A full year has gone by and internship is over. Somehow, between a Tuesday at the end of June and the following Wednesday, I became a junior resident. I started off as one of two juniors on Bigelow E (“Big E”), one of the busiest general medical services at Massachusetts General Hospital. With 24 patients and a high turnover rate, my co-junior and I were now responsible for 24 patients, four interns, two subinterns (fourth-year medical students), and one medical student. There are five Bigelow services: the two largest, Big A and Big E, are led by two juniors. Big B, C, and D are led by single juniors. The number of attending physicians varies by service, and staff attendings cover the majority of patients.
Overnight, my role changed. To be sure, I was apprehensive, and in the first few days as a junior, I almost wanted to be an intern again. As a Bigelow junior, I am responsible for not only caring for patients and ensuring that as the new interns arrive nothing slips through the cracks, but also for coordinating the disposition of patients with case managers, social workers, physical and occupational therapists, and nutritionists. On top of this, the role is one of teacher, both to interns and students.
In preparation for this change, several of the other July Bigelow juniors and I worked on some strategies: how to divide up the roles of teaching, case management, and patient care and what the most important topics are to teach the new interns. We thought back to those that had challenged us in those first heady weeks of internship, and the basics were the most compelling: entering orders in the computer system, repleting electrolytes, pain control, bowel regimens. Also included were subjects such as what to do if a patient develops respiratory distress or chest pain. On the day I went through one such algorithm, one of the patients on the floor became acutely hypoxic. With one intern on hand, we worked through the steps we’d discussed earlier that morning.
In one month in the role of junior, I continued to learn at what felt like light speed—not only more about medicine but managerial aspects of care as well. I also spent a great deal of time talking with families of patients. I remember that as an intern, family meetings were handled by the junior and, now, being a junior, it was rare not to spend a good portion of the day working on social and other nonmedical issues.
And then there was the mundane: scheduling follow-up appointments for patients leaving the hospital, writing discharge summaries, sifting through orders in the computer to make sure they made sense, reading through all the patient charts at the end of the day to make sure that nothing was missed.
Through all of this, the sometimes-tedious details actually taught me a great deal about the breadth of patient care. As an intern, I was focused on the purely medical aspects of care, but as a junior, the question of where the patients are going after the admission is also an important concern. The entirety of their medical and social picture comes into focus.
Throughout the month, we compiled statistics on the patients we took care of, more than 140 in all. There were some dramatic medical cases: a patient with alcohol intoxication and hallucinations found to have a brain mass causing visual deficits; a patient transferred to MGH with the diagnosis of bone infection found to have late-stage lymphoma; a patient presenting with fevers and headaches diagnosed with acute HIV; a youngish man with abdominal pain and weight loss diagnosed with metastatic cancer; and a middle-aged man with shortness of breath diagnosed with Langerhans cell histiocytosis, a rare pulmonary condition. We had our fair share of patients with chest pain admitted to rule out myocardial infarction, lots of alcoholics detoxing (some in more dramatic fashion than others), some drug seekers, some patients with urinary tract infections, COPD exacerbations, and heart failure patients.
Change is rarely easy, and the abrupt transition each year that occurs in July—when medical students become interns, interns become residents, and residents become fellows—is fraught with uncertainty. I know I’ll never forget the uncertainty of my first night on call as an intern, or my first day as a Bigelow junior.
Erica Shenoy, MD–PhD ’07, is a resident in internal medicine at Massachusetts General Hospital.
