Chapter 8: Residency

      As I arrived at St. Vincent's, I was quite nervous about the ordeal everyone had told me I would be going through. It was to be the most intense training I would undergo. I was also nervous about living in New York's infamous Greenwich Village and being in a big city where I had never lived before. New York City is like no other city in the world and it was to be my new home on and off for three years of my life. It can be quite intimidating and it was for me. It was going to be a big  adjustment for the white Anglo-Saxon boy from the suburbs to make. So I looked forward to it with mixed feelings of nervousness and excitement. After the usual paperwork and processing, all the new house staff of interns and residents got together for the first time and were given the basic ground rules by which we were to operate under over the next year. Many of us were new to the hospital and it would take awhile before we would be able to just get around the immense institution. We were introduced to several of the department heads, some of which we knew by their reputations and publications in their various specialties. I also found out that my salary had increased to a whopping $9,000 a year. What would I ever do with all that money? It really didn't make much difference however because there would be no time to spend it anyway. Later on, when I had time to calculate how much time I would put in, I would realize that I would be making the enormous sum of $3 an hour on a regular day. There were very few regular days ahead. One of the biggest decisions to make was how I was going to live on that meager salary. It was time to stop living off my parents, so I mulled over my options carefully. I soon realized that there really were no options. I could not afford to live in an apartment with the prices they were asking and getting for living in the city. My only real option was to live in the resident housing building known as the Martin Payne Pavilion. Being single, I was required to live with another resident for space reasons. Only married couples were given their own apartments and all of that went by seniority, of which I had none. So I moved in with everything I owned at the time, which consisted of my clothing, typewriter, and many textbooks. I had no furniture but, fortunately, there were a few basics included in the apartments. The Payne was also very convenient as it was part of the hospital complex. That would prove to be invaluable in the future when I needed a few hours of rest while on call. It was nice to be able to escape the rigors of the hospital and retire to my own room. And it literally was a room which contained a bed,  bookcase and a desk. I had to share a bathroom with my roommate, so I felt like I was back in one of the dormitories at college.

      My roommate happened to be one of the chief residents in Ob/Gyn. Dr. Jorge Perez was a Cuban refugee who was one of the nicest people I ever met. He had his own hospital clinic in Havana before he escaped from the Castro regime and, when he came to the United States, he had to do an internship and a full residency again in order to practice as a physician.  Jorge was about 45 years of age and what a humiliation it must have been for him to start from scratch again. Here was a man who was fully trained in his country and had been in private practice for many years before he came to the United States. He had left everything behind except for his wife. I am sure that was very difficult for him. But he was very happy to be in this country, away from the horrors he would share with me of his home in Cuba. Yet most of his family still lived there, and he missed them dearly and worried about them constantly. I was so fortunate to be matched up with him for the next year. At first I thought it would be quite difficult to live with my immediate boss, but he was a pleasant man and he made me feel quite at home. We became a good team as I would help him with his English and he would help me to become an obstetrician. I strived very hard to make sure that I would be the best resident I could be, both for myself and to make Jorge's life a little easier. I'm sorry to say that some of the attendings looked down on this man but it only revealed their ignorance. I wonder how many of them would have been able to do what he done. A chief resident is responsible for all that takes place in the department and a lot depended on the residents below them. So some of my initial anxiety was being relieved by this fortunate matchup. Once again, fate had dealt me another good person to guide me.

      The Ob/Gyn Department was spread out over several floors in the hospital. The department chairmans’ office was on the top floor. Spellman 10, as it was called, was in a portion of the hospital named after the famous Cardinal of the New York Catholic Archdiocese and it was one place you did not want to be called to. If you were,  it usually meant that you had done something wrong and were about  to be chewed out royally. Below that on the ninth floor was the labor and delivery suite along with the OR’s. The postpartum area was on the sixth floor and the private patient Gyn floor was just below that. There was another area in the department that was called the wards or where the indigent Gyn patients were cared for. Multiple patients were cared for in one giant room each separated by only a curtain. And also lets not forget the other inhabitants of the wards – giant cockroaches. They seemed to be  everywhere even climbing on IV tubing attached to patients. Yes once again the nice white Anglo-Saxon boy from the suburbs was getting a good dose of reality with the poor of New York City. So that was to be my world both day and night for the next several years. I would come to know each and every inch of those areas very well. That would be where I would work, eat, and many times sleep while I completed my training. City hospitals can be very dingy places and St. Vincent's was no exception. But it was quite a busy place full of learning experiences and I would be rewarded for my hard work by having an all-encompassing exposure to my specialty. I was about to see and do many things I had never done before.

