NEAL CONAN, host:
This is TALK OF THE NATION. I'm Neal Conan in Washington.
Most of us served some sort of apprenticeship, because no matter how much we study there's often no substitute for doing. Medical students face an especially rigorous course of academics, and then once they're doctors an even more difficult period of practical training. The first-year internship involves long hours, a steep learning curve and it challenges new doctors' skill, stamina and their ideals.
In a new book, Sandeep Jauhar writes candidly and sometimes graphically about his apprenticeship at a teaching hospital in New York, about what he's learned, about what works and what doesn't in the education of a young doctor.
If you'd like to talk to him about the differences between study and practice, about a doctor's doubts about himself and the system he works in, our number is 800-989-8255. E-mail us: email@example.com. You can also join the conversation on our blog at npr.org/blogofthenation.
Later on the program, it's your chance to talk with the Democratic presidential candidate Mike Gravel. You can send questions by e-mail now, if you'd like. Again, the address is firstname.lastname@example.org.
But first, Dr. Sandeep Jauhar. His new book is called "Intern: A Doctor's Initiation." And he joins us from NPR's bureau in New York. Thanks very much for coming in today.
Dr. SANDEEP JAUHAR (Author, "Intern: A Doctor's Initiation"): Thank you. It's a pleasure to be here.
CONAN: And I wanted to go back to your first day as a doctor, your orientation session at New York Hospital. And the first person - one of the first people you're briefed by is a risk assessment officer.
Dr. JAUHAR: That's right. That was during the orientation. One of the laureates for the hospital talked to us about malpractice and told us that we were all likely going to be sued at some point during our careers and we might even be sued during residency. So he gave some advice for what to do to avoid that happening.
CONAN: And among it never admit wrongdoing.
Dr. JAUHAR: Well, that's one of them, yes.
CONAN: Is that a realistic goal?
Dr. JAUHAR: Well, you know, it's hard to say. I mean, I think that, traditionally, doctors have sort of fortified themselves whenever mistakes occur. They close ranks. But, you know, there's a lot of evidence now to show that the reason why doctors get sued is not because they've made a mistake but because they have been unwilling to be truthful to a patient, and in many cases unwilling to apologize.
And now, there is sort of a movement toward increasing physician apologies. I think 17 states now have passed legislation that would make physician apologies inadmissible in court to sort of, you know, encourage physicians to be more open about their mistakes and be honest with patients. And, you know, I think that when that happens, patients are much, much more forgiving.
CONAN: Was that among the ideals that you had to lose in order to become a successful doctor because you write that at least part of the process was to stop demanding so much perfection from yourself and from the system you worked in.
Dr. JAUHAR: That's right. You know, I grew up in a family where doctors were, like many immigrant Indian families, revered. You know, my parents wanted me to become a doctor. And…
CONAN: That was a great line in your book, where you say rebellion in the immigrant Indian culture is to say you're not going to become a doctor.
Dr. JAUHAR: That's right. That's right. And, you know, even though my father had mixed feelings about doctors, he, you know, like my mother, you know, he believe that they could do no wrong, could make no mistakes. And, you know, there is this sort of this sense in the lay public and perhaps even in medical students that the doctors are superhuman and they don't make mistakes. They don't make errors. But, in fact, we do. And a lot of the time, we're practicing in very uncertain territory.
And it's funny because, you know, I was talking to my father the other day and, you know, my mother now has a difficult-to-control hypertension, very high blood pressure. So, you know, he said why don't you - all you doctors just figure this out and give her the right cocktail of medications? And, well, he suggested a conference call. And I just - I was trying to tell him, you know, it's not that simple.
CONAN: Hmm. There's an episode - your older brother, Rajeev(ph), is also a doctor. And just before you decided to apply to medical school, you toured the intensive care unit in San Diego with him. And he made some remark about a patient, who was dying apparently - circling the drain is I think is what he said.
Dr. JAUHAR: That's right.
