We’re posting transcripts of Working, Slate’s podcast about what people do all day, exclusively for Slate Plus members. What follows is the transcript for Episode 1, in which Slate culture writer Aisha Harris talks to Alexandra Charrow, a medical resident at Boston’s Brigham and Women’s Hospital. In this podcast, Charrow describes a typical day in her life, how she’s learning to grapple with death, and how her job is far from Grey’s Anatomy. To learn more about Working, click here.
We’re a little delayed in posting this episode’s transcript—apologies. This is a lightly edited transcript and may differ slightly from the edited podcast.
Aisha Harris: Welcome to Working, Slate’s podcast about what people do all day. I’m Aisha Harris. I cover culture at Slate and I’ll be your host for this third season of the show.
If you missed the first two seasons of the show, hosted by David Plotz and Adam Davidson, respectively, you should definitely check them out. This season some of our guests will be inspired by the ideas you’ve sent us. In fact, this first episode came from one of those listener recommendations. Like you, I was curious about a job that we often see performed by very, very good-looking actors in medical dramas on TV. So, what’s your name and what do you do?
Alexandra Charrow: My name is Alex Charrow, and I am a resident.
Harris: I don’t know much about what that world is like. Mostly my experience is based off of Grey’s Anatomy. I’ve been watching it for 10 years. So, I guess what I’d like to know is, what does being a medical resident really mean? Like, are you a doctor? Where are you in your education?
Charrow: Explaining residency to people is sort of like explaining Game of Thrones to somebody who’s never watched it. Like, you have do a huge amount of world-building just to be able to give anybody any kind of semblance of a plot. I don’t even watch Game of Thrones, but that’s the sense I get from looking over my husband’s shoulder when he’s watching it.
I should back up and say, I am a physician. I graduated from medical school, and when you graduate from medical school, you sign on to be part of an apprenticeship, a paid apprenticeship, and that apprenticeship lasts between three and seven years depending on what your subspecialty is that you go into. I am a second-year resident. I’m doing a somewhat atypical training process in that I am getting board-certified in two things at the same time. I’m getting board-certified in internal medicine—that’s, generally speaking, a three-year residency—and I’m also getting board-certified in dermatology, which is a four-year residency. I will do the two of them together in five years.
I’ve completed my intern year, which is the first year of anybody’s residency, and I did that in internal medicine. Now I’m continuing on through the rest of my residency.
Harris: So, where do you work?
Charrow: I work at the Brigham and Women’s Hospital in Boston.
Harris: What is the environment like, and what makes that hospital different or special compared with other hospitals?
Charrow: It is an academic medical institution, which means that it is filled with trainees. So, there are interns, there are residents, and there are fellows everywhere, many, many young people, and then there are attendings who often have gone through many, many years of training and subspecialty training. What it really is is a tertiary care hospital for people with either rare or very critical conditions.
Harris: You’re in a call room right now. What is it like in there, and what goes on in there?
Charrow: A lot has changed about residency. People don’t for the most part spend more than 30 hours in the hospital at one time except on very specific rotations. So, the call rooms are used for those rotations. People will spend a few hours sleeping in them. On my night rotations that I had over the past year as an intern, if I was lucky—especially on services where there is two interns on at night covering a hundred patients—if there was a respite between 2 and 4 a.m., then maybe I would sleep for a couple of hours. That happened once or twice.
I’ll sometimes use the call rooms to call back patients in. I think people who are on for longer hours at a time—which I’ll be looking forward to next year—will spend at least a few hours in the call room. But they’re pretty sad. It’s really sad to wake up in one of these places. You have no idea what time it is. You feel like you’re in a casino, and you leave here, and you almost feel like you never—even if you’ve slept for like, six hours, you feel like you never left the hospital, which you really didn’t. You feel like you really never went to bed.
Harris: How many hours a week are you working at this point in your residency?
Charrow: Right now there is a pretty stark contrast between the outpatient dermatology side of things and the inpatient internal medicine side of things, but it also depends on what service you’re on within each of them, respectively. So, if I was on a consult dermatology service, I might expect to work 60 to 80 hours a week, but on the outpatient side I’m working more like 40 to 60 hours a week. Last year as an internal medicine intern, I was working 80 hours a week, and most of my co-residents who are in the internal medicine residency program are working 80 or—I can’t really say that they’re working more since technically we’re not allowed to work more, but if it were legal for them to work more, then they might be working more than 80 hours a week.
