Friday Reflection 3: The Days of the Giants

PS is a 26-year-old man who presents to the emergency room with fever, fatigue, confusion and right upper quadrant pain. He is known to be HIV positive without history of an “AIDS defining illness.” He is on AZT and aerosolized pentamidine.

Every generation has its stories. My grandfather came to this country with pennies in his pocket. My father played hooky with his sister to sneak into the 1939 World’s Fair. My wife swears that it was never above freezing when she waited for the school bus. These stories are occasionally appreciated but usually just tolerated by the younger generation. In medicine these are referred to as stories from the “days of the giants” -- as in “back when giants walked the earth…”

My favorite “days of the giants” story is from September of my internship, 1993. It is the story I always tell during slow days on rounds. Its lessons have evolved over the years.¹

I began my residency with a month at the VA hospital in Brockton Massachusetts followed by a month on the cardiology service at Beth Israel Hospital in Boston. We fondly called Beth Israel “The BI” to differentiate it from some of the other local teaching hospitals: “The General”; “The Brigham”; “The Deak”; “City”; “NEMEC”. I remember almost nothing of these first couple of months, probably because I was on call overnight in the hospital – essentially a 36-hour day -- every 3rd night. I was moderately overwhelmed but seemed to muddle through. I do remember one bout of sobbing in a hallway after being berated on the phone by an attending cardiologist. I was able to hold it together while he explained to me that I had been irresponsible in sending home one of his patients.

A nurse noticed me looking upset after I hung up the phone. She walked up to me and whispered, “Don’t worry, everyone knows he’s and douchebag.” I broke down weeping as she hugged me.

So maybe I was more than moderately overwhelmed.

With September, I began my first month as an intern on the general medicine service, the core experience for an Internal Medicine resident. I entered this month with some real optimism. Call was every fourth night, and we were promised our first day off. I remember the argument for not getting a day off earlier went something like: “You barely know enough to care for your own patients, how could you possibly cover someone else’s?”

In its own twisted way, not an unreasonable point.

Arriving on Monday morning, my co-intern and I picked up our new service. We were faced with a daunting roster of patients. My memory was that there were 30 patients, 15 for each or us, and a resident, Jim, who had been pressed into service to cover for the actual resident – the one who knew the patients – who was out sick for the day. I am sure there were patients that today would not even be in the hospital, but there were also some who were deathly ill.

PS was one of those the patients. He was about my age and even looked a bit like me. He, like many of the patients, was in the hospital suffering from the consequences of late stage AIDS. 1993-1994, the year of my internship, coincided with the peak of AIDS deaths in the US. Although we could certainly do more for our patients than the doctors who cared for the very first AIDS patients a decade earlier, we still had little to offer.

PS had hepatic pneumocystis. Because his immune system was so horribly compromised by the HIV virus, he was at high risk for pneumocystis pneumonia. By 1993 we had learned to prevent PCP, as we then referred to this pneumonia. The best treatment, then and now, was an oral antibiotic – trimethoprim-sulfamethoxazole. However, many patients could not tolerate this medicine and thus received alternative treatments. One of these was aerosolized pentamidine. This did a pretty good job of preventing the fungus from infecting the lungs but did not protect the rest of the body, hence the pneumocystis infecting his liver.

When my resident and I entered the room, I was faced with the sickest patient I had ever seen. I was overwhelmed not just by this young man’s tenuous hold on life but by the number of things we needed to address. There were electrolyte abnormalities, drug dosing, a failing liver and failing kidneys, the need to discuss end of life wishes, the need to communicate with his primary physician and his family – who, if I remember correctly, had only been peripherally involved in his life for years.

Oh, and I needed to see my 14 other patients.

As Jim and I left the room I turned to him and asked, “what are we going to do?” Without missing a beat his response, “I don’t know Adam, it’s kind of the blind leading the blind today, huh?” I can still remember my palpitations. (It was a few weeks later, when Jim joined the service as the supervising resident that I realized he was, in fact, the ideal resident -- someone whom I tried to model myself after for the next three years. He was smart, calm, patient, caring toward the patients, supportive of his colleagues, all in addition to being in possession of a killer, dry wit).

I called PS’s attending physician to update him on his patient’s condition and get some guidance, less on the medical decisions and more on how to navigate the necessary end of life discussions. I remember being patched through from his office to his house on Cape Cod. News of the goings on had reached him before my call did.

Me: Dr. M, this is Adam Cifu, I am one of the interns at The BI taking care of your patient PS.

Dr. M: What the hell is going on up there?!

Other memories from this month remain fresh, almost 30 years later. There was the night I was called to see an unresponsive patient. Walking into the room I developed a medical version of stage fright, forgetting everything I knew. A nurse, my age but already with years of clinical experience, stood next to me calmly directing me: “Check a finger stick glucose, check the pulse ox, review the vital signs and meds list…”

When I thanked her later, her response was just a shrug and a: “It’s only September. Don’t worry.”

There was a wonderful man, with a partner so dedicated and loving that talking to the two of them always broke my heart. He was admitted with Kaposi sarcoma (KS) of the lung.

KS is a malignancy in which blood vessels proliferate abnormally. It usually presents as bluish skin lesions. To develop the disease a person needs to be infected with human herpesvirus 8, but most people with this infection never develop KS. The disease was first described in 1872 and existed mostly as a rare disease in older men of Mediterranean and Jewish descent. When HIV began to ravage the immune systems of patients, KS became epidemic. An obvious outward sign of immune devastation within.