CONAN: And then you upbraided him for being insensitive. And he says, so you'll be a different kind of doctor?
Dr. JAUHAR: That's right. He said you'll be a different kind of doctor once you get out of the ivory tower. I was a graduate student at the time and really struggling with a lot of doubts about graduate training and really started thinking about medical school and sort of fulfilling that, I guess, dream of my parents and also a dream that have become my own, sort of, midway through graduate school.
And I went to visit my brother, and we walked through the intensive care unit. And he said, you know, you need to get out of the ivory tower. The real world of medicine is very different. And I didn't really appreciate it until I was thrown into the fire of internship. And I realized that there are a lot of pressures - physical, mental, moral. And I've, you know, I've changed.
CONAN: Hmm. Yet, the picture you describe of the way hospitals operate and certainly certain wards - New York hospital, where you went, very good hospital. Let me stipulate that. No arguments there.
Dr. JAUHAR: Excellent. Yes.
CONAN: But nevertheless, just the way the system work - you were fed up, disgusted at various points, saying what good are we doing here.
Dr. JAUHAR: That's right. That's something that we struggle with that apprentice interns and residents struggle with is, you know, a lot of the time, you know, you see - you're overwhelmed. It's physically demanding. And you don't have the time to fulfill the ideals that you've brought into medicine. And, you know, you know you should be spending more time with your patient.
You know you should be, you know, in many ways, treating them more sympathetically. But you just don't - you don't have the time. The system sort of demands that you move on; everyone is sort of running around on - running on a treadmill. Patient turnover is very quick. And, you know, you start to struggle and you realize that you're not doing all the things that you thought, that you planned on doing when you became a doctor.
CONAN: We're talking with Dr. Jauhar - Dr. Sandeep Jauhar about his new book, "Intern: A Doctor's Initiation." If you'd like to join the conversation, our number is 800-989-8255. E-mail is email@example.com.
And let's start with Amanda(ph). Amanda is with us on the line from St. Louis.
AMANDA (Caller): Hi. I actually, I'm a physician also. I finished my residency about six years ago, and thank God I survived that. But I think the books like this are excellent. And I think that anyone who ever plans to be sick should read this and understand what exactly the physicians that are caring for them in their sickest hour through. The things about compromising your ideals and not being able to practice the way you want to, they're all absolutely true. Internship can be very terrifying, and it's just something that everybody should understand and know about.
CONAN: What ideals, Amanda, did you have to change to survive?
AMANDA: Well, I mean, just exactly as he said, you know, wanting to do the exact, you know, wanting to do the best for your patient, wanting to be able to spend the amount of time that your patient needs and counsel them and discuss with their family and make sure that they understand their condition. But a lot of times, you're doing what we refer to as putting out fire. You're just running from one place to the next, just trying to keep people from, you know, from dying. And I think I actually went to medical school with your author, so he knows exactly what I'm talking about.
CONAN: Dr. Jauhar, does that sound familiar?
Dr. JAUHAR: Yes, it does. I don't recall you, Amanda, but I'm sure we'll get a chance to talk at some future point. But that's absolutely true. You know, when I was an intern - I remember just one example. I walked over to a patient who was late. I want to get out of the hospital. And she was sitting on the bedside commode and she said, you know, can you help me? And I said I'll call a nurse and have her help you. But I said first, first, can I just examine your lungs? Can I just have you take a deep breath?
CONAN: While she's sitting on the toilet.
Dr. JAUHAR: Well, she's sitting on a toilet. And I'm just thinking to myself as - of course, she complied. I'm thinking to myself as I'm doing this, have you lost all shame? This is the most absurd scene. And you know, these are things that you don't realize, but, you know, when you're an intern and you're overwhelmed working 80 hours a week or more and you're faced with doing a lot of work and not always knowing why you're doing that, you know, one of the most pressing needs is just to get out of the hospital. And shortcuts are made, unfortunately.
