In honor of the 10th Anniversary of Clinical Correlations 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 the 1990’s!
Part 4: the ‘90s
Residency at a Pivotal Time for the HIV Epidemic and Residency Hour Restriction
Interviews with Dr. Doug Bails and Dr. Neil Shapiro
Dr. Doug Bails warmly received me in the Chief of Medicine office at Bellevue for the last tale of this series on the history of the Bellevue house staff. His office carried the odor of fresh paint, a process several months in the making (Dr. Bails asserted that no one is immune to the plodding Bellevue pace, not even the Chief of Medicine). I could not help but be slightly distracted by the baseball corner in his office. He recalls being interviewed by Dr. Saul Farber in that very same office in 1989, the year he applied to the Internal Medicine residency program .
After graduating from the NYU School of Medicine in 1991, Dr. Neil Shapiro decided to stay at Bellevue for his Internal Medicine residency, his Chief Residency year, and then his Pulmonary Critical Care fellowship .
The hospital itself has not changed much since the mid-‘70s, but the work hours certainly improved in the ‘90s. In 1989, a night float system was implemented as per the Bell Commission recommendations in the aftermath of the Libby Zion case. House staff rotated through the night float service four weeks per year, and on these nights the residents were completely in charge. Indeed, though the hospitalist system at Bellevue started in 1999, it was not until 2009 that there were attendings in-house overnight . The house staff of the ‘90s operated on a four-day call schedule – long call, post-call, pre-call, and short call. Each team admitted patients every other day, both in the mornings when on short call and in the afternoons when on long call. The average patient length of stay lasted nine to ten days, a much faster turnover rate than in the ‘60s but still much slower than today . Residents carried approximately twenty-four to thirty patients at a time while interns took care of anywhere between eight to fourteen patients each. Additionally, the Medicine floor teams took care of patients in the CCU, though patients in the newly opened MICU were cared for by a separate team .
A Typical Day
After early morning work rounds with the resident and two interns, the house staff attended morning report every day at 9 am, during which a case was presented to a specialist (there were no young hospitalists around yet). Then at 10 am, two gray-haired attending specialists alternated teaching rounds on all the new patients at the bedside [1, 2]. These teaching rounds were sacred; interns were not interrupted by pages . As always, the full patient workup had to be complete, and the interns had to be prepared to thoroughly explain their differential diagnoses and thought process [1, 2]. Additionally, the intern’s white H&P sheet and the resident’s pink admission H&P sheet had to be in the patient’s chart. These write-ups were long and detailed, and had to reflect how much the intern and resident knew. Fortunately, several medical textbooks were available at night in the call room and in the chiefs’ office. Attendings discussed their initial thoughts on the new patients during rounds, wrote a brief note on the pink sheet, and never saw the patients again .
Attending rounds generated significant anxiety among house staff. Patients’ X-rays were often repeated early in the morning if their initial X-rays could not be found . Furthermore, although night float started at 10 pm, admitting residents usually stayed until 2 or 3 am on call days to complete their new patients’ workups, as it was bad form to sign out any potential work to night float . It was not at all unusual for residents to stay all night long to complete these workups [1, 2].
The limited resources at Bellevue often delayed workups. Dr. Bails recalls that there was only one CT scan, for which trauma cases were prioritized. Any patient with AIDS who developed a headache required a double contrast head CT to assess for toxoplasmosis and, if there was no sign of mass effect, a lumbar puncture. House staff hid contrast in their lockers to make sure they had it when needed. To get a CT scan done the same day, the interns had to hang the contrast themselves in a glass bottle and wheel their patients to Radiology. Once there, they needed to call Radiology to convince the radiologist that their patient needed a CT scan, that the patient was ready by their door, and that the second bottle of contrast was running . MRIs, meanwhile, would not become available until the late ‘90s .
Interns also placed their own peripheral IVs (the IV team was created in 1994) and central lines. It was so difficult to find 20 gauge IVs at Bellevue that house staff stocked the ones available at the University Hospital (now Tisch Hospital) in their white coat pockets [1, 2]. There were no PICC lines yet, and central lines had to be changed regularly . As is mostly the case nowadays, residents performed their own thoracenteses, lumbar punctures, and paracenteses . Senior residents additionally taught lab techniques such as gram staining or spinning the ketones of patients with diabetic ketoacidosis to their interns . By the end of an admitting day, interns’ hands would often turn purple from all the gram staining [1, 2]. They also had to perform cell counts and look for yeast with India ink, a tricky process given how difficult it was to differentiate between yeast and air bubbles [1, 2]. To add to the chaos, nobody ever cleaned the lab, and there was a rumor that the India ink was contaminated with Cryptococci .
Starting in 1990, lab results were available on computers. There were six computers per Medicine floor, and they could only be used to view lab results. House staff still had to go to the fourth floor to obtain the results of cultures and acid fast bacilli tests . They also spent a lot of time down at Radiology looking at films and discussing cases with the radiologists . However, for the most part, house staff had no time to stop and learn; they were always busy trying to complete the workup so they could eventually go home .