Harris: Can you describe what a typical day for you, now that you are a resident, is like?
Charrow: Absolutely. So, a typical day for me right now, it’s different depending on whether I was an internal medicine resident on the internal medicine side or whether I was on the dermatology side. Right now I’m on the dermatology side of things but I still have my internal medicine continuity clinic. I know this is very confusing. I have an outpatient primary care practice, and then otherwise for the most part I’m seeing primarily dermatology patients in-clinic.
That looks like me waking up at 6:30 or so, going to didactics—because we’re still learning and training—and that’s where we learn about dermatology. I learn about that for about an hour, and then I do clinics throughout the rest of the day.
Harris: And what happened today? Could you kind of walk me through what exactly happened today? Was there anything surprising or interesting that happened during your day today?
Charrow: Sure. It’s hard because I’m trying to figure out—so, before I did this interview, I talked to my program director to make sure it was OK to do it, and then I also talked to the head of communications for the hospital. Her recommendations were that I try my best to not allude to specific dates, times, or patients unless I changed significant information about that patient. So, I can sort of give you a generic day, but maybe not today.
On a generic day—we can imagine this was this past week—I spent the morning in didactics and I learned about how to describe skin and skin characteristics. Then I spent the morning in a dermatology clinic seeing general dermatology patients, and characterizing their skin findings, and writing notes for the attendings—who then proceed to change a lot of the notes because I still am learning. So, they might correctly acknowledge that I don’t yet know all that there is to know about dermatology.
Then in the afternoon, I might go to my primary care clinic, and in my primary care clinic I would see what somebody would see at any primary care clinic office. Maybe a patient comes in and she wants STI screening. She’s afraid that she has either gonorrhea or chlamydia. And then another patient who’s been hospitalized a few times, and also has a diagnosis of cancer and is coming in after a recent hospitalization. I would spend some time going through all of her medications with her and making sure she understands exactly what happened during her last hospitalization. I might see a few urgent care patients who are coming in with an upper respiratory infection, poison ivy, or something.
Then it really depends. At my particular clinic, it’s the clinic for the hospital, and the patients tend for the most part to be quite sick. They will often be managed by many, many subspecialists, and so I’m spending a lot of my time coordinating care with those subspecialists.
And then at the end of the day if I have time, I’ll go through all of the results for all of my outpatient dermatology patients and for all my outpatient medicine patients, and then I’ll call patients back and give them results. So, for the patient who was afraid she was pregnant, I’ll call her back and let her know that she’s not pregnant. For the patient who I was afraid was anemic, I’ll call her back and let her know that her blood counts are so low that she actually needs to come to the emergency department, and then I would write a note to the emergency department to let them know to expect her there.
After that, if I have time, especially now that I’m on dermatology, where the schedule is a little bit easier, it’s expected that I should be learning some dermatology and some medicine, and so I’d spend some time trying to learn as much as possible about some of the people that I saw that day. And then I’ll go home.
Harris: What time of the year or day tends to be busiest for you? I imagine that sometimes—like, we just had the Fourth of July and so there’s lots of people playing with fireworks—is there any time of the year when you can expect that you will be working way more hours than normal?
Charrow: I think that there’s definitely an increases in the census in the hospital, which definitely increases the workload for all of the inpatient services in the winter, when the flu season is bad. This year the flu season in particular was bad. The flu vaccine didn’t work very well. I think it had an 18 percent efficacy rate, which is way lower than usual, and so we had a lot of flu patients. They just filled up the ICUs and they filled up the floor. We had a few patients who got very sick. A few years ago, some patients died of the flu. So, it can be very, very serious, and I’d say that overall the census is a little bit higher then.
But it’s hard to really know. Over the course of this year, it seems like we’ve been in extreme census, which means that we’re opening up extra floors of the hospital. We’ve been in extreme census, I feel like, half the time that I’ve been here. It’s really hard to predict.
