As she leans on the arm of the hospital bed, Teeb al-Samarrai MED ’06, a first-year resident in Internal Medicine at Yale-New Haven Hospital, speaks soothingly to the frail old man next to her.
“Is the pain tolerable right now?” she asks him as she gently pats his distended belly.
The patient indicates his weak assent. Although he wants to keep fighting, there is only so much al-Samarrai and her fellow doctors can do for his medical conditions, a potpourri of failing organs and infections that she sympathetically summed up as “awful, awful, awful.”
Still stroking the old man rhythmically, al-Samarrai explains her plans for the day, an array of procedures and treatments that may or may not make any difference in his suffering. This patient is the last of about 10 she will see today with her six-person team.
At 8:55 a.m., Maor Sauler, a fellow resident, takes over, and al-Samarrai returns to the cubbyhole that serves as both locker room and office for all of the residents in the ward. She needs to order patient prescriptions and make phone calls to other hospitals before she can go home.
By the time she leaves at around noon, al-Samarrai will have been on the job for 30 hours straight. She arrived at 6:00 a.m. yesterday to check on her patients, before her workday began at 7:30, and stayed overnight in case any emergencies arose. At 10:00 the following morning, she sounds tired but surprisingly cheerful.
“I tend to have a post-call delirium,” she said. “You’re lucky I didn’t make any inappropriate jokes during rounds.”
Premed students may stress over covalent bonding, but general chemistry is only the beginning. Before they can practice on their own, doctors face four years of medical school followed by three to seven years of residency — a trial-by-fire initiation where new MDs are exposed to an ever-changing variety of patients, diseases and what one called “bureaucratic nonsense” on four-week rotations in different hospital departments.
But in lieu of the supply closet make outs shown on “Grey’s Anatomy,” residents face an ever-present sleep deprivation that pales in comparison to knowing that a missed symptom or slip of the scalpel could mean a patient’s death. It sounds like a nightmare, and residents say it can feel like one. But after almost a year of caffeine-fueled all-nighters, grieving families and shifts with only IV drips for company, al-Samarrai said, she is finally starting to feel like a real doctor.
A triple-shot latte with a side of caffeine
The empty coffee cups that litter the residents’ changing room represent a lifeline, not just a morning drink. Al-Samarrai and her fellow residents begin trickling in at about 6 a.m., although residents in some of the hospital’s 69 other programs — which include General Surgery, Pediatrics and Psychology — arrive on the job as early as 5.
“You see all of the patients quickly in the morning and end up having to wake them up,” Sauler says. “Then they all hate you.”
“I don’t have that problem,” Al-Samarrai quips ironically, as Sauler playfully feigns offense.
Residency has come a long way since the 1980s, when 120-hour weeks were standard, said Walter Longo, a former Yale-New Haven resident and now the director of the General Surgery residency program. But while the guidelines imposed in 2003 by the Accreditation Council for Graduate Medical Education ostensibly limit residents to 30-hour shifts and an average of 80 hours of work per week, 100-hour weeks are still acceptable, as long as the extra time balances out over the four-week rotation.
While Yale premeds say that concerns about residency take a distant second to genetics labs and MCATs, many said they are not sure they will be able to handle the infamously long hours. Erik Geiger ’08 said he jokes with his friends that early-morning soccer practice and organic chemistry are “kind of a good preparation for residency, where the stereotype is you don’t get much sleep.”
Today, al-Samarrai predicts, she will be able to leave the hospital almost exactly 30 hours after she arrived, but while her fellow residents make an “enormous effort” to pick up some of her work so that she can leave on time, her shifts sometimes slip over the limit.
“There’s part of you that gets used to it, and there’s an element of getting an adrenaline rush,” she said. “But sometimes during a really rough night on call, I’ve felt like if I have to do this for one more night I just won’t make it.”
