Bellevue

Chapter 4

Monday, July 1, 7:30 a.m.

“Okay, I’m going to make this short and then turn you over to Dr. Van Dyke here, who supervises first- and second-year residents along with our rotating third-year NYU medical students. My name is Dr. Vivek Kumar, and I am the Bellevue Hospital chief surgical resident. I assume you remember meeting me briefly during your orientation over at the medical school last week, but then again you were being introduced to a lot of people. What I want to do this morning is give you two newbies an idea of what specifically you will be facing here at Bellevue over the next two months and what’s going to be required of you.”

Mitt certainly remembered Dr. Kumar and had been impressed from the moment he laid eyes on him. Mitt’s favorable initial assessment was now being confirmed in spades. The man, who had arrived at precisely the time specified, radiated an aura of total confidence along with a vast and almost inconceivable knowledge of medicine, particularly surgery. And now, perhaps because he was on his home turf and feudal domain, he also projected an expectation of excellence and hundred percent commitment along with a low tolerance for suboptimal performance. Mitt briefly glanced over at Andrea, wondering if she felt the same intimidating vibes.

Returning his attention to the chief resident, Mitt saw the man was of average height and inordinately handsome, with a trim silhouette and movie-star good looks. His dark complexion and particularly thick, shiny black hair were highlighted by his outfit. Kumar was dressed as the quintessential surgical resident plucked from central casting with a spotless, highly starched, and wrinkle-free white doctor’s coat over sharply creased white slacks. There were a few colorful pens and a lone penlight in his breast pocket, and a stethoscope was slung casually around his neck.

“You two are about to get your first taste of the power and joys of the practice of general surgery,” Dr. Kumar continued. “And from the word ‘go’ you will be key members of our team. Particularly at night and on weekends, one of you will be the first line of defense for any problems with our in-house surgical patients, both on the surgical wards and in the intensive care units. Of course, you will have the support and backup of on-call second- and third-year residents, who have consultation access to us fourth- and fifth-year residents, along with our talented attending staff, but you will be called first to analyze the situation and decide how to proceed.”

Mitt again looked briefly at Andrea, and this time she returned the glance. The choice of the initial comments by the chief resident served to fan both their anxieties, especially his mention of intensive care units. Everyone, including medical students, knew that the ICU was where the most critical patients, those with sophisticated and potentially life-threatening needs, were located. For Mitt and Andrea to face such situations at this point in their training seemed beyond their capabilities.

“Starting this morning you will be assigned specific patients who are either in surgery or scheduled for today. These patients will officially be yours to follow closely and manage with the support of more senior residents and the attending surgeon. Also, today you will be assigned patients scheduled for admission and surgery tomorrow. These people will also be your patients. What that means is that you will do the admission workup, prepare them for their surgery, assist at their surgery, and then manage their postoperative course. Each day at morning rounds, which start at six thirty sharp in this room, you will have already examined each of your patients and be in a position to present their conditions to the entire team. Are there any questions so far?”

Mitt’s anxieties ratcheted upward, and he glanced yet again at Andrea, who nervously returned the look.

Dr. Kumar paused, staring back at the newbies. When neither gave any indication they wanted to speak, he continued. “This all might sound like a lot of work, and for good reason. It will be. But there’s more. A weekly three-hour protected educational block must be respected, meaning besides your clinical responsibilities, you will be required to attend our SCORE lecture series, which our senior residents present in conjunction with the appropriate attending surgeons. Additionally, you will also be expected to attend Thursday grand rounds, provided your surgery schedule permits, as well as various departmental conferences, including most particularly the Mortality and Morbidity Conference. On top of that, you will be expected to spend time in our simulation center, particularly to gain familiarity with laparoscopic instruments and techniques.

“What you are hopefully gaining from my remarks this morning is the clear understanding that you are here at Bellevue primarily to learn, and we want to make absolutely sure that happens. Any questions at this point?”

Both Mitt and Andrea were too intimidated to ask questions, and both unconsciously settled more deeply into their respective seats to avoid calling attention to themselves. At the same time, Mitt knew that there was a conflict between learning and service, particularly during the first year of residency. First-year residents were, when all was said and done, remarkably cheap labor and had been historically abused as such. The year was, in reality, exactly the same as what used to be called “internship.” When the abuses that interns had suffered became common knowledge, the name changed but the demands didn’t.

