“The only way to do great work is to love what you do. If you haven’t found it yet, keep looking. Don’t settle.”

Steve Jobs, former CEO Apple

Occasionally, as a student, you get to carry a beeper when you are on call.  You feel quite important, with that beeper clipped to your waistband, even if no one ever pages you.  When I got my very own beeper, I have to admit, I was a little excited.

“Yeah, I’m important.  I’m a doctor.  People need to be able to reach me, because I’m an important doctor.”  That’s sort of how it feels.  I paged myself once or twice just to get the feel for it.  I was pretty excited the first couple of calls I received.  I loved my new beeper.  But over about a week, I grew to hate the beeper.  The very sound of its chirp became annoying, sending shivers of irritation down my spine.  An intern can’t ignore it, or turn it off.  Its call only signals problems that need taken care of, more work to be done, or some unsatisfied person needing to talk to you.   It becomes a source of constant aggravation.  We picked up our beepers, got all our computer access codes, and learned all about all the paperwork we would need to be able to complete. 

     The boring part of orientation was finally done, and we were ready to go meet the teams and see our patients.  The new interns were going to “shadow” the old interns for a few days, to learn the ropes.  They were only a year ahead of us in training but were lightyears beyond us in experience.  That intern year is the time when the most dramatic development as a young doctor occurs.  An intern, fresh out of medical school, starts out barely able to take care of themselves, let alone run an entire service of sick patients.  By the end of the year they acan do a reasonable job of taking care of twenty or thirty patients at once without much senior level help.  The upper level residents give more responsibility to the interns as their abilities grow and judgement improves through experience.   

     Residency has a strict hierarchy, a chain of command, every bit as sacred and unchallengable as that in the military.  Each level of resident has a responsibility to teach the residents junior to them all that they know, and to submit completely to the opinions of the residents senior to them and blindly obey them.  We could gripe and complain privately amongst ourselves about how ridiculous or stupid one of our senior residents was, or that the decision they made was totally wrong, but we carried out the orders.  Being one year ahead of someone in training gave you total control over them.  This unspoken chain of command was rarely broken, a tradition that has been a part of resident training for as long as anyone can remember. 

     The intern is at the bottom of the hierarchy.  They arrive to work the earliest, do the majority of the actual work involved in patient care, go home the latest, and answer to various levels of more senior residents, and the attending physician. Most problems on the service are the intern’s fault, and result in a reprimand from someone, if not two or three someones.  The intern just tries to make it through each day with the least amount of personal pain and suffering possible.     

     I learned very early that a key to reducing the pain of internship is to keep the nursing staff happy.  The nurses possess the capability to make your life utterly miserable, your very existence intolerable, if they choose.  The nurses on the surgical floor took a fairly quick dislike to Shahid, because he tended to be very condescending towards them, among about a thousand other reasons.  They would plan to call him at night with a question every twenty or thirty minutes when he was on call.  It could be anything.  They would notify him that Mr. Smith was requesting to watch television, or Ms. Johnson had a clean bandage with no drainage, just like she did two hours ago.  A call every twenty minutes means no sleep at all for the entire night.  But if they liked you, then they would wait until two or three people had questions, give you one call, and leave you alone for a few hours.  And they always had food somewhere, in the middle of the night, when you were exhausted, too busy to eat, and starving.  They could quietly call to your attention your little mistakes, things that you had forgotten, or meant to do but didn’t have time, so you could fix them before the senior or attending noticed.  Or if they chose, they could call it to the attention of the chief or attending instead. 

     I learned names, took the time to chat with people, and was always polite and friendly.  If you are a smart intern, you develop this network of connections that includes the cafeteria people, the housekeepers, the orderlies, the secretaries in the different departments, the medical records clerks, the lab and x-ray techs, and numerous other people that you need on your side to make life a little more bearable.  An extra blanket or pillow for the bed, clean towels, actual soap, all these little things that make life nice, all come from housekeeping.  If you are in good with the cafeteria staff, they’ll let you in the back door even though they closed ten minutes ago. They’ll let you get your lunch even though you forgot your meal ticket if you promise to bring the ticket later.  Anywhere you can find a shortcut to get something done is worth the effort when you are the surgery intern.

