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Health & wellness

In Practice

Internship and revisiting ‘The House of God’

Dan Page for the boston globe

At a barbecue on the Fourth of July in 1986, I passed out. It wasn’t the heat or the beer or a bad batch of potato salad. I dropped from exhaustion.

Four days earlier, I’d started my medical internship. I showed up at 8 a.m. on the morning of July 1 in a crisp white coat and skirt, my pockets bulging with flashlights, reflex hammers, and cards crammed with all the information I feared I’d already forgotten since receiving my MD a few weeks earlier. On call that first night, I worked 34 hours without sleep — until 6 p.m. the following evening. I worked about 10 hours for each of the next two days and then, on the evening of the Fourth, went to my in-laws for a backyard feast.

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I’d eaten very little in the previous few days and I stuffed myself before sinking into a lounge chair. When I stood up to go home, I was GTG, as we interns used to say about patients who fell or fainted: gone to ground.

I didn’t realize it at the time, but GTG, along with much of the other irreverent lingo we used among ourselves then — including GOMER, an elderly and chronically ill patient to whom you wished you could say: “Get Out of My Emergency Room” — were coined or popularized by psychiatrist Stephen Bergman. Writing under the pseudonym “Samuel Shem,” Bergman published “The House of God” in August 1978.

A raunchy, dark-humored, fictionalized account of Bergman’s internship at Boston’s Beth Israel Hospital in 1973-1974, “The House of God” did for medical training what Joseph Heller’s “Catch-22” did for the military: It exposed the dehumanizing aspects of a hierarchy whose underlings are made to feel that they, and not the system, are insane.

I certainly had reason to wonder about my own sanity during my internship. I became so obsessed with sleep that I envied the cashier at the grocery store, who could go home after an eight-hour shift. I envied dogs napping on porch steps. I envied Alex Trebek, the host of “Jeopardy!,” because he never had to be on call. I even envied my patients. During particularly low moments, I fantasized contracting an illness — nothing life-threatening or disfiguring, just bad enough to land me in a hospital bed for a few blissful days of rest.

I knew these were not the thoughts of a healthy mind. Still, I didn’t question the necessity of working 100 or more hours a week, as Roy G. Basch, the intern-hero of “The House of God” questioned it, and as Bergman himself did.

I certainly had reason to wonder about my own sanity during my internship. I became so obsessed with sleep that . . . I envied dogs napping on porch steps. I envied Alex Trebek, the host of “Jeopardy!,” because he never had to be on call.

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When I met recently with Bergman at his home in Newton, where he still writes since his retirement from psychiatry a few years ago, I confided to him my complete lack of rebelliousness as an intern. He speculated that perhaps, having been too young to participate in the student activism of the 1960s, I wasn’t primed to question authority as he and his peers had been.

I think he’s right, but there was also another reason for my docility: As a young woman in a male dominated system, I feared appearing soft. The nickname of my especially rigorous training program was “The Marines.” I wanted to be a good Marine, to remain at the bedside of a sick patient through the night and beyond, tough and uncomplaining. Exhaustion, I assumed, was the price of joining the elite club of medicine.

It no longer is.

Under current regulations established by the Accreditation Council for Graduate Medical Education, and updated most recently in 2011, medical trainees can work no more than 80 hours a week and no more than 16 hours in one shift. The regulation of what’s known as “duty hours,” was inspired, in part, by a notorious and tragic case. In 1984, an 18-year-old woman named Libby Zion died at a New York hospital after medical trainees unwittingly prescribed a fatal combination of medications. Zion’s father successfully sued the hospital, in part, on the grounds that overworked and inadequately supervised trainees had exercised poor judgment in treating his daughter.

Not everyone is enthusiastic about the duty hour rules. Surgeons, especially, have voiced concerns about whether residents are getting enough experience under the new regulations. They talk of the absurdity of veteran surgeons performing appendectomies in the middle of the night while trainees take required naps.

And, perhaps surprisingly, data about whether the new rules improve patient safety are, as of yet, far from conclusive. One randomized trial showed that while interns who were better rested made fewer errors, their patients suffered no fewer negative consequences than the patients of interns who worked unlimited hours.

Even Bergman isn’t sure limiting trainees’ hours is a good thing. He told me he “narrowly comes down on the side of duty hours,” but worries about whether placing young doctors on strict shifts will further fragment patients’ already too fragmented care.

I worry about that, too. Ridiculous as my internship schedule was, it did promote continuity of care. My first night on call, I admitted a man with diabetic ketoacidosis, a serious condition that requires vigilant monitoring. How well I remember staying up all night, drawing his blood every couple of hours, adjusting his insulin. I really learned about the course and treatment of that condition and, more importantly, I truly bonded with my patient during those long hours.

I also remember, vividly, the last patient I admitted during my internship, at 2 in the morning on July 1, 1987. He had acute hepatitis and I watched over him until I transferred his care to one of the new interns at 8 a.m. My replacement wore crisp whites and her pockets bulged with instruments and cards. Her arrival signaled that I was no longer an intern.

I was never so happy to see anyone in my life.

Dr. Suzanne Koven is a primary care internist at Massachusetts General Hospital. Read her blog at www.boston.com/inpractice. She can be reached at inpracticemd@gmail.com.
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