Harris: And what happens if you get sick? Like, are you allowed to take a sick day? How does that work? Because I imagine if you’re on call or if you’re always working, you’re not allowed to take as many days off as some people in other professions might be able to.
Charrow: I think, actually, to most programs’ credit and to my program’s credit, there’s usually a designated rotation that most people have for two weeks in which they are the sick call for people. In the winter, everybody’s sick call. All those people who are waiting to be called in for the other residents who are sick, they are almost always called in, because there are people with the flu, or one year there was norovirus, which is gross, and diarrhea, and awful. That pulled in everybody from sick call. But there are people for sick call.
Because a lot of the patients that we work with have had bone marrow transplants, or are on chemotherapy, or have many comorbidities, it would be a harm to them to come in. Unless what you have is allergies or something that you know you can sort of work through, then you’ll call in sick. I think I called in sick once last year, which is actually surprising. You’re around so many sick people, but for the most part I feel like my husband got sick a lot more than I did. I think I brought home all of—I was just this huge vector, bringing home all of my illness to him.
Harris: Could you describe for me what a bad day might look like for you? Like, a particularly bad day?
Charrow: Yeah ... I mean, I can think back to bad days, this past year especially, during my intern year. I think at the beginning of the year, a lot of my bad days revolved around my just feeling incompetent. But I can think about a sort of pseudo-constructed day from this past year in which I was on an oncology service, and in the morning I went to see some of my patients. Especially on the service that I was on, they were very, very young. A lot of them were in their 30s with metastatic cancer. I would go to see them in the morning.
What an intern does is, they wake up at—you know, I think at 5 and they come in at 6—and they go through all the data for my patients for that day. Then I would pre-round on all of my patients. I’d go and see all of the patients individually. If one of them was really sick overnight, then I had to pay special attention to them and talk to them. In particular I had one patient in her 30s and she was really ill, and I spent a lot of time talking to her and her family about the fact that she was getting sicker. Then I might go see another patient in his 40s and I would talk to his family about whether or not they wanted to get some invasive procedure that day that would make the patient feel better.
And then I’d go and see my other patients. We’d round as a team. The attending, my residents, and me and my co-intern would round as a team, and then the rest of the day is spent getting a lot of things done for all of those patients. So, coordinating care with the other subspecialists who are consulting. Making sure that all the tests that are supposed to get done for those patients get done.
If it’s a really hard day, what that probably means is also emotionally I’m spending a lot of time with really sick patients in either “goals of care” meetings with the patients, where we’re talking about what they want to pursue in terms of treatment, whether they want to go with hospice. When you’re talking about really young patients, that can be especially difficult. Those days, on days I would just—yeah, it was a lot. It was a lot emotionally to take, yeah.
Harris: So, it sounds like a bad day for you involves a lot of very sick patients, and especially young sick patients. What was your kind of experience or understanding of death before you were a student, and how has that changed now that you are just in it every day?
Charrow: I mean, so, so dramatically. So dramatically. When I was in medical school, I had never seen somebody die, and by the time I finished my intern year, I had probably pronounced 10 people dead, if not more, and had many more of my patients die than that, patients who we sent home with hospice. A lot of them were really young.
In addition to that, you see the sort of process of dying both in an acute setting, which is a code, and a chronic setting, which is somebody who has a chronic illness. Seeing somebody who’s chronically ill pass away is really awful, and it can be really frustrating and hard, especially because until you’re working in a hospital your experience with a hospital as a young, otherwise healthy person is to come to the hospital once for one thing, and then leave and never come back until 70 years later. But for a lot of people in the hospital, when we’re catching them it’s a time slice and they’re going to be coming back multiple times. It’s unclear whether they’re going to be coming back 10 more times before they pass away or two more times before they pass away, but our whole team generally acknowledges that if they’ve been in and out of the hospital over the past year, that they’re likely going to die by the end of this year depending on what their condition is.
And I think that can be really, really hard to sort of mentally wrap your head around, especially as a medical student, to see people seem so callow and to see people seem so callous about death. But I think that sort of acknowledging that is helpful in terms of having good discussions with people, because they might see their one hospitalization as a hospitalization that they can get through and then go home, but if you see it the context of all of their other hospitalizations, I think it can become clearer how to proceed with treatment and discussions with families.
