I'm FREE!

Well, sort of.

Not that being a resident will be a piece of cake, but INTERN YEAR IS OVER.

And that means I'm no longer at the bottom of the totem pole.

No more progress notes. No more discharge notes. No more seventy-five-item to-do list after rounds. No more calling the family to arrange a family meeting. No more chasing down the specialists for a consult. No more answering fifty nurse pages a night.

I mean, there'll be some of all of that stuff, still. But it won't be the bulk of my day. As an intern, that's basically all you do. You're a medical secretary and taskmaster. As a resident, there's more thinking, there's more delegating, there's more interaction with the attending and coming up with the plan instead of just executing it. And, yes, there's more responsibility, but there are still fellows and attendings and other residents there to help. It doesn't all fall on your shoulders, and yet you're not completely disempowered to do anything. That's not a word, is it? Disempowered? It should be.

I feel a lot more capable than a year ago. And I feel like I know how to be a decent resident. The residents I've worked best with have been the kind who trusted the interns to get their work done and didn't micromanage. Who were there to help but didn't get in the way. Who didn't make you feel terrible if you messed up, or like you didn't even want to tell them if something was going wrong. The residents who knew when they were handing off too much, and took some of it on themselves. The ones who remembered what intern year was like.

I can do all of that. I think. I hope.

My new interns start tomorrow. It'll be a long day, I'm sure-- teaching them the computer system, etc, while getting to know a whole new set of patients at the same time. It's like the first day of school, except since it comes one day after the last day of school, there's not really any time to get excited.

I have a story to share from today-- a sad, crazy one-- but it'll have to wait. I'm treating myself to a reward for getting through this year without killing anyone (including myself). I'm going to spend more than $15 on dinner. Probably more than $25, and maybe even more than $35, which is a crazy splurge for me. Sushi. Unfortunately, sushi by myself, but at least I'm trying. One year down, two to go. I can do it? I can do it.

Stroke patient, elderly woman, not talking, we need to insert a nasogastric (NG) tube.

Resident says I should hold the patient down while she inserts the tube. I grab her hand. Resident starts putting in the tube. Patient starts struggling, fighting, waving her arms--

But, wait, I'm holding her hand--

Except did she somehow break free?

Seems like it, except-- I'm still holding her hand--

And then I look down. I'm holding the resident's hand!

Oops.

To: My brand-new team of interns
From: Your Resident
Re: On July 1, your new life begins

Welcome! I saw that you'll be on my team starting this Thursday, and thought I would send you a quick e-mail to say hello and give you some preliminary information about what you'll be doing.

When I was in your shoes a year ago, I didn't know what to expect, there was no one to ask, and my resident didn't even bother to learn my name until two weeks in, so I thought this would be a better way to start.

Just some basic logistics:

-- We round at 8. It is your responsibility to pre-round on your patients before then. That mostly means making sure they're still alive. If you take an attending into a patient's room, and the patient is dead, the attending will be annoyed that you wasted his time, and will probably give you a poor evaluation.

-- I can't leave until all of your notes are written. That means the slower you are, the more I want to kill you because you're keeping me in the hospital. Competent interns aren't only helping themselves, they're helping me get a good night's sleep. Please be competent.

-- The hospital serves lunch on Tuesdays and Thursdays. You won't want it. Plan accordingly.

-- If you forget your computer password, you're screwed, and the woman who can help you is never at her desk. Ever. I don't think she even exists. Without your password, you can't enter orders. Don't forget your password.

-- Mr. Edwards likes chocolate milk. Mr. Edwards was here a year ago when I started, and he's still here now. He will be here forever. Get him an extra chocolate milk.

-- Put your name on your stethoscope.

-- Looking bored and sad isn't going to get me to tell you that it's okay to leave early. I tried that. A lot. It never works. You're stuck here, for a lot of hours.

-- Finally, please show up on Thursday having read something in the past three days that you can talk intelligently about, and that isn't related to medicine or the patients. We spend a lot of time together, and I can't talk about sputum for 80 hours a week. There needs to be other conversation. We can talk about your personal life, or lack thereof-- I'm sure I will talk about mine-- but sometimes it's just nice to talk about some war going on somewhere, or the state of the economy, or who won the Cardinals game. Be prepared.

-- And, one more time, because it bears repeating: if you're presenting a patient, before you start, please be sure he is not dead. It's really embarrassing.

Get some sleep, and see you soon!

Someone sent me a Bloomberg article about a proposal to trim the length of intern call times from a maximum of 30 hours to a maximum of 16.

First reaction: Why couldn't this have happened a year ago?

Second reaction: Why only interns and not residents?

