© Copyright 2020 by Doctor Anon
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I did my medical internship in 1970 when a hospital’s house staff (interns and residents) was poorly paid, worked long hours and had very few rights. For most of the year I worked every other night. Then, my program was at one of three institutions at which interns worked every other night, the other two being Johns Hopkins and Duke. When I started, I considered this work schedule a badge of honor, thinking those working a lesser schedule were wussies. After several months I was mentally exhausted and sorely regretted my decision. Every third night “on” or better looked very appealing. Please understand that working every other night was not a 9 to 5 proposition. The work day started at 7 a.m. After working my shift, did I go home at 7 a.m. the following day? Au contraire, I usually had further duties to perform. These included putting the finishing touches on the history and physicals (H&P) on patients admitted the day before which often could not be completed the same day as we were usually quite busy admitting patients from the medical staff and the Emergency Room. In addition to my work I also had to take care of the patients in the hospital from an intern who had the night off. If there was one unbreakable rule laid down by my chief of staff it was that the complete history and physical of a patient, without fail, had to be on the patient’s chart by morning rounds the next day following admission. Rounds were composed of myself, my resident, my attending physician, and numerous medical students. Every patient was seen and chart reviewed. During the wee hours of the morning a decision had to be made: sleep or write histories and physicals. Often sleep won out and the result was a rush to get up early and complete the patient record. If I did not sleep when I could, I would never sleep, as something frequently went wrong with patients all through the night and the phone next to my bed would be ringing.
A medical school friend who came to the GSUH at the same time was caught by the inflexible rule on histories and physicals. I had heard whisperings that someone had broken the rule by putting a short “holding note” on the chart rather than a complete history and physical, and got a good dressing down from the attending physician and chief of staff the next day. But, I did not learn the name of the culprit. Later that week my friend and I had dinner with his wife at their apartment. Early in our conversation I said “did you hear about the poor slob who did not get his history and physical on the chart in time?” He and his wife looked at each other and he said “it was me.” Open mouth, insert foot, one of my specialties. I apologized profusely, but our friendship was never the same after that and I never got a repeat dinner invitation.
A perhaps apocryphal story about patient rounds occurred while I was in medical school. As a patient’s room was approached, the attending physician asked an intern how the patient was doing. The intern said the patient was fine. Unfortunately, the patient had died the night before and the intern had not seen the patient and was trying to fake it. The result of the intern’s major faux pas was that he had to leave the program at the end of his internship. Every medical school may have a similar story.
My further next day duties also included performing lab work on patients, otherwise known as “scut work.” The interns did all the routine lab work on patients. We examined urine, performed blood hematocrits on tiny centrifuges, tested for blood sugar levels, looked at blood smears under the microscope, if indicated, and cultured every patient orifice and fluid source if he or she had a fever. These days if an intern wants a blood test, he or she writes the order, a lab technician draws the blood whereupon it goes to the laboratory where a machine determines the result. The patients we hated to see admitted were the diabetics whose blood sugars were out of control. Treatment required frequent blood and urine testing (by interns) which often lasted for several hours until the patient’s blood sugar could be controlled by insulin. Of course, we did not hate the patients, but we hated losing the tine needed for our other work. Today, nearly every lab test is done by machine and specialized technicians draw blood. Nurses obtain urine samples and blood cultures. Until the advent of reliable laboratory machines for this type of work, and, perhaps, house staff rebellion, university hospitals had a free source of lab workers for many years. So, after all the paper work and scut work were done I was free to go home, usually around lunch time, sometimes later. A 24 hour shift often became 30 hours or more. Time to rest and start all over again at 7 a.m. the next day.
