Jan 17, 2017
“Alternating ecstasy and despair characterize resident life in particular, and medical practice in general.”
A hospital at night is like a forest after dark. It never really sleeps. The mad clamor of the day ebbs, but a hum of comings and goings persists into the wee hours. Tonight I am walking the halls with a plastic bag of Thai takeout. No one bats an eye. Through the emergency department waiting room, then the observation unit, up the stairs and a right into the resident lounge for forks and knives, and finally a double-back to the anonymous beige corridor that houses the call rooms. An intern leans against a wall, looking down at the pager in his hand with hatred and suspicion. The aroma of my cargo rouses him; he flashes a dim smile as I pass, then returns to his battle of wills.
I deliver a light courtesy knock to one of the doors, then dial the entry code.
“Oh, thank God,” I hear from within. “Get in here.”
I find Sabrina gazing into a computer screen like Frodo into Mount Doom; some painful task lies ahead, and she’s trying to postpone the moment of reckoning. The call room looks like it has been recently vacated by an early-stage hoarder with a fondness for syringes, Post-its, and drugstore candy. There is a smell.
“Did you get the Mongolian beef?” she asks. “I can’t look at this chart anymore. I don’t know what the medicine service did except write twenty-five notes about glucose levels.”
Sabrina is a second-year general surgery resident, or “R2.” In my hospital, as in many, surgery R2s suffer the worst lot among all residents. They are the ones assigned to twenty-four-hour “in-house call,” which means they cannot leave the hospital for a twenty-four-hour shift that usually balloons to about thirty. They’re responsible, in short, for managing virtually any surgery-related question or issue that arises in the hospital, especially at night, when professional staffing is down to bare bones. It can be quiet, or it can be a dusk-to-dawn, life-and-death sprint from fire to fire.
Sabrina is not having a quiet shift. Amidst a flurry of consults and an emergency surgery, she hasn’t had time to catch up on documentation work, let alone eat dinner. She’s currently shoveling as much of the food I’ve brought into her face as she can in the four minutes before her pager starts to vibrate, making a slow, suicidal passage toward the edge of the desk.
I am not a resident, nor a doctor at all, but I form a small part of the machine that helps educate them. In short, I help teach young doctors using healthcare simulation, a catchall term for any training method not done on actual patients: suturing on pigs’ feet, practicing difficult conversations with standardized patient actors, managing operative crises on a high tech mannequin with real lung sounds and blood pressures. These simulated scenarios grant residents valuable clinical experience without the pressure and risk of patient lives at stake.
My job means I spend every working day around residents, in clinical and non-clinical situations. I have the privilege of bearing witness to their setbacks and breakthroughs. Dear friendships have bloomed with some, like Sabrina, in the cracks between workups and lectures and surgeries. Plans go unrealized, movies unwatched, but I don’t mind; that’s the life of a resident, and whatever Sabrina is doing when she doesn’t answer my texts is more important than after-work martinis. Likely as not, she’s elbow deep in gastric contents, dissecting a bowel tumor. She says the “cool” factor dissipates quickly. Remove enough gallbladders and appendices, and operating becomes carpentry. I find this difficult to imagine. But knowing Sabrina offers me a precious glimpse into these obscure wisdoms that attend a physician’s career.
After thirty seconds of insectile buzzing, Sabrina picks up the pager, glances wearily at the screen.
“They need a response within an hour,” she says. “I’ll call back in fifty-nine minutes.”
Residency is a strange, liminal chapter in the life of a doctor. You’ve earned a full-length white coat (medical students wear the awkward truncated ones) with a neat MD embroidered after your name, but you know little about the day-to-day practice of medicine. You’ve chosen a specialty—dermatology, radiology, pediatrics—but it will be years still, anywhere from three to seven or more, before you are permitted by most institutions to practice on your own. In the interim, you undertake a closely supervised apprenticeship, a mix of education and service and education-through-service, which asks much and pays little.