      So as the first morning came to an end, I reported to the labor and delivery floor as I was to do my first six months on Obstetrics. It consisted of a long hallway with delivery rooms off to each side. The main area was the nurses’ station behind which was the residents’ lounge. Lounge sounds much more pleasant than it really was. It was a small room with bunk beds and a bathroom and, oh yes, a television. I was to spend many hours in that small room over the years to come and I can still picture its dreariness and remember it's foul smell. So there I was in the bowels of that great institution eager to begin my next level of training. We met with the Chief of Obstetrics, who was a stern, no-nonsense man in his mid-40s. The next person we met was the head nurse. She was a young woman in her late 30s. Unmarried, she fit the bill for her position to a T. Hard-nosed and demanding she made sure you knew  who was boss. Several of the staff nurses  were then introduced. And lastly I met my partner, the other first-year resident. She was a small blonde woman with a soft voice who, at first, I thought would not be tough enough to make it but, oh, how wrong I was. She, first of all, was unique in that she was a woman in a surgical specialty and, second, was very bright. I would have to give a 120% just to keep up with that tireless woman. So that was the group I was about to have many trials and tribulations with over the next six months. The stage was set with all the players and it was time to get down to business. I was going to be the junior resident on-call the first night. How lucky I felt! No time to calm down, just thrown right into it. And what a night it would turn out to be. I remember feeling a little ticked that my female colleague had got a pass for the first night and I wondered if that was going to be the way things went because she was a woman. What happened to the fact that women were the newcomers to this specialty? It didn't take long to realize I was wrong and we were both going to endure everything on an equal basis.

      So the first night on-call began with meeting my intern. There finally was someone below me that I could pass along all the menial tasks  to, or so I thought. Wrong again because I had a rotating intern who was interested in Internal Medicine and was only on Ob because he had to be for the next 6 weeks. I also found out he loved to sleep and it was darn near impossible to wake him up in the middle of the night. I had great sympathy for this at first but then it got very annoying. He also had never delivered a baby so I would either have to teach him everything or just do it myself. The latter was the way I usually handled things. It was just easier that way. A night on call in labor and delivery usually meant delivering anywhere from 5 to 10 babies. Most of those were clinic patients but, occasionally, one of the private attendings  would not make it in time and I was the person who was called to deliver the patient. At first I resented doing their work which they were well-paid for but, with time, many of them would do more for me than I did for them. So after delivering a couple of babies with the chief resident observing me and the intern watching, Jorge retired to our room and told me to call him if I needed him. I was determined from the start that would not be necessary but again I would be so wrong.

      Shortly after midnight when I had just gone to bed the phone in the lounge rang and the night nurse said a clinic patient had just arrived in labor and that she did not look well. Great, I thought, there goes my sleep for tonight. I got up, washed my face and headed out to one of the labor rooms partially awake. I remember saying to myself you better learn to wake up fast because this is what life was going to be like from now on. The nurse told me what room the patient was in and, as I entered, I found a young Puerto Rican girl who was writhing in pain and appeared very short of breath. I quickly found out that she only spoke Spanish and, guess what, I did not. At least not fluently. Over the years, however, I learned enough Spanish to get by. Taking a history from this patient was impossible, so I began to do a physical exam and I was shocked when I listened  to her heart. It was making noises I had never heard before and it was very fast and irregular. Her  blood pressure was also sky high. I asked the nurse to quickly call whoever was the medical resident on-call, as I realized the patient was terribly sick. I then did a pelvic exam and determined that she was almost fully dilated and would be delivering the baby soon. Well, soon it was because about 10 minutes  later I delivered a little boy who was obviously quite premature. He immediately screamed almost as loud as his mother. Because he was premature, I would now have to have the nurse call for the pediatric resident. Great, I was up so I might as well wake everybody else on-call up too. As I finished putting stitches into her episiotomy, the medical resident appeared and she was not very happy. She was a senior resident and pretty annoyed that I had disturbed her. Well anyway, I explained what the situation was to her and she began to examine the patient. After she listened to her heart she told me that she thought the patient had some type of congenital heart disease and was in heart failure. Just then a family member arrived who spoke some English and was able to tell us the patient was 19 years old and had not seen a doctor since she became pregnant about seven months ago. He was aware that she had been told that she might have a heart problem as a child but had never followed up with a cardiologist. Meanwhile, the medical resident was making arrangements to transfer my patient to the intensive care unit. I could not believe what was happening to me on my first night on-call. It was now time for me to wake Jorge up because I didn't want him to be in the dark when we made rounds in the morning. I also needed someone to reassure me that I had done everything correctly. I was scared and had lost any confidence I had previously acquired. After I explained what had happened, he assured me that I had done everything properly. I then went to the nursery to check on the baby with the pediatric resident and I wondered if his mother would ever see him again. The rest of the night, as if in a trance, I wandered back and forth between the nursery and the ICU. So my first night on-call as a resident was quite memorable and I still remember most of the details quite vividly. Unfortunately around 6 AM I received a phone call from the medical resident that my patient had expired. I was crushed! There I was on my first night on-call and the worst tragedy possible had just happened. I had lost a mother. Later I would find out after attending her autopsy that she had been born with a congenital heart defect which left her with only a three chambered heart instead of the normal four. Typically those patients with heart disease run into trouble around the sixth or seventh month of pregnancy and, unfortunately, without prenatal care, there was not much that could have been done for her by the time she went into labor. The added stress of labor was just too much for her heart to handle. So as my first night on-call drew to a close, I was sad, shocked and wondered how I was going to explain to the other doctors in the department that I had just done the unthinkable for an Obstetrician. I had lost a mother that night. It was an aweful feeling that I hoped would never happen again but, unfortunately, it would not be the last of my career. I seriously questioned that maybe Obstetrics was not for me. A few days later I also learned that her baby also did not survive. I could not have had a worse start to being an Obstetrician.

