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The Intern Blues: The Private Ordeals of Three Young Doctors.

The Intern Blues: The Private Ordeals of Three Young Doctors. Robert Marion. William Morrow, $19.95. It's well known that the worst part of a young doctor's ordeal is the internship - the first year out of medical school when he or she is sent to a teaching hospital. Work weeks average 100 hours or more. And most programs require every third night "on call." This means an intern works an entire day, straight through the night and on into the next day - about 36 hours - with rarely more than an hour or two of sleep along the way.

Robert Marion, a pediatric geneticist, shares the belief that internship is a grueling and perilous ritual. But what makes his book especially valuable is that it consists of the year-long journals of three new doctors who interned under him. The result is striking first-person evidence that the familiar arguments against the intern status quo are on the mark.

It is a testament to the medical profession's subtle, but powerful, system of rewards and punishments that the entire book is cloaked in anonymity, The names of the three interns, and just about everyone else, have been changed "to protect their identity" from, we presume, the wrath of the medical community. Even Marion himself draws the line at identifying the hospital where he works.

The three young interns, Andy, Amy, and Mark, start their year full of apprehension and anxiety. None of them believes he or she is ready for the huge new responsibility. It's not just professional fears. It's also worries about what a 100-hour work week is going to do to their lives.

Four months into the internship, overwhelmed by chronic exhaustion and immersion in death and disease, all three are displaying serious symptoms of depression. They've become apathetic and have, to a frightening degree, withdrawn from contact with the outside world. When Marion asks Andy how he's doing, he replies, "I can't talk to you, and I don't know if I'll ever be able to talk to you again. If I think about what's happening to me, I'll start to cry, and once I start crying, I don't think I'll be able to stop."

Soon the interns begin to resent their patients, whom they see as an impediment to home and sleep. As Andy cynically concludes, "The doctors who do the best with their own lives are the ones who don't talk to the families, who don't play with the children, who don't thoughtfully consider things."

For years critics have argued that internship is a pointless endurance test that turns idealistic young medical students into hardened cynics. But it was the issue of compromised patient care that finally made the public take notice. The fortress of medical education was dealt a sever blow with the death of an 18-year-old Bennington student at New York Hospital in 1984. Libby Zion was admitted to the hospital late at night with symptoms of fever and agitation. After assuring the Zions that Libby would be fine, the intern and resident caring for her sent her parents home around 3:00 a.m. A little after 7:30 a.m., the Zions received a call from the hospital. Their daughter was dead.

Libby Zion was the daughter of Sidney Zion, a lawyer and occasional writer for The New York Times, who had lots of friends in high places. Zion was convinced his daughter's death was due to mistakes made by inexperienced, overworked, and exhausted young doctors. A New York City grand jury agreed. They issued recommendations for major changes in teaching hospitals.

As a result of those recommendations, New York State has enacted regulations, going into effect right now, that limit the hours interns and residents can work. Other states, including California and Massachusetts, are also considering regulating intern and resident hours.

None of the patients described in this book dies as a result of a tired intern's negligence. But mistakes are made. Mark passes out from exhaustion while taking blood from a child. Andy falls asleep four times while interviewing a mother who has brought her sick child to the emergency room. In her rush to get home to her baby, Amy neglects to request a blood test.

There is little doubt that the current intern system does teach doctors how to practice medicine. At the end of their internships, Andy, Amy, and Mark all seem very confident and capable. But they all have also been embittered by their experience. The system has made them care less about their patients. "This last period of internship has turned me into a very selfish and self-centered person," admits Andy, the most sensitive of the trio.

This hardening of the young doctor's soul is surely the cause of much that's (often lethally) wrong with the medical profession. Marion includes many accounts of "attending" physicians (more experienced doctors who supervise interns and residents) who don't come to the hospital when called about crisis. In one of his more horrible examples, a young boy who's had a kidney transplant comes down with complications requiring an operation on a Sunday. As Amy recounts the story, the "urologist refused to come in! He just refused to come; he said it wasn't such an emergency that it needed to be fixed on a Sunday night and that he'd be in the next morning." As a result, the boy spends an excruciatingly painful night and may have damaged his new kidney. In another incident, when a young child dies, the stricken family's physician never shows up, and an intern they barely know has to break the news to them.

Marion never takes a firm stand on reforming the intern system. But in light of awful episodes like these, the solution isn't very hard to figure out: senior doctors should care the burden. If each of the more experienced attending physician would spend a couple of long days and nights a year at the hospitals that give them privileges, the problems detailed in this book would be eased immediately. Until such measures are adopted, however, the prudent reader will think twice before ever again admitting himself into a teaching hospital in July, the month interns begin their assignment.
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Author:Stark, Elizabeth
Publication:Washington Monthly
Article Type:Book Review
Date:Jul 1, 1989
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