She's my mother's mother. She's over eighty and she lives in New Rochelle by herself. I try to get over to her apartment for dinner at least once a week, usually on Tuesdays, if I'm not on call or too tired. I went last night and I found out she was really sick.

She's got a bad cellulitis on her leg. She cut herself with a knife about a week ago. When I showed up yesterday, she was febrile and looked terrible; she could barely get out of bed. She showed me the cut; it was all red and swollen with lots of pus. Her temperature was 102.5, and I told her she had to go to the hospital for IV antibiotics. She said I was crazy. She's a little on the stoic side. I argued with her for about an hour and finally convinced her to let me take her to the Mt. Scopus ER to at least get a third opinion. I got her seen without any wait. A medical intern looked at her and said, “You've got to come into the hospital for IV antibiotics.” She started to tell him he was crazy, but I guess maybe she really wasn't feeling so well because she finally said, “All right.”

She's on one of the medical floors. They put in an IV and started her on megadoses of pen and naf
[penicillin and nafcillin, two antibiotics]
. They didn't get her settled until after two in the morning. I stayed with her until six and then went home to change my clothes and take a shower. I might as well just move my stuff over to the hospital. As it is, at this point I'm only just occasionally visiting my apartment.

Anyway, I don't know how I got through work today. I've got seven patients, and I don't remember what happened to any of them. I was like in outer space for most of the day. My mother showed up this afternoon to stay with my grandmother, and I came home. I'm going to sleep now. I remember sleep; I think it's something that feels really good.

Friday, July 26, 1985

The past few days have been nothing but a blur. I was on last night and I managed to get some important sleep. My grandmother's much better; they're probably going to send her home over the weekend. And my time on Children's is coming to an end. Of course, I'm on the last day of the month. You can almost set your calendar by my on-call schedule. And then on Monday, I start on Infants'. I have the feeling the shit's about to hit the proverbial fan. Infants' is a bitch!

The only good thing about all this is that I know I'm not going to be on the first night. The chiefs may have decided they don't like me for some reason, but they're not crazy. They couldn't make me work two nights in a row. But actually, since I'm on Tuesday, I get a weekend off next week. Weekends off, I remember those; that's when you get to visit your apartment for two whole days.

Bob

JULY 1985

 

You might wonder how these three interns wound up coming to our little corner of the world. It is not fate or destiny that brought them here, but rather the bizarre intern mating ritual known as “the Match.”

All of medical school—in fact all of life—is nothing but preparation for the Match. It's the first of many horrendous and inhuman experiences to which house officers are exposed. In other professions, a person who wants a particular job submits an application and a résumé; the person goes on interviews, trying to convince the employer that he or she is right for the job; if the job is offered, the person has the right to accept it and begin work, or to reject it. But this system, good enough for American business, apparently is too simple for medical residency training. After all, there's no torture involved.

The search for the perfect internship begins early in the summer before the medical student's fourth and final year of school. The student interested in pediatrics or internal medicine fills out as many as twenty applications for residency programs. He or she then spends a month interviewing at hospitals around the country, asking numerous questions of the house staff and attendings, trying to get a feel for the place. After narrowing the field down to a few top choices, the senior arranges to do “high profile” rotations at these hospitals. These rotations, often a subinternship in an ICU setting, give the student the opportunity to work himself or herself sick, taking call every third night, in hopes that somehow the director of the program will notice and think highly of him or her and possibly place the person near the top of the match list. But I'm getting ahead of myself.

Here in the Bronx, a committee of pediatric faculty members is attempting to select an outstanding group of interns from a pool of hundreds of applicants. For our entering group of thirty-five, more than 225 senior medical students were interviewed in the fall of 1984. This interviewed group was ranked from one to 225 on the basis of grades, letters of recommendation, the impression made during the applicant's interview, and performance during these elective rotations spent at one of our hospitals.

The fun of the Match actually begins in January. Each applicant sends off a list of programs to which he or she has applied, ranked from first choice to last, to the National Intern and Resident Matching Program (NIRMP) in Illinois. Simultaneously, the director of each program submits a list ranking all senior students who have applied for a position. All this information is fed into a computer and the machine grinds out the Match, coupling applicants and programs. One might think that this chapter of the matching procedure would end with a friendly letter mailed from NIRMP and received anonymously and privately in a mailbox some days later. But no; nothing in an intern's life is that simple!

