I spent August back at the medical center, working in their NICU. Although I was feeling more comfortable with preemies after my month at the maternity hospital, I encountered many other problems. First, two months in a row in a NICU is cruel and unusual punishment. Preemies, unlike older children and adults, don’t seem to understand the difference between day and night. They didn’t discriminate: they’d crump at any moment, morning, afternoon, evening, and in the middle of the night. As a result, when working in a NICU, it’s almost impossible to get any sleep during nights on call; you usually don’t even get a chance to see the inside of the interns’ on-call room.
Second, although the neonatologists will tell you that saving preemies is an exciting and exhilarating experience, to me the unit was an unbelievably depressing place to work. There were a lot of deaths, and although dealing with the parents of the babies who died was sad and difficult, it was even harder to care for some of the very tiny and extremely sick infants who didn’t die. These survivors often didn’t have a snowball’s chance in hell of leading anything resembling a normal life. Yet we were ordered to do everything possible to keep them going, and their parents were often given unrealistic expectations about how their infant would turn out. That conflict between what was medically demanded and what seemed ethically correct took a toll on me and on a number of my fellow interns.
The third problem that struck me when I made it back to the medical center was that I felt alone. There were two reasons for this. First, all the other interns had met and become friends during July. By being farmed out to the maternity hospital, I had become “odd man out.” It took me months to make inroads into the cliques that had formed.
The other reason I felt alone was because my wife and the rest of my family were back in New York. In a situation almost parallel to Andy Baron’s, while I was off in Boston, my wife was a graduate student in New York. We would see each other only on those weekends when I had at least a full day off. Since that happened only two of every three weeks, there were long stretches of time when I was completely alone. Without friends and family, my life was miserable.
And miserable was the tone set for the entire year. I felt overworked, dead tired, conflicted by what I was being called on to do, and uncared for by the senior people in the program. And even though I had originally planned to stay in Boston for the three years of my training, I decided to leave the medical center after my internship. I made my first call to Alan Cozza, the chief of service at Jonas Bronck Hospital, asking for a job as a junior resident toward the end of August. By September I informed my chief resident in Boston that come the following July 1, I’d be moving back to the Bronx.
In retrospect, my experiences in Boston were not unique. All interns suffer during their internships. Although there might be some variations, the issues are pretty much the same for everyone. The main issue is the hours: Being on call every third night all year long makes it impossible to lead anything like a normal life. Regardless of how caring the people who run the program are, or how nice the city in which it’s placed is, or how much support is available from family and friends, interns usually spend a hundred hours or more per week in the hospital. And anytime someone spends that much time at their place of work, there are going to be problems.
But why do house officers have to spend so much time in the hospital? What do interns do all day long? To explain this, I should outline what a typical intern’s day is like.
On a typical day, most of the interns show up for work at about 7:30 A.M. They briefly walk around the ward, making sure that all their patients have literally survived the night. They check the vital-sign records kept by the nurses to see if the patients have had fevers or any other complications. Then, at about eight, work rounds begin. The ward team, made up of three interns, a resident, the head nurse, and the third-year medical students who are assigned to pediatrics that month; walks past each patient, reviews his or her progress and decides on a plan of action for the day. The interns must carefully note the plans for each of their patients; it is their job to make sure the plans are carried out, to order the tests, schedule the appointments, send off the lab specimens, and check on their results. It is at work rounds, which last until approximately nine o’clock, that the interns generate the “scut lists” that will occupy them for most of the rest of the day.
At nine, an intake conference occurs. At intake, all patients admitted the night before are reviewed with the chief of the service. This is a teaching conference, and a large portion of the house staff usually is present. The interns are expected to present their own patients briefly and, if recommendations regarding management are made, to add these to their usually already burgeoning scut lists.