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 1980’s!
Part 3: the ‘80s
Residency in a NYC Public Hospital at the Heart of the HIV Epidemic
Interviews with Dr. Nate Link and Dr. Ann Marie Schmidt
Dr. Nate Link and Dr. Ann Marie Schmidt both graduated from medical school in 1983 and were in the same residency class [1, 2]. Notably, Drs. Link and Schmidt started their residencies one year before the death of Libby Zion, and completed their residency before investigations into the Zion case and the consequent work hour restriction controversy had gained steam. Dr. Link attended medical school at Washington University in Saint Louis and afterward moved to New York with his wife to begin his residency. Since his residency graduation in 1986, Dr. Link has practiced at Bellevue Hospital with ever increasing levels of responsibility, save for 1990 when he spent a year in Kenya working on a public health project. Starting residency a year before the creation of the Primary Care residency track did not preclude him from practicing in the Primary Care setting.
Dr. Schmidt had gone to medical school at NYU, so she was already familiar with the vast clinical exposures of the Internal Medicine program at Bellevue. After completing her fellowship in Hematology and Medical Oncology at Bellevue, Dr. Schmidt embarked on her research career at Columbia University before coming back to NYU in 2010. Attending a residency program fully dedicated to patient care did not hinder Dr. Schmidt from pursuing a flourishing research career.
The Hospital
The H building has changed surprisingly little since opening in 1975. The main difference, completed much later in 2005, was replacing the clinic on 2 West with the vast and gorgeous ambulatory care building that now constitutes Bellevue’s front entrance. As in the prior two decades, the Emergency Room remained divided into two parts: the Adult Emergency Service (AES) and the Emergency Ward (EW) [2]. However, unlike in the ‘60s when only Internal Medicine interns staffed the emergency room, the ‘80s ushered in an era of full time Emergency Medicine doctors – overseen by Dr. Lewis Goldfrank – and relegated Internal Medicine house staff to brief rotations through the AES [2].
In accordance with one of the fundamental principles of Bellevue, the hospital doors were open to everyone, so much so that there were no security guards patrolling the entrance [2]. Indeed, it was unclear at any moment how many extraneous people were walking around [3]. Thankfully, the Medicine house staff worked in highly trafficked areas, and their call rooms were locked and required a code for access [2]. Tragically, on a weekend in 1989, a pregnant pathologist specializing in thyroid cytology was beaten, raped, and killed by a homeless man on the 4th floor of the H building in a secluded area of the pathology department. The perpetrator had been living in an equipment room on the 22nd floor, and was able to elope after this brutal incident [3, 4]. An investigation followed to ensure no one else was living in the hospital rafters [2]. From then on, the H building staircases have been locked from the floor side [3].
Teams, Call Schedule, and Admissions
The ‘80s introduced a shakeup in the composition and schedule of Bellevue medicine teams. There were now seven medicine teams, each comprised of one resident and three interns. Each team was “internally autonomous,” uninterruptedly taking care of its patients without ever needing coverage by other teams; there were no sign-outs or night float [1]. This system provided for remarkable continuity in patient care, but also necessitated extremely long working hours. House staff were on long call for 36 hours (admitting for the first 24), off for 12 hours, then on short call for 12 hours, then off for 12 hours, then on long call again [1]. In total, this schedule summed to 120 hours of work per week, though house staff often stayed even longer to complete their patients’ workups [2]. The two interns whose call schedules did not synchronize with their team’s resident were dubbed “orphan interns”; they would work with a resident from another team [1]. Interns only took care of the patients they admitted and only covered patients from their own team. Furthermore, the CCU and MICU were “open”: patients on these units remained in the care of the medicine teams; there were no separate CCU or MICU teams [1].
New admissions were distributed amongst the seven admitting interns according to a “wheel.” Teams were not “capped”; new admissions were assigned to one team after the other sequentially, regardless of the number of patients carried by the team at the time. This system created incentive for house staff to be efficient with patient care and discharges, to “push the wheel.” Meanwhile, residents handwrote H&Ps for newly admitted patients. On average, each team carried twenty to twenty-five patients, including about five ICU patients. Teams would admit approximately two to three patients per 24-hour period [1].
A Typical Day
As in the ‘60s and ‘70s, attending rounds took place daily from 10am to noon, during which the intern would present new admissions to the attending physician at the bedside. This encounter marked the only time during their admission that the patient would be seen by the attending. After rounds, the attending would return to the University Hospital (now Tisch Hospital), leaving the house staff entirely in charge. Additionally, the chief residents were assigned two PGY-2 residents with whom they would run the list daily and physically round on the CCU and MICU patients [1].
