Crozet Annals of Medicine: The First Year

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by Robert C. Reiser, MD

This month I am pleased to have two guest columnists, Dr. Thomas Laughrey and Dr. Edward Hawkins. Both just completed their internship years at UVA and I asked them to reflect on the process of shaping a physician. These are their stories.

Are You My Doctor?

“You’re my doctor?”  Walking into a patient’s room, I nearly laughed, because I’d been thinking the same thing. Nobody feels ready for their first day as a doctor.  Patients expect a lot from their doctors: the patient who asked me that question on my first day was really asking if I was ready to lift his burdens and fix his problems. It seems impossible that in one year, some young man or woman can go from a medical student to an upper-level resident, having achieved at least basic competence and a measure of trust from the rest of the hospital. How did it happen? It starts in the first week, when it becomes obvious patients’ goals are often not the same as their doctors’. This initially means a lot of stress and conflict, but it’s an opportunity, too, to glimpse who we are. Learning to get people what they need is as much a part of medicine as any antibiotic or arcane bit of trivia.

Most fourth (and final) year medical students find time for more vacation than they’ve had since summers in high school, and they arrive on their first day of intern year feeling happy and well-adjusted, ready to conquer the world.  Wearing scrubs and a new, fresh, knee-length white coat with my name embroidered on it, I felt like I knew a lot, but most of it wasn’t about real-life diagnosis or treatment. I had a vague understanding that I would have to comfort people in horrendous moments, something I felt I’d always been pretty good at. I wanted to be liked. When people hear an acquaintance is going to be a doctor, they say things like, “You must have such a big heart, and so smart!” Nice things, partially validating years of study and poverty. The patients, in pain, sometimes unable to breathe, feeling like they’d vomit at any moment, didn’t talk like that (and who would—God bless the few who do say “thank you.” They are far more composed than I am, but it makes my day.) It’s a big change when, suddenly, the expectation is 60 to 80 hours a week, all at one’s pastoral and intellectual best. Nobody cares that you haven’t urinated or had anything to drink since yesterday, or that you feel sad or stressed or unprepared. Nobody cares, that is, unless you’re moving too slowly at getting their painkiller.

The beginning of intern year is a dark time for a lot of new doctors. Dawn comes slowly, and it comes from the same source as all the fear and the angst and the unbridled pain. Patients are the reason for everything in the hospital; one day, having tried everything else, most interns eventually start to listen to them. Patients are people and they are hungry and thirsty. We learn to give them food and water (unless they’re about to have surgery, then we give them moist sponges and stop feeling sorry for ourselves for missing lunch.) Patients need pillows and blankets. They need to know how long this will take. People are afraid when they’re sick, and they need to know they’re not alone. They need a day off from work, because they are sick. They need the end of their pain. They need a lot of things more immediately, but they also want to know what’s wrong and why and what to do about it. Getting them situated quickly, with everything else taken care of, allows the focus to shift from the patient’s basic needs and back to today’s problem.

The mechanics of medical thinking change momentously, too, over the course of intern year. The brain reorganizes, not unlike an intelligent search engine, recognizing and refining patterns and key phrases. A year ago, when somebody brought in his elderly father with “the worst pain of his life” in his belly, I thought about dead bowel, the equivalent of a heart attack in the stomach. (When the system is functioning correctly, this is what medical school gives brand new doctors. It puts them in the ballpark.) Now, I can almost see the face of the first patient I met with his intestines dying, and I move quickly, urgently, knowing that there will be delays in getting the patient to the CAT scan and delays in getting a surgeon and operating room mobilized. Where I used to worry that they’d think I was stupid (think Chicken Little) if I thought something terrible was happening when it wasn’t, I now know the surgeons and radiologists I’m calling, and I’d rather they think me excitable than watch someone’s grandfather lose more small intestine while we muck about worrying about being wrong. I remember how much worse the first old man’s pain got while he awaited surgery, and I’m aggressive with fluids and pain medicines. It’s not that I’m any smarter or know more medicine (though continued studying hopefully means I do.) Experience in medicine is not completely unlike knowing what gas stations and restaurants are at each exit on a highway. It helps to have been there before, even if you have a GPS (or medical textbook.) I wonder at how much has changed, and I wonder how much more is to come.