The results of the computer's work are stored in a vault and released in the middle of March. The senior students from each school are assembled in a centralized location, one usually designed to maximize feelings of anxiety and hopelessness, and the envelopes are distributed one by one by the person, usually a dean of the medical school, charged with guarding the secrecy of the Match. A name is called, the student rises and slowly approaches the front of the room; the envelope is handed over, it's cautiously opened, and the student either sighs a sigh of great relief because his dream has actually come true, he's matched at his first choice program and as a result his future is assured, or he lapses into an immediate and frightening anxiety attack, often complete with hyperventilation, because he's gotten his third, or fourth, or, God forbid, fifth choice and is going to have to work at a hospital with a bad reputation or, worse yet, at a place that's considered “anti-academic” and no matter how hard he works in his internship, his residency, or his fellowship, he truly believes that he will never be able to become a true success.

Those anxiety attacks are fueled by a fact known to all subscribers of the Match. Unlike normal job offers, the Match assignments are binding. Unless there are major extenuating circumstances, there's no chance of changing once an assignment to a hospital has been made.

Why fourth-year medical students put up with this system has something to do with the whole mentality that supports internship. “It's the way it's always been done,” “it's accepted,” “there's nothing we can do about it,” are the usual responses when the question of why it continues to be done this way is raised.

Well, that explains how the interns got into our program. I probably should next explain a little about the composition of our program.

The Schweitzer School of Medicine's pediatric training program is made up of two campuses. The one that's presently referred to as “the east campus” is composed of two hospitals: Jonas Bronck, a part of New York City's municipal hospital chain that provides primary care to the poor and not-so-poor of the northern reaches of the South Bronx; and University Hospital, a voluntary facility that mainly acts as a tertiary-care center for patients referred for consultation to the school's subspecialists by private physicians in the North Bronx and in lower Westchester County. University Hospital is located about a half mile south of Jonas Bronck.

“The west campus” is also made up of two hospitals: the Mount Scopus Medical Center, a huge voluntary hospital that, like University Hospital, serves as a base for subspecialists; and the West Bronx Hospital, sometimes referred to as WBH, another municipal facility that, like Jonas Bronck, provides all medical services for the indigent families of the western region of the borough. Mount Scopus and West Bronx are literally attached to each other. Although the Mount Scopus–WBH complex is immense, filling four square city blocks, the pediatric services in the two hospitals are adjacent to each other and conveniently connected by a bridge. The east and west campus hospitals are separated from each other by about five miles.

The program, with over a hundred house officers, 120 full-time faculty members, four chief residents, and over two hundred inpatient beds spread over the four hospitals, is one of the largest pediatric training programs in the country. Our interns rotate through three emergency rooms, six primary-care clinics, seven general pediatric wards, two pediatric intensive-care units, three neonatal intensive-care units, and three well-baby nurseries. If you're confused reading this, just think what it must be like for the interns who have to become familiar and comfortable with the nursing staffs, ancillary services, medical forms, and peculiar habits of the laboratory personnel in all these different hospitals before they can even think about taking care of patients.

So the question naturally must be asked, why would anyone electively want even to attempt to deal with all this? Internship is difficult enough, what with the long hours and the frequently depressing subject matter; what would possibly motivate someone to want to come to our program, where the difficulty seems to be compounded by the massive size and complexity of the place? Well, probably the main reason medical students want to train at the Schweitzer program is because of the amazing variety of experiences to which they will ultimately be exposed. Our residents see asthma and pneumonia, ear infections and lead poisoning, the mundane, “bread and butter” of pediatrics at West Bronx and Jonas Bronck, the municipal hospitals; but they also see the congenital heart disease and the renal transplant patients, the craniofacial cases and the weird metabolic diseases, all of the rarer medical and surgical problem patients who wind up being referred to Mount Scopus and University Hospital, the voluntary hospitals in which the subspecialists lurk. So when a resident finishes three years in the Bronx, it can safely be said that he or she will have seen every kind of pediatric patient who exists. Our graduates know that nothing will ever surprise them; they'll have had experience with anything that might darken the threshold of their medical offices.

That's why Mark Greenberg came to the Bronx. He told me he wanted to get as much experience with as many types of patients as possible during his training. After meeting him for the first time at orientation, I got to know Mark a little better this month. He told me he had chosen pediatrics because it was the third-year clerkship he had enjoyed the most. He had liked it for the same reason most people are attracted to the specialty: He said it seemed to make more sense to watch sick children get well than it did to watch sick adults get sicker and die.

