Residencies test limits of doctors' endurance

Maida Lynn has cried twice.

Once, for a precocious 6-year-old boy who didn't get a new liver.

The second time, for a premature newborn hooked up to every bag ofmedicine imaginable to keep her heart, liver and lungs functioning.

"No child should ever die alone," an attending doctor told Lynntwo years ago during her first year of pediatric residency at RushChildren's Hospital.

But nobody told the third-year resident it would take the newbornthree hours to die, each hour passing slower with the occasional gaspfor air, the blanket around the fragile body soaked in blood.

Medical residents work hard. They work very hard.

They work 36 hours straight when they're on call. Other days arecalmer. Just 12 hours.

But the work never stops. Patients don't plan their illnessesaround residents' schedules. They don't plan their own deaths,either.

Sometimes, residents are the first voices a child hears in themorning after throwing up all night. Sometimes, residents are themessengers who explain heaven to a 7-year-old girl with leukemia. Andsometimes, residents are the only family holding a dying man's hand.

Residency programs haven't changed much in almost a century. Theystill run on a pay-your-dues hierarchy: long hours, little sleep,lots of coffee, junk food and the daydreams of a soft bed.

But the attitude has changed. Residents are demanding rights.

The National Labor Relations Board has sided with them, allowingthem to unionize at private and public hospitals alike.

A New York state law tries to protect the rights of residents,limiting work weeks to 80 hours. They should have at least one dayoff out of every seven. They shouldn't be on duty more often thanevery third night. Four hundred residents and interns at two privateNew York hospitals recently joined the Committee of Interns andResidents, a union affiliated with the Service EmployeesInternational Union.

In Chicago, Rush-Presbyterian-St. Luke's Medical Center has had ahouse staff organization, a step below a union, for 20 years. Thelabor group, represented by 20 to 25 residents from each department,negotiates with the hospital for salary raises, book funds, bettercall-room conditions and other resident life issues.

"It's about having a say in the decision-making," said MaureenMacMahon, chief internal medicine resident and a former president ofthe organization.

But the very idea that residents can bargain scares many doctors,who say it violates the trust between student and teacher.Northwestern Memorial Hospital residents formed a house stafforganization last month, causing tensions to mount between theadministration and the students.

"Residents start out 100 percent students, and they end up 100percent physicians," said Dr. Samuel Gotoff, chairman of Rush MedicalCollege's pediatric department. "They need to be completely prepared.Doctors can't work 18 hours and then stop because they want to."

8 a.m. 5 Pav (fifth floor), Rush Children's Hospital

"General Hospital," Lynn said, grinning, her eyes curved into half-moons. "I'm serious. I wanted to be this rich doctor with a beautifulhusband, a beautiful house and play golf all the time."

Four years of medical training and two years of residency later,the "General Hospital" dream that urged her on this seven-yearmedical pilgrimage seems far away.

The accomplishments along the way, though, are plenty: the M.D.after her name, the white coat, the stethoscope and the confidencethat oozes doctor-ness.

Then there are the children on 5 Pav.

There is the 17-year-old girl with cancer, hanging by the threadof her life. Her mother died of cancer a few years ago. Her fatherdied last year of a heart attack. Her remaining family members havesigned a "DNR"-do not resuscitate-order for her.

"DNR doesn't mean we shouldn't treat her, though," Lynn told afirst-year resident. "We should at least try, right? I know she'sreally frail, but she may surprise us. She has surprised us to date."

There is the 8-year-old boy in the intermediate ward-a halfwaypoint between normal and intensive care units-with severe braindamage. He had meningitis when he was 2 months old, leaving him withlittle ability to do much other than smile widely when his tummy istickled.

He has been in and out of Rush Children's for most of his life.The rest of the time, he lives in a rehabilitation center forchildren.

"Will you let us look at you?" Lynn asked the little boy, ticklinghim to a giggle, as her team of medical students and first-yearresidents crowd around to watch, listen and learn. "Now, hisbreathing seems to have gotten better. Is there any action we shouldplan for today?"

The decision today is no.

The learning process never stops.

Medical students learn from first-year residents, also known asinterns. Interns learn from senior residents. Senior residents learnfrom their attending physicians.

There also are small group discussions, journal article reviewsand drills by senior residents, attending physicians and departmentchairmen.

"It's a chance to either show off or bomb," Lynn said. "At onepoint or another, I got asked and tortured with the same questions. .. . The education you get, it's what you make of it."

Applying for a residency is like sorority rush.

Hospital work during the last two years of medical school iscrucial to the process: surgery or radiology? Pediatrics orneurology?

In the fall of their fourth year of medical school, they choose afocus.

