Intern (18 page)

Some hospitals had instituted changes in response to the violence. A hospital in Detroit had put metal detectors into its emergency room, which in the first six months detected thirty-three handguns and more than a thousand knives. In Australia, a hospital created a “violence management team.” Made up of a doctor, a senior nurse, and four orderlies, the team received almost three hundred calls in its first four years of operation.

When I told Rajiv about the Diaz incident, he shrugged it off, as if my exaggerated reaction was just further evidence of my naïveté. He told me a story from his own days as a resident. Once, at about three in the morning, he was performing a history and physical on an HIV-positive patient when, without warning, the man became enraged and blocked the exit of the examination room. “I asked him a question, like did he ever do drugs—you know, a standard part of the social history—and he freaked out. He said that no one cared, that doctors always assumed that he was doing drugs. He started shouting that I was a foreigner, how I was following a set protocol, how I was the third person to ask him that question that night, how I didn't care about understanding him.”

“So what did you say to him?” I asked. “How did you draw him out?”

“Draw him out?” my brother replied. “Are you kidding? I pushed him out of the way, ran down the hall, and yelled for security.”

By this point in my internship, I had already come to appreciate that there was a fundamental disconnect in the hospital. Good relations with patients weren't rewarded; efficiency was, which meant focusing on the work at hand, operating with a kind of remote control, in front of computer screens and nursing charts and requisition forms, and on the phone. Face-to-face time was a relatively insignificant part of the job. The high counters around the staff workstation delineated not just a workspace but a type of kingdom, too. It might as well have been ringed by a moat.

The great secret of doctors, known only to their wives, but still hidden from the public, is that most things get better by themselves; most things, in fact, are better in the morning.

—LEWIS THOMAS
,
THE LIVES OF A CELL: NOTES OF A BIOLOGY WATCHER
, 1974

 

S
eptember was an awful month. Four interns announced they were quitting. Cynthia, a classmate, informed Dr. Wood that she was transferring from internal medicine to psychiatry. The news threw me for a loop because I had been thinking about doing the same thing myself. When we talked about it, it was clear that Cynthia didn't see herself in internal medicine. The work was overwhelming—and Cynthia was quick to get overwhelmed. One morning I found her post-call: greasy face, matted red hair, stethoscope draped lopsidedly around her neck, all signs of a rough night. “Patient crumped last night,” she said, referring to a rapid and unexpected clinical deterioration, as I handed her a bagel and coffee. “Then he coded. Before I knew it, he was dead.”

She opened the aluminum wrapper and started wiping away some of the cream cheese with a plastic knife. “And you know what?” she added almost parenthetically. “I was kind of hoping he would die. One less note for me to write. That's how I felt. Is that wrong?”

“But you know what?” she went on, not waiting for a reply. “I had to write a note anyway, and fill out a death certificate, and deal with
the morgue, and call the attending and the family. So it didn't really save me any time at all.”

Days on the wards were blurring into each other, and yet every single day was all too painfully real; you couldn't even find solace in amnesia. Checking vital signs, updating medication lists, inserting IVs, drawing blood, reviewing labs, examining patients, one after the other after the other, like an assembly line. After a while, it was hard to stomach. I was starting to snap, taking out my frustrations on the people least equipped to fight back. One particular exchange I remember:

“Oh good, you're here. I have a bunch of questions about all these medications.”

“Yes, ma'am.”

“So first of all, the fo-fo—”

“Fosinopril.”

“Yes, when do I take that?”

“In the morning.”

“Yes, but what time?”

“When you take the rest of your medications.”

“When should that be?”

“When you normally take them.”

“Yes, but when?”

“With breakfast.”

“When should I eat breakfast?”

“Eight in the morning.”

“I don't wake up that early.”

“Then at nine or whenever you wake up.”

“I can wake up at eight if you think I should take my medications then.”

“No, nine is fine.”

“What about the warfarin?”

“Anytime.”

“Well, you said at night.”

“Then take it at night.”

“Because if you say take it at night, I'm going to take it at night.”

“Night is fine!”

“What time at night?” And so it went for each drug, twelve in all.

