Dear Bree,

Your reaction to making mistakes is a common one, and has been experienced by me and many of my colleagues. Here is a quote from one of the best doctors I know, a successful cardiologist, who was an intern with me 10 years ago:

“One time, second year, I took care of this woman whose potassium was low. We were repleting her potassium every day, several times a day even. When I left one evening, I signed out to check her potassium level. For whatever reason—maybe I didn’t impress it hard enough, I don’t know—it didn’t get done, and in the middle of the night, she had a cardiac arrest because of high potassium. Her potassium was off the scale, and then it came to light that she had been getting saline with eighty milliequivalents of potassium chloride at one hundred and twenty five cc’s an hour. I didn’t know it. I should have known it, but IV fluids weren’t written on the nursing medication sheets, and I had been too lazy to check the computer. I marched straight to Dr. Wood’s office and told him what happened. I said, ‘Dr. Wood, I just killed a patient. I killed her, or at least I didn’t prevent her from being killed.'”

“How did he respond?” I asked.

“Of course, he broke it down. He told me it was because of the bad kidney function. He said her kidneys couldn’t excrete potassium properly. He said, ‘If I give you potassium-enriched fluids, will your body be able to handle it? Of course it will,’ and so on and so forth. He broke it down medically, but really what I wanted to talk about wasn’t medical. I had nightmares about that death. As an intern I never felt like that, but as a second-year, you just felt more responsibility.

“So I started this conference for residents to talk about their mistakes, away from Dr. Wood, away from the attendings. Even the chief residents weren’t allowed to sit in. I wanted it to be just house-staff run. Everyone makes mistakes; even if we don’t think we’ve made them, we’ve made them. People would come to the conference and talk about their mistakes in a nonconfrontational way. I saw residents cry at that conference. I talked about the lady with the low potassium. It felt good to get it off my chest. I felt like, if I don’t make this public—not out in public, of course, but just to my colleagues—if I don’t talk about it, then it would become one of those things that never really happened. It would cease to exist.”

So you are not alone. Have you thought about starting a similar conference at your hospital? You might be surprised by how many of your fellow residents feel the same way as you. A poignant telling of the vicious effects of mistakes on a doctor’s psyche can be found here.

Sandeep

Dear Dr. Jauhar-

Thank you for your insightful book. I am in my final year of clinicals as a respiratory therapist, and I found your book most interesting.

I am in my mid-fifties, and respiratory therapy is my second career.  I practiced law for over two decades, before switching the healthcare. I live and work in a rural area, where we acutely feel the shortage of physicians generally and family practice physicians and surgeons in particular. Even as a student RT, I am often called upon to advise doctors on diagnoses, drugs, treatments, and patient prognoses — simply because the allied health professional is often the only trained person available to evaluate and treat the patient on an ongoing basis. In the hospitals where I work, RTs enjoy great latitude and broad responsibilities, rather than being mere dispensers of aerosol treatments.

Here is my question: How can I be most helpful to our younger doctors, particularly to interns? Being experienced in corporate work settings and in licensed professions, I am relatively mellow compared to most other allied health personnel. I see many young doctors under great pressure, obliged to make important decisions with little experience. How can I best interact with these young professionals? I get along quite well with doctors my own age — in fact I find our pulmonologists, cardiologists, and thoracic surgeons are eager to instruct me, generous with their time in showing their preferred techniques and their favorite approaches to patient care. But to be honest, they seem to have more time for me than for the interns, on whom they are very hard. Residents seem to be somewhere in the middle. They are usually younger than I, but they seem to have their sea-legs, and we share a mutual appreciation for the difficulties of providing optimum care while still being in the midst of learning. How can I best share information and foster a sense of teamwork with these young doctors? Your insights would be most welcome.

LV

LV,

The fact that you took the time to write this query suggests to me that you are an unusually supportive healthcare professional who is probably very well liked by the interns and residents you work with. Continue to teach them about what you know, and ask them how you can help them do their jobs. The best hospital staff teach interns. As an intern, nurses taught me how to put in catheters and adjust ventilators. They told me which medicines to avoid. They taught me how and when to initiate discussions with families about end-of-life treatment. There is a lot a respiratory tech can teach an intern. After all, yours is an essential job in the hospital, especially the ICU.

Best of luck in your second career.