Medical students court the teaching hospitals of their preference.They have a few hours to sell themselves, explain the "C" in organicchemistry or the summer they fished in Alaska instead of working in ahospital.

The hospitals make their pitch, flash their state-of-the-artfacilities and list famous alumni of their residency program.

Students and hospitals then rank each other for that match made inheaven.

"It's very barbaric, but it's the most systematic and organizedway to do it," Lynn said. "You get this envelope. When you open it,it's your destiny."

3 p.m. Nursing station

"I just had trouble dealing with the fact that adult illnesses areoften self-inflicted," Lynn said, her second Diet Coke in hand. "IfI'm going to hear whining, I'm going to hear it from a kid. Theyreally get sick by no fault of their own."

Eight hours into the shift, the day seems to have just started.

Ten more children are admitted to the hospital through theemergency room. Eight-year-old Tyler with chronic constipation.Thirteen-year-old Nichelle with cystic fibrosis. Twelve-year-oldReggie with a spinal tumor.

"Oh no, Reggie's back," Lynn told Rebecca Weiss, a family medicineintern. "He has a left foot drop."

Reggie was in Rush Children's just last week. Both of his feethave gone numb now. He can't control his bladder very well anymore.Reggie needs an MRI to see whether the tumor is causing compressionson the spine, which can cause paralysis.

A call to radiology. A call to anesthesiology. The two departmentscan't coordinate their schedules to give Reggie the MRI he needstoday.

"That's ridiculous. Do you realize this is an emergency?"

Lynn slouches back in her chair at the nursing station, hands overher forehead, elbows propped up against the desk. Reggie's biopsyfrom last week isn't back from pathology yet. They don't know whatkind of tumor he has.

"So much for tertiary care. . . . This is a medical legalnightmare waiting to happen."

Managed care is increasingly governing the medical world: morebureaucracy, less funding. But the physicians' commitment to carehasn't changed. A child's chuckles are all the encouragement theyneed. The sobs are reasons to care.

The worst part of the job?

The phone calls, the coordination, the paperwork.

Reggie's MRI is scheduled for 6:30 the next morning.

The big hope overnight is Reggie's condition will remain stable.

"I think I'm all caught up now." Lynn sighs, looking through her 5-by-7-inch index cards, notes about each patient scribbled all over."This was standard chaos. Well, a little more than standard chaos.But this is how the day usually is."

7:30 p.m. Home, Forest Park

Without her white doctor's coat, Lynn appears younger than herage, her hair pulled back loosely with a black clip, strands ofsilver and gray hair shimmer in the warm light of the living room.

Her husband, Herbert Chen, looks at his watch and shakes his head.

"You're home late tonight."

"Yeah, this boy Reggie is back again. . . . He has the spinaltumor."

Conversation is sparse between Lynn and her husband, her headstill twirling with thoughts about Reggie's MRI, Nichelle'santibiotics, the 17-year-old girl with cancer.

"It's so easy to feel very lonely when you come home," said Lynnwho met her husband in medical school. "You have to have a socialbase, or otherwise you'll lose it."

The social circle for residents shrinks after medical school. The36-hour on-call shifts strain marriages and friendships. But marriagehas also been a default social base.

"I'm lucky that I'm married. . . . I don't usually have anoverwhelming desire to paint the town red."

A simple dinner, movie or a long walk with her husband willsuffice.

Next year, Lynn will follow her husband to Los Angeles, where hewill start his radiology residency at UCLA, leaving behind theirfriends who, in other cities, also will practice the skills they'velearned in residency.

But another class of residents will come to Rush Children'sHospital.

In one day, they will be the gentle voices a sick child hears inthe morning. They will explain heaven to little girls with cancer.And they will cry for the little boy who didn't get a new liver.

AROUND THE CLOCK

7 a.m. Patient visits: Interns and medical students find out whathappened overnight, then do rounds with the medical team, includingthe interns, medical students and senior residents.

8:30 a.m. Morning report: Senior residents attend closed sessionwith chief resident and department chairman to discuss the cases thatcame in overnight.

9 a.m. Journal review discussion: Required for all residents andinterns.

10 a.m. Rounds: Presentation of patients to the attendingphysician.

11 a.m. Mini-lecture: Discussion among the medical team on a topicpertaining to one of their patients on the floor.

Noon. Conference: A specialist or attending physician gives alecture to all doctors, including the medical students.

1 p.m. Followup: Time to take action on decisions made in themorning rounds, such as looking at chest X-rays or lab results,calling specialists, doing discharges and admissions.

5 p.m. Sign-out: Those not on-call present summaries of theirpatients to the on-call team, cautioning them on what to expectovernight.

6-6:30 p.m. End of shift for those not on-call. For on-callers,another day just started.