A Year Inside a Medical Residency: Part 1

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As new doctors spend their first days in the hospital, they learn what their lives are really going to be.

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[flickr/JoseGoulao]

I am the director of a medical residency training program. Over the next year, I will share with you behind-the-scenes looks at how we develop and train young doctors. 

Internship -- the famous first year of doctor-hood -- is the forge upon which every doctor develops their knowledge, skill, and bedside manner. I will explore the emotional travails of internship and bring you a better understanding of the training process for doctors in the United States.

***

July. Twenty new interns have undergone more than a week of orientation, getting their ID badges and passwords; learning where to eat, rest, and find scrubs in the hospital. They've been talked at for hours upon hours about residency and hospital policies, the importance of remembering to sleep, and how not to accidentally stick themselves with needles. They are eager to get to work, to become real doctors -- beyond the newly-acquired "M.D." after their name. They are nervous as hell. They want to achieve, to help their patients, and most of all, to avoid making mistakes.

Is it true that July is the worst time to be a patient in a hospital?

You can find evidence on either side of the argument. (Here's a yes, another yes; a no. A recent piece in The New York Times by nurse Theresa Brown generated a lot of pushback when she opined that new doctors make more mistakes.) 

There is certainly merit to the question. What other profession routinely kicks out a third of its seasoned work force and replaces it with brand new interns every year? To be sure, running such a training program takes a certain amount of stamina and skin-thickening to handle the yearly transition.

In my view, we provide greater supervision to our interns and residents in July and August, when the days are long, spirits are high, and the trainees are hungry to learn and hear feedback from the faculty. In fact, we double up on the number of senior residents (second and third year trainees) supervising our care teams on the wards. So there are actually extra pairs of eyes and hands there to facilitate both patient care and teaching.

As supervising faculty, we too are sensitive to the newness and wonderment of our interns and strive to be patient with what are sometimes rudimentary and repetitive questions. As a program director, I believe in the importance of being scheduled to work directly with new interns early on in the academic cycle, both to form firsthand opinions of their talents and to role model the type of doctor that I want them to be.

My anticipatory emotion is often dread. Who wants to ride up along such a steep learning curve yet again? But once they show up, their sheer enthusiasm and willingness to throw themselves into their new roles overcomes my disdain almost immediately. Perhaps it's a reaction proportional to their collective fear.

My experience with intern disasters is that they seldom occur in July. They tend to happen later in the academic year, during the winter months, when interns have shed their fear and become more confident. They tire of asking for help, not wanting to appear "weak" in the eyes of their seniors. Not recognizing the limits of one's own knowledge can be a fatal flaw in this business.

At one of my previous institutions, an intern confidently decided that she did not need help removing a large-sized catheter from a big vein in a patient's chest. (IVs and such "central lines" are removed before patients are discharged from the hospital, except in select cases.) Cavalierly, without noting that the patient was on blood thinners, she yanked out the line without proper precautions in place, precipitating a gusher of blood that transformed the patient's room into a sanguinous pond.

The patient was rushed to the operating room and ultimately survived. The retrospective on the case was that the intern was not properly supervised and made errors of both omission (not recognizing the patient's anticoagulated state) and commission (taking out the catheter without proper guidance).

I offer examples like this one to encourage my residents to follow procedural checklists to the point that safety is an ingrained behavior rather than solely an externalized concept. I also want to remind them that judgement errors can happen to any of us.

In a slightly different vein, I share an experience from my own intern year with my trainees in the hope that it illustrates the highs and lows of what it means to be a medical intern. The hazing, the ignorance, the patient care - and, above all, induction into the cult of "doctor-hood."

My first day on the wards, I took over the care of a patient I'll call Mrs. Manganelli. She was an unfortunate woman in her mid-fifties, afflicted with severe multiple sclerosis. MS wreaks havoc on the connections between nerves, and between nerves and muscles, making things we take for granted -- swallowing, walking, breathing -- very difficult. It also affects "toileting."

Mrs. Manganelli had been admitted to the hospital specifically for the purpose of severe constipation. Her MS had made her intestines barely able to move food and the resultant waste products along their course. An x-ray confirmed that her colon was entirely full of stool.

My supervising resident and the patient's nurse gave me a strange look, with big eyes and a smile I mistrusted, telling me that "disimpacting" was the intern's job. I was scared to admit that I didn't know what disimpacting was, but their looks told me it wasn't pleasant. To hide my ignorance, I asked what "tools" I'd need for the job. The resident pointed his finger at me, and the nurse handed me a chux, those ubiquitous blue pads that are all over hospitals to place under patients and clean up messes.

Then I understood: I was going to be making and cleaning up a mess from poor Mrs. Manganelli.

"I don't want to be a doctor," I thought to myself, in response to what I perceived as a form of hazing. "This is going to be a long and awful year."

Mrs. Manganelli was apparently used to having disimpactions performed because of her illness. She rolled onto her side (with help) and assumed the position. Using a gloved finger and lubricant, I found what we would technically call "copious amounts of soft brown stool in her rectal vault." Her disease meant she had nearly no sphincter tone, so once I was able to initiate the flow of poop out of her bottom, it started coming out on its own. Lots of it.

I tell that story only to the point of illustrating the importance of the lesson it taught me.

Mrs. Manganelli felt about a million times better after being disimpacted. It was remarkable, not just seeing how dramatic her improvement was, but knowing that it was the direct result of my work. The initial feeling of grossness felt immediately petty.

When my family wanted to hear about my first day of internship, I proudly related what I'd been through. Their visceral reactions to the details told me that I'd crossed a line. From then on, even with the people closest to me, I would feel unable to share the unfiltered details from my medical world. So now, for better and worse, my interns and I live behind a magic curtain of people's expectations and perceptions.

As I welcome the interns to the hospital with this story, my point is for them to understand that we're in this bizarre and fascinating medical world together. We'll all continue to learn from each other, and many of our shared experiences will begin to feel only relatable within our small medical community. After even just a few days of working in the hospital, their friends and family won't be able to understand them - in certain ways - as well as the colleague they just met sitting next to them.

Some will argue that academic hospitals in July are mayhem, even unsafe places to be. Many attending physicians will purposely go on vacation to avoid dealing with the integration of the new interns. But I choose to work in the hospital every July, and I trust that our patients, too, benefit from the ethos of "all hands on deck." With the change of guard come new questions, new relationships, and a generation of our country's brightest minds quickly understanding that they are real doctors.

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John Henning Schumann, MD, is a writer and physician based in Tulsa, Oklahoma. He runs the internal medicine residency program at the University of Oklahoma School of Community Medicine.

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