The Doctor at Six Months

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Internship is a panoply of experiences.  My first day was a new EMR, a new hospital, a New York City emerging from fog and trauma. The first month was every order triple guessed and checked. It was me standing outside the room of a COVID-19 patient fingering the edges of my duckbill N95 to ensure a secure fit. It was me supervising the transport of a patient with a tracheostomy down to the CT scanner, where the technician pulled me over to look at another patient’s imaging with a “Hey, doc, what d’ya think?,” while his hand swept over a pair of lungs ravaged and wrecked by COVID. That first month I had just one COVID-19 patient directly under my care. Otherwise, I was caring for a typical batch of General Medicine patients: diuresing a patient with interstitial lung disease, ruling out a myocardial infarction, performing paracenteses, and guiding another patient through a safe alcohol withdrawal. The first month had me juggling the barrage of notifications and questions and to-do’s and filtering the chaos through the experience of my senior. On the wards of the hospital, I was one of many frenzied interns taking orders and answering summons and coordinating the ground communication of a grand medical bazaar.  Going in, I would have thought that the pandemic—its restrictions and victims—would overwhelm the day-to-day and make my intern year unidimensional. The surprise of my intern year was its variety. It was finding out how much the pandemic failed to dominate our everyday experience.

Placing every order correctly was the first hurdle of intern year. I felt the responsibility of every click, the weighty consequence borne in the lettering, e.g., mg vs gm. Another hurdle was keeping focus amid the onslaught of distraction, for which the checklist proved irreplaceable, both anchor and compass. That blank piece of paper became an inscrutable mess of scratches and checkmarks but it was my guide to the day, and it always made sense to me. Yet another hurdle became the ability to flex, to complete the day’s tasks for the four patients remaining on service, successfully discharge the fifth, transfer the sixth, and admit a seventh, and if needed an eighth. In our culture that was accomplished as a team, and one of the great joys of intern year has been that core relationship between intern and resident. Nobody has taught me more than my seniors.

Some of the patients I remember most are those for whom we could do the least. These were the ones for whom definitive therapy remained elusive. These were the ones in the final chapters of a long journey of which I saw the briefest of summaries – an entire decade surviving cancer summed up in a one liner and a spread of bullet points documenting key events and treatments. Our role was to help them navigate the final weeks or days or hours. I also learned that performing a paracentesis offers an excellent opportunity to discover the person behind the patient. I’ve had several insightful conversations waiting for a patient’s abdomen to drain liters of clear, yellow fluid. The faces of these patients – the ones with whom I spent a few extra minutes conversing, or over whom I felt distressed due to the futility of our treatments, or for whom I was able to offer small gestures of comfort– these patients’ faces remain with me more easily than I would have expected. It surprises me how many of their faces I can remember given how briefly I met them and given a year in which I cared for hundreds of patients. It speaks to the intensity of these moments, how deeply they sear in my mind, that I can recall them so easily. Despite our masks and gowns, despite the limited visiting hours, despite the constant fear of COVID-19, there were countless poignant moments that the pandemic could not prevent nor wash away.

On night float, there was much to do, despite the unnatural hours. The hospital at night could prove just as busy as the busiest day, and between a code, two tenuous patients, and a few admits, the night could pass quickly. But the night also came with greater autonomy that highlighted the partnership of the two junior doctors responsible for a preset list and what admits would come. I rarely felt more pride than when the attending had little to add to our management of hepatic encephalopathy or osteomyelitis or acute limb ischemia. I felt less like the busy intern taking orders and answering summons. Instead, I was making diagnoses. I was exercising clinical judgment and consulting the literature. In other words, there was a doctor putting out branches, showing leaves, and digging deep roots in my mind. 

And yet, as in the daytime, there was the partnership of resident and intern to fall back on. It amazed me that we were separated by only one year, or at most two, and yet separated by a gulf that somehow only ever appeared insurmountably wider as the months rolled on. When would I make that leap? In just six months? It was another hurdle of intern year to be overcome and by far the grandest. 

Already I have diagnosed Graves’ disease, diabetes, and cardiac amyloidosis. Performing EKGs and ABGs have become routine. As an intern, I have become adept at navigating complex, emotionally fraught discussions. My patients speak Bengali, Creole, Russian, French, Arabic, Portuguese, and Mandarin. My patients’ families have thanked me with cards and cookies and many genuine well wishes.  Every day I read and experience and find yet more I do not know, yet more nuance to medicine and the human body and the care of humanity to which I have committed myself. All this has gone on despite the pandemic, and something about that seems miraculous. Although the pandemic has dominated the last year and upended our daily lives, it has not prevented us from having an intern year filled with the variety and breadth of medicine that originally drew me to an internal medicine residency and that I consider essential for my training. This struck me again and again as something for which I must be grateful because it was not guaranteed in the setting of a once-in-a-generation pandemic.

When I wrote this essay at the end of my two weeks in the MICU, awaiting the surge of COVID-19 that my intern class had so far avoided in New York City, I was reflecting on the variety and diversity of experiences of my intern half-year. The horror stories from the spring abound, and the sheer amount of death that cascaded upon the hospital back in March and April left its scars. But the hospital, the nurses, the residents, and the attendings, despite their weariness and trauma, have welcomed us and set us on our feet, and I admire them for it. The COVID patients I cared for in the MICU were examples of the ferocity of the virus. They arrived to us in poor condition, but there were stories of those like them who walked out of the MICU on their own feet, and of course we kept doing all we could for them, hoping their kidneys wouldn’t continue to fail, hoping their lungs wouldn’t continue to scar and fibrose. 

It’s difficult to imagine how intense and disorienting it must have been to have been present during the initial wave of COVID patients back in the spring of last year. So far New York City has managed to avoid returning to those times, and as a result, I can look back on my time as an intern and celebrate how much medicine I have witnessed and how fortunate I have been to care for such a diversity of patients, of so many walks of life, both those facing COVID-19 and those struggling against the chronic and acute diseases that have plagued humanity for much longer. Still, it has been an unnatural experience. Something similar is unlikely to happen again for a long, long time. It will become something that makes my intern year unique. And despite the seriousness and sadness, there is some element of awe I feel as a witness on this grand stage, the hospital. A dark cloud hangs over the world and I am here, locked arm in arm, doing my best to keep it at bay, all the while collecting the panoply of experiences that will make me a doctor in more than just name.