Authors: Robert Marion
The Intern Blues
The Intern Blues
The Timeless Classic About the Making of a Doctor
ROBERT MARION, M.D.
To my parents, Ann and Sam Marion, who sweated and slaved to put me through medical school so that I could sweat and slave as an intern
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and to the pediatric house staff who compose our program, without whom this book would not have been possible
Imagine walking into a room occupied by thirty-five tiny and very sick premature newborn babies. For the next twelve hours their well-being, their very survival is your responsibility. That was how my internship year began. It was definitely one of the most terrifying days of my life.
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I somehow survived that year in spite of the fact that I and the other interns in my group received negligible guidance from the senior people in the program. I was overworked, overtired, lonely and insecure, often depressed, and conflicted by my own responsibilities, whether admitting an infant with a dangerously high fever or coping with the psychological and physical stresses of dealing with AIDS patients.
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From July 1985 through June 1986, I worked with three interns: Amy, Andy, and Mark. Together, we've collected very personal notesâoften recorded after a grueling night on callâabout what it's really like, day by day, to spend a year as an intern, meeting too often with frustrations and not enough encouragement.
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The
Intern Blues
is the product of those notes.
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R
OBERT
M
ARION
, M.D.
Preface to the Perennial Edition
Monday, January 6, 2001
“T
ell me about your worst night on call.” Without hesitation, Emily, a senior resident who was spending January doing an elective with me in Medical Genetics, responded to my request. “It's hard to single out an absolute worst night. I've had a few that would make the finals. They all happened during the winter of my internship. Winter is terrible for interns, you never see any sunlight; you get to the hospital when it's still dark, and you leave at night when it's dark again. You're never outside when it's sunny, and that's bad. But probably my single worst night was a Friday in February. I was working on the Infants' Unit at Mount Scopus, and that morning, a ten-month-old baby came in who we thought might have a septic hip
[an infection of the hip joint; a medical emergency because if left untreated, the infection can destroy the joint, leading to long-term disability]
. The intern who'd been on call Thursday night admitted her, and by the time we finished rounds in the morning, the orthopedic surgeons had whisked the child off to tap her hip before any of us had a chance to see her or meet the family. The child came back to the floor from the OR in the afternoon. About four o'clock, I got a call from the pediatric radiologist who said, âI just reviewed the X-rays and I see multiple fractures of the hip. They make me suspicious of child abuse.' He told me to bring the kid down right away for a skeletal survey to see if there were any other signs of fractures. So I brought the kid down to the radiology department. The films were taken, and the radiologist saw what he thought were three old, healed fractures of other bones. They were subtle; he said he thought another radiologist might not have read them the same way, but he felt strongly enough about it that he thought a report needed to be made.
“So I took the baby back upstairs, and as the intern on call that night, it became my responsibility to make the phone call to Child Protective Services. I had to tell the family what was going on. That was horrible. They were Spanish-speaking, and my Spanish is not so good. Plus, since only one parent is allowed to stay in the hospital with the child, the parents were split: the father was home, and the mother was in the baby's room. As best I could, I told the mother that we'd found evidence of new and old fractures on the X rays and that we suspected child abuse . . . she was devastated, horribly devastated. She started crying, and I didn't know what to say to her to calm her down.
“Then the investigators from Child Protective Services came to speak with the mother. By this point, it was about midnight. They talked to the mother, and then they interviewed me; they wanted me to be the expert witness. They asked me questions about the radiologic findings. What did these fractures mean? How could they have happened? Is there any way they could have occurred other than through abuse? I had no idea how to answer them. And this poor mother was asking me questions, too, questions she deserved answers to. But I didn't have any answers for her, and it being the middle of the night by this point, there was nobody around who could give her those answers. It was horrible.