Third reaction: Now I know how the attendings feel when they tell us we have it easy, they used to be on call for 60 hours in a row, or do eight straight overnights, or not sleep for a month, or whatever crazy stories they tell us.

Yes, we have it easier than interns used to. We're "limited" to 80 hours a week, and most of the time we do in fact work less than 80 hours a week. We're "limited" to being on for 30 hours in a row, and never have two consecutive overnights (except when we're working only nights, and then we're off during the day). We have at least eight hours off between shifts. It could be worse, and used to be worse.

That doesn't mean it's great, or that it couldn't be better.

I can't decide whether 16 hours is a little bit excessive as far as the limit, or whether the system has simply made me accept that long days are a part of the job. Because 16 hours is a lot, and I shouldn't forget that just because I've been forced to do 27 hours in a row for, I don't know, 30 or 35 days over the course of this past year. I don't want to be someone's patient when they're in hour 27, and I'm not sure I really want to be someone's patient in hour 16 either.

So I applaud the new rules, even though, sadly, I won't benefit from them-- unless I'm ever a patient.

On Thursday, July 1, I become a second-year. Mere days until I'm the one in charge (to some extent), I'm the one telling the interns what to do, I'm the one making decisions. Yikes.

"This patient better die today. He needs to die," said my resident.

And, yeah, the patient's in bad shape, suffering, in pain, nothing we can really do, the family's just waiting for the inevitable.

"And he'd better die by 6:00, because I have concert tickets."

These are the perverse incentives created by the system.

If all of your patients die, hey, you can sign out early!

I mean, you still have to stay until 3:30, but it's a heck of a lot better than being here until 10:30 checking on blood work that's slow to come back.

Well, better for you. Not so much better for the patients.

Schizophrenic patient has an infection that has turned gangrenous.

Amputation is necessary to prevent the infection from spreading.

Patient has paranoia about doctors, doesn't trust anyone.

Is refusing the procedure. Seems to understand the risks. Is still refusing.

What do we do?

The schizophrenia means the patient is not considered competent to make her own medical decisions. The family wants the amputation. Two doctors sign off and say it's absolutely necessary.

So the patient, despite refusing, is wheeled into surgery and her leg is amputated.

Clearly, this won't help the patient and her paranoia that doctors are trying to harm her.

I mean, the doctors just cut off her leg. Despite her refusal. She has reason to be paranoid.

Who's being served here? The patient, or the family?

The patient is the one who has to deal with the loss of the leg. The patient is the one who has to go through the rest of her life like this. Who's to say that the patient would want to live like this, the mental illness on top of the loss of the leg? Well, the family and the doctors say she would, and so that's why the procedure was performed.

Is there a lesson here? I'm glad I'm not a surgeon? I'm glad I'm not schizophrenic? I don't know quite what to take from this one.

A few weeks ago, my team had a patient in pretty bad shape. She'd been in an accident, and was not doing well at all, unresponsive, really nothing good to say about her condition. Stayed that way for a couple of days, no improvement, no sign of improvement at all, seemed pretty futile to do much more.

Textbook case. The attending brought the family together for a meeting, told them things were not looking good, wanted them to consider withdrawing support, asked them to think about whether she'd want to be living this way, kept alive by machines, etc. His recommendation, and the recommendations of the consultants who'd seen her, and of everyone on the team, were all unambiguous. There is no good outcome here.

The family was reluctant, said they wanted everything possible to be done, keep her alive, do a high-risk, low-reward procedure to relieve pressure on her brain that we didn't think would do anything-- and in fact it didn't. Every day there'd be some conversation among the team asking why is the family torturing her, why can't they just let her go, there's nothing left, don't they see that.

I rotated off that service, forgot all about the patient. Then yesterday I'm talking to a friend in the call room, and he gets a page-- and I recognize the patient's name. "She's still here?"

"Yeah, pretty crazy story. She's alert, she's talking..."

"She's talking?"

"Yeah, we're going to move her to a rehab facility in a few days."

"This is the same patient whose family--"

"Yeah, they were right. There's definitely some issues going forward, but she's functional, she's going to get to go home."

Well, how about that, the family was right. To me, it's a lesson-- sometimes the body takes time to heal, we don't always understand it, but it's not always so clear, even to people who've been doing this for a long time. And sometimes a patient can get labeled as hopeless when maybe they aren't, and maybe the initial trauma just hasn't had a chance to resolve itself.

I don't want to overstate the lesson here-- most patients do not magically get better, and this patient isn't going home in the same state she was in before her accident, she suffered some degree of brain damage, it's a difficult road ahead-- and in maybe 99 out of 100 cases, she would not still be alive. But medicine isn't perfect, and the longer I'm a resident the more I realize we don't always know, even experienced doctors are guessing sometimes, and the body is complicated and unpredictable.

