Internship is the year of residency that nearly everyone in medicine programs hates. Whether it was other prelims like me, who counted down the minutes until we arrived at our primary program; or the sad souls who hadn’t yet been matched with a residency program but who had accepted the position in the hope that it would buy them some time as they scrambled to reapply to a residency; or the folks who actually wanted to practice internal medicine and so swallowed the bitter pill of the first year and accepted its drudgery as conventional hazing—we were, after all, the scut slaves of the hospital. The first to be paged for everything, we ran around chasing electrolyte levels, refilling Tylenol orders, and preparing morning presentations—just a fraction of the duties we performed on minimal sleep.

The internal medicine program director I worked under, Dr. Jaiswal, was a forceful character. She was intelligent and skilled clinically, but not particularly nice. As we interns gathered for rounds, the morning ritual where we visited patients to check on their progress, we always knew when she was approaching by the click-clack of her shoes on the linoleum. She matched her sensible yet stylish kitten heels with jewel-toned suits that always seemed to be at least one size too large for her petite frame.

One summer morning, after I had been on call the night before, we would be starting with my presentation of patient signs and symptoms followed by the prescribed evaluation and treatment plans for anyone I had admitted overnight—at which point, I could go home to rest while the others on the team continued with rounds. The day before, Dr. Jaiswal had reamed out Helen, another one of the prelims, for her presentation on pneumonia, and Craig for his feeble attempt to present a patient with thrombocytopenia (low platelet count) in view of everyone in the vicinity of the doctors’ stations where we were rounding. Everyone feared Dr. Jaiswal, harboring a resentment toward her that bordered on hate. In the resident lounge, the comments made about her were brutal, and we complained incessantly to one another about how overly critical she was and how stingy with positive feedback.

While Dr. Jaiswal was less than forgiving of careless intern error, I had to admit that she was probably on point with her criticisms of Helen and Craig: Their presentations had been weak. And in her defense, she could tell you everything about her patients. For example, Dr. Jaiswal knew that Mr. Jones, who had been brought to the hospital in multi-organ failure, had suffered a botched knee replacement five years earlier. Fearing another bad hospital experience, he waited at home for three weeks with increasing knee pain and swelling before he allowed his family to call EMS to transport him to the ER for his septic joint. Also, she was a good diagnostician, and had even spotted in one patient acute intermittent porphyria, a disease rarely ever considered outside Discovery Health Channel’s Mystery Diagnosis or the movie The Madness of King George. And though she was brusque, if you could absorb her example, you had every chance of becoming a phenomenal clinician. Tenderness would have to be learned elsewhere.

On that uncomfortable summer morning in my first month of intern year, it was my turn. As our medical team headed to my patient’s room, I felt myself getting light-headed from a mix of sleep deprivation and fear. The walk from the fifth floor felt like a sprint. We were already on the seventh floor as if by time travel. Had we gotten on an elevator? I shuffled my papers, willing myself to remember everything I had learned about the patient the night before. (Dr. Jaiswal berated us if we glanced down at our notes during a presentation. Her logic: If we couldn’t retain the information on a couple of patients at a time, then we had chosen the wrong field.) Nervously, I reminded myself of what I knew: The patient had a history of high cholesterol and hypertension. He was on no medications other than Crestor, for his cholesterol.

“So, Michele,” Dr. Jaiswal said to me as we made our way to his room. “I hear you enjoyed a quiet evening. How lucky for you! Only one admission for us this morning? Well, we’ll make the most of it!” She smiled, baring even, white teeth behind matte crimson lips. (She always wore red lipstick, and the hue seemed to amplify her every word.)

Quiet? Had she just used the word quiet? When I’d walked into the hospital last night, it was as if I were walking the plank. Just three other interns and I were covering the ward, and I felt the usual dread of holding other people’s lives in my not-yet-capable hands. Two of my patients spiked fevers, one became hypoxic, one had chest pain, and another went into a rapid heart rate, which made me go into an even faster arrhythmia. There was nothing about the evening that had felt quiet, and now I didn’t feel “lucky,” either.

We reached the door to the patient’s room and gathered around. I cleared my throat and began to present. “Mr. Frame is—”

“Oh, no, no, no,” Dr. Jaiswal said. “Let’s go in. Let us see the patient. Very important to actually go to the bedside and see the patient you are caring for. Assessment starts at first glance.”

She couldn’t be serious. Not only did I have to present to Dr. Jaiswal after I had been up all night, but I had to do so in front of the patient? As Dr. Jaiswal ushered the team inside the room, there was no time for me to anticipate the myriad ways this could all go terribly wrong. With a swiping motion of her finger, she indicated where each of us, obedient sheep that we were, should stand around the bed.

“Good morning, Mr. Frame,” she said to the patient. “I’m Dr. Jaiswal, the head of the medicine team who will be taking care of you. I hope you don’t mind that we will be discussing your care right here with you.”

“Not at all. Nice to meet you all,” Mr. Frame responded. He was a nondescript, middle-aged white man with dark hair and a medium build. The spotlight of my having to discuss him to my supervising physician at his bedside gave him a new level of distinction.

“Hello, again,” I said, nodding to the patient.

Then I began anew: “Mr. Frame is a fifty-nine-year-old male with a history of hypertension and high cholesterol with a chief complaint of worsening fevers, chills, cough, and nausea who was admitted with a liver abscess. He had been treated for this with two courses of antibiotics before coming to us. He completed a ten-day course of Augmentin, and then his primary care provider changed him to a course of Clindamycin. He was on day seven of ten when he presented last night.”

“Dr. Harper, this already sounds very strange. Who was treating him?” Dr. Jaiswal asked.

“His primary care provider.”

“Just his primary care provider? Huh. And what was he being treated for?”

“As I understand it, it was for a liver abscess, until his doctor sent him into the hospital last night.” In my mind I scrolled through my notes, but I feared they wouldn’t help. I didn’t know. I hadn’t adequately reasoned through the case. “Um, yes, I seem to remember that it was only his primary care provider who had been treating him before he came in last evening.”

“Does that strike you as odd? Why would his primary care provider take this course of action to treat him, as a sole provider, with only oral antibiotics for a liver abscess? There’s something missing here, something missing in the history. It simply doesn’t make sense.” Dr. Jaiswal paused as if to give me space for an impossible redemption.

I could hear each intern’s bated breath and the rustle of Mr. Frame’s crisp white hospital sheets as he shifted in bed. The air was humid and stale with the smell of half-eaten toast from the breakfast tray at the foot of his roommate’s bed. In the hallway, nurses opened and closed cabinet drawers for the morning medication administration. The housekeeping staff knocked on doors asking permission to clear trash. Against the backdrop of this din, I stood in the cramped room in front of a ring of interns and our resident, floundering for answers I didn’t have.

Finally, I spoke. “Well, the patient had a fever with his infection and continued to have fevers through the Augmentin, so the physician changed him to Clindamycin.”

“Huh? What testing had been done prior to his presentation?” she asked.

“As I gathered from his history, lab, and radiology results the patient brought with him, his primary care doctor had completed blood work consisting of a CBC [complete blood count], basic metabolic panel, blood cultures, and also a chest X-ray. There was a persistent elevation in his white count and a small pleural effusion on the chest X-ray.”

Dr. Jaiswal grimaced. “Uh-huh. Dr. Harper, you are clearly missing some critical information as well as basic medical knowledge, which has degraded your presentation and assessment here. Proceed for now, and we will get back to it,” she directed.