“Hi, [sir or ma’am], I’m one of the ER docs. What can I do for you today?” I pack as much meaning in my grammatically garish icebreaker as I possibly can. My tone tells them I’m confident, ready, and prepared. It says, “I’ve eaten, I’ve had enough to drink, I’ve had plenty of sleep, and this day isn’t killing me. I’m ready to help you and make you feel better.” It’s a lot easier to do this because I’m more efficient now, another consequence of a year’s experience, and there’s time to tend to my own needs, too. It’s a lot easier, too, because I’m learning to base my opinion of myself more on my own developing competence (and continuing hard work) and less on what others think. It’s a lot easier because patients’ problems remind me of those who came before; the road isn’t as dark or unknown. “Are you my doctor?” Yes, I am.

Edward Hawkins, MD

All at Sea

“Call me Ishmael,” Melville’s opening words from his classic novel Moby Dick echoed in my mind as I passed through the emergency department doors on my first day of internship. Much like the unaware and inexperienced Ishmael ready to set sail for an epic adventure in pursuit of the great white whale, I passed through the threshold of the hospital doors, embarking on a grand adventure of my own: internship in emergency medicine. Intern year is often considered the most difficult step of the drawn-out and arduous progression to a career in medicine. Like navigating the Cretan Labyrinth, internship feels like walking down foreign corridors, not knowing what potential peril exists around each turn, holding on by a thin thread, all the while attempting to maintain composure while a thousand medical facts clank together in my brain like bumper cars at a state fair.

A brief trip down the rabbit hole of the intern’s life consists of days that usually start before dawn and end well after sunset. Coffee becomes your best friend. Calls to family and friends are shortened to the quick and superficial, “I’m still alive. Everything okay with grandma? Yes, I am eating and sleeping. Love you, too, and I will call you later.” Long nights are spent in the ICU. The reward is bags under your eyes and grease in your hair. There is constant exposure to fluorescent lights. There’s a constant search for the holy grail of call nights: the 30-minute nap without a single admission, consult, or low potassium (3.6 to be exact) page from a floor nurse. Each day is a tempest.

While physically exhausting, the real challenge is mental. This is a test of one’s spirit. Having to call the time of death at the end of a 45-minute code, muscles twitching from multiple rounds of CPR, makes the most simple tasks, such as dialing a phone number, difficult. You wipe the sweat off your face, drink a glass of water, and then walk into the next patient’s room. The problem today is, “I need my pain medication refilled.” As the physician you don’t have the luxury of fatigue, so you greet them with a smile.

There are catch phrases associated with intern year that cause angst under the guise of growth. The most beloved and frequently used are, “This is a great learning opportunity,” and “This sounds like a great intern case.” Our teachers use this graveyard humor to lessen their guilt at dumping the most emotionally difficult patients and repeat customers (typically without accompanying grave medical illnesses) at your feet. [Annals Editor’s note: we feel no guilt assigning these great learning opportunities.] But the smile and “God bless you, child” from the 77-year-old septic patient I treated swiftly and appropriately, reaffirms my career choice and breathes life back into me. I am ready to see the next patient.

The intern year is a year of first-time experiences: first saves, first losses, and for most of us, first self-reflection. At times, it felt like I was doing well just to tread water myself, let alone throw life preservers to my patients, desperately trying to keep them afloat. At some point during intern year, whether early on or on the last shift of the year, the compilation of experiences melds and composes the first layer of bedrock of the aspiring physician’s foundation.

As I end my intern year I understand the admonition a wise attending quoted to me in my first week as an ER physician, “Thomas, seeing patients without reading is like going to sea without charts. Reading without seeing patients is like never going to sea at all.”

Thomas Laughrey, MD