Tomorrow and tomorrow and tomorrow creeps in this petty pace

I’ve always been a writer, and most of the time I have no choice but to write. The words and feelings migrate up and need to spill out of my head and onto the keyboard or else I pace restlessly or can’t sleep. There are two times in my life when I stopped writing altogether, during the slog of residency and the second and third year of the pandemic.

In some sort of psychology class long ago they taught the example of boot camp and how the intensity and group togetherness going through something difficult, even hellish, made you more dedicated to the rewards or job or achievements afterward. Taleb would call it “skin in the game.” The modern idea of medical residency in the United States got its start from the Socratic teaching method of Dr. William Osler, a professor of medicine at Johns Hopkins from 1889-1905, and Dr. William Halsted, also of Johns Hopkins in much of the same period.

One hint…it was called a “residency” because you lived at the hospital.

When I was in medical school 4th year we did little family medicine weeklong internships with outpatient doctors. I had the privilege of interning with an 82 year old family doctor in Texas who graduated from the University of Texas Galveston Medical school in the 1940s. She did all her charting on those large 5x9 index cards. Most of your medical history she kept in her head. Her internship after medical school was one month, and her extra residency in addition to that was three months long. When I graduated medical school in 2000, my residency was an additional four years.

Halsted of Johns Hopkins teaching fame was addicted to opioids and cocaine most of his career.

When I was a PGY3 (post-graduate-year-3) or third year resident at Harvard/Brigham and Womens (I’m sorry for the name drop, it’s just what happened! This is a diary after all) I was the on-call psychiatric consultant for the whole hospital overnight and on weekends when my turn came up, and I remember rounding in the morning with the internal medicine residents who were on q3 call themselves. Rotations were generally for a month at a time, sometimes longer. Q3 was an ordinary schedule for residents in the ICU. It meant you worked from maybe 7 am to 6 pm for two days and on the third day you stayed overnight and took all the new overnight patients and then worked through the next day. Sometimes you got sleep on call, often you didn’t. On a typical month q3 call you spent at least one full 24 hours on call every weekend in the hospital. One weekend in the month was called a “golden weekend” and you could go home from Saturday morning to Monday morning and count your blessings.

As a psych resident I did less call but psych is much more emotionally involved…I was always more tired after a q5 psych inpatient rotation than a q3 ICU rotation. But by the time I was a senior third year resident helping with ICU consults the Brigham had started a study tracking the exhaustion levels of their medical residents. They actually convinced the poor post-call ICU interns and 2nd years to spend an extra 30 minutes to get EEG leads glued to their heads to see what their brains were doing during post-call rounds.

“Rounds” are just the team from overnight or the day before relaying all the important medical information, like vital signs, lab and study results, rule-outs and discharge plans for the day team coming to take over care. Osler and Halsted used rounds to do a lot of teaching to the younger residents and that model persists today.

The post-call interns went through rounds mostly in stage 1 sleep, according to their EEGs from the study. The data gathered from this study in the next few years went to evidence in addition to deaths of residents in traffic accidents post-call and medical errors to outlaw the kind of residency hours we routinely endured when I was in training, limiting overall hours in a month and shift lengths to 24 hours.

I didn’t have anything extra in residency to write, if you can imagine.

The fevers were something like that. All my recovery time went to resting. It was all much more dull than my time in the hospitals.