CONAN: Fewer and fewer of us are now planning to be sick, I can tell you that.
Amanda, thanks very much for your call. I appreciate it.
AMANDA: Thank you.
CONAN: And doctor, the pictures you paint, it's sometimes - there's an episode in your book where, for example, if somebody had the hiccups and you said, well, there's this drug that might - you know, it sounds silly, but this was in an oncology ward, a cancer ward and you said, well, you know, there's this drug that might do it and then you happened to look at the chart and said, oh, the patient is violently allergic to this particular drug, and so you didn't give it to her. But nevertheless, it was a close-run thing.
Dr. JAUHAR: That's right. There's a patient who had hiccups now, you know? These were no ordinary hiccups. These were hiccups that have been going on for 24 hours. This patient was so fed up and hadn't been able to sleep for days because of the - these recurring hiccups.
And I asked a nurse, you know, how do treat hiccups? I had no idea. I, frankly, at that point in my internship didn't even know what caused hiccups. And she said, well, sometimes this drug is used. So I ordered it, and then as I was casually checking through the chart, I noticed in - scribbled in one of the progress notes that this patient had had a very severe allergic reaction to this particular medication. And for whatever reason, this allergy was not documented in the chart and it wasn't documented in the sign-out.
And, you know, these are the things that happen when you're working as an intern. You know, you can't be in the hospital all the time, so you have to have cross coverage. You have to have some doctors come and take over the care of the patients of a doctor who needs to go home to rest. But the problem is that the information transfer is not always adequate, and, you know, we need to figure out a better way to do that.
CONAN: We're talking with Dr. Sandeep Jauhar about his memoir - about his first year as a doctor. It's called "Intern: A Doctor's Initiation." And we're taking your calls: 800-989-8255. If you'd like to join us, you can also send us e-mail: firstname.lastname@example.org. Or check out what our listeners have to say on our blog: npr.org/blogofthenation.
Stay with us. I'm Neal Conan. It's the TALK OF THE NATION from NPR News.
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CONAN: This is TALK OF THE NATION. I'm Neal Conan in Washington.
We continue to follow developments in Pakistan. Former Pakistani prime minister Benazir Bhutto was assassinated after a campaign rally earlier today. Grief is spilling over into violence in some cities there. Angry supporters rioted in the city of Karachi firing shots at police, having tires and cars on fire and burning a gas station.
You can hear more on this story throughout the day at NPR News, and confined an analysis of Benazir Bhutto's career and legacy as well as detailed coverage of today's attack at npr.org.
Right now, we're talking about one of the hardest apprenticeships around, a doctor's internship. Dr. Sandeep Jauhar is with us. His memoir of the experience is called "Intern: A Doctor's Initiation." One Friday night, when Dr. Jauhar was on call, one of his patients began having violent seizures. You can read about what happened on our Web site at npr.org/talk.
If you've been through the medical internship and (unintelligible) sounds familiar, go ahead, weigh in: 800-989-8255. E-mail us: email@example.com. You can also check at our blog at npr.org/blogofthenation.
And, Dr. Jauhar, I have to admit that as a kid, I worked as an orderly at the Hospital for Special Surgery, which is across the street from New York Hospital, or the orthopedic hospital that's associated with it. And I have to say that one of my jobs was that - in the orthopedic hospital, if anybody actually got sick, one of my jobs is to wheel them through a corridor underneath the street to New York Hospital. It was considered a very bad form for people to be sick in an orthopedic hospital, very bad for morale. So I'm somewhat familiar with New York Hospital.
Why New York Hospital, though? You're from another part of the country, entirely, what brought you to New York?
Dr. JAUHAR: My brother, Rajeev, actually trained as a cardiologist at New York Hospital. I went to graduate school in Berkeley. I moved to St. Louis for medical school at Washington University. And then I came to New York.