      After I collected myself, I took a shower and prepared for rounds with the Chief of Obstetrics. I went over everything with Jorge  and he again assured me that there was nothing else I could have done and I did everything correctly. He made me feel better as I really was devastated. Exhausted I now had to explain everything again to the Chief and my fellow residents. I was tired, depressed, angry and in no mood to make it any more of a learning experience but that was what I was there for so I proceeded with the grilling I knew I was going to get. Fortunately, everyone was quite sympathetic once the full story came out. It's times like those that everyone else thanks God it wasn't them. I wondered to myself how would I be able to deal with future tragedies like this. But I knew it was a rare event to lose a mother and maybe it was a blessing to have gone through it so early in my training. I knew things could only get better, at least I hoped so. So like all tragedies in medicine, once it is over we must move on and I did. But I will never forget it, and I hoped and prayed it would never happen again.

      So after one of the worst days of my life I was about to experience one of the best. I had heard from some of the other residents that the new graduate nurses from St. Vincent's Nursing School were about to begin their first day of work. It was quite a special day for them and every single male resident  equally looked forward to meeting  them also. I was at the nurses station that morning as the elevator door opened and a beautiful redhead nurse appeared in her neatly pressed white uniform. Wow, I literally was mesmerized as she approached the desk and introduced herself to the other nurses and doctors. I knew immediately that she was special and can honestly say that I think, no I know,  it was love at first sight. She said her name was Kathy and she was just gorgeous. After a failed first marriage and in the process of a divorce I had absolutely no interest in another relationship but that was all to change.  Jorge had to literally drag me away from the desk to complete our rounds. One of the other nurses told me that she would be working nights and, more importantly,  that she was single. I couldn't wait to be on call with her. I managed to make some switches in my schedule and got myself on-call with her the next night. The first night we worked together I stayed up all night talking to her. She was friendly and intelligent besides being beautiful.  Our immediate friendship slowly developed into a courtship over the next few years that would end up in marriage and four wonderful children. What a first week I had with tremendous highs and lows which profoundly influenced the rest of my life.

      As I mentioned before, the other first-year resident with me was a woman. It was very rare at that time for a woman to be in a surgical specialty, but she was more than up to the task. We had a friendly competition throughout that first-year. She was very bright and a tireless worker. I really think that our competitive natures made us both excel. I had to work very hard just to keep up with her because she was very focused and dedicated. She began the year on the Gyn rotation, but we spent a lot of time together in meetings and journal clubs. Journal clubs are meetings in which new articles from the current medical journals were discussed by the resident doctors. After the first six months we switched services to complete the year. We had to do many presentations during the year and we each tried to one up the other, which I know made us both better physicians. One presentation that I gave was entitled Premature Labor. It took me a full three months to prepare to give that lecture to the entire department and then successfully answer many questions from the audience. It was a nerve-racking experience, but I enjoyed it very much. I developed a love for teaching and that helped me to excel in those types of activities. Some residency programs are what are known  as pyramids. In those programs, there are more junior residents than senior resident positions. That means one or two residents are not invited back at the end of the year. That type of program leads to tremendous competition and often rather devious behavior to look better than your colleagues or, worse yet, to make them look bad. We were very fortunate that our program was not like that, but it still was not automatic that each resident doctor would be invited back for the next year. You could always be replaced by someone from the outside if your performance was not up to par. There were always residents from other programs in the city or elsewhere who wanted to fill those positions at St. Vincent's. So besides all the hard work in terms of hours put in, there was a lot of tension to make a good impression on the Chief and the other members of the teaching staff. I have purposely not mentioned her name because, as fate would have it, she would wind up practicing in a sister hospital nearby in New Jersey after we completed our training. I hope if she does read this book that she will realize that I did then and still do have the utmost respect for her as a person and as a physician. Our friendly competition made us both better doctors.

