In honor of the 10th Anniversary of Clinical Correlations over the next four weeks we are presenting a wonderful 4 part series of life as a house officer at Bellevue Hospital in the 60’s, 70’s, 80’s and 90’s. Former resident Olivia Begasse de Dhaem conducted extensive interviews with our faculty who worked at Bellevue in each of these decades. With guidance from David Oshinksy, Olivia has written a story of what binds our students, residents and faculty and patients together through Bellevue’s rich history. While much has changed in our daily workflow, so much has stayed the same. Most obviously, the esprit-de-corps that develops while working on the halls of Bellevue Hospital has not changed and is so apparent throughout these interviews…enjoy!
Part 1: Tales of Survival from the ‘60s – Residency in the Old Hospital and Before Medicaid
Interviews with Dr. Jerry Lowenstein, Dr. Martin Kahn, Dr. Anthony Grieco, and Dr. Lois Katz
By Olivia Begasse de Dhaem, MD
With a rich 280-year history of continuous active service to New York City, Bellevue Hospital is a special place. It has always been ready to take care of numerous, extremely destitute patients. The following is the first in a series of articles detailing the lives of Bellevue medicine interns and residents in decades past, as told by current NYU faculty who trained at Bellevue during these eras. My hope is that learning about the culture, mission, and history of Bellevue through the perspective of past house staff will allow current residents to appreciate its spirit and will inspire us moving forward.
The Interviewees
The office of Dr. Jerry Lowenstein instantly transports its visitors back to the ‘60s. As a former resident quarter, the sink and closet space are still present, though the two beds have long since been removed. He presents to me the original, meticulous description of the “methanol” epidemic of 1963, the typewritten paper now foxed, the dark glass presentation slides with light writing still preserved. I then pore over a notebook from 1949 penned by Dr. David Baldwin. Its contents include careful recordings of the daily weights, urine outputs, proteinuria, and weekly inulin clearance of a patient with nephrotic syndrome, along with the days on which he received nitrogen mustard, a common therapy at the time. Dr. Lowenstein, upon graduating from the NYU School of Medicine in 1957, ventured uptown to Montefiore Hospital for his internship. He would later spend two years at the National Institute of Health in Baltimore studying the effect of aging on glomerular permeability before ultimately returning to Bellevue in 1960 to resume his clinical training as a PGY-2 [1].
Dr. Martin Kahn and Dr. Anthony Grieco both graduated from the NYU School of Medicine in 1963. Dr. Kahn’s office even boasts a picture of the class of ’63 on the wall. He requests that, before taking a seat, I attempt to find him in the photograph. To decrease the pressure, he jokingly adds that he will still talk to me regardless of whether I succeed. I am amazed from the photograph at how little Dr. Kahn and Dr. Grieco have changed [2]. Dr. Grieco’s office, meanwhile, is neatly organized, mirroring his thorough physical exam and structured clinical reasoning during teaching rounds, traits that one can imagine trace all the way back to attending rounds circa 1963 [3].
Dr. Lois Katz graduated in the NYU class of ’66. She then spent her first two years of residency at Bellevue Hospital and her PGY-3 at the New York Hospital (Cornell) before starting her fellowship in nephrology at the Manhattan VA. She also managed to have a child during medical school and another during residency. Notably, unlike Bellevue, where PGY-3s rotated through medical consult and covered the emergency room, the PGY-3s at the New York Hospital rotated through different specialties (ie Oncology at Memorial Sloan Kettering, Infectious Diseases, Nephrology) for blocks of three months [4].
The Divisions
In 1960, the Medicine service at Bellevue Hospital consisted of four divisions, though this configuration would change dramatically over the next decade. The first two divisions belonged to Columbia and Cornell University, respectively, while the third and fourth divisions were held by NYU [3]. Initially, the third division housed medical students, house-staff, and attendings, while the fourth division employed doctors already in private practice who wanted to specialize [3]. Later, in the early 1960s, the third and fourth divisions merged [1,3]. In addition to the Medicine divisions, Bellevue Hospital also had a Medicine-Psychiatry division in the Psychiatric Hospital, now home to a men’s shelter.
At the end of June 1968, it was announced that a new Bellevue Hospital building would be constructed with a capacity of less than 1,000 beds, replacing the old 2,000-bed building [3]. Concerned about insufficient patient numbers in the new facility, Columbia and Cornell immediately withdrew their services from Bellevue [3]. Suddenly, NYU teams had twice as many patients for whom to care, prompting the creation of the Intermediate Medical Care Unit (IMCU), a non-teaching, non-house-staff ward with retired physicians taking care of less active patients with the help of nurse practitioners [3].