The GSUH staffed the University Hospital as well as the Veterans Administration Hospital next door and the city’s General Hospital, aka “the General.” The internship rotation included stints at the University Wards, the University ER, the General Hospital wards, the General Hospital ER, the VA Hospital and a short elective. I was lucky in that my first assignment was at the Veterans Hospital working under a pleasant, low-key, but controlling resident. Perhaps too much so as he later became overtly schizophrenic. The Chief of Medicine at the VA was rumored to be a brilliant alcoholic who was rehabbed by the GSUH Chief of Medicine (the overall chief throughout the system) and given his job with the proviso he remain sober. He did remain sober and treated me well while I was there. He was pragmatic in his approach to medicine and I learned a great lesson from him: newer is not necessarily better, especially with regard to new drugs. He had a list of about 20 drugs that he would use on the patients he treated and would not use any others. The drug representatives always pushed the latest drug, sometimes with unforeseen consequences to the patient. This was, in my opinion, because drugs, like a lot computer software today, were and are not been tested long enough to discover all its significant adverse side effects or glitches. The child of a fraternity brother of mine fell prey to this. A pediatrician treated my friend’s young son with a then new drug, chloramphenicol. The child developed aplastic anemia which was an rarely known side effect at the time. It is not a good thing for your bone marrow to stop making blood cells. I do not know the end of the story as when my friend was telling me about the experience he was very angry at the pediatrician, the world, and by the end of the conversation, me. Just because I was another stupid doctor, I suppose. I never spoke to him again. Another sidelight: the life of the VA Chief of Medicine was later touched by tragedy. His daughter was murdered in her apartment by a homeless person and he was the one of the first to discover her body. I learned early that one’s life can completely change with a single phone call.
I remember vividly my first day at the VA. Other than a small salary we were provided with “whites” which were made up of starched cotton long pants and starched short sleeve collared shirts. Inherently lazy about some things I often wore my whites until they were filthy; no one seemed to mind. I believe my shoes were “white bucks” which also were not white for long. After a short organizational meeting I departed for my assigned floor at the VA, tightly starched and scared nearly witless. Fortunately, as I have mentioned, my resident was friendly and welcoming and the nurses were nice, although, as seasoned pros, they would not trust me for a second alone on my first rotation (with good reason, I had 95% textbook learning only). Besides being new and totally inexperienced I had another factor working against me. I did not look like a Dr. Marcus Welby (“a kindly California doctor”, if you are old enough to remember). In fact, I looked like I was 15, despite my long hippie hair and granny glasses. It is hard to engender confidence looking like Doogie Howser. His act may work on television, but not in real life. One day as I was walking down a hallway to see a new patient I heard his daughter, standing at the the end of the hall, ask a nurse: ‘that’s not my father’s doctor is it?” I got a fair amount of that. And it hurt.
My first admission at the VA was an elderly gentleman in severe heart failure. His heart was huge and he was quite thin and malnourished. He had obviously waited a long time to come in to the hospital. We administered the routine treatment for this problem and he gradually pulled out of it. According the VA Chief this was a classic case of “cardiac cachexia” wherein the heart was functioning so poorly the body was not able to obtain proper nourishment often combined with lack of appetite. Later that day our little team (we had two medical students from the local black medical school observing) took over the care of an older black man who tried to kill himself with rat poison because he had been jilted. He had taken a lethal dose, all his organs were shutting down and, in retrospect, everything we did was really futile, but we did the best for him we could, as we did for every patient. Later in my career I was often asked “what would you do if this was your mother?” I was always offended by this and would answer “the same as with any other patient.” One problem with care in our medical system was revealed by the rat poison case. Because of the poison the patient’s blood pressure was very low. There were two ways to go. One newer medicine increased the blood pressure and preserved blood flow to the kidneys and other internal organs. The other medicine also increased blood pressure but faster and at the expense of cutting down blood flow to the kidneys. The overall object was to keep the the blood pressure to the brain at an acceptable level. The latter medicine was the standard fix for low blood pressure and hope for the best kidney-wise. The admitting team had put the patient on the standard medicine. We changed the order to the other medicine and put a note on the chart fully explaining our reasoning. The next time we saw the patient, without a word to us or a note, the medicine had been changed back. The patient’s kidneys failed shortly thereafter, and because of the rat poison he was not a candidate for kidney dialysis he lasted only a few more days. Honestly, he would have died anyway. But it galled me and was my first example of medicine resisting change just because something had always been done a certain way. The rat poison patients family was very attentive and we became friendly as often happens. Open mouth, insert foot: the day the patient died someone in an adjacent hallway asked me how the patient was doing. In a very cavalier way I waved the patient off and said “oh, he just died…” Out of the corner of my eye I saw a family member start crying. Just another of my regrets.
