The Intern BluesThe Intern Blues

Robert Marion M.D.Robert Marion M.D.

Layout of the BookLayout of the Book The Intern Blues is a collage of the experiences of The Intern Blues is a collage of the experiences of

three young doctors (2 male and 1 female). three young doctors (2 male and 1 female). It was written as a narrative from the tape-recorded It was written as a narrative from the tape-recorded

diaries of three young doctors during their first year of diaries of three young doctors during their first year of post-graduate medical residency at the request of Dr. post-graduate medical residency at the request of Dr. Marion.Marion.

Their names and the names of the hospitals where Their names and the names of the hospitals where they worked were altered.they worked were altered.

The book is sectioned off into months, with each of the The book is sectioned off into months, with each of the interns having their own individual diary entry for every interns having their own individual diary entry for every month.month.

After the three entries for the month are complete, Dr. After the three entries for the month are complete, Dr. Marion presents his opinions and/or experiences Marion presents his opinions and/or experiences dealing with similar situations. As well as commentary dealing with similar situations. As well as commentary on the state of medical education. on the state of medical education.

About the AuthorAbout the Author

Robert W. Marion M.D.Robert W. Marion M.D.

Educational BackgroundEducational Background

M.D., Albert Einstein College of Medicine, Bronx, M.D., Albert Einstein College of Medicine, Bronx, NY, 1975 - 1979 NY, 1975 - 1979

Internship/ 1Internship/ 1stst Year of Residency: Boston Floating Year of Residency: Boston Floating Hospital/Tufts New England Medical Center, Hospital/Tufts New England Medical Center, Boston, MA, 1979 - 1980Boston, MA, 1979 - 1980

Pediatric Residency: Bronx Municipal Hospital, Pediatric Residency: Bronx Municipal Hospital, Bronx, NY, 1980 - 1982 Albert Einstein College of Bronx, NY, 1980 - 1982 Albert Einstein College of MedicineMedicine

Human Genetics Fellowship: Bronx Municipal Human Genetics Fellowship: Bronx Municipal Hospital, Bronx, NY, 1982 - 1984 Hospital, Bronx, NY, 1982 - 1984

Board Certified: Clinical Genetics, 1984Board Certified: Clinical Genetics, 1984

General InformationGeneral Information

The director of clinical genetics at both the Montefiore The director of clinical genetics at both the Montefiore Medical Center in the Bronx and Blythedale Children's Medical Center in the Bronx and Blythedale Children's Hospital, Valhalla, New York. Hospital, Valhalla, New York.

He is the author of six published books, including The He is the author of six published books, including The Intern Blues, Rotations, and Learning to Play God: The Intern Blues, Rotations, and Learning to Play God: The Coming of Age of a Young Doctor. Coming of Age of a Young Doctor.

He lives with his wife, Beth and three children Isadora, He lives with his wife, Beth and three children Isadora, Davida, and Jonah in Westchester County, New York.Davida, and Jonah in Westchester County, New York.

Academic AppointmentsAcademic Appointments

Professor of Pediatrics, Albert Einstein College of Medicine, Professor of Pediatrics, Albert Einstein College of Medicine, Bronx, NY Bronx, NY

Professor, OB/GYN, Albert Einstein College of Medicine, Bronx, Professor, OB/GYN, Albert Einstein College of Medicine, Bronx,

NYNY Faculty Member, Graduate Program in Human Genetics, Sarah Faculty Member, Graduate Program in Human Genetics, Sarah

Lawrence College, Bronxville, NYLawrence College, Bronxville, NY

Dr. Marion wrote The Intern Blues eight years after Dr. Marion wrote The Intern Blues eight years after his own internship.his own internship.

He still describes that year as the hardest, most He still describes that year as the hardest, most devastating of his life.devastating of his life.

And states that some of the pain, anger, anguish, And states that some of the pain, anger, anguish, and exhaustion are still with him. and exhaustion are still with him.