CONAN: All right, let's get some more callers involved in the conversation and we'll turn with to Doc(ph), Doc with us from Harrisonburg in Virginia. And I take it, that's not just a nickname.
DOC (Caller): Yes, that is a nickname. That's a nickname I earned as a Navy corpsman.
CONAN: Okay. Go ahead, Doc.
DOC: …back in 1966 to 1970, had the opportunity to work with many doctors. And, of course, I call, like many people who call in to a show - I don't do this very often. But just like many people who call in to a show, I started out with one idea that I wanted to ask you about, and as the conversation progress, it went thought something else.
Two main areas that I wanted to ask Dr. Jauhar, if you would, please, to address. One is that very crucible in which you worked as an intern, and you're able to absorb a lot of different things going on. And in the past 30 years or so, obviously, there are more reports of mistakes being made in hospitals. And there's the support staff that you have as an intern, they're supposed to be getting more educated, but apparently, according to complaints I've heard from other people, they seem to be acting in a manner that's inapt to that greater education. They seem to be more ignorant. Or is it just simply that they themselves are suffering stress in the patient ward because of the overpressure, the need to respond to all of these things. And maybe I didn't (unintelligible) that very well, but the other thing I…
CONAN: Why don't we take one at a time here, okay?
Dr. JAUHAR: Well, you're absolutely right. There is more pressure in the hospital today than there was 20 years ago. Nurses are caring for more and more patients. Residents are caring for more and sicker patients. And, you know, and that sort of pressure gets transmitted down the ranks, you know, across the ranks. So there's definitely a lot of pressure. I think that mistakes get made by individuals, but I think mistakes are also made by the system.
And, you know, we all want accountability in medicine and in every facet of life. You know, we want to point a finger at someone and say, look, this person made a mistake. And sometimes that happens. But I think more often, the mistakes are made by the system. And, you know, I recall the well-publicized case of the teenager at Duke who got a heart transplant and she got - she was transplanted with an organ that wasn't properly matched. That wasn't any one individual's mistake. That was the system. There weren't enough people checking to make sure that the blood types were compatible. Those are the things that we need to address.
CONAN: Okay, Doc. And if you'd make the next one quick.
DOC: Yes, very quickly. Is it ego or liability, the fear of liability that prevents older, more seasoned doctors, older residents from admitting their mistakes, from admitting that there could be a mistake unless they're in a room full of other people who've made those same mistakes.
Dr. JAUHAR: I think that there's both. I think fear of liability is definitely a big concern, but, you know, as I said earlier and as other people have pointed out that when physicians apologize for their mistakes, they're much less likely to be sued than if they try to hide them. Families of patients who have suffered, patients themselves, they want their doctors to be upfront and honest. And we have to encourage that.
So I think fear of liability is one issue. I think ego is also probably partly to blame. You know, we're trained in medical school to - I really think of medicine as, at least in the early years, think of medicine is just a sort of well-formed science that has answers, and a lot of medical students think of their attending physicians are superhuman and infallible that we find, as we go on, that so much medicine is uncertain and our attending superiors are very fallible. So I think that we sort of get inculcated into a system where it's not easy to admit mistakes, not easy to admit fallibility.
CONAN: Doc, thanks very much for the call.
DOC: It's okay.
CONAN: Here's an e-mail from Anica(ph) in San Francisco. I'm also a resident coincidentally was just driving home exhausted after a 30-plus hour shift with about 30 minutes of sleep, thinking - rethinking as I always do with this time, if it's worth it. When everyone around you, including your mentors, accepts the craziness of working this kind of schedule, week after week, year after year, it's so refreshing to hear someone in medicine talk about this subject in clear terms and recognize it as the madness. It is. Can the author comment on how he would like to see the residents in his system change to improve patient care and doctor education?
Dr. JAUHAR: I wish there were easy prescription…
CONAN: And keep it to a couple of minutes, if you would.
