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Nolgren MD, Intern-1
James Robert Nolgren MD. He liked the two letters at the end. The first three words, his name, were familiar. He'd written them for years. They appeared on his birth certificate, his social security card, on the inside of his collars, later on his driver's license, a bunch of applications for this card and that box and to this institution and now, his degree. He counted again. High School. Four years. College. Four years. Medical School. Four years. Those were the years that earned him the last two letters. Next up was his residency, a high-pressure cooker environment where his mentored decisions would affect lives.
The two letters at the end were the sum, the visible proof, that his last four years of stupefying labor was rewarded in some small measure. No matter the circumstance, whether he ended up in a penal colony someday or death row or became Duke of Nottingham (not likely, God wot), no one, be that person judge, priest, royal personage or half-baked President, could strip those two letters from the three words of his name. He earned that degree and graduated in the top third of his class of medicine.
James giggled, thinking of the nervous medical student banter before important examinations along the way...the epitome of cynicism.
What do you call the guy that graduates last in his class in the school of medicine? "Doctor."
He had applied to a program at the university hospital where he was trained to a program in obstetrics and gynecology. The working hypothesis behind that choice of institution was the director of the residency program (a physician running the program) would place him higher in the program's ranking list than some faraway program whose directors didn't know him from a hole in the ground.
The computer that matched medical students to their residency was an uncomplicated task which took in lists from students and residency programs.
The student's list ranked those programs to which they had applied, '1' for the program they wanted most, '2' for their second choice, '3' for their third choice and down the list; the residency programs looked at the applications they received and told the computer which students they preferred for their program slots beginning with the top ranked student, again a '1', trending down to the worst applicant they would consider, giving them the highest numerical score and, crucially, the number of slots they had available in what specialties.
On the day of match, the computer looked for a '1' on the program's list to see if that student had marked the program specialty as their '1'.
If it found a '1-1', it matched the student with that program, then removed the student from further match consideration; otherwise the computer began again and if more slots were available for that program, it looked at the program's choice of the student it had ranked as '2', matched again if it found that student had ranked that program as '1' for that program, repeating the process while that program still had slots available, increasing the program's ranking number by one each pass until the student '1' rankings for the program were exhausted.
The computer then began to look for the student's '2' rankings for that program if more program slots were available and, importantly, the student hadn't matched to a program already they had marked as a '1' elsewhere. All of this occurred for each program simultaneously at first, almost. The algorithm had been perfected over time, so the match computed faster, but the idea hadn't changed very much in many years.
This process, these iterations, repeated very quickly. Many programs were full, showing matches for all slots in the first few seconds. The business of medicine had to go on efficiently and quickly.
If it found matches, the computer informed both parties that they were 'married' for the next four years and repeated the process thousands of times until all programs and students were paired. Upon entering the match process, programs and students committed to the results of the match, although exceptions were known.
The students were not allowed to tell the programs they had ranked them as '1', nor were the programs allowed that privilege, but it happened.
"We'll rank you as '1' if you rank us '1'..." was verboten according to the rules of the match, but it probably happened.
That way, the residency programs who 'cheated' got their prized students, and the students who went along were likely to get the programs they wanted.
As it happened, if six students ranked a program with five slots as a '1', chances were reasonable that the computer would group those students temporarily for a microsecond or two, then look at the program's rankings, see if any of the six were '1' to '5' on the program's rankings and as many as five of the six instantly matched before more computing happened.
Student number six went back into the 'fate undecided as of yet' pool for a few more microseconds. And so on and so forth...for a very short period of time a very fast computer did its work; work that would have taken clerks weeks to perform before transistors and silicon, before Microsoft and Apple...double-checking itself for viruses, double checking its results for the algorithm it had been fed.
No one would have known if the programmer had been paid a million bucks by some residency program to favor them over another, however the results spoke for themselves. The programs and the students never complained about the results or demanded a 'recount' (in public anyway).
No program worth its salt got a student that it ranked much lower (i.e., higher number) than the number of slots it had available and obviously no program was ever assigned more students than slots available. Plenty of mediocre or new programs were assigned students that they had ranked higher than their number of slots, however.
It sometimes happened that a program matched with its '100'th choice or lower ranking, not an auspicious sign for the residency program director's career or the institution's health as a teaching center.
Every student got assigned somewhere simply because there were always more slots available around the country than students. Not every student got the specialty they wanted, however.
A 'socially-impaired' or 'grade-impaired' or otherwise low-ranked student found themselves in a specialty training residency far different from which they had planned in a far-away state. Similarly, a few residency programs found themselves saddled with what might kindly be described as the 'bottom of the barrel'.
Oddly enough these residents had to work harder, and some became fabulously successful, understanding better than some privileged others that 'affable and available' would buy their Bentleys and send their kids to Ivy League schools.