In the acute stetting, I think I had never been to a code, or maybe I’d been to a code once as a medical student. A code is when either somebody’s heart stops beating, or they stop breathing, or their heart is so irregular that they don’t have a blood pressure. Basically, it’s a medical emergency in which you mount all of the forces of the hospital to come together to try to save somebody’s life. As an intern, your job is to go to the codes—especially if you hold the code pager, which is distributed among the services sort of arbitrarily—and my first day of intern year, I went to a code.
I’ve been to a lot of terrible codes. Probably the worst one that I’ve ever been to—it still sort of haunts me to the core when I think about it—it’s not very common for a patient of yours to code. Usually you’re running to some other service’s code. But this was a patient of mine, and we had rounded on her maybe 10 minutes before. We as a team had seen her and she seemed find, and then we left the room and a code was called, and we ran to the room and it turned out to be my patient.
And the thing to remember about codes is that they’re—when you’re doing chest compressions on a patient, you’re doing it in order to beat their heart for them. You’re not doing chest compressions to start their heart up again if it’s stopped, you’re doing it literally to beat their heart for them while you figure out what’s going on. For this particular patient, her heart had slowed down and then stopped, and so she basically had died. We were coming in to beat her heart for her while we figured out if we could reverse whatever process caused her heart to stop beating. And what it means if you’re actually doing compressions correctly—if you’re actually pushing down and beating somebody’s heart for them while you figure out what’s going on—is that they were dead, and then they’ll come back to life. And for this particular patient we were doing chest compressions, and she started to respond to commands, and she was much more directed in her movement—so, if we told her to squeeze our hand, she would squeeze our hand—and then as soon as we would stop doing chest compressions, she would die. It was one of the most difficult and awful experiences I’m sure that she ever had, and certainly that we ever had—certainly that I’d ever had—that I still think about. It makes me think a lot more about how we handle emergencies, and it made me think a lot more about whether these sorts of efforts are worthwhile.
And so on the acute side of things, I think those sorts of experiences definitely color an intern and a resident’s experience of death on the acute side, and on the chronic side it’s all of the people who are very sick who are coming back and forth to the hospital.
Harris: Do such experiences like that make it more difficult for you to forge relationships with your patients? Or do you try at all to kind of keep things as straightforward as possible? Because I realize the more you interact with a patient and the closer you get to them, if something like that occurs it can be even more emotionally daunting for you. I’m curious if these experiences have made you kind of step back a little bit in terms of how you deal with your patients.
Charrow: It’s a really good question. There was probably a point in the middle of the winter in which I had seen so many young people pass away that I literally—I don’t think that my response to that was to—my response to that wasn’t to sort of pull away from patients, but instead to just sort of fall into a deep sense of despair and sadness. I think that one of the greatest joys of being a resident is the privilege that you have of being able to forge these relationships with patients, and if I didn’t have that, I don’t think it would have been possible for me to get through the year, even if those relationships were themselves were a source of a lot of pain and sorrow.
It’s certainly much more difficult for the patient themselves than it is for me and for their families, but at the same time you’re absolutely right. I’m sure I wasn’t functioning—I went to two weddings last year toward the end of the winter and the beginning of the spring and literally people would come up to me and I would tell them the sort of same line, which is that I’m not really good at cocktail parties right now. Like, I couldn’t have normal conversations with people. I couldn’t really engage in social and fun things for a long time.
Now I have sort of—dermatology is a lot more uplifting, you can sort of help people out with their quality of life—and it’s been great to sort of interact with patients in the outpatient setting. I have a little bit more time, and the patients I’m seeing are for the most part less sick right now, but it’s certainly a real thing that I think happens to a lot of residents and interns. Either the response is just like you said, to sort of pull away a little bit—which is a totally reasonable thing for an intern or resident to do—or to sort of fall into a pit of despair about how sad things are.
Harris: Can you talk a little bit about what the social life is like among you guys? Just because I know—I’m going to bring it back around to Grey’s Anatomy—but you are working so many hours, and it seems like you are always around the same people. Is it true that there is a lot of hooking up and stuff like that going on? Is that a normal thing that happens among you guys?
