Doctored (38 page)

I took Gupta's place on the court. Everyone greeted me pleasantly, though I could tell that Chaudhry was a bit uncomfortable with my being there. “All right, it's the Jauhar brothers,” Matt announced as I hopped up and down at the baseline to warm up. “Let's get some good old-fashioned competition going. I know Sandeep is not going to want to lose to your ass.”

Soon I was sliding from side to side on the Har-Tru as Matt fed us balls. Though I'd played a lot in high school and occasionally on weekends since moving to New York, my strokes were off, and I was hopelessly out of shape. “Move to the ball!” Matt commanded. “One bounce, one bounce!” After long rallies I'd crouch at the baseline, panting. Matt came over and instructed me on the proper form for my backhand. “Follow through,” he said, extending my arms upward. “Never stop in the middle. When you stop halfway, that's the worst thing you can do.”

After about fifteen minutes of intense workout, my back started to spasm, and I had to lie down on the side of the court to ease the tightness. Gupta held up my legs, angling them to stretch the muscle, as I tried in vain to dodge the bullets dripping off his chin. “You've got to stretch more,” he said, while the others kept playing. He told me he did kung fu to stay fit. Crouching beside me, he told me to throw a punch at him, which he easily slapped away. Then his hands went into a rapid circular motion, and before I could say anything, his right hand had grabbed my throat. “See, that's how a tiger moves,” he said proudly. “You should try it sometime.”

When the hour was up, the others shuffled off the court. I overheard Rajiv and Chaudhry talking business on the sidelines. “It's forty percent overhead, boss … no, we can get you the space. The tech will come in, but you need to establish the accreditation…” They walked up to where the rest of us were.

“When I leave here, I always tell myself I'm going to get into shape,” Rajiv said.

Goldner added: “Mine is the opposite reaction. I feel like I've gotten my exercise for the month.”

We started to gather up our wallets, watches, BlackBerrys, and beepers. Matt surveyed the accessories. “Take a picture of this, guys,” he said. “This is our lives.”

Rajiv slung his tennis bag over his shoulder. Pointing at Matt, he said to me, “He's having a midlife crisis, too. What do you always say, Matt?”

“The older I get, the better I used to be.” Everyone laughed.

Rajiv and I walked out together to our cars. I told him that Sonia and I were planning our first dinner party for physicians. He quipped, “If you don't get at least a couple of referrals out of it, it's a waste of time.” I asked him how Chaudhry was doing. “The same,” Rajiv replied. “He says every day is a headache. He's thinking about taking on another gig, reading studies for some doctor named Hasani.”

“Hasani?” I was nonplussed. “I thought Chaudhry hated Hasani.”

“Who's going to turn down a chance to make more money?”

“When you're making as much as he is?”

“It doesn't matter how much you make. Most people want to make more.”

*   *   *

One night in Mohan's room, I banged my knee on his bedpost and cried out in pain. Later he asked me why dads don't cry.

“Sometimes we do,” I said.

“When?”

“Like when we're happy. Like the first time you scored a goal in soccer, I got a tear in my eye.”

“What about when you get hurt?”

“Not so much.”

“Why?”

“I don't know. The tears get dried when you get older.”

“Do you try to cry?”

“No, but even if we did, the tears wouldn't come out.”

“Because you use up all the tears in your tear ducts?” he said, showing off some knowledge he'd acquired.

“Yeah, I guess so,” I replied, chuckling.

“That's good,” he said, settling into his pillow.

I put on a Beatles song, as I often did when putting him to bed.

“This song reminds me of going to the park in New York,” he said.

“Yeah, when we were lying on the grass. Do you remember?”

“Yes.”

“Do you miss the park?”

He thought for a moment. “Not really.”

I felt relieved. “This song reminds me of when I was younger,” I said.

“When?”

“When I was in college, before you were born.”

“Before I was born?”

“Yeah, I wasn't always your dad.”

