The Intern Blues(46)

The vast majority of the patients who come to the emergency rooms at Jonas Bronck and West Bronx hospitals are black or Hispanic. The vast majority of the house officers are white. Sometimes it’s difficult for the patients to relate to these doctors who know very little about how poor people live or what makes them tick. When I was a resident, I saw a six-year-old boy who had come to the emergency room with a fever. I diagnosed an ear infection and prescribed an antibiotic in liquid form. I carefully instructed the boy’s parents to give one teaspoonful of the medicine every six hours around the clock and to keep the container refrigerated. A week later, the child was back with the same symptoms. When I asked if they had given the medication as prescribed, the mother explained that she had tried, but since they didn’t have electricity in their apartment, they couldn’t keep the stuff refrigerated, nor was there enough light at night to measure it out. The therapy was bound to fail because I had no understanding of the social situation. It became necessary to treat the child with a capsule form of antibiotic to treat the infection effectively.

Dealing with these kinds of social situations is a huge problem for our house officers. As I’ve already mentioned, frequently social conditions are the direct cause of our patients’ illnesses. The house officer can treat the asthma or the lead poisoning, but after the child is better, he or she will be sent back home and most likely will encounter the same environmental hazards that caused the illness in the first place. To provide really effective care, the home conditions would have to be altered, a monumental and frustrating task. Our overworked house officers wind up having to settle for treating the symptoms rather than the underlying disease, an unsatisfactory but necessary compromise.

Another big problem our interns and residents face is caused by their lack of understanding of their patients’ cultural background. For example, people from certain areas of Puerto Rico have a very complex belief system based on hot and cold. Some illnesses are considered “hot,” some are thought to be “cold.” Similarly, remedies are believed to be effective for either hot or cold illnesses, but usually not for both. If a doctor prescribes what turns out to be a “cold” remedy for a “hot” illness, not only will the parent of the patient not use the medication, but also he or she will lose all confidence in that doctor.

Many of our patients speak no English and must rely on a doctor, nurse, or other patient to translate for them. In the emergency room, this slows down the doctors’ progress through the pile of charts of patients waiting to be seen, lengthening the waiting time dramatically. The net effect of all these problems is that hostility builds between patient and caregiver.

Sometimes there’s a great deal of hostility. Many of our patients use the emergency room as a kind of walk-in clinic, showing up at all hours of the day or night for problems the house officers consider trivial: belly aches that have been going on for three or four months, headaches for which no aspirin or Tylenol has been tried, mild gastroenteritis, complaints that the interns and residents know could be handled in a clinic setting, over the phone, or by the parents just using a little common sense. Since no one who shows up at the door of the ER can be turned away, the house staff winds up having to see these patients, getting backed up, and ultimately losing sleep because of what they consider this abuse of the system. And when one is chronically sleep-deprived, this can easily turn into resentment and anger, the ultimate effect of which is that the house officer will come to view the patient as an enemy.

Although hostility might exist between patient and doctor, it’s nothing compared with the hostility that exists between a doctor and some of the other members of the staff. The best example of this is the relationship between the interns and the people who work in the laboratories. The intern knows, almost instinctively, that fighting with the lab technicians will only bring him or her misery. No matter what happens, arguing with a technician is a fight the intern can only lose. The lab technicians, after all, hold the key to the completion of the scut list; without the results of lab tests, the intern can never go home. But sometimes it’s impossible to hold back.

As a house officer, I managed to hold back every time but one. When I was a senior resident, I was taking care of a sick preemie who was scheduled to go to the operating room the following day. It was my job to make sure that the child was pre-op’d, which included sending a specimen of blood to the blood bank for typing. The intern on call that night tried six times to get blood from this poor baby, who seemed to possess no visible veins in his entire body. I tried and failed four more times. Finally, on my fifth attempt, I succeeded; I managed to get about two cc’s of blood.