If internship was supposed to stoke intellectual curiosity, I never saw it. Like me, most of my classmates seemed disengaged, mentally exhausted. With patient rosters of fifteen or more each, we were preoccupied with getting our work done. Anything that got in the way—even a bona fide medical mystery—was more often seen as a bother than a learning opportunity. When faced with challenging cases, we almost reflexively called for an expert consultation so we could move on to the next task, however routine. Many consultations were appropriate, but many simply allowed us to avoid thinking about a hard case, because thinking took time. There was no reward for clinical excellence, only the sound of your own hand patting your back.

I was taking care of a man in his seventies with a peculiar problem: when he was sleeping, he would periodically stop breathing. When he was awake, he was lethargic and disoriented, sometimes psychotic. No one on my team knew what was wrong with him. I still don't.

One day the attending physician, a smart and able man, was on the ward perusing the patient's voluminous chart. “You know what?” he said to me. “One day they're going to talk about this guy like they talked about AIDS patients twenty years ago. He falls outside our paradigm. He's a real mystery.”

Then he said: “You know what he needs? A medical student.”

I must have looked puzzled. He went on: “He needs someone who can spend time with him. Get a new history, read through this chart, examine him from head to toe, ask questions. He needs someone who's going to make him their project.”

I nodded, and then we got on with our work. I was caring for about twelve patients at the time. He, in addition to his teaching and research responsibilities, was seeing patients in clinic. There didn't seem to be any time to grapple with a medical mystery. We both realized we were failing our patient by not devoting adequate attention to his problem, but we were too busy to care enough to do something about it. Rajiv had once told me that if you didn't make a diagnosis
within forty-eight hours of a patient's being admitted, it never got made, and for the most part, I had discovered, he was right.

The worst was when you were alone with patients and you realized you knew next to nothing about them. They'd be on bi-level positive airway pressure ventilation or something, and you didn't want to go through the chart to figure out why, but you felt guilty, so you hedged and read a little bit and learned a little bit, and read some more and discovered some more, and you realized how much you learned was dependent on how deeply you were willing to look, and what was pushing you was a sense of duty, but the duty was ill defined and couldn't you just ignore it and go home? You'd get mad at the consultants who came by and casually left their recommendations in barely legible handwriting, focusing on a particular organ system, until you realized that you were no better than they. You also didn't want to take responsibility. There was a constant tug-of-war between desire and duty. Your desire was to get the hell out of the hospital and have a life; your duty was to be a good doctor. You wanted to do the right thing, but doing the right thing took time. Patients were complicated; there was so much information to gather and digest, and even if you collected it all, you probably wouldn't know what to do anyway, so why bother?

If you did everything, you felt overwhelmed. If you didn't, you felt guilty. Like my patient with the bedsore. Should I look at it? He was heavy as a rock, and waiting for a nurse to help me push him on his side was going to take too long, so every morning I'd let it go, rationalizing it by thinking,
What's the point? What am I going to do about a bedsore anyway? The surgeons are already involved
—but I wasn't sure they had looked at it either. Could I really come by every morning and pretend it didn't exist? It was these sorts of compromises that made me feel perpetually guilty. I felt paralyzed by my desire to live a life outside the hospital and to do the right thing inside it; to be the kind of doctor I had hoped to be and also be the kind of intern I was expected to be. It was a Faustian bargain. So I would compensate by writing long off-service notes, hoping someone on the next rotation would address
the issues my team had ignored. When I complained to Rajiv, he said, “You can't save everyone,” which was just the sort of glib remark he was good at making but that never made me feel better at all.

ON CALL NIGHTS
, the ward was like a sleeping village, and you were the night watchman on patrol with your penlight and stethoscope. Senior residents were available for backup, but after 10:00 p.m. they were almost always admitting patients or at home sleeping. You could call them if you needed help, but few of us ever did. Not calling backup, I quickly learned, was considered a sign of strength, and for an intern there was nothing more flattering than to be considered “strong.” Once, I made the mistake of calling a third-year resident at her apartment in the middle of the night to ask for help performing a spinal tap. She roared at me on the phone for not taking care of the procedure earlier, before she came on duty at 10:00 p.m. When she arrived on the floor, she quickly saw my patient, told me a tap was unnecessary, and then berated me some more for wasting her time. I never called another resident for the remainder of the year, electing instead to page Rajiv (in the middle of the night, if necessary) when I needed help. If I could get so much flak asking for help managing a potential case of meningitis, I could only imagine the kind of wrath I'd incur calling about atypical chest pain or something equally benign.