Diseases and Patient Population
New York City, and Bellevue in particular, was an epicenter of the HIV epidemic. More than 30% of Bellevue patients in the early ‘90s suffered from HIV [1, 2]. The virus was so prevalent that seemingly every patient’s differential diagnosis included HIV . Out of precaution, gloves were available in every room , though accidents inevitably occurred. When Dr. Bails had a needle stick during his intern year of 1990, he did not tell anyone about it, since at the time there was no treatment available. This event lingered in the back of his mind for five years until the disease was better controlled and he got tested . Nevertheless, house staff had little fear when taking care of HIV patients, as they were fully aware of Bellevue’s patient population and were ready to do what needed to be done. There was, however, a great deal of stigma, cynicism, and derogatory comments made toward these patients, accompanied by the notion that HIV patients were responsible for their own illness .
In August 1990, four weeks into his intern year, Dr. Bails commenced his first rotation on the brand new Virology service on 17 West. This service had opened one month prior to accommodate the burgeoning HIV patient load. Most patients on the Virology service at Bellevue suffered from Pneumocystis pneumonia (PCP), cryptococcal meningitis, and toxoplasmosis; by contrast, the Virology service patients at the University Hospital were mostly white homosexuals with Kaposi sarcoma . Taking care of patients on the Bellevue Virology service in 1990 posed an incredible challenge; HIV inevitably meant AIDS. No matter how intense the care these patients received, their serum bicarbonate inevitably plummeted, their condition worsened, and they ultimately died. Accordingly, the Virology service also incorporated a slower-paced annex on 12 South that functioned like an inpatient hospice for dying AIDS patients . Remarkably, over the course of Dr. Bails’ residency, this service evolved dramatically from one with acutely ill patients who were dying within a few months to one of chronically ill patients, thanks primarily to the arrival of the first antiretroviral medication for HIV: azidothymidine (AZT) [1, 2]. The Virology service eventually closed in 2012, as the disease was much better controlled by antiretroviral therapy, and far fewer HIV patients required hospitalization .
Tuberculosis (TB) became rampant again in the framework of the AIDS epidemic . At the time, Dupont isolators were used to test blood for tuberculosis. Those who tested positive were subjected to the new Directly-Observed Treatment (DOT) regulation. As a result of DOT, as well as the generally poor efficacy of treatment, TB patients were held in the hospital for isolation. They were given rifampin while their sputum cultures were sent to the Jewish Hospital in Denver for analysis. The Chest service housed numerous TB patients who were either awaiting their culture results or were suffering from a multidrug (MDR)-resistant strain. These MDR infections often granted patients extremely long hospital stays, sometimes for years .
On the whole, Bellevue inpatients in the ‘90s usually presented with acute illnesses rather than with chronic illnesses such as hypertension or diabetes, though many diabetic patients still had to be admitted for disease management . Bellevue accommodated a disproportionally high number of “shooters with fevers” who were admitted to rule out endocarditis , as well as those who presented with the triad of alcohol withdrawal, chest pain, and HIV with fever . Additionally, along with the plethora of TB patients, the Chest service harbored many patients with COPD. Indeed, there were far more COPD exacerbation admissions than there are today .
Once lab results became available by computer, patient follow-ups were much easier .
The perks of being a chief in the early ‘90s? Going to lunch with Dr. Farber every Saturday after walk rounds in the ICUs of both the University and Bellevue Hospitals. Dr. Farber shared stories from his residency and his time in the military. The chiefs played such a critical clinical role at Bellevue that Dr. Shapiro considered his chief year to be the most formative year of his career .
Residents in the ‘90s benefited from a strong sense of autonomy and ownership. Other than the attendings’ initial thoughts and brief notes on new patients during rounds, the residents were fully responsible for developing and enacting the plan of care [1, 2]. To be sure, backup was available. The chiefs functioned similarly to today’s hospitalists. They supervised the residents and together flipped the index cards about each patient every day; they assessed patients at the bedside if there were any questions or concerns; they formed a makeshift rapid response team before its official creation. Moreover, just as most of the intern teaching came from the residents, so too the bulk of resident teaching came from the chiefs .
In light of the AIDS epidemic and its reputation as a program “heavy in scut work,” the Internal Medicine residency program at Bellevue attracted a specific kind of doctor, one who was dedicated to others while not scared of getting their hands dirty. Most of the residents at the time were New Yorkers and NYU School of Medicine alumni. House staff generally cared more about whether patients were nice than about their specific disease presentation .
Bellevue sometimes felt like a battle-zone. As resources were limited, house staff had to get creative, and often hid or stocked up on commonly used items. Quality control was also virtually nonexistent. Sedatives and physical restraints were more commonly used, especially for patients who presented high on drugs. Dr. Shapiro remembers performing a lumbar puncture on a patient high on phencyclidine with a fever of 104 F who was so agitated that four staff members had to hold him down during the procedure .