Resident life is bad in ways that have become familiar to the public through TV shows like Scrubs and articles that track the ongoing controversy over restrictions on resident work hours. (Which are long, but somehow, according to some people, not long enough.) As a resident, your time is considered infinitely elastic, and the parties who order you around have little to no sense of the competing demands placed upon you. You are blamed for missteps that aren’t your fault and it’s unseemly to defend yourself.
Your superiors grill or “pimp” you, usually in front of your peers, on arcane knowledge you once spent two minutes learning in the first year of med school—or worse, anatomy you should know but have lost in the heat of public humiliation, despite spending your “free time” (midnight to 3 a.m.) studying. Patients ask if you’re “even a real doctor.” Non-resident friends, family, your significant other, and dog have forgotten what you look like. Your pager owns you and your sleep is invaded by recurring panic dreams about its screeching chirp. Every day you wade through a miasma of disease and death and body horror that never, ever clears.
“I’d like to kill the person who told me to go to med school,” says Tanya, another resident friend of mine. “I could have been a PA (physician assistant), or a nurse practitioner. Get out of school sooner, work better hours, still make good money.”
We are out with a few other residents at a small, dark bar around the corner from the hospital. Most residents develop strategies for managing the trauma and exhaustion of their everyday existence. Some residents exercise, some have hobbies. A small minority find relief through talk. But almost everyone drinks. In volumes just this side of having a problem. Never at work or on call (at least the ones I know), but at any other time, it’s typical to witness some amount of coping-by-intoxication. It’s part of why we get along so well.
Dressed in dirty scrubs, hair a frantic halo, Tanya wears the day on her person. She’s three whiskeys in and past caring. In a few months, her marriage will fall apart. It will barely register.
“I spent an hour being physically abused by a patient, so that was great. I had to hold pressure on this giant hematoma on her leg. I’m alone, of course. I get up on the bed, use my full weight. She’s hitting my arms, my face, hollering at me the whole time: Get off me, get off me! I try to explain: Ma’am, if I move away, you will die. Meanwhile, a nurse walks by, hears the yelling. You know what she does? Swear to God. She closes the door to the room.”
By this point, we are all doubled over, wheezing into our cocktails. It’s impossible not to laugh in the face of such total, abject bleakness. Especially when you’ve been there, dozens of times, hundreds of times, as a matter of course. For a minute I envy this cozy band of brothers and sisters their camaraderie, a bright spot of joy along the glum trudge through medical education.
“Thanks, guys,” Tanya says. But now she’s laughing too. “I can’t wait to find out what kind of shit tomorrow will rain down.”
She is rotating on the bariatric service. This could be literal.
5 p.m. at the end of a long, overcast Monday. Andy, a drawling first-year from South Carolina, crumples like a pair of cast-off scrubs into the chair facing my desk.
“Please,” he says. “Tell me you’ve got some food in here. I haven’t eaten since this morning and I just snuck out of an eight-hour Whipple for a piss. Which Dr. Green yelled at me for.”
“Uhh.” I extract a handful of mini Snickers from a bottom drawer.
“Perfect!” He grabs them and begins to shuck wrappers.
Andy used to be a lawyer—of course, he still is, but a few years into practice, terminal boredom prompted a radical career shift. As a result he’s a bit older than most of the other residents. I ask him whether he thinks residency has changed his perception of what’s “normal.” He says no. I remember the first time I went over to his apartment and noticed a framed picture of something red-brown, slick, and bulbous on a side table in the living room.
“It’s a gallbladder,” he’d explained. “The first one I ever removed on my own, skin to skin. Not a bad conversation piece with the ladies.”
I watch him now, an early middle-aged man horking down expired sweets in a stained fleece, staticky blonde hair trying to escape his surgical cap. All of a sudden he looks about eight years old, just plain tired and hungry, with no understanding of the injustices to which he is subjected. A rush of tenderness takes me over.
“Do you want me to run out and get you something?” I ask. “Even just Starbucks . . . ”
“Nah, it’s fine. Hopefully they call a code in the cafeteria soon. It’s Meatloaf Monday.”
