Learning Experiences The Life and Times of Some First-year Residents

Rebecca Levy calls it the ‘dungeon.’

That’s her friendly colloquialism for an area on the ground floor at Baystate Health. Those who take the stairs — and she does — must descend several flights to get to this quiet, less-well-lit place that’s off in a corner and away from the hustle and bustle of the ER or the surgery centers. It can be just a little scary there late at night, she said, noting that this is, after all, where the morgue is located.

Levy has been spending quite a bit of time lately in this place that so few visitors to Baystate ever visit or even know exists, because her regimen as a first-year resident in Pathology dictates that this is the work she will focus on during that time. “This is my third month, and that’s autopsy month,” she said, adding that she must perform 50 of these macabre procedures during her time at Baystate to gain licensure.

This is not the kind of assignment that most people on the path to becoming a doctor would relish, but Levy enjoys it in some ways because it appeals to her passion for research, or, to use some of her words, “detective work.”

That’s one of myriad ways to describe pathology, or the study of the disease process, she told The Healthcare News, adding that, when she started what would her first residency at Minnesota’s Mayo Clinic, her designs were on being a surgeon. But she ultimately decided that this wasn’t where her heart, and that aforementioned passion, lay.

So she switched gears, and, essentially, started over.

“I went back and examined what it was that I really liked about medicine,” she explained. “It’s not that I didn’t like the bedside part of it or thought I wouldn’t be good at it; I just liked the research side, and finding answers — to whatever the questions happen to be.”

By the time most medical-school graduates become residents, they have done such requisite soul-searching, and know what they want to do with a career in medicine, said Hal Jenson, chief academic officer at Baystate Health Dean of the Western Campus of Tufts University medical School. And over the course of three, four, or five years, they will hone their skills in a manner that will “provide core knowledge, and also help shape the attitudes for the physician, to become not only an expert their area, but also a valuable member of the team taking care of the patient.”

And this ‘shaping’ process begins early — be it through delivering a baby, performing a surgical procedure on the victim of a motorcycle accident, or, in Levy’s case, conducting an autopsy to help provide a family with a firm cause for the death of a loved one. These are just some of the experiences already logged by some first-year residents who spoke with The Healthcare News.

Oscar Martinez has taken the lead on a number of deliveries since he arrived at Baystate in late June, including one close call involving a patient who never reached the delivery room and instead had her baby in the evaluation room outside.

“I was in the WETU (Women’s Evaluation and Treatment Unit) at the end of my shift, and one of the admissions people came in and said, ‘I’m registering someone, and she says she wants to push,’” he recalled, noting that, in the parlance of this specialty, this means it’s go time. “So we went outside, and she was ready to deliver; as soon as we got behind closed doors … she pushed.”

Meanwhile, Ruchi Thanawala has performed a wide range of procedures during the first few months of what will be a five-year residency in surgery, a field that effectively blends her fondness for problem-solving with a desire to work with people.

“There’s a nice mechanical component to surgery,” she explained. “You’re dealing with complicated problems, but very simple solutions — as long as you can figure out what the problem is. The techniques take time to learn, which is why it takes five years and a whole lifetime of learning to do this, but the actual solution is not that farfetched.”

For this month’s issue, The Healthcare News sat down with Levy, Martinez, and Thanawala to examine the life and times of first-year residents, people who have left one important phase of their nearly life-long quest to become a doctor behind them, to start another, usually in a place far from home, family, and friends.

Several years ago, legislation was passed that restricted the number of hours residents can work up to 80 a week. That’s still roughly double the number most people log, and these are filled with work and study that is taxing on a number of levels. Residents say they try to maintain a semblance of a life outside the hospital, but it’s not easy.

“You need a good support system,” noted Martinez, who says he has one in his family back in Paterson, N. J., and especially his brother, with whom he converses on the Yankees, his nephews, or anything other than what he did that day.

“You have to put it aside at the end of the day,” he said, adding that his residency work occupies enough of his waking hours — and then some.

Resident Experts

It’s called the 1-2 Room.

There have probably some other, more-descriptive names for it over the years, said Martinez as he talked with The Healthcare News in the small, two-room space now set aside for first-year residents to rest and reflect (it was once for first- and second-year residents, and the name has somehow stuck). It has a refrigerator, table, some shelves full of serious-looking textbooks, and a small bed for grabbing quick naps.