And of course it brings up another point-- I only know what happened because I was there when the intern got paged about that patient. Normally, we rotate off a service and don't find out what happened to our patients. We might see them months later when they're back in the hospital for another reason, if they happen to be on our service. Or we might hear about them in passing. But most of the time, we leave a service with 4 or 5 or 6 patients we've been treating, who are still there, and we never know what happens unless we think of them and decide to check, which almost never happens. I'm not sure that's the best system. I'm not sure it wouldn't make sense to have a more standard follow-up report system where we can quickly check the discharge notes of everyone we've followed, just so we know. Just so we know if something unexpected happened, if we were wrong, if we were right, how our decisions ultimately played out. Because we don't always know. And maybe we could learn something.

On Friday we had an orientation to prepare us for the start of second-year. They had all of the interns gather in a conference room, and we talked about the responsibilities of being a resident, having to motivate the new interns, etc.

Today I found out that while we were all in the orientation, and the residents were pulling double-duty for a few hours to cover for us, there was a code called in one of the hospitals.

And there weren't enough doctors around to perform CPR.

And the patient died.

Because we were all in orientation.

This shouldn't be funny-- this isn't funny-- except it is. "Why'd the patient die?" "Not enough doctors." "Where were the doctors?" "Orientation."

I can't read or watch anything medical anymore without wanting to scream. I posted about the Grey's Anatomy season finale last month; this morning, someone forwarded me this New York Times article about a woman who watched her father suffer a long and unpleasant death.

And somehow she blames his pacemaker.

Read the article if you want, but I'll try to explain what's going on even if you skip the piece. Man has debilitating stroke, which the article leads the reader to believe caused vascular dementia. Quality of life seriously impacted. Man develops hernia, needs surgery. Surgeon reluctant to perform surgery without implanting pacemaker to address slow heartbeat. Pacemaker goes in, man has cascade of other medical problems over the next five years, and the situation gets more and more difficult and unpleasant until he finally dies, and daughter blames pacemaker for having unnaturally kept him alive. And blames the doctors for being unwilling to deactivate the pacemaker.

First, the doctors should have deactivated the pacemaker if the health care proxy was asking them to. She quotes a doctor saying he wouldn't do it because he was worried his heart would instantly stop and he would drop dead. Which makes no sense. The pacemaker was regulating the heartbeat, but it can't keep a dead heart beating. Shutting off the pacemaker might have hastened his death, it might not have. It is not a life support system. It wouldn't prevent an arrythmia. It's not a defibrillator.

Which leads to my second point. He was old, he had old-person illnesses. His macular degeneration, his falls, his dementia-- they weren't caused by the pacemaker, they weren't caused by his doctor, they happened because he was old and old people unfortunately get sick. I'm not saying that putting the pacemaker in to begin with was a perfect decision-- it wasn't. But at the point they implanted it, the article makes it seem like he was still functioning, albeit in a limited capacity, post-stroke, and with some degree of cognitive impairment. But people with dementia can live for many years, and the alternative to the surgery was a hastened death.

What did the daughter want from the doctors? It seemed like she just wanted her father to die. And while that's understandable-- he was suffering, the whole family was suffering-- and the situation was unfortunate, it's unfair to blame the doctors for not finding a way to kill him sooner. We don't know how illnesses will progress, and at what point a patient will cross the line from intervention being a benefit and enabling more years of life of enough quality to be worthwhile to intervention merely prolonging suffering. The system is set up to help people, not to kill them.

But what frustrated me most about the article is that the medicine makes no sense. I'm just guessing at half of this. Did he have vascular dementia, or did he have Alzheimer's, or did he have both? Did the doctor refuse to disable the pacemaker, or merely encourage against it? Did he have one stroke, two strokes, many strokes? She writes about the natural course of progression of disease-- what disease? what progression? He had many diseases. The pacemaker didn't cause them. If the New York Times is going to publish something like this, with all of these details, at least get the medicine right. Be clear, be accurate.

And why they're letting this writer trash the doctor--by name-- who put in the pacemaker, I have no idea. It's only her side of the story, and it's not clear at all that she's painting an accurate picture.

I feel like in the media, death-before-modern-medicine is romanticized, as if everyone died in his sleep, as if everyone had a peaceful and wonderful death back when we didn't have medicine. You know what? They didn't. People suffered. And in a lot of cases, they probably suffered much more than today. We have medication, to cure things, and to manage pain. We've eliminated so much of what killed people eighty years ago. We're not performing unanesthetized experimental surgery, we're enabling people to live longer lives, with more years of health. People suffered. You think cholera was a pleasant way to go? You think mass plagues were fun? How about infection and sepsis? Do people really think we have it worse off today, because of doctors?