From his writing and the diaries of the three From his writing and the diaries of the three interns, Amy Horowitz, Andy Barron, and Mark interns, Amy Horowitz, Andy Barron, and Mark Greenburg, you come to understand that their Greenburg, you come to understand that their experience during the first year of residency, while experience during the first year of residency, while unique to the individual, is equally grueling for all unique to the individual, is equally grueling for all who experience it.who experience it.

Central ThemesCentral Themes

Convey the struggles, stress, and Convey the struggles, stress, and transformations that young doctors go transformations that young doctors go through during their first year of residency.through during their first year of residency.

To present his view of the current system of To present his view of the current system of

medical training as antiquated, unnatural, medical training as antiquated, unnatural, and unhealthy for both the patients and the and unhealthy for both the patients and the physicians themselves. physicians themselves.

Struggles and StressStruggles and Stress

Throughout the book the suffering of each intern is Throughout the book the suffering of each intern is apparent.apparent.

““I’d like to think that overall this has been a good year, but I I’d like to think that overall this has been a good year, but I can’t.” –Andycan’t.” –Andy

““I don’t think I’ll wear that costume again. The bloodstains I don’t think I’ll wear that costume again. The bloodstains kind of take all the fun out of it . And next year if I’m on call kind of take all the fun out of it . And next year if I’m on call on Halloween again, I don’t think I’m going to dress up.” - on Halloween again, I don’t think I’m going to dress up.” - Mark Mark

““I’ve been thinking about that little girl constantly since I I’ve been thinking about that little girl constantly since I finished with her. All through the rest of the night…that little finished with her. All through the rest of the night…that little girl didn’t leave my mind. It’s really terrible. I’m sure I’ll see girl didn’t leave my mind. It’s really terrible. I’m sure I’ll see her face in front of me for years and years to come.” – Amy her face in front of me for years and years to come.” – Amy

I’m going to kill them, I’m going to kill them all! – MarkI’m going to kill them, I’m going to kill them all! – Mark

Struggles and StressStruggles and Stress

Lack of sleepLack of sleep– On call every third day (36 hours with no sleep).On call every third day (36 hours with no sleep).

The MatchThe Match– The system by which you are placed in your residency.The system by which you are placed in your residency.

Working an average of 100 hours every week with only one Working an average of 100 hours every week with only one day offday off– An average of 16.6 hours a day.An average of 16.6 hours a day.

DepressionDepression Changing to a different ward every monthChanging to a different ward every month

– You have to adapt to a different system, acquaint yourself with new You have to adapt to a different system, acquaint yourself with new surroundings, and learn to get along with a different set of co-surroundings, and learn to get along with a different set of co-workers.workers.

Struggles and StressStruggles and Stress

Responsibility for the life of another human Responsibility for the life of another human being.being.

Identifying and reporting child abuse and Identifying and reporting child abuse and raperape

Deciding if children should be taken away Deciding if children should be taken away from their parentsfrom their parents

Watching a patient die without the ability to Watching a patient die without the ability to help them in any wayhelp them in any way

Ethical Dilemmas Ethical Dilemmas

Dealing with DeathDealing with Death Over his friend, Enkidu, Gilgamesh cried bitterly, roaming Over his friend, Enkidu, Gilgamesh cried bitterly, roaming

the wilderness. "I am going to die!--am I not like Enkidu?! the wilderness. "I am going to die!--am I not like Enkidu?! Deep sadness penetrates my core, I fear death, and now Deep sadness penetrates my core, I fear death, and now roam the wilderness.roam the wilderness.

Dealing with the deaths of others and your own mortality Dealing with the deaths of others and your own mortality on a daily basis has to be another major cause of stress. on a daily basis has to be another major cause of stress.

