You pull into the hospital parking lot just before dawn – one of the first cars in, one of the last cars out. As a doctor in your first year of training you make up in hours what you lack in experience. You speed-walk to the back entrance of the hospital through the fog of early January.
You start to wonder if you left the iron on in your apartment. No matter how many times you iron and bleach your white coat, it never looks or feels clean. You never look or feel clean. You often wonder how many different strains of staph you’re colonized with at this point. Your best friend just had a baby who you haven’t gone to see yet in part because you’re afraid you might infect him with some resistant strain of hospital-acquired bacteria. You already missed her wedding and baby shower. You’re a bad friend these days. You’re just trying to be a good doctor, although you don’t really feel like one yet.
Your pager goes off at seven on the dot, indicating it has been activated for the day. For 14 lucky patients, you are now the first to call for aches, pains, medications, codes, questions and complaints. It’s game time.
You exit the quiet, sterile hospital hallway and enter the frenzied cacophony of “signout.” It always starts quietly – a few residents, interns and medical students who are just starting the day saunter in with crisp scrubs and venti coffees in hand. Your colleagues, bleary-eyed from working overnight, rifle through the papers in their pockets, trying to piece together the events of the last 12 hours. Within minutes the room grows hot and loud with bodies and voices. The nurses always have to come in to remind you that patients are still sleeping. But you all know that no one ever sleeps in the hospital.
As you walk to your workroom you mentally map out a route to see your patients as efficiently as possible. It’s already 7:30. You set aside half an hour to review labs and vital signs on the computer. You then have two hours to see your patients before Morning Report. That means less than 10 minutes each to see how they’re feeling, perform an exam and check in with their bedside nurse. Three of your patients still think you are the bedside nurse. This is sexist and ageist and an insult to your last 9 years of schooling, but you’ve learned to live with it.
You scribble down a few numbers from the electronic medical record. The meticulously organized notes you took as a medical student have devolved into a few illegible scratches on an 8”x11” sheet folded over and over until it’s the size of a business card. All you need now is this grid of names, numbers and abbreviations. The rest you’ve learned to keep in your head. You wonder how many of your precious memories have been quietly replaced by medical data. You put this thought out of your mind because it makes you sad. You don’t have time to be sad. It’s time to walk into 14 rooms and say “good morning” like you mean it, even though it really isn’t a good morning for either of you.
You breeze through the observation floor, the step-down unit, the oncology ward. You force yourself to take the stairs – it’s the only exercise you get these days. You pass by countless paintings and poems decorating the hallways, many of them by patients. You wonder if someday you’ll have the time and emotional energy to stop and appreciate them. You can’t afford to today – it’s already 9:30 and you’re only halfway through your list.
You hadn’t accounted for the six family members that each had questions about Mrs. B’s pneumonia, or the 20 minutes you waited to get a Tongan interpreter to explain to Mr. L why he has to use his insulin, only to resort to charades and wild hand gestures. Meanwhile the pager on your hip buzzes every few minutes like clockwork – Mr. H wants to leave AMA even though he needs 6 more days of IV antibiotics. He’s been drinking two pints of vodka per day and the withdrawal is starting to kick in. Ms. S on the other hand, doesn’t feel ready for discharge. Wouldn’t it be better to stay an extra day and make sure all her oral medicines manage her pain? Can she just get one more push of IV dilaudid before she leaves?
It’s 9:55 and you have one patient left – Mrs. T. You might actually make it to Morning Report at 10am if you keep things brief. You’ve been taught how to do this – walk in and set an agenda (“Good morning, Mrs. T, I wanted to check in and see how you’re feeling.”), manage expectations (“I only have a few minutes to chat, but I will definitely be back later to talk more”), make the patient feel heard (“I’m sorry you’re still feeling nauseated. Did the Zofran help?”), examine while you talk (The patient is alert and oriented, heart is regular, lungs are clear, belly is soft and nontender, sclera are icteric, unchanged from admission), answer any questions (“Your bilirubin is 17 today”) and exit courteously. You are on this last step when you make a critical error.