Most of my patients were routine, but I certainly I had some strange diseases and incidents throughout the rest of the year. I have often wondered if this is the case for interns at all the university type hospitals, where the “zebras” or unusual patients tend to herd. One was at the VA again. During the physical examination of the patient I noticed a number of pustules all over his body. I thought they were, basically, zits. When I drew his blood, it looked like creamy tomato soup. In fact, it was so creamy that the lab was unable to analyze it. I had no idea what was going on, but duly noted these things in the patient’s chart. Wow, things got very exciting after the resident and the attending read my note. Swarms of attending physicians and house staff came to examine the patient, even from the GSUH. The patient was a victim of inherited hypercholesterolemia (elevated cholesterol), so much so that it completely clouded his blood and was bursting out through his skin. I do not have followup on this patient, but as there was not a good medicine at the time to lower cholesterol I would estimate the patient did not do well.
I continued my VA rotation and gradually learned the system, gained a minimum amount of trust from the nurses and eventually my resident allowed me to take in house night call without bothering him until something came up that really needed his attention. He slept in house as did I. Others higher up in the chain were at home, theoretically available to call for advice and even come in if the situation warranted, although I can never remember this happening. One nice thing did happen when one of the medical students from the local black medical school volunteered to accompany me at night. I found this a comfort and would bounce ideas off him. I am not a bigot , but it was well known that the local black school was poorly equipped both in equipment and teaching staff. If an applicant failed to get into one of the first level university internship programs it was either a second level black medical school or its equivalent elsewhere in the States or an out of country medical school where you best learned the local language before you attended. My two medical students were desperate for knowledge. I had a notebook I brought from medical school which had several lecture notes on various topics and when we had time I would “lecture” my students for which they were very appreciative. One of their wives even baked me a cake.
I had two tours at the VA. The second tour was toward the end of the year when I knew I would not continue in Internal Medicine and had been accepted for a Radiology residency. I was killing time and my performance showed it. A patient was admitted with very large kidneys due to a genetic disease that eventually leads to renal failure and death. I performed and wrote a very perfunctory H&P for the chart. I was slightly late for rounds on the patient the next day and when I walked into the room the attending physician was giving the house staff a withering criticism of my H&P. For what seemed like an eternity he slowly went over what was wrong with my physical examination; for example I had failed to note that the patient’s kidneys were so enlarged they bulged from his flanks. I will admit I had done a poor job, but what got to me was the expression on the attending’s face. He seemed to be smugly enjoying sticking the knife to me and there was no intent to improve, only to tear down and humiliate. He was successful.
After my first rotation at the VA ended I moved on to the General Hospital’s Emergency Room where I had a complete opposite experience. This ER was extremely busy, especially on weekends, as it took all comers and a lot of trauma cases, including injured criminals brought in by the police. We also treated the police and they always moved to the head of the line. An extremely ill gentleman was brought in and he soon went into cardiac arrest. The “code blue” team performed CPR for quite awhile and after looking at what I thought was a flat line EKG, I called the effort off. The next day the Chief of Medicine quietly explained to me that the tiny wiggles in the EKG that looked flat to me at a glance really represented a “fibrillating” or quivering heart that was not pumping out any blood and should have been “shocked.” I had made an honest mistake and he was able to correct me and teach me without tearing me down, which was much appreciated. Especially on ER weekends things could get pretty wild. Most of the staff believed that business would be at its greatest during a full moon and it seemed to be. The hairiest thing I saw was a surgical resident opening a stabbing victim’s chest in the ER to treat the chest wound and massage the victim’s heart which had stopped. We did a lot of treating, but at this ER location the interns and residents played a strange game of “how sick can you send a patient home?” The object seemed to be admit as few patients as possible, a completely foreign approach today, and, in retrospect, pretty juvenile and foolish. Some cases were spoken of in awe and disbelief, as “how could you possibly send that patient home?”, but to my knowledge no one was ever criticized or disciplined for this approach, and if a patient died “outside” I had no way of knowing.