Patients as teachers
Al-Samarrai’s day started yesterday morning, but work officially begins at 7:30 a.m. today for the rest of her team, when they meet to discuss the patients al-Samarrai admitted the night before. A whiteboard on one wall of the bare conference room still has the indecipherable signs of an earlier meeting: “44 yr 3 mo ago non-trep VRDL.”
The doctors-in-training drink coffee from travel mugs and take notes as al-Samarrai begins to detail the medical history of the three new admits, running through a list of mundane-sounding ailments like headaches and shortness of breath.
While Al-Samarrai does most of the talking herself — her speech peppered with terms like “white count,” “EKGs” and “necrotizing pancreatitis” — the two third-year residents will occasionally interrupt, asking questions they clearly know the answers to or gently suggesting diagnoses.
Al-Samarrai, with her white knee-length lab coat, calm bedside manner and ever-present stethoscope, is indistinguishable from a licensed doctor, but she is also still a student, learning about new conditions even as she treats them.
The team structure allows older residents to tutor the younger ones, and all are under the ultimate authority of Michele Barry, the attending doctor on the ward. Barry said she does not participate in the day-to-day management of patients, but makes sure her residents “don’t hurt anyone” and evaluates each of them at the end of their rotation.
Cyrus Kapadia, director of the Internal Medicine residency program, said theory cannot be divorced from practical experience: While residents attend a daily lecture on everything from malpractice lawsuits to the anatomy of the knee, the best teachers are the patients themselves.
“Unlike, for example, a history major, where if I want to learn about the Battle of Bannockburn, I don’t have to go there, one can’t learn medicine from books alone,” he said. “One has to be at the bedside.”
Diet Coke and hepatitis
Once al-Samarrai has brought everyone up to date, the team begins the first set of rounds, where they will speak with the patients under their care and detail the treatment plan for the day. One patient, a diabetic, asks for a soda.
“I will get you a Coke [from] downstairs,” al-Samarrai says. “A Diet Coke.”
The residents remain uniformly comforting, even when one woman begins cursing when Sauler proposes a treatment that will limit her time outside. But most patients answer questions cooperatively, and while some seem disengaged — perhaps disoriented by medication or frustrated by conditions that never improve — others express good-natured annoyance at being confined to bed, and a few make weak jokes about hospital food.
Al-Samarrai said one of the things that attracted her to Yale-New Haven is the range of people the hospital receives, from rich suburbanites to homeless drug addicts to recent immigrants who speak little English.
Some patients have shrine-like displays of cards and colorful children’s drawings in their rooms, but for others, the only adornment is a plaque on the wall that reads, “Hospital
Dismissal Time 11 a.m.” Many patients who end up in the ward suffer from alcohol-related liver problems or diabetes caused by a poor diet. A social worker, who makes sure all of the patients have a place to go when they are released, joins the residents partway through rounds.
“All of these patients have social problems at home,” Sauler explains. “You can’t just kick them out of the hospital.”
‘From the ridiculous to the sublime’
Residents round on patients three or four times a day, but once in a while, a patient will stand out from the monotony of what al-Samarrai called “the bread-and-butter” cases that make up most of her workload.
This morning, the progression of headaches, coughs and failing livers begin to blur together, but a patient who needs to preserve his sperm before undergoing chemotherapy provokes a collective giggle.
Michael DiLuna ’98 MED ’03, a fourth-year Neurosurgery resident, said he has faced situations “from the ridiculous to the sublime” in the course of his residency. He remembers with particular clarity a patient who was convinced he was Moses. The man was picked up on the streets of New Haven in Old Testament regalia — complete with a full beard and leather sandals — and brought into the psychiatric ward, where DiLuna interviewed him. “Moses” answered all of DiLuna’s questions in character and was so convincing that DiLuna said “his delusion carried over to me.”
When a senior doctor asked him what he thought, DiLuna replied, “I think I just spent a half hour talking to Moses.” The doctor laughed and told him, “You’ll be very sad to know that Moses’s tox screen came back positive for crack.”