Morning and noon conferences generally garnered poor attendance, as interns and residents were equally busy and exhausted. Indeed, as in prior decades, interns continued to perform a great many tasks in patient care, including transport of patients to tests and gathering information for their patients’ workups [1]. Phlebotomists performed blood draws once daily in the morning on weekdays only, though interns were still required to “set up [their] blood” first by gathering and labeling the tubes, writing the requisition, and packaging it all together for phlebotomy to pick up at the nursing station [1]. Interns furthermore journeyed to the labs themselves to retrieve the rectangular paper slips that marked the lab results, and afterwards transcribed these results into the grids at the back of their patients’ charts [1, 2]. The interns frequently went to Radiology to go over their patients’ X-rays and CT scans with the radiologist [2].
At night, interns admitted new patients with their residents, saw and wrote night notes on all their CCU, MICU, and EW patients, and took care of all the floor patients on their team, which gave them precious little time to sleep [1]. Remarkably, interns placed all peripheral IVs – often running out of 20-gauge catheters – and also inserted a plethora of central lines thanks to the large number of patients with IV drug use-related endocarditis [1]. The house staff were moreover responsible for running the codes on their own patients, during which both anesthesia and the nurses in charge of the codes were paged STAT [2]. Ultimately, the interns heavily relied on the expertise of senior residents. In keeping with the culture of decades past, the house staff was overall incredibly supportive of one another [1].
Diseases and Patient Population
While the house staff of the ‘80s continued to be privy to a matchless diversity and abundance of clinical exposures, including an ongoing diabetes epidemic [2], this decade would be highlighted by a rather frightening and formidable new infectious disease. During his residency in the ‘70s, Dr. Jeffrey Greene took care of four patients in rapid succession one evening who presented with Pneumocystis pneumonia (PCP). The first case was referred by a gay private physician in the Village who did not recognize this disease entity and instead entrusted Bellevue with the workup and management of the patient. All four patients ultimately had to be intubated for respiratory failure, and were so severely sick that the attending came back from home overnight [5].
After that evening, Dr. Greene took care of increasingly more patients with PCP. Some of these patients also harbored Chlamydia infections. One patient presented with a large purple lesion on his nose, initially thought to be a melanoma before a biopsy confirmed the diagnosis of Kaposi sarcoma. The Chest Service quickly filled up with patients with diffuse PCP. Open lung biopsies of these sick PCP patients frequently also showed CMV, Cryptococcus, and Kaposi sarcoma all in the same specimen. Doctors became suspicious that they were witnessing the beginning of something big [5].
Not much was known at the time about PCP. Many afflicted patients were homosexuals, or were heterosexuals who also had sex with men in exchange for money to pay for their heroin. These patients were later found to be devoid of a T lymphocyte response on cutaneous allergy testing; however, it was unclear whether immunosuppression caused the disease or the disease caused immunosuppression. Dr. Greene went to the Pathology department to search the accession book for the diagnoses over the prior five years, but he could not find any prior case of PCP. He called the Center for Disease Control (CDC) to inquire about the worrisome spike in PCP cases in New York City. To his dismay, the CDC case worker refused to come to New York to assess the situation; her argument: an epidemic was impossible because PCP could not spread from person to person [5]. The idea of a new pathogen would only come much later.
Soon thereafter, during his Infectious Diseases fellowship in 1981, Dr. Greene was asked to present about this new disease at the Inter-Science Conference on Antimicrobial Agents and Chemotherapy. When he saw at the beginning of his talk that the conference room was overflowing with curious and befuddled physicians and scientist alike, he quickly realized that this phenomenon extended far beyond the walls of Bellevue Hospital [5].
The newly discovered Gay-Related Immune Deficiency (GRID) was soon renamed Acquired Immune Deficiency Syndrome (AIDS) when two additional risk factors (other than homosexuality) were described: intravenous drug use and Haitian descent [1]. During Dr. Link’s residency from 1983 to 1986, about half of his patients suffered from AIDS. The etiology and transmission of the disease were unknown, so people feared the disease. Patients with AIDS were not allowed outside of their rooms, and only their doctors would enter their rooms. Even their food trays were left on the floor outside of their rooms for the patients to pick up.
