University Hospital was erected some years after Man’s Greatest Hospital —  with the vision of its leadership — to satisfy the needs of many. Namely, the financial supporters, trustees and patients of course. The hospital’s motto was to “Make hospitals great again.” Patients were provided window rooms to see the sunshine directly from their beds through the maze of their eyelids, delirium and the blinds. Some even had a view of the busy traffic and wailing ambulances buzzing past below.

Lobbies were built to exude awe and attract donation dollars for their grandeur. Walking through the halls was like walking through a theater: the curated set telling the tale, a beautiful distraction from the disarray and filth behind the drapes of the staff corridors. Large conference rooms and suites were created with lavish woods, supple leather armchairs, long glossy tables and framed paintings of old physicians in white coats that donned the walls for the C-level executives (or better, Chiefs of Everything) to look at their reflections as they spoke. All details and stakeholders were taken into consideration in this design with the exception of the poor, insignificant ones who actually run the place: the housestaff (or as some progressive institutions call them, ‘residents’ — because it has so much more positive of a connotation). These rooms are not for the housestaff members. They are not welcome here.

When the fat dollars came rolling in every few years, despite its debts, the hospital would build a new tower that would be equipped with the latest technology and designs. There would be no space in the budget to renovate the old. It was “on with the new.” First, there were long corridors of bunker rooms with two peas in each pod. A man with liver cancer and a woman with diabetes could find a new romance in a serendipitous admission. Later, hospital executives took those rooms and made their size comparable to shoe boxes in order to be compliant with the “Human Interaction Prevention and Patient Privacy Act” and advertise “private arrangements.” If family members visited, the room for breathing was tight and the stench after their departure lingered.

Eventually, the Chiefs of Everything determined that the nurses were walking too far from their computers and the electronic hell record (EHR) to see the patients for who they cared. Something had to change! Everything had to become strategically efficient a la Lean Six Sigma. That’s right: for safety and efficiency, a new tower went up. This time, the “powers at be” convened in a circle around the nursing stations on each floor. This way, the doctors would round all day in circles and never find their way out of this impossible citadel.

The patients were accommodated in this first, outermost ring of hell. They were the ones in limbo who were ill and paying so they got the window rooms. This way they could see the sun and the world that they had left behind. Near this, the circular corridor was the location where the teams huddled, learners were pimped, and the interns furiously wrote “checky boxes” for the day. The corridor itself was an obstacle course to make sure all were awake during rounds. The teams would navigate the random machines, computers on wheels (COWs), pumps, chairs, walkers, and whatcha-ma-call-its with more finesse as the year progressed. Allowing them to be close enough to serve their ailing ones but far enough away to leave patients’ machines beeping without annoyance, the third ring of hell was for the nurses and their stations. Finally, the core of the building proudly boasted a windowless, cramped, shared workroom in the middle of the unit adjacent to a tiny, filthy toilet room where it was not uncommon for a pager to fall from a belt or pocket and into the sewer. This was the space reserved for housestaff. 

This Dante-inspired architectural triumph speaks volumes about how those in charge feel about the housestaff. The funny thing is that the housestaff thought they were the fortunate ones, and were unaware that they had agreed to work in an enclosure unsuitable to even be seen by any stakeholders. After graduating from the Ivy League, housestaff must be 1) humbled and 2) trampled. They’re just doctors and not even good ones yet. Why waste valuable real estate on them when they don’t even make relative value units?

The housestaff are not significant enough to be considered by name. They are just numbers that keep the institution’s numbers rolling. Dr. 3853 enters the House this morning looking fresh with a cup of joe in a jar, the bags under his eyes neck-in-neck in size with the one hanging off of his shoulders. Doc has survived ‘ternship and was starting a fresh new day, dark and early, at the 65th hour of that week. 

It’s 2020, and interns are things of the past. They’re medterns, oncterns, gynterns, surgterns. The titles just roll off the tongues for their superiors — much like feces roll downhill toward them. Also, these millennials should be silent and not complain. Elder physicians believe that these housestaff members are “soft” and treated very delicately compared to “back in the day.” A few years ago, the American College of Graduate Medical Education placed a time limit on the job: 80 hours per week averaged over four weeks. If residency programs did not abide by this new constraint, they would be reprimanded, and their accreditation, and more importantly, reputation and funding would be on the line. Naturally, housestaff were forced to start to fudge the numbers. So, on paper, this is hour 65, but in reality, it’s hour 83. Those directors have to keep their hands clean and the operation illegitimately “legitimate.” 

