A Year Wiser, Medical Interns Earn a Rite of Passage

VENTURA —  Between his patients’ labor contractions, first-year resident Dr. Steve Mills brainstormed with a colleague in the obstetrics ward at Ventura County Medical Center.

An important deadline was fast approaching.

Mills and the 12 other interns at the county hospital were close to concluding their first year of a three-year residency and scrambling to put together their final project.

This project, though, had nothing to do with medicine.

Following hospital tradition, they had to present a series of skits to introduce a new crop of residents to hospital life.

The performance would spoof their superiors as well as themselves.

All the doctors, administrators and new residents would attend what has come to be called Ondulando--after the Ventura clubhouse where the first play was staged more than 20 years ago.

During this, their final week, the young doctors rushed about the hospital, taking over the operating room to film a video late at night, frantically trying to memorize lines between checking patients, and furtively shooting pictures of unsuspecting--but slightly paranoid--hospital staff members.

Mills, who has emerged as the class jokester, had become the de facto director. He also penned the main skit.

It was about a patient admitted to the emergency room with a vicious hangnail. First-year resident Dr. Christina Zaro, soft-spoken but strong, would play the groggy intern subjected to the outlandish advice of a cadre of eccentric physicians--based on characters at Ventura County Medical Center.

Just out of earshot of the attending doctors, Mills and another first-year resident decided Dr. Andrew Bruton--easily the hairiest of the first-years with his beard and long hair--should play a pregnant woman in a skit about the obstetrics ward.

Even minutes before the skit, the residents rehearsed--running through dance numbers and trying on costumes. They were not as ready as they could have been.

“But then, we’ve never been ready for anything all year,” Mills quipped.

In the last year, they have welcomed babies, wrinkled and red, into the world, and bid farewell to the sick, the injured and the old, who could not hold on any longer.

On Tuesday, the 13 fledgling doctors completed the first year of their three-year residency in the family practice program at the medical center.

“They can never repeat this year, with its emotional turmoil, and the toll it takes on them,” said Dr. Lanyard Dial, the head of the medical center’s residency program. “That initial transition feeling, of ‘I’m incompetent’--that doesn’t happen again.”

Fresh out of medical school, the untested doctors were thrust onto the hospital’s front lines last June.

They battled sleep deprivation, lack of experience and their own fears.

They have rotated through every department--removing organs, sewing up lacerations, diagnosing diseases and talking to people who have no one else.

They have treated children, criminals, addicts, migrant workers and even Ventura’s mayor.

They are tougher now.

They have fought an ever more miserly health care system to get patients the care they need.

Many have developed a new cynicism. Some witnessed the abuse of the system by drug addicts seeking fuel for a habit, and watched in frustration as other patients refused to help themselves.

In the course of it all, they earned the right to practice medicine. In the state of California, doctors can be licensed after one year of residency.

They can officially put out a shingle and set up their own practices if they want to.

They have also developed their own personal styles.

Learning to Behave Like Doctors

An old man waited, cane in hand.

Dr. Jennifer Scott broke from her morning meeting in the intensive care unit and went to him.

For days the man’s wife had teetered on the brink of death.

She had been in a car accident. Now only the tubes running through her nose and into her arms kept her alive. A monitor’s light flashed red.

The old man and his family had come this morning to say goodbye. By noon the woman was dead.

As Scott took the old man into her arms, he started to cry. His frail body seemed to hang on her.

He thanked her and let her go. Then he hobbled down the hall and out the door.

“This is so sad for me, because it reminds me of my mom,” Scott said later. Her own tears began to run.

Scott’s mother was hit by a car while on vacation in France last fall. At the time, some of Scott’s fellow residents wondered if she had the emotional and physical reserves to make it through her grueling internship.

In the months that followed, she was forced to rely on her fellow first-year residents in ways she had never imagined.

Along the way, she also learned to channel her immense personal pain into compassion for her patients.

When Scott emerged from the woman’s room, her attending doctor tried to console her.