It's the middle of the night, so anything goes.

Gloves, masks, double-checking the medication labels... no one's watching!

I don't mean to criticize the nurses, because being a nurse means a lot of messy and unpleasant work, many of the nurses work hard, and this isn't just a nurse problem, it's a doctor problem too...

But, somehow, all of the careful procedures and protocol that happen during the day magically disappear when it's 2AM and no one's around except for the lonely intern, asleep in the call room.

A lot of, "I just did this-- can you put in the order?" calls. Or, "Yeah, I think we gave him that medication, but I forgot to write it down." Or, "Did we get those results back from the lab?? I don't even think we sent the sample TO the lab yet!"

And I'm not sure I saw anyone wash their hands between midnight and 6AM, which isn't just a problem for the patients, but a problem for the people with dirty hands too. I wash my hands a thousand times a day, because I don't want to get sick if I don't have to. And I don't get any sick days anyway.

Which is another thing that seems pretty silly. We get zero sick days. If we're sick, and we can't come to work, we have to make up the day-- in the huge amount of free time we get, of course. Our one-day weekends! So of course the incentive is not to take a sick day unless you literally can't get out of bed. Which means sick doctors roaming the halls... potentially giving patients all sorts of new illnesses.

If there's one profession we should want sick people to stay home from, isn't it doctors?

Fortunately it's not as if doctors are likely to get sick, since it's not like we're around sick people all day.

"[John] might have been an effective member of the team if he had wanted to be there, but it was fairly clear he didn't. Among the medical students I have worked with, he was uniquely lazy, uniquely uninterested in learning anything about what we were doing, and uniquely unpleasant as far as both his attitude about the job and his general disposition. I recommend that [John] rethink his interest in internal medicine, or in working with patients in any capacity, and pursue a career in radiology or pathology."

I didn't actually write that evaluation, but I was tempted to. I just filled out a backlog of med student evaluations on the internal evaluation system. We're supposed to fill out an evaluation every time we work with anyone-- attending, resident, medical student-- but I know I've only gotten about 25% of the evaluations I could have possibly received throughout the year, so I expect that's pretty much the average compliance rate. I've tried to do better, but it's hard for filling out evaluations to move to the top of the to-do list especially when I know my evaluations don't really matter. I'd have to say something pretty extreme for it to affect someone more senior than me, and I'm not nearly senior enough to have any impact on what anyone thinks about the med students.

It's frustratingly hard to know how honest to be on these things. I don't want to lie, but I also know that everyone gets to read their evaluations, they're not anonymous, and I don't want to needlessly make enemies because I'm trying too hard to be accurate.

Some med students have been good, and some have been useless. Would the evaluation at the top of this post be fair? Maybe. But who am I to judge when often I'm just as bad-- I want to leave early, I don't want to be there, I hate half the patients. So I temper my criticism and end up writing boring evaluations and giving them perfectly adequate scores when they probably deserve less. Really, I hope that by grade-inflating, I'm sending some good karma into the world, so when I get a resident who hates me, they decide to give me a nice evaluation anyway.

"[John]'s base of knowledge was also questionable at times. He recommended we withdraw support to a patient on the road to recovery, and told one visitor that her daughter was in a coma when in fact she was merely asleep."

Night float recap: things you would never dream of calling a doctor about if you were at home, in bed, suddenly become things that require a doctor's attention at 4:30 in the morning. I made my rounds at midnight every night, told the nurses to page me if anything important came up but otherwise I was going to try and get some sleep. And, sure, if a patient needs me, great, page me, I'll be there. But over the two weeks, I was called with the following urgent middle-of-the-night issues:

-- "hiccups"

-- "sneezing"

-- "a little bit of heartburn"

-- "thinks he's well enough that he doesn't need to take any more antibiotics"

-- "wants to know if he's allowed to use the toilet"

-- "thirsty"

-- "would like physical therapy in the morning"

-- "needs a sleeping pill, or just more quiet in his room"

-- "doesn't like his roommate"

-- "wants to know what time the doctor will be coming in the morning"

-- "thinks his son took his socks home"

-- "would like ginger ale"

-- "had a dream the nurses were doing something bad to him"

Ah, night float... I will miss you...

Excuse me while I rant for a few moments.

You ever try to work from home, and not tell anyone? Answer your e-mails, call the people you need to call, and no one needs to know you weren't actually in the office?

Now imagine you're a doctor.

Hey, doesn't really work, does it?