Dr. 3853 schleps in every day armed for a journey. The pack on doc’s back, compressing his spine, is overflowing with a laptop, water bottle, breakfast, lunch, snack, dinner, crinkled patient face-sheets, scribbled notepads, an extra sweater, expired over-the-counter analgesics, phone chargers and OR shoes. He knows not where his belongings will go. He has to pre-round, write notes, then round, then go to the clinic across the way, write more notes, then return for afternoon rounds, finish notes, and sign out to the night riders before the day is done. 

In a rush to prep for rounds, Dr. 3853 puts everything down, dons the once pure but now stained white coat in the same manner as his team, and drops his bag right on the floor with all of the filth that didn’t get mopped up this month. The perfect place for a fomite! If one looks closely enough at the walls beneath the desks, the scuff marks and coffee splashes from the years gone by are like a modern Rorschach.

It doesn’t matter if housestaff members dot their I’s or cross their T’s. The sentences written in patient notes and charts don’t even have to be sensical anymore. It’s not like the housestaff members’ brains have the energy to do that anyway. The goal is to fill as many boxes of auto-populated nonsense into the longest note possible and make a really expensive “problem list.” Without ever reading the content of the gibberish, those who bill for services rendered will tally the problems, accept the note, and keep the money flowing. If there is anything missing that could cost a dime, the billers make sure to flood residents’ in-baskets with reminders. 

Let’s take a look at the inpatient workroom in the mid-century tower as Dr. 3853 sits furiously clicking F2 into the EHR to smart select the words into his note. Some specialties just don’t fit or make the buck, and it shows. They say in real estate that location is everything. Try being a generalist in a specialist world, and one will see that location, like profit margin, is subpar. This doctor’s decision to practice in an earnest, generalist field often comes into question when the sub-specialists walk by in a pack, wearing the latest matching monogrammed name brand “fruit” scrubs, heading to their special lounges donning the expressions of “You can’t sit with us” similar to a scene straight out of Mean Girls. Really though, the Chiefs of Everything should be wearing the fig leaves to cover their absurd understanding of how the place works.

One day, a Chief of Everything walks by the workroom during a review and notices bags on the floor. There are a million arguments that this Chief can make for why this bag didn’t have to be put on the floor and instead blame this young doctor for obstructing valuable square-footage. He believes it is a lazy, millennial “choice” and asks “What about the desk?”

In his head, Dr. 3853 would like to say “Ah yes, the scantest surface shared by many hands and home to the computers, long since invaded and occupied by the endlessly reproducing dust bunnies and a barrage of empty styrofoam cups.” 

“What about the hooks behind the door?”

“Those that are overflowing with the symbolic coats of a time past that now drag onto the floor, much like their souls. Anyway, most of these are from doctors long-since graduated and forgotten. No one had cared enough to look.”

“Really? Even 2nd graders have cubbies for their things.” 

“Didn’t they tell you that residency is the ultimate regression in your training? For some, even their spouses pack them PB&J for the day.”

“What about the locker room?”

“A mile and a maze away if you’re lucky enough to have one. The housestaff members are too glued to their pagers and computers to have enough time to make it back there if they need anything.”

“The lounge?”

“Oh, don’t get me started…”

“What about it?”

Sure. One could picture the resident lounge and may imagine a scene out of Grey’s Anatomy. Ideally, it is an academic, dorm-like common room with couches, a working-order coffee machine, water fountain, weights, a few recent medical journals, and some desks: a functional and safe space for work, rest, and Dr. House-like academic discourse.

Inconveniently isolated at the farthest end of the unit, the real resident lounge shares a dual purpose as one of the team workrooms. It’s the patient room that was converted when the residents of yesteryear complained. Here — as punishment for their asking — is a 6’ x 8’ cell with a small, narrow and tinted window, too few lockers for its inhabitants, overflowing ‘mail’ slots, an icing of dust, and textbooks so old that they may soon be of historical value.

