What happens in residency stays in residency

IMG_5114.JPGInternship and residency can only fairly be described as indentured service.  You’re at the mercy of the hospital and the program, and your personal needs and wants when it comes to control over your life schedule and activities are second to making sure you’re doing what you’re supposed to do in the hospital for as long as you’re supposed to do it.  I can’t speak for everyone’s experience, obviously, only my own (internal medicine at Tufts), but in all honesty, it was seriously the best. time. of my life.

In my program, you got your signout at this event held yearly at the program director’s house. It started with a barbecue, where we ate cheeseburgers laced with anticipation and drank beer mixed with terror.  After an hour of tense socializing, the outgoing interns gave the signout to the incoming interns, and that made it official.

So you show up on your first day as an intern.  You have no freaking clue where anything is; your badge doesn’t work to get into the lounge; you gotta figure out where the bathroom is and if it’s ok to leave rounds to go pee, or if you should hold it until it squirts out of your nose.  You’re wearing the new long white coat, which in my day served to carry no less than three or four reference books (the Pharmacopeia, the MGH medicine guide, the little thing that tells you how to write orders and has a picture of the dermatomes).  Before long, the white coat begins to cause musculoskeletal aches and pains in places you didn’t know you had.

You are holding your hefty signout in your trembling hands, and you are determined that you will take whatever comes your way and you will not complain because you know that no one wants to hear it (and you are right).

Your main goals for this year to a) figure out where all the bathrooms are, and which ones are private so you can poop at work.  b) figure out where you can find free food in the hospital at any hour of day or night (hint: check UNDER the patient nutrition station, sometimes they hoard hot chocolate there).  c) figure out who’s sick and who’s not.

I know that sounds trite, but TRUST me, figuring out who’s actually sick and who isn’t is a serious skill and it WILL take you the better part of the whole year to figure it out.   It is the foundation of what they call “clinical judgement.”  Example: I was a second year resident when a senior medical student from the ER called me.

“I got this lady,” she says.  “She’s such a drama queen.  She arrived from Ireland today and came off the plane with a headache and came straight to the ED.  Every time I go in there, she vomits, it’s so weird.”

Now, as a second year, I’m no genius, but having made it through my intern year at the very LEAST I can tell who’s sick.

I walk in there, and I don’t see a histrionic woman; I see a woman with a diffuse petechial rash, who wants the lights out because of her headache, and who cannot lift her head off the bed.  I freak out.  I freak out so much that I believe the exact words used by my friend John who picked the patient up from me in the morning was “erythematous dipshit” because I was so flushed and hivey, but he says it was with love and compassion.

I’ll give you a second to guess what the diagnosis was in the end.

… … …

Hint: pus came out when we did her LP.  

… … …

That’s right, it was meningococcus.

That’s the difference a year makes.

Anyway, because you’re so green that you’re basically sucking your thumb and bumping into walls and each other, you’re are really not expected to do anything important or make any decisions, despite what you might have imagined in your head.  Your job is to listen to the plan put forth by the resident and attending, and to carry that plan out diligently.

Because you don’t know anything but you don’t want anyone else to realize that, you quickly learn to never answer a question straight on.  Phrases like, “I have to look back,” and “I can find out” get top use, and sometimes, you just lie. (“Did the patient complain of tenesmus?” You don’t freaking know, what’s tenesmus anyway, so, “NO.”)  You lie because it is better, you realize, to come back and say, “I was wrong, patient DID have tenesmus,” than it is to admit you don’t know right off the bat.

At first, you’re all caring and you really get involved with your patients.  You cry for days when a sweet old lady dies of cancer on your watch during your oncology rotation.  Seven months later, on the same rotation, you start saying things like, “Chemo? why? what’s the point?” and your attending will make fun of you for being so seasoned and jaded in comparison to your snotty weeping self a mere seven months prior.

And before you know it, you go to the same barbecue at the program director’s house, and this time, you’re eating cheeseburgers with a side of gloating and drinking beer mixed with elation because you think that second year residency is going to be so awesome (you’re wrong, fyi).

When you come back as a second year resident, strutting through the hospital like you know your stuff, unfortunately, it does not take long for you to realize how much worse it is to be a second year resident than it was to be a mere intern.  I mean, you know where the bathrooms are, but now you’re responsible for a group of wall-bumping thumbsuckers who have no clue and who think that you do, where you know that you really still don’t.  I mean, you can kind of tell who’s sick and who isn’t, but you still quietly shit your pants when you recognize someone who is.  It’s true.  Buy some Depends before you start your training, because you’re going to need them.  Bring some Chux on rounds.

As an intern, all you thought was, “How much longer do I have to be here?”  But as a resident, you don’t care how much longer.  All you think is, “I hope I didn’t fuck up.”  You begin to understand what “The longer you stay, the longer you stay means.”  Never truer words.

Your goals for second year are: a) to figure out who all those invisible people are who send you the random shit that clogs your inbox (lab tip of the day: make sure your c diff sample is true diarrhea!);  b) figure out which attending you’re going to suck up to in case you’re applying for fellowship; c) try to “win the game,” ie, discharge everyone off the service.  No one has EVER won the game, btw.  No one.  

Your job as a second year resident is to make a plan, and the intern will carry it out.  

Second year is pretty brutal.
But then comes the third year.  I suggest this year as a year to reproduce, by the way.    Reproducing as an intern is a kamikaze mission.  As a second year you had at least six months of being on service, so it’s still pretty hard-core, but as a third year it’s only like four months of real work.  The rest are rotation such as “Lyme clinic” (none of them have Lyme, btw.  I saw not a single Lyme patient in the Lyme clinic, only people who brought 20lb of records with them for us to tell them they had fibromyalgia, and for them to get mad that we weren’t going to “participate” in their plan for a year of IV antibiotics), and “research,” where you can do research on… sleeping… eating… going out on weekdays… and other important things like that.  Or you can reproduce, which, as I already said, I suggest if that is one of your life goals.  Then, you’ll be doing research on NOT sleeping but also breastfeeding and diaper changing (for another person, not you this time).  There are a few potentially terrifying months of being chief in the ICU, but honestly, you’re totally cruising by that point, so you’re cool with it.

Despite the easy living, you completely shed the resolution of not complaining because no one wants to hear it, and you complain constantly because you’ve been disillusioned and jaded the last two years, and nothing else matters at this point.  It’s amazing, you discover, how much anger a person doing research on eating and drinking can have.  Just saying.  But you’re still the happiest.

The reason I say they were the best days of my life is because along with all the terror, encopresis, fatigue, hard work and all the rest of it, there is a ton of camradery-ing going on.  You band together like never before, better than summer camp, better than boyscouts, better than youth group (or whatever).  Work is a social outlet, and despite the grueling hours, it’s fun because your friends are there.

When it’s time to graduate, you walk out of the hospital for the last time, and it is both anticlimactic and cathartic.  You have an enormous void in you but at the same time, you’re ready.

@lifeofamedstudnt

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