As if on cue, nearly all
40 of the new medical interns
are paging each other at the same time. Odd, since
they’re all in one room. “Here,” says
one intern to another, seated close enough to feel
the man’s breath. “Page me.”
And so begins the annual flocking of short white
coats to a room on the Hospital’s fourth floor—with
brand new pagers proclaiming the births of brand new
physicians. It’s 7:38 on a Sunday morning, the
first day in July, traditionally the first day of active
residency for fledgling physicians at teaching hospitals
all over the country. And, also in accord with tradition,
all the interns are clad in noticeably abbreviated
hip-length lab coats that denote their status as first-year
residents. Within 10 minutes, a handful of senior residents
will arrive—all cloaked in the coveted knee-length
lab coats that show seniority—to usher their
chosen beginners to the bedsides of sick people.
The room is fully bursting with earnest would-be
healers, all super-bright, all hand-picked. They have
been drawn here by a feverish desire to save the world,
of course, and they are sublimely fine students; by
dint of their medical school performance, at least,
they are masters of books.
But what about the real world of fulminating complications
that awaits them, where qualities like character and
stamina will become paramount? And what of their patients,
many teetering on the edge, whose lives will rest in
the hands of these fresh-faced first-week doctors?
The intern year has become the stuff of classic medical
humor. One popular online residency forum has lately
circulated an iconic poster. Under the heading “New
Interns,” it shows a young boy of about 8, swaddled
in an over-size white coat and decorated with a stethoscope.
The tag line: “Don’t go to a hospital in
in the inner sanctum on
Osler 4 where they’ll
spend much of their first year, one small cluster of
interns is briefed by a senior resident about a patient
with an attitude. “This one’s a bit ornery,” says
Peter Benjamin. The man’s 82 and seems to know
that new interns are now flooding the halls. The patient
questions every visitor in a white coat. “What
year are you?” he asks. “I want to see
your badge.” The inquisitions so impeded the
man’s care that an outgoing resident had laid
down the law for him the previous evening. “Sir,” said
the resident commandingly, “if you die tonight,
it’s your fault.”
The interns in this group raptly absorb the litanies
of horrifying details on each of their 20 patients.
Virtually without exception, the patients suffer from
a riot of chronic problems—lots of heart failure
mixed with hypertension mixed with addictions mixed
with infections mixed with diabetes mixed with renal
failure. Most are elderly, many unemployed, some non-verbal. “They’re
all sad stories,” says Patricia Ross, a pharmacist
who has served this residency training unit for four
years. She has seen her share of them.
The patients are divvied up among the four interns,
typically five patients each. In an arrangement rare
among major teaching hospitals, the interns are imbued
with instant responsibility. Their patients “belong” to
them. If any of these patients dies tonight, it’s
the intern’s fault. Or, at least, they’ll
probably feel like it is.
Sara Keller is about to officially introduce herself
as a physician to one of her very first patients. The
25-year-old intern with striking red hair lingers over
the man’s progress chart outside his room, calmly
studying and jotting notes for nearly 15 minutes at
the compact “wallaroo” fold-out writing
tablet in the hallway. “Mr. Hartline?” she
asks brightly upon entering. “My name’s
So far, so good.
Mr. Hartline is a 56-year-old soft-spoken sort with
a droopy mustache and bushy eyebrows—and a deep-vein
thrombosis that has swollen one arm to painful proportions.
It probably came from his new angioplasty and recent
dialysis. More dialysis is coming. He’s got heart
disease, renal failure and diabetes. He has battled
constant pain for years, with mounting layers of high-end
medicines steadily losing impact. His blood pressure
careens wildly, defying the will of drugs that would
The young Doctor Keller can’t wave a magic
wand, but she can manipulate Mr. Hartline’s chemistry
and alter his course. “Where, exactly, has it
been hurting?” she asks, placing her hand gently
on his forearm and studying the intravenous lines and
then proceeding to probe his torso for the source of
sharp pain storming through his belly. “I’m
sorry you’re in such pain,” she says, tapping
him on the hand. “Maybe we can take off some
of the edge.”
It’s a smooth beginning. If Keller has knots
in her stomach, they don’t show from the outside.
