The Intern Blues

by Robert Marion

  Children’s isn’t so bad, though. First of all, Elizabeth is there this month [Elizabeth Hunter, one of the other interns, went to medical school with Mark], and it’s nice to be together with her. And the other intern, Peter Carson, seems like a nice guy. And everybody tells me that Children’s is much easier than 6A. I can see that that may be true: I was on last night and actually got three hours of sleep. Three hours of sleep! It was the first time I’ve even seen an on-call room since I got here. There are fewer admissions, and the patients aren’t as sick. The chiefs have promised me that they’ll still give me the month of Children’s I’m scheduled for later in the year, so maybe this will work out well. I doubt it, though; in internship, nothing is supposed to work out well.

  I spoke with Carole a little while ago and told her I missed her. I think she was surprised to hear me say that. I’m not what you’d call the most demonstrative person around, but I really do miss her. I miss everybody! All I’ve done since starting this internship is work or go home and fall asleep. I don’t know if it’s possible to survive a year like this.

  I’m going to sleep now. Maybe I’ll dream that it’s next June and all this is finished.

  Thursday, July 11, 1985

  Yesterday was my third night on call on Children’s. When I was on last Thursday and Sunday, I didn’t have any trouble. I didn’t get a single admission, and I slept three or four hours each night. I was thinking maybe I’d try to arrange to go to Children’s for my vacation this year. So I wasn’t at all prepared for what happened last night.

  I got five admissions. There was one every hour or two. I’d just have time to finish working up one when the next one would show up. They weren’t really very sick: an eight-year-old who came in to have a repair done on his cleft lip that had originally been repaired when he had been a baby; a kid who had developed an infection in his leg after he had been bitten by a dog and needed IV antibiotics; another kid who had periorbital cellulitis [an infection of the tissue surrounding the eye; dangerous because it can lead to infection of the eye itself and, occasionally, of the brain] and who needed IV antibiotics; and an asthmatic. The sickest kid was also the most interesting; it was a four-year-old with a week’s worth of facial swelling.

  He had kind of an interesting story: His mother noticed the swelling around July 1 and brought him to their local doctor. The LMD [local M.D.] sounds like he graduated from a medical correspondence school. He brilliantly decided the kid was allergic to trees and started him on Benadryl [an antihistamine used to reverse effects of allergic reactions]. The mother was back at the guy’s office in two days: Not only didn’t the Benadryl work, it also seemed to make the swelling worse. Now not only was the kid’s face swollen, but also his hands and feet were puffy. The LMD told the mother that sometimes it takes a while for the allergy to get better, especially since there are so many trees around, and that she should give the medicine more time to work.

  Well, she gave the medicine as long as it took for the kid’s belly and scrotum to get swollen and then she brought him to our ER, where one of the residents made the diagnosis in less than a minute. The kid, of course, had nephrotic syndrome. [This is a disorder in which the urine contains large amounts of protein and, as a result, the body becomes protein depleted, leading to swelling of the body. The face, especially the area around the eyes, is typically the first area affected in children. The disorder usually is self-limited; it is treated with steroids and usually resolves in weeks.] For God’s sake, even I could’ve made the diagnosis! So we admitted him, I called a renal consult, and we started him on ’roids [internese for steroids].

  One of Elizabeth’s patients almost got kidnapped two days ago. This three-year-old had been brought to the hospital by her aunt last week. The kid had a couple of episodes of blacking out while the aunt was baby-sitting for him. A whole workup was done and everything was negative except the tox screen [toxicology screen, a blood and urine test looking for toxic substances in the system], which was positive for alcohol. So social service started an investigation. The mother and her boyfriend showed up on Tuesday at noon, and after visiting with the kid for a while, asked to speak to the doctor. Elizabeth showed up and they asked her how the baby was doing. Elizabeth said that he was fine, and before she could say another word, the mother said, “If he’s fine, I want to take him home.”

  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 pu
s. 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.