Sandeep

Dear Dr. Jauhar:

I recently came across your book…in fact I became acquainted with it while browsing a table at the Borders bookstore in Manhattan! It has been a truly wonderful read so far! THANK YOU!

I’d been looking online for certain things, trying to do research, even speaking to family members in the profession, but no one really gave me detailed insight.

My questions are a bit unconventional but I will ask anyway. I am with someone who is a 1st year resident—he wants to get into cardiology, also. I am not in the medical profession at the moment. I have always been interested in psychology but circumstances did not permit me to pursue it.

Having very limited knowledge of what an intern goes through I hope this book can help me both with understanding him, our relationship and seeing what’s in store for me should I get back into school. So here are my questions:

1. Can a 1st year resident have a relationship and if so, can it be with someone who is not in the medical field at this time?

2. What can I do to be supportive of him during this time? Anything I should not do? I feel that this is a very lonely time for him and I want to be there but am having obvious difficulties with someone who has no time to call or see me much—hence my questions.

3. For myself—I am 31—is switching to a career in psychology, where I may have to go through more years of schooling, a bad move at this age?

Any answers would be appreciated.

I will continue with your book and I hope to be writing to you very soon with questions about my first year.

Sincerely,

AGA

Dear AGA:

Thanks for reaching out. I’m not sure how good I am at relationship advice, but I’ll give it a try:

1) Interns most definitely can begin or sustain a romantic relationship during their first year of residency. I see it all the time. In fact, I’d say the majority of interns I work with have a spouse or significant other. But it isn’t easy. I met the woman who would become my wife at the beginning of my internship. I was unprepared for the toll that work would take on my ability to lead a life outside the hospital. I had very little time and energy to devote to nurturing the relationship. (I remember falling asleep at movies and at the theater, zoning out at dinners, forgetting basic niceties, getting irritable when I was most sleep-deprived, etc.) To me, this spelled a relationship in trouble, but fortunately, my future wife came from a family of doctors and was very understanding of my schedule. In the fall of my internship, she moved to Washington, DC, so we only saw each other on weekends after that. We managed to make it work because we were committed to each other and she, a medical student, knew exactly what she was getting into. When she went through her internship, I was a 3rd-year resident, with a fairly light schedule, so that definitely made it easier on us (I had more time to devote to her, the relationship—and household chores!) I think it’s harder when both partners are very busy with work. The key to all this is understanding and knowledge. As long as both partners know what they’re getting into and the overwhelming work schedule isn’t a surprise, you can definitely make it work.

2) At some level, he has to fight the daily battle of internship alone. Of course, you should ask him what you can do to be supportive. He may just want time an space alone after work (like I did), or he may desire a more active supporting role from you. You should talk about it.

3) It’s never a bad move if it’s your passion. 31 doesn’t seem too late at all (especially from my vantage point today!). Life is too long to be stuck in a career which doesn’t fulfill you.

Good luck!

Sandeep

When interviewing for an internship program, what sort of qualities, beyond the obvious ones, should I look for?

RC

You want to find a program where the housestaff are reasonably happy, so talk to them, outside of the usual tour. I also think it’s important to find a program that’s committed to teaching interns, not just junior and senior residents, which is the norm. My current hospital, for example, has just launched a new teaching initiative using computer modules that I predict will be very successful. It is a big selling point on interview day. But in reality, most of what you learn as an intern will come from direct patient contact and care.

On a different note, don’t underestimate the importance of the city where the program is located. Manhattan was one of the few saving graces of my internship. It’s important to try to maintain some semblance of a life for yourself and your family when you’re not working.

Sandeep

In response to your blog entry “Code New,” I wonder about the ethical implications of the physician inviting the family member in while the patient coded. Is this practice fairly common? If it occurs during my residency, and I disagree with the act, would it be in line to ask the family member to leave the room? I fear some codes might be too graphic or traumatizing for anyone unfamiliar with seeing a person die.

CW

I think this is a very uncommon practice. At least, I had never heard of it prior to a few weeks ago. Unfortunately, as an intern you have little say in how things operate, so even if you disagree with the practice, there’s little you can do—or should do… your focus must be on the resuscitation, not who’s watching, which is another reason I feel such a practice should pursued cautiously. Having a family member there might be too distracting. What to do when a patient or senior physician’s request conflict with your own sense of right or wrong is a much more complicated question which I’ll post on later. For now, I’ll refer you to this article.