She appears utterly poised. Yet the day is young. She
has learned of a 50-year-old patient on the third floor
who’s facing end-stage heart failure. His lungs
can’t cope. Sweet man. Talkative. Married to
a physician. There’s no sugar-coating this one;
both the man and his wife know exactly what’s
going on. The challenge for Keller, and for the man’s
private physician—who also serves on the faculty
of Keller’s residency group—is to see if
they can squeeze a few more months out of the declining
patient’s vital organs. Could they bridge him
to a heart-lung transplant? Keller stops at the wallaroo
outside the patient’s room to study her most
acutely challenging case.
Back in the 15-by-15 room on Osler 4 that serves
as the world headquarters of the so-called Thayer Firm,
26-year-old Adam Gerstenblith has checked into one
of the eight Dell computers to enter orders for one
of his new patients. Suddenly a dialog box pops up: “Are
you sure you’re entering orders for the correct
patient?” In the modern provider order entry
system, even the computers are patrolling to keep physicians
at all levels on high alert.
In a month of especially intensive vigilance, Gerstenblith
might be the most alert July intern in the hospital.
The son of cardiologist Gary Gerstenblith, Adam is
a Hopkins Medical School graduate who has previously
assisted this same training unit. His patient interactions
and presentation skills have been startlingly flawless.
Up since 6 this morning, Gerstenblith has been designated
the first intern to take the overnight call—actually
a 30-hour shift that will keep him on deck through
the night and into Monday morning, finally releasing
him from its iron grip late in the afternoon the following
day. A senior resident will track him through the nighttime
Instead of relying on caffeine, the dynamic young
doctor says he’s propelled by “the sheer
joy of medicine.” In the coming days, he will
become comically notorious for trying to admit new
patients during his overnight shift despite his senior
resident’s efforts to “protect” him
from the extra workload by steering them elsewhere. “What’s
the big deal?” he asks good-naturedly after one
such interception. “He was an interesting patient!”
Monday morning. Day two. The firm’s
chief resident and two senior residents are on the
floor, making the rounds with their four interns—along
with the team pharmacist and four medical students.
As the entire white-coated tribe weaves through the
hallways as one, they inevitably cross paths with other
roving tribes of medical firms with July interns, clotting
up the morning halls with traffic jams. It feels like
a high-energy hive. It’s been 24 hours. No one
has died overnight. No patient has even crashed overnight.
The new kids are making it look suspiciously easy.
At one point, Gerstenblith leads the troupe into
the room of an 84-year-old man with jammed arteries
and sleep apnea and chest pain. Attending Chief of
Service Timothy Scialla, a bespectacled 30-year-old
true believer from a three-physician family, has already
armed his group with a lecturette on the art of diagnosing
chest pain. Now in the patient’s room, he insists
that all 12 people introduce themselves to the patient
by name and position.
And then, for Gerstenblith, comes one of the most
dreaded tests in a new intern’s life—“presenting” a
patient case, live, after 28 waking hours, in front
of peers, all of whom are judging your every word.
With a nod from the chief, he launches into a textbook-perfect
presentation of the complicated case. He cites lab
values, blood numbers, pressures, “I’s
and O’s” (for fluids in and fluids out),
and more, with almost no reference to his handheld
notes…. Until it’s time to guide his colleagues
through the man’s EKG tracing back in the hallway,
where he detects a tracing pattern “characteristic
of a right bundle branch block.”
After an X-ray study and some case-related lessons
from the two senior residents, chief Scialla turns
back to Gerstenblith: “Bring it home,” he
says, prompting the young doctor’s diagnosis
and care plan. Scialla rejoins: “Are you worried
about pericardial effusion?”
No, says Gerstenblith, confidently explaining why.
Scialla can barely contain his smile. “It’s
a great workup for someone with chest pain,” he
says. “Fantastic.” He checks his watch.
He notes that the discussion took 45 minutes, much
longer than the desired 15 to 20, “but he’s
a great patient.”
In the coming days, with the steady unfolding of
each new intern’s disarmingly coherent presentations,
Scialla’s celebrations become more emphatic,
graduating to outright victory pumps with his left
hand. “Yes!” Whenever an intern presents
a patient who has improved to a key threshold, the
chief applies a golfing term for pronouncing the job
well done; the patient can be sent home: “Let’s
tee her up.”
Scialla had forecast chaos for these early days.
He expected the interns to display fear, confusion,
even some occasional hand-trembling amid procedures
like on-the-floor injections. This quartet is almost
too good to be true. Surely some must be in for a bigger
trial by fire.
