The Internship Year

When I graduated in December 1949 it wasn't mandatory to spend a year doing a supervised internship before being granted a license to practice medicine independently – that became the law a few years later – but it was unusual for new graduates to go directly into practice.  I think only one of my classmates did so, joining his father and others in a small group practice. Adelaide followed the prevailing pattern of Australian medical schools and those in many other countries, with a system of rotating internships: new medical graduates moved through a series of supervised training positions usually at two-month intervals. All posts included general medicine, general surgery, many provided 1 or 2 months in ‘casualty’ – the emergency department – and some included anesthetics.  I had all these, and one month each of orthopedic and neurosurgery, infant care, and long term chronic care.  It was a good mixture of experiences but by no means the best. The ‘best’ rotations went to the top graduates, who had first preference among the clinical chiefs, that is, it was based on performance in the final examinations. I did well in all but one exam, my internal medicine ‘long case’ clinical (practical) exam, in which I failed to detect an elusive heart murmur. I passed that clinical examination by a hair’s breadth, and consequently graduated some 10-15 places lower than otherwise would have been my fate.   

I graduated well enough to get a reasonable rotation, not well enough to get the pick of the best of them. I was happy at the thought of being able to put behind me the long hours of study, and bewildered, even dismayed at the prospect of having to decide what I wanted to do, medically speaking, with the rest of my life. It was assumed that whatever else we did, most of us would first go into general practice, and I did that before the ink was dry on my medical degree certificate, working as a relieving GP in a country town about 50 miles north of Adelaide. It was a scary experience. On my first night in that practice, I had to deliver a baby, which went well enough; but then the placenta wouldn't deliver, and all the time the woman was bleeding, first a trickle, then more, then yet more and more until I began to worry. It was probably all perfectly normal, but I had never delivered a baby without somebody else standing by, and here in the labour room of a small country hospital, I was utterly alone - the duty nurse had gone off about her business, leaving me to fend for myself on a hot and sweaty night. It was my first medical "emergency," a self-made emergency. It ended safely in due course after what felt like hours, was actually less than an hour. It was the beginning of a stressful few weeks.

Another experience in that practice introduced me to medical ethics, on which we’d had a single lecture near the end of our final undergraduate year. The lecturer, an elderly former president of the state medical association, warned us against sexual involvement with our patients, told us we must never procure abortions, and gave us a tutorial on how to complete official documents like death certificates. That lecture didn’t prepare me to deal with a task my boss assigned me on my first day in the practice: I was to give a 40-year old woman daily injections of penicillin but warned on no account to tell her what the injection was or why she was getting it. She was having a course of penicillin because her husband, the mayor of the town and my boss’s golf-playing partner, had brought back some gonococci as a souvenir of a business trip.  She wasn’t stupid. The first time I saw her she asked me if I was giving her penicillin, and was it because her husband had given her a dose of the clap. I was truthful. I answered “Yes” to both questions.  All hell broke loose.  I was almost fired on the spot, saved only by the hard fact that my boss would not have been able to get a replacement for me, and was leaving next day for annual holidays.  I learnt the importance of telling patients the truth – a task my boss had failed dismally to perform.  I was young and inexperienced but I knew he was in the wrong and I was not.  It didn’t help but it did make me feel better.

My internship year was much like those of more eloquent writers than I who have devoted books to the subject of this rite of passage into the medical profession. We worked intensely hard, often going without sleep for a couple of days, getting rich and varied experience. I mastered several techniques: giving complex anaesthetics, inserting needles for intravenous sedatives into tiny veins on the back of the hand, even the back of the forefinger, passing endotracheal tubes, doing minor surgical procedures like removing sebaceous cysts, and common surgical operations like removing acutely inflamed appendixes, repairing simple inguinal hernias, reducing simple and compound fractures of the wrist, ankle, forearm; and the minor procedures of acute medicine - lumbar punctures, putting up intravenous drips, etc. I soon became competent at these technical procedures, and got better too at dealing with people, the part of the work I enjoyed most.

But I remained undecided about the ultimate direction in which I might move as my medical career unfolded into maturity. My experiences included both extremes of age: I started the year at the Mareeba Babies' Hospital, a semi-chronic care institution, full in those days of sickly infants with the mysterious condition called Pink Disease, not identified until some years later as mercury poisoning caused by ingesting mercury in teething powders. Later I had a month at the Magill Old Folks Home, a chronic care division of the Royal Adelaide Hospital, where the incurable, “boring,” elderly kinless were sent to die a lingering death. We all hated this posting, it wasn't “real” medicine, we had the perception that there was nothing we could do for these patients; all too often they died at night, and we had to get out of our warm beds, drive all the way out to Magill, and certify that they were really dead. How callous and uncaring we were! The highest aspiration that some of us who did that rotation could imagine was to find witticisms to add to the voluminous case-notes that had accumulated about many of the patients who had been there for years. Looking back now I cringe with embarrassment and guilt at my callousness and lack of compassion.  