Friday night I thought I had the laziest resident in the hospital. I had to transfer a patient to the ICU-- usually this wouldn't be the kind of the thing the intern does by himself. I'd page the resident, he'd come and take a look at the patient, maybe he'd talk to the ICU resident, maybe he'd call the attending, maybe he'd take a look at the notes that the day team had written, maybe he'd just want to make sure I'm doing all the right things and not going to kill the guy.

So as soon as the patient starts going downhill, I page the resident. Calls back a couple of minutes later. "Oh, sounds like you have things under control. Why don't you handle this yourself?" Okay, whatever, he doesn't want to make sure I'm not incompetent, he trusts me, I'll do what I think we have to do. Patient continues to become less stable. I page the resident again. "Yeah, just keep doing what you're doing, sounds like it'll be fine." While this is going on, I get a page from one of the nurses about another patient who needs to be looked at. I call her back. "Can't right now, dealing with an ICU transfer, page my resident." Okay, back to this guy. I get him to the ICU, we get him stabilized, the ICU intern has everything under control, I start to head back to the floor, I get another page from the nurse. "You really need to get back here and deal with this patient." "I'm on my way-- what did my resident say?" "He said it sounded like it could wait until you were finished with the ICU transfer--"

So I run back to the floor, and, sure enough, we need to call a rapid response on this guy-- the ICU resident comes over, we get this guy stabilized... I page my resident. "Oh, it seemed like you could handle it."

I get home yesterday morning, having gotten no sleep overnight, and thinking this I just had the worst night float experience ever, and had the laziest resident in the world, who didn't even feel like he needed to come help me, and what could he have possibly been doing that was more important than making sure the patients didn't die...

And last night, I find out from the ICU resident-- this idiot's friend-- that my resident wasn't even there. And no one knew, and everyone just assumed he was lazy-- but they realized in the morning when the person he was supposed to sign out to couldn't find him, and he tried to do the sign out over the phone but the day team was insisting on seeing him in person-- especially because of everything that had happened overnight.

And it would be bad enough if he was at home, lying to everyone all night, answering his pages, pretending he was there, it would be bad enough if his "game plan" had been to take it easy unless there was a real emergency and then rush in-- but in fact he wasn't even in the state.

He'd been off on Thursday, and he was off on Saturday-- so he figured, hey, I'm going to go away for three days and I'll just stay up all night on Friday and pretend I'm a lazy resident, answer all my pages, and no one will even know. He was visiting his girlfriend, a two-hour plane ride away.

I am flabbergasted that someone would do this. Not only to the patients, but to his colleagues. I'm a first-year resident, and, unbeknownst to me, I was the only one on the floor the whole night. There was no one else there, two patients need me at the same time, and one of them wasn't going to have a doctor. And if I'd made a bad call-- a call I'm expected I might make merely because I'm an intern and interns make mistakes and that's why we're supervised by residents-- there was no one to back me up, there was no one to step in and fix things. Patients could have died, and it would have been my fault. And I didn't even know that I was alone there.

Needless to say, I'm furious. I'm furious that someone would do this, and I'm even more furious that it seems like the hospital is going to give him a slap on the wrist and nothing more. Because nothing bad happened-- because I did my job-- he gets a, "don't do this again," and "that was really irresponsible," and he gets to keep his job. They fire interns for being slow, and this guy, who skipped a shift, spent the whole night lying about it, and put our 55 overnight patients at risk-- he gets a free pass because he's a third-year, and two weeks away from leaving for a prestigious fellowship.

Like he's going to be a specialist I'd ever send a patient to.

It's one thing to make a mistake, accidentally, while trying your best. Mistakes happen, bad outcomes happen, it's unavoidable. It's quite another thing to try and beat the system, to spend the whole night lying to people, and to knowingly put patients at risk. Be skeptical, it teaches me. Being a doctor doesn't mean good motives.

One more night and then I get to become a normal person again.

Some people have asked in the comments about the eye post from a couple of days ago. I have no idea how the eye was put back in place without any damage-- the amount of ophthalmology we learn, in med school and beyond, is frighteningly insufficient to deal with any actual eye problems. But every doctor's best friend (Google) tells me that this can indeed happen, and the eye can be put back into place without necessarily causing loss of vision. As for how the eye came out of its socket in the first place, I'm not really sure I have an answer to that except that this patient had previously swallowed safety pins in an attempt to stay in the hospital, so the sense is that he somehow did it to himself.

Ethical dilemma.

Patient has terminal illness. Not terribly alert-- can mumble his name, sometimes. Can open his eyes. Has a very clear advance directive-- no intervention, nothing life-prolonging.