Dr. JAUHAR: Sure, sure. You know, it's not an easy question to answer, and a lot of good people have tried to figure out what the best way is. You know, it's very clear that people don't work well when they're sleep deprived. That's true for pilots and anesthesiologists. And so clearly we need to encourage or develop a system where residents have adequate sleep. The problem really then comes down to cross-coverage. When one resident is sleeping, what do you do when you're patient is being cared for by a resident who's rested but doesn't know the patient?
CONAN: Yeah, the night float, as you described it.
Dr. JAUHAR: The night float. So the question really comes down to - it really boils down to - is it better to be cared for by a sleep-deprived resident who knows your case or a rested resident who doesn't? And I have not come to -there's no clear answer. But I think that recent studies, you know, published in the New England journal a couple of years ago suggest that when residents are encouraged to sleep in intensive care units, serious mistakes were avoided. So we need to do more about the cross-coverage system. And I think one step is to computerize information systems in hospitals, so that the information that's available to the day residents are easily accessible to night residents.
CONAN: Here's another e-mail. This is from Jennifer via our blog. The 80-hour work week has destroyed continuity of care and ownership of patients. I worked in the South Bronx and one of my attendings congratulated me because my patient knew my name. Well, I had seen her every week for two years. I was vested in her care and trying to get her to make changes for her long-term health. More importantly, by knowing her, I could pick up changes and problems weeks before shift worker could.
The reason the system has not yet collapsed is because the senior residents have a sense of responsibility and will not abandon the patient. To that end, they falsify their time. All my doc friends joked as to who it is who's going to be trained to take care of us? Not so funny anymore, concludes Jennifer via our blog. Would you agree with that?
Dr. JAUHAR: Yes. I mean, I think, what's interesting to see when resident work hour restrictions - they really started in New York because of the Libby Zion case. And they sort of proliferated and were disseminated across the country in 2003, so now there are 80-hour work hour weeks for residents. So, you know, so things have differently changed. But what I see is that very often, interns and residents who were supposed to go home at an appointed hour, say, at 9:00 a.m., will very often linger in the hospital because they want to see their patient through a crisis. They want to attend a teaching round.
It's, you know, it's, you know, it's very difficult to order someone to get out of the hospital to sort of just to obey a rule. I mean, some interns may be very fatigued after that sort of shift and other interns may want to hang around. And, you know, I think that, you know, one of the most important things that I learned in internship is that it's important to see your patient through the course of illness, to sort of observe the arc of the disease. And I remember many nights, staying up all night where the patient I, you know, having intractable seizures or in cardiogenic shock. And that where you learn the most. So it's a very difficult thing to answer. You know, when is too much or, you know, too much. When is staying up for, you know, 30 hours just too much, and when does the education start to suffer? There's no easy answer.
CONAN: Let's get Tom(ph) on the line, Tom with us from Los Gatos in California.
TOM (Caller): Yeah. Great show, Neal, and…
CONAN: Thank you.
TOM: …thanks for taking my call.
TOM: Good work and good work, Dr. Jauhar. Keep it up. Yeah. What happens to an intern when they go to an HMO or a public hospital and they get paid minimum wage or what they call capitation in HMOs, which amounts to minimum wage per patient, is that going to really inspire a doctor to do the best care that you've described yourself doing? Or is it going to, you know, it's going to make a doctor jaded before his or her time?
Dr. JAUHAR: Yeah. That is a big problem. I think what you're referring to is the reimbursement system for general physicians, general doctors. And that's - there's been a lot written about that and there's - and it's a big problem, you know, the way that the reimbursement system is structured America. Doctors who perform procedures get paid the most and doctors who sort of coordinate care, like, primary care physicians get paid much, much less. And that really is dissuading a lot of medical students and interns and residents from entering primary care. And it's so…
TOM: I saw that the interns are actually the best, they're the most educated. You know, the senior doctors, you know, have the power, but the interns have all the education and the goodwill, you know, and the drive and the energy, like, to stay to work 30 or four-hour shifts.
