Victoria Saah Giffi furiously scribbles patient information on a notepad, like a waitress taking breakfast orders during the morning rush.
Sitting in the large atrium at the University of Maryland Medical Center downtown, she is technically on a break, but only technically—the pager at her waist starts beeping before she gets the notebook into the pocket of her white lab coat. The 27-year-old doctor juggles CT scans, lab results, and prescriptions for a dozen to two dozen patients at any one time. Even though she has a good memory, lists are the only way to keep track of it all.
"In a minute, I'll be told something else," Giffi says. "It's automatic. I start making check boxes."
This is the life of a first-year doctor. There are jobs that you can fake your way through until you know what you're doing. This isn't one of them. Twelve-hour workdays and weekend shifts are the norm. All doctors start this way, as residents, with the toughest schedule and the largest workload, under the supervision of more veteran doctors.
There are about 2,600 residents in Maryland, according to the Association of American Medical Colleges. The length of residency varies by specialty, but four years is typical. In their first year, they are sometimes called interns, though the designation might sound misleading, as if these new doctors aren't making actual decisions about patients' care.
"It's hardest when you're doing your best and you're not making the patient better," Giffi says, getting a little choked up. "You want to make a difference."
We spent time with Giffi, as well as Sarah Stewart de Ramirez, an intern at Johns Hopkins Hospital's Emergency Department, and Rayomand Bengali, a first-year doctor at Greater Baltimore Medical Center in Towson to find out what it's like to be a rookie doctor.
Giffi started making life-and-death decisions on her first shift.
"I remember being called about a patient's blood sugar, which was abnormally high," she says. "The nurse asked me, 'What do you want to do, doctor?' I couldn't answer. I had to hang up and call back." Giffi was shell shocked by the volume of information she was being asked to keep track of. "That first week, I remember saying, 'I don't want to be a doctor.'"
It's still dark most mornings when Giffi cranks up the car outside her Hunt Valley home. By 6:15, she's at University of Maryland Medical Center, catching up on what has happened with her patients overnight. She does exams, checks vitals, and writes notes, a process known as "pre-rounds."
By 9 a.m., she's ready for rounds, this time overseen by the attending physician, with medical students observing. It's a process made familiar to most Americans by Grey's Anatomy and Scrubs: The first-year doctors summarize the patients' information. The attending physician grills the students and first-years about what might be causing the illnesses and what treatment options might be best. It's part presentation, part pop quiz.
"Usually, the attending starts at the bottom, with the students. If they don't know, he asks the first-years, then the older residents," Giffi says. "Yes, there are those deer-in-the-headlights moments, but it makes you so much more responsible for the knowledge."
But this isn't a TV show. The attending physicians aren't vicious and the residents aren't secretly hoping their colleagues give a bad answer. Supervising veteran doctors don't gleefully assign scut work, Giffi swears, or bark orders like drill sergeants. And, unlike on TV, she says, "I don't think people are having sex in the closets."
The afternoon is a whirlwind of blood work, discharge instructions, and scans. By 4 or 5 p.m., Giffi prepares her instructions for the overnight nurses and the resident on call. The "sign out" report includes medications to give her patients and symptoms to watch for. Most days, she doesn't leave the hospital before 6 p.m. Every fourth day, Giffi won't go home at all, because she's on call.
"On call," which suggests the doctor will go home and only to be summoned in an emergency, is a misnomer. What it really means is that the doctor will be working literally around the clock—30 hours straight.
Giffi's record nap during an overnight shift is two hours. After 30 hours, it's hard to stay awake on the drive home. "I usually call someone to talk on the ride," Giffi says. "My mom expects to hear from me every four days."
Giffi says one resident, on bad days, goes to the maternity floor to be cheered up by seeing the babies. "Sometimes you just have a good cry," she says. "It gets easier, I'm told."
Medicine is her family's business. Her father, a University of Maryland Medical School alum, is a physician specializing in infectious disease. Her mother is a former nurse turned hospital administrator. Her stepfather is an anesthesiologist.
Giffi, a Bryn Mawr School graduate who grew up in Ellicott City and Severna Park, fell in love with medicine working as a nurse's aide in college. "I enjoyed talking with patients," she says. "I thought being a doctor would resemble that. So far, it hasn't. . . . Being a doctor is documenting."
Still, only a few months into her first year as a doctor, Giffi has already helped save several lives with CPR and a heart defibrillator. "It's rewarding when you see the heartbeat come back on the monitor," she says. "But you can't celebrate too much: There's a really serious problem that has brought them to that point."
One of her favorite parts of being a doctor is seeing patients when they return to a clinic for follow-up checks and treatment. "I saw them at their worst," she says. "It's good to see them when they're better, with their families."
A maximum 80-hour work week is now mandated by law for patient safety, Giffi says. During less-enlightened eras, like in the 1970s, when her father became a doctor, first-year M.D.s never left the hospital. "That's why they're called residents," Giffi says. "They were literally residents of the hospital."
Sarah Stewart de Ramirez took her first medical trip when she was 13.
Her father was on the board of the local hospital in her hometown of Peoria, IL, and when Ramirez told him she was interested in seeing the places where her family's church fundraising went, her father told her about a group of doctors going to Haiti.
She went along to help and returned with the group each year. One young patient stands out in her mind. The doctors repaired a hole in his heart from rheumatic fever. But the next year, when she and the doctors returned to the boy's village, she couldn't recognize him. "He was so malnourished," she recalls. "A lot of it is about economics."
