“New doctor rule #1:  walk fast and look concerned.  Nobody will notice the confusion.”

Anonymous, but quickly learned by every new doctor.

     I tried to finish writing up the History and Physical to get our abdominal pain lady’s paperwork done as Stuart wrote the admission orders.

“So, what should I write down as our diagnosis and plan?” I asked.

“Put that we will listen to her whine every single day and do absolutely nothing except give her narcotics because she is a drug seeking insane person who wants unnecessary surgery.”

     I just stared at him blankly. 

“Okay, for this kind of admission we have to come up with some legitimate sounding diagnosis and plan, or insurance won’t pay for it.  Diagnosis: gastroenteritis with dehydration, partial small bowel obstruction or possible ileus.  Plan: intravenous hydration, NPO, and serial abdominal exams.  That’s a good, generic assessment and plan that’ll work for just about any abdominal pain admission,” he answered.

     We went back and told her we would be admitting her, with no plans for surgery.  She was very unhappy that she wasn’t going straight to the OR, and warned us we would be sorry, because she would probably be much worse by tomorrow, or perhaps even dead.  Stuart promised her some IV dilaudid to help with the pain and informed her that the senior resident would be down to see her.  She was at least temporarily satisfied, grumbling something about hoping the senior resident knew more about surgery than we did.   

“You might as well go home, since you are not actually supposed to be working yet.   You are more than welcome to join me for a delicious meal in the cafeteria, but then I would think you are some sort of deranged freak for not seizing the opportunity to get the hell out of here.  Meet us in the department office at five-thirty tomorrow morning, and we’ll show you how to do the list and stuff.  Enjoy getting home at a decent hour – it won’t last.”

     The alarm went off way too early.  I got myself ready and drove through the dark quiet streets to the hospital.  The interns and second and third year residents shared a big office in the department of surgery.  There were six desks, a few computers, a shelf of reference books, and various types of AV equipment.  The senior level residents and chiefs had separate offices down the hall, near the chairman and program director’s offices.  I found that it didn’t matter much that our office was crowded, because we only spent about fifteen minutes a day in there.  We had the office so we had a quiet place to go read when we had time, but as it turns out, no intern ever had spare time to read anything.  Stuart was already in the office, chugging down orange juice and fixing the list.  Since he had been on call, he was adding all the new admissions to the list of patients.  He showed me how to find the list on the computer and how to add people.  Jack showed up, coffee in hand, and got copies of his patient list.  Tad came in at about ten til six, and Stuart briefly told him about all the new patients.  He had admitted eight patients, and they had done one appendectomy during the night.  Our service had five new people, and Tad’s service had three new ones.

“Fairly quiet night – no trauma, nothing big.  Jessie made me admit everyone that came close to the ER, so sorry for all the bogus admissions, you’ve got about twenty-four people in house now,” Stuart stated.  The doctors referred to the hospital as “the house”.  They would talk about getting patients out of the house or who had come into the house.  I am not sure where this came from, but it likely originated from the fact that residents practically lived at the hospital.  Stuart had gotten about two solid hours of sleep, so that was a decent night for the intern on call.  Tad and Stuart gave us some pointers on what to do, and what not to do, then they headed off to meet the rest of the team to round.  That idea of shadowing the old interns for a few days appeared to be a good idea but couldn’t actually ever work out.  The “shadowing for a few days” turned into a few quick ten-minute lessons on how to be an intern.  Tomorrow was July first, and we would be officially taking over then.

     July is a month that is dreaded within teaching hospitals.  There are brand new interns everywhere, who may have never actually written medication orders, or put in central lines, or had any real patient responsibilities.  The majority of the interns just got their MD degree a few days ago and are as inexperienced as any doctor will ever be.  The nurses on the floors hate July, because they know that they have to train an entire new class of physicians.  They know they will be making numerous phone calls to interns to check on orders they have written that are clearly wrong.  They will need to clarify things like whether the physician wants the fifty milligrams of dilaudid given to a patient as ordered, to actually kill the patient, or if they might prefer just two milligrams be given to relieve their pain. 

