This past June marked the 50th anniversary of my graduation from medical school. It also marked the beginning of what I believe was the single most important year for professional development of my 50 years in medicine. I remember much of my internship year and the impact it had on my morphing gradually into a competent physician.
First, here is a bit of background. In 1960 I was married to Patricia Ann Sheahan on May 28th, graduated from the Stritch School of Medicine of Loyola University on June 7th, and started my internship a couple of weeks later at what was then Presbyterian-St. Luke's Hospital, now the Rush Medical Center, on the West Side of Chicago. I took a rotating internship, the only option offered at that time, which proved to be an important asset in my development.
We lived in a unit in Kidston House, a hospital-owned apartment building across the street, for which we paid $100 a month. Our “stipend” was $100/month, but was raised for the married house staff to $200 (minus $8 for Pat's health insurance).
I was assigned to 2-Pavillion with another intern and a medical resident. The interns and residents were on call every other night and every other weekend. The interns were responsible for their call obligations and if one was ill or had a family emergency, the other covered that call. My partner's mother died and she was gone for 10 days, during which time I was on call every night. Interns wore white pants and a white tunic that buttoned up the side of the chest to the neck, like Dr. Kildare in the old movies/TV show. It was cool, in both senses, to leave the top three buttons undone.
I am not giving these details to garner sympathy for what today's house staff would call slave labor, so don't roll your eyes expecting another “when I was an intern” story. I am simply trying to describe an environment just the way it was.
Set Clinical Priorities Immediately
Within the first few days a patient was admitted complaining of a headache. I went to the room, sat in a chair, and began taking a history, just as I did as a student. I wanted to do a good job so I elicited many details, examined the patient and went to the nurses' station to complete the write-up and write orders. The patient had a mild stroke and the process continued. The next day the resident took me aside and said that the attending physician (this was a “private” patient) had complained that I was too slow and that I failed to call him promptly after my assessment. I was crushed.
The resident was not sympathetic and he proceeded to give me a lecture. I don't remember the words, but the gist was, “You aren't in med school anymore; this is the big leagues, and you are to take responsibility for the patient's well being, not just record stuff. You know that a stroke or a CNS bleed was in the differential diagnosis and should have hurried the process along, treating this case with urgency and getting the staff and attending engaged quickly.”
He may as well have said, “You're not in Kansas anymore, Dorothy.” I never forgot that episode and never forgot to set clinical priorities immediately and adjust them as circumstances dictated.
Many Opportunities for Acts of Kindness
Another episode during those first two months: A 17-year-old girl, Janet, was admitted with severe ulcerative colitis. She had bright red hair despite her Italian surname and she and her mother were scared to death. I worked her up and tried to explain what was happening and what she might expect. After the workup, her attending physician called in a surgeon. He saw her and recommended a total colectomy.
I was almost as stunned as the family: a teen-ager living with an ileostomy for the rest of her life? She and her mother asked my advice—me, a brand new intern! I said, lamely, that I was no expert so I would probably do what her doctors recommended. I went to see her when she was admitted for surgery and checked on her postoperatively.
I never again saw her as one of her physicians, but she and her mother called me now and then to explain something and to be reassured. I got a Christmas card from Janet that year—and I have received one every year since. She always found me when I moved and I always reciprocated.
She married some years later (she had called me several times before committing to wed) and had two daughters who themselves have children. On a trip to her city many years ago I had dinner with her and her family and had a wonderful time reminiscing, marveling at how she handled herself.
Janet taught me that we have many opportunities for acts of kindness, for unhurried attention to a frightened patient, and that the impact of a few minutes or more can affect a lifetime…ours as well as the patient's.
‘Thinking Doctor or a Cutting Doctor?’
One of the great things about a rotating internship was the wide variety of experiences. I spent two months on general surgery. My resident was an older man who had emigrated from Lithuania. At 20 he had been a fighter pilot in the German army; he never talked about how he ended up a doctor. Peter was colorful. His first question to me was, in a moderately heavy accent, “Will you be a thinking doctor or a cutting doctor?” I still wasn't sure but at the end of my rotation he said, “You will be a thinking doctor,” obviously having seen my ineptitude for things surgical. He was kind-hearted under the crust and brought me a baby gift when my daughter was born.
We cared for a patient, first name Delta, who had had a super radical mastectomy for breast cancer, which was standard in those days. It recurred and then was treated with radiation. Delta was like Peter, tough on the outside, soft on the inside. Her chest was a mess of sores and dead tissue and she was admitted several times just for management of that problem. Changing her dressings was a chore and a challenge because everything was so fragile.
One day, burned in my memory, we were in her room changing a dressing when she started to bleed heavily from the wound. It was difficult to tell where it was coming from, probably an intercostal artery. We (mostly he) tried compression to no avail and the bleeding was so brisk that we couldn't see well enough to use a clamp. We were getting desperate, so he took a clamp and blindly grabbed where he thought the source was.
On the second try, he stopped the bleeding and managed to put in some sutures. We were both soaking wet. Delta knew she and we were in big trouble, but God bless her, she remained calm and still.
Delta and Peter taught me important lessons about cancer, cancer therapy side effects, and courage under pressure.
Grace and Rapid Action Under Pressure
The most difficult rotation was cardiovascular surgery, which consisted of long operations with me holding retractors, being on call every other night and getting home at 9 or 10 pm on my nights off. The four attending surgeons were pioneers in vascular and closed heart surgery and had a huge practice. The rotation was coveted by surgery residents, but not by interns. I was so exhausted that on one occasion when the phone rang in the middle of the night, I got up and went to the front door to see who was there.
But I also saw amazing (to me) surgical feats. I was asked once to help the senior attending surgeon with a “minor” procedure on an infant's heart. I believe it was to close a patent ductus arteriosis. To my shock, there was no resident at the operating table, just the surgeon with me on the other side and a nurse in her usual position.
The surgeon deftly opened the chest and was moving along when the heart began to enlarge rapidly and turn blue. He asked for a scissors, used a pickup to grasp the atrium and snipped a hole in it, releasing a gusher of blood—the baby had been over-transfused. He looked at the anesthetist with a glare but said nothing and quietly finished the operation without further incident.
This was another instance of grace under pressure and rapid action made possible by vast experience and total command of one's area of expertise. I admired him and hoped to emulate his temperament and demeanor in my (non-surgical) career.
Finally, rotating interns had one month for an elective rotation. I chose pediatrics. I don't know why except that by then we had had a baby daughter and I had been enthralled by her magical, miraculous development. It was a fortuitous choice that made it easy for me to choose hematology fellowship training in a pediatric department (conveniently only a city block away) despite my residency training in internal medicine. I did not know that this choice would lead to a long career in pediatric hematology-oncology.
If one could quantitate learning and formation, there is no question that I learned more about medicine and being a doctor in that year than any other single one that followed. It is common to talk about steep learning curves; in that year mine was almost vertical.