Black Cloud

My internal medicine sub-internship is over, and, like the first sunny days after a long winter, I feel a buoyancy and optimism I've been missing.

Don't get me wrong -- I've enjoyed all my rotations, and even this sub-I had its merits. The residents and attendings at my hospital were very supportive, and effective teachers. The patients have been largely friendly and appreciative. And, when it comes down to it, I'm still a blessed student, and though my responsibilities are growing, my stress level is benign compared to the interns.

But this past month was the closest I've come to refusing to get out of bed in the morning. There's an inescapable dread factor in medical ward months -- the Short Call and Long Call days where you're admitting new patients. The pressure comes from wanting to keep your patient list short going into call. And it's always a day away.

Some residents are described as "white cloud" or "black cloud" depending on whether they bring good luck and short patient lists, or bad luck and endless complicated admissions. I think it's either a polite way of pointing out who's efficient, or a silly superstition. Because the truth is, during medicine ward months, everyone has a black cloud over their heads -- pressuring us to discharge, discharge, discharge.

I remember pitying my fellow sub-intern, who was on Long Call on Superbowl Sunday. He ended up enjoying the game in the lounge, as the admitting team got just one new patient that day (I'd be curious to see what admissions were like in Philadelphia). As a consequence, his workload was light all week. As for our team, we were on call the next day, and we capped (and most came in within four maddeningly stressful hours at the end of the day). What's worse, we had to frantically work to unload these patients all week before short call (where we also capped) and the next long call (also capped).

When your list is long, there's no joy in anything. The patients always have too many questions, the learning opportunities always seem to be a distraction.

The days began with rounds, which are the most awkward and unnatural of human interactions. Then you've got a crucial period to get notes written, labs ordered, and consults arranged. If a discharge is being planned, you've got to get the ball rolling early in the day. But most days of the week, our work is interrupted with teaching attending lectures, morning conference, noon conference, and Grand Rounds (I much prefer the web-only version).

There's nothing more frustrating than being forced to watch a presentation on a rare, rare case of sarcoid cardiomyopathy when you're trying to manage the paperwork for your patients with common, common COPD exacerbation.

I found myself saying, often, "Thank goodness I'm going into Emergency Medicine." In EM, the didactic sessions actually seem to matter -- you learn stuff you'll actually use (in Medicine, the take-home message of these rare case presentations always seems to be, "consultants order more tests than you can possibly remember.")

One of the big drawbacks to EM, they say, is the lack of continuity. Well, this much-touted "continuity of care" seems overrated and overestimated. I've had attendings tell me "I've known this patient for years, I'd discount her anginal symptoms" and then blanche as the patient gets quintiple-stented. Meanwhile, with the weekly personnel changes of residents, students, or consultants, and the elusive weekend coverage, there's not a lot of continuity to begin with.

What got me down the most about this month was this: seeing the same patients on rounds every day rarely engenders positive feelings. Usually it was guilt or frustration or, at worst, suspicion. Guilt for not curing the patients immediately. Frustration because the consultants disagree or the biopsy results aren't back or the nursing home is refusing the patient. And suspicion, when the patient looks improved enough to go home but won't.

All that continuity seemed to generate resentment (both ways) and erode the patient-healer bond, not strengthen it. I contrast that to my experience in the ED, where in brief encounters I was able to connect with all but the most abusive patients, and often help relieve all but the sickest.

People talk about burnout in Emergency, and the time-honored ways of the medical wards. But I have a different idea about which field suits me, and which could drive me mad. Thank goodness I'm going into Emergency.