“I’ve only used that a couple of times so far,” Martinez said of the bed, noting quickly that he expects he’ll become more familiar with it over time.

Only a month or so into his residency experience, Martinez said it has come pretty much as advertised. The hours are long, and the work is difficult, but in most ways exhilarating, he explained, adding quickly that, after just a few weeks, he can see and feel that his residency work will effectively prepare him — clinically, mentally, and physically — for the career he’s chosen.

And that’s essentially what a residency is all about, said Jenson.

He told The Healthcare News that there are probably 300 or so residents and fellows (those who pursue additional study in a subspecialty after their residency is completed) working at Baystate at any given time. They are spread across nine specialties — Anesthesiology, Emergency Room Medicine, Internal Medicine, Obstetrics and Gynecology, Pathology, Pediatrics, Radiology, Surgery, and Medicine Pediatrics — with a 10th, Psychiatry, to be added in 2009. Statistics show that roughly one-third of these individuals will practice medicine in the Pioneer Valley.

Residents are given a salary (around $50,000 at the low end, meaning those in the first year) and benefits, said Jenson, and those in their final years hold junior-faculty status with the Tufts University School of Medicine because they are instructors as well as doctors-in-the-making, teaching younger residents. “All in all, it’s not much for people with eight years of college education who are working 80 hours a week,” he said, adding that the real rewards are obviously elsewhere.

When asked to describe what a residency is and what it is carefully designed to do, Jenson did so in this manner: “some people say that medical school is really seven or eight years long — but they award the diploma in the middle.”

But while residency is in many ways an extension of medical school, there is a notable transition involved, he said — specifically, from one level of responsibility to another that is significantly higher, and will continue to escalate as one moves through his or her residency.

And while first-year residents are in all ways at the very bottom of the totem pole in terms of seniority and credentialing, they are already doctors and possess a great deal of competence and confidence, said Jenson.

“They’ve been in college for eight years — and they’ve been freshmen twice,” he explained. “They’re not what would be considered freshmen here.”

Only a few months into their experiences, those residents who spoke with The Healthcare News provided some real-life experiences — and thoughts about them — that echo and reinforce what Jenson said.

Martinez, for example, returned to that delivery in the evaluation room, and some other early experiences at Baystate, to qualify that higher level of responsibility that Jenson described.

“By your third year in medical school, you’re doing low-risk deliveries, always with someone there with you, and you assist on C-sections and other gyn procedures,” he said while explaining the transition to residency. “The difference now is that a lot more of that responsibility is on me — now, it’s pretty much all on me; I’m in charge of the delivery, I’m in charge of the patient, from the minute they step on the floor until they deliver, and even after they deliver.”

Fascinated by health care — and specifically the work of his family’s physician, an obstetrician — for as long as he can remember, Martinez said he started volunteering at the hospital not far from his home when was 13. A graduate of Rutgers University, he attended the Edward Via College of Osteopathic Medicine (part of Virginia Tech) and, eventually, focused on obstetrics and gynecology, or ob/gyn.

It’s a well-rounded field — you get to do medicine, you get to do surgery,” he said of his interest in that specialty. “You get to do a little of everything, and it’s very fast-paced; there’s always something happening.”

As he found out almost immediately upon arriving at Baystate — which was the last hospital he visited but ultimately his first choice for his residency — and getting down to work.

“There’s never a dull moment, and that’s what I really like about this field,” he said, “It’s amazing to be there and be holding that baby and controlling the head.”

Stitch in Time

Thanawala majored in engineering at Duke University and strongly considered attaining a graduate degree in that subject. Her father was in that field, and she told The Healthcare News she was attracted to the discipline because it involved identifying, or defining, problems, and then solving them. But she also was drawn to health care, and enjoyed working with and on behalf of people.

So she sought out a career path that could provide essentially all of the above, and found one in surgery.

“I’ve always been intrigued by medicine simply because you get to think things out and then sort them out,” she said. “What I like most about the thought process of medicine is that, for the most part, you’re figuring out what a problem is, and you’re fixing it. And that’s why surgery appeals to me; you’re manually fixing something as opposed to philosophically fixing something. Plus, you get to use gadgets.”

