Nothing so identifies me as those two words for if you have survived internal medical training at Duke, you have run the gantlet and come out the other side. You have stepped into the cauldron of fire and lived. You have weathered the arena and fought on. Why is this so?
To understand you have to go back to the origins of the Duke School of Medicine in the 1930s and the transplantation of many young, talented academic physicians from Johns Hopkins who were trained rigorously. And then there was Dr. Stead. Eugene Stead was a famous cardiology researcher at Emory and then Duke where he led the Department of Medicine for many years. He was a master clinician and thinker. He proposed what became known as the “forward theory of heart failure” implicating more than just a stoppage in the pump with back up in the system as the cause of pulmonary edema. He was proved to be right as there are several factors other than just physical blockage that explain the manifestations of congestive heart failure.
Dr. Stead was a bit of a martinet. He was uninterested in whether or not his interns and residents had a home life. So, we worked. All the time, even though Dr. Stead was no longer chair when I was an intern, the precedent for the program had been set. We had one week night (usually starting about 6 or 7 PM) and one weekend day off. If that day was Saturday, you still came to 10 AM rounds and usually were in the hospital until one or two finishing your chart work. If your off day was Sunday, you didn’t come in in the morning, but you usually were in at supper time making sure nothing horrible had happened to your patients while you were away and that you were ready for work rounds Monday morning. When you were off, you mostly slept.
Why was that work schedule necessary?
It probably wasn’t, BUT…
You were able to follow the natural history of diseases from the bedside without missing anything. You became responsible for every one of your patients and many who you would care for when the other intern was off. And you never missed anything…
The woman with pneumonia who actually had Sheehan’s post-partum necrosis of the pituitary gland with a suppressed level of cortisol and enhanced susceptibility to infection whose menstrual cycles were not thrown off because she was using birth control pills.
The woman with one chest x-ray infiltrate suggesting a simple pneumonia who my brilliant junior resident found actually had two shadows on the chest x-ray allowing him to make the diagnosis of right-sided staph endocarditis in a drug addict.
And surely the woman with lupus profundus with necrotizing lesions of the subcutaneous fat requiring debriding until the plastic surgeons could step in and save her life was an important episode in my life. I almost became the only Duke intern on a Dermatology rotation to lose a patient.
On day one of my internship, I was petrified I would kill someone. I never did. On day 365 I knew only two words for any patient coming through the emergency room to my care. “Bring it.” No fear.
My internship was probably more of a 365-day ground battle than I suppose a simple learning experience, but learn I did. I could put a 20-gauge intravenous catheter in anyone anywhere and do a spinal tap in the middle of the night with no sleep. Tap a joint—no problem. Tap a chest—easy. Run a cardiac arrest team, any time.
I was no doctor when I finished medical school and was really not a good one after that first year of internship, but after a year of residency and then a year at the National Cancer Institute as a clinical associate, I was ready for anything.
I miss that feeling of being truly competent at patient care. I worry that the less rigorous training programs of today will not produce doctors with my depth of knowledge or confidence then. And I’m counting on those doctors. I’m not getting any younger, but they seem to be.