Charrow: Oh my God, if only we were so good-looking, seriously! So, I feel like comedies often get this sort of atmosphere—they understand it better than maybe dramas do. So, in the same way that Veep is probably a better representation of—I assume it’s a better representation of Capitol Hill than maybe The West Wing, I feel like Scrubs is a better representation of my life than Grey’s Anatomy.
We go out. A lot of people drink, especially on Friday night. There’s actually a dedicated night for going for a beer after work, and people let loose some steam. The single people I’m sure—though I’m not privy to all the good gossip—I’m sure that the single people are all making out with each other. My particular program is a lot more married with children and a little bit more boring and subdued than some of the other programs, but I think it’s really hard to date what I would call a “normal” person—I think it’s really hard to date a “normal” person because like you said, you really do spend so much of your time with other interns and residents, and so much of your time sort of engaged with really sad or difficult issues, that you want to be able to talk about with somebody. It becomes easy to talk with your co-interns and residents about those things and create close ties.
I don’t think that that can be underestimated, the degree to which—this year, although the hours were hard, they certainly aren’t as hard as they used to be and they certainly aren’t as hard as probably somebody who works two minimum-wage jobs. And so they’re hard, but it’s really I think the emotional part that was much harder for me, especially over my intern year, was confronting this sort of sadness of people and of illness.
Harris: How do you balance that out? I mean, besides commiserating with your colleagues, do you also bring it up outside with your husband, or is that something that you kind of just deal with on your own?
Charrow: I mean, my spouse is—he’s a “normal,” as I would call him—he has a nonmedical job. It’s wonderful that he does, and I really am so happy that he does, but one of the keys to making sure that I don’t sort of keep everything inside is that I have to start to make a practice of talking to him every day about what I was seeing and what I was doing. Because otherwise, like I sort of prefaced this before, you haven’t built enough of a world for somebody to understand and then you sort of give up on trying to explain it to them.
And so, there were definitely months—especially over the course of the winter—when I was on incredibly difficult services and where I came home every day and cried. I kind of can’t believe that he was able to put with that, but you sort of need a space in which you can let out that emotional steam and in which you can sort of sit with the idea that there’s a huge amount of suffering in the world, and to have somebody who is willing to kind of listen to that is a real blessing.
Harris: What made you even want to do this and take on such an emotionally daunting career path?
Charrow: At some point I realized—I spent some time, about three years out of college—I had been a philosophy major, and I spent some time out of college sort of circling around various medical things that were much more distant from the patient and much closer to sort of the public health perspective. And so I did some research, some science, some global health, and some other stuff.
In the end, the things that I found most fulfilling involved actual patient contact with an actual patient. I think it can be probably very frustrating. I’m sure there’s a lot that a resident shares with teachers in terms of how we experience the world. So, we’re working kind of in these very cloistered environments. It’s just us and the patient. Really, we’re having only individual impacts on individual patients. There are all these other factors that don’t have anything to do with health that we have to contend with and that are likely driving a lot of patient sickness, whether it be their poverty or other social issues for them that make them sick. That can be very, very frustrating. But I found that the interactions that I had with patients were incredibly fulfilling, regardless of how much of an impact I was necessarily having.
Actually, to be quite honest with you, I think a lot of people can come to residency, come to medicine, or come to medical school and can be really frustrated with the level of impact that physicians have. I found that maybe it’s because I felt for the most part like the most joy that I got was from interacting with patients, that it almost didn’t matter.
My hope is obviously to help patients get better and feel better, but if I can have a really good conversation with a family where we sort of decide or they decide that they are not going to pursue further aggressive treatment and their family member is able to have a good death, that’s a really good intervention to me, maybe more powerful than any of the really expensive and fancy things that we could probably do. So, from that perspective that was one of the reasons why I decided to go into medicine.
Harris: So, you’re in your second year of your residency. How many more years do you have left, total?
Charrow: It’s a five-year residency.
Harris: And that’s including both the dermatology and the medical together?