James' published paper on the response of the Escherichia coli organism's symbiotic relationship with thirty-odd different sub-types of the human papilloma virus species in Sri Lankan rat intestines hadn't been a flash for the five o'clock news but had counted as a published paper for his resume and it did advance medical knowledge. A very little.
Enough to count, anyway. Most medical students hadn't published anything. Most didn't have the time, the resources, or the opportunity.
The major professor whose name was on the door of the laboratory where the research had been done got his name listed as second author on the paper.
His name was first, as principal author of the paper, on forty more major published papers on E. coli as it related to this and that.
When E. coli experts at other institutions wrote their own papers now, they looked at all of his papers first as part of a review of the literature, an important step.
Some scientific experts didn't want to disagree with one of their own who, after all, might just do the peer review on one of their papers in the literature one day with some power to bury it or pass it for publication.
Researchers often cited their fellow experts' opinions in their papers. It was a compliment, an unspoken bow to the cited author.
The collegial bonds between experts were, however, both incestuous and pragmatic. "You like mine and I'll like yours" was an unspoken agreement in some disciplines.
The residency was divided into the first year (which some still called the 'internship' year) and three more years after that, which bore the names '2nd year resident', '3rd year resident' and 'senior resident'. 3rd Years didn't always round as they were in early to begin scrubbing for surgery with the attending. Seniors rounded briefly at times to make certain all surgical cases available were plucked from the ward and to make certain that plucking process was smooth. The seniors supervising clinic rounded even less. There were enough clinics and wards and operating rooms to call all of the fourth-year residents 'senior residents'. There wasn't a 'chief' resident. That would imply power, which none of the attendings ceded to anyone.
Attending physicians' earnings for the faculty group constituted their real job, although teaching and publishing were their nominal duties. The outstanding clinical teachers who were also popular with alumni or related to someone on the Board of the University or medical school could, after a few years, back off on didactic teaching and even publishing, but they still had to bring in money to fund a building, perhaps a scholarship, or persuade someone else to donate.
The fights in the faculty group, though few in number, were torrid arguments over how fair it wasn't that the highly trained surgeons who brought in the big bucks had to subsidize the 'mice killers' in the laboratory who didn't bring in the big bucks.
Sometimes a huge research grant happened to wend its way to a very gifted researcher, usually an unforgettable bastard whose wild physical appearance showed to advantage at national medical meetings and brought them attention from the National Science Foundation geeks who passed out the nation's money for research.
The obstetricians, gentle, affable, self-effacing guys and popular with their lady patients, did both deliveries and gyn surgery of various kinds. Early on they spent low-income time in the clinics for routine prenatal care; later they hired lower-wage assistants to do that work and at least made the difference.
The gynecologic oncologists, hip, usually the most skillful surgeons, full of unwarranted cheerfulness and self-confidence, just did cancer surgery and their fees were astronomical.
The reproductive endocrinologists did some surgery but spent enough hours in the office to struggle to be on top unless they delivered their own patients sometimes.
The maternal-fetal medicine docs, blunt, matter of fact, inwardly wincing at fate, precise and sometimes comforting did a little of everything but rarely made a fortune, augmenting their income with a few in-office procedures like amniocenteses and delivering some of their own patient's babies.
James Robert Nolgren MD was soon to enter the pressure cooker of residency and couldn't wait to begin. He and five other residents, summoned to the Director of the Residency's office at 9 am on June 12, were oriented to their residency by handing them a schedule.
"Be at your assigned ward or clinic or OR by 7 am tomorrow. Ask your 2nd Year on Schedule B to give a list of your patients. Introduce yourself to your patient and examine them, then review their charts, study their progress, study their symptoms, figure out the differential diagnoses and treatments for each and be prepared to discuss all of that for each patient by 7 am on rounds."
"You should have a Senior resident, a 2nd Year and a flock of medical students on rounds and sometimes an attending. Uniform is long white coat with your name tags please. Here's your first name tag. Everybody loses theirs sooner or later. We have extras. You'll get a paycheck in two weeks."
"It isn't much so tell your wife or partner not to spend like a doctor yet."
"If you have to stay up all night with or for your patients, too bad. They have to suffer twenty-four-seven until you get them figured out so get to it. We don't function as a complaint department. Leave my secretary alone unless you have flowers for her. She works for me, not you."
"Remember that accurate and steady work gets the job done right the first time. The 2nd Years are eager to show you how much more they know than you, so give them frequent opportunity and ask questions when you get stuck."
"You are primarily responsible for teaching the medical students, so bone up. They are sure to ask questions that have answers on occasion as well as questions which will make your skin crawl. Keep them from killing anyone."
"Demand that they show you all of their work including patient orders for you to counter-sign after you read the work. Don't skip that step. You are a physician in our state now governed by the Medical Practice Act and can be sued for malpractice now (isn't that a fun fact) so be both obsessive and compulsive about patient care, yours and theirs. Students can't be sued. You and the hospital can."