On their first gathering in the Thayer
Firm office, interns listen as
their new chief shares thoughts
about first-day jitters.
In the Thayer Office,
it is suddenly Monday tea time. Just before 5 p.m.,
guiding alpha doc quietly slips into the room, peering
over his bifocals to take in the ragtag gathering of
five white coats before spotting senior resident Peter
Benjamin, who looks slightly startled to see him. “So,
Thomas Traill with a trace of his British accent (“pee-tah”)—“are
“It’s been a year and a half since we’ve
both been in this room,” smiles Peter.
“Well, then,” says Traill, “maybe
we should put the kettle on.”
At 60, cardiologist Traill is right at the sweet
spot of middle age. He’s sought-after for his
teaching prowess, but also sees up to 300 new heart
patients a year. He holds weekly “Traill rounds” with
interns in his outpatient office, along with pivotal
social functions for residents throughout the year.
His frequent tea time visits to the office are the
Firm’s most constant character trait.
While the other young physicians pause amid their
duties to greet their faculty leader—and Benjamin
sends out an all-points-bulletin on his pager to alert
other colleagues that it’s tea time—Traill
sets about washing cups in the nearby sink. He stops
to lift the foil cover off a plate of aging food. “What’s
lurking in here?”
“Dr. Traill, can I ask a question?” inquires
medical student Sahael Stapleton, who at 6-feet-8 towers
over everyone else in the room. “Should we be
able to see delta waves after an ablation?”
“No,” Traill answers, measuring out “three
and a bit” scoops of his favorite Bengali tea.
When Sara Keller walks in several minutes later, Traill
greets her with a warm mug.
“I like tea!” she gushes. “Thank
you very much!”
It is here, in this sequestered space, where the
firm’s deepest tribal bonding unfolds. The office
can be playful, intense, even confessional. Mistakes
are caught and corrected. Brownies are shared. The
refrigerator’s merits are debated. Communal cleaning
is announced. Up to half a dozen conversations can
unfold all at once. Teaching arises both formally and
spontaneously, 24 hours a day, 365 days a year.
For all of the intense corrective guidance, the office
can become a womblike refuge of support, much of it
orchestrated by the chief and his three seniors. The
words Thayer Love are splashed across the room’s
whiteboard. Scialla has stood before it and warned
his charges that people outside this room “will
want to make you cry. But you guys’ll be great,” he
told them. “Listen to your seniors.”
Thayer’s three senior residents constitute
a nearly steel-trap backup that’s partly invisible
to the patients. While the interns might visit their
patients solo, their diagnoses and care plans are carefully
vetted by their senior, often here in the firm’s
office. At key moments a senior can even take pressure
off an intern by quietly shifting into the role of
functionary. In one case, while intern Joyce Sanchez
was deeply caught up in the minutiae of entering orders
on multiple patients, senior resident Hansie Mathelier
silently walked Sanchez’ patient’s fluid
samples to the basement pathology lab, just to
ensure the rigorous chain of custody.
Splashes of humor are evident around the room. A
pair of giant green rubber fists is tucked away on
a shelf, in case someone needs to relieve stress. Above
it rests a simple face-mask of Mike Weisfeldt, the
head of Medicine. The eyes are cut out, so anyone can
don it if they’re in need of extra authority.
“This is a really merry office,” beams
Traill, who suddenly looks up to see an old colleague
“Joseph!” he exults. “Good to see
Joe Cofrancesco is the physician for the 50-year-old
man with end-stage heart failure, Keller’s patient.
Cofrancesco wants to get Keller up to speed for the
looming challenge. “What we’re really looking
at here is what happens to a person 30 years after
heavy cancer radiation,” he begins, pulling up
a swivel chair.
As a lad of 12, according to Cofrancesco, the patient
was sent to a dentist who suspected the boy’s
tooth problem was not related to his teeth. After a
series of tests, an oncologist detected lymphoma
and immediately admitted him for heavy radiation treatments.
In the late 1960s, physicians weren’t quite sure
of the optimal levels. Their thinking at the time,
says Cofrancesco, was that “the boy’s not
going to live unless we blast him.”
At the start of his first 30-hour
shift, intern Adam Gerstenblith
will forgo caffeine for “the
sheer joy of medicine.”
They saved the boy’s life but “fried” his
vital organs. He’d gotten a three-vessel bypass
and a metal heart valve in recent years, but now the
heart is failing and the lungs can no longer assist
with clearing bodily fluids. The man is puffing up.