A code is a cardiac arrest. I don’t judge. No one here would. Rigorous schedules force residents into bizarre and erratic eating habits; it’s no wonder that food becomes the ultimate object of longing. Knowing how poorly residents eat and how little money they earn makes it harder to criticize them for accepting dinner invitations from pharmaceutical reps. If you prorated resident salaries by hours worked, you’d find many of them make minimum wage. The great irony of the medical profession: the total failure of doctors to care for themselves and each other.
One day after morning conference, Sabrina walks into my office, closing the door behind her. Her eyes are glassy. In our three years of friendship, I have never seen her cry.
“What happened?” I ask.
“Nothing different from usual,” she says. “I’m just tired of it today.”
I know immediately what “it” is: the manifold delights of being a woman doctor. Today, a senior resident has mimicked her high-pitched voice in front of the entire residency. Hardly the first or worst such incident. An attending once told her she was “too pretty” to be a surgeon. Another likes to take nonconsensual photos of the female residents when they wear nice outfits to clinic. Medicine is, as it ever was, a boys’ club, and no specialty resembles a fraternity more than surgery.
Mistreatment takes structural forms too. Pregnant residents work until the day labor kicks in. Residents whose spouses are pregnant are lucky to get a week off after the birth. One day, a near-term resident stands too close to a patient bed and almost electrocutes herself defibrillating the patient. She is roundly chastised. But I can tell the attending isn’t really angry—he’s just afraid for her and the life inside her. A few hours later, he brings her tea and a muffin, and a repentant smile.
Amidst a fog of panic and exhaustion, patients start to feel like the enemy. They seem to seek medical care for chronic conditions exclusively between the hours of 2 and 4 a.m. They call for urgent prescription refills the day after running out of meds. They refuse to comply with lifesaving postoperative therapies; they argue passionately for diagnoses they discovered on the internet this morning. They cast a skeptical eye upon the resident assigned to care for them, asking how old he is and how many times he’s performed this procedure. A junior anesthesiology resident confesses to me: “I’ve started saying, ‘Mr. Smith, I’ve done an adductor canal block a number of times before.’ It’s not a lie. Zero is a number.”
But residents who survive are the ones who remember that patients also represent salvation. They hang on to thank-you cards, notes, small gifts. In a business where you’ve succeeded if you never see the customer again, these tokens play a role incommensurate with their literal worth: They provide material testimony to lives made livable once again.
“My cardiac patient has two blown IVs, a blocked internal jugular, another thrombosis, and a pulmonary embolism.”
Ashley, an internal medicine resident, has spent the last two weeks rotating in the Intensive Care Unit, where team members try to hold the hospital’s sickest patients back from the edge—or, in some cases, help them broach it gracefully. Nurses and doctors need equanimity and resourcefulness to thrive in the ICU, ground zero for tragedy and melodrama, and only periodic victory.
“Oh, and pneumonia,” she continues. “Can’t forget the pneumonia. Meanwhile, Dr. Ambrose criticizes every idea I have for trying to get access. He’s the sweetest little old man I’ve ever met.”
“Dr. Ambrose?” I ask. “He’s early forties and an absolute jackass.”
Ashley smirks. “The patient. Despite crashing every five minutes, he’s in a great mood. Up for anything I suggest. I look forward to seeing him every time. Even when I have to give bad news. Even though he’s taken over my whole day. With him, it feels like a privilege, somehow.”
I can tell what she’s trying not to say.
“He’s going to die.”
“Yeah,” she says, and exhales. “I just hope he does it before I start my next rotation. He’s got two sons and a daughter, three grandkids. I’d like to be the one to have that conversation, not some intern who’s meeting them for the first time.”
In that moment, I’ve never met anyone braver. Ashley wants to tell a family that their beloved patriarch will talk, eat, laugh with them no more. I think of my friends outside the hospital—artists, writers, activists—and the stick some of them give me for spending so much of my time with doctors. Sellouts, they’ll say. Bourgeois professionals. Maybe. But when I remember the kind of deep presence and humanity that doctors offer of themselves, every single day, the sheer bone-deep vulnerability of it all, those epithets are utterly emptied of meaning.
