Second Year Is (Almost) Over

In a little more than a month, the new interns will arrive. Much like last year when I wrote “Intern Year is Over,” I greet this milestone with joy and relief – not because I am thrilled and excited for the interns to roll in, but because I am thrilled and excited to be DONE. WITH. SECOND. YEAR.

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“Why?” the interested reader/grandma may ask. After all, if intern year is when you learn the byzantine system that is medicine at two different academic centers, second year is when you focus on your actual medical knowledge. Your procedural skills. Your team-based communication.

Second year is a time to grow. It’s a time to grow professionally, personall—HAHAHA no it isn’t.

Second year is a time to survive, like that idiot Hawaii yoga instructor that got lost in the forest for 17 days. Despite making literally every possible incorrect move – she wandered off the trail, followed her “gut,” fell down a cliff, ate unknown plants, drank standing water, and somehow lost her shoes – nevertheless, she persisted. This analogy for the R2 year is astoundingly robust, when you think about it.

Second year can be is often a dark time, both figurative and literally. Figuratively, because you will come home at points and envy the regular and simple schedule of the sanitation worker hitting the button on the trash compactor on the back on the garbage truck. He does not need to wake up after four hours of restless, Benadryl-and-melatonin-induced daysleep to go back to yet another twelve-hour shift discharging the worried well with colds and stubbed toes.

And literally, because you work enough night shifts to develop a vitamin D deficiency to accompany your deprivation-induced depressive episode.

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(this is… this is too true.)

Speaking of which (and on a serious note), after a particularly prolonged run of nights this winter I became globally sad enough to actually seek help. If you know me well, you know that me going voluntarily to any kind of mental health professional is about as likely as getting eaten by a shark. While being struck by lightning. On a sunny day.

And yet, there I was, sitting in a psychologist’s office and explaining quite rationally why I thought I was depressed.

I majored in psychology in college and was familiar enough with cognitive behavioral therapy (CBT) to know that it’s supposed to work. After I requested that we start with that, which relies on identifying ‘distorted thoughts’ and mentally challenging them, my psychologist asked me to vocalize my thoughts around residency.

After telling her my reasons for my gloom, she sat back and said, “you know, I don’t think your thinking is disordered at all. Your work life and schedule does sound pretty terrible.”

Huh.

She and I now focus on mindfulness techniques, which are an entire field of study fundamentally centered on the Serenity Prayer. “Grant me the serenity to accept the things I cannot change.” (Even as a Jew, I know that part!)

Despite being a novice to mindfulness, it does help. But you know what helps much, much more?

Not being on night shift for an entire month.

My lowest point of residency so far was probably in April, which despite being my birthday month contained the last four weeks of a six-week solid run of pure night shifts. No days. No sunlight. No circadian rhythm. Just unrelenting night shift after night shift, punctuated by the occasional day off where you have a choice between briefly flipping your sleep schedule back to normal and having a zombie-like encounter with friends, or sleeping during the day and spending your night off binge-watching Ted Bundy documentaries until the sun rises and you go back to sleep.

There is not enough mindfulness in the world to make up for that.

This month, happily, I get the other end of the stick. For the first two weeks of May, I had exclusively day shifts. Now, I’m on “home elective,” which I have learned is code for “do as much nothing as possible.” I’ve slept, on average, 7-8 hours a night. I am awake when the sun is in the sky. I am asleep when the 4 AM Cortisol Low rolls around. The Bringer of Life came to visit.

I feel like a normal human being again.  It seems the solution to being sad and burnt to a crisp in residency is just to sleep like our evolution intended. Who would have thought.

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Anyway. IT’S TIME FOR SOME LESSONS FROM SECOND YEAR.

One. The physicians are not in charge. This is probably the biggest misconception I had as a premed and a medical student. When interviewing for med school, a common question was always, “why medical school and not NP or PA school?” My answer was always honest: I must be in charge.

It’s a curse of my family’s DNA. We are universally awful at taking orders, probably because my paternal line is a driven collection of almost all males, united under a common belief that the overwhelming majority of people are idiots. It’s unfortunate, but a) it’s true and b) it’s my destiny and I can’t escape it.

Enter residency. As an intern, I was too freaked out and confused to realize my place in the system, besides that I was at its bottom. As a second year, you see a little more of the underpinnings of the hospital because you have a bit of cognitive space to do so. Hospitals are not run by doctors, although the C-suite executives often have “MD” after their name. Real power resides in nursing.

To be clear: nurses and doctors, at least the frontline ones working at the bedside, are wholly on the same team, and we usually work together well and with collegiality.

But if you want to make any kind of a system change as a physician, and you don’t have the support of the monolith that is Nursing Administration, your idea is deader than dead.

Two. Keep your head down.  Second year is when you start to realize that different attendings have different practice patterns, often based on zero science or evidence and wholly on their own training and experience. Two different attendings may treat the same patient completely differently – one might admit and the other might discharge the same patient. I’ve had a patient with a very mild form of diabetic ketoacidosis (a complication of diabetes) and admitted them to the ICU on an insulin drip, and I’ve taken a sicker version of the same patient, treated them in the ER, and sent them home.