For a moment he didn't say anything. Then he said, “Did you want me to be a boy or a girl?”

I laughed. “I wanted a boy. And I got you. I didn't just get a boy; I got the best boy.”

He smiled. I switched off the light. We were lying in the dark. “Dad?”

“Yeah.”

“If you're bored, instead of putting me to bed, you can just go do your computer.”

“That's okay, Mohan, I like putting you to bed. Remember when I never had time to do that?”

“Now you do it all the time.”

“Well, I love spending time with you.”

“I love spending time with you, too, Dad.”

He turned and put his hand on my shoulder. I stroked his head and told him to go to sleep.

*   *   *

The Huntington Historical Society was doing an exhibit about Long Island medicine. It was in an old farmhouse on a quiet street of quaint shops and galleries not far from where I played tennis. The exhibit featured a former chief of obstetrics at Huntington Hospital named Samuel Teich. Born and educated in Huntington, he joined the army in 1940 and landed at Normandy on D-day, for which he was awarded the Bronze Star for bravery. When he came home from the war, he hung up a shingle in Huntington Station and started a private practice. He became the chief surgeon of the Huntington Police Department and eventually the chief obstetrician at Huntington Hospital, which had opened its doors only three decades earlier.

Teich's career spanned an era of great change in medicine. A big shift, thanks to the GI Bill, was the rise of specialists. In 1940, three-quarters of America's physicians were general practitioners, but by 1960 specialists outnumbered generalists, and by 1970 only a quarter of doctors counted themselves general practitioners. (Today the trend away from primary care continues, threatening access to care for millions of Americans.) Physicians' average salary (corrected for inflation) increased dramatically over this period, too, and the average net profit from private practice quadrupled. This increase paralleled an equally dramatic rise in national medical expenses, from $3 billion in 1940 to $75 billion in 1970.

The venue of care also shifted. In 1930, 40 percent of encounters between doctors and patients took place in patients' homes. By 1960 that number had dropped to 10 percent. In 1935 half of all births presided over by doctors were home births. Twenty years later, only 4 percent of all births took place at home. In the early 1930s, only one physician in sixteen worked in a hospital full-time. Today that number is more than 50 percent and rising as hospitals and health systems, eager to acquire more leverage in negotiating contracts with insurers, rapaciously buy up private practices.

Perhaps the biggest change has been in the doctor-patient relationship. The exhibit showed a replica of Teich's examination room, like my grandfather's, with old-fashioned instruments, evoking a bygone era: an exam table with wooden stirrups, a cystoscope, a hemometer for estimating blood counts, an old-style wicker baby scale. There were photographs of Dr. Teich with nurses in white vestments and white hats. On display were Christmas cards with pictures of some of the ten thousand babies Teich had delivered, some spanning three generations. But most striking were the scores of patient testimonials. “We shall always remember you as a friend, and it is a privilege to know you,” a patient wrote. “Some Saturday we shall grace your office just to say hello. We have planned that for a long time, but it is not so easy to borrow a car.” Another said: “I am enclosing a check in your favor for the amount of one hundred dollars, as an additional payment on account of the services you rendered us and for which your statement has never been received. I have no idea of the actual amount in dollars and cents, but I am convinced that any further payments that may be required to balance the books would indeed be a very poor substitute for the feeling of gratitude that we bear toward you.” And another (in May 1964): “Words are inadequate. My husband and I were heartbroken when we lost the other baby, but now we have a beautiful, bouncing baby boy. You were so kind and thoughtful all through my pregnancy that I felt I just had to say thank you again.”

