Sample text for On call : a doctor's days and nights in residency / Emily R. Transue.

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It was a misty New Hampshire morning, July 1994. The silence was broken by a siren, an ambulance racing toward the pretty white-and-green hospital in the woods. I was a medical student in my first week of clinical work. I helped wheel the woman on the stretcher out of the ambulance and into Emergency. I watched as her clothes were cut off and replaced with tubes and monitors. I helped pound on her chest until at last she was declared dead.

How does a person react to an event like this? I had woken up that morning having never seen a death, and by lunchtime I had been part of one. Nothing in medical school or in life had prepared me for that moment. Amid the jumble of predictable emotions--sadness, fear, confusion, a certain excitement--I felt wrenchingly and terribly alone. I had seen a heart stop, I had felt ribs break under my thrusting palms. The people I loved best in the world were not in
medicine. Would they understand what I had just seen and done? Would I be inevitably separated from them by this experience and those that would follow it?

I did the only thing I could think of. I sat down that afternoon and wrote it all down. If I could tell my mother, my brother, my friend in film school, exactly what had happened, then I wouldn't be alone. And maybe, while trying to make them understand, I would come to
understand it, too.

That first story, sent out as an e-mail, led to more stories. What began as a way of staying connected to my loved ones outside medicine became a way of staying connected to myself. Writing became a part of the practice of medicine for me, a guard against numbness
and burnout, a reminder to listen closely to each patient and to my feelings as I interacted with them. As I shared the stories, first with friends and later through publication, I discovered that my experiences, which often felt so solitary and isolating, resonated with those of other students and doctors. I was shy at first in confessing to my patients that I wrote, though I tried to ask permission when I wrote their stories down. To my surprise, patients and their families said the stories gave them a better sense of the "other side" of medicine.

I graduated from medical school in 1996, and moved to Seattle to begin my residency--postgraduate specialty training--in Internal Medicine. I was twenty-four, a few years younger than most of my colleagues, having graduated from college at twenty and gone straight through to medical school. I would become an internist, a "pediatrician for adults," responsible for all aspects of adult care except surgery and obstetrics. My residency training would last three years, of which the first, the internship year, would be the most exhausting and intense. In Seattle's program, I would rotate among four hospitals: the university hospital, specializing in the more obscure problems, the county hospital, the center for trauma
and indigent care, the Veteran's Administration or VA hospital, and a private community hospital. I would rotate among months in the Intensive Care Unit, on the general medical wards or "ward services," in such specialties as Cardiology and Oncology, and in
the Emergency Room. In general, I would spend every fourth night "on call," spending the night in the hospital as well as the day before and after. I would get four days off each month. For half a day each week during the three years, I would have my own clinic, a "continuity clinic" where I would be a primary care doctor for a group of patients. I would also have "clinic blocks," months spent in my continuity clinic and in a variety of specialty clinics, with
no weekend work or call.

By the time I started internship, medicine and writing were entwined for me. As things happened I wrote them down, scribbling fragments of conversation on the backs of my patient notecards.

Sometimes I would weave these fragments into stories right away, sometimes I waited months or years. In the most exhausting times, all I could do was keep a few barely intelligible notes. But even these reminded me to stay in the moment, to cherish my experiences, the hard as well as the happy ones, the shameful as well as the proud.

This book is a compilation of those experiences, beginning on the first morning of my residency and ending on its final night. I have tried to capture some of what I learned in those long and difficult years. Names and other details have been changed to protect confidentiality, but otherwise I have tried to render both the people and the medicine accurately.

If I had to describe my experience of becoming a physician in two words, one would be "fatigue." The mental, physical, and emotional exhaustion of this process is a theme that runs throughout this book. The other would be "gratitude." These difficult, dark years
were brightened at every point by the friends and colleagues who taught me and learned with me. The medical training system can be brutal in some ways, but the people within it are deeply supportive of each other. I am honored to have such friends. Most of all, I am
grateful to my patients and their families. I learned more from them than from anyone--medical lessons as well as life lessons. The great joy and privilege of medicine is being welcomed into people's lives in critical and quiet moments, being invited to share their stories.
It is these stories that make up this book.

A Long White Coat

Medicine is a secret society of sorts, a world unto itself, with its own language, codes, and symbols. One of the subtle but powerful codes is found in the hierarchy of the white coats. Medical students wear short coats, to the waist or hip. Interns and residents--recent
graduates in their first and subsequent years of specialty training--wear long coats, knee-length, grown-up coats. Beyond that the distinctions are more subtle; attendings--teaching doctors, who have finished training--wear classier coats, with braided cloth buttons. But the primary difference is in the length: when you become a doctor, you wear a long white coat.

For me, this was the strongest symbol of the passage into internship. More than the pomp and circumstance of graduation, with all of its glorious moments: turning to face the assembled crowd as my mentor laid a green stole around my neck, whispering in my ear, "Now you're official--"; the reciting of the Hippocratic oath; the proclamation of the dean and president, "I hereby bestow upon you the degree of Doctor of Medicine...." More than the heart-wrenching
good-byes to my medical school friends, the abrupt and painful dismantling of my apartment, packing all my possessions into a truck and driving three thousand miles across the nation. More than any of those things, what made me suddenly realize I'd become a doctor was
looking into a mirror on my first morning of work at the county hospital in Seattle and seeing my reflection in a long white coat.

Probably it's a result of years of conditioning and constant reinforcement: people in short coats are students, long ones are doctors. There are places that don't use this system, a few
hospitals in the country where interns, or all residents, wear short coats. But it's bred into me now: the long coat is synonymous with authority, with competence. The coat seems stronger than my own persona, I try to become the person who is wearing it. I notice myself adjusting my posture, my bearing, to match the coat. I occasionally allowed myself a certain frivolity as a student, which seems inappropriate in this new attire. Act your age, the coat seems
to insist. You are a doctor now.

My first morning of internship, I plan to get to the hospital an hour early, have breakfast in the cafeteria, arrive at clinic calm and settled. But the morning is fraught with delays, as I struggle
to find my stethoscope, not seen since the move, I suddenly realize, my name tag, which was in one of the two dozen envelopes I've been given in the last two days, my parking pass, in yet another envelope, my pager. I get lost on the way to the hospital, then realize I have no idea where I'm supposed to park. I arrive with just enough time to find my clinic. Five South, my schedule says. I take the center elevators, the only ones I know, to the fifth floor, step out into a corridor of small doors with prominent locks and tiny windows. In fact, I realize as the elevator doors close behind me, 5 Center is a locked psychiatric ward. There is no door to 5
South, there's no reentry to the elevator without a key, there are no staff in sight.

At the moment I become, officially, an intern--my first moment as a real doctor--I am involuntarily locked on a psychiatric ward. Despite my near tears of panic and frustration, I have to laugh at the image: I could imagine getting committed at some point in this whole residency process, but I didn't envision it happening quite this early...

Copyright 2004 by Emily R. Transue

Library of Congress subject headings for this publication: Transue, Emily R, Interns (Medicine) United States Biography, Physician and patient