A doctor's learnings from his internship

Guest Column/ Dr Sandeep Jauhar, cardiologist at Northwell Health, New York City, and author most recently of My Father’s Brain

I did my medical internship 25 years ago, but I still remember it the way soldiers remember war. It was a brutal year in New York City, probably the most trying of my professional life. Working 80 or more hours per week and staying up every fourth night or so on call, I spent the year in a state of perpetual exhaustion, as a near-ascetic with regard to family, friends, food, and other pleasures.

After our son Mohan was born, my wife Sonia, also a doctor, referred to the newborn period as a kind of internship, and it definitely wasn’t easy, staying up night after night. But taking care of a newborn was very different from internship. In internship, when you were awakened in the middle of the night you had to be prepared to deal with almost anything―often alone and in the worst possible state, too. It didn’t matter if you felt like you were going to drop. You still had to be at the top of your game.

Our residency director told us during orientation that assistance was always available. “You should feel free to call on us anytime, day or night,” he said, amid nervous chatter. “The only mistake you can make is not asking for help.”

However, as the long year got started, I soon discovered that senior residents and attending physicians rarely wanted to be woken up in the middle of the night. You could call them if you needed help, of course, but few of us ever did. Not calling backup, I quickly learned, was considered a sign of strength, and for an intern there was nothing more flattering than to be considered “strong”.

One time I made the mistake of calling a third-year resident at her apartment in the middle of the night to ask for help performing a spinal tap. She roared at me on the phone for not taking care of the procedure earlier, before she came on duty at 10pm. When she arrived on the floor, she quickly saw my patient, told me a tap was unnecessary, and then berated me some more for wasting her time. I never called another resident for the remainder of the year. If I could get so much flak asking for help managing a potential case of meningitis, I could only imagine the kind of wrath I would incur calling about non-cardiac chest pain or something equally benign.

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Having a more senior physician with me didn’t always guarantee a successful outcome either. I remember spending most of one call night at a patient’s bedside in the coronary care unit with a supervising fellow. The patient, a middle-aged Polish man, had suffered a cardiac arrest after a myocardial infarction and was now in status epilepticus, or constant seizures. A bright ceiling lamp illuminated his naked body. The convulsions initially subsided with medications but seemed to gain in force and amplitude with the passage of the night. Eventually his whole body was quivering like a bowl of gelatin. We tried everything: glucose and thiamine; Versed, a potent sedative; a cooling blanket. Nothing worked. An anaesthesiologist eventually showed up at 5am and put the patient on a general anaesthetic. The seizures immediately ceased, but by then he had suffered irreversible brain damage. He died two days later after withdrawal of care. I can sometimes still hear his wife crying loudly, “Wake up, wake up, I don’t want to live without you.” Her cries were heard in the unit for hours, yet the place just rolled on as usual.

On night duty, it wasn’t necessarily the emergencies that overwhelmed so much as the little things, the minor issues―the insomnia, the constipation, the headaches―that the nurses had to make you aware of in the middle of the night. Even when the nurses didn’t call, it was impossible to enter any sort of restful sleep. Just the expectation of the pager going off was enough to keep you in a state of chronic anxiety.

There were set times when you could expect a flurry of pages, like when the nurses checked vital signs at 4am. That was when they called about fevers. Your response was always the same: blood and urine cultures and a portable chest X-ray to rule out pneumonia―but sometimes you discovered that a patient was already on antibiotics or that blood cultures had been drawn every night for the past week, every single one negative, and then you had to decide whether you really needed to stick him again, but most of the time you did so anyway, not for the patient’s sake but for your own, lest someone fault you in the morning for not doing it. That was the sad reality of internship: much of the time you were ordering tests to protect yourself. “The endgame of life is so depressing,” I wrote in the diary I kept that year. “Look at Mr Fisher. Successful lawyer, Goldberg patient. Now look at him. Sick, febrile, dying of who-knows-what: cancer, TB, sarcoidosis? If you think about it, it could make all of life seem unworthwhile if, in the end, we end up dying in the hospital, awakened at 4am by a stupid intern trying to draw another set of blood cultures.”