For those who do not fit into this protected space and astutely choose not to cohabitate with patients, there is only one other viable option. In an effort to help with collaboration, some person, who never really worked here, is credited with developing the shared interprofessional break and workspace for housestaff and nurses. “It’s good for patients,” the Chiefs of Everything say. That’s not entirely untrue. The term “interprofessional workroom” sounds like an intuitive, maybe even innovative euphemism to mask that the Chiefs of Everything are cramming in more patients for the square footage by forcing the staff to make the big squeeze. 

This space is the place where beeper pages come to life instantly, no longer only interrupting with a beep, but now, a human face demanding answers and halting the housestaffs’ thoughts altogether. Note pended! How many “doctor aware” notes will be charted that one can no longer recall ever even processing? Now, focus is doomed because one cannot help overhearing Nurse 27514’s personal life. If one dares to ask them to lower their voices, one will almost certainly pay for it later by midnight pages from the same group members to ask if they can administer the PRN acetaminophen that has already been ordered to avoid this very situation.

And while these housestaff members are here, let’s really take in our surroundings. The room is arranged in a circle with working desks, as formerly described, occupying the circumference and surrounding a large table with a medley of stained and broken chairs. The shelves over the desks are overflowing with nursing manuals and a mix of expired sutures, instruments, textbooks, and garbage in no particular order. The arrangement is a demonstration of entropy itself for the pre-meds. Housestaff members had better watch their heads there while they type for it may come tumbling down.

There are papers taped up like graffiti: abrasive and unsightly which all seem to be screaming the latest policies, EHR requirements, and reminders. When a new policy is unrolled, it gets added to the walls so they continue to close in. There are so many layers of tape that your fingernails would fall off trying to take them down. Even the old refrigerator moans and lets out a sigh with its nauseating halitosis every time someone opens its door. Whose responsibility is it to clean up when no one is responsible for the place?

Out of the kindness of his heart, Dr. 3853 peels away from the computer when he could feel the student’s curious eyes burning the back of his head. Doc remembers what it was like to want to learn and to be eager despite the drudgery that abounds. There is hope. After all, this is University Hospital where we teach the future of medicine. It is always innovating new and better ways to do everything. 

Doc looks around to draw out an algorithm to demonstrate how he had so astutely made a diagnosis at first glance. But gone are the days of chalk talks and oral discourse between the master and the pupil. These are the days of the quickly repurposed and ill-designed PowerPoint and its sidekick the overpriced question bank. There is no chalkboard in this lounge. There is no whiteboard. Doc and his pupil decide to go for a walk to find a place for learning. 

The medical school is closed at this hour so they take one of the many staff stairwells. This one is new for the student. It was new to Doc last year when an attending physician took him as a shortcut to the cafeteria. I guess the housekeepers forgot it existed since it hasn’t been cleaned in at least 10 years. Maybe it is a secret stairwell for starving doctors and was just never in the blueprints: a gift from the past! The team members get excited when they find a new whiteboard in the interprofessional workroom, but it’s not what they think. This one is not for their learning. It’s already all marked up with the details and monitoring of the latest safety and quality initiative for the Chiefs of Everything to show that they’re making things better (by making the people at the bottom fix it). Who needs good old-fashioned learning? Scribble it on the back of your prescription pad why don’t you? That’s right. You don’t have one. They’re left to doodling on the back of a patient face sheet. 

Some time goes by, and finally, it’s the end of the day. The rocks have been tucked into their garden. The electronic hell record has been thoroughly updated for the umpteenth time. The night riders have been filled in so they can babysit until dawn and hopefully keep everyone alive. Doc gathers all his things and carefully refills the sack to throw on his back which somehow seems heavier than before. Maybe it’s just the weight of it all. Doc walks with slumped shoulders down the hall and into the dark lot leaving the “house” — tall and shimmering with the lights still on — behind. It is time to go home, for now.

Editor’s note: This satirical piece is a work of fiction and is published under a pseudonym.

Image credit: rectangles by Dean Hochman is licensed under CC BY 2.0.