"The devil is in the details. Those details include being kind and listening to patients as you've been taught. Observe the popular attendings for clues about how to relate to patients and other docs. Thank you and make us proud out there."
None of that amazed or amused James. He'd gone through rounds as a student for the last two years and observed the interaction between residents and interns and attendings.
He knew that attendings loved to get rounds done so they could make their surgery times. He knew that the main goal of the 2nd Years was to shepherd the Interns and students and supervise the direct patient care on the wards.
He had a vague idea that the 3rd Years spent time assisting in the OR and studying surgery so that by the Senior level, they could teach the 3rd Years they had just been.
He also knew that very few university surgeries were done without an attending present to mentor and teach as well.
The typical major gyn surgery, then, had an attending, a senior, a 2nd Year and a student to assist and learn. Due to space considerations, three could see into the vagina, the surgeon and the two standing on both side of the surgeon. The poor medical student stood on one side of the patient with no view, tugging on a retractor and getting shouted at or at least their retractor got moved a lot, sometimes a little viciously, the surgeon grabbing it out of the student's hand, repositioning the instrument and handing it back to the student to haul back on. The student had the advantage of not taking the responsibility for the outcome of the surgery, though, and watching the anesthesia types and observing the nursing staff.
Also, in the room were the anesthesiologist, sometimes a CRNA, a scrub nurse, circulating nurse and a hovering nurse without title that did intra-op liaison with the Head nurse of the OR, tattling on the slow surgeons and giving warning of fore-shortened surgeries to keep the rooms optimally supplied with both patients and surgeons.
This information was critical to shorten 'turn-around' times. This time period between surgeries was monitored very closely by the finance people and the department of nursing. No money was made during turn-around time.
This scheduling challenge was one the Head nurse dealt with every weekday and sometimes on weekends and she was on her game, the gatekeeper, the undisputed Boss who only spoke to the Chief of General Surgery attending with any degree of subservience and that was more of a collegial relationship, beneficial to both.
This scheduling challenge was one the Head OR nurse dealt with every weekday, sometimes on weekends, and she was on her game. She, the gatekeeper, the undisputed Boss, answered only to the Chief of General Surgery, an attending who received a minimal degree of subservience from the Head OR nurse.
Even that was more of a collegial relationship, beneficial to both. The Head nurse was perfectly willing to call a surgeon and order him, nicely or not, to assemble his team sooner than a scheduled time or later in some cases. Many OR Head nurses had the hide of a very long-lived alligator...thick, tough, slightly scarred and darn near invincible.
James met his 2nd Year a half-hour later, a sweet, no-nonsense woman, a transfer from an upstate program, slightly edgy, in a hurry, who filled him in with all essential details in a very short period of time.
"You'll have all our patients on the ward for the first three months."
His pupils must have constricted; his Adam's apple must have moved up and down a little, because she peered up at him, eyebrows narrowed. "Is that going to pose a problem?"
"Oh. Uh, no it won't. I understand we begin at 7 am tomorrow?" She nodded, watching his expression.
"We certainly do. Three of our patients are either in surgery as we speak or in the post-anesthesia care unit with their charts. You'll have to travel over and find those patients. This is a ward census, current as of last shift and I've marked which students are assigned to which patients. Beds 2A, 3A and 5B are empty at the moment out of fourteen rooms and room 13 A and B is still being de-contaminated."
"Central registration put overflow renal patients in 11A and 11B to accompany the 10A and 10B they stole from us yesterday. We obviously don't have to know them or round on them. Their own team will cure em or kill em."
James knew that game and made a mental note to do nothing of the kind. He would see those patients on their return to the ward. If they, God forbid, died in PACU, he wouldn't have to work them up anyway.
It hit him then that the students would do the workups. He just had to verify them by repeating the exam, reading through their workups, thinking about their conclusions (not always germane), reviewing them with the 2nd Year, reviewing their orders (frequently changing them), signing their workups, (never changing that report, just writing his own which took precedent) and establishing his own rapport with each patient, not to mention the senior and the attending as well.
No, being an intern wasn't easier. The change to intern was similar to the frog that jumped out of the frying pan right into the fire.
In the meanwhile, back to the PACU thing, he thought. The gyn surgeon who operated on them and the anesthesia types who ran the PACU were ultimately responsible for patients while in PACU, not him, and, come to think about it, the PACU nurses generally saved the surgeon's and anesthesiologists' butts every day, not to mention the patients themselves.
"Beds 1A and 7B," the 2nd Year went on, "have difficult co-morbidities (pulmonary edema and diabetes respectively) and internal medicine residents are consulting and managing them and their reports and orders are on the chart, but the patients are here primarily to treat their gyn problem so here they sit."
