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Monthly Archives: July 2010

After years of paper-based standardized testing, I thought I was finally done filling in bubbles with number 2 pencils. Little did I know that all of those tests were merely preparation for my internship, small immunizing doses against the anaphylactoid response generated by the never ending to-do list of a medical intern. To my chagrin, I have been wasting precious calories by drawing boxes, inefficient four-sided monstrosities that not only expend extra ink but also milliseconds in the construction of perfect ninety-degree angles. These boxes are inevitably lopsided and injurious to my compulsive soul. I have resolved to adopt the circle as my new indicator for a task to be accomplished, a practice used by my wife, a pediatrics resident, who introduced me to the term “bubble jockey.”

I am a bubble jockey. My life is occupied by my 15-hour work days which are in turn dictated by a single sheet of paper covered with little black macules. The driving force of each day is the quest to fill in each of those circles by closing time. Closing time, however, is determined less by work-hour restrictions than it is by those circles and all the forces that conspire to prevent their fulfillment: nurses abusing pager availability to send nonsensical messages (or punt their work to the physician teams), ancillary health workers failing to do their jobs (like take vital signs or draw blood for tests), computers going into status bluescreenaticus, family members demanding explanations and updates, and the diseases of patients not responding as one would expect to the standard of care. Of these, one would hope in an ideal world that only the last one or two would occupy the time of physicians who are tasked to think of solutions to problems rather than perform time-wasting scutwork.

Unfortunately, the numbers of circles to fill does not always correspond with the acuity, severity, and worrisomeness of illness. In these first two weeks of my internship, I have found myself spending more time dealing with pain control and comfort complaints than sleuthing the cause of an unexplained hemolytic anemia or renal failure. Sometimes the least sick patients are the ones with the most energy and less prefrontal cortical activity: they complain and fuss, whereas the newly but dangerously sick patients are more stoic. I find myself using the phrase “If you feel something is wrong, call your nurse and have them notify me” much more sparingly and only for the patients who are less likely to call for help in the face of a medically worsening condition.

Sometimes I find myself hating my job, and sometimes I find myself loving it. I hate that my ability to concentrate is shaken by pager-induced arrhythmias. I hate that the task list for interns explodes like the most horrendous case of bullous pemphigus on rounds, and I find myself constantly relying on others to get the work of patient care done despite my usual tendency toward extreme self-reliance. I hate that I spend more time dealing with the annoyances of cross-covering the demanding patients of my co-interns (patients with whom I have developed less rapport) than I do treating and connecting with my own patients. And I hate that I feel bitter and my performance feels slack after leaving work around 9 PM for three days straight (while others on the team are refreshed and sharp). Then again, I love finally being THE doctor for my patients: “Are you the doctor? Yes, I am your doctor.” I love, with the right amount of apprehension and fear, the challenge of making real decisions about patient care: the decision to transfuse, the choice and dose of antihypertensive medication, and even the decision to treat or not treat. I love that, despite all of my inadequacies and skill deficiencies, I have at least one shining talent: the ability to develop a strong rapport with my patients and their families. And I love being able to teach medical students: to model the interns who were great teachers and good coaches to me, and to avoid the mistakes of those who were failures.

Two weeks down, forty-six more weeks and several thousand more bubbles to go. I look forward to the day that practicing medicine is less task-oriented and more reliant on cognition and intelligence than tenacity and stamina.

One week down, forty-seven more weeks to go. In the past seven days, I have worked 90.5 hours, admitted nine patients, and provided cross-coverage for many more for my team and others. These numbers are not meant to impress: there are many others who have worked longer and cared for more patients. I am very much of the sentiment that there is no need for one-upsmanship or overzealousness: there is no shame in sleeping on your call night, not capping your admission quota, or needing that third cup of coffee.

The intern year has begun and has already left me weary, frustrated, and at times outright enraged. Perhaps most frustrating has been my reflection on my own performance: abysmal, by my prior standards. Starting this year is quite reminiscent of my early days as a third year medical student: inefficient, inexperienced, easily fatigued, and baffled by the idiosyncrasies of this hospital system. Even though my fourth year respite from clinical duty was much shorter than that of many of my classmates, my last true wards rotation was back in September, and my factual recall is despairingly rusty. I have one pristine skill – my ability to develop a strong rapport with my patients – which remains largely intact and has helped provide me with one anchor against the constantly raging storm.

My first day of work was an overnight call day. My job was to admit patients from 6 PM to 6 AM. Typically, the overnight intern gets to sleep during the afternoon when the workflow has diminished, but last Friday was about as quiet as the day the Red Sox advanced to the World Series. I capped within the first hour I was on call and was also cross-covering for other teams at the time. Owing to an unexpected page about an angry mother who wanted her daughter (cared for by another team) out of the hospital that night, I wasn’t able to get anything done in the first hour, and I had little sense for how to approach the numerous tasks I needed to accomplish to admit a patient. Despite several quick and clear explanations from my resident earlier in the day, it was nearly impossible for me to retain any detail without actually going through each step (which my co-intern had the opportunity to do). By the time I was able to get in all of the orders simply to initiate comprehensive care for the five new patients, it was already past midnight and I still had five History & Physical notes to write. My last one was written between the hours of 4 AM and 6 AM when I was floridly encephalopathic and almost prepared to use words such as “penultimate.” Nonetheless, several residents, co-interns and my attending commented that I looked surprisingly awake and put-together.

That, perhaps, is the beginning of the great lie. I have grown fond of most members of my intern class, and the only time I see them is in the brief moments when we are sitting at adjacent computers or passing in the hallways. When I ask “How are you doing?”, I get a variety of answers, the only genuine ones ranging from numb indifference to tired but thankful commiseration. Amazingly, I have overheard chief residents and others kindly asking my fellow interns the same question with the inevitable response being, “Good! Alright! Fine!” My program, from the attendings to the chief residents to the supervising residents and program coordinators, have been showing overwhelming displays of support, much more than I would have expected. However, in these brief and benign exchanges, I have seen a completely different story being told to me: we are all going through the same experience together, and no one else really knows what it feels like. The unifying sentiment: our more senior physicians have forgotten what it was like, and those who will never experience the intern year will never know what it means. This may not be true, but as I write this on my first day off, my day to finally recover from the disorientation of the first week, I think of a man who frequently dislocated his shoulder and would reset it himself by ramming it against a wall. Shoulder to the wall.

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