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 u
s. 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.
Amy
JUNE 1986
Thursday, June 5, 1986
So far, this has been the best day of my internship. Today’s the day of the Pediatric Department picnic; the attendings all cover the wards so we can all go out to some park somewhere and have a good time. That’s not exactly what I decided to do. When our attending showed up and told us we could leave, I came right home, picked up Sarah, and took her to the Bronx Zoo. Just the two of us; it was the first time all year I got to be alone with her during a workday. I’m so glad I decided to spend the day with her instead of going to the picnic. I’m really missing the best parts of her childhood.
The Infants’ ward is pretty much what I expected. In some ways it’s like being in the NICU except there aren’t any really tiny preemies around. There are a lot of babies who graduated from the NICU. The ones with any real chance of a normal life go home; the disasters come to Infants’.
Of three babies on the ward who are DNR’s, I’m taking care of two of them. One is Kara Smith, an eight-month-old who got meningitis about four months ago. She spent most of February in the ICU upstairs; she had everything wrong with her, there were problems with every single organ system, and all the doctors who had anything to do with her were sure she was going to die. But she didn’t die, and eventually they transferred her down to Infants’, to the DNR room, where she’s been living ever since.
It’s really sad; she’s completely vegetative; she can’t do anything. She has no head control, she can’t smile, she can’t suck. The nurses feed her through a G-tube [gastrostomy tube: a tube inserted through the abdominal wall and into the stomach; G-tubes facilitate feeding of children who are neurologically impaired enough not to be able to suck or swallow]. Five times a day they squirt blenderized baby food into her, and an hour or so later they change her diaper. She also has a trach so she can be suctioned [babies with no gag reflex will not swallow the normal secretions that build up in the back of their throats; as a result, if these are not removed mechanically, the children will choke]. And pretty much, that’s the extent of her care. Since she’s a total DNR, we don’t draw bloods on her for anything, we don’t culture her if she gets a fever, and we’re not supposed to start her on any antibiotics. Eventually she’ll probably develop pneumonia and die. But it’s already been four months and she hasn’t gotten pneumonia yet.
One of the nurses who’s really attached to her told me that Kara’s mother used to come every day when she was first moved down here. Eventually she only came every other day, then a couple of times a week. Now she comes maybe once a week. I haven’t met her yet; usually she shows up late at night, so I suspect some night when I’m on call I’ll run into her.
My other DNR baby is Lenny Oquendo. He’s six months old. He’s never been out of the hospital, and it looks like he never will be. He was one of the NICU disasters; he weighed a little less than six hundred grams [one pound, five ounces] at birth and spent three months on a ventilator. He has a grade IV IVH, severe hydrocephalus, and about a dozen other problems. He also has a G-tube and a trach. Lenny’s mother hasn’t come to see him in months. She seems to have completely lost interest in him.
There’s a third DNR baby in the same room, but he’s Ellen O’Hara’s patient, and I don’t know much about him. But that room is so depressing! The nurses and the rest of the staff buy these kids clothes and toys and things to try to liven up the atmosphere. But it doesn’t help, it only makes everything that much sadder; the clothes and toys only make you realize how different these kids are from normal children. Just going in there and seeing those three hopeless and helpless babies lying in their cribs, it makes you want to cry! But at least they aren’t much trouble. The only thing we have to do for them is rewrite their orders once a week and remember to sign them out to the intern on call.
The rest of the ward is filled with assorted disasters. There are three babies with spina bifida who have shunt infections [infection of the ventriculoperitoneal shunt, the device that drains fluid from the brain into the abdominal cavity] and are getting IV antibiotics, there are two babies with infantile spasms [a severe form of seizures] who are being treated with ACTH [the medication used in this type of seizure disorder], there’s a nine-month-old with AIDS who was in the ICU last week with PCP but who’s getting better. There are even a few normal children who have bronchiolitis.
Working on this ward really takes a lot out of you. It’s emotionally very taxing. So having today to spend with Sarah was especially good. It raised both our spirits.
I’m on call tomorrow night. I’m going to stop now and actually cook dinner.
Sunday, June 8, 1986
I’ve been in a good mood this weekend. The schedule for the next year finally came out on Friday. They actually came through with what they promised: I’m scheduled to have my CERC rotation [a month spent learning developmental pediatrics at the Children’s Evaluation and Rehabilitation Center on the east campus; CERC is a calm, nonstressful experience] in October, my vacation in November, a month of elective without night call in December, and my neuro selective [a rotation learning child neurology; like CERC, neuro is pretty laid-back] in January. They gave me what I wanted. Finally, after everything that’s happened this year, I wound up getting something without getting screwed!
It’s hard for me to believe that I have only three more weeks of internship left. At this point in time, I’m fairly sure I’m going to be able to make it the rest of the way. I hadn’t been able to say that before this week. I’d been dreading working on Infants’ for months; I’d heard only bad things about it. But actually, although I can’t say I’m really enjoying the patients I’m following, I am having a good experience here. We have a very good attending, Alan Morris. He’s an excellent teacher and I’ve been learning a lot from him on attending rounds. And we have a strong team: Ellen O’Hara and Ron Furman are the other interns, and they’re a lot of fun to work with. And our senior resident is my very favorite person in this whole program, Ben King. Ben’s a little burned out at this point; this is his last month of residency, and I don’t think he really wants to be in the hospital. Yesterday, on work rounds, he got into a wheelchair and made Ron push him around the ward. He’s funny and he makes working easy because he’s got excellent judgment. So, probably for the first time all year, I’m actually part of a team I like being on.
I was on call with Ben yesterday. It was a very quiet day. I had only two admissions, an eight-month-old sickler with dactylitis [inflammation of the hands and feet, usually the first painful manifestation that occurs in children with sickle-cell disease] who didn’t require any work, and a nine-month-old with bronchiolitis who was admitted from the West Bronx emergency room but who Ben immediately sent home. It was really funny: I went down to the ER to get the baby at about three in the afternoon and he really didn’t look that sick. But I didn’t question it, I just brought him up to the ward. Then Ben came by to see him and he said, “Why did they admit this kid?” I told him I didn’t know. He listened to the baby’s chest and said, “This kid doesn’t have bronchiolitis. He’s healthier than I am! Send him home before something bad happens to him!” Just like that. His mother got him dressed and they left. I don’t know any other resident who would have done that. But if you ask me, it was the right thing to do.
So all in all, I haven’t been too overly stressed on Infants. Calls haven’t been bad, and I’ve been getting out at a reasonable hour: not three or four in the afternoon, but usually no later than five. It’s staying light out until seven o’clock now, so when I get home I can take Sarah out onto the lawn in front of the apartment building and just sit out there with her. It’s nice. It’s too bad the rest of the year hasn’t been like this.
Sunday, June 15, 1986
Kara Smith died Friday night. She had developed a fever on Thursday; Ron was on, he examined her, and he thought she had pneumonia. He didn’t do anything about it, just wrote a note documenting it in the chart. Then on Friday during the day her breathing became very labored. She must have been hypoxic. I felt very uncomfortable. I kept coming into the room to check on her. I knew she was DNR, but just sitting around doing nothing really bothered me. I wanted at least to get a blood gas and maybe start some oxygen, but the rules are no treatment.
The Intern Blues Page 39