Some patients, would develop KS in organs other than their skin. My patient had developed lesions in his lungs that led to large pleural effusions – collections of fluid around the lungs. One day, I drained this fluid (performed a thoracentesis), pulling off a few liters from around each lung. He and his partner celebrated when I finished, hugging me as his breathing was already so greatly improved. However, as I lifted the glass jars into which I had drained the fluid, I was horrified to notice that the fluid, on cooling, had mostly solidified into a gelatin-like substance the shape of the vessel. Seeing something like this, so strange to me, made real how little time this man had left.

And, there was the time I was nearly killed driving home. I stopped at a light and wisely decided that it would be OK to close my eyes for a bit until the light turned green. I awoke to horns after I fell asleep, took my foot off the brake, and drifted into the intersection.

On the third weekend of the month, my day off arrived. I called a college friend who had grown up in the area, and was taking some time off between jobs. I told him he needed to get me away from the hospital for the day; I needed to escape. He informed me that he would call Mike, a high school buddy, and we would go to the beach. I’d have to drive, though, as he did not have a license and Mike had a DUI. These were two people living very different lives from mine.

The trip to the beach marked the low ebb of the year.

On a beach, Crane Beach, my friend and his companion smoked and carried on with jovial banter.

I lay on my back, eyes closed, bemoaning my existence. I silently enumerated all the things that were going badly. I had worked so hard to get to this point and I was miserable. It was getting hard even to go to work each day. The hospital scared me. What else could I do? I remember running through various other careers before deciding that I just had to stick it out.

Things got better. I started to get more sleep and got a day off at least every two weeks. I got the hang of life in the hospital, so I no longer lived in fear at work. I started to see patients in the outpatient clinic — something I was actually pretty good at. I had a call day, Thanksgiving day, when I got only one admission at 10 AM. I had a turkey sandwich at 8, went to bed at 10, and woke at 6 sure my pager was broken. When I got to the nurse’s station, there were six charts with orders for me to sign; orders that the nurses didn’t think were worth waking me for.

The benefits of this year were clear. I saw dozens and dozens of patients. I answered hundreds and hundreds of pages. I made a thousand decisions: large and small, right and wrong. I could evaluate a patient with chest pain in my sleep -- I often did -- and could place arterial lines, perform lumbar punctures and “float swans” like a pro.

However, the cost was enormous. I realize how much more I could have learned, how much better I could have performed, how much safer things could have been for the patients if the training had been more humane.

Lying on Crane Beach that day, I had symptoms of burnout: exhaustion; emotional unavailability; a lack of efficiency; poor self-esteem. Such an easy diagnosis now, I didn’t even have a word for it then. I just thought I was failing.

My symptoms of burnout?

I was exhausted, though I am not sure if this was a symptom of burnout or chronic sleep deprivation. I’m not sure that even matters. I certainly did have signs of emotional unavailability, compassion fatigue. I remember being angry with my patients, feeling as if their illnesses were more of a burden for me than for them. Fortunately, I lived alone that year, my fiancé not moving to Boston until the summer my internship ended. I probably was less efficient at work than I could have been, but like the fatigue, was this a symptom of burnout or just a symptom of not being terribly good at the job?

It’s probably a testament to the resilience of 26-year-olds that there were so many symptoms of burnout that I lacked. I still actually liked medicine. Even though I fell asleep immediately at every teaching conference, I loved discussing our cases. I was proud of what I was doing and kind of amazed of where I was. I adored and respected my fellow residents and the nurses with whom I worked.

How much more could I have learned if I was less tired? How much better could I have done with my patients if I had the headspace to think more about their lives? Only recently have I gone back and read widely about what it was like to be part of the gay community at the time, a time when it seemed like everyone was dying. Most recently, I’ve read How to Survive a Plague and The Great Believers, a book that paints a beautiful but tragic picture of life in “Boystown” in Chicago in the ‘80s and ‘90s. The Great Believers led me to read Taking Turns, a masterful graphic novel created by a nurse working on an AIDS unit in Chicago at the same time I was training in Boston. I see how I much I missed by being too burnt out to actually care about the people and the community at the same time that I was caring for the patients and learning about KS, PCP and cryptococcal meningitis.

I hold no ill will against my residency program or medical training in general. Maybe, to paraphrase Jonathan Franzen, it just wasn’t so bad that it didn’t later seem good. Sure, my program director was not a revolutionary, using the residency to model humane medical training. Those who ran the residency program were concerned about our education and our safety and the safety of our patients. Our schedule probably seemed downright lovely to those who had trained a generation before when being a resident meant being a resident of the hospital (unmarried, clad entirely in white, skin included). Our training was a step in the evolution to where training is now, which I hope is step toward a time when training is actually spent deliberately practicing medicine.

Learning medicine is, and should be, hard. The volume of knowledge is enormous and ever expanding and the need for vast clinical experience is essential. People ask of you more than you can possibly provide. You blame yourself for bad outcomes over which you have no control (and, even worse, for things you do). Other people blame you as well. You’re kept up at night not only by the pedestrian worries we all share but also by thoughts of the test result you forgot to act on a week before.

Our ever-present goal should be to assure that medical training is as difficult as it should be, maximally effective, and atraumatic.

1. Still defending myself, I had, in fact, done all the right things, except alert him, a second time, that the patient was being discharged.