"The responsibility is much more than you ever had without the M.D. behind your name."

O. W. is a third year pediatric resident at Cleveland Rainbow Babies and Children's Hospital. She is a 33 year old married woman without children, who has never been a nurse.

I think a lot of my decision to be a doctor goes back to my father being a doctor, and a lot of our friends had fathers who were doctors. So I had a lot of exposure. Then the jobs and volunteering I did through high school were all medically related. So I was plugged in very early. When I went to college I decided I wanted to do different things. I was a French major. In the back of my mind I still kept medicine as a possibility but it certainly wasn't in the forefront, because I only took a few science courses. So there was no way I was going to be able to get into medical school without obtaining more education.

After college I was manager for a store that sold French goods, toiletries, wine. I worked very closely with a French couple who treated me more like their daughter than their affiliate. And I realized that wasn't what I wanted. I had to look very hard at what skills I had and what interests I had had before. Knowing what medicine was about, I decided I still wanted to do that. So I took all the science courses I hadn't taken in college and I got excellent grades.

Taking all the courses and the MCATs took me a year and a half. I took the bare minimum and maybe one extra course in human physiology. My dad helped me find a job at UCSF doing research and that's when I did my applications. I was accepted by George Washington in March. George Washington is known for accepting a wide variety of students, and they have a good record for aid-blind admissions.

I didn't know what to expect in medical school. I don't think I realized the magnitude of how much knowledge, how much material needed to be memorized and covered. I did feel a bit disadvantaged in that I didn't have a biochemistry or science background. A lot of people had taken biochemistry and anatomy in college.

In my class, even though there were a lot of us who had done other things and taken time, there was still a huge proportion of students who went straight through, who seemed very young to me. They certainly had an advantage from the classes they'd taken. In making friends I gravitated to the older students.

Everything was new to me. I had to work hard. (Working hard wasn't new to me.) I was also disadvantaged because P. and I were apart. Even though that gave me more leeway to study harder, I didn't know how to study well. When I'd taken one science class, or two, in college, I could do well in them, but having to study for four different science classes at a time was very hard for me.

During the clinical years I felt much more comfortable because I did feel pretty mature. I liked working with patients and interviewing them. The medical students were put in groups together. For a lot of the younger men, the patient contact was more difficult. But they got used to it. For me it was still all new situations -- being in surgery or doing OB/GYN or presenting on rounds. Presenting on rounds was hard for me initially until I felt really confident. But that was due to my own personality.

I went through the residency match, but not while I was in medical school. Right after medical school I was married. P. had been living in the Bay Area while I was in Washington for those four years. I don't think very many long-distance relationships made it through my medical school class. We were one of the few. During that next year I matched at Rainbow Babies and Children's Hospital in Cleveland, which is part of University Hospitals.

It is scary in the beginning. The responsibility is much more than you ever had without the MD behind your name. I'd bet people who had nursing backgrounds had more practical skills, and clinical expertise. They're the first ones at the bedside, so they have to deal with the initial problem. They do what they can to stabilize the patient before the doctor gets there. So they're placed in a lot of situations that can be scary and stressful, and they're supposed to learn how to cope with it. I can imagine nurse/doctors feeling more advantaged that way.

With rotation after rotation you're exposed in pediatrics to different age groups, to different situations. You're gaining more and more practical skills, and efficiency. You're never left alone. You get whatever kind of help you need. It may not be immediate but within the immediate future it's there, and you grow from all that experience. We always have backup, except in the emergency room as juniors. Each year and each rotation you're gaining more skills and you're becoming better at everything you do. It becomes second nature.

When you're a junior you don't do much teaching, but as a senior you start to do a lot of teaching and directing the interns. They come to you to get the bloods and the IVs, and you get them. Occasionally you can't, but generally you do, so you look back and think, Boy, I remember when I couldn't get these, either. It's an eye-opener.

A week ago I had to work thirty-seven hours straight. I hadn't slept. I didn't think the system worked then. It made me angry that I was there the next day and had to direct the interns and get bloods and do more admissions, when I had been working the whole day before, helping the interns do the admissions during the day and then at night be admitting and taking care of sick patients, until I went home at seven o'clock the next evening.

There are a lot of traditions that don't work that well, that aren't safe. More than not being safe, it's not appropriate for any human being, whether you're a doctor or any other professional, to have to work hours like that.

The nurses I've worked with tend to test you initially. Once they trust you they don't bug you about things so much. On certain floors, some nurses will call about the stupidest things that could have waited six hours, or some will wait to call you for an appropriate thing. Sometimes the interns don't respond quickly enough because they don't know that the nurse would not call unless they really needed you.

Now the nurses don't come right out and say that they want you. When they want you to come, they sort of let you know and interns don't always quite get it. Interns have to learn to differentiate which nurses they can trust and which they can't. Because we're asked to do so many crappy, stupid things, interns haven't had enough experience to see when something is really important and when it's not. So you have to evaluate the kid yourself to be confident enough to say, "This kid is okay. There are certain things I look for that you should look for and let me know if any of these things are happening."

I think it happens, a little bit, that nurses can call someone to irritate them. In fact, I've heard nurses discussing how they would page some resident they had been annoyed by to a fake number over and over during the night. You're never going to be liked by everybody. You have to be careful, and you have to be strong and stand up and be confident and not get walked all over, too, because you can be. That happened to me a bit.