“Oh, sorry,” the intern will say, “I was thinking of the dose for Demerol, but wrote dilaudid.”  

     They will find two or three elderly, confused patients lying on the floor, and have to teach the new interns to put the side rails back up on the bed when they are done examining patients. 

     They will have to teach them to clean up the blood and pus that they spill on the sheets and floors.  They will teach them exactly how certain attendings want dressings on wounds done, so that when the attendings come around the nurse doesn’t get blamed for doing the dressings all wrong.  They will need to teach the new interns to write all the little orders for things like Tylenol and Milk of Magnesia and suppositories for constipation so the nurse doesn’t have to track them down every twenty minutes for something.  And just when they get the new interns molded and trained perfectly, it will be July again, and a whole new, clueless group of interns will arrive.  

     The attendings spend July trying to figure out which interns and residents are reliable, whose judgement they can trust, and who needs to be watched closely.  The system usually works pretty well, and usually no big errors go unnoticed.  The interns’ work is reviewed by numerous people involved in the patients’ care – nursing staff, pharmacists, senior residents, and attendings.  But I have often thought that if I ever needed surgery at a teaching hospital, I think I might avoid July.

     We had another early morning orientation talk that lasted quite a while longer than it really needed to.  We heard many stories of Dr. Kaczanek’s training days, his philosophies on surgery and what it means to be a physician.  He regaled us with stories of all the important people in surgery that he knew, trained, worked with, worked for, liked or disliked.  Thankfully, around nine am he got paged by the operating room.  Karen sent us out to catch up with our teams. 

     Dr. Zayed, a clinical third year resident, was sitting at the nurses’ station on the eighth floor.  He had just finished his lab year. In our program, all the residents were required to spend the third year working in a research lab.  They still took SICU (Surgical Intensive Care Unit) call two or three times per week.  His full name was rather long and difficult to pronounce, so everyone just called him Zayed, or simply “Z”.  This was his first day back as the senior resident on the service and he had rounded early this morning with Stuart.

  Zayed greeted me sourly.  “So, now interns don’t have to show up for rounds?  Where were you this morning?  We round at six every morning, earlier if we need to.  We have too many people on this service.  Jessie never wants to discharge anyone.”  Jessie had been the senior resident on the service, and as I already knew, was sort of soft when it came to kicking people out of the hospital.  As a result, her service was usually on the heavy side. 

“We met with Dr. Kaczanek at six for orientation stuff, and they just sent us up,” I replied.

“Why does he have to have all these meetings?  He hasn’t been here long, but he sure likes to hear himself talk.  Did you learn anything useful?  No, you needed to be up here so you know what the plan is on these people.”  He seemed a little stressed.

     Then he shrugged his shoulders and said “Well, you gotta do what they tell you.  They’re the boss.” 

     We went over a few things that I needed to get done, and he was off to take out someone’s thyroid.  Unfortunately, most of the things I needed to do involved having computer access that actually worked, knowing where the radiology department was, and knowing how to “get rid of at least four patients”.  I was capable of none of these things.  First on my list of patients to get rid of was good old Ms.Warren, the abdominal pain patient from the ER last night. 

     Jack was going through the charts of the patients on his service. 

“She was pissed that I wasn’t at rounds this morning,” he reported, referring to Kenna Gibson, his senior resident.

“So was Zayed.  At least things are consistent,” I said.

     While Zayed went off to do his thyroidectomy, I sat down and started going through patients’ charts to try to get familiar with my service.  Raj, one of our students, gave me a list of all the patients’ labs.  We had some x-rays to look at, so Raj showed me the way to the radiology department.   I was due to help someone do an excision of a lipoma around noon, so that gave me a few hours to try to get things figured out.