-Sandeep

Hello Dr. Jauhar,

I am a 4th year med student applying in internal medicine and am consequently in between many residency interviews earlier this month and another batch coming up in January. I just heard your interview on NPR for your new book and am looking very much forward to reading it. My question regards choosing a medicine residency and the interview process.

I have been disappointed by several of the interviews I have gone on for internal medicine earlier this month. …Having chosen (internal) medicine in a climate when so many of my classmates are looking for an easier lifestyle with a much higher salary afterwards, I hoped that the interview process would respect this choice by honestly relating what life would be like as a resident in their program.

Consequently, as I have visited programs I have tried to compare how different programs represent themselves to us regarding institutional climate, work hours, and lifestyle during residency. Unfortunately I have felt like these prestigious programs have largely been duplicitous in their depiction of themselves during their interview days. For instance, several programs have had lengthy introductory lectures by the program director or chairman of medicine in which they talked extensively about the history of the hospital, the program’s goals, etc. However I often felt these overviews to be just like a used car salesman trying to sell me a clunker, and talking endlessly about how every facet of “XYZ program is great.” When I actually went on a tour with a resident, he made some disparaging comments about certain aspects of the program, and immediately after the tour I went back to hearing more from the chairman about the greatness of the program. Needless to say I felt like these chairmen and program directors were out of touch with my concerns.

Another program made the mistake of sending us out on rounds after the tour to actually let us see what life was like on the wards after an introductory talk about how great everything was there. The postcall interns were absolutely exhausted after a 30 hour q3 ICU shift. One kept making mistakes during rounds like saying a patient was on pressors when in fact the patient had been weaned from them, and that the patient was intubated when in fact they were on BIPAP. I can easily imagine myself making those mistakes postcall on rounds next year in a q3 program and felt like this program had inappropriately represented itself during the opening lecture and that its true nature of fatigue and overwork was being seen on rounds.

Another program sent us on rounds where the residents didn’t have many patients so they spent the time mostly talking to us about how collegial the atmosphere was at the hospital and how everyone from attending down to medical student was always friendly…Then, an exhausted looking fellow who had been consulted stormed up hurriedly and barked out a few nasty orders at the team (despite the obvious five of us in black suits), immediately making me doubt all they had told us about a collegial work environment. If a member of the house staff would behave like that in front of prospective interviewees, what would it be like on call trying to page him?

(T)he lack of any attention to duty hours, call schedule, and sleep hygiene by the program directors during interview day is disappointing to me. I have yet to hear a program director talk seriously about maintaining reasonable sleep schedules while minimizing handoffs, blind cross coverage, and the loss of continuity of care if a program becomes a largely shift work program. I also haven’t heard anyone talk seriously about the flaws of their MICU when it is listed as Q3.

My question relates to all of this- how can I get an honest feeling for a program from a 7 hour interview day so I can make the most informed decision possible when it comes time to submit a rank list, in a month and a half?

Thanks again and I look forward to reading your book-

PL

Dear PL:

Thanks for writing. Seems some of the programs you’ve interviewed at could use a PR consultant! The 30-hour, Q3 ICU call is especially troubling. The NEJM published an article in October 2004 that showed that interns working in an ICU made 36 percent more serious medical errors during a traditional Q3 (every third night) call schedule than during a schedule that eliminated extended work shifts and reduced the number of hours worked per week. The total rate of serious errors on the critical care units was 22 percent higher during the traditional schedule than during the reduced schedule, and interns made 21 percent more serious medication errors and 5.6 times as many serious diagnostic errors. The researchers concluded that eliminating extended work shifts and reducing the number of hours interns work per week can reduce serious medical errors in the intensive care unit.

I understand your desire to practice in a collegial work environment. When I was an intern, we had to deal with a notoriously foul-tempered ID fellow, who seemed to relish tearing into diffident interns (including me). I hated having to call him for consults (which, I suppose, was probably the point).

The short answer to your question is that there is no way to reliably assess an internship program within 7 hours on interview day. In general, interviews are notoriously unreliable for assessing prospective employees (or employers). What you need to do (as you probably already know) is contact the housestaff to ask them questions and get the honest lowdown. If possible, go back to the hospital on a different day and just wander around to get an unfiltered sense of the place. That’s what I did before submitting my cardiology rank list, and it really helped. Good luck!

-Sandeep