I moved on to the GSUH wards. Here the town physicians and the university hospital physicians admitted patients and were more hands on, directing the care of the patients. At the General and the VA, patient care was pretty much in the hands of the interns and residents with some basic supervision from a few physician professors. Here there was some “town/gown” conflict, but not much as I remember. My most interesting patient was a middle aged man admitted for a heart attack. Because the nerves or “wiring” of his heart were abnormally incomplete, he had what is known as “heart block.” As a result, his EKG was meaningless, the signals given off by the heart a jumble. A heart attack could not be demonstrated by this test. The diagnosis had to be made clinically and by elevated blood enzymes showing heart damage. He and his wife did not understand what was happening. One day I mentioned “heart block.” They said “What’s that?” So I explained what was going on, no one had bothered to explain the situation to them. They were very appreciative. The patient recovered and went home only to return to the ER several weeks later DOA (dead on arrival), presumably from another heart attack. Had he been stricken today I am sure there is more that could have been done for him, but this was almost 50 years ago and even pacemakers were not in general use then.
Another interesting patient was a middle aged lady admitted with pneumococcal pneumonia, a common bacterial pneumonia easily treated with penicillin. What made her out of the ordinary was her rather swollen knee. I drained the fluid from her knee, cultured the fluid and then “stained” and examined it under a microscope. I discovered pneumococcal bacilli in the fluid along with many white cells. The bacteria in her lung had entered her blood stream (“sepsis”) and for an unknown reason had settled in her knee joint, giving her a “septic” knee infection. Pretty unusual, to say the least. So much so, that when I called the attending physician, he dismissed my diagnosis out of hand and was rather rude about it, thinking I was too inexperienced to make such a diagnosis. This man was one of the reasons I left Internal Medicine for Radiology. He was like the cardiology professor, very critical, aggressively so. He was symptomatic of one of the ills of the system, still present today: doctors don’t praise doctors. Basically, house staff work was (pardon my French) what the feminists call “shit work.” Work only noticed if done poorly. There was no positive feedback and I needed it. Most of my work was routine, but as I sometimes made mistakes and always heard about them, I also made good, out of ordinary calls or diagnoses, never to hear a good word.
The GSUH ER was next. There was a different attitude in place versus the General’s ER. The main object appeared to be to discourage patients from coming to the ER. Once in, if the patient was not a true emergency he or she was disparaged apparently with the hope that he or she would never return. This attitude continued until a consultant told the administration that by driving patients away it was losing millions of dollars in admissions and followup visits and tests. After that, there was an attitude adjustment. While not a madhouse as the General ER often was, this ER could be busy, especially at night. and some very sick patients could come in. My sickest was a middle aged gentleman brought in by his roommate for “acting funny” then becoming non responsive. He exhibited the “O” sign which was an constant open mouth while unconscious. (In our dark humor, if the tongue was also sticking out, this was known as the “Q” sign). Our Chief of Staff had taught us on these occasions to act first, then ask further questions. The first act was to hang a penicillin intravenous drip infusion, and the second act was to perform a spinal tap. Time was of the very essence. If the patient had bacterial meningitis, which could be diagnosed by seeing white cells in the spinal fluid, and later cultured, penicillin would usually cure it fairly rapidly. Bacterial meningitis destroys brain cells quickly and can kill a person in 24 hours if untreated, so treatment cannot be started too soon. If the patient does not have meningitis then the penicillin can be discontinued with no harm done and other diagnostic avenues pursued. The spinal tap had another function which was to look for blood in the fluid which would indicate a cerebral subarachnoid hemorrhage, two birds with one stone. I think it was during this rotation that I realized that most, not all, of the patients I was seeing had nothing really wrong with them. Symptoms were the result of psychological problems and I could not deal with this realization, I wanted to cure disease not neuroses. These people were not malingering or making up symptoms for emotional gain or attention, but, again, the problem was mainly psychological and the more extreme of these patients were known as “crocks.” When I realized that a lot of my patients in the future were going to be “crocks”, I decided Internal Medicine was not for me. I was fortunate to obtain a Radiology Residency at the GSUH after which I worked in my new home town for over 30 years in private practice. Unbelievable changes in medicine have occurred for the better (mostly) over the past 50 years and I have been a fascinated observer.