While not necessarily representative of all JHU/Sinai Hospital residents, the following is an example of Dr. Chuck Albrecht's days as a resident at Sinai Hospital.
Roaming the halls of Sinai Hospital are scores of eager young men and women learning and practicing the art and science of medicine. Some physicians might be concerned that these neophytes need extra help, have lots of questions and occasionally disrupt the flow of hospital work. But all attending physicians and probably the patients themselves would agree that these doctors lend energy and enthusiasm to a profession rife with long hours and endless paperwork. These newbies keep Sinai and the doctors who train them on the cutting edge of medicine, and remind every physician why they got into this business in the first place.
A new day begins!
Charles Albrecht, M.D., lives in Essex with his wife, 2-year-old daughter, and a newborn. He starts his day with 30 minutes of exercise and then spends another 30 minutes watching educational videotapes from the American Medical Association's physician series. Before he heads out the door, he has just enough time for a few minutes of play with his baby girl. Traffic is light this time of day, and the commute to Sinai Hospital takes just 15 minutes.
6:30 a.m. Using a computer in the physician's lounge, Albrecht accesses the test results of his recently admitted patients. As a third-year resident, Albrecht manages two interns, each of whom may carry a caseload of up to 12 patients, and two Johns Hopkins University Medical School students. Albrecht has two prime directives; one stated and one implied. First, reduce the caseload of the interns. Twelve patients are far too many to handle well--half is better. Second, expose the medical students to as many different experiences as possible as they follow him throughout his day.
"I'm trying to be a good role model for my interns," Albrecht says.
He arrives early. He sticks to his schedule. He writes neatly on his patients' charts and returns all pages promptly. Albrecht is busy but remains calm, almost serene, throughout the day.
An attending physician supervises Albrecht's group. Because Albrecht is a third-year resident, the attending physician gives him more responsibility over patients. Albrecht can order lab tests and make diagnoses.
On this particular day in July, Albrecht is the assigned MAO (medical admitting officer) so he's armed with two pagers (one personal, one for the MAO), a hospital-issued cell phone and his PDA. Assorted papers, a stethoscope and a small notebook spill from the pockets of his white lab coat, and a rainbow of ink pens line the coat's breast pocket. (He says your coat pockets will get lighter the more experience you have.)
Albrecht gathers his two interns, Ben Wakefield and Gitana Bradauskaite. Third-year medical school students Russell Hales and Arvin Hariri join the group. (You can pick the medical students out easily, they still have to wear short, white lab coats.) This team meets every morning in the medical resident library on the second floor of the Shapiro building.
Other resident-led medical teams gather here as well, and the din increases as each team discusses the status of patients admitted the previous day or overnight. The night float resident fills them in on every detail. Albrecht writes the names of newly admitted (but not yet visited) patients in red on another piece of paper that he slips into a clipboard.
Hales' wife has made cookies, which are devoured as the plate is passed around the room.
Med students, residents and interns shoot questions across the table about each patient. Like children struggling to figure out how a new toy works, these young doctors overlook nothing as they check and double-check test results and discuss what they may indicate. The med students and some of the interns carry a small book around with them, the Differential Diagnosis, to which they will refer throughout the day.
By 7:30 a.m. the group is on the sixth floor. The first patient they see is hardly able to communicate. One of the team members tries to get him to squeeze his hand or blink to communicate. But he is fully intubated and immobile. Cancer is spreading rapidly throughout his body. The group turns him and checks him for bedsores. The smell of the patient's recent bowel movement permeates the air.
"Get someone in here to clean him up," Albrecht says.
There are six doctors in the room; each tries to connect with this man whose deep brown eyes stare into the middle distance. Perhaps it is just the pain medication. Perhaps he is not long for this world. Reassuringly, Albrecht pats the patient's hand.
"We'll talk with your wife when she comes in," he says gently, and the group quietly moves on to the next patient, who fainted while working on a car.
Hariri looks up "syncope" in the Differential Diagnosis book. "Here are all the possible causes of syncope," he says as his eyes scan the list. "Hypotension seizure disorder, hypoglycemia, the heat, or it could be cardiac arrhythmia."
The most common heart-related cause of syncope is an abnormal heart rhythm. If the heart beats too slowly, too rapidly or too irregularly, it will not pump enough blood to key parts of the body, including the brain.
The patient's leg is swollen. Diabetes? Yes, the man says, he is diabetic. Albrecht begins to quiz the patient.
Have you ever fainted before? How long were you unconscious? Who found you? How many pillows do you sleep with at night? How much alcohol do you drink? Do you smoke? Do you use any narcotics? Do you take any herbal supplements?
Have you ever had seizures?