He has a subdural hematoma. Without intervention, blood builds up, brain herniates, and he dies. Certainly a quicker death than his terminal illness. But advance directive is clear.

Daughter insists we need to ignore the advance directive, insert a drain into his head, keep the blood from accumulating, will prolong his life some undeterminable amount of time. Unclear if it really increases suffering, because he's suffering regardless, but certainly predisposes him to more infections, etc.

Dying regardless. Advance directive clear. Daughter insisting we ignore advance directive.

I knew this patient when he was alert, I treated him a few months ago for the terminal illness, we don't want to just let him die, but he's dying regardless of what we do.

So do we insert the drain, or do we honor the advance directive? On the one hand, what's the point of the advance directive if it's not going to be followed. On the other hand, his daughter is the health care proxy and she wants the procedure done.

Ethically, the right answer seems clear-- the advance directive is clear, the advance directive is the representation of the patient's wishes, we should listen to the patient. Practically, it is more difficult, because the daughter is a real person, who cares about her father, and wants us to help him. And is making it difficult for us not to help him.

Medically, it's the thing we would do if not for the advance directive. The daughter wasn't trying to force us to do something that we wouldn't do, from a purely medical standpoint. It's only the advance directive that changes the calculation.

So, what do we do?

(and while I think I know what's being done, based on what people were saying yesterday, I won't know for sure what they ended up doing until I'm back at work tonight)

3AM page while I'm laying down in the call room. I call back--

"Doctor, I'm sorry to wake you."

"It's okay, what's up?"

"Patient in 1303 pulled his eye out of his socket."

"Pulled out what??"

"His eye."

"His EYE?"

"Yes."

"Um, I'll be right there?"

Don't ask. Just don't ask.

Amazingly-- amazingly, because I have only seen one thing grosser than this, and I'll save it for another post-- amazingly, the overnight ICU resident was able to put it back in place without any instantly-obvious consequences. Not for the squeamish.

I found out this morning that two of my co-interns aren't being asked back for next year. And neither one even killed anybody.

I don't even know what the right terminology is for not being asked to come back. I guess you'd say they've been fired. It's a job, we get paid, they don't have the job anymore, so that means they're fired. But it's more than just being fired, because it's not like they can very easily find a replacement job-- residency programs, at least not *decent* residency programs, don't seem like they'd be terribly interested in picking up someone who's been dumped from another program, even if they somehow have an empty slot.

It's mostly shocking because no one really tells us that hospitals do this. Not that they necessarily shouldn't, but it's kind of a locked-in path. You go to medical school, you apply for residency, you match with a program, and the understanding is that you're in that program for x years (3 years for internal medicine, other fields vary) and then you're a licensed doctor. Can't be a doctor without completing a residency. The 4 years of medical school becomes pretty pointless without completing a residency. [Not entirely pointless-- there are consulting firms that hire MDs, there's public health work, pharma, etc-- but assuming someone goes to medical school to be a doctor, you're not a doctor without completing a residency.]

And it's not like they paint this as an up-or-out profession. I have friends at law firms who go in knowing that there's a pretty decent chance they're not going to last until they make partner, and will probably be long gone way before then. This is different. No one expects to be fired mid-residency. Unless you do something horrible, you're supposed to be able to get through. That's the expectation. They already had schedules for next year-- the whole system has to be rejiggered now, because the hospital scheduled them for rotations next year, and now they have to move everyone else's schedule around to fill in the gaps. Hospitals don't really have extra doctors. Someone has to be doing admissions in the ER, someone has to be covering every floor, it's not like they can get rid of two residents and then we'll just have no one covering the patients on the 12th floor in September. They either have to hire new people to replace them [from where?] or cut everyone else's elective time.

The mechanics of how this plays out are not that interesting, I know. It's more about everyone being shocked to hear that these two people were fired without warning (at least without any warning anyone has heard about). I'm not saying there aren't reasons-- I'm sure there are reasons-- but what makes it alarming is that it's not because of anything black and white-- neither of them made any individual decisions that caused someone great harm.

It's a continuum-- we're all somewhere on this continuum between "ready to be a doctor" and "still seriously lost" and I don't think any of us really know quite where we fall. Like I said last week, I've had mostly good evaluations, but not entirely. Another poor evaluation or two, and would I be on the chopping block? I don't think I'd be-- I have no reason to believe I'd be, and even my less-than-awesome evaluations haven't had any magic words like "shouldn't be trusted to see patients," or "lacks effective medical judgment." But it's hard to be completely blase about it, because the stakes are so high.

Kicked out of residency means not just the loss of the job and the paycheck but really the loss of professional future, without exaggeration. The hospital just told two people who've spent years and years and hundreds of thousands of dollars that unless they can make a miracle happen and find another program that will take them mid-stream, they won't be doctors.

