On July 1 across America, recent medical school graduates will engage in an activity that will be altogether new, and probably terrifying.
They will start caring for patients.
They will write their first prescription. They will make their first incision. They will enter their first note in a medical record without the need for a co-signature. For some, this may even be their first job.
Should those of us who might be on the receiving end of this rite of passage be worried?
At 7:00 AM on July 1, 1996, my first day of internship at the Massachusetts General Hospital, I entered the Medical Intensive Care Unit to begin my first rotation. And I was scared out of my wits. I pushed the big silver button on the wall outside the MICU to open the automatic doors, walked through, and was struck at first by the sounds: medication machines beeping in sets of three ("Bing-bing, bong; bing-bing, bong") to notify the nurses that a medication had run out or that an IV line was kinked; cardiac monitors for each patient recording normal heart rhythms ("Bee-boop, bee-boop, bee-boop...bomp") or warning of abnormal ones ("Ring! Ring! Ring!"); and the ventilators alarming (during periods when patients stopped breathing) in one, long, continuous screech ("Meeeeeeeeeeeeeeehhhh!"). Within a few days, I could close my eyes and identify every sound and know which were serious and which I could ignore. That first day, though, I was still an outsider.
I joined the other interns and resident in a windowless conference room for sign-in rounds, to review the events from the previous night. The post-call intern-resident pair gave report on all the patients. They looked like hell. I learned that I would be on call that first night, and wondered if I would emerge looking any better. To prepare for my first day and night, I packed my stethoscope, reflex hammer, ophthalmoscope, reference books, a brand new white coat, a slew of pens, a comb, and a change of underwear. Sadly, the last two would go unused.
Dave, the resident with whom I was paired, and I then dispersed to round on our patients: an 85-year-old woman who had been in the hospital for two months with pneumonia complicated by destruction of her lungs; a 74-year-old man with a devastating stroke leaving him paralyzed on the right and unable to speak or to understand questions; and a 45-year-old man with low blood pressure awaiting a liver transplant. I started to ask the first woman how she was feeling before realizing she couldn't answer with the ventilator tube in her mouth. So much for substantive patient interactions. We examined the patients together, fighting the cardiac monitor leads and IV lines with our stethoscopes. I struggled to figure out how to read the flow sheets of vital signs while Dave wrote the progress note for the day and dictated the plan. He also showed me how to use the computer system. I felt like an infant - everything I experienced was new, and I could do little to help Dave with the day's work.
Rounds with the attending lasted three hours. That afternoon, Dave showed me how to place an arterial line into a patient and I wrote my first order as a physician (to give a patient potassium). Actually, the nurse told me the patient needed potassium, taught me how to write the order, what to give, where, and when. But I was able to sign my name without any help. At about 7:00 p.m., we reconvened for sign-out rounds, during which we sat with the list of patients and assiduously listed all of the tasks the other intern-resident teams gave us to perform on their patients that night. Everyone else left for the evening, and we were alone.
Alone. I know that during times of extreme terror people can remember every detail of an experience and it never leaves them, but a lot of that night is now a blur. Astutely (as I did not have a clue what I was doing), Dave sent me on errands while he stayed in the Unit to manage the patients. I went down to the cafeteria at 9:00 p.m. to grab dinner for us. I was sent on a journey to the largely abandoned radiology department to find some X-rays and quickly got lost along unlit hallways. I also escorted a newly-ventilated patient from the Emergency Room back up to the Unit and wondered what I would do if, God forbid, he coded in the elevator.
I remember running into a couple of patients' rooms with Dave when those patients suddenly dropped their blood pressures that night, and into another room when a man became short of breath. We got a stat X-ray of his chest and saw that he had a large pneumothorax, a partial collapse of the lung. We quickly called the surgeons, who placed a chest tube in-between his ribs to re-expand the lung. Later, in one of the happiest moments since graduating medical school one month before, I saw the sunrise over the Charles River. As the others returned that next morning around 6:45 a.m., Dave took a couple of washcloths and ran them under the "boiling water" faucet in the sink and handed one to me to put over my face, as barbers do before giving a customer a shave - my consolation for having gotten no sleep. It felt so good.
So should we, the future patients of America, be worried?
Eighteen years after my first day of internship, training programs have become much more humane, limiting the number of consecutive hours interns and residents can work as they have recognized the deleterious cognitive consequences of sleep deprivation (per Accreditation Council for Graduate Medical Education guidelines), and instituting closer supervision so that trainees are not asked to practice medicine beyond their abilities. Medicine remains an apprenticeship, but one that better safeguards the health of its subjects.
With any luck, the only people who will suffer from these changes are the doctors who will no longer be able to tell such dramatic stories.
Dr. Sekeres is Professor of Medicine and Director of the Leukemia Program at Cleveland Clinic. Portions of this essay are excerpted from the book On The Edge Of Life: Diary Of A Medical Intensive Care Unit (Sekeres and Stern, MGH Psychiatry Academy Press, 2014).