Thursday, June 29, 2006

Intern's Lie

I’m drawing a blank. In these instances, I have learned, the optimal solution is to post something you’ve written in the past. I wrote this in the beginning of my second year of residency. Looking back I realize it’s kind of immature, but, right on the money!

Tomorrow, 7 am sharp, I embark on a new journey. I will be head of the team. This team will encompase one Attending, one Resident (that is I), two Interns (first year residents), one Sub-Intern/ fourth year med-student (from here on the “Sub-I”), and two third year med-students (a.k.a. “Students”).

To serve the readership yet unfamiliar with the medical hierarchy that governs today’s fine medical establishments I will now take the time to explain this stepladder of ass-slurpers. The understanding of this is essential for our future relationship and so if you have any questions feel free to ask.

I will comprise the list to range from least kissed ass to practically dripping. Remember, each member of the team has a primary goal, a secondary goal (if applicable), friends and enemies. It is long; I am sorry for this, but essential for the upcoming month. Let us begin:

1- The Students/ Third Year Med-School

Primary goal: To impress Attending and Resident with knowledge we were sure they never had. Secondary goals: To cloud a simple clinical scenario by suggesting that the patient has as many extremely rare diseases as possible, to name a disease the Resident hasn’t heard of and to send out for as many of the most expensive blood tests we have as the Resident allows. The sub-I is their best friend as he is closer to the resident and is always up to date on their performance thus far. Enemy: Interestingly enough, they are each other’s enemy as they are always being judged comparatively to each other. This undercurrent of hate is masked very well and only a thorough Freudian understanding of the subconscious can uncover it.

2- The Sub-I

Primary goal: Impress attending, Sub-I’s need recommendation letters for the residency match so they too can be taken advantage of by residency programs and government. Secondary goal: Discharge patients, less patients mean less work and try not to sound like Student by naming any rare disease.

The Sub-I’s friends are the Intern and the Resident, possibly third year but only if they agree to do his blood draws. Enemy: Patients with extremely rare diseases (makes Sub-I extremely uncomfortable as he now has to sound like Student).

3- Intern

Primary goal: Discharge patients. Intern will do or say anything to achieve this goal as he/she is usually overworked and would love to have one less family and upcoming tragedy to deal with. Secondary goal: Anything that ends in less patients (I cannot stress this enough).

Their friends are the other interns, amazing bonus point if able to really swing Resident to their “point of view” (often wrong!). Enemies: Patients!!!!
4- Resident (my new position)

Primary goal: To impress Attending and Chief of Medicine while also keeping Intern happy, motivated and feeling that Resident is truly on his side. Secondary goal: Constantly remember that Interns LIE! Again, they do anything to get patients out and Resident must continually double check Intern behind Intern’s back as INTERNS LIE! Friends: The Attending and other Residents. Enemies: Everyone on a certain level: as Interns LIE, Sub-I wants information primarily for Student, Student wants to name rare disease and make Resident look bad. To counteract Student, Resident must immediately say “I don’t know that but why don’t you give us a presentation on this tomorrow morning” (Gotcha Ya Bastard!).

5- Attending Doctor

Primary goal: Come for 2 hours in morning, teach, and leave as fast as possible, keep name out of chart so no one knows who to sue later. No Secondary goal. Friend: All. Enemy: No one. Remain completely oblivious to the ass smooching going on a round you. Wipe ass off after morning round.

6- Chief of Medicine

Primary Goal: Teach and run Medicine Department. Secondary goal: Absorb all ass-kissing, taking it all in as one continuous lick that lasts for many years. Secondary goal: Try to remain seemingly very humble, once in while give a lecture which makes every resident in the room feel like he knows absolutely nothing/ give up his medical license and go back to medical school.

This is the system within which we all operate. If there are any questions please feel free to ask. Tomorrow, I will do my best to avoid all questions and appease Intern to join my view of things. This will be my greatest chess match yet.

Friday, June 23, 2006

How We Die in America

In undergrad we had a course titled "life and dying". I'll never forget the first words my instructer said as he entered the room: "I don't know why they call it life and dying when the course is really all about dying".

What a great course too. It was there that I visited my first hospice, learned about the choices that people in our culture commonly make when it comes to their own (impending) death and the realities that those who never think about this have to face.

Residency was a course in itself. I don't think a day went by where I didn't have to do something to a patient that I knew I would never want done to me had I been in their situation. The truth is that unless a patient specifically states his/her wishes in advance we are left with little choice but to do everything in our power. Sometimes, that translates into procedures, painful ones, dangerous ones as well.

The Schiavo case brought the issue to the public's attention and really was a prime example of how the beliefs of family members and the lack of public knowledge of one's wishes can cause tremendous chaous.

A reader requested that I post a link to this article. The article has some interesting revelations about the contrast between how we "think" we're going to die and how we're actually likely to checkout. It's from the new book, "UNPLUGGED: Reclaiming our Right to Die in America."

Here's a little exerpt:
Our doctors are equally subject to technology's allure. They learn in medical school to assess, treat, and cure. They then move into a hospital culture where a death, even among the aged, is seen as a failing. The young Dr. Lown in 1959 plied the silver paddles on the chest of a living human for the first time, and saw a miracle; a racing, out- of-control heart instantly returned to a normal heartbeat. The young Dr. Potter in 1963 compressed a chest and saved a hardware store owner, and the whole town knew it. Their tools were unbelievably primitive compared to the arsenal available to a young doctor today, but the miracles are equally wonderful. How could we deny today's doctor such joy? Or today's patient? Why in the world would we want to?

In truth, we don't want to, and we shouldn't want to. We want the technology, and we want the cure. When surveyed, the majority of us say that when our dying comes, we hope to be at home, free from pain, surrounded by loved ones, and not hooked up to machines. In the abstract, that's likely true. We also very much want to be hooked up to those machines right up to the very moment when the doctor is sure that those miraculous tools can't fix us. Trying to find that exact line is no easy business.

Sunday, June 11, 2006


This time I mean for real. I am in the middle of a move to upstate NY. If not for this GPS thingy that I bought I'd still be lost on some back country road, withering away.

Congrats to Dr. Charles on making the move to his new address. We started blogging together and, at the beginning, had very similar blogs. He would blog literary stories of his start as a family physician and I would blog about my experience as a resident. We found each other pretty quickly back then and have found a way to keep in touch, maybe one day we'll even meet face to face.

But the times they are changing. I am nearly finished with my residency and he is nearly finished being a "starting" physician. Now, it will be my turn to blog as a beginning hospitalist and he can dish me the wisdom of one who is more advanced.

I am planning on writing a post that's a summary of my residency when I can see through the pile of boxes in this office. I was even thinking about writing a book about my residency and incorporating a lot of the madhouse posts into it somehow. All ideas that will have to wait for me to pass the boards.

Hopefully, I will have the time to write soon. Judging by my first week in my new local, time will be one of the things I will have plenty of.