The Hospital
Each Medicine division had two patient wards: one male, one female [1]. These wards contained large, poorly lit rooms, with mice and insects scuttling between two to three rows of patient beds [1,4]. The entrance to each ward contained a separate examination room with an X-ray view box. It was here that doctors performed the initial admission history and physical exam [1]. The hallways connecting these rooms also housed patients at times, particularly during the winter months given the high proportion of homeless patients living on the Bowery [4]. The sickest patients were placed furthest away from the nursing station to be left alone [1], while curtains enveloped the beds of patients with pneumonia [4]. Measles patients, meanwhile, were admitted to the isolation ward, composed of twelve private rooms shared by the Medicine and Pediatrics departments [4].
The most critically ill patients were admitted to the Emergency Ward (EW) until 1962, when the Intensive Care Unit (ICU) opened [3]. The ICU housed between twelve to sixteen patients [4]. The only ventilators available in the ICU at that time were Bird respirators [2,4]. Interns and residents would set these respirators at a peak inspiratory pressure of 15, though what that number actually represented sometimes remained unclear [2]. Iron lungs, conversely, could be found on the Chest Service. Indeed, although active polio was rare after the vaccine was introduced in 1955, iron lungs were still used for residual polio and other diseases such as Guillain–Barré syndrome [3]. As everyone was allowed to smoke tobacco in the hospital, one could often find Chest Service patients indulging in a cigarette on their iron lung break [4].
The Emergency Room (ER) exclusively provided outpatient care, and thus experienced rapid patient turnover [3]. Patients were not permitted to stay in the ER for observation, and required admission to the hospital for any tests, even for an ECG [3]. Only interns rotated through the Emergency Room; there were no residents nor attendings; private physicians had to be called in when needed [3]. Accompanied by a driver and an aide, ER interns traveled in ambulances to help with out-of-hospital child deliveries and death assessments [2,3,4]. Consequently, interns sometimes found themselves pronouncing people dead in the middle of active, dangerous street fights [2].
Though not quite the international hub it is today, the Bellevue of the ‘60s still harbored a culturally diverse patient population [4]. Signs in the hospital appeared in four languages: English, Yiddish, Spanish, and Mandarin [1]. However, neither in-person nor phone interpreters existed to aid with patient communication. Doctors instead commissioned their patients’ English-speaking children, other patients, or staff to help with translation, inevitably leading to misunderstandings [2,4]. Indeed, on one occasion, Dr. Kahn enlisted an Italian patient to converse with an Albanian woman; surprisingly, after a lengthy inquiry into her abdominal distention, he discovered that the Albanian woman was, in fact, pregnant [2].
Calls and Admissions
For most of the ‘60s, Bellevue interns were on call every other night. An intern who started their shift on Monday at 8 am would clock out between 6 and 8 pm on Tuesday, only to return at 8 am on Wednesday to begin another 36-hour shift. After taking Friday off, a marathon weekend shift commenced, running from 8 am Saturday to 8 pm Monday. Thereafter, the intern would work Tuesday morning to Wednesday evening and Thursday morning until Saturday at noon, taking Sunday to rest before restarting the two-week cycle the following Monday [2,4]. Residents, meanwhile, were on call every third night [4]. Interns and residents were each provided rooms in the resident quarters with two beds, a window, a sink, and a closet [1,2,3]. They could usually siphon a few hours from their long shifts for sleep [1,2,3,4]. Of note, interns had no need to sign out to each other, as their shifts always overlapped for rounds and they covered each other’s patients.
New patients were admitted to Medicine divisions sequentially, regardless of the number of patients on each division’s wards [1]. However, new patients with previous admissions could get bounced back to their prior teams, assuming house officers could track down their old charts in the record room [1,4]. Due to limitations in space, wards were capped at 36 patients, in which case new admissions would be sent to another team [1]. Compared to today, the patient population of the ‘60s had far fewer acute problems, and length of hospital stay was much longer [4]. Patients with acute myocardial infarction required three weeks of hospital bed rest; those with endocarditis needed four weeks of IV antibiotics;those with hepatitis stayed up to two months until their liver function tests improved [1].