On night duty, it wasn't the emergencies that overwhelmed so much as the little things, the minor issues—the insomnia, the constipation, the headaches—that the nurses had to make you aware of in the middle of the night. Even when the nurses didn't call, it was impossible to enter any sort of restful sleep. The expectation of the pager going off was enough to keep you in a state of chronic anxiety. Sometimes I'd pace back and forth in the call room, or just outside in the corridor, looking out the window onto the East River and the points of yellow light dotting the skyscape, wondering what sort of calamity would next be visited on me. If I did fall asleep, I usually woke up with a drenching wetness on the back of my neck. Once, a nurse called to tell
me that a young man, nervous about a procedure scheduled for the morning, had had fleeting chest pain. When I saw him, he was visibly nervous but otherwise fine. When I told the nurse that a twinge of chest discomfort in an otherwise healthy young man did not require an extensive workup, she made it clear that if I didn't at least perform an electrocardiogram, she was going to file a complaint. So I went and got a machine and wheeled it to the patient's room, but it was broken, and I went and got another one on a different ward, but it was broken, too, and by the time I performed the EKG forty-five minutes later, the patient was fast asleep and irritated at being woken, and, of course, his EKG was completely normal.

There were set times on call when you could expect a flurry of pages, like when the nurses checked vital signs at 4:00 a.m. That was when they called about fevers. Your response was always the same: blood and urine cultures and a portable chest X-ray to rule out pneumonia—but sometimes you discovered that a patient was already on antibiotics or that blood cultures had been drawn every night for the past week, every single one negative, and then you had to decide whether you really needed to stick him again, but most of the time you did so anyway, not for the patient's sake but for your own, lest someone fault you in the morning for not doing it. That was the sad reality of residency: much of the time you were ordering tests to protect yourself. “The endgame of life is so depressing,” I wrote in my diary. “Look at Mr. Fisher. Successful lawyer, Goldberg patient. Now look at him. Sick, febrile, dying of who-knows-what: cancer, TB, sarcoidosis? If you think about it, it could make all of life seem unworthwhile if, in the end, we end up dying in the hospital, awakened at 4:00 a.m. by a stupid intern trying to draw another set of blood cultures.”

Sometimes I worried about how I was going to get through another night on call, until I realized that my patients were helping me. Their bodies had homeostatic reserve, the capacity to self-correct, to compensate for my mistakes. In physics, an oscillator quickly returns to its equilibrium position after being displaced, and so it is, I came to believe, with the human body. Most of my patients were going to be
fine despite anything I did, and if they were going to die—well, that was probably going to happen despite me, too. Health was like the wilderness: it could only be spoiled by human intervention. “We're not saving patients,” Rajiv told me. “We're just stabilizing them so they can save themselves.”

I became awed by this concept, but most of my colleagues seemed indifferent to it. We performed our interventions with such confidence, such arrogance, but most of the time there was no way of predicting whether we were doing the right thing, or even a good thing. We'd give potassium for hypokalemia, or diuretics for edema, or nitroglycerin for high blood pressure—and we would overshoot. The diuretics would make our patients dehydrated or the nitroglycerin would lower their blood pressure too much—and then we'd have to give them intravenous fluid or raise their blood pressure with other drugs, and the process would start all over again. Sometimes we would give drugs just to treat the side effects of other drugs. Sometimes we would do illogical things like giving fluid and diuretics at the same time, and no one questioned it, including me. There was too much going on, too much complexity, to start asking questions. I wasn't sure where to begin; I wasn't even sure I knew enough to know what to ask. My energy was low, my enthusiasm flagging, and the system was in automatic drive anyway. The easiest thing to do was to get out of the way.