Normal Struggles and Stress Normal Struggles and Stress CompoundedCompounded

Relationship problemsRelationship problems– You’re so tired you can’t give your partner the time they You’re so tired you can’t give your partner the time they

need.need. Lack of a home-lifeLack of a home-life

– No time for friends, family, children, hobbies, or No time for friends, family, children, hobbies, or exercise.exercise.

– You’re either at work or asleep so you have virtually no You’re either at work or asleep so you have virtually no social life.social life.

– Even with a family emergency it is almost impossible to Even with a family emergency it is almost impossible to get off work without lying.get off work without lying.

Problems with your boss and co-workersProblems with your boss and co-workers

Time for a ChangeTime for a Change Serious reform of resident duty hours did not Serious reform of resident duty hours did not

begin until 1984 after the death of 18-year-begin until 1984 after the death of 18-year-old Libby Zion at New York Hospital.old Libby Zion at New York Hospital.– The resident on duty did not medicate Ms. Zion The resident on duty did not medicate Ms. Zion

properly.properly.– The intern, responsible for numerous other The intern, responsible for numerous other

patients and having already worked more than patients and having already worked more than 18 hours without a break, ordered restraints as 18 hours without a break, ordered restraints as well as another drug. Libby died soon after.well as another drug. Libby died soon after.

InvestigationInvestigation

Libby Zion's father, an attorney and writer for The New Libby Zion's father, an attorney and writer for The New York Times, persuaded New York District Attorney York Times, persuaded New York District Attorney Robert Morgenthau to begin a grand jury investigation Robert Morgenthau to begin a grand jury investigation into his daughter's death. into his daughter's death.

There were no criminal indictments of the doctors, There were no criminal indictments of the doctors, however, the grand jury investigation did result in an however, the grand jury investigation did result in an indictment of the system. Listing sleep deprivation and indictment of the system. Listing sleep deprivation and inadequate resident supervision as major problems inadequate resident supervision as major problems leading to Libby’s death.leading to Libby’s death.

In response to the indictment the Bell Commission In response to the indictment the Bell Commission (named after its chair Dr. Bertrand Bell) was (named after its chair Dr. Bertrand Bell) was established to make suggestions for changes to the established to make suggestions for changes to the current system.current system.

Bell CommissionBell Commission

Proposed Proposed – To Limit resident work hours to 80 hours per weekTo Limit resident work hours to 80 hours per week– No more than 24 consecutive hours of on-duty timeNo more than 24 consecutive hours of on-duty time– At least one 24-hour period off-duty each week. At least one 24-hour period off-duty each week. – Recommended onsite Attending Physician Recommended onsite Attending Physician

supervision in both emergency rooms and acute supervision in both emergency rooms and acute care inpatient units.care inpatient units.

The Bell Commission's recommendations became a The Bell Commission's recommendations became a New York State regulation (section 405 of the New New York State regulation (section 405 of the New York State health code) on July 1, 1989. York State health code) on July 1, 1989.

Further DevelopmentsFurther Developments

Funds were not allotted to monitor for Funds were not allotted to monitor for compliance.compliance.

In 1999, a cardiology fellow training in New In 1999, a cardiology fellow training in New York died in an automobile accident after a York died in an automobile accident after a night on call. night on call.

This led to the Health Care Reform Act of This led to the Health Care Reform Act of 2000, which gave adequate funding to 2000, which gave adequate funding to monitoring hospital compliance with resident monitoring hospital compliance with resident work-hour regulations. work-hour regulations.

Salient Changes in Medical Salient Changes in Medical ResidencyResidency

In 2003 the American Council for Graduate In 2003 the American Council for Graduate Medical Education (ACGME), the private non-profit Medical Education (ACGME), the private non-profit in charge of accreditation of medical residencies, in charge of accreditation of medical residencies, set up the following standards.set up the following standards.– Doctors are limited to no more than 80 hours of work Doctors are limited to no more than 80 hours of work

per weekper week– Residents cannot work for more than 24 hours in a shiftResidents cannot work for more than 24 hours in a shift– Residents will have one day off in seven and get a 10 Residents will have one day off in seven and get a 10

hour break between being on call and working a shift hour break between being on call and working a shift

The debate over what to do with resident The debate over what to do with resident work hours was mentioned in the book.work hours was mentioned in the book.