Charrow: Yeah, exactly. Exactly, it’s five years. I’m sort of escaping with in some ways a much shorter training than a lot of people get nowadays. A lot of people go and they do their internal medicine residency—that’s three years—and then they do another three or four years of subspecialty training. So, a cardiologist that you meet on the street has had six or seven years of training after medical school. A subspecialty surgeon that you just happen to run into on the street has had seven years of residency and then one or two years of subspecialty service. That’s why Grey’s Anatomy is just so much fun, because they basically never leave the hospital!
You know, those folks are in training for nine years, maybe. Neurosurgeons are the same. A family practice doctor might be in training for three years, but then they get a lot of their training sort of on the ground when they’re actually doing the work in the community.
Harris: Is there anything else that I haven’t asked you yet that you’d want tell me?
Charrow: Yeah, probably. Let me spend a second thinking ... I think maybe I’ve made residency a lot less sexy than you thought it was before, Aisha, for which I apologize. I’m sure that in these halls there are people who are doing all sorts of untoward things and there are lots of attractive residents who are making out with each other, but I am not one of those residents! But I’m sure that it’s happening.
I think for the most part, people—a lot has changed about residency. People don’t really spend as much time in the call room that I’m in right now as they used to. We still spend a lot of time at the hospital, but I think we have a healthier balance in the amount of time that we spend at the hospital than used to be the case. That change, although nobody would probably say it out loud, has allowed physicians in training to have children, and a lot more women to go into medicine. These official changes have led to all sorts of unofficial benefits, I think, for all of medicine and for, by extension, patients.
Harris: So, what is the layout like in terms of the space? Because you mentioned there are clinics, and it’s sort of a place where people go to learn while they’re also helping people who are sick. What makes it different? I should preface this by saying that Alex and I are not in the same room, and so would you—I do not know what the hospital looks like. If you could describe a little bit like, where you are right now and what this space is like?
Charrow: So, I’m actually calling from a call rom, which I thought would be a good place since it’s sort of a sensory deprivation chamber here. There are call rooms scattered throughout the hospital. There’s also a dedicated area of the hospital that is low-lit, and sad, and sufficiency good to be a call room, which is where we are right now. I’m sitting in a room with two plastic bunk beds and a window with a blackout curtain on it at the moment.
So, there are rooms like that interspersed throughout the hospital, and then there is a big tower that has inpatients in it, and another tower across the street that also has inpatients in it. And then there’s a building that runs parallel to it that has all of the outpatient clinics.
And so, all together it’s a huge maze of inpatient and outpatient clinics and hospital beds, and lots of frantic people in white coats and scrubs at any given time. And then on the first floor, crucially, there’s a 24-hour Au Bon Pain, which at this point is so—it feels me with a sort of visceral reaction when I think about it, because I’ve eaten so many food things there late at night.
Harris: Is that where most of the doctors and residents go to eat? Is that the only kind of source of nourishment there?
Charrow: There’s a cafeteria that’s open at pretty wide hours, from like 6:15 until, I don’t know, 11, I think, 11 or 12 at night. But if you’re working on nights or if things get really crazy, or if you’re sick of the cafeteria food—and especially in the morning, actually, because most people get to the hospital—especially earlier in their intern year and earlier in their residency, they’ll get to the hospital before the cafeteria opens.
So, by the end of the year, I had a whole system down—by the end of my intern year, I had a whole system down whereby I would round on my patients, and then I would go the cafeteria, and I would get two hard-boiled eggs and a Diet Wild Cherry Pepsi, and I felt really great about my life. But before that it was a little sadder.
Male Voice: If someone goes to the Au Bon Pain, what should they eat?
Charrow: Oh my God, that is one of the most—if somebody goes to the Au Bon Pain, that is one of the most contentious questions of residency, really. So, there’s this mac and cheese that comes in a vat from the soup bowls and that has probably like, 8,000 calories and is responsible for all 20 pounds that I gained this year. Oh, it’s so great. It’s just liquid crack, it’s great. I really, really like it.
Harris: That sounds delicious!
Charrow: I would recommend it highly, yeah. Sorry, I don’t mean to put in shameless plugs. I don’t endorse ABP, I apologize.