“Then the detectives came. First they interviewed the mother. She was horrified; she denied that she or the baby's father had done anything wrong, and I believed her. . . . I believed that she didn't have anything to do with it. The detectives asked me the same questions the Child Protective Services investigator had asked. I don't know. . . . This was the first time I'd ever dealt with anything like this, the first time I'd ever had to handle any of the legal aspects of my job. My approach to the same situation is very different today, after two years of experience dealing with these kinds of problems. But back then, I didn't know. . . . I thought, âHere I am, the pediatrician in charge of the case. I'm supposed to know the answers to all these questions the detectives are asking me.' They were hounding me, writing down every word I said. I figured that since I'd called them and they'd come in at three o'clock in the morning, that I should have at least been able to tell them for sure whether this child had been abused or not. It was horrible, horrible for me, horrible for the mother, horrible for the family, horrible for the kid, horrible for everyone involved.
“Meanwhile, while all this was going on, it was a typical busy winter night on Infants'. By the time the detectives came, we had three or four more admissions to work up, and a few IVs had fallen out and needed to be replaced. There comes a point in the night when you're working and working and you finally realize that you're not even going to get fifteen minutes to lie down. You're not going to have time to eat, you're not going to have time to go to the bathroom. I had all this work to do, all these thoughts about the baby with the fractures going through my mind, I was exhausted, and I was having trouble concentrating. At about five thirty, I was talking to the mother of one of the new admissions, trying my hardest to stay awake and take the history. I was definitely half asleep while I was talking to her, droopy eyed, and after asking a question, this mother turned to me and said, âDoctor, I think you already asked me that.' The fact that I had lost track of what I was doing kind of jolted me out of my sleepiness. I got really worried that I was going to screw up and make a major mistake, and so I willed myself to pay attention. Then, I walked out of the room and saw the intern from one of the other floors. She had come down to see how I was. Just seeing her face and realizing she was also awake at that hour brightened the night enough to help me get through it.”
“So you got through it,” I said.
“Yeah, I got through it. I got through all those horrible nights on call as an intern. It was bad.”
“What happened to the baby with the fractured hip?” I asked. “Did they ever figure out how she had broken those bones?”
“Not that I know of,” Emily replied. “The mother continued to deny that she'd done anything wrong. The father also denied hurting her. The investigators blamed one, then the other, then the first one again. They finally sent the baby to a foster home pending completion of the legal case. I had to appear in court. That was another horrible experience, one I haven't thought about in a while. But I don't know what ultimately happened. I never got follow-up.”
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As I write this
, it's been over fifteen years since Andy Baron, Mark Greenberg, and Amy Horowitz, the three frightened, inexperienced medical-school graduates whose audiodiaries serve as the basis of
The Intern Blues,
and I first talked about this project. Since that morning in late June 1985,
when we sat sprawled on the lawn outside the home of Peter Anderson, chairman of the Department of Pediatrics at the Albert Schweitzer School of Medicine, a lot has changed in our residency program. When Andy, Mark, and Amy began their residency, our training program was huge. Our more than 100 house officers staffed seven general pediatric inpatient wards, three neonatal intensive care units and well-baby nurseries, two pediatric intensive care units, three emergency rooms, and about six outpatient clinics. These many activities were distributed among four major teaching hospitals arrayed on two separate campuses in the Bronx. In trying to provide care for the sick infants and children who were admitted to these inpatient units, as well as for the more healthy ones who visited the ambulatory care clinics, our interns were unbelievably stressed. They were on call every third night, usually spending those nights awake in the hospital, often caring for critically ill, sometimes dying patients; having to deal with frightened and angry parents, lab technicians who didn't give a damn, intimidating and demanding nurses, and abusive attending physicians; rarely even having a glimmer of a chance of getting some sleep. They spent their days traveling from one campus to the other, providing care to their inpatient charges, then signing out and heading off to one of the other sites where a full panel of clinic patients awaited them. Since they spent most of their hours outside the hospital trying to catch up on sleep, they had little or no time for a social life, often going weeks without speaking with friends, family, or, in fact, anyone who worked outside the hospital.