      One of the private attendings on the OB service was a Chinese doctor with a rather large following in the Chinatown community. He was a general medical practitioner and he had an arrangement with the department that his patients would be delivered by the residents. Dr Bowe or his assistant Loretta would come in with their patients to translate because almost all of them did not speak English. He would on occasion give the residents a small cash stipend for delivering his patients. He also once a year would take all the residents out for a fabulous meal in Chinatown which we all enjoyed immensely. But to be honest it was the money that we appreciated the most. It was always interesting to see him in the recovery room after his patient had delivered. By custom, the husband would pay him at that time in cash. It was quite a ritual to see take place. I can still remember the money being counted and the traditional bows of respect and thank you. Chinese  patients were very stoic when it  came to their pain tolerance in labor. They would barely make a sound despite labor usually being a very painful experience. It was quite a contrast to the Spanish patients who were very loud. One interesting thing we began to notice with time was that, when they reached full dilatation of the cervix and began to push, they would frequently smile because they knew the end was near. So the moral of the story is if you see a Chinese patient arrive in labor and she was smiling, you better be ready to deliver that baby quickly. I enjoyed taking care of those patients very much not just because they were quiet, but they were very respectful of the physicians who cared for them. They were very appreciative to have a doctor care for them in a hospital, which was a rare occurrence in their native country of China.

      One of the other rituals that took place in the OB department was the monthly meetings at which time complications were discussed and cases reviewed. We would also review every physician's cesarean section rate. At that time, programs and physicians were rated on how low their cesarean rates were. Years later when I went for my board exams the rates were also reviewed and felt to be a reflection of your skills as an Obstetrician. Quick to cut and impatient Obstetricians were easily recognized. High cesarean rates were a sign of a poorly trained and inexperienced Obstetrician. Numbers between five and 10% were commonplace as opposed to more recently where rates between 20 and 30% are not unusual. Those physicians with rates above 10% had all of those cases reviewed and criticism was quite harsh at times. Overall department  rates were composed mostly of clinic patients delivered by the residents and  the chief residents were graded partly on how low those rates were. But, of course, that was before malpractice cases began to skyrocket and, as a consequence, cesarean section rates began to soar as doctors practiced more defensive medicine. I will get into that subject in much greater depth later but it was a unique combination of years where I was able to see the changes that resulted from lawsuits and how they have influenced the practice of medicine, in general but, particularly, in Obstetrics.

      As my time in Obstetrics came to a close, I looked  forward to doing surgery on the Gyn rotation. The Chief of Gyn was an older gentleman who was feared and demanded more from the residents than  almost any other physician in the department. He would begin rounds on the Gyn ward every weekday morning at 7 AM sharp, which meant I was to be there an hour before making sure that I knew all the patients. It was the job of the junior resident to present every new case to him and then, like in medical school, the fun would begin. Questions were tough and probing but always fair and with a  purpose. I distinctly remember how nicely he would speak to those patients and he was a great role model for me for the future when it came to taking care of non-paying clinic patients. To him, they were no different from private paying patients  and that is exactly the way it should be. That was one of the many things he would teach me, but it certainly was and remains a very important lesson for which I am grateful to him.  Dr. James Nealon was another example of the many wonderful, principled people I was fortunate enough to be exposed to in my career. In addition to a skilled surgeon he was a true gentleman.

      It was the job of the senior residents to teach us to perform minor surgical procedures, the most common of which was a dilatation and curettage of the uterus or popularly known as a D&C. No, that does not stand for a dusting and cleaning but, rather, to dilate the cervix and curette or scrape the lining of the uterus. I was going to perform that operation thousands of times in my career but at that time I was finally the one who was  doing the surgery on MY patient. What a thrill it was to finally be in that position. I remember the first time that I signed an operative report that said surgeon - P. Ketelaar MD. I had worked so hard to get there and I was enjoying every minute. The thought that a patient's life was in my hands was a tremendous responsibility that I did not take lightly then or now after many years. As I learned other procedures, I started to feel more and more confident. There was always more to learn however and it is always a humbling experience. As the senior residents or the attending were performing those operations, I couldn't wait until it would be my turn. I would have to wait a while however for that experience. Chief residents wanted to do as much surgery as possible, so there was little left over for us novices to do other than the minor operations and wait for our turn.