At best, says Cofrancesco, “we’re looking
at either a new valve, or new organs. This case is
enormously complicated,” he adds, now staring
sympathetically at Keller, whose expression would seem
to confirm that she has absorbed every detail. “Welcome
to internship!” he says, patting her on the hand.
great cliché of the intern year is that
young doctors typically arrive with romantic notions
of saving worthy lives but end the year exhausted and
cynical. Thayer is not immune to the syndrome. “It’s
grueling,” says Ed Ostrin, slumped over with
exhaustion after an end-of-year soiree at Traill’s
home in Sparks. “It’s toxic.” Other
graduating interns describe similar feelings (though
the funk seems to lift as they decompress in the post-intern
weeks.) “But by the end of the year,” admits
Ostrin, “you can handle anything.”
It’s not just the volume of patient complications
that wipes the interns out, says Thayer’s recent
ex-chief Joshua Schiffer, but the recycling of patients
on the Firm’s service who can’t seem to
follow the medical advice intended to keep them well. “By
February,” says Schiffer, “these guys will
all know who the ‘frequent fliers’ are.”
Adam Gerstenblith may already have one. In his first
week, he presents a 40-something man who arrived with
acute chest pain. As he presents out in the hallway
at morning rounds, Gerstenblith takes on a carefully
neutral monotone. The patient’s pain came after
he snorted five vials of cocaine. He has HIV. “Previous
job,” the doctor recites, “‘I was
in jail.’ Diet: ‘Living off graham crackers.’” The
man funds his drug habit with disability payments.
It’s the sort of twisted list of self-destructive
horrors that might prompt dark humor, but all of the
gathered white coats are poker-faced. The only essential
question is whether the man should still be referred
to drug rehab. He’s already been through it repeatedly.
Scialla doesn’t think the question is even
worthy of debate. “Your chances always improve
every time you go to rehab. So never give up. Ever.”
And then come the cases where interns in the medical
service must think like those in the emergency room.
Just after 8 a.m. during her first Friday as a doctor,
Keller arrives in the room of a 68-year-old woman whose
heart rate has soared to an alarming 160 beats
per minute and stayed there. Keller is accompanied
by Peter Benjamin, who asks nurses to set up an EKG
The woman’s eyes bulge, glaring at the two
young doctors. She says nothing. In the course of a
few requests by Benjamin, it becomes apparent that
the woman can’t communicate at all. She responds
to none of his requests. After quickly studying the
woman’s heart rhythm, the two doctors opt to
give the woman a dose of adenosine. The drug will intercept
the signals of the heart node that drives her racing
pulse. They must “push” the dose into the
vein in the patient’s neck, stat.
With the second patient in her new
career as a physician, Sara Keller
probes for the source of pain.
“Sara,” says Benjamin, “have you
ever pushed anything through an I.V. before?” She
has, but nothing of the potency of adenosine. Benjamin
says he’s only done it once.
In moments, Keller has the I.V. access to the woman’s
“Are you ready?” she asks the patient,
who registers no awareness of what’s going on.
Sara depresses the plunger. The woman winces, grimacing
as the tendons in her neck rise in a spasm. The woman
squeezes the nurse’s finger as her heart comes
to a complete halt. Then, steadily, the heart restarts.
The rhythm pattern on the monitor settles into an easy
60 in the span of about 10 seconds.
“This may only be temporary,” Benjamin
cautions, as he takes the printout in his left hand
and scrolls across the strip with his right. “But
I think we’ve broken her,” he says, studying
the pattern. The rhythm stays settled for 30 seconds,
then 60, then 90. “Beautiful,” he says
at last. He and Keller exchange the most guarded of
smiles. “Let’s keep this strip,” he
suggests to the nurse, “so we can save it for
Wordlessly, the patient’s wide eyes relax.
Her attention shifts to the various tubes that attend
her, which she tends and adjusts as she settles in
for her sustained return to a normal heart rate.
As Keller walks back into the Thayer office, she
tries to tame the long strip of paper that will serve
as a memento of one of her first finest moments during
this crucible of a first week.
“That’s a lot of rhythm strips you’ve
got there,” says Patricia Ross.
“It was exciting,” smiles Keller, as
Scialla compliments her cool in pushing the adenosine
to cut the patient’s heart rate. Then Keller
presses her own heart. “But I’m still doing
120,” she says.