The list seems endless and it's not evident to the patient where Albrecht is going with his line of questioning. The patient answers reluctantly and seems to be downplaying the significance of any previous symptoms he's experienced. Albrecht wants to see the EKG.
Every moment these residents spend with patients accomplishes several things. For one thing, patients seem to appreciate the attention. "Studies have shown that many patients feel more comfortable when they are treated by a team," Hales says. For another, it brings the student's classroom education to life.
"Sometimes the things you learn in class don't really make sense until you see it in person on a patient," Hariri says.
"And every patient is unique. Each can have the same symptoms but they present differently," Hales adds.
Albrecht likes to give his "students" little tests throughout the day. "Normal or abnormal EKG?" he asks as he holds up the patient's report. The group concurs that the EKG is abnormal and recommends a conference with Singer.
Delving deeper, the medical team determines that this patient has a history of syncope and has been noncompliant with his diabetes medications. These facts, combined with the abnormal EKG, allow Albrecht to begin to formulate a diagnosis. GÇ£Better get a bed ready for him in the PCU," he says.
Students and interns have learned another valuable lesson.
"There is a lot of subtle information, a lot of simple things that can make a big difference," says Hariri. "The residents and interns are infinitely better at recognizing them the art of medicine is learning to tease that out."
The group moves on to the fourth floor to visit a patient who has been having trouble breathing. She's a heroin addict but is currently suffering from asthma. She's frail but alert. Albrecht squats down to chat with her briefly while she sits on the bed. Treatment has improved her breathing and she says she's feeling much better.
They move on.
The next patient is suffering from alcohol withdrawal and, shortly after he was admitted, barricaded himself in his room with the hospital bed and chairs. Security had to be called in to assist. Now, he's calm but not too responsive. The team can't get much new information from him so they move on. There's one new patient to see during this part of the day.
The group convenes in the ER. The patient is an older man who's recently had surgery at another hospital. He's highly medicated and he drifts in and out of consciousness.
Each student and intern takes turns, listening to his heart.
"What's the matter?" one student asks.
"Nothing," says Albrecht. "I just wanted you to hear what a normal heart sounds like."
The resident's "Power Hour" is from 9 to 10 a.m. One of Albrecht's interns and his medical students spend this time making requests for lab work and preparing the paperwork for patients ready to be discharged. Wakefield stays with Albrecht and they continue to see more patients.
The next patient, an elderly woman, speaks only Russian, and Albrecht must rely on her middle-aged daughter for information. Is she telling the doctors everything they need to know, or just putting her own personal spin on her mother's condition?
At 10 a.m. the residents gather in a small auditorium on the second floor of the hospital. Steve Gambert, M.D., Professor of Medicine at Johns Hopkins and Chief of the Department of Medicine and Program Director of the JHU/Sinai Hospital program in Internal Medicine and Gary Kerkvliet, M.D., associate director of the JHU/Sinai Hospital program in Internal Medicine are there to lead the discussion on a variety of medical cases.
"Does anyone have anything to share?" Gambert asks.
Yes, indeed, they all have something to share. Nearly every resident takes turns describing an interesting case. Each describes in detail the patient's symptoms and vital signs, the results of any tests ordered, diagnosis and treatment, and, if known, the outcome of treatment.
The other residents ask questions and dig deeper, sometimes offering suggestions if the case seems particularly problematic. During the discussion, the issue of herbal supplements comes up. Gambert explains "hypervitaminosis" and shares a personal experience about a patient who essentially "killed herself by going to the health food store."
Open discussion like this is followed by a case study, which is presented by a resident. What is the diagnosis?
Gambert beams as he works with these new doctors.
"This is a teaching hospital and that is why I chose to be affiliated with Sinai. It is an honor to teach young physicians and to mold them as best as possible and hope that at least some will choose to model their own future practices after something they saw me do or say," says Gambert. "Educating and training young doctors is our mission and challenge."
Working with the residents has a positive affect on all the doctors at Sinai and even the reputation of the hospital.
"A teaching hospital tends to be perceived as a more prestigious, a center of academic excellence," Kerkvliet says. "Our focus is on the new knowledge coming out of medical school. There is less of a chance of settling in, and everything you do and say is challenged by these new doctors. The attending physicians have to stay up-to-date on everything. You can't allow yourself to be isolated."
Learning also makes you hungry, and one good thing about residency is that a resident rarely has to pay for food. Today's lunch is catered courtesy of a local pharmaceutical company. The menu consists of lasagna, salad, bread and drinks. The residents can also load up their pockets with freebies bearing the drug company's name. The residents chow down, because, for most of them, this is the only chance they'll have to sit and eat all day.
Albrecht has a chance to reflect.