     The attending physicians are at the top of the hierarchy.  Attendings are fully-trained, practicing doctors who have agreed to teach residents their art.  They are responsible for teaching them to safely perform operations and to understand when to operate and why to operate, and which operation to do.  They have to take extra time in the OR to teach an intern how to tie a knot or a senior resident how to sew bowel back together.  They also bear all the legal responsibility for the patient, and for any mistakes the residents may make.  In return, the residents do most of the annoying paperwork that goes along with being a doctor, and they see patients in the middle of the night in the ER.  The residents learn all the idiosyncrasies and quirks of the attending surgeons and try to cater to their needs and wants, no matter how unreasonable they may be.  The residents endure ridicule and temper tantrums, and try to bolster their attendings’ egos as much as possible.  This can be an extremely painful process at times, but as a surgery resident, you have to stay in good favor with your attendings.  If we want to learn how to become surgeons, we have to hold the scalpel and cut.  An attending surgeon has to allow you to do that to his or her patient, for whom they are totally legally responsible.  Unhappy, disgruntled attendings do not give you the scalpel. 

     Later that afternoon, we walked up to the eighth floor, where most of the surgery patients were located.  We saw a guy in scrubs and a white coat sitting at a computer with some charts, and assumed we had found one of the old interns.  I could see his name on his badge as we got closer.    

“Hi, Dr. Wells?  I’m Carol Sawmiller, the new intern,” I said as I stuck out my hand in greeting.  He looked up, then jumped up out of the chair, gave me a huge bear hug, actually lifting me off the ground, then put me down and stepped back.

“My God, am I glad to see you!  This means it’s all real, my intern year is actually ending, and you are here to take over all this, to end my suffering!” he exclaimed. 

     Stuart Wells and Tad Masters were the old interns.  They were about to move up to the second year, handling the SICU, with senior level residents watching over everything.  The second year resident was pretty much overworked like the intern, but they had a little independence, and they got a break once in a while to go down to the University and do rotations in Cardiothoracic surgery and Pediatric surgery.  Tad would be doing his first rotation as the SICU resident.  He gave the impression of knowing everything, one of those guys that said everything with bold confidence, whether he knew what he was talking about or not. He was actually very nice and usually pretty helpful.  You could tell he was used to getting about everything he ever wanted without having to work too hard for it.  He was a “smooth operator”, slick in a used-car-salesman kind of way.  He planned to go into plastic surgery, a field that suited him perfectly.  Stuart was a very artsy type of a person for a surgeon.    He was the socialite of the group, friends with literally every person in the hospital, I think with every person within fifty miles of the hospital.  He had the networking thing down to a science, and had established his connections in every aspect of hospital life.  He knew everyone on a first name basis, and everyone knew him. 

He looked Jack over.

“And you must be the other ‘tern.  Don’t get your feelings hurt, you’re too big for me to pick up, and I’m too tired.  I am just as glad to see you’re here.  And don’t call me ‘Dr. Wells’.  That just sounds weird.  You’re not a med student anymore, so you can actually use my first name.”

     He handed us each a sheet of paper with a list of names, room numbers, and diagnoses.  I would be taking over Stuart’s service, and Jack would take over Tad’s service.  Shahid was starting out on orthopedics, so he had gone off to meet the ortho PA’s.  The orthopedic service had two physician’s assistants, or PA’s, that took care of the inpatient service.  There were no orthopedic residents at the hospital, so it was just the ortho PA’s and a surgery intern.

“Jessie will be up to meet us for rounds in ten minutes.  Jack, you will find Tad in the ICU with Marcos and Ann, the new chiefs.  Go down to the second floor and follow the signs,” he instructed.

     As Jack walked off, a group of three medical students arrived.

“There’s our students,” Stuart whispered before they got to us.  “Lexie, the girl, is good, you can trust her.  The tall guy is Raj, he’s okay.  The other guy, he sucks.”

“Okay, studs, what have you got for me?” he bellowed at them as they approached.

     The three students split up the patients and followed them throughout their hospital stay, so they each had six or seven patients.  They all had their lists with various notes scratched all over them.  Lexie handed Stuart some x-rays.

