At the Still Point of the Turning World
Residency is over, NOW what? (While I'm waiting for the answer, I'll get some spinning done....)

Saturday, July 12, 2003


As of July 1st, I am officially a third-year resident here at the Monterey County hospital. This is a tumultuous time; all at once, there are new interns stumbling around the hospital, getting lost and puzzling over how to log onto the computer. The former interns, now second-years, suddenly look worldly and accomplished, even as they slug their way through newly-packed clinic sessions and assume responsibility for the terror known as ICU call. The former third-years have already become a fond memory; only gone two weeks, their escapades have been engraved on the collective memory of the hospital. ("Remember the time we convinced ____ that a baby had a rare inherited disorder of the penis? He almost persuaded the baby's father to submit to an examination of his OWN penis....") And the former second-year residents--my class--have been shot out of the cannon of junior residency into a position of uncharted professional responsibility.

In residency, promotion often precedes complete acquisition of skills. Overnight, it seems, we have been placed in charge of all the work the call teams do after hours, a constellation of duties that we used to think about vaguely and dismiss as an occurance that was placed too far away in the future to ever acually happen. These on-call duties include the following:

1. Supervise the intern on call closely on every facet of the intern's work. This includes supervising his/her performance of vaginal deliveries and repair of (intended or unintended) episiotomies; and overseeing their inpatient admissions, with attention to the legibility and soundness of their written history and physicals, AND the correctness of their admitting orders. This is the primary responsibility of the third-year on call and means that the third-year will only sleep as much as the intern. (Not much.)

2. Respond to calls from the Mental Health Unit when psychiatric patients are placed in seclusion rooms. Third-year residents are required to have their medical licenses, and therefore have the authority to sign seclusion orders. When the MHU calls, this requires the third-year to trudge resentfully down to the locked unit, wait to be rung in, locate the patient, and determine if the patient is actually breathing and being cared for in an acceptable environment. Sometimes the patient is combative and this assessment merely consists of peering through the window of the locked room and seeing the patient hollering at the top of his lungs. The reasoning is that a person cannot holler if he is not breathing. This is the kind of keen clinical acumen that results from four years of medical school and two years of residency, and it comes at a price. After the patient is determined to be alive, the third-year has to sign a form and return back to Labor and Delivery...

3. ...where the intern is trying to run a busy Deck of laboring women and handle the triage of pregnant women who think they might be in labor, or who have caught a miserable cold, or whose backs hurt and they just can't take it anymore. Running the Deck, as L&D is called, is an art, not a science, and takes a long time to learn. The third-year resident has to teach the intern how to prioritize their management of, say, a dozen women, some of whom can go home and some of whom need a little bit of help in labor. The third-year also has to struggle with the following competing truths:

a) The intern has to learn to run the Deck while on call.
b) The intern will take an hour to to what the third-year can accomplish in five minutes.
c) If the third-year does the work in five minutes, the intern will never learn to do the same work in less than an hour.

A good third-year, faced with these truths, will grit his or her teeth and let the intern do as much work as possible.

4. Ensure that both the intern and the second-year resident eat regularly, drink enough water, and do not faint while on call. An unconscious resident is absolutely no use whatsoever.

5. Play a noninvasive, yet watchful, role with the second-year resident on call. The second-year resident has graduated to a position of almost total autonomy while on call, responding to cross-cover calls and admitting babies to the NICU with only a brief phone call to the attending physician. This does not mean, however, that the second-year resident is immune to error or has no pressing educational needs. A good third-year keeps this in mind and directs the second-year's admissions accordingly.

6. Responds to pages from the Emergency Room attending. These calls usually mean there is a patient to be admitted to the hospital. The third-year listens to the ER doc's report about the patient and determines which resident should do the admission. He or she then has to trudge resentfully down to the ER to assess the patient and to leave a brief admission note on the chart. If the intern is going to be doing the admission, the third-year has to pay particular attention to detail because it is the senior resident, not the intern, who will be taken to task in the Morning Report if there are major errors in the patient's management. When I was an intern, my favorite senior told me, "Chan, you can't make any mistakes. If there's something wrong with the patient's admission, it's my fault." This is the standard I live by.

7. Is the first person the junior residents go to when they have questions. This responsibility is the strangest, because it assumes that the third-year actually knows what to do. The part I worry about the most is interpreting EKGs. There's a lifetime of study contained in the average EKG and I've been intimidated by them for years. Now I have to be the one to wrestle with the tough ones. Ow.

8. Runs to all Code Blue calls. The entire call team should respond, but the third-year, as Source of Knowledge, is often the one who has to get things moving smoothly. (It's a big relief when the on-call anesthesiologist arrives, that's for sure.)

9. Assist on all Cesarean sections performed on call, and on any general surgery cases (appendectomies, exploratory lapartomies) for which the on-call surgeon requests help. For those of us with no affection for the OR, this is no source of joy, and often a source of panic. Our residency has always been known as a program in which residents could obtain enough C-sections to qualify for their own privileges after graduation, and recent graduates have been "section sharks" in their efforts to boost their numbers. My class, however, is unique--none of us is particularly hungry for C-sections, not even me, who almost went in to OB/GYN.

10. Runs the Morning Report. This involves rounding up the X-rays of the patients admitted the night before, making sure the junior residents are ready to present the patients, and getting started on time. Even if the day teams are late, I start Morning Report on time, in the hope that we will end on time. As the old medical adage goes: "The longer you stay, the longer you stay."

What do we get for all of this? Release from most inpatient services, which means no more rounding at 6 AM every day of the week. More outpatient clinics, and generally a cushy daily schedule.

And at the end of the year--graduation. Without succumbing to short-timer's syndrome, I'm facing this last year with a frothing inner turmoil, a calm public face, and the knowledge that I still have more to learn than the year can possibly bring. That's the beauty of medicine--there's always more to discover.