     We had two chest x-rays to look at, and Ms. Warren’s abdominal x-ray from this morning.  Miraculously, she had survived the night.  Her labs were still all normal, and her abdominal x-ray showed a nice, normal pattern of gas within the bowel.  I was trying to sound knowledgeable and point out the differences on x-ray between the large and small bowel when my beeper went off.  I jumped a little bit as I eagerly pulled it off my waist and took a look.  There were five digits, followed by a dash and a bunch of sixes.  I showed the student.

“I think Satan is calling me, look at the six-six-six,” I said.

He smiled.  “No, no.  That’s a chief calling.  They put their year level after the phone number, so you know who is calling you.  You’re supposed to put a bunch of one’s at the end of yours if you page another resident.  So you better call this back quick, it’s a chief.  If they put a few sixes, then some sevens, that’s really bad.  That means they have an attending with them.” 

“If I’m a bunch of ones, what do you guys put?”

“Oh, we’re a bunch of zeroes.  We try not to let it hurt our feelings,” he responded.

     I called the number, and it was Ann Coleman, my chief resident, telling me to come to the OR to do a hernia with Dr. Budros now.  The patient was in pre op and needed a history and physical done, so I needed to hustle over there.  I started to say something about needing to go back to the floor to do a few things Zayed had told me to do, but quickly realized this was of no interest whatsoever to Ann.

     We arrived at pre op and were greeted by a nurse who said they had been waiting for me to do the physical, so could I please hurry it up so they could get the case moving.  She informed me that the intern was supposed to get the history and physical done prior to the attending getting in there, otherwise it held things up.  I tried to explain that I didn’t know I was doing this case until about two minutes ago, so I did not know I even had a physical exam to do.  But again, I quickly realized that this information was of no interest whatsoever to the nurse.

     The resident assigned to the case was supposed to check all the pre op labs, EKG and chest x-ray, examine the patient and write a history and physical, and make sure the patient understood the risks and benefits of the surgery and have them sign the consent form.  This needed to be done before the attending saw the patient, then they were rolled back to the OR for their surgery.  By the second month, I could easily get this all done in about ten minutes, but right now, it was overwhelming.

  I found the patient and introduced myself.  I quickly listened to his heart and lungs and had him stand up to do a hernia exam.  I wasn’t sure if I felt a hernia or not, but figured I didn’t have time to stand there poking around any longer.  His labs were on the chart and looked okay.  He didn’t have any questions about the surgery, so he signed his consent form and I went to change into scrubs.

     Out in the hall, I ran right into a gentleman reeking of cigarette smoke, dressed in scrubs.

“OR time costs about $218.00 a minute.  You now owe me about two thousand dollars.  I have been ready for ten minutes, which you have wasted.  This time, since it is your first day, you get a break.  Don’t make me wait to start a case again.  I’m Dr. Budros,” he said, sticking out his hand in greeting.

“Oh, uh, I’m Carol Sawmiller, the new intern,” I replied.  “I’m sorry, I just found out…”

     He held up his hand, clearly indicating he did not want to hear my reason for holding him up.  By this time, I finally realized that there was not one person in this entire hospital that gave a shit why I was late for this case that I didn’t know I was doing. 

“You need to know the patient, get the paperwork done in a timely manner, and be in the room before me if you want to learn how to operate from me.  I have simple rules, there they are, follow them at all times.”   He walked off towards the lounge.

     I hustled into the locker room, changed into scrubs, and briefly considered taking a bathroom break.  I had to pee, but what if I didn’t get back to the OR room before Budros?  I can hold it, I thought, and zipped out of the locker room back to OR five.  This was the first time of many where I had to make the choice between dealing with a patient need versus dealing with some basic human bodily functional need  of my own– like peeing, eating, sleeping, or taking a shower.

I had not read anything on hernia repairs for about three months, so if he asked a bunch of questions, I was screwed.