One day, you find yourself on the edge, peering into the abyss. Then someone pushes you in. Welcome to the first day as a surgery intern. Few folks outside of medicine fully fathom the rigors a doctor must endure during post-graduate training. From the get-go, we were thrown into the fire, responsible for complicated, sick hospital patients, in what felt like a prolonged boot camp, where ridiculously long hours, horrid scolding, and humiliation were commonplace.
July 1st, 1990. The first day of the rest of my life. I began my internship on the surgical team of residents and medical students assigned to a group of attending surgeons, one of whom was none other than The Chairman of the entire department of surgery. Notice “Chairman” is capitalized as a proper noun, just as God is capitalized in the Bible, for it was impressed upon us that Chairmen were of divine esteem. Chairmen would unlikely argue against this form of grammar, since many Chairmen believed they—as it was portrayed to us—were not much different than The Almighty Himself.
We were cheap forms of labor back then. There were no limits on work hours, a time before the U.S. capped the workload for doctors-in-training to 80 hours a week. I was on-call every other night much of that year. Working a hundred hours a week or more was not uncommon. After a while, I thought I’d crack. A few of the Attending Surgeons (notice the capitals) posed half-jokingly, “What’s bad about every-other-night call?” The bona fide answer: “You miss half the good cases!” implying we should be on-call nonstop, 24/7, and they generously were lenient on us wimps.
We lowly interns missed the “good cases” anyway, mired in thankless grunt work, rushing around attending to patients on the wards, ICUs, and ERs; paged endlessly (we had no cell phones); drawing blood and inserting I.V.s into any vessel we could find; threading nasogastric tubes and urinary catheters into tight orifices; changing dressings, debriding nasty wounds; copiously writing orders and notes; and then calling for lab and path results, scouring the expansive medical complex for all the X-rays, CTs, MRIs on large sheets of film. Information technology was unheard of, computers were virtually non-existent. It all was exhausting, mentally, physically, and emotionally, sucking the lifeblood from our sleep-deprived bodies.
The Attendings wanted to add a “13” to the clock face, so the running joke went, to bleed more hours from us. God (the real one) forbid, if a patient had an unintended problem or complication and we were otherwise occupied because of, let’s say, sleeping, eating, or using the bathroom, we were derided as selfish or lazy or both. All too often, I was the object of ear-shattering yelling for an eternity of inadequacies, with bouts of “Goddamit Fong!” or “What’s wrong with you, Fong?” I’d stand silent, heart thumping so loudly into my ears, I swear others nearby could hear it too. All of us took the verbal beatings, since the real God had not delivered interns and residents from the bondage of academic medicine like He had for the Jews from Egypt.
The operating room was primo space for a good lashing, depending on the Attending. I longed for cases where the senior resident was the lead surgeon. I quivered whenever it was just me and The Attending on simpler cases. The experience could be highly unpredictable; things would start rather benignly, then wham! Hell would unleash, raining down a tirade of yelling and screaming and good old-fashioned condescension, all directed at yours truly. Fortunately, the surgical mask hid my shock and shame.
One night on-call during my second week as an intern, I found myself in a bad predicament. We had a patient who was admitted several weeks before I started the service, who had a previous esophageal surgery some years prior by the Chairman himself. This patient was intermittently vomiting blood. Prior tests and imaging were not forthcoming, and he was not stable enough for an esophagoscopy by the GI docs. I called the senior resident several times that night for advice, as the bleeding worsened until ultimately it poured out of his mouth, nonstop. He deteriorated fast, but fortunately one of the more senior cardiology residents was there to help me. Despite intubating him, running fluids and blood as fast as we could, he coded, and we could not revive him. Days later, the team was able to attend the post-mortem autopsy, where the pathologist revealed the remnant esophagus and aorta were scarred to one another; in this scar tissue formed a small flap hinged on one side, acting like a valve, allowing blood from the aorta to shoot into his esophagus. It was an unusual sequelae from his prior surgery and radiation therapy. Fear mounted since I knew what was coming. M&M.
M&M was the dreaded weekly morbidity and mortality conference. M&M could be horrible, wrenching your innards terribly, winding loops of bowel into knots only Houdini could release. Any patient on the rosters from all of the various surgical teams were fair game for discussion, and it was the intern’s duty to present the history leading up to the complication or unintended consequence, from memory, no notes allowed. We stood on a stage, in front of a large audience of Attendings, visiting surgeons, residents, interns, and medical students. Questions and then public lashings could spew from any of the Attendings sitting in the front rows. When it came my turn to present the aforementioned case, I shook in my white coat, but elaborated his entire hospital course, including the awful final night and the later-discovered cause. The Chairman happened to be out of town that day, but the other Attendings held back their natural chastising, for they too were surprised by this unpredicted pathology. This was an exception to the rule, where dressing down along with threats of firing or making a resident repeat a year were not uncommonly employed to whip us into shape.
That was another era, a long time ago. The Attendings were disciplinarians, who believed their disciples must accept all responsibility for anything and everything that goes wrong with a patient, no matter the cause. Soldiers are trained mercilessly to prepare for war, where fear is a strong motivator. Doctors must train likewise for the war against disease—the lives of the sick are placed in our hands. Much of the intimidation was unnecessary, but I harbor no ill will. I’ve learned long ago to take the good with the bad and mine the gold, no matter how little, from every experience I’ve had.
Randall S. Fong is an otolaryngologist and can be reached at his self-titled site, Randall S. Fong, as well as his blog.