A Typical Day on the Wards
The days started with bed-to-bed work rounds during which the teams – one resident and two interns – visited with each patient [1,2,3]. Interns and medical students drew blood, pushed the chart rack, and carried a scale to record daily weights [4]. Interns were also expected to present new patients at attending rounds, which started at 11 am [3]. Attending rounds alternated between two teaching attendings: a full time clinician-researcher and a private practice physician [1,2,3]. Attendings were experienced “white hair” clinicians who expected rigorous presentations with a meticulous physical exam, along with all diagnostic test results to be ready for review [1]. In the afternoon, attendings returned to the University Hospital, leaving house staff to manage patients without supervision [1]. Additionally, chief of service rounds were held one evening each week, generally in the form of teaching and quality control rounds to ensure the accuracy of histories, physical exams, and diagnoses [2].
The responsibilities of the house staff were seemingly endless. Interns and residents each independently wrote thorough admission and daily progress notes by hand [2]. Moreover, house staff were responsible for performing intubations, ECGs, blood work, peripheral IV insertions, sigmoidoscopies, chest tube placements, lumbar punctures, and biopsies (rectal, liver, pleural, bone marrow) [1,2,3,4]. BiPAP and CPAP were not yet available, and thus a high proportion of patients had to be intubated [1,2,3]. Complicating matters further, the hospital was only equipped with a handful of ECG machines, and interns typically had to page overhead to locate one [4]. As for blood draws, house staff did not have the luxury of disposable butterfly needles and vacutainers; they instead relied upon pre-sterilized needles and syringes, often requiring a prolonged search for supplies and some added creativity [2,4]. Interns then carried the blood work to the lab themselves, jumping from roof to roof to change buildings because it was faster than going through the tunnels or out to the streets [4]. Lastly, interns ran the complete blood counts, urinanalyses, and ascitic and cerebrospinal fluid analyses themselves [1,2,3,4].
Their responsibilities did not end there. Interns were also tasked with rotating the bottles of patients undergoing peritoneal dialysis, lavaging patients who presented with an overdose, and wheeling patients to their tests [2]. They furthermore hung their patients’ IV fluids or medications themselves [4]. A nurse would then count the drops per minute to determine the infusion rate, as infusion machines were not yet available [4]. House staff even trained themselves to work the manual elevators, as elevator operators were only available during business hours [4]. When house staff managed to sneak a break, they could only be contacted by overhead speakers (pagers were still a thing of the future); these calls could not be heard from the bathrooms [1].
Diseases
The most prevalent diseases seen by house staff included cardiovascular (drug-related endocarditis complicated by valvular disease and heart failure, rheumatic fever), infectious (residual polio, pneumonia complicated by meningitis, miliary tuberculosis, diffuse gonococcal infection, schistosomiasis in Puerto Rican patients) and malignant diseases [1,2,3]. Duodenal ulcers and associated gastrointestinal bleeding were also commonplace, as H2 blockers did not yet exist [3]. Ulcers were managed with hourly milk or cream ingestion alternated with aluminum hydroxide [3]. Tuberculosis, meanwhile, afflicted doctors and patients alike. Indeed, Dr. Katz developed a positive PPD during the course of her residency, though her chest X-ray was clean; she subsequently received two years of isoniazid treatment [4]. Overall, approximately one member of the house staff per year developed the type of tuberculosis observed in highly immune individuals: pleural effusion without evidence of a pulmonary lesion [1]. If the staffer had to be admitted for treatment, they remained on the ward for one to two months. Curtains were placed around their beds for privacy [1].
Many patients also presented with complications related to alcohol and drug use [1,2,3]. In fact, the majority of patients admitted to the Psychiatric-Medicine division were alcoholics and/or drug abusers (mostly heroin) [4], though this division also housed patients with other serious medical conditions such as delirium, drug toxicity, congenital disease, carcinoid syndrome, and Creutzfeldt-Jakob disease [2,3]. Some injection drug users, particularly those who had blown their veins, had started to inject subcutaneously, leading to various infections [4]. In addition to caring for such patients, the Psychiatric-Medicine division also contained its own Prison Ward, mostly comprised of accused murderers who were being evaluated to see if they could stand criminal trial [3].
Disease diagnosis often presented quite the ordeal, especially when it came to Streptococcus pneumoniae infection. Patient sputum was injected into a mouse intraperitoneally; once the mouse died, its peritoneal exudate was withdrawn with a pipette, and the Quellung method was then used to test the serotype [3]. The workup of edema posed an even greater adventure, in part because the echocardiogram had not yet been invented [4]. First, central venous pressure (CVP) was measured with a water manometer, then repeated while pressing on the abdomen. Second, cardiac output was determined based on the arm-to-tongue circulation time, as calculated from the decholin test. High CVP and low cardiac output indicated likely congestive heart failure, while high CVP and high cardiac output suggested possible anemia, further necessitating a blood draw and peripheral smear examination [2]. Pulmonary edema was managed with supplemental oxygen, intramuscular injections of a mercurial diuretic, IV morphine, and sequential application of a tourniquet to each extremity to decrease venous return [3]. Second line treatment included digoxin and removal of a unit of blood [2].