Of course I'm neglecting to focus on the flipside... maybe they shouldn't be doctors.

Because as high as the stakes are for the residents, the stakes are higher for the patients. And as people who use medical services-- if I can ignore the specifics of this situation, that two people I know and like now don't know what the heck they're going to do with their lives-- it's a terrible system if hospitals are reluctant to fire residents who they don't think are on the road to being great doctors. The last thing a patient should want is to be at a hospital that doesn't want to fire its residents because it's too messy a situation. If a resident can't be trusted to do a competent job, it's a real problem if they're your doctor, and it's a real shame if they get to finish the program and the world ends up with a doctor who doesn't know what he's doing.

I could fairly easily make the argument that residency ought to have a huge dropoff rate, that the hospital ought to cut people all the time-- that residency is our first real test of whether we have the capacity to be doctors (being able to pass exams in medical school is a terrible proxy for whether we can practice medicine) and it's a terrible disservice to the profession and to the public if people can skate by without having to prove themselves truly capable.

But the fact is that that's not the system as it currently exists. Residents don't get fired, not often, or at least no one talks about it if they do. Which is why this is really quite a shock-- and whether it's influenced by budget considerations (two fewer residents = two fewer salaries to pay -- although I hope that wasn't the driving factor) or the two interns simply had issues no one seems to be aware of, I don't know-- and is making everyone very nervous.

And, yeah, the first line of my post sounds like a joke, but I wasn't kidding. If you'd asked me yesterday what someone needed to do to get kicked out of residency, I'd have said you'd have to kill someone. What that means for our medical system is something I'll leave to you to discuss in the comments... because I need a nap.

I'm not like the other people here.

There's a personality to being a doctor-- maybe it's not even about being a doctor, a personality to being someone who's sees themselves as professionally successful, ambitious, driven, I don't know-- it's not that the other residents care more, or work harder, or are better than I am. And I'm not even sure it's that they get more fulfillment out of it or like it more than I do. It's that they're so enmeshed in the hospital, they're so completely consumed by their professional lives as residents that they don't even think about the rest of it.

Not that there's any time to have much of a life-- there isn't. But I worry about that-- I feel like I have other needs, that I can't be at the hospital 24 hours a day, that I need sleep, I need friends, I need to have other things in my head besides the work. And that my entire existence shouldn't necessarily be defined by the job. And that wanting to leave when my work is done-- being able to joke about things with my colleagues-- being a human being instead of a medical robot-- can't be a bad thing.

But that makes me different. And not in a good way.

I'm being vague, when I don't have to be. One of my residents gave me a lousy review. Most of my reviews have been really good-- surprisingly good-- especially from the attendings. Apparently I'm competent at this, even if I don't always feel like I am. The attendings like me, they trust me, my patients like me, and I haven't made any colossal mistakes (yet). Most of the residents I've worked with have been fine-- I've clicked with some more than others, of course, but they've been fine.

And yet one of them gave me a lousy review. He said I'm always working with an eye on the clock, that I push too hard to leave, that I don't seem invested in being there. He said I don't care enough-- not in exactly those words, but close. And I'm not really sure what to make of it. He's right that I work with an eye on the clock, he's right that I want to leave when I'm done-- when we're on days, it's 6AM to 7PM-- on our feet, racing around the hospital all day-- so, yeah, if none of my patients are in acute distress, I am thrilled to be done at 7PM and sign out to night float. That's what night float is there for. This resident routinely stayed until 9, 10, 11 at night-- did it hurt the patients? Of course not. Did it help them? No, not really. There's always more to do. There's always labs to follow up on, family members to talk to, notes to write. If you wait around long enough for someone to stop breathing, someone will. Or there'll be a new admission. Or something will happen that needs a doctor's attention. But we have a night float team. And I need sleep, at least sometimes, to be a decent doctor the next day, and actually help my patients.

And wanting sleep can't make me a bad person. Or at least I hope it can't.

And, see, it almost wouldn't be so bad if he gave me the lousy review but sat me down and talked to me about it. I could explain that, yeah, maybe I don't like staying for quite as many hours as he does, but I try to be efficient and get things done and help the patients, and I could apologize if I seem like I'm rushing to leave, and we could be, I don't know, civil about it. Instead, I feel like he gave me the lousy review and now he's my enemy. Every time we pass in the hall, I feel like he's giving me a dirty look.

And I walked into the ICU last night, just to say hello to the night float people over there-- and he's in there, and he wouldn't even say hello. He and a bunch of his friends were talking about nothing-- the hospital food, whatever-- and he made a point to not include me, he made a point to not be friendly. As if I've done something personally offensive to him-- as if somehow-- even if he thinks I'm a lousy resident, which I don't think I am-- this is a personal issue for him.