“How’s it going?”
“You know, the usual. Feeling up guys’ junk. Draining dick blood.”
“You love that,” I say.
“I can’t deny it,” he says. “It’s very satisfying.”
Chris, a urology resident, cuts a curious figure: a sun-loving, hair-pomading, existentially perturbed bro from San Diego. He shifts from “Fuck yeah, I had my hands in a dude’s kidney today!” to “God, why do I do any of this?” in a matter of seconds. Today, he’s high, born aloft on the wings of simple physiologic triumph.
“This guy had an erection for twelve hours. Can you imagine? They transferred him from another hospital because the docs there gave up. Not me, though. How could I abandon a brother in need? Needle in each hand, lots of force. Bam.”
But just yesterday, laid flat on the conference table in my office, he wondered: “What’s the worst that could happen if I dropped out?”
Alternating ecstasy and despair characterize resident life in particular, and medical practice in general. I hear residents say all the time: If I can just make it through residency. But I wonder how they envision what awaits. Residents, at least, have the thrill of scaling a steep learning curve, even if it is accompanied by terror. A few years into independent practice, many physicians find the highs and lows have evened out into a humdrum emptiness.
Differential diagnoses and operations perform themselves. The number of hours in a day stay the same, but demands on physicians increase. The ceaseless multiplication of billing codes and documentation requirements. This is the hard-won prize at the end of a long apprenticeship: drudgery, punctuated by moments of healing and connection. For the fortunate, enough of these moments add up to a sublimity that compensates for the quotidian insults of doctoring.
But in residency, you can’t know whether you will be one of the lucky ones. And even if you did, you couldn’t do anything about it. The truth is, residency, for those not born into wealth, is a kind of indentured servitude. Saddled with debt from college and medical school, most trainees cannot afford to quit the programs that will enable them to practice on their own and eventually achieve financial solvency.
The tiered structure of medical training (college, med school, residency, fellowship) relies on a compelling myth: The illusion that each progressive level of accomplishment ushers one closer to a culmination of one’s efforts, which will serve as final proof of one’s worth, and bring an end to a long phase of striving and uncertainty. But just as the system builds up this illusion, it also tears it down. Within the grinding, repetitive endlessness of residency lies its final and most important lesson: Medicine is not teleological, but infinitely renewing. Doctors dip into people’s lives at moments of crisis, then retreat; dip into another, retreat. The wise ones learn that all medical practice is training, preparation for a final emergency that never comes, just as all living is also preparing to live.
Rotating at a local children’s hospital, Sabrina sends me me a text. “Today I get to sew on a baby’s heart!!!” That night, another, simply: “Whoa.”
“Half the time, I hate my job,” says Andy. “Half the time, I’d do it for free.”
Each day, the waiting room is refilled. The exam table is wiped clean. The OR light flickers to life, a white sun rising. I arrive at work right around the changing of the guard. Residents coming off the night shift pace the halls, sluggish and dark-eyed, sewing up last-minute requests and handing off patients and pagers to the day team. If you asked, they probably couldn’t name what day of the week it was. Chatter buzzes around the coffee urn in the lounge: new admissions, planned discharges, rare and exciting diseases, breakfast hopes, attending moods. At computer stations, junior residents scribble down morning vitals for their patient lists. Soon it will be time to round, to scrub in, to draw up vials of emergency medications to keep in one’s pocket just in case, because you never know. They will do their best to know.
This article first appeared on catapult.co
Read at https://catapult.co/stories/the-surgical-resident-life
Jennifer R. Bernstein is a Seattle-based writer and co-founder of The New Inquiry. She has written essays and criticism for LARB, LitHub, Pacific Standard, Brooklyn Magazine, Ploughshares, and more. She lives on Twitter @jenniferrenu.