These differences are now expected. The trap is to disagree or argue with your attending’s management plan, whose license is ultimately on the line if something goes bad. In particular, when you want to send someone home and the attending wants that same person admitted, it’s tempting to argue your case. This is because it is less work for you to discharge a patient than to admit them.

For any admission, it is my job to talk to the admitting team about why they have to admit the patient, and it’s an unpalatable exercise when:

a) you think it’s a stupid admission, and/or
b) the admitting team, who are often your friends, then consider you a dipshit for wasting a hospital bed.

Talking to the team about a “soft admit” guarantees having to justify your decisionmaking to the intellectually superior medicine residents, who more often than not try and shame/humiliate you into discharging the patient. It’s not a fun experience.

(PS: they are intellectually superior to me. That wasn’t sarcasm.)

Arguing your point with the attending ends up being a recipe for getting academically drop-kicked in the face, and will make you miserable. In the worst case scenario it can damage your relationship with someone you both respect and work with frequently.

Better to ask what their reasoning is to try and learn something from the experience, and note your difference internally with a grumble of “I will do this differently when I’m an attending.” Even though you probably won’t.

I am still working on this one.

Three. Supervising procedures is exceptionally scary. While I am a medically subpar resident at best, I consider myself both a decent proceduralist and a good teacher. Despite this, when helping a junior learner – med student, senior intern, random friend of patient with a head laceration who I let cut the suture ends (don’t tell) – perform a novel procedure, my internal dialogue tends to mirror the same emotional state you have as when an unaware idiot almost merges into you on the highway:

“hey hey hey don’t- DON’T YOU- WHAT THE FUCK HOLY SHIT HOLY SHIT HOLY SHIT” <beeeeeeeeeeeeep>

I recently supervised a resident performing a lumbar puncture, where you stick a needle into someone’s back and take out some fluid for analysis. This relatively safe (if uncomfortable) procedure is one I’ve done a zillion times. I’m proficient at LPs. The patient was a skinny guy with easily palpable landmarks. We were set up for success.

After talking the intern through sterilizing the field and getting sterile herself, I coached her as she numbed up the area and started to advance the needle. Outwardly, I made the appropriate supportive noises. “Mmhmm.” “Yep.” “That’s right.” “Keep going.”

As I felt the interspaces between my fingers begin sweating, my inner monologue was slightly more panicked. “YOU ARE GOING TO PARALYZE THIS MAN! WHERE THE FUCK IS YOUR NEEDLE GOING?! THE AORTA IS RIGHT NEAR THERE! STOP! STOP IMMEDIATELY! WHY ISN’T THERE FLUID COMING OUT?”

“Mmhmm. Advance just a little further,” is what I actually said.

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(somehow, “Children Must Be Supervised At All Times” really struck a chord here.)

Four. No one actually knows how to deal with the nights. One of our faculty members here is an esteemed sleep medicine expert and researcher. When he found out I was self-dosing with different varieties of sedatives to try and achieve restful sleep during the day, he was nearly apoplectic. He printed out study after study that proved, beyond a doubt, that pharmacologically-induced sleep was bad for learning, sleep quality, memory, survival, your immune system, and strangely your seizure threshold. With an open mind, I thus asked him a simple question.

“How am I supposed to sleep during the day?”

He recited the usual things. Blackout shades, reducing exposure to blue light, cooling down the room, and avoidance of caffeine.

Despite evidence to the contrary, I am not stupid. I, and everyone I know, already do these things. I have blackout shades that weigh more than my idiot dog. I have a phone app and computer filter that reduces blue light. I walk home in the morning wearing sunglasses to avoid sunlight, like some kind of depressed groundhog.

And yet… if I try to sleep without drugs, I will spontaneously awaken at 2PM and am unable to fall back asleep.

I followed up. “Would it be better to roll into a shift with four hours of unmedicated sleep, feeling like death, or with eight hours of sedated sleep?

He shrugged his shoulders and walked away.

We don’t know anything about sleep.

Five. Eat when you can, sleep when you can, don’t fuck with the pancreas. Brownie’s advice rings eternal.

As with last year, I feel compelled to imbue this lengthy wrap-up with some kind of conclusion. While I’ve learned a lot and had plenty of good times, my ultimate takeaway is that residency sucks, especially the second year, and the most we can reasonably ask for is to make it out alive and with a minimum shortening of life.

Despite all that, somehow second year – with the much-worse sleep deprivation, months in the ICU, and self-induced pressure to see more patients – is still better than intern year. Perhaps this is because I did not have to spend time in my own personal seventh circle of hell, my main hospital’s cardiac ICU.

I am assuming that next year will follow this arc, and is better than this one. If not… I’m gonna need more mindfulness.

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I’m putting this here again because it’s so awesome.

 

4 thoughts on “Second Year Is (Almost) Over

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