“It’s hard to separate yourself emotionally,” he told her. “Older people remind you of your parents. Once you have kids, kids will remind you of your kids.”

Steely detachment is not a top priority for Scott or the other young doctors.

Bruton is gently encouraging with his patients. In a hospital where nearly one-third of the patients speak only Spanish, his command of the language helps put many patients more at ease.

Zaro has moved this year from tentative to strong. She presents her cases at morning meetings with confidence and authority.

And Mills, at 33 the oldest of the first-year class, has learned to put patients at ease by joking gently with them. He likes the intensity of working in the ICU, caring for the hospital’s sickest patients.

Confidence Grows With Experience

In June there was a buzz at the hospital.

Mug shots of the newest residents were pasted around the hospital at nursing stations and on bulletin boards. Wandering the halls, they looked bright-eyed and scared. They reminded the current first-year residents--known traditionally as interns--of how far they had come.

The third-year residents whom the interns have looked to for guidance would soon depart--dispersing to family practices across the country. They reminded the interns of how far they still have to go.

Part of the reason the residents could laugh at themselves and their life at the hospital was because they had come so far.

Their progress shows.

The residents now fluently speak the lingo of the medical profession. Multisyllabic Latin terms effortlessly trip off their tongues. They say “palpate” instead of touch, and “ambulate” instead of walk.

They are more confident.

Zaro worried at times this year that her inexperience would cause patients discomfort.

Last October in the labor and delivery room, she was sometimes reluctant to check the cervical dilation of expectant mothers if they had already been checked by an attending doctor. She was afraid of the pain she would cause with her unpracticed hands.

Now her colleagues joke that they have turned her into a monster.

Zaro is still mindful of patients’ comfort, but she pushes for tests when necessary.

On a recent day, Zaro visited a patient in her mid-40s with diabetes. The woman had already lost a leg and some toes to the disease. She was in intense pain, but displayed a number of mysterious symptoms.

After consulting with several attending doctors, Zaro had decided to take a bone marrow biopsy from the patient’s hip bone to try to figure out what was causing spikes in her fever, among other things.

When Zaro poked her head into the room, the woman was groaning in pain.

Unfazed, Zaro ordered the nurse to proceed. The nurse injected morphine in preparation. It was the attending doctor who urged Zaro to wait.

“She’s already writhing in pain,” the attending said. “This is not important enough to hurt her.”

Zaro can feel the difference in her style.

“There is so much I know that I never knew I knew,” Zaro said. “I’m more confident. Especially with patients. Instead of talking to the patient and then going to the doctor, now I’m already making the diagnosis with the patient, and maybe running it by the doctor.”

Increased Confidence Breeds Efficiency

Indeed, the residents have become more efficient.

Last fall an initial patient interview often took 20 minutes to half an hour, and the questions were wide-ranging.

Now their interviews are only as long as they need to be. Their questions are focused, their examinations routine.

Last September when a farmer from Santa Paula came into the emergency room with battery acid in his eye, Dr. Andrew Bruton lugged an eye test machine across the emergency room. He struggled to figure out how to work it and where to plug it in.

The attending ER doctor pointed out that usually doctors take the patients to the machine.

On a recent Friday night Bruton moved through the ER with ease. In three hours he stitched up the V-shaped scalp wound of a woman who had flipped her car, sewed shut a nick in the cheek of a 6-year-old who had fallen down while playing and put a woman with chest pain onto medicine to bring down her blood pressure.

More than anything, the doctors are more at ease in the hospital, with patients and with themselves.

Earlier in the year the residents were often unsure of where to be, how to act and what to do.

Now they are comfortable letting on what they don’t know. On a recent day Dr. Mills used his elementary Spanish to break down barriers and bond with patients and their loved ones in the obstetrics ward.

As he prepared to go in and check a patient in labor, the attending doctor advised Mills to go and give the Spanish-speaking woman support.

“Just put your fingers where you want her to push and say, Empuje a mis dedos para 10,” counseled the doctor.