"You'll need to speak to those residents and somehow, ideally get them to round here in the morning about the same time we get to the room for a few minutes so we can talk to them. Good luck with that."
James dismissed that one too. He smiled internally. This new resident had a few things to learn. One didn't summon other residents from their rounds to come help you with yours. It just wasn't done.
"Our students aren't totally bad this summer. Three really bright woman, a great male student, and one moron male named Tommy who is more interested in horoscopes than medicine. It's the Peter principle, I think. He's good for diversion, but not good for patients. I try to teach him and have concluded he might be trainable, but not able to be educated really."
"Note the allergies before the students correct you on a pharm order. You want to look like you know more than they do. On your mark, get set, go..."
She gave him a gentle push and he sat down to look at the census, rapidly getting a good feel for how many beds total there were on the ward (28), and what 'problems' were in each bed.
On a small notepad, he wrote names, ages, gravida status (total number of pregnancies to date), para status (total number of pregnancies brought to 20 weeks or more regardless of outcome) and aborta status (how many pregnancies were not brought to 20 weeks (ie, miscarriages and early abortions for example), and the date of the first day of the last menstrual period.
He added the diagnoses, meds, allergies, surgeries, illnesses, family history, immunizations, vital signs, symptoms, salient physical examination findings if any, tests, test results, differential diagnoses and current workup and treatment.
All of that with steady writing took two hours. He took the list of ob and gyn diagnoses with him to the small ward library and sat at a conference room table with William's Obstetrics and a good gyn text and made notes about each diagnosis and the possible differential diagnosis list for the symptoms and signs with which the patient's presented.
Under each list he noted the lab results or test results that tended to rule out that diagnosis and those that tended to rule it in.
Then he made a few notes about the two co-morbidities before lunch, noting the salient facts about each which might interact with their gyn problem.
Hungry now, he sailed through the cafeteria line with a tray full of food, some of it nourishing, most of it comforting and sat at a table not seeing the person on the opposite side of the table in the busy cafeteria.
He looked up into the face of a young man his own age with a long white coat, a name tag that said "Lawrence Favre, DDS" and blinked when he encountered luminous green eyes looking right into his own.
He felt dizzy for a second, like he was falling into those eyes, but knew he couldn't fall into somebody's eyeballs.
He looked away, looked back, same face smiling now, and felt the same feeling again.
"You're a long way across campus from the Dental School aren't ya?"
"Yeah, some of us elect to take an optional dental anesthesia fellowship.
"I'm Lawrence, by the way." His hand came across the table to shake James' hand. Your tag says 'James'. Nice to meet you. I'm starting my time in the OR to learn how to do anesthesia right."
James thought this guy would have a hard time doing anything wrong, but politely refrained from saying so. The young dental resident looked about 28 years old, classic face, well-groomed and well-dressed, but then all dental students were.
Well-groomed and well-dressed, that is. This guy's skin was smooth without a mark, every hair was in place. Even his nose hairs were clipped. He wondered what this guy looked like without the well-dressed part, this last a random, horrifying thought, again unspoken. Perhaps he was more stressed than he knew on his first day.
What the hell was he thinking?
"Do you guys take call in-house?" He heard his own voice say it while his brain tried to figure out a way to retract the question.
"Yes, I have to sleep in the on-call room with you real docs."
The on-call rooms were very nice with two rooms, one a quiet room with two beds and a quiet well-lit bathroom connected with a solid wood door that blocked some of the light from the remaining sleeper. Enough light came under that door to illuminate the sleeping room a little.
A quiet fan constantly hummed in the bathroom.
The dental students didn't wear wrinkled, sweaty scrubs. Usually they slept at night, but not in their scrubs.
They showed up every day looking like they had just stepped out of Brooks Brothers along with their 'Stepford' dental hygiene pals with the perfect teeth, perfect make-up and fixed gorgeous smiles (probably the 'picking out a wealthy husband smile' if James knew smiles) while the haggard, sleepy medical students on clinical service filed past them on the way home to die for a while during the day.
One never saw a dental student in that condition, ever. No one, he guessed, wanted a tired dentist trying not to breath in their face during an extraction, worse yet smelling their underarms near their numbed-up jaw, or to study the creases in his or her uniform while learning how to brush one's white enamel for the umpteenth time.
The few dental students sleeping in the on-call room always presented with pristine fresh scrubs with the dental school logo and rose only to void, probably sitting down, and attend operations that might happen on an emergency basis at night. Most of the time they slept.
James imagined the two of them sleeping together in the same room. He imagined watching Lawrence sleep and turn, stretching, until his covers shifted, and his manly chest became visible in the sliver of light from the bathroom. He imagined an illuminated, near perfect hairless chest with muscles and erect nipples, a child-like peace on his sleeping face...