By Rachel Stosur


Rachel is a rising junior at Baltimore City College. She is interested in medicine and has been working at the Berman Institute of Bioethics through the Johns Hopkins Summer Jobs Program.


Over the past two weeks, I have had the opportunity to shadow two doctors: Dr. Renee Boss and Dr. Janet Serwint. I was able to experience the Neonatal Intensive Care Unit setting, and both inpatient and outpatient pediatrics. I rounded on patients, talked to interns and residents, and gained insight into a day in the life of attending doctors at Johns Hopkins Hospital.  


Days 1 & 2: NICU


As the elevator came to a stop, a child’s voice announced on the intercom that I had reached the 8th floor of the Bloomberg Children’s Center. I would be shadowing Dr. Renee Boss in the Neonatal Intensive Care Unit for two mornings.


I had expected to see one room full of incubators, the “bay style” NICU like on TV, but here every baby had their own room. According to Dr. Boss, this allows for more privacy for families but it also does not promote as much bonding among parents. Although the four hallways of patient rooms looked similar, each baby’s room was personalized with toys or a colorful blanket. As I looked into the rooms, one of the first things that struck me was how small the babies were. Most were premature, and some were born months before their due date. One infant weighed only 470 g at birth, slightly over one pound. Her fingers and toes were tiny, and her ears were only the size of a penny. Even the smallest babies were surrounded by machines covered in tubes bigger than themselves.


I followed Dr. Boss as she rounded on patients. The NICU can hold about 50 infants, and Dr. Boss’ team was assigned to half of the patients. Each baby had a team of healthcare professionals, including nurses, nurse practitioners, fellows, a dietitian and an attending doctor. During rounds, the team discussed every patient and any changes over the past 24 hours. Depending on the complexity of the patient, it could take 20 minutes or more just to discuss changes from the previous day. The babies all had many labs and tests, and the results were spoken in acronyms and shorthand hard to understand without medical training.


Work in the NICU is difficult and intense. During rounds and throughout the day, the medical teams stand for hours on end. Alarms went off every couple of minutes to indicate a change in heart rate or breathing in one of the patients. Some babies had up to 12 “events” of oxygen desaturation or irregular heartbeats overnight. On the second morning of rounds, there was a surprise delivery. Pagers sounded and the residents rushed off in gowns and face masks to deliver the babies. There were also some complex cases in the NICU including a case involving a gunshot wound.


Ethical principles can be complicated when applied to the NICU.  There can be issues of autonomy since the infants do not have decision-making capacity, leaving parents to make medical decisions for their children. However, the parents’ and doctors’ views are not always in line, and they may not see eye to eye about what is best for the child. For example, they may disagree about whether a treatment should be prescribed that may save the infant’s life but could possibly lower their quality of life or cause lasting complications. The situation becomes even more difficult when another party becomes involved. One patient in the NICU was medically complex and was also under the care of the state, so he would eventually become a foster child. His parents were deemed unfit to care for him, and since they no longer had custody, they were not able to make medical decisions for their child. The autonomy of the infant and the wishes of the parents, the state and the doctors all had to be balanced with the best interest of the patient, leading to questions about how to deal with conflicting opinions and who should have the final say.


Overall, this experience has been eye-opening. The smallest people can have the most complex medical problems. Some of the babies were receiving morphine to help with pain and had to be sedated to tolerate a breathing tube. For anyone, especially a child who has only been alive for days or weeks, that is a lot to handle. Families watch their children who may need surgery and sometimes stay in the NICU for months. Some extremely premature babies need technological intervention to help them stay alive and can have lasting medical issues.  The patients in the NICU have no say in their medical care, leaving the families and medical team to make decisions that impact the babies for life.  As an intern for the Berman Institute of Bioethics, it is easy to see how this environment results in ethical dilemmas that medical professionals encounter in the Neonatal Intensive Care Unit every day.


Days 3 & 4: Pediatrics


For two days, I had the opportunity to shadow Dr. Janet Serwint as she took care of pediatric patients in The Charlotte R. Bloomberg Children’s Center, where the patients ranged in age from infants to young adults. During rounds, Dr. Serwint, the attending physician, and a team of residents and interns discussed each patient’s progress and treatment plan and updated the family. As we went to the rooms, Dr. Serwint explained the patient’s background and told me signs she looked for during physical exams. For babies, it is a good sign if they are moving all limbs and if the fontanel (the soft spot on their heads) is flat, not overly depressed or bulging.


One of my shadow days was the last day for the residents who had been working on pediatric rotation for a month and would be gaining clinical experience in other specialties, such as neurology and the emergency department. To wrap up their time in pediatrics, Dr. Serwint held Attending Rounds. The residents gathered in a conference room and were surprised to see that Dr. Serwint and the interns had baked them a cake with “Thank you” spelled out in chocolate chips. Then Dr. Serwint wrote every patient they had taken care of over the past month on the whiteboard, giving the residents the opportunity reflect on the lessons they had learned and memorable patients. One child had been diagnosed with an untreatable disorder, and a resident was disappointed in how the news was broken to the patient’s family. The neurologist that shared the news did not normally work with pediatric patients, and the resident believed more empathy could have been shown to the mother, who was without her husband when she learned of her child’s diagnosis. Other lessons included learning how to face and talk directly to the patient while using an interpreter and building a trusting relationship with parents.


Also during Attending Rounds, the residents looked at hospital bills for patients they had treated. The costs varied by length of stay and diagnosis, and the total bills (before insurance) ranged from $5,000 to $30,000. The medications were actually the least expensive part since many of them cost less than a dollar. The room was the most expensive fee, but the imaging (MRIs, x-rays, CT Scans, etc.) added up quickly. The purpose of seeing the bills was to encourage mindfulness about the cost of medical care. Of course it is essential to provide the highest quality of care possible, but it is also important to only order tests that are necessary and also consider the cost to the patient. For example, children with asthma often get daily chest x-rays which are expensive and may not be critical to their care. Some patients at the Children’s Center are covered under Medicaid, so they have little to no money to pay, while others have various forms of private insurance and may have to pay more of their bill.  


One patient was a teenager who was developmentally the age of an infant. The child’s parents had signed a form stating that no extreme measure should be taken to resuscitate the teen if they stopped breathing or their heart stopped. This was not a decision the parents took lightly. When a doctor went to discuss their decision, the parents told stories of their child and the teen’s importance to them, leaving both the parents and the doctor in tears. The ethical principle of beneficence, acting the welfare of the patient, is important in this situation. While some people may argue that it would be best to keep the patient alive using life support if needed, this family was concerned about the physical and emotional cost of keeping their child alive. This patient may not be able to ever come off of the machines that would keep her alive or fully recover from the experience, leading to a reduced quality of life. Being resuscitated would be a traumatizing experience, especially for this patient who would not be able to understand what was happening. The parents and doctors decided that resuscitation would lead to prolonged suffering for their child and that it would be in her best interest to sign a Do Not Resuscitate order.  


I learned so much from shadowing, not just about the hard science of medicine, but also about the importance of compassion and relationship building with patients. I would like to thank Dr. Boss and Dr. Serwint for the amazing opportunity to be exposed to different specialties in medical field and to interact with patients. As a high school student, this experience has been invaluable as I think about college and a possible career in medicine.

10 people like this post.



Tags: , , , , , , , ,

2 Responses to “Brushes with Bioethics: Internship Experiences”

  1. […] Brushes with Bioethics: Internship Experiences […]

  2. […] Brushes with Bioethics: Internship Experiences […]

Leave a Reply