Medical school graduates embark on rigorous residency program

   Dr. James Knutson winced when the voice crackled over his pager.
   “Code 9. Third floor. Code 9. Third floor.”
   Someone’s heart had stopped. It was Knutson’s first day as a medical resident at Signature Healthcare Brockton Hospital. He had been there just four hours, but would have to respond.
   He ran up three flights, his heart pounding, and scrambled to the doorway of the patient’s room.
   Knutson wasn’t needed. Others had already begun to restart the patient’s heart.
   “I got there just after the real doctors took over,” he said.
   Knutson is a real doctor — he just doesn’t feel like one yet.
   But he’s working on it.
   So are seven other residents, or interns, in the region’s only full-service hospital who are working, learning and healing as doctors-in-training for the next 12 months.
   In pursuit of their state medical licenses, they will rotate among the hospital’s different units — inpatient care, surgery, critical care, outpatient clinics, the emergency room, and electives of their choice.
   As medical students, they observed and studied other doctors. Now, having graduated from medical school, they will for the first time write their own orders, send for their own lab tests, and dictate their own treatment plans.
   They will be guided and watched, but for the first time, people’s lives will be in their hands.
   Knutson, 30, was one of the three residents on call that first night in June.
   He would be at the hospital until 10 p.m. — a 14-hour day — responding to non-life threatening emergencies until the resident on the overnight shift relieved him.
   The attending doctors — staff physicians at the hospital — are supposed to handle the life or death cases. Gunshot wounds. Heart attacks.
   But they could easily be a phone call away.
   Knutson knew anything or anyone could walk through the emergency room that night.
   But what was he ready for?
   “Just shy of anything,” he said, laughing nervously.
   “I have, sort of, all my worst-case scenario code cards and booklets,” Knutson said, his features turning sober. “We can also knock on wood and pray for a relatively uneventful night, that the citizens of Brockton are injury-free and avoid illness.”
   As a medical student at Wake Forest University, in North Carolina, Knutson had shadowed residents on call. So, this night wouldn’t be his first time on call — but it would be his first time calling the shots.
   “Nothing puts hair on your chest like the very first night of call, when you sort of barely know what you’re doing,” Knutson said. “That little bit of pressure makes you learn a little faster.”
   The stethoscope around Dr. Leah Palifka’s neck is the same one she started with in medical school.
   It’s not lucky or sentimental. It’s just the one she’s always used.
   Soft-spoken and thoughtful, Palifka, 34, is a corporate refugee.
   A Brockton native, she started her career as a biomedical engineer, but was drawn to the doctors she worked with in research.
   That feeling gnawed at her.
   “I just felt I wasn’t interacting with people as much as an engineer sitting behind a computer,” Palifka said. “At the time, it was a very hard decision because I had already gone through school and it required moving. And my husband wasn’t planning on being married to a doctor.”
   But Palifka was happier as she began her first day as a doctor.
   She was also 26 weeks pregnant — she will be the first resident to deliver a baby while in the 34-year-old program.
   Palifka is due Sept. 30. She plans to deliver at Signature.
   In her easygoing way, Palifka didn’t think beginning residency at the end of her second trimester would be unreasonable.
   Then she got tired. More tired, it seemed, than every other resident doing laps around the hospital for 10 to 14 hours each day.
   “I’m pretty much a zombie when I go home,” Palifka said. “(My family) doesn’t get to see much of me as a person.”
   But on her first day at the hospital, this hadn’t sunk in.
   Palifka was focused and attentive in the hallway with the other residents, as her group gathered around the attending doctor and listened while he ticked off details about her patient.
   It was an elderly resident of a nursing home who came to the hospital after repeated falls.
   She cradled his hand as she introduced herself: “Hi, I’m Dr. Palifka.”
   The rest of the week, she would repeat that sentence — it never got old.
   Before entering each room, Palifka would read a chart with a patient’s temperature, blood pressure, heart rate, breathing rate and blood-oxygen content seconds.
   Juggling three to four patients per day, which residents do in the ward, she would start most conversations the same way:
   “Have you had any trouble breathing? Any chest pain?”
   Then Palifka would check their feet — if they were swollen with fluid, it could be a sign of heart, kidney or liver failure.
   Some liked to joke around while she examined them. Some didn’t, and refused the tests she ordered as part of her medical plan.