The uncertainty about the disease created a “big cloud [over the house staff’s] future.” They were not sure whether they had contracted the disease or how long they would live [1]. At the time, Dr. Link surveyed 130 Internal Medicine house officers in seven New York hospitals on their attitudes toward the disease, and found that 36% reported needle sticks with blood from patients with AIDS, while 48% professed moderate to major concern of acquiring AIDS from their patients [6]. Indeed, Dr. Link did not start his fellowship applications until he was able to be tested for HIV after his residency, as he was not sure whether he had contracted the disease, nor whether he would still be alive by the time his fellowship started [1]. Perhaps most remarkably, 40% of house staff reported that the fear of acquiring AIDS substantially increased the stress of their residency experience, and 25% asserted that, if given the choice, they would not provide care for their AIDS patients [6]. Nevertheless, despite the risks and uncertainties, the Bellevue house staff remained committed to their patients [1].
Patient Population
The Bellevue patient population has always been incredibly diverse. In the ‘80s, phone interpreters became available for most languages during regular business hours. Furthermore, a medical Spanish class was offered to house staff and medical students who already had some prior competency in Spanish. Nevertheless, the house staff continued to rely heavily upon colleagues and family members to aid with translation [2].
Culture
Strikingly, Bellevue Hospital ran solely by the grace of its house staff, who were in turn shepherded by the chief residents [1, 2]. There were no hospitalists. Interns and residents were responsible for the full spectrum of patient care – from transport and blood draws to running codes – and took care of patients both on the floors and in the ICUs. The highest-level doctor who saw floor patients regularly were the PGY-2s. Residency at Bellevue Hospital provided a strong hands-on clinical training with a primary focus on patient care, not academia [1, 2]. The phrases “trial by fire” and “you are it” became mantras that captured the Bellevue house staff experience [1]. Indeed, house staff could only rely on each other when taking care of patients [1, 2], as there was no attending feedback or independent sets of eyes to watch over them [1]. Interns and residents had a complete sense of ownership and responsibility toward their patients and quickly developed a decisive, comfortable, and confident approach to sick patients [1]. Residents furthermore formed a “close-knit community” and were overall quite happy despite the workload [1, 2].
The Bellevue Internal Medicine residency program of the ‘80s attracted a particularly special type of doctor, one who celebrated diversity and equality in patient care. Bellevue at the time housed a disproportionally large number of AIDS patients and, given the fear invoked by this disease, only the most dedicated individuals applied to the program [1]. Additionally, Dr. Schmidt recalls the program to be extremely fair in terms of gender equality; house officers were recognized solely based on merit [2]. Accordingly, although men comprised three-fourths of the Internal Medicine residency class of 1986, three out of the five chiefs from that class were women, including the senior chief [1].
Conclusion
The mission of Bellevue and the commitment and hands-on clinical experiences of its residents shone through again in the ‘80s. The new H building that opened in the mid-‘70s, with its Chest Service, isolation rooms, and clinically available ABGs, was immediately put to good use with the arrival of the AIDS epidemic in the late ‘70s and early ‘80s. During a time of long work hours, when house staff were the pillars of patient care, performing the entirety of patient workups themselves, these dedicated Bellevue residents persevered in caring for a great many extremely ill patients suffering from a disease about which little was known. To further accommodate this epidemic, a Virology service opened in the ‘90s. Hour restriction regulations also started in the ‘90s, beginning with the creation of a night float system. The Chest Service would continue to hold importance in the ‘90s given the resurgence of tuberculosis secondary to the AIDS epidemic and the new public health requirement to ensure patients completed their treatment: the DOT (Directly-Observed Therapy). More to come on the ‘90s in the next episode.
Acknowledgements
I would like to thank Dr. Nate Link and Dr. Ann Marie Schmidt for their precious time, insight, and teaching. Dr. Link was my first interviewee. He helped me structure my next interviews and this project. I would also like to thank Dr. David Oshinsky for his invaluable support, feedback, and advice.
References
[1] Link, Nate. Personal interview. 4 Nov 2015.
[2] Schmidt, Ann Marie. Personal interview. 13 Nov 2015.
[3] Greene, Loren. Personal interview. 10 Nov 2015.
[4] Barbanel J. “Suspect in slaying was treated at Bellevue.” New York Times. 12 Jan 1989. http://www.nytimes.com/1989/01/12/nyregion/suspect-in-slaying-was-treated-at-bellevue.html.
[5] Greene, Jeffrey. Personal interview. 14 Nov 2015.
[6] Link RN, Feingold AR, Charap MH et al. Concerns of medical and pediatric house officers about acquiring AIDS from their patients. Am J Pub