Shivering in the brisk October air, I stood clutching a small pudding cup, licking the plastic spoon. Standing — no, hiding — on the roof with a friend and colleague, we stared out at the inky midnight darkness of Central Park and the buildings and streetlights of the Upper West Side and beyond, finishing our snack. Chocolate, yum. While this might be how TV networks portray a similar scene, this was not how I imagined my life as a doctor.
At the time, I was a second-year resident in pediatrics at Mount Sinai Kravis Children’s Hospital in New York City, and that night, I was on call in the neonatal intensive care unit (NICU), where premature or otherwise very sick infants come after birth. We had finally confirmed that one of my two-day-old patients had been born with non-functioning kidneys — a condition that is, in doctor-speak, “not compatible with life.” My job was to keep him alive until morning, at which point his parents could come and peacefully hold him and say their goodbyes while we would discontinue life support and he would die in their arms. Keeping a child already marked for death alive knowing the scene you’ll witness in the morning is gut-wrenching; not anyone’s idea of a good or even tolerable experience.
One of my co-residents (I’ll never remember exactly who it was)1 saw me struggling to cope with all of this and took me aside. “Come on, let’s go get pudding.” She led me up to the 8th floor obstetrics postpartum area, to a fridge in the patient and family pantry that was filled with pudding snacks. A chocolate pudding cup and spoon were thrust into my hand, and, ignoring my slack jaw and incredulous face (how could I not have known?! pudding!), I was led up to the roof.
The roof deck on Mount Sinai’s children’s hospital is usually used as a public space for residents to relax or eat lunch. It is hardly a secret space. But that night, with the pudding and the emotional baggage of the day and evening, it felt like our own private corner of the world, our little secret.
There are times it’s helpful to talk and process. This night was not one of them. At that moment, I was just trying to go. Away. Somewhere. Anywhere but that hospital on that night. And the pudding, the roof, the late hour: they all transported me briefly Somewhere Else; away from the hospital and its burdens, its responsibilities. After an indeterminate time that can’t have been more than five minutes, I finished my pudding, went back to the NICU, and finished my shift as I’d been trained to do, dutifully keeping this baby (and about 10 others I was responsible for) alive. We disconnected his ventilator at 9:00 the next morning, just before I left to sleep off the 24-hour shift.
Working in a children’s hospital can be an amazing and wonderful thing. Many times, I’m helping sick or dying children get better. But there are the awful and intolerably sad times when they don’t. At those times, the overwhelming human urge is to just escape, to get out of the hospital. As this is often impossible, we do the next best thing: we go somewhere that we can pretend is not a hospital, where we are not surrounded by death or sickness, at least for a while. Ideally, this is somewhere we won’t be found, or at least won’t be looked for, though it does not necessarily have to be truly secret or exceptional. Rather, these are ordinary places where extraordinary mental gymnastics take place to allow us some reprieve to cleanse our minds and go back to work five minutes after being told we will spend our morning watching a child die.
A view to die for
The first time I discovered one of these spaces was in my fourth year of medical school. I was rotating through the pediatric ICU at Morgan Stanley Children’s Hospital of NewYork-Presbyterian at Columbia University Medical Center, and I was working the same 24-hour shifts as the residents. I had been up all night, bouncing from room to room, patient to patient, no chance to sit or lie down. I was getting the summarized overnight vital signs for the patients on our team when I saw the sun rise. Just peeking over the rooftops of Washington Heights, it had begun to stream in through the floor-to-ceiling picture windows in the parent lounge. I stood there for about 30 seconds, soaking it in, recharging, before I was summoned to rounds.
I went back to that lounge on other mornings, retreating out of the cold and dark that can consume a hospital filled with sick kids and into the light and warmth of the sunrise. I never did see the residents go in there, and no parents ever arrived that early to visit, so I was usually alone, hiding in plain sight. Once I went there after a child had just died, noting the irony of the new day this kid was now missing. Other times it was just a more comforting moment. But it became a routine and it was mine: my first experience with a special place to call my own, in which to escape from the hospital day.
Dr. Josette Bianchi is an assistant professor of clinical pediatrics at Stony Brook University Hospital, in the division of hospital medicine. For her, too, a connection with the outdoors, or a view, is important in a place to escape to. “The stairwells within the children’s hospital where I trained had a gorgeous view of the Nashville skyline,” she recalls. After a bad outcome, she used to stand in the stairwell with a colleague, staring out at this view. Even now, as an attending physician, she says she will often stand in the skybridge between buildings, staring out at the view of Long Island Sound, being transported by it to places beyond.
But not all find such a place early in their training. My wife, Ilana Harwayne-Gidansky, MD, a second-year fellow in pediatric critical care at NewYork-Presbyterian Hospital Komansky Center for Children’s Health, says that she never found such a place in medical school. “We rotated through so many different hospitals, it wasn’t on our radar,” she explains. “As a resident, you’re in one hospital for several years, and the senior residents know you’re there to stay, so I think they feel more comfortable revealing secret places. A lot of these places are passed down by residents.”