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My older brother, Rajiv, a cardiology fellow at the time, would try to quell my angst. My patients’ bodies had homeostatic reserve, he would tell me, the capacity to compensate for my mistakes. Most of my patients were going to be fine despite anything I did, and if they were going to die―well, that was probably going to happen despite me, too. “We are not saving patients,” he said. “We are just stabilising them so they can save themselves.”

This was one of several important lessons I learned that year that I have carried with me, valuable knowledge earned over many sleepless nights. I also learned that patients will almost always tell you what is wrong with them, if you are willing to listen. I learned that the most important thing in clinical practice is common sense. And perhaps the biggest lesson of all was that medicine is a lot more complex than I had ever imagined. It is a glorious, quirky, inescapably human enterprise, with contentious debates, successes and failures, villains and heroes, oddities, mysteries, absurdities, and profundities. It is testament to the power of my profession that after internship I could not imagine a life outside medicine.

Apart from teaching valuable lessons, internship also strengthened me in many of the ways I had hoped for. I discovered a physical hardiness I didn’t know I possessed. I learned how to cope with―and inflict―pain. (Internship toughened me, but it coarsened me, too.) I learned how to withstand pressures―mental, physical, and moral. I learned to become passably competent with my hands. I learned how to think in schemata and to simplify, perhaps oversimplify. And finally I learned how to make big decisions, and not always after ponderous reflection. At one time I had worried that my ruminative nature would impair me as a physician, and no doubt it hurt me when I was an intern. But in the end, my unwillingness to act reflexively probably made me a better doctor. The very characteristic that was least adaptive when I was an intern probably helped me the most afterward.

Since my internship ended in 1999, regulations have been introduced in the United States to reduce some of the misery of the experience. For example, most interns now are not permitted to work shifts longer than 16 hours. They are also encouraged to nap while on overnight duty and are mandated to leave the hospital immediately after completing a shift.

At first glance, such reforms make sense. Studies have found that doctors who got no sleep during a night on call scored lower on tests of simple reasoning, response time, concentration and recall. Indeed, a single night of continuous sleep deprivation has been shown to be roughly equivalent to having a blood alcohol level of 0.10 percent―that is, being drunk.

But there are downsides to these regulations, too. Limits on work hours lead to frequent patient handoffs, which are susceptible to breakdowns in communication between doctors, thus potentially creating errors. In aviation, most crashes occur on takeoff and landing, and in medicine, too, most mistakes happen during transitions. In fact, a study in the Journal of the American Medical Association found no evidence that reductions in work hours improved the quality or safety of patient care. Rigid work-hour restrictions may also be aggravating safety problems by compressing the same amount of work into shorter shifts.

But perhaps the biggest downside of enforced work shifts is that they interrupt learning and create a kind of clock-watching mentality that is antithetical to the ideals of doctoring. I believe that interns and residents should be allowed to stay at a sick patient’s bedside, for example, or attend a teaching conference after completing a work shift if they are so inclined. I remember some years ago working with an intern who refused to take a patient having an acute stroke for a CT scan because it was the end of her shift, and she was ready to go home.

I have come to realise that there probably isn’t a better way to learn medicine than a rigorous, intense internship. Internship is a classic apprenticeship of immersion. Some of the suffering may be gratuitous―the 36-hour shifts and 100-hour weeks interns used to endure endanger patients and doctors alike―but there is only so much you can ease away and still preserve the core of the experience. In learning to become a doctor you have to work hard and stay late and devote yourself to medicine to the near exclusion of everything else in your life. Interns and residents must experience a broad range of clinical situations before they can become competent, independent physicians. You have to see a patient’s illness through its course―observe the arc―to get a grip on the dynamics of disease. Internship may not need to be as painful as it used to be―as it perhaps still is―but it probably has to retain a certain degree of wretchedness to serve its purpose.

In the end, internship is a time of firsts: first prescription, first call night, first death. These formative experiences stay with doctors their whole professional lives. Though internship was the toughest year of my professional life, I am glad that I went through it. There is so much in store for you, dear intern, such a wealth of experience. Like me, you have probably been reading Harrison’s textbook of internal medicine. Let me tell you that it isn’t necessary. The real learning is going to happen someplace else.