Ramirez, a Harvard Medical School graduate and a Fulbright scholar with a master's degree in economic development from the London School of Economics, continued to travel after completing her studies, doing field research at hospitals in Tanzania, Malawi, and Rwanda before starting her residency at Johns Hopkins Hospital this year.
"Sickness creates poverty, and poverty creates sickness," says Ramirez. "It's a cycle. You can see it in rural Africa. You can see it in the sub-acute room at Hopkins."
Eventually, Ramirez wants to establish emergency medical systems in poor countries. But first she has to master Johns Hopkins Hospital's Emergency Department—a hospital within a hospital with its own entrance, its own admitting staff, its own nurses, its own CT scanner, and its own lab for quicker results.
Everything is computerized. Even the supply closets, which look like vending machines, are electronic, with fingerprint sensors.
There are three trauma rooms and an elevator that goes directly to the rooftop helicopter landing pad. An intercom broadcasts expected arrival times of ambulances and Medevacs.
Emergency medicine demands two things, Ramirez says: efficiency and teamwork. "You're never alone," she says, adding that as many as eight doctors and nurses are in a trauma room, each with a different assignment. Interns are typically tasked with routine procedures like starting central IV lines. "They know you've just started," Ramirez explains.
Outside the trauma room, Ramirez is caring for about six patients at any one time. "It can be overwhelming," the 31-year-old doctor says. "You have a lot of really sick people."
"In the emergency department, you're trying to figure out what got them to this point," Ramirez says. The doctors start by ruling out the most life-threatening possibilities. For example, before Ramirez can diagnose a patient with a headache, she has to know that bleeding, infection, or a tumor isn't the cause.
But it's not all medical history, tests, and scans. While you're doing all of that, she says, you're learning about your patient—how many kids they have, what they do for a living, where they live. "Every patient—they're someone else's whole world," says Ramirez.
Emergency room doctors don't work the 30-hour stretches common in other departments. They always work 12-hour shifts, sometimes during the day, sometimes at night. During a recent rotation, days went by, and Ramirez and her husband, an intern in orthopedic surgery at Union Memorial Hospital, didn't see each other once.
"The only way I knew I was married was because there was less food in the fridge," she sighs.
Ramirez is one of 11 interns in the Hopkins Emergency Department. When they started in July, they went camping together to get to know each other before the first day of work, sleeping in one big tent.
The friendship was almost instantaneous. "You're all going through this major life change together," says Ramirez. The group still goes to dinner a few times a month and meets weekly for lectures. "If we have a hard day, if we're struggling with a decision, we call each other."
Being called "doctor" takes some getting used to. "But that's not what makes you feel like a physician," says Ramirez. "It's realizing that these are your patients, your responsibility. You're the physician."
Rayomand Bengali has known that he wanted to be a doctor since he was 13, when he watched his mother be treated for, and later die from, cancer.
"I'd go with her to the treatments. I'd ask, 'Why does she need this or that?' I was the one with all the questions," Bengali recalls. "She knew that I'd become a doctor."
It is why he went to medical school in India and came to the U.S. for residency. Today, Bengali is one of a dozen first-year doctors at the Greater Baltimore Medical Center.
Bengali spends several weeks in each of the various departments in the hospital—the intensive care unit, cardiology, geriatrics.
"I really liked the general-medicine floor," says Bengali. "I had a patient, a woman who was 86 years old with abdominal pain and a small bowel obstruction. She'd been in the hospital for a long time—a week and a half to two weeks. I got to know her pretty well."
Most patients can't wait to leave the hospital and, on the way out, all they say is "bye." But this patient was different. "She said, 'I'll miss you,'" says Bengali. "It really touched me."
Those moments are why Bengali wants to specialize in geriatrics and palliative care—the measures taken during the last stages of life. He'll spend the final months of the year in that field.
"Our patients need us most in that last stage," Bengali says. "And if they don't have family, especially, sometimes more than doctors, they need a friend. Sometimes, you just have to sit there for a few minutes with them."
Of course, losing a patient is never easy. Recently, one of Bengali's patients with HIV died. "He was not that old, but he had complications," says Bengali. "It was sad."
Still, the year has not been without its kindnesses.
Veteran doctors show mercy to the interns who have worked overnight, Bengali says. The attending doctor knew that Bengali didn't have a car and asked if he needed a ride to the supermarket. Bengali does grocery shopping with his roommate, but he says, "I was really touched that he asked."
Those outside the medical profession tend to assume that doctors are well-paid professionals, with vacation time, luxury cars, and prime parking spots. But at this early stage, doctors are usually saddled with more than $100,000 in student loan debt. They share apartments, pack brown-bag lunches, and carpool. In some ways, it is like the hazing part of fraternity initiation—without the tequila.
"I guess that's the consolation—everyone has to do it," Bengali says.
At the beginning, veteran doctors assured the 26-year-old that things would get easier, but he wasn't convinced. He couldn't imagine ever watching the TV in the on call room—that would mean walking past the bed without collapsing onto it, an unthinkable choice during a 30-hour shift.
"Guess what? I've watched it a few times," he says, laughing. "I would not believe it a few months ago." He's seen the Presidential inauguration, American Idol, and a soap opera he's been following since he was a kid.
The schedule is still grueling, but, Bengali says, "I'm finishing my work faster. When we did rounds at the beginning, I asked the patients every question. Now, I just ask the relevant ones."
"I never thought this would get easier," he says. "But it has."