The Intern Blues

1. The Intern Blues Robert Marion M.D.

2. Layout of the Book • The Intern Blues is a collage of the experiences of three young doctors (2 male and 1 female). • It was written as a narrative from the tape-recorded diaries of three young doctors during their first year of post-graduate medical residency at the request of Dr. Marion. • Their names and the names of the hospitals where they worked were altered. • The book is sectioned off into months, with each of the interns having their own individual diary entry for every month. • After the three entries for the month are complete, Dr. Marion presents his opinions and/or experiences dealing with similar situations. As well as commentary on the state of medical education.

3. About the Author • Robert W. Marion M.D.

4. Educational Background • M.D., Albert Einstein College of Medicine, Bronx, NY, 1975 - 1979 • Internship/ 1st Year of Residency: Boston Floating Hospital/Tufts New England Medical Center, Boston, MA, 1979 - 1980 • Pediatric Residency: Bronx Municipal Hospital, Bronx, NY, 1980 - 1982 Albert Einstein College of Medicine • Human Genetics Fellowship: Bronx Municipal Hospital, Bronx, NY, 1982 - 1984 • Board Certified: Clinical Genetics, 1984

5. General Information • The director of clinical genetics at both the Montefiore Medical Center in the Bronx and Blythedale Children's Hospital, Valhalla, New York. • He is the author of six published books, including The Intern Blues, Rotations, and Learning to Play God: The Coming of Age of a Young Doctor. • He lives with his wife, Beth and three children Isadora, Davida, and Jonah in Westchester County, New York.

6. Academic Appointments • Professor of Pediatrics, Albert Einstein College of Medicine, Bronx, NY • Professor, OB/GYN, Albert Einstein College of Medicine, Bronx, NY • Faculty Member, Graduate Program in Human Genetics, Sarah Lawrence College, Bronxville, NY

7. Dr. Marion wrote The Intern Blues eight years after his own internship. • He still describes that year as the hardest, most devastating of his life. • And states that some of the pain, anger, anguish, and exhaustion are still with him. • From his writing and the diaries of the three interns, Amy Horowitz, Andy Barron, and Mark Greenburg, you come to understand that their experience during the first year of residency, while unique to the individual, is equally grueling for all who experience it.

8. Central Themes • Convey the struggles, stress, and transformations that young doctors go through during their first year of residency. • To present his view of the current system of medical training as antiquated, unnatural, and unhealthy for both the patients and the physicians themselves.

9. Struggles and Stress • Throughout the book the suffering of each intern is apparent. • “I’d like to think that overall this has been a good year, but I can’t.” –Andy • “I don’t think I’ll wear that costume again. The bloodstains kind of take all the fun out of it . And next year if I’m on call on Halloween again, I don’t think I’m going to dress up.” - Mark • “I’ve been thinking about that little girl constantly since I finished with her. All through the rest of the night…that little girl didn’t leave my mind. It’s really terrible. I’m sure I’ll see her face in front of me for years and years to come.” – Amy • I’m going to kill them, I’m going to kill them all! – Mark

10. Struggles and Stress • Lack of sleep • On call every third day (36 hours with no sleep). • The Match • The system by which you are placed in your residency. • Working an average of 100 hours every week with only one day off • An average of 16.6 hours a day. • Depression • Changing to a different ward every month • You have to adapt to a different system, acquaint yourself with new surroundings, and learn to get along with a different set of co-workers.

11. Struggles and Stress • Responsibility for the life of another human being. • Identifying and reporting child abuse and rape • Deciding if children should be taken away from their parents • Watching a patient die without the ability to help them in any way • Ethical Dilemmas

12. Dealing with Death • Over his friend, Enkidu, Gilgamesh cried bitterly, roaming the wilderness. "I am going to die!--am I not like Enkidu?! Deep sadness penetrates my core, I fear death, and now roam the wilderness. • Dealing with the deaths of others and your own mortality on a daily basis has to be another major cause of stress.