      I would like to relate some interesting stories that took place on the Gyn rotation. The clinic was where we saw patients for checkups, Pap smears, and gynecological problems. We also did a number of minor procedures, like biopsies of the cervix. Well, the story goes that an intern was doing a cauterization of the cervix and inadvertently, instead of using an antiseptic, mistakenly prepped the vagina with an alcohol solution. When he activated the heat cautery unit, it suddenly ignited the alcohol and flames shot out from the patient's vagina. What a sight! You can’t even make this stuff up! That story has been related to every new intern and resident on the service as a word of caution. Everybody usually also wants to know how the fire was put out, but I'm not going to go there. The patient was injured but not seriously. Unfortunately it turned out to be a big lawsuit for the hospital and, while I feel sorry for the patient, it certainly is an interesting story to perpetuate. Being in a city hospital in Greenich Village  certainly allowed us to see some strange things. There was a young man who was a cross-dresser who periodically would try to gain access to the Gyn clinic. It was funny to watch the new interns take a history from her/him and then their total surprise when they began to do a physical exam. As I said, we were exposed to many unusual things there and that was just one of  many. He was a nice young man and, over the year, I would have to escort him out many times unless we had a new intern we wanted to have a little fun with. I remember one intern in particular who took his history and then went into the other room to do an exam. A few minutes later he came running out of the room screaming “she’s a guy”. He always played along and I'm sure he enjoyed seeing how far each visit would go.

      About midway through the year I was shocked to receive a letter from the United States Air Force informing me that I was being called to active duty. As a medical student, I had signed up for what was called the Berry Plan. Because the country still had a draft system during the Vietnam War years, that was a way for a specialist to be deferred from active service until their residency was completed. The military needed fully trained specialists and this was the way they got them. It sounded like a good thing to do at the time so, during my internship, I was commissioned a  Captain in the Air Force Reserves in Newark, New Jersey. I never gave it another thought until I received the letter stating that, because of the shortage of physicians in the military,  that I was going to be activated. I remember the sinking feeling as I read the letter. Was I going to be sent to Vietnam like many of my nonmedical friends and how was it going to affect my residency? I wasn't afraid to serve my country or even go to war, but it came as such a shock at that time in my training. Would St. Vincent’s be willing to hold my position until I returned from two years of service to our country. So I made an appointment to see the Chief of the Ob/Gyn Department and I had much anxiety about what he would say. Fortunately he had also served in the military as a young man and was very understanding. He told me I was an excellent resident and that they would save a place for me when I returned. Well, that was one hurdle but I had to wait to see where I would be going and what I would be doing as I was only a partially trained Obstetrician. So once again my life was turned into tremendous turmoil and someone else would decide another path in my life. Little did I know then that it would turn out to be two of the best years of my life. But it was still a pretty scary time as I pondered the possibilities. The letter said that I had to report to the Pentagon in Washington, DC, within 30 days for assignment.

      So a week later I took a day off and journeyed down to Washington to find out more information. As I navigated my way through the Pentagon I was beginning to accept my call into the military.  I met with a Major in the medical corps who informed me that I was to report to Sheppard Air Force Base in Wichita Falls, Texas, on July 2 for the physician version of basic training. As part of the interview he asked me if I had any preferences as to where I would like to be stationed after that. He did say that it was highly unlikely that I would get my first choice, but I mentioned that I preferred to serve somewhere on the East Coast. That was to prove to be a fortuitous request and would ultimately have a great bearing on where I would be assigned. He informed  me that because I had not completed my specialty training that I probably would be assigned as a general medical officer or GMO and, unfortunately because of the tremendous demands of the Vietnam War, that was probably where I was initially going to go after basic training. When I returned home I called my parents and told them after which my mother cried for days. She worked so hard to put me through medical school and now I was going off to war with a chance of not coming back like some of my friends from high school and college. I had always been raised with a tremendous love of my country and I still feel that it is everyone's duty to serve in some way. Once I knew what was going to happen, I accepted it and even looked  forward to the experience but not without some obvious concerns. So as my first year of residency drew to a close I said my goodbyes to my teachers and friends. They all wished me well as I prepared to enter the military. And, oh yes, I said goodbye to the gorgeous redhead I had met and wondered if we would ever see each other again.