Lakeside Medical Musings

Sleepless in Dallas

I graduated from the Medical College of Georgia, Georgia’s public medical school, in 1979 with what was, by all accounts, a top-notch education.  I had found my niche, excelling in both my classes and my clinical rotations, and I finished in the top 10% of my class.  I routinely received high praise for those top scores, as well as for my clinical acumen and the relationships I forged with patients and coworkers.  I was rewarded for my efforts with election to Alpha Omega Alpha, the Phi Beta Kappa of medical school, an honor I wore with pride throughout my career.  I subsequently did great on the National Boards, placing in the top 5% in the country. While I knew that I was well-prepared for my residency, I also knew that MCG wasn’t Harvard, Yale, or the University of Chicago. (I specifically exclude Duke from this list because Duke has pissed me off more times than I can even count at this point, and well… it is, after all, Duke. Go Tar Heels!)  Scoring so well on both the basic science and clinical parts of that great leveler, the National Boards, made me think that I knew just as much as those ivy-garlanded  students but with less than 10% of their student loan debt.  I felt good about myself, the school I’d chosen, my about-to-blossom career, and my future in general.  On that scorching hot June day in Augusta, one could almost hear a collective sigh of relief from the graduates.  We had made it.  We were now physicians, M. frickin’ D.’s, for God’s sake, and we were ready for the next step, or so we thought.

In 1979, 1,100 medical students applied for the 38 available internal medicine internship slots at Parkland Memorial Hospital.  Formally known as the University of Texas, Southwest, at Dallas, this was literally and figuratively the Mecca of Medicine.  It was considered one of the top two internal medicine training programs in the country.  To give you an example of the esteem in which Parkland’s training program was held, Harrison’s Principles of Internal Medicine was considered THE medical textbook and, in 1979, three of the four editors were faculty physicians at Parkland.  Brown and Goldstein, (they were always referred to exactly that way) were definitely going to win the Nobel Prize, which they did in 1985, and Don Seldin, a.k.a., “The Don,” was a God among physicians and was the Chairman of Parkland’s Department of Medicine.   And I, a graduate of MCG, was going to be one of those 38 interns training in one of the most prestigious programs in the country.  I was proud.  I was excited. And to be honest, after all my success at MCG, I was probably more cocky than scared.  One of the things that MCG prided itself on was successfully preparing its graduates for the next step, clinical internships.  We had the medical knowledge but, equally important, we had the technical chops.  Other higher-ranked schools produced students who – and I know this from working with many of them —  were very book-smart but clinically inexperienced and inept.  I could start an IV or an arterial line in – literally — any patient.  I was already skilled at performing such procedures as a thoracentesis, a paracentesis, or a lumbar puncture. I could palpate, intubate, and resuscitate, and I was fearless. In the immortal words of The Fat Man in Samuel Shem’s The House of God, “THERE IS NO BODY CAVITY THAT CANNOT BE REACHED WITH A #14G NEEDLE AND A GOOD STRONG ARM.” I had a good strong arm and the confident swagger of Willie Mays. Put me in, Coach! I am READY.

In reality, being an intern was nothing like being a medical student.  In medical school, there was a steady stream of positive feedback from my attending physicians and professors.  In training, there were endlessly long hours coupled with lack of sleep, poor nutrition, and relentless hazing by faculty members.  This had been a rite of passage for generations in medical training (just ask my father!) and despite my confidence, I was absolutely not ready for it.   I should have been warned by the interview process when I was trying to decide where I would apply for my residency.

Carl and I were driving in his 1968 Cadillac in early September of 1978 when we barreled out of Augusta on I-20 heading west to Birmingham for our first residency interview trip.  We were both from the Northeast, and I knew there was no way I would ever live again, by choice, in the land of endless, dark, gloomy gray winters. Carl was planning to return to the New York area for training, but the University of Alabama’s Department of Medicine was reputed to be one of the best in the South, so an interview there was a reasonable exercise. This was my first residency interview, and I was incredibly excited.  My interview was scheduled with the Chairman of the Department of Medicine and, thirty minutes after my appointment time, his secretary escorted me into his richly paneled office. The doctor, whose name I gratefully don’t remember, glanced up at me from the pile of newspaper on his desk, nodded, and barked, “Sit!”  There was no greeting, no handshake, no introduction, no small talk.  He asked me what I wanted to do, and then picked up a section of the newspaper. I squirmed uncomfortably in the cold leather chair, and I replied that I was here for an interview, that I was a senior medical student at MCG and I was very interested in being a resident in his program.  The man read the newspaper the entire time we talked.  Other than when our eyes met when I walked into his office, for the 20 minutes it took to complete our “discussion,” I never saw his face again, not even when I left his office.  I was furious that I had driven four hours from Augusta and didn’t even receive the smallest courtesy of twenty minutes of his attention.  He had already received my transcript and board scores and, my reasoning went, if he didn’t want me in his program, why would he have asked me to interview?  Was there something wrong with me that had caused his rude behavior?  I now had a nagging worry in the back of my brain.  Maybe, just maybe, I wasn’t as good a resident prospect as I was being told in Augusta. (Back to my propensity for holding grudges…  I am a major UGA football fan, but I always have a little extra oomph behind my cheering when Georgia plays Alabama.  Go Dawgs!) The first seeds of doubt about myself had been planted.