As ancillary services were frequently unreliable, residents often felt that they were advocating and fighting for patient care against the hospital system. Phlebotomists rounded twice – once in the morning and once in the afternoon – but did not go to the prison ward on 19 South. Residents performed most if not all of their patients’ workups themselves which, while time-consuming, also assured that every test was completed in a timely manner. Conversely, many residents today hesitate to perform a test or transport a patient to imaging in the hope that it will be taken care of by ancillary staff, which often leads to delays in patient management. Overall, this feeling of workup accomplishment despite a seemingly immutable system strengthened the camaraderie among house staff .
The mission of Bellevue and the dedication of its doctors has not changed over the years. It remains a hospital principally run by house staff. It still opens its doors to all comers and offers free medication to those in need. It is always ready to face new and sometimes daunting challenges, as evidenced by 9/11, Hurricane Sandy, and the AIDS and Ebola epidemics [3, 4].
In accordance with the recommendations of the Residency Review Commission (RRC), Bellevue implemented a hospitalist system in August 1999 [1, 2]. At that time, this system had the sole aim of increased resident supervision; the emphasis on patient safety and quality improvement, and the presence of hospitalists on committees, only emerged later in the 2000s . In the beginning, Bellevue hired four hospitalists, each overseeing the management of forty patients. As a consequence, residents and chiefs lost some of their autonomy and direct teaching from specialists, while interns were not as included in patient management discussions . This system did, however, substantially decrease the stress of attending rounds; it also created a friendlier work atmosphere, promoted patient safety, and added consistency to patient management .
Prior to the arrival of hospitalists, there was close to no supervision on patient workup and management . As a result, PGY-2s and 3s often felt overly confident in their abilities or knowledge . With the hospitalist system in place, the house staff now benefits from what Dr. Bails calls “measured autonomy,” with supervision by attendings who refrain from micro-management and simply guide the thought process. In 2009, Bellevue also introduced an overnight hospitalist. Additionally, in 2016, to improve the quality of house staff teaching in an era of young hospitalists, a system of “open consults” was created, during which the primary team rounds with a specialized attending on patients with diseases related to their respective specialty .
New initiatives and technologies have altered the complexion of Bellevue over the decades, and have on the whole eased the house staff workload. The work schedules improved from the insane hours of the early ‘60s to the every third day call in 1968, followed by the creation of a night float system and a four-day call schedule in 1989. Lab results became available on computers in 1990, and patient notes started being entered into the electronic medical record in 2006. The computer system helped tremendously with continuity of care, as less patient information was lost. Nevertheless, despite these changes, some things about Bellevue have not changed: the Emergency Department and H building, the bright colors adorning the hallways, and the antiquated phones. Indeed, the Bellevue phones likely date back to the opening of the H building in 1975, and still require a measure of dexterity with the phone cords for adequate communication. Having experienced seven hospitals in New York, this writer for one finds it quite magical to work in a place so full of history, and with unquestionably the best ABG syringes and phone interpreters around.
What struck me the most in this project was the consistency between my interviewees’ stories for each decade. I expected vastly different versions of the same events – à la Raymond Queneau’s Exercise in Style – that I would need to miraculously piece together. Instead, their uniformity nicely illustrates the spirit of camaraderie between residents; they lived the same experiences together.
Hearing these stories from the house staff of the ‘60s through the ‘90s illuminated the current Bellevue Internal Medicine residency program. These stories make us feel that we belong to something far bigger than ourselves, and implore us to appreciate and honor the unimaginable work that has been done before us. They help us to understand the origins and evolution of various aspects of the residency at Bellevue, and imbue us with perspective. I feel strangely better about the struggle to reach radiology by phone after 4 pm, to convince them to protocol a CT scan, and to wheel the patient myself alongside a dedicated medical student to imaging, because this still represents significant progress even since the ‘90s.
As Dr. Bails expresses much better than I do, Bellevue has a mission and a spirit. It plays an indispensable public service role in a major city, and it stands tall in the face of epidemics and natural catastrophes alike. The Internal Medicine residency program has continued to evolve for the better, all the while preserving its most fundamental aspects such as dedication to patient care, measured autonomy, and excellent clinical training. Increased supervision and patient safety came with the years, but the house staff continues to be supported in their creativity and ideas. The medical staff truly cares about the patients and are supportive of each other. No patient is turned away. Everyone is ready to roll their sleeves up. It is not uncommon to see house staff or sometimes even attendings provide a bedpan to a patient. My senior resident gave $20 for cab fare to a patient who did not meet the criteria for social work help, but was too weak to take the subway home upon discharge. Bellevue self-selects for special doctors, those who, as Dr. Bails shared at the end of our interview, “don’t curse the darkness, but light the candle .”
I would like to thank Dr. Doug Bails and Dr. Neil Shapiro for their precious time, insight, and teaching. I would also like to thank Dr. David Oshinsky for his invaluable support, feedback, and advice.
 Bails, Doug. Personal interview. 13 Nov 2015.
 Shapiro, Neil. Personal interview. 16 Nov 2015.
 Ofri D. “The storm and the aftermath.” N Engl J Med. 2012; 367(24):2265-7.
 West MG, Dawsey J. “Inside Bellevue’s Ebola Treatment Ward.” Wall Street Journal. 2014 Nov 11. NY region.