Maybe I am too detached. Maybe if I felt more personally invested, I would stay until midnight every night. Maybe I'm wrong for thinking the job doesn't have to consume every moment of my life, and every piece of my existence.

But even if that's true-- and I hope it's not-- why does it mean this guy has to be my enemy? I don't want an enemy. I've worked with residents who don't seem to be that great. It's unfortunate for the patients when they screw up, and it makes my life as a doctor more difficult. I don't feel like I take it as a personal affront. I don't think it means I'm less civil to them as human beings. I may not want to work with them again, but I don't hate them.

Clearly I'm letting it get to me.

For three days, we'd been trying to get a surgeon to do a consult on one of the patients-- but it's a low-priority case, patient needed a biopsy but another day or two wasn't going to change anything. I probably called half a dozen times and they kept pushing it off, the patient was getting annoyed-- why haven't they come already / I want to go home / what kind of a hospital is this?

So finally I got one of the attendings on the phone and I basically begged him to come and take a look, just to get the wheels in motion, so we didn't have to wait yet another day. He tells me he'll come in a few hours.

A few hours pass, he pages me to let me know he's on his way, we walk into the patient's room.

He looks at her.

"What is this?"

"What do you mean?"

He lifts her arm, lets go, it drops. He tries to get a reaction from her-- nothing.

"Why isn't this woman in the ICU?"

"Yeah... I think I might need to call a rapid response here."

The patient wasn't opening her eyes to commands, was having trouble breathing... certainly not a candidate for surgery.

As the rapid response team rushed in, the surgeon walked out.

"Don't waste my time again," and he rolled his eyes.

"I'm having trouble breathing. Look, the machine says my oxygen saturation is low."

"Yes, it does. I'm going to get the nurse to suction some mucus out of your airway."

"Yes, the number keeps going down."

"I think watching the monitor is making you anxious."

"It is."

"I just want to make sure. My chart says DNR/DNI. That means if you continue to have trouble breathing, we are not going to put in a breathing tube. Do you understand what that means? Is that still what you want?"

"No breathing tube."

"The doctor explained that you have a significant amount of disease and that it isn't getting better?"

"Yes. The number keeps going down."

"I know. We're going to suction some mucus out. The oxygen mask should be helping you a little."

"Yes, but the number makes me nervous."

"I think we should shut off the monitor and that might help you feel a little more relaxed. You can use the PCA pump to give you morphine. You'll feel more comfortable."

"Am I dying?"

"Did you have this discussion with your doctor?"

"Yes, but I want you to tell me. Am I dying?"

"Right now, I want to get some of the mucus out of your airway."

"Am I dying?"

"Hopefully not tonight."

"But I'm dying?"

"Your cancer is very advanced. Unfortunately, this is the progression of the disease. We can't reverse the disease at this point. It's hard to predict exactly how much time your body can continue to fight, but what we can do is make you as comfortable as we can and hopefully the suction will improve your breathing."

"But I'm dying."

"Yes."

I started on nights last night, for the next two weeks.

I quickly remembered why working nights is terrible.

Especially the first night.

I know none of these patients, I'm the only intern on the floor, there's no time to get up to speed on the problems any of them might have before the pager starts going off...

There's a reason why visiting hours end at a certain time in the evening, and the fact that it's never enforced doesn't mean the families should expect that they can speak to an informed doctor 24 hours a day. The nurse pages me and tells me the family is refusing to let them take blood from the patient.

"We want to talk to the doctor. They keep taking blood from our father and we don't know why they need all of this blood. We think they're taking too much blood from him, it's going to make him sick."

"I understand your concern. We need to monitor a number of things in your father's blood, that's why we're taking blood every few hours. Especially if he's going to have surgery tomorrow, we need to make sure he's a safe candidate and everything is doing okay with his blood."

"Well, it's not going to be safe if you keep taking all of his blood."

"I promise you this is standard procedure, he has enough blood, we need to keep taking samples to test, every few hours. This is not putting him in any danger."

"I don't believe you."

"I'm sorry you feel that way, but I assure you, it is much more dangerous for us not to do this than to do this."

"We're not going to let you."

And they proceeded to physically block anyone from touching their father. An hour of reasoning-- went nowhere. As I shuttled back and forth between their room-- where the family got more and more agitated as they kept arguing with the nurse-- and the other rooms I kept getting paged to check on.

Finally, we had no choice. We called security to physically remove the family, kicking and screaming. So we could take the patient's blood.

Hopefully they won't be back tonight.