“Okay,” Dr. Kumar said. “I’m glad we are on the same page. Still, there’s one more important issue I want to raise. Our program here at Bellevue respects the Accreditation Council for Graduate Medical Education, or ACGME, decision on resident work hours. We are serious about adhering to the limit of ‘eighty hours per week over a four-week stretch.’ You will hear more about this issue from Dr. Van Dyke. That’s it! How about now? Any questions for me?”

Mitt and Andrea didn’t dare to breathe lest any movement might draw unwanted attention.

“Okay,” Dr. Kumar said with a brief hand clap followed by a gesture toward Dr. Gloria Van Dyke. “Now I’ll turn this over to one of our talented third-year residents. She will be filling you in on some of the necessary details and getting you started on your journey.” With a final nod toward the two first-year tyros and then to Dr. Van Dyke, he briskly exited the room.

“All right, I’ll also be quick,” Dr. Van Dyke said. A strikingly athletic young woman dressed in scrubs under a white doctor’s coat, she stepped behind the vacated podium and projected a confidence nearly equal to the chief resident’s, suggesting she was a dutiful understudy. In Mitt’s mind, it underlined something he’d already garnered as a medical student about the field of general surgery. It was based on a very hierarchical system that had changed little over its hundred-and-fifty-year history. Those on the lowest rungs of the ladder, like he and Andrea, had to be bullied or somehow cowed to earn entrance into the “club.”

“First and foremost,” Dr. Van Dyke said, “please make certain your cell phones are hooked up with the hospital communication system. For the nurses and me to be able to get ahold of you at all times is obviously of prime importance. And as recent medical school graduates, I’m going to assume you are more aware than I was that it is essential to enter everything you do and even think into our electronic health record or EHR. Do I have that right?”

Both Mitt and Andrea nodded. Establishing their connectivity had been one of the first things they had done, and they’d been fully indoctrinated into the demands of the EHR.

Dr. Van Dyke then pulled a couple keys from her pocket and held them up. “I have keys here for the two on-call rooms you will be using and which I will be showing you shortly. It’s vitally important that these rooms be locked at all times. I imagine you both have heard of the Dr. Kathryn Hinnant tragedy.”

Mitt and Andrea nodded. A bit more than thirty years previously a vagrant who’d actually been living in a Bellevue Hospital mechanical room raped and killed a pathologist who was working in her isolated office on a weekend. It had had a profound effect on the institution, as it should have.

“Literally thousands of people are in and out of Bellevue on a daily basis,” Dr. Van Dyke explained. “On-call rooms must always be locked.”

Both Mitt and Andrea nodded.

“Also included in my tour will be our eighteen ORs, where you will be spending a significant amount of your time, the OR locker rooms, as well as the surgical inpatient wards. I’ll also be quickly walking you through the ambulatory surgical areas as well as the intensive care units on the tenth floor.

“Now I’d like to follow up on Dr. Kumar’s comments about ACGME rules on resident hours. It will be your job to keep track of your hours and give them to me. We do want to make certain that the program is in compliance, as we don’t want to lose our accreditation.” She laughed hollowly. “If that were to happen, none of us would be able to become certified by the American Board of Surgery. I don’t have to explain to you what kind of disaster that would be.”

Mitt nodded once again as if he were agreeing that it was appropriate for him and Andrea to be responsible for reporting their hours. He could already see that the system was designed to thwart the attempt by the ACGME to limit resident hours for the safety of patients and for the residents’ health. If he, as a surgical resident, were to report — essentially complain — that he was being asked to work too many hours, he’d risk being blackballed and possibly fired. Such is life, he thought. But he wasn’t surprised. When he’d applied for a surgical residency, he had a pretty good idea of what was involved, including very long hours and a very hierarchical, almost feudal structure.

“Okay,” Dr. Van Dyke said. “Before we start our tour, are there any questions?” She left the podium and approached Mitt and Andrea, handing them both their on-call room keys.

“I have a question,” Andrea said, finding her voice. “Which one of us will be on call tonight?”

“Ah, yes. Thanks for asking. Dr. Fuller will be first at bat. I went with alphabetical order to make the decision. All right, let’s head out!”

Andrea turned and looked questioningly at Mitt as if to say: How the hell did you know?

Mitt merely shrugged.