13. Normal Struggles and Stress Compounded • Relationship problems • You’re so tired you can’t give your partner the time they need. • Lack of a home-life • No time for friends, family, children, hobbies, or exercise. • You’re either at work or asleep so you have virtually no social life. • Even with a family emergency it is almost impossible to get off work without lying. • Problems with your boss and co-workers

14. Time for a Change • Serious reform of resident duty hours did not begin until 1984 after the death of 18-year-old Libby Zion at New York Hospital. • The resident on duty did not medicate Ms. Zion properly. • The intern, responsible for numerous other patients and having already worked more than 18 hours without a break, ordered restraints as well as another drug. Libby died soon after.

15. Investigation • Libby Zion's father, an attorney and writer for The New York Times, persuaded New York District Attorney Robert Morgenthau to begin a grand jury investigation into his daughter's death. • There were no criminal indictments of the doctors, however, the grand jury investigation did result in an indictment of the system. Listing sleep deprivation and inadequate resident supervision as major problems leading to Libby’s death. • In response to the indictment the Bell Commission (named after its chair Dr. Bertrand Bell) was established to make suggestions for changes to the current system.

16. Bell Commission • Proposed • To Limit resident work hours to 80 hours per week • No more than 24 consecutive hours of on-duty time • At least one 24-hour period off-duty each week. • Recommended onsite Attending Physician supervision in both emergency rooms and acute care inpatient units. • The Bell Commission's recommendations became a New York State regulation (section 405 of the New York State health code) on July 1, 1989.

17. Further Developments • Funds were not allotted to monitor for compliance. • In 1999, a cardiology fellow training in New York died in an automobile accident after a night on call. • This led to the Health Care Reform Act of 2000, which gave adequate funding to monitoring hospital compliance with resident work-hour regulations.

18. Salient Changes in Medical Residency • In 2003 the American Council for Graduate Medical Education (ACGME), the private non-profit in charge of accreditation of medical residencies, set up the following standards. • Doctors are limited to no more than 80 hours of work per week • Residents cannot work for more than 24 hours in a shift • Residents will have one day off in seven and get a 10 hour break between being on call and working a shift

19. The debate over what to do with resident work hours was mentioned in the book. • Dr. Marion seems mostly in favor of the 80 hour limited work week recommendation. • He however would most likely have problems with the limitation to 24 hour on- call shifts.

20. As stated earlier, the author presents his opinions and/or experiences dealing with similar situations that are addressed in the interns diaries. • These include: • The effect of poverty on treatment • How best to deal with premature babies • How residents learn to speak to parents who have lost their child • How AIDS has changed how doctors deal with patients • How residents’ relationships are effected • Possible changes to intern work schedules • Childcare for female doctors • And many others

21. Poverty and Medicine

22. Three Types of Premature Babies • Type I – Good Prognosis • Type II – Bad Prognosis • Type III – Less than 2 lbs. but above the 24 week mark

23. My Opinion • This book brings you face to face not only with problems in the first year medical resident’s life but also some of the biggest problems in society. • Child molestation/abuse • Ethical questions about extending life artificially • The way the book is written you feel like you’re the one making each decision, feeling inadequate, and getting yelled at by your superiors.

24. My Opinion • The author, in spite of his position and experience didn’t come out and try to answer all of the big questions posed by the interns experiences. • He gave us the issues the residents deal with everyday (taking children away from their parents/ letting a patient die or not) and let us deal with them. • He may have laid the book out this way because he doesn’t know the answers, but it is still a very effective way of engaging his audience and stimulating the thought of the reader.

25. Transformations • Beginning their internship, Amy, Andy and Mark were tense, uncertain about their abilities, and full of fear. • At the end of their internship they had developed confidence in their judgment and technical ability. • Through the internship much of their enthusiasm and spirit was worn down. • And in the words of the author, they truly became physicians but in the process lost some of their innocence, humanness, and fundamental respect.

26. Is it all worth it?

27. References • The Epic of Gilgamesh • Marion, Robert M.D. The Intern Blues • AMA website • FREIDA website