“These are Smith’s films.  Radiology called it normal, but I think something looks funny, so I brought them up.”  This was before we had digital imaging.  All the films printed out and were kept in cardboard jackets down in the radiology file room.  One had to physically go get the film and put it up on a light box.  She went on to report some other labs and x-ray results.

Raj then took his turn, reporting on the afternoon activities of his patients. 

“Okay, Sam, what did Mervin’s small-bowel-follow-through show?” Stuart asked the third student tentatively.

“Well, I haven’t seen the result on that yet, I don’t think she has had all the films yet.  I can look up the labs now to see if…”

     Stuart held up his hand and interrupted, “Stop.  Stop. The films were done at two pm.  They started it at seven am, how long do you think it takes?  Luckily for the patient, someone other than you is following up on them.  That was your one job for the day. 
You had one job:  follow up on Mervin’s x-rays.  They showed a complete obstruction at the mid small bowel.  So now what do you want to do?”

     Sam looked at Stuart, and started to mention that he had been scrubbed all day and had not had a chance to get to radiology.  Stuart knew this was not the case, as he had seen him eating lunch in the cafeteria earlier.  If a person had time to eat lunch, they had time to go to radiology and look at films.

“Okay, so we have established that you totally screwed up and did not look at the films, now what are you going to do with Mrs. Mervin’s obstructed bowel?”

     After an uncomfortable silence, Stuart informed him that Mrs. Mervin was already in the OR for her exploratory laparotomy, where they had found an internal hernia with a loop of bowel stuck in it, causing her obstruction.

“Hint for the future:  When you can’t think of any intelligent answer to a question, just say you’d take them to the operating room.  This is your surgery rotation, so you have a good chance of being right, even if you have no idea what you are talking about,” Stuart advised him.  “If you are on cardiology, say you would cath him.  If you are on a GI rotation, say you would scope him.  If you are on a Medicine rotation, say you would order sixteen more tests and consult a subspecialist.  Get it?”

“Okay, I’ll remember that,” Sam answered.

“By the way, this is Dr. Sawmiller, your new intern.  Make sure she doesn’t get lost, and do what she tells you to do,” Stuart introduced me.

     Jessie came up as we finished collecting all the lab data.  She had just finished the exploratory laparotomy on Mrs. Mervin.

     Jessie Chung was about to move up to the fifth-year spot.  The fifth-year residents supervised the SICU, operated a lot and read a lot.  She was very atypical for a surgeon.  She would admit anyone and everyone, keep them on the service forever, and seemed to thoroughly enjoy spending hours rounding.  She was always overly sympathetic to even the most unreasonable patient.  She would spend hours rounding and talking to patients.  She was always around the hospital at all hours, popping in just when you needed some advice, or some help with a procedure.  Jessie didn’t seem to need any sleep at all.  She was a mix of characteristics that just don’t belong together.  Among other things, she was Chinese, fully six feet tall, and spoke fluent Spanish. 

     Dr. Grant Wisneski, the other fifth year, was her polar opposite.  He was a total intellectual surgeon, more of a scientist type.  He had a long list of publications, did very well on the yearly surgery exams, and spent most of his time reading.  He was not fond of patient interactions unless the patient was anesthetized and he had a scalpel.  Grant wasn’t known for a warm bedside manner. 

“Okay, are you guys ready?  I need to be in the unit in thirty minutes, so let’s make it fast.”

She was going to meet the ICU team and do rounds with them when we finished.  Stuart introduced me to Jessie. 

“The only way we can get rounds done in thirty minutes is if you wait right here,” Stuart told her.  She laughed and said that was not true.

“Jessie has these long, painful conversations with every patient – she talks to them about their hobbies and where they’re from and their favorite food and their favorite color and what brand of underwear they prefer.  Rounds take three times as long as they should…”

“Oh, shut up,” she responded to Stuart.  “I hope these guys don’t warp your thinking too much before you even get started,” she told me. 

I carefully gathered the patient charts and straightened out my crisp, clean white coat over my blue scrubs.  I took a deep breathe in and glanced around the nurses station, bustling with activity.  At that moment, I felt a mixture of excitement, trepidation, and anxiety.  But I felt a calm certainty that this was exactly what I was meant to be doing. I was about to start my first rounds on real surgery patients as an actual doctor.