Mills did that, then parlayed the interaction into a mini Spanish lesson with the woman’s friend, who sat holding her hand. The friend smiled, and began to talk. The husband relaxed.

At lunch, Mills and several other residents adjourned to a lounge to watch a freshly prepared Ondulando video.

Geogy Thomas, another first-year resident, shut the door and swore everyone in the room to secrecy before popping the tape into the VCR.

It was an infomercial advertising an indispensable book to the new first-year residents: “Where Not to Stand in the Hospital.”

“Are you an intern that’s scared?” first-year resident Dan Kim said earnestly into the camera. “Are you always in the wrong place at the wrong time . . . ? Then I have the product for you.”

The video featured a series of sly jokes about erupting boils, projectile vomiting and unfortunately aimed infant urination.

The residents howled. Lunch ended and they rushed back to their duties.

Interns Have Earned More Responsibility

All 13 of the first-year residents have struggled in the past year to balance the pressures of their professional lives with their private ones.

One resident became a father. One ended a long-term relationship. And one resident--separated from his girlfriend by distance, and deciding family practice medicine was not for him--decided to leave the program.

He will move to San Francisco to be with his girlfriend for a year and begin an emergency room residency at UCLA in 1999.

During their second and third years of residency, the young doctors will take on more responsibility.

Although they worked the longest hours their first year--often staying up all night every fifth night on call--the interns always had an attending doctor or a more senior resident to consult.

But in the coming year they will be the only doctors on duty at night in obstetrics and the intensive care unit. They will be the doctors in charge in the ER, with responsibility for a first-year resident as well.

On a recent morning, Dial met with the first-year residents.

“Let’s talk about next year,” he said to the white-coated doctors seated around the conference table before him. “There is going to be a clear workload shift. The number of hours you work goes down, but the responsibility goes up. You are going to be the backbone of the hospital, taking care of patients.”

He goes on: “You can never repeat the internship. All the anxiety, and emotion you’ve gone through, is over.”

“Thank God!” one intern breathed into her coffee.

Making Light of Serious Work

It was a Sunday afternoon under the cool oaks of a private campground nestled in the mountains between Santa Paula and Ojai. After two weeks, the preparations were complete. Ondulando was about to begin.

The 13 first-year residents--wearing propeller beanies to distinguish them--sat crowded into the front row of the clubhouse with family and friends.

The attending doctors--steeling themselves for the mockery that lay ahead--crowded onto folding metal chairs and stuffed sofas.

The lights dimmed and the strains of the “Mission: Impossible” theme filled the room. A slide of the Ventura County Medical Center flashed onto the screen.

“The impossible mission force has been called forth once again,” a voice intoned over the loudspeaker. “We have reason to believe a number of the world’s most notorious criminals have infiltrated the hospital and are posing as doctors.”

To roars of laughter they ran through the new residents, and then the medical staff.

With the simulated click of a spy camera, a picture of Dial flashed on screen.

“Dr. Dial, a.k.a. Barney, is posing as the head of the residency program. Actually, he is designing tactical nuclear weapons disguised as golf clubs. Mondays and Wednesdays he can be seen out on the golf course testing out his prototypes.”

The presentation concluded with barely veiled warnings for the hapless new residents.

“As you can expect, you will be exposed to torture . . .,” the slide show warned. “The hospital uses sleep deprivation as a weapon . . . . You can expect to be deeply undercover for three years.”

The show continued.

The attending doctors winced and the new residents laughed halfheartedly, not completely understanding the jokes.

The plays ended and some residents drank beer and swing-danced to the tunes of Big Bad VooDoo Daddy. But the pagers didn’t come off. They are doctors.

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About This Series

“Making of a Doctor: A Boot Camp for Family Medicine,” followed young doctors through their first year of residency at the Ventura County Medical Center. Today’s installment--the final in a four-part series--looks at what the residents have learned since they arrived fresh out of medical school a year ago.