Between 1985
and the late 1990s, a series of events began to pare away at our program, both internally and externally. Government subsidies for the training of young doctors shrank. Because of a presumed “doctor glut,” hospitals were offered incentives to train fewer residents. A major internecine struggle between Mt. Scopus Medical Center, the major teaching hospital of the Albert Schweitzer School of Medicine, and New York City's Health and Hospitals Corporation caused our program to withdraw its trainees from our two municipal hospital affiliates (Jonas Bronck and West Bronx Medical Centers). As a result, by the time Emily began her internship in July 1998, the program had shrunk dramatically. Emily became part of a residency force of only sixty-five, less than two-thirds the number with whom Andy, Mark, and Amy had worked. She and her colleagues spent most of their training time at Mt. Scopus Medical Center, venturing out to University Hospital only for rotations in the Neonatal Intensive Care Unit. They cared for children on only three general pediatric wards, in one NICU, one well-baby nursery, one pediatric intensive care unit, one emergency room, and two outpatient general pediatric clinics.
Although the paring of the size of our program had an effect on our trainees, no single event in the lives of interns and residents had as much of an impact as the adoption of the Bell Commission Regulations. In July 1989, New York became the first state to institute laws regulating the working conditions under which young doctors could be trained. Back in the days Andy, Mark, and Amy were interns, there were no regulations governing the conditions under which house officers worked. Interns and residents typically worked 110 hours per week, spending 36 or more hours in the hospital during a single on-call shift, working 18 to 24 hours in the emergency room without relief. The new regulations changed this outrageous situation: They limited the number of hours a house officer could work to 80 per week, with no more than 24 consecutive hours as part of a single shift, and no more than 12 consecutive hours working in an emergency-room setting.
As a result, by the time Emily began her training, life had become much different for interns. Emily was on-call every fourth night instead of every third. Instead of having to hang around until five or six (or seven)
p.m.
after spending another sleepless night in the hospital, as had been the custom back in the days prior to the introduction of the regulations, she was encouraged to leave no later than noon on her post-call days. No longer needing to spend precious minutes commuting from one campus to the other to fulfill her patient-care responsibilities, she was able to get out of the hospital earlier on non-call days, too, contributing to her ability to have some semblance of a social life. Yes, thanks to the Bell Commission Regulations, life for house officers should have improved dramatically.
The key phrase there is “should have.” “The fact is,” Emily said later in our conversation, “residency was actually pretty good. But internship was horrible. Even though I was on every fourth night instead of every third, it was still brutal. By the time February rolled around, I was chronically overtired. During the first few months of the year, I was so nervous and scared I was going to accidentally screw up and kill someone, I had trouble sleeping even during the nights I wasn't on-call. And seeing kids so sick, and watching some of them die, and dealing with their parents and familiesânothing in life prepared me for that. By the time I became a resident, it wasn't as bad. I felt more sure of myself; I knew what to do for my patients, how to handle most situations. But internship? I'm glad I never have to go through that year again.”
So, although the events documented in
The Intern Blues
occurred more than fifteen years ago, the message delivered by the three young doctors-in-training is still relevant. Yes, it's true that some of the events that occurred may be dated, and some of the methods used to train house officers are no longer in use. But there are things about internship that will never change. As long as medical school graduates are plunged into a setting in which they have to care for sick and dying patients over long hours with very little support from those around them, the experiences of Andy, Mark, and Amy will continue to ring true.
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Since the original publication
of
The Intern Blues
in 1989, I've had the opportunity to speak with a lot of people who've read the book. In addition to noting similarities between the experiences of one of or more of the interns whose lives were chronicled and their own experiences, many former residents have noted that the book was most valuable to them as a way of educating their loved ones. “My parents never understood what I was going through,” many have commented. This was the case with me, as well. When I was a resident, my father used to ask me, “When you're on-call at night, what does that mean? You go home and wait for them to call if they need you?” After reading the book, he finally understood.
I think this function,
The Intern Blues
as an educational tool for non-doctors, is also still valid today. In fact, I think reading the book before beginning one's internship may be harmful to the future intern's health; rather, the book should be read by the parents, other family members, and loved ones of interns prior to the start of their training years. That's the only way they'll truly understand what hell their loved ones' life is likely to become.