Al-Samarrai, on the other hand, remembered one young man whose family had just learned that he was going to die. As she discussed his disease with the rest of her team, the family started singing “Swing Low, Sweet Chariot.”
“It was a very strange and surreal moment,” al-Samarrai said. “This is a boy who’s my age and the age of many of my friends, and I’m watching his family learning about this and literally grieving. At the same time, we’re standing apart from them and going over the physiology of the process of what’s actually happening to him.”
Learning to live with loss
Unexpected moments of comedy and poignancy can make long days on the job bearable, but residents also learn to face the constant specter of tragedy. On rounds, al-Samarrai and her team are comforting while speaking to patients, but in the hallway they occasionally show the effects of the emotional strain. One murmurs, “So sad,” about a man in advanced stages of dementia, and another shakes his head after leaving the man with the distended belly.
“There’s so much wrong with him, and it’s not his fault,” al-Samarrai’s fellow resident, Mohamedtaki Tejani, says.
When doctors can no longer do anything to help, al-Samarrai said, “part of your role is allowing people to die.” But the unremitting intrusion of death can be overwhelming. And while some deaths are inevitable, a resident sometimes has to make a split-second decision that determines if a patient lives or dies.
Debdut Biswas MED ’08 said the pressure residents are under “scares the hell out of me,” and Ali Ozturk MED ’06, an intern — first-year resident — in the General Surgery program preparing for a Neurosurgery residency, said it is especially frightening to be alone on call in the middle of the night, when there is no one around to share the responsibility if a patient suddenly has a seizure.
Kapadia said “a great deal” of his time is spent assessing the aftermath when something goes wrong. When residents make a mistake, Kapadia said, “we all talk about it in a non-threatening way” to keep it from happening again.
Sometimes the mistakes are funny and have only minimal consequences, like the time DiLuna caused a massive epidemic of diarrhea by accidentally replacing an electrolyte solution with a powerful laxative. But all residents know that an overlooked symptom could be far more serious, and the pressure has sent many promising medical students running for the nearest lab.
A warm — and empty — bed
About to enter her 28th hour on the job, al-Samarrai is joined by Sauler, who helps her finish the phone calls, review patient charts and, Sauler said, generally “be like a master secretary.”
“What can I do to get you out of here?” he asks al-Samarrai.
On this rotation, the residents are able to keep a relatively normal schedule; others have residents arriving home when most people are waking up.
“Wow, it’s 7:00 in the morning,” Sauler remembers thinking after one shift. “I’m going to make myself a nice gin and tonic.”
Ozturk said he has maintained a successful relationship with his fiancee, although it “takes a lot of sacrifices on her part.” But DiLuna said he and his fellow residents have been through “numerous failed relationships” that could not stand up to the pressures of the job.
“The fatigue brings out the worst in your personality,” he said. “You’ve got to find right person, who is combination of sympathetic and very understanding. When a resident comes home tired and is grumpy and angry and surly and inadvertently talks to you like a nurse that pages [them] at 3:00 in morning, you have to be able to not take it personally.”
Acting like a doctor
Although she is not quite used to the “Dr.” before her name, al-Samarrai says that she is starting to grow into her role. The long hours, sleep deprivation and overwhelming responsibility have not gone away — DiLuna said when he leaves the hospital, he sometimes wishes he could trade jobs with the man who takes his ticket in the parking lot.
But the small triumphs, when a stubborn cancer responds to treatment or a surly patient opens up, represent the parts of medicine that al-Samarrai said make it more than a science and allow her to share in the “human condition.”
“Why do I do it?” al-Samarrai asks. “It’s really satisfying.”
Her cat’s-eye glasses can’t hide the bleariness in her eyes as she focuses on her computer screen. Al-Samarrai still has notes to copy and prescriptions to call in, even though she is approaching the 30-hour maximum. She may speak wistfully of a hot shower and a warm bed, but she will not leave until she knows her patients will be taken care of.
Taken care of, that is, until she returns at sunrise tomorrow.