Dr. Marion seems mostly in favor of the 80 Dr. Marion seems mostly in favor of the 80 hour limited work week recommendation.hour limited work week recommendation.

He however would most likely have He however would most likely have problems with the limitation to 24 hour on- problems with the limitation to 24 hour on- call shifts. call shifts.

As stated earlier, the author presents his opinions As stated earlier, the author presents his opinions and/or experiences dealing with similar situations that and/or experiences dealing with similar situations that are addressed in the interns diaries. are addressed in the interns diaries.

These include:These include:– The effect of poverty on treatmentThe effect of poverty on treatment– How best to deal with premature babiesHow best to deal with premature babies– How residents learn to speak to parents who have lost their How residents learn to speak to parents who have lost their

childchild– How AIDS has changed how doctors deal with patientsHow AIDS has changed how doctors deal with patients– How residents’ relationships are effected How residents’ relationships are effected – Possible changes to intern work schedulesPossible changes to intern work schedules– Childcare for female doctorsChildcare for female doctors– And many othersAnd many others

Poverty and MedicinePoverty and Medicine

Three Types of Premature BabiesThree Types of Premature Babies

Type I – Good PrognosisType I – Good Prognosis

Type II – Bad Prognosis Type II – Bad Prognosis

Type III – Less than 2 lbs. but above the 24 Type III – Less than 2 lbs. but above the 24 week mark week mark

My OpinionMy Opinion

This book brings you face to face not only with This book brings you face to face not only with problems in the first year medical resident’s life but problems in the first year medical resident’s life but also some of the biggest problems in society.also some of the biggest problems in society.– Child molestation/abuseChild molestation/abuse– Ethical questions about extending life artificially Ethical questions about extending life artificially

The way the book is written you feel like you’re the The way the book is written you feel like you’re the one making each decision, feeling inadequate, one making each decision, feeling inadequate, and getting yelled at by your superiors. and getting yelled at by your superiors.

My OpinionMy Opinion

The author, in spite of his position and experience The author, in spite of his position and experience didn’t come out and try to answer all of the big didn’t come out and try to answer all of the big questions posed by the interns experiences.questions posed by the interns experiences.– He gave us the issues the residents deal with everyday He gave us the issues the residents deal with everyday

(taking children away from their parents/ letting a patient (taking children away from their parents/ letting a patient die or not) and let us deal with them.die or not) and let us deal with them.

He may have laid the book out this way because He may have laid the book out this way because he doesn’t know the answers, but it is still a very he doesn’t know the answers, but it is still a very effective way of engaging his audience and effective way of engaging his audience and stimulating the thought of the reader. stimulating the thought of the reader.

TransformationsTransformations

Beginning their internship, Amy, Andy and Mark Beginning their internship, Amy, Andy and Mark were tense, uncertain about their abilities, and full were tense, uncertain about their abilities, and full of fear.of fear.

At the end of their internship they had developed At the end of their internship they had developed confidence in their judgment and technical ability.confidence in their judgment and technical ability.

Through the internship much of their enthusiasm Through the internship much of their enthusiasm and spirit was worn down.and spirit was worn down.

And in the words of the author, they truly became And in the words of the author, they truly became physicians but in the process lost some of their physicians but in the process lost some of their innocence, humanness, and fundamental respect. innocence, humanness, and fundamental respect.

Is it all worth it?Is it all worth it?

ReferencesReferences

The Epic of GilgameshThe Epic of Gilgamesh Marion, Robert M.D. The Intern BluesMarion, Robert M.D. The Intern Blues AMA websiteAMA website FREIDA websiteFREIDA website