Perhaps the most diagnostically challenging cases came during the “methanol” poisoning epidemic of 1963. Bellevue had a large contingent of homeless, alcoholic patients living on the Bowery. Since liquor stores were closed on Sundays, alcoholics would drink paint thinner diluted in water. However, the composition of paint thinner had recently been changed to include a greater concentration of methanol and an unidentified hepatotoxic compound; it was this latter compound that ultimately landed a number of alcoholics in the hospital. Indeed, Dr. Lowenstein took care of twenty-two such patients, and did so without the aid of blood gas analyses (not clinically available until 1967, when Dr. Frank C. Spencer began utilizing them to ensure safer surgeries [3]). To aid in the care of the “methanol” patients, Dr. Saul Farber gave the keys to his laboratory to Dr. Lowenstein so that he could access his blood gas analysis machine, pH meter, flame photometer, and osmometer. Remarkably, many of these patients had a serum pH under seven and a bicarbonate of less than two; there were no guidelines on how to manage such patients. At the time, Bellevue only possessed one hemodialysis machine – on the Urology service – and it was unavailable. Dr. Lowenstein thus instead concocted an isotonic peritoneal dialysis solution that would correct these patients’ acidosis without loading them with sodium: he removed 200 mL from 1 L bottles of distilled water, and then added back 200 mL of sodium bicarbonate [1]. Curiously, despite an extensive police investigation, the hepatotoxic compound was never isolated.
Rotations and Clinic
Interns and residents rotated in two-month blocks [3]. One such block, the homecare service, entailed house staff being driven to patients’ homes, toting a large bag filled with the necessary medical equipment and medications [4]. These homecare patients suffered from various maladies, such as chronic heart disease, strokes or other neurological problems, and severe rheumatoid arthritis contractures [4]. Senior residents rotated through electives, including the Chest Service, Neurology/Neurosurgery, and various consult services [3]. They also served at the University Hospital, initially located on 28th street and Second Avenue until 1964, when it moved to what is now Tisch hospital [1,3]. The Manhattan VA hospital, conversely, had its own house staff, and thus Bellevue residents did not rotate there [3].
Since each class had 26 interns, each intern was afforded two weeks of vacation per year, with only one intern on vacation at any given time [3]. “Jeopardy”, as we know it today, did not exist; instead, chief residents covered for sick residents or interns [1].
Culture
Although the Bellevue mission, culture, and some vestigial components remain from the ‘60s, the clinical and work environments have since changed substantially.
Bellevue Hospital never turned a patient away. When other hospitals closed their doors to new admissions because they were full, Bellevue accepted them [1,3]. Both outpatient and inpatient services were completely free of charge regardless of the patient’s legal status or income; medical costs were completely covered by taxes [3]. Even after the introduction of Medicaid in 1965 and the implementation of a charge structure, Bellevue has remained a welcoming place [3].
By the 1960s, Bellevue’s residency program was already well known for its hands-on clinical experience with acute, severe illnesses in medically complex patients, as well as for the resultant high quality of its house staff. Compared to the Columbia and Cornell divisions, the NYU divisions at Bellevue were less patriarchal and formal, and the house staff were generally more enthusiastic [1,2]. They touted the motto, “see one, do one, teach one [3].” The house staff were also given complete autonomy, and residents rotating on consult services – not the fellows or attendings – answered the consults [3]. With such a high level of responsibility, learning came quickly [2]. Though their autonomy has gradually constricted over the ensuing decades, Bellevue residents today, with backup from hospitalists, remain the primary decision makers for patients. Moreover, they still receive incredible support from faculty in their clinical and academic endeavors, as Dr. Lowenstein did from Dr. Farber more than fifty years ago.
The every-other-night call schedule pushed the interns’ bodies to their limits. The resulting physical exhaustion at times rendered them less capable of showing empathy for their patients. Moreover, their long shifts within the hospital left them disconnected from the outside world. Consequently, interns did not always function optimally from an emotional and cognitive standpoint [2]. As Dr. Kahn pointed out, people need to be exposed to just the right amount of responsibility and challenge; there exists a fine balance [2]. He further recalled one instance of house staff suicide [2]. Although senior psychiatrist Dr. Marvin Stern was available for medical students and house staff, there was not nearly the psychosocial support available as there is today [2]. In 1978, The Humanistic Aspects of Medical Education program was introduced to allow students and house staff to share their experiences of becoming a physician. The program is still active today.