Mark told me his biggest problem with being an intern is that his brain is always tending toward entropy. Unless he tries very hard to keep his life controlled, he becomes exceedingly disorganized. Disorganized is not a great way to be during internship. All interns share a common short-term goal in life: to get out of the hospital as soon as possible. One must be very organized to accomplish that. If Mark continues to be disorganized, he might have to consider permanently moving into an on-call room.

There's something about Mark I noticed very early in the month. It's a funny thing: There are some people who look great after a night on call. No matter how many admissions come in and how little sleep they get, these people look unbelievably good the next day. Mark is definitely not one of these people. He had a couple of bad nights during July, and this was readily apparent in his appearance the next morning: His eyes were very droopy; his reddish-blond hair was uncombed and shot straight up in the air in all directions; and his clothes looked as if they'd been slept in, which obviously was not the case because Mark always claimed that he hadn't gotten any sleep at all.

Amy Horowitz didn't really decide to come to Schweitzer; she decided to stay here. She had been a medical student in the Bronx and had stayed on because she liked the program and felt comfortable with the people. She's always lived in the New York metropolitan area. Born in Morristown, New Jersey, she was her parents' only child. Her father owns an office supply business.

I've known Amy for a little over a year. In March, when she was in the ninth month of pregnancy, she told me that she'd thought a lot about being an intern and having a young baby but was somewhat concerned that she wouldn't have time to be both a good intern and a good mother. But she's convinced she can do it. It's because of this conflict that Amy's the one intern in the entire incoming group about whom I'm truly worried.

Early in the month, a crisis developed involving Amy. While working in the emergency room at Jonas Bronck, she was told by one of the attendings to get some blood tests on a patient. Amy swears that she drew the blood and sent it off to the lab. The attending, in checking on the situation a little later, could find no evidence that the lab had received the specimen or even that the blood had been drawn. He confronted Amy and, when she affirmed that she had done what was requested, he accused her of lying.

Whether this is true or not, lying about lab results is about the worst sin a house officer can commit. The implications are far-reaching. First, although our department is immense, word of mouth travels like wildfire, and within three days of this incident, rumors about Amy had already reached every member of the outpatient faculty. Second, and more importantly, whether she was guilty or not, Amy has lost a great deal of credibility. Interns have to be trusted. Although life-and-death decisions are always made by more senior physicians, such as attendings or chief residents, interns must be expected to function fairly independently with only occasional supervision when it comes to performing the more mundane, everyday types of activities, such as drawing blood, checking lab results, ordering tests, or making appointments for their patients. Amy's ability to function independently has been called into question. Whether she drew that blood or not, Amy probably will have an attending or senior resident perched over her shoulder at all times to make sure she does what she's supposed to do, at least for the immediate future. Amy is smart and a reasonably good worker, and within a month or so she'll probably make everyone forget that this happened. But if she screws up just one time, she's going to get nailed. And that could be it for her for the rest of this year.

I'm pretty sure Andy Baron doesn't want to be in the Bronx. I think he was one of those people who had a major anxiety attack when he opened his Match envelope last March and found out he was coming here. I don't think he objected because of our program. It's just that he never thought he would actually have to leave Boston.

Except for college at Princeton, Andy's spent his whole life around the Boston area. He returned to that city after college, attended medical school at Tufts University, and vowed that he'd never leave again. He told me he ranked Boston Children's Hospital first on his list, and he'd been led to believe that getting in there wouldn't be a problem. So you might say he was more than a little surprised when he found out he hadn't matched there.

I think leaving Boston will have a major impact on Andy. Back home he had a very structured and broad-based support network. His family and friends are there, and, most importantly, so is Karen.

Karen Knight is the woman Andy's lived with for the past year. Karen is a fourth-year medical student at Tufts; she's going to have to spend a good portion of the year there. Andy has told me repeatedly that their relationship is strong, that it had lasted through a lot of adversity in the past, and that he feels it will easily be able to weather this year of separation. It sounds almost as if he were willing it to be that way.

And what was waiting for Andy here in New York? Almost nothing; there are a few friends who attended college with him, but nobody close who would understand or be there when things start getting rough. Internship is hard enough when you have a lot of love and support to help you through; it's nearly impossible when you have to go it alone.