You see, unfortunately Mrs. T is your favorite patient. She’s a retired nurse who was admitted 4 days ago with painless jaundice and a pancreatic mass. She knows enough to know what this means. She greets you every morning with warm, motherly eyes – she’s seen hundreds of frazzled interns like you pass through these halls in her 35 years on the wards. “They get younger every year!” she jokes whenever a new doctor enters her room. She humors you as you robotically run through your routine questions and exam. You try to wrap things up by summarizing the plan for the day.
“We’re hoping to have the preliminary biopsy results back this afternoon. Then we can figure out the next steps…” You trail off as you notice her eyes start to glisten with tears. You instinctively reach for her hand. It’s even smaller and colder than yours, which is rare. It’s 9:59 and you decide to sit down on the edge of her bed.
Over the last three hours, you have placed over 50 orders, answered 17 pages, listened to 14 hearts and 28 lungs, talked to countless patients, nurses, residents and social workers, but you realize this is the only real doctoring you’ll do today. These are the 60 seconds that will matter.
You both sit in silence for a moment. Mrs. T’s lips tremble while you search for the right words. You’re not sure you have them and you tell her that. She understands and says “thank you.” You start to feel your own eyes welling up. “Aren’t you late for Morning Report?” Mrs. T says with a smile. “You better get going.” You’re in this together now and you both know it.
As you scurry off to Morning Report you scroll through all the pages you ignored while you were with Mrs. T. Mr. H is in the hallway yelling now. Security had to be called. Ms. S is still demanding those pain meds. The Tongan interpreter showed up and is waiting for you outside Mr. L’s room. He’ll have to wait a little longer.
Morning report usually runs from 10 to 11am. A mystery case is presented by the chief resident, while other residents and interns in training are invited to ask and answer questions about the case in order to hone their diagnostic and medical management skills. Some residents see it as an opportunity to show off their encyclopedic knowledge of medicine. You see it as daily potential for public humiliation in front of friends and colleagues.
You enter the room at 10:05 and the case is already underway. A 29 year-old graduate students returns from India with fevers and diarrhea. You marvel at how everyone around you can eat muffins and scones while discussing diarrhea. This is the strange world you live in now, and you still feel like an imposter. You take a seat in the back of the room, trying to look inconspicuous. You sense some slides of blood smears coming and you don’t want to be the one tasked with interpreting them.
You choke down a few sips of lukewarm instant coffee and it makes your thoughts even more manic then usual – the iron on in your apartment, the dilaudid you need to order, the baby you haven’t seen, the Tongan interpreter waiting for you in step-down, Mrs. T’s tiny, cold hands. You’re having trouble focusing on the case. The combination of coffee and chronic stress has given you terrible reflux but you’ve learned to live with it, if this can be called living.
You feel your pager go off again.
“Re: Mrs. T. Prelim path c/w pancreatic adenocarcinoma x54674”
You feel an ache in your chest and you’re not sure whether it’s heartburn or sorrow. You stare helplessly at your pager until the backlight goes dim. You slowly become aware that the chief resident has been saying your name.
“Dr. Singh? Do you want to share with the group your approach to fever in a returning traveler?”
Your mind goes blank as 20 sets of eyes turn to look at you. You know this is not going to be pretty. You know it will only confirm what others suspect about you and what you sometimes believe about yourself – that you aren’t a good doctor.
You take a deep breath and try to tell yourself what you learned today and what you wish you could tell every overworked, self-doubting, burned-out intern to come after you:
These are not the 60 seconds that matter.
 against medical advice
Photo Credit: Instagram
I’m in awe of this, Sonia, and it left me in tears. Thank goodness you are who you are–I feel great comfort in knowing that you bring some humanity, insight, and beauty to the practice of doctoring. And the fact that this piece was published in the NEJM means that countless others will be inspired to do the same. Thank you.
Thank you for writing about love and compassion in practicing medicine. I cried also. You have many gifts.