The house staff did not necessarily always show each other the utmost support. They compared each other’s clinical skills, and were judgmental of colleagues whom they thought were not working as much as they should [2]. The paucity of women in the program sometimes created an atmosphere more suited to a men’s gymnasium [2], though Dr. Katz noted that she was given the same respect and consideration as men by her peers and attendings during residency [4]. Nevertheless, the cohesion of the house staff remained strong, thanks in no small part to the rivalry against the Columbia and Cornell divisions. The dining room also served as a source of camaraderie. Meals were provided four times per day: at breakfast, lunch, dinner, and midnight [4]. Families of house staff were allowed to join the feast on weekends [4]. By 1968, the intern call schedule had lightened to every third night, signaling a shift toward reduced working hours and, consequently, a friendlier atmosphere [2].
New technology has changed the clinical and work environments over the past few decades. The romantic hospital of the ‘60s – with sprawling wards where interns jumped from roof to roof to transport patient labs – has been replaced by our dear H building, where interns can record their rather heavy “honest weights” outside the attending rooms while admiring the flamboyantly-colored artwork adorning the walls (my favorite piece hangs over the sink in the 16SW observation room). The house staff of the ‘60s performed virtually every task themselves, including blood draws and lab analyses [1,2], and nurses were far more limited in their responsibilities [4]. There was only one nurse per ward at night, including in the ICU [4]. Furthermore, since the rest of the healthcare staff was unionized, doctors were effectively stuck at the bottom of the totem pole, and ultimately responsible for getting anything done [4].
These difficult circumstances notwithstanding, the house staff of the ‘60s benefited from a remarkable continuity of care, in-depth learning, and more hands-on experience. The combination of long work hours with much longer patient lengths of stay also gave the house staff a better sense of the natural history of disease [1]. One’s stature as a house officer depended both upon physical exam skills and accomplishing a thorough workup before attending rounds [2]; interns would thus spend their nights ensuring they had all of the necessary diagnostic tests ready for the next morning [2]. During attending rounds, the focus was on a meticulous physical exam and rigorous clinical thinking; indeed, as CTs and MRIs were not yet available and X-rays were often of poor quality, the physical exam was crucial. Decisions to send patients to surgery were often made solely based on the physical exam [2]. This reliance on the physical exam has slowly evaporated over the years with the advent of new imaging technologies.
Conclusion
As Dr. Kahn nicely concludes, the powerful diagnostic and therapeutic tools and the electronic medical record system that have developed over the past fifty years have changed the nature of the work of the house staff and their responsibilities [2]. “Improved coordination of the health care team in their day-to-day work” and electronic medical records have helped to preserve continuity of care despite the shorter work hours [2]. Some aspects of the program have been lost along the way: strenuous call schedules, long hospital stays with acquaintance to natural history of diseases, and the hands-on clinical experiences of the house staff who had to develop a diagnosis from a thorough history, physical exam, and tests they performed themselves. The clinical experiences of the ‘60s house staff were more experimental, which strengthened their ingenuity and understanding of pathophysiology. However, the core culture of Bellevue has not changed. The same passion for saving lives, taking care of all comers, and critical learning of medicine still pervades. Complete autonomy has been replaced by “measured autonomy.” And, if anything, patient care has become more empathic [2].
Let us now see how the Bellevue house staff experience has progressively evolved decade by decade from the romanticism of the ‘60s. In the coming articles, we will discuss the progressive evolution into today’s fast-paced, sign-out-heavy, computer-oriented practice of medicine.
Acknowledgements
I would like to thank Dr. Jerry Lowenstein, Dr. Martin Kahn, Dr. Anthony Grieco, and Dr. Lois Katz for their precious time, insight, and teaching. I would also like to thank Dr. David Oshinsky for his invaluable support, feedback, and advice.
Dr. Olivia Begasse de Dhaem is a former NYU internal medicine resident and now third year resident in neurology at Columbia Presbyterian.
Image courtesy of Wikimedia Commons
References
[1] Jerome Lowenstein, personal interview, 9 Nov. 2015.
[2] Martin Kahn, personal interview, 9 Nov. 2015
[3] Anthony Grieco, personal interview, 9 Nov. 2015
[4] Lois Katz, personal interview, 13 Nov. 2015.
