TV Medicine is often humorously awful. You can’t go more than a season of any medical drama or war series without seeing a tension pneumothorax reversal or chest compressions so bad that they should even embarrass the victim. Unfortunately, there are a tremendous number of errors made on TV medicine. Ever wonder how many? Luckily your TwoGreenDocs are here to tell you!
First, on the Medicine on TV series: Game of Bones - A Medical Analysis of the Game of Thrones. Today we’re talking about Season 7 episode 1, featuring a hilarious montage of Samwell Tarly beginning his “training” at the citadel. Now we’re not the first ones to point out that Sam is pretty much the equivalent of an intern in medicine (what I am currently doing). Watching that poor guy struggle through his daily tasks made me want to write up a little bit about what I do every day.
How is Sam Like an Intern?
In case you are not familiar with what an “Intern” actually is, I thought I’d give a brief description and history. In the United States, after finishing 4 years of medical school, medical students receive their doctorate (M.D. or D.O.) and begin training in their specialty. Most training programs, or “residencies”, are 3-5 years with some brave souls choosing to suffer through 7-10 years of residency and fellowship before they can begin seeing patients all by themselves. (That’s right: at a minimum, your doctor has gone through 4 years of undergrad, 4 years of medical school, and 3-10 years of specialty training!) During the first year after graduating medical school, everyone in residency is called an intern.
Up until the early 20th century, no regulated training programs existed in medical education. There was little to no regulation that dictated when a physician was done training. You could see patients without any supervision pretty much whenever your teachers thought you were ready.
In 1773, the managers of a Philadelphia Hospital began to take in hospital apprentices for training in order to immerse new physicians in healthcare so that they may learn how to better practice medicine. Over time, the title evolved to become “resident” because the trainees resided in the hospital and were paid nothing more than room, board and laundry services. However, as other hospitals took in their own residents, the limits of who was a resident and who was a licensed physician became unclear, and many programs were discontinued.
In 1889, inspired by European training programs, Johns Hopkins Hospital in Minnesota took in 12 men from the top of their medical school class to train them for one year and called them “interns.” By 1920, the American Medical Association released a position statement that internships and residencies are ideal for everyone entering the field of medicine. In 1911, Pennsylvania became the first state to require this training before practicing as a physician. Every other state followed soon after.
The intern year has always been associated with lack of sleep, depression, and emotional distress. In an attempt to make the experience more humane, mandates such as restricted hour limits have been discussed, although there is still significant debate about the issue. (link to our post). However as it exists now, the intern year represents one year of general medicine that virtually all medical trainees must complete.
Most medicine on TV portrays a highly inaccurate depiction of interns. For example, on Gray’s Anatomy, you see first year residents doing way more surgery or procedures than would be allowed. The lines are often blurred between students, residents, and attendings, which adds to the general confusion most patients have when they interact with medical trainees. However, believe it or not the Game of Thrones does a pretty good job when compared to other TV medicine.
On the first episode of season 7, Sam moves to the Citadel in order to train to become a maester, and we see him go through some repulsive and repetitive tasks that seems more akin to hazing than training.
Does this sound familiar?
Before I begin, a moment of disclosure. We want to make it completely clear that we love what we get to do everyday and appreciate the privilege of going through intern year (and all the other years) of training to be a physician. However, medicine is a very hierarchical system and if you can’t find humor in being at the bottom - then what’s the point? But know that this is all in jest.
Some of the comments we make are tongue-in-cheek, and serve as a way to point out the similarities and differences between real and TV medicine.
The first part of the montage shows Sam checking in or “rounding” on each patient.
This is pretty much exactly what we interns do first thing in the morning, every morning. While rounding we check in with each patient, ask how they are doing, collect labs and vitals from overnight and begin to think about our plan for this patient for today. We do a quick but thorough full body physical exam, and perform any special tests as indicated. Yes, during our morning rounds we sometimes even do the “gross” stuff like the digital rectal exam, genital exam, collect stool samples, or whatever is necessary if the patient requires it.
Then we round again with our “senior” residents, and then round yet again with our attending or “head” doctor.
And around and around we go…
Next, we see Sam looking exhausted and lugging around countless books into the huge library. He is taking care of the tasks needed to keep the Citadel running, so that it is ready for the next day.
This is also exactly what it feels like to be the night resident keeping the hospital running. On night float, we work from 7pm-8am (which means that we actually work from 6:30pm-9am) to provide coverage for many physicians. This means that we carry more than 40 patients, are required to carry around 7 or more pagers, and need to be on our toes to address anything and everything.
It’s a busy shift: nurses page us, patients call to us when we are walking through the halls, we are constantly looking up papers and guidelines so we can provide the best care and the right medication dose. Because we need to be prepared for anything, we keep tons of things in our pockets, and develop sore backs and tired faces by the end of a 14-24+ hour shift.
Now we see Sam serving up brown slop in the cafeteria.
Though we do not serve food to people literally, what we do on a day to day basis can very much compare. After rounding (the second or third time), we compile a large list of tasks we need to do for each patient for that day. These tasks vary: we place intravenous lines, order required imaging and labs, place tubes, call other doctors to talk about our mutual patients, we discharge patients, write notes, and call pharmacies. In between these tasks, we answer pages, order STAT labs if a patient’s condition worsens, we see our sickest patients, and follow up on all orders. Finally, we prepare a long list that includes everything we’ve done that day so we can inform the night doctor that takes over for us what is going on.
And sometimes, in between all these activities, we get to eat some soup.
Finally, after all his work, hours of blood, sweat, vomit and tears, Sam gets to speak directly with the head maester and asks for what he secretly wishes and dreams to achieve during his training.
And then he gets denied. Splendidly.
I cannot help but relate to Sam, as could pretty much every other resident. I have a cousin getting married in September and, with months of advance notice I asked for the day off (on a weekend, no less). Can you guess what kind of response I received?
After almost two weeks of significant back and forth with the administration and my chief residents, I was finally approved to have one day off. However, that gift came with some caveats... In order to accommodate my request, I am now working an overnight shift the day before and an overnight shift the day after the wedding, so I technically have a 36 hour period hospital free!
Oh well… It’s to be expected. This year, I will also miss another wedding, mine and my partner’s birthdays, Christmas, New Years, and pretty much every other holiday. My colleagues will miss major milestones in their children’s lives, not see their spouses for days at a time, and allow their mental and physical well being deteriorate in order to better serve their patients. But, that is what in means to be a medical intern in the United States.
So far, Sam’s experiences at the Citadel are uncannily accurate to medical training. There’s a bit of hazing, a strict hierarchy, and poop… Lots of poop. As far as TV Medicine goes, Game of Thrones S07E01 gets a High Pass. The only thing we thought could be improved upon was an utter lack Sam breaking down into tears because his chief resident yells at hi during morning report, although it's not his fault because he had 20 pages in the last hour and I couldn't find which of his 7 beepers that one came from, and the patient is totally okay so it wasn't a big deal, and you shouldn't yell at me in front of everyone... whoops. That might just be me. Anyways...
Just like Sam, I have no intention of quitting. I am exactly where I need to be in order to serve. I will endure, I will learn, and one day I will be on the other side.