The nursing staff in PICUs are working with the patients one on one, one on two, maybe, whereas we physicians are watching the whole PICU. In our PICU there are sixteen or twenty beds. There's a doctor in there monitoring all of them, whereas there's a nurse between one or two beds. On the floor it's the same. You're watching your eight or nine patients and the nurse is taking care of four. Occasionally they have more. They become the patient advocate and sometimes it goes to an extreme.

We have a floor, the adolescent floor, where the nurses are territorial. They stick up for their patients and will fight every fight if they don't think what we're doing is right. To some extent it's good to have the person be a patient advocate, but sometimes they lose sight of the whole picture, that we too are doing things in the interest of the patients. They sometimes pit patient against doctor.

When I was an intern, my very first month, I had a patient (a baby) who needed to be cathed for urine about every eight hours because he had spinal paralysis from birth trauma. When I came on the service the kid was being cathed at certain hours that were really difficult to do. It didn't matter what time the kid got cathed. He needed to be cathed about once every shift and the nurses didn't do it because he's a boy. They don't cath boys in our hospital, they only cath girls. It makes no sense whatsoever, but that's the practice.

This nurse pitted the family against the resident by saying, "The doctors are changing the time they're going to cath your baby. They're going to cath your baby at these hours because it's more convenient for them." She said all sorts of things that really were totally inappropriate. If she had come to me to address her concerns, it would have been much more appropriate than to make it seem like we were out to get the baby. And that's when they consider them-selves some kind of patient advocate. So sometimes it can go to an extreme.

My goal is to take care of the patients and if the nurse helps, I'm happy. If they get in the way, it can be rather hard. They don't always address their concerns to the doctor, the appropriate person. They take them to the wrong person or they don't address the person directly.

Where I trained, here at Rainbow, and as a new intern who hardly had any experience, I was always open to listening to what the nurses had to say. If a nurse told me, "I think you should do this," I would listen to them. I mean, why not? They have had experience and it's not going to kill the patient, more than likely. So I was pretty open to getting help from the nurses. In our PICU and NICU they are very knowledgeable. They can take care of the patients while you get an hour's rest, and they do.

They don't know the medical background to the extent we do. They know a bit, but much, much less than we do, so when they're wrong, we know they're wrong, because something doesn't make sense in what they're suggesting. What I've found is that they're perfectly reasonable if you explain to them why something they want to do doesn't make sense, or why what you want to do makes sense medically. It's a give and take. As a trainee, always learning, I'll listen to nurses a lot. They'll help me make a decision sometimes when I think this kid might need to go to the PICU. They've helped me many times.

The only one thing is, it's hard when you're an intern and you're trying to preround. They're very territorial about their paperwork and you need the paperwork to see how the patient did overnight, so you can present it in the morning on rounds. You ask the nurse, "How did the kid do overnight?" but you still need the numbers. So to get the numbers you have to get the papers and most of the papers are supposed to stay at the patient's bedside, but at the end of the night, or the end of their shift, they're adding things up. It was always torture to get those damn papers from them. Most of the time it was a little earlier than their change of shift but they still had to be territorial about that.

We have these interdisciplinary rounds, care conferences, every week when patients are picked out to be talked about. As an intern, those were awful. They're time-consuming and you have tons of work to do. The nurses sometimes help you with getting everybody there, so you don't have to do too much of that. Every group that's taking care of the patient, including the primary nurse, is there. The nurses are very involved again in patient advocacy and trying to make sure no one gets abused and thinking of the whole person, all things that are very appropriate. But sometimes things get taken to the extreme and that can be hard. The nurses tend to love those rounds. They ask, "When are we going to have a care conference?"

We get some training with normal kids. I don't think we get enough. We spend two to four weeks as an intern in the normal newborn nursery. Generally you go to the high risk deliveries or meconium or C-sections. Then you're dealing with a normal newborn but they're in and out of there in twenty-four hours so it's not like you do a whole lot.

We go to our own clinic a half day a week and then every year you have a couple months in the outpatient clinics where you're dealing with typical outpatients. You're in the ER quite a bit and our ERs are very much like outpatient clinic because a lot of people use the ER that way, not for emergencies. We get quite a bit of exposure but it's all one-sided. We see the lower socioeconomic groups that don't have insurance or are on Medicaid who use the emergency room as their physician. Or they come to our clinic because it's free care.

We save a lot of twenty-four week premature babies now and when you see some of these twenty-four weekers at a later time, they are doing pretty well. When people say, "Look at that twenty-four weeker that was saved and he's doing pretty well, how could you have not saved the rest of them?" it's hard. But I have trouble with it. I think that we save too many babies that probably we would be better off saying good-bye to when they first come out. It's very hard if they're kicking and screaming and crying, to let them go.

There are a few twenty-four weekers who don't have handicaps. Not too many, but an occasional one. Some of the older gestational premature babies can have very severe and significant problems, so it really does depend. We just saw a tape put together for parents on three or four premature infants who had different problems. They showed them over time. It was amazing. We don't see that, as a resident. We see the sick ones who come back into the hospital over and over again. But we aren't out there in the community seeing all those babies who were premature that do just fine.


I don't think anybody gets enough positive feedback about what they're doing--nurses or doctors. It's easy to always see the bad things and to have them pointed out: You're doing this wrong and you need to shape up with it. People rarely tell you when you're doing a good job. That's true as residents, too. Our program tries to work on that but we all could use more of it. I try to remember, when I'm working with my interns, to tell them when they've done something good. Whether they've done something great or not, I always tell them they're doing a good job unless they're really, really blowing it. Because I don't think I got enough. And it makes your day.