That such places are not institutionalized by the hospital but rather by the staff may explain why some find them and others do not. It also makes sense that many physicians have long forged their own ways of coping and sought spots to do so. Hospital administrators have only recently publicly recognized the stress burden that the workload puts upon trainees. For decades, residents and even medical students were expected to essentially live in-house, with few or no restrictions on work hours, no separation of work and home life. Recent changes in work hour restrictions — as well as recent improvements to resident curricula, such as teaching coping strategies and training residents to watch for danger signs in those who aren’t coping — have helped make doctors more cognizant of the need to find better ways to deal with the stress. But they haven’t necessarily changed the places where we do it.
Paging Dr. Call, Dr. Ron Call
One place that most doctors have at their disposal to retreat to is actually institutionalized and provided by the hospital: the call room. Unlike what may be portrayed on Grey’s Anatomy, call rooms are not usually places you go to conduct an illicit affair with a coworker or where someone is beaten up or stabbed. They were originally intended simply to be places for doctors to sleep when they were working an overnight shift in the hospital, on call but also on site, ready to be paged to a patient’s bedside at a moment’s notice. For many, they have become so much more.
For Ilana, a fellow in the pediatric ICU, the high acuity of illness of her patients requires her to stay in the unit. There are no trips to the roof or to a window with a view. Instead, she simply goes to the call room and turns out the lights so she can be alone with her thoughts. I ask her where her thoughts go, what she thinks about. “Nowhere,” she says. “I don’t think about anything. I mean, it’s the silence and the solitude. I go there to stop, to get it to stop.” Even if a patient isn’t dying, the ordinary demands of the hospital day — the pages, the orders, the charts to check — can get to be too much. For her, there is no better place to get away than a dark room with a bed. Or, sometimes, a bathroom.
One of the quirkier yet more poignant moments in my interview with my wife is when she mentions going into the bathroom for relief — not that kind of relief, but rather escape. “There is a bathroom in the call room with a shower stall. This stall is probably the smallest space in the whole ICU, and, with the curtain pulled, the safest.” The safest from what, I ask. “From being found.”
I never escaped to bathrooms. For me, the call rooms, with the bunk beds we sleep on, evoke memories of summer camp. If I close my eyes, I feel like I’m back in the woods of Vermont, surrounded by teenage boys, hooting and laughing.
The one common thread in all of these examples has been a need to get away. But does this change over the professional lifespan? Trainees grow and learn. Single young medical students and residents become attendings, with jobs that need less of their time and attention — and more importantly, households and families of their own.
Home is where the mind is
These days, as an attending done with my training, I don’t as often need a special, secret place to go. I go there every night, even when I’m on call — because now I take that call from my bedroom or living room. I get to see my wife, hug my kids and put them to bed, and truly bring myself away from and outside of the hospital and its mindset. I get to spend more time, physical and mental, at home. On the more rare occasions at work when I need to go Somewhere Else, I go to my office and look at pictures of my son or daughter, or the drawings they made for me.
Josette, who has a daughter, agrees that now she just spends the mental time she would have spent looking at a view or in a call room at home instead. She also has pictures of her family stationed all around her office, so if she has to get away while at work, she has a bit of home with her. Many other attending colleagues of mine agree, and even those without children will decorate their office with photos of their spouse or pet, or with jokes or cartoons. In the same way, they seem to have compartmentalized home as a way to balance the stressors of work.
As we get further along in our careers, we learn new ways of compartmentalizing. The physical spaces, which used to signal a transition to a different mental space, matter less than they once did. Many of us have to find new ways to flip the switch in our heads without being able to pull that shower curtain or close the stairwell door. But it takes time to learn how to do this, and how to rely only on home time as a counterbalance to work time. For trainees, those secret spaces are essential.
As Ilana and I talk about our personal histories with secret spots, she’s visibly more emotional, her voice quavering. “Our jobs are so hard,” she says. “You have to be strong for your patients. Even when you’re scared out of your mind, everybody’s looking to you to lead the team of doctors, the team of nurses, the patients, their families. They expect you to know the answer, even in the scariest of situations. And for me, I needed some place where all of that background noise and fear can go away.”
Patients sometimes wonder where doctors go when they’re not present on the floors. The best answer I can give is Somewhere Else. And if I were the patient, I wouldn’t want it any other way.
My memories from these bad nights are sometimes a bit of a blur, with moments of clarity around seemingly trivial points and utter blanks around the important details. The mind does funny things to protect itself. ↩
Saul Hymes is an Assistant Professor of Pediatric Infectious Disease at Stony Brook Long Island Children's Hospital, not far outside New York City. When he is not caring for children with infections, doing clinical research on antibiotics, or teaching the next generation of doctors, he greatly enjoys writing, and would have been a journalist or computer programmer in another life. He posts infrequent medical musings.