Thus, medicine is like engineering, but it has a strong people component not encountered when one is designing roads, bridges, or sewer lines, she continued. “Surgeons get to do the actual medicine part of it, but they get the added benefit of coming up with a physical solution to a physical problem — like planning out how you’re going to approach a surgery from start to finish, from where you’re going to place the incision to how you’ll mobilize some kind of tissue, to how you’ll repair suturing … all of that.”

A native of rural southern Virginia and a graduate of the Ross University Medical School in the Bahamas, Thanawala said Baystate provided a nice geographical fit for her — her fiancé is working toward a Ph.D in biomedical engineering in Boston, and she likes the Pioneer Valley’s lifestyle — and the hospital was, by reputation, supportive and “friendly to women, especially in surgery.”

Like Martinez, Thanawala said the responsibilities that are part and parcel to a residency are much greater than medical school, and she’s assumed such responsibilities (in an assisting role) with general procedures such as appendectomies, bowel surgery, gallbladder removal, and others.

Meanwhile, she’s handled a great deal of trauma surgery, which involves gunshot wounds, stabbings, motor-vehicle accidents, and the like, which has been eye-opening, because she hadn’t before been exposed to many of the things she’s seen in the Baystate ER.

“There’s a lot to absorb,” she told The Healthcare News. “What you learn in med school compared to what you see in the trauma bay are two very different things, because you have much more responsibility and you have to make judgment calls and make decisions. You’re learning a lot about ‘if this happens, what do I do.’”

Like the others we spoke with, Thanawala said she’s heard about the days when residents worked 100 or more hours a week. She says 80 is still a load, but it does allow enough time — usually just enough — to manage the rest of what life throws at her.

“It can be challenging, and it is definitely exhausting at times,” she said. “But it’s enough where you work and you learn, but you still have time to relax, and do your reading on the outside, and do laundry, go grocery shopping, and … exist. Eighty hours allows you to do all that.”

Overall, she said her residency is helping her develop her skills, but it’s reaffirming and strengthening her passion for her chosen profession.

Levy agreed.

A native of New Orleans, she told The Healthcare News that she’s wanted to be a doctor since she was 9, or about the time she did a science project on the human brain and how it works. She continued to focus her studies on science at the University of Texas, where she completed undergraduate work, and then medical school at Texas A&M.

She was only a few months into her residency at the Mayo Clinic when she realized that surgery wasn’t what she wanted, so she took the somewhat unusual, but ultimately necessary, step to start anew in a field, pathology, that manages to fulfill her professionally in ways that surgery didn’t and couldn’t.

And she said it’s the ‘detective work’ nature of this specialty that she enjoys — whether she’s looking at a slide under a microscope at her cubicle in the residents’ room, or at work in the morgue trying to help determine why someone seemingly healthy when they came to the hospital was now dead.

“The cause of death changes about 30{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of the time when there’s an autopsy,” Levy said, adding that it is rewarding to help solve a riddle — and not all of them are completely solved.

“Sometimes, we can’t even come up with the right answer,” she said, citing one recent case that has defied a definitive resolution of the basic question — what caused death? “Sometimes, instead of answering questions, you simply raise more questions. That’s frustrating, but it’s also intriguing … it makes you want to dig deeper.

Summing up both aspects of pathology — anatomical (autopsies) and clinical (lab work) — Levy said that some have referred to those who do this work as ‘the physician’s physician.’

“That’s because our consults come from other doctors who aren’t quite sure,” she explained, “and want us to try to help them narrow it all down.”

“The work we do may have a lot to do with how people are treated in the future,” she continued, referring to the many types of rewards that come this investigative, or medical detective, work. “When we can go back and say, ‘this is what happened,’ that can help a physician treating a patient. There might be something that can be done differently next time. That’s very rewarding.”

Putting Her Career Under a Microscope

As she talked with The Healthcare News, Levy glanced at her watch more than a few times.

There were no pending emergencies, and her beeper never went off, but there was work to do. There always is for these individuals who are only at the start of what will be a long, hard grind to becoming a licensed physician.

This was “autopsy month,” as she said, and there were some matters to take care of in the dungeon.