Doctors in Teich's era, practicing on the heels of revolutionary medical advances, commanded unusual respect and influence. However, as Dr. Abigail Zuger argues in a 2004 article in
The New England Journal of Medicine
, this golden era was probably an aberration. Several nineteenth-century American doctors wrote in their memoirs of their fathers' “contempt” and “disgust” on learning that they had decided to enter medicine. One doctor, writing in a medical journal in 1869, called medicine “the most despised of all the professions” for educated men. At the beginning of the twentieth century, medical education was not standardized. Quacks routinely cut into doctors' business. In 1913 the American Medical Association estimated that no more than 10 percent of physicians were able to earn a comfortable living. “A doctor's life is made up of moments of terrible nervous tension,” wrote a physician in the early twentieth century. “There are times when the powers to continue such a life are entirely exhausted and you are seized with such depression that only one thought remains—to turn your back on all and flee.”

Gauging our professional lives by the short-lived golden era of medicine is a bit like judging a marriage by a honeymoon. Expectations are impossibly high, a recipe for dissatisfaction. Fulfillment in medicine, as with any endeavor, is about managing hopes. Probably the group best equipped to deal with the changes racking the profession today is medical students because they are not so weighed down by their expectations. It is the doctors ensconced in professional midlife who are having the hardest time. Of course, there are many factions to blame for the state of American medicine—insurers, malpractice lawyers, the federal government—but doctors must take a hard look at themselves, too. Managed care alone didn't create medicine's midlife crisis. Indeed, this crisis was also spurred by the abandonment of professional ideals in the pursuit of profit that made managed care necessary in the first place.

*   *   *

Today I am living my life in archetypal roles: often doting father, occasionally reserved husband, at times discouraged doctor. There are recurring patterns in our lives, in the characters that we play. In thermodynamics the triple point of a substance is that temperature and pressure where three phases (gas, solid, and liquid) coexist. This feels like the point I am at in my midlife: husband, doctor, father—all in uneasy equilibrium. I am learning to be more modest in my expectations and more humble in my ignorance. Like my father, I have begun to appreciate that the old wisdom has a lot to offer.

Of course, I wish I'd more consistently lived up to my youthful ideals. I've made the same compromises that Rajiv, Chaudhry, and others have made and continue to make. But tolerance develops for life's circumstances, especially if they develop slowly. In congestive heart failure, if cardiac pressure increases gradually, the left atrium enlarges and becomes more compliant, thus able to accommodate the increased volume of blood. It is only when the pressure increases rapidly that the patient crashes and burns.

I see a glimmer that these middle years will make me stronger, that eventually I'll master my most difficult experiences and look back on them like a vivid dream. Yet it still feels at times as if I am running in place, like one of Chaudhry's patients trying to keep up with the treadmill. So I will muddle through this period, trying to find peace with the changes that are occurring. I have already mostly forgotten the pain of my internship. All I have now is the memory of that time, and it doesn't seem so awful. Perhaps all this will blow over, too, and I will be able to revise in my mind how I felt about it.

What kind of doctor do you want to be?
This is a question that all physicians have to answer at various points in their careers. And they have to do it with the knowledge that people often place outsize expectations on our profession. People often think of doctors as either consumedly avaricious or impossibly altruistic. There is a disconnect between how the lay world views medicine and how doctors experience it from the inside.

One weekend when I was on call in the ICU as a second-year resident, I was on rounds with Abe Sanders, the attending. Dr. Sanders was a portly, avuncular man with a mischievous grin. Despite the miseries of the ICU, he always maintained a relentlessly upbeat manner.

It was a brilliantly sunny day, perfect weather for sailing. Midway through long, protracted rounds, Sanders called us over to a window. He pointed down at a sailboat on the river. A man was standing on the deck, looking up at the hospital. He looked as if he were about Sanders's age, though fit and tan. He was holding a drink, and a party with attractive people was being held on board. “See that guy?” Sanders said. “Do you know what he's thinking?”

We were standing in a patient's room. The alarms were going off. No one ventured a guess.

Sanders said: “He's thinking, ‘I should have been a doctor!'”

Of course, I now have a much more nuanced view of medicine than the man on the boat. Having been in medicine for the better part of my professional life, I have seen that there are all types: knights, knaves, and pawns. In fact, most doctors—myself included—are an amalgam of all three. Neither we nor the profession in which we practice is perfect.