Dr. JAUHAR: Right. But what's going to happen to that goodwill when they enter a system where they're not, you know, adequately reimbursed for the care, for the coordination, for all the things that general doctors do, you know. It's…
TOM: A single repair would be the way to go, don't you think? You know, have the government pay, like, in England, in other, you know, candidate, in another country?
Dr. JAUHAR: That's a very difficult question to answer in a short amount of time, but that's certainly one possible way of going about it.
TOM: Thanks for addressing the caller, too.
CONAN: Can thanks. Yeah. Tom, thanks for the call.
TOM: You're welcome.
CONAN: Bye-bye. We're talking with Dr. Jauhar about his book "Intern: A Doctor's Initiation." Sandeep Jauhar will continue with us.
You're listening to TALK OF THE NATION from NPR News.
And let's see if we can get Randy(ph) on the line. Randy is calling - excuse me - this is Elizabeth(ph), Elizabeth calling from Menlo Park in California.
ELIZABETH (Caller): Hello. I just have a quick question plus comment. I am a daughter of a physician. My father is an anesthesiologist and is now somehow retired. And the internship/residency protocol hasn't changed much. And it really has - was difficult for our family. When my father was snooping around, he was on call 24 of 24. And I was wondering if you personally experienced this disruption of your personal/family life, and if you saw any movement towards the more humane way for both the physicians and their families?
Dr. JAUHAR: I think things are changing, fortunately. I think there's a huge change in the demographics in - among physicians over the past 10, 15 years. Many, many more women have entered the field than in the past. So now, you know, in my medical school class, which was in - graduated in 1998, the class was, I think the majority were women. And I think both the men and women in medicine have decided, for the most part, that they're willing to sacrifice personal life, family life. You know, it's difficult to know how best to do that in a professional it really demands lot of concentration, attention and time.
In my case, you know, I went through internship and residency before I had a son. So, you know, at this point in my life, I mean, my family really anchors me and so I try to maximize, you know, quality time with my family. But you know, as a cardiologist, I also continue to spend, you know, 60 hours in the hospital per week or more. So it's hard to know, but I think the general trend is toward medical students and interns and residents choosing specialties that emphasize lifestyle. The most popular specialties today are dermatology, radiology, anesthesiology, where there is relative - there is some control over your schedule, and that there aren't too many emergencies in the middle of the night.
CONAN: Thanks for the call.
ELIZABETH: Yes, thank you, and thank you for what you do.
CONAN: Oh, thank you.
Dr. JAUHAR: Thank you.
CONAN: And this e-mail from Marcella(ph). What's your reaction to TV shows portraying interns - "Grey's Anatomy" and "ER" - do they do any harm?
Dr. JAUHAR: Well, you know, it's not realistic.
Dr. JAUHAR: But I, you know, I'm not sure. I don't think they do harm. I think one show that is a very enjoyable show, I watch her all the time, but really is very unrealistic but maybe not in the way that one would expect is "House." "House" is a show where you have this uber-doctor who goes and solves these medical mysteries and he has a team of physicians that work with him. The - what I find sort of funny about that show is that you have these doctors who go and, you know, go to patient - visit patients in their homes or go do sort of a real detective work to solve these medical mysteries. And it's admirable, but the reality in teaching hospitals is very different because residents are so overworked.
One of the saddest things is that when they're faced with a medical mystery, very often they will react to it with sort of groans, because medical mysteries take time. And they just have - they're overworked. They have too much to do. So there's a - this general deterioration in the intellectual climate in teaching hospitals, I've noticed over the past, you know, 10 years that I've been working in hospitals.
CONAN: Well, thanks very much for being with us today, and we appreciate your time.
Dr. JAUHAR: Thank you.
CONAN: The book is called "Intern: A Doctor's Initiation." The author, Sandeep Jauhar, and he is now working as a physician at a teaching hospital in New York City. And you're listening to TALK OF THE NATION.
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