"When I first got into medicine I thought I could really make a difference, could really help everyone. But I learned quickly that you see the same people back again and again with the same problems; drinking, drugs, faking illness. It can seem like a waste of resources. But I also know that being a physician, I will always be learning something new and that I will never be bored with it."
At noon Albrecht sees the other members of his medical team in Zamoiski Auditorium. Instead of the usual noon teaching conference, Dr. Marc Lowen is giving a lecture on diversity to the House Staff of Sinai Hospital (HASH).
From 1 to 4 p.m. Albrecht works in Park West Medical Center/Sinai Community Care Clinic. His first patient speaks only Russian and interpreter Margarita Noznitsky translates every word of the conversation, making the office visit twice as long as it would normally be.
Regardless of the time it takes, Albrecht spends 30 to 40 minutes with each clinic patient. "I try to make every patient feel like he or she is the only patient that I've seen that day," he says.
"Some attending physicians may complain that having to train residents slows them down. But we all want the house staff. They are on the front line," Kerkvliet says. "An attending could try to do it alone but it would be overwhelming. Likewise, what the residents learn from being with the attending physicians and patients is invaluable. They keep an energy infused into the system that might not be there otherwise."
At 3 p.m. Albrecht sees his second patient, a mild-mannered African-American woman who is complaining of shoulder and neck pain so bad that she has lost her appetite. She's dropped 20 pounds in about four months.
Albrecht's questions are thorough, especially concerning her family history for a variety of joint-related conditions. She's been to the ER recently and blood work was done.
From her answers, Albrecht suspects polymyalgia rheumatica, but he can't be sure until he reads the results of her lab work. The most typical laboratory finding in people with polymyalgia rheumatica is an elevated erythrocyte sedimentation rate. His suspicions are confirmed when he pulls the results of her test from the computer.
"I nailed it!" he says, pumping his fist in the air. High-fives are exchanged. "Sometimes you just feel like Sherlock Holmes."
When Albrecht returns to the exam room with the news, the patient appears to have been crying. He calms her and tells her that relief from her excruciating pain is in sight.
Albrecht's final patient is another elderly Russian who comes prepared with a written list of every medication she is taking. It's not clear why she is here today though she is experiencing a little vertigo. Albrecht makes some adjustments to her medications and answers all her questions.
By 4:30 p.m. Albrecht finishes his clinic work and moves over to the ER to check on any newly admitted patients. He spends a few minutes catching up with his interns on the phone. There have been three new admissions since noon. A couple of patients have been discharged. He starts to leave to go check on them but is suddenly called back to help with another patient.
The patient is an HIV-positive woman in her mid-30s with a history of heroin use. She is suffering a severe headache, a fever and mental confusion. She was originally admitted as a psych patient but is being held in the ER Observation Center until the physiological causes of her fever and confusion can be determined.
Albrecht and his two interns try to get some information from her but she is not very responsive. Her boyfriend encourages her to answer. From her symptoms, Albrecht suspects meningitis, but the only way to confirm this is through a lumbar puncture. Finally, she gives verbal consent for the spinal tap.
By 5:45 p.m. they are prepping her for the lumbar puncture. Albrecht gets assistance from another resident, Dave Cozzi, M.D. Albrecht very carefully removes his wedding ring and ties it to one of the drawstrings of his scrub pants. He also takes off his watch and slips on some rubber gloves.
A local anesthesia is administered and Albrecht encourages the interns to watch closely as Cozzi carefully positions the 4 inch long needle between the L4 and L5 vertebrae. It takes several tries, but finally a milky yellow fluid, the spinal fluid, begins to drip from the end of the inserted needle. The team gathers enough to be used for a test, and the sample is sent to the lab right away.
In under an hour the team knows that the patient has viral meningitis. Before the end of their shift, the medical team will have to pick this woman up off the floor of the bathroom adjacent to her hospital bed. They will also have to pronounce dead the first patient they saw this day and meet with his family.
Additional paperwork, legwork and heartbreak will keep them at their posts until the night float resident arrives.
Tomorrow it begins again at 6:30 a.m.
Editor's Note: Chuck Albrecht, M.D., joined the JHU/Sinai Hospital Residency Program in Internal Medicine's teaching faculty and serves as an Associate Program Director. He is also Director of the Hospital Medicine Section and Medical Consultation Service, and a graduate of the University of Maryland. In 2007 he assumed the role of Division Director, General Internal Medicine.
Dr. Gitana Bradauskaite completed a residency at JHU/Sinai and then served as a Chief Medical Resident. She is currently a Nephrology Fellow in Boston .
Dr. Dave Cozzi completed his residency and is currently completing GI Fellowship in Pennsylvania .