   “It feels scary, but good,” Palifka said. “It was a lot of work to get here.”
   “The responsibility is now more on me than it was as a medical student,” Palifka said. “I’ve noticed it takes me a lot longer to do things like write notes — everything — just to make sure I have the bases covered.”
   She reread anything she wrote that day. Patient histories. Physical exam results. Medical histories. Recent status updates.
   On that first day, it took her more than an hour to dictate her findings on one patient to an answering service, a task all the residents must do for every patient.
   Palifka didn’t know it at the time, but in just three weeks, it would take her 15 minutes.
   “Of course I know how to do a physical and write a note — I’ve done that a million times in medical school — but I haven’t done it recently,” she said that first day. “You’re questioning whether you know the right medication or which labs or tests would be best for the patient.”
   As soon as the smell of sweat, urine and sterilization hit Dr. Justin Routhier, he knew he was back.
   It had only been a few months since Routhier, 26, had been in hospital wards as a medical student, but so much had changed.
   He had graduated on May 25 from medical school at Brown University, the Ivy League school in Rhode Island, his home state.
   Five days later, he got married in Boston’s Old North Church. Then, he and his wife, Jennifer, escaped for a two-week honeymoon in Bali, Indonesia.
   But here he was — trying to forget memories of paradise — back in his cornflower blue medical scrubs a day after his plane landed. Back in the hospital.
   Back home.
   “I was a little bit nervous yesterday,” he conceded. “(But) as soon as I stepped onto the floor and the smell hit me, I knew I was back in action and there was no turning back.”
   He was the only one who came to work in sneakers and scrubs the first day — the two-piece, pajama-like protective garment meant for surgeries but often worn out of the operating room.
   Routhier said he couldn’t summon the energy the night before to unpack and iron anything else.
   The other residents all wore slacks, button-down shirts, black shoes.
   But clothes were the last thing on Routhier’s mind.
   “It’s just the first day,” he said with an unshakeable smile. “You’ll see. Everyone will be showing up in scrubs soon.”
   He buzzed around the supervising doctor, who reviewed their cases for the day.
   Compared to Knutson and Palifka, Routhier had the largest caseload.
   He had four people in his care. He would check in on them all day, ordering a new treatment, reviewing test results and, he hoped, sending them home.
   The next day, it would start all over again.
   His first case was a young man with autism, who had recently had a seizure and had since become aggressive. Routhier and his supervisor disappeared inside a room.
   “Should I have psych talk to (him)?” Routhier asked his supervisor as they emerged.
   “I’ll find out who’s covering him,” the staff doctor responded.
   Even as he prepared a treatment plan for the patient, Routhier said the “doctor” title still feels foreign.
   “I still don’t introduce myself as Dr. Routhier over the phone,” he said. “Maybe because I’m shy about it and still don’t think I’m a doctor yet.
   “It’s kind of weird,” he later acknowledged. “I still don’t even really know where I’m going in this hospital.”
   At the end of their first day, the residents were all a little rattled.
   But they agreed — it wasn’t as painful as they expected.
   Yet by the end of week one, things changed.
   At a late Friday meeting, Dr. Dale Ellenberg, who runs the residency program, asked all eight residents to explain how they felt after the first week. He asked them to use the same pain chart employed in the ER, where patients rank discomfort from zero, represented by a happy face, to 10, a sad one.
   “I’m a two,” Routhier offered through a turkey sandwich stuffed in his mouth. It was the first thing he ate since beginning at 8 a.m.
   Sitting next to him, Palifka shrugged.
   “I’m about the same,” she said.
   Ellenberg tipped his chair back and looked to Knutson.
   “I started out as a five and went down to a three,” said Knutson “I’m back to five, pushing six.”
   It wasn’t being a doctor that was stressful, the residents said. It was working in a hospital — finding misplaced charts, navigating new computer systems, battling mountains of paperwork.
   “At this point, I feel like a person who doesn’t know any medicine,” Palifka said. “I’m trying so hard to get the notes done on time that I don’t feel like I’m thinking about medicine.”
   “I feel like I’m an idiot at medicine,” said Routhier, the Ivy League alum. “I hope that will get better.”
   Knutson said he felt like he has been “perpetually holding somebody up.”
   “I still have somebody in the (emergency department), I still have to discharge somebody,” he said.
   “But,” he added, “I have the luxury of being here all night.”