The next day was Nashville and my interview at Vanderbilt. I hoped for the best, but my confidence was shaken. Vanderbilt was certainly more welcoming than UAB, but I noticed that all the interns had a similar look in their red-rimmed, dark-shadowed eyes.  It was an eerie zombie-like combination of exhaustion and detachment.  Everyone was nice, but there was no animation in their faces or their speech. I am not someone who notices what people are wearing or attuned to fashion at all (ask my wife!) but even I noticed how wrinkled everyone’s clothes were and how their hair looked unwashed and disheveled. Finally I had my interview with the department chair. He gave me a warm hello and a firm handshake.  “I understand that you will be an intern in internal medicine next year.  That’s great.  We have a very good training program, and you are just the type of physician we are looking for.”  Now this was a nice change, and I felt much better about both myself and Vanderbilt.

But, of course, there was a catch, and it was a big one: the on-call schedule. At most programs, interns and residents were on call every third night, meaning the house staff worked thirty-six hours straight, off for twelve hours, then back in the hospital for ten hours, then off for fourteen hours, then back on for thirty-six. And the pattern repeats, over and over, for three years. But Vanderbilt was “old school,” like my father’s training program, on-call in the hospital every other night. That meant interns and residents worked thirty-six hours, off for twelve hours, then thirty-six hours on, off for twelve.  That is the definition of beyond brutal.  That’s why the interns looked like zombies. Because they WERE zombies! They were, literally, the walking dead.

Being one who always believes in cutting to the chase as quickly as possible, I said to the Chairman, “I am a little concerned about being on call every other night.  I am a hard worker with a strong constitution, but Vanderbilt is one of the very few programs in the country with every-other-night call which, by any measure, is brutal. What are your thoughts on this?” I never forgot his answer. “John,” he replied, “you are correct. There IS a problem with every-other-night call.” He smiled at me and said, “You miss half of the really great cases.”    I smiled back, and ran like hell.

I ultimately made Parkland my first choice, and we “matched.” After graduation, I packed everything I owned into my trusty non-air-conditioned Datsun 1200 and I and Mariah, my golden retriever, moved to Dallas.  In July of 1979, the average daily temperature was 94 degrees, one of the warmest summers on record. My drive into the hospital at 6:45 am was early enough that it was usually only around 85 degrees, but the ride home was almost always over 100 degrees.   But sweat-soaked or not, I wore a long-sleeved, knee-length heavyweight cotton white lab coat over my slacks, dress shirt and tie, and everyone called me Doctor Scherr. For the first few moments of July, 1979, life was bliss, excitement, and the perennial eagerness of the Type A over-achiever.  It is shocking to me now, in retrospect, how quickly that all crashed to the ground in a tsunami of distrust, cynicism, anger, exhaustion, and hostility.

There was virtually nothing about being a resident that made me feel valued or validated in any way, especially when seen in contrast to my years of medical school.  Working ridiculously long hours was expected, and since we were considered students, it wasn’t even required that we be paid a minimum wage.  We saw our attending supervising physician only on the weekday mornings when we made rounds, and rarely on Saturday or Sunday.  We were completely on our own taking care of patients. I am certain that I would not have survived my internship year had it not been for the compassion, mentoring, and friendship of many of my residents.  Paul, my first resident on my first rotation, the Pulmonary Service at the VA Hospital, became a good friend, a physician I admired and respected from Day One. He was a very bright guy from Buffalo, and a huge Bills fan, who went to medical school at Johns Hopkins.  The Pulmonary service was an ICU rotation, which meant that while we took care of numerous patients on the general pulmonary floor, we also managed the Medical ICU.

On my first day, Paul sat me down in the government-issue-green cubicle the residents shared and said to me, “John, we need to talk. Joyce, our Attending Physician, is not going to like you, and she hates me.”  “What?” I asked, incredulously.  “Why wouldn’t she like me? And what did you do to make her hate you?” I was nervous enough just being an intern on an ICU rotation, but to now know that my attending for the next six weeks was not going to even give me a chance before she’d even met me was pretty deflating. Paul said with an evil smile, “She hates me because I am from the North, and she won’t like you because she hates me.”  “No, really,” I said.  “What did you do? And, by the way, I am from the North, too.”  “Don’t tell her that, or she will hate you, too.  Just tell her you are from Georgia.  Then she just won’t like you because you are my intern,” he instructed.  This was just too bizarre for me, but later that morning when we rounded on our first patients and I met Joyce for the first time in the ICU, I began to grasp the enormity of Paul’s remarks.   Joyce was a caricature straight out of the television show Dallas, a loud, brusque, 45-year-old woman with short brown hair wearing cowboy boots.   After leaving our first patient’s room in the ICU, she said, “Let that &%$% die. He’s a Northerner.”  She laughed, and I would have thought she was joking had I not been forewarned by Paul.  It was clear from the tone of her voice when she deigned to speak to Paul that she didn’t like him, and she barely glanced at me.  But I was an intern—a lowly Untouchable to an Almighty Attending, so I wasn’t that surprised by her treatment of me.  But as the excellent, dedicated, experienced resident that Paul was, I was pretty shocked by her treatment of him. The six weeks I endured on Pulmonary were longer than long and extremely difficult.  Not one kind word was ever directed my way.  She was critical of most of the decisions that Paul and I made, and she demeaned us as often and as brutally as she could.  I noted that Joyce rarely had us actually make changes to our treatment plans, but she always criticized what we were doing and she was consistently, unrelentingly unpleasant.  As Chuck, the intern in The House of God, put it, “How can we care for our patients, man, if nobody cares for us?”

I had initially planned to finish my three-year internal medicine residency and then continue with a fellowship in a Renal subspecialty, but within a few months of the start of my first year, I knew I wasn’t cut out to spend one minute longer in Hell than absolutely necessary. Mecca, my ass.  More stories of training brutality and debasement will follow in future blogs, but they are mainly for entertainment purposes now. Thirty years of practice were built on the rigorous demands and harsh learning conditions of Parkland’s training, and the scars have finally healed, but the amusement value remains and I enjoy sharing it with you.

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