In other ways the month at Magill was a time to relax, there were few emergencies and nobody harassed us, so we could enjoy the beer-sodden party life of the residents' quarters. We played as hard as we worked, much influenced by role models, registrars (senior residents) a few years ahead of us, who had themselves learnt how to live it up from their predecessors. We had the doubtful privilege of being influenced by some men of an older generation, who had been away at the war and had returned to the teaching hospital system to learn from those who would examine them for the higher examinations in medicine, surgery, obstetrics etc that were required before becoming bona fide consultant specialists. Some of these men were really wild, letting their hair down after stressful experiences during the war.  I had to treat one of them for an acute episode of malaria one memorable weekend (I made a blood film and saw for myself the malaria parasites and disintegrating red blood cells). He was on the way to a career in gynecology. Others were heading for internal medicine, or general or orthopedic surgery, having already done a great deal of war surgery; two who were our immediate seniors were younger surgical registrars who taught us how to drink beer, fry eggs in butter, spin dinner plates out the windows on the upper floors of the building where we lived (“Flying saucers,” we called these dinner plates as they broke with satisfyingly loud crashes, when they hit the ground or the building across the parking-lot if they glided far enough). One night two of them went into the Botanical Gardens that adjoined the RAH, swam under water in a duck-pond, and pulled down under the water a couple of mallards, drowning them before bringing them back for others of us to pluck and clean so they could be grilled over an open fire on the third floor veranda of the residents' quarters. They taught us also many dirty songs, and how to play billiards on the battered old table that had been part of the furniture in the residents’ quarters for generations. On another occasion, not during my time, some of them blocked the drain in one of the bathrooms, sealed the cracks in the door with putty, and filled the entire bathroom with water to window level, getting in to swim in the pool thus created through the window from the third floor balcony. All went well for a few days until the cleaners reported that they couldn't get into this bathroom, and had the door broken open. The resulting flood severely damaged the stored medical records on the ground floor of the same building... It was a long time before that episode was forgotten!

All but three of our immediate seniors were men. The demographic transformation had not yet struck the medical profession. My class was the first with an appreciable proportion of women and for some years it was the only one. Among our registrars (senior residents in modern terminology) there were 3 women, a neurosurgical trainee, an anesthetist and a woman heading against strong opposition into obstetrics and gynecology, at that time an exclusive domain of men. The modern male-female 50-50 balance in the medical profession was still some 10-15 years away in the future. Several women in my class were among those who began to shift the balance.

That year as hospital resident was the first time I had lived independently away from home, cutting the ties that had bound me tightly to my home and my possessive mother. Probably the bonds had been unusually strong because of the combination of my mother's personality and the break-up of her marriage. She had always been unwilling to let me go, always insisted on a detailed accounting for my every action whenever I came home after being out of her sight. The year at the Royal Adelaide Hospital began to liberate me from this relationship, which only then I realized was stifling me. I began to realize then that this relationship was one way in which I was different from my peers, all of whom had broken free from parental surveillance many years earlier, often while still in school. 

The experience of so many clinical rotations in the short space of a year did nothing to help me resolve the doubts I still had about what kind of doctor I wanted to be. I enjoyed and was good at many of the clinical tasks I had to carry out, perhaps most of all the fine manipulative skills that required proficiency with a needle or a scalpel. Yet I was sure I didn't want to be a surgeon. Equally surely, I didn't want to be a psychiatrist. In those days, mental disorders were disturbing to contemplate and mostly they were mysterious and frightening, a great gap in our clinical training. I didn't learn anything about mental and emotional disorders until several years after I went into general practice, consolidated the little I'd learnt by targeted experiences during my epidemiological training. If I lent towards anything, it was the obvious direction that almost all of us took, towards general practice. Yet I had much uncertainty about this too, partly because I lacked confidence in my ability to function on my own, partly because the field seemed to me to lack much intellectual stimulation. I still wanted most of all to be a writer.

Late in the winter of 1950, just after the Korean War began, I escaped for a two-week spell relieving a doctor in a country town about 150 miles north of Adelaide and enjoyed this experience of general practice much more than I had when I had briefly worked as a country GP just after graduating. Yet I didn't feel ready to embark upon a career in general practice at the end of the internship year at the RAH. Like most of us, I applied for a six-month period as house officer at the Adelaide Children's Hospital. I also considered enlisting, joining the Australian contingent that was preparing to deploy to Korea. I've sometimes wondered how differently my life might have turned out if I had served in that forgotten, unfinished war.

During 1950, along with all the others who lived in the residents' quarters at the Royal Adelaide Hospital, I had many close encounters with large numbers of cockroaches. The building was infested big time. If one of us went into the kitchen of our quarters late at night and turned on the light, the entire table top and the benches beside the sink were a moving carpet of purple or black carapaces, long antennae waved as if gusts of wind blew across them; they made a sinister sounding rustling noise but were otherwise silent, unlike some of us, especially the women residents who had been known to scream at first sight of them, although like the rest of us they soon got hardened to the sight. The largest of them were two or more inches long and if we could suppress our disgust at the sight, they were really rather beautiful with their shiny carapaces and long, gracefully waving antennae.  Ten years later when I was learning medical entomology during my public health training, the delightful expert who taught that component of the course told us two interesting things about cockroaches: they are scavengers that clean up organic waste, much as carrion birds in India dispose of rotting meat from animal carcases; and, surprisingly, they do not carry any human diseases.  Cockroaches, therefore, do not deserve the revulsion they arouse in so many of us. Years later in 1978-79 when we lived in an apartment in Manhattan that was heavily infested with the New York variety of cockroaches we had many house guests and once when I was awakened in the small hours by screams of a squeamish woman who was staying with us, I tried to reassure her with these two facts about cockroaches. Not surprisingly, I failed to convince her. As for me, I admire them more than they disgust me.