Intern (20 page)

I filled up a second bottle and told my patient that we were done. Even with just two liters out (plus whatever was on the floor), her abdomen was noticeably less distended, and she said she was feeling better. I pulled the catheter out of her belly and threw the tubing and sundry sponges and towels into a red biological waste bag. I took the bottles over to a “soiled utility” room and left them by the sink. Back in her room, I got a roll of paper towels and wiped off the floor and chair, working quickly before anyone arrived. “Thank you,” she said as I searched the bedding anxiously for stray needles. “You're welcome,” I said curtly.

At the workstation, I told a nurse what had happened. “You could have called me,” she said in an exasperated Caribbean twang. “I was sitting right here.”

I told her I was sorry, that I hadn't wanted to bother her, and, much to my surprise, she told me to leave. She would call Housekeeping for me.

I sprinted the block back to my apartment, peeled off my scrubs, and jumped into the shower. My skin felt cool and sticky, and even though I was already a half hour late, the urge to wash away the hospital grime was irresistible. Under the warm water, amid the crackle of droplets ricocheting off the porcelain, I thought about Rajiv's latest heroics. Just this week, he had inserted an intra-aortic balloon pump at the bedside into a patient with an acute myocardial infarction, then wheeled him to the cardiac catheterization lab, where he performed
angioplasty and saved his life. What a contrast to my own incompetence! I had frozen on a simple abdominal paracentesis. I didn't even have the presence of mind to pinch off the tubing when the fluid was spilling on the floor.
Never rush a procedure!
I had often told myself. But I couldn't even follow my own rules.

Outside, around 8:30 p.m., Second Avenue was ringing like a sharply illuminated, multicolored carnival. Young people were stumbling drunkenly out of bars, smoking cigarettes. Rich kids in suits and evening dresses were stepping into a limo, perhaps on the way to a cotillion. Long, bare, sexy legs dangled off brownstone stoops. I had nearly forgotten there was a world outside the hospital, and it was neatly going on without me.

I thought about what I was going to say to Josh. Was I really going to quit internal medicine like Cynthia? I couldn't help but think that all my work—the sacrifices, the debt, the suffering—would be wasted if I quit now. Yet the thoughts—the second thoughts—kept swirling in my head, like an obsession I could not block.
What are you doing? You don't belong here.
The sacrifices I had made so far were minor compared to what would be required of me in the future—as a resident, or fellow, or attending physician. Medicine was supposed to lead me to a world of responsibility. What did it say about me that I had desired the challenge but couldn't sustain the commitment?

I had struggled to feel interested, competent, but that state of mind had eluded me. Out of desperation, I had tried being more friendly with my supervising residents, hoping to find succor in fraternity, but they preferred to maintain the traditional resident-over-intern hierarchy. No matter what I did or how hard I tried, they always managed to find a weakness. If I thought I had picked up an unusual diagnosis, they would start pressing with questions that would force me to give up my hypothesis. If I thought I had composed a watertight case, they would find an oversight. “Where's the EKG?” Rohit would demand in the middle of a presentation, and when I would pull it out, he'd look it over nonchalantly, hand it back to me, and say, “And the old one?” and then I'd have to stammer an excuse for why I had been unable to find
it and feel deflated again. It was hard not to succumb to a culture where missing something gets magnified into personal failure. Even the language of medicine betrayed this attitude. The term
failure
was used to describe not only organs that had ceased to function, but also those that were merely insufficient.

Rohit admonished me for taking too long to write my progress notes. “How am I supposed to write my notes without labs?” I demanded. Test results weren't posted in the computer until late morning.

“Just write ‘labs pending.' ”

“Then how am I supposed to come up with a plan?”

“That's not your job.”

“So what is my job?”

“To write a progress note.”

“Why am I writing the note?”

“To document that someone examined the patient.”

“That's all?” I said angrily.

“That's all,” he replied with brusque finality. “No one reads your notes.”

The truth was that I had already stopped writing long notes. I had stopped paying attention to social history, habits, the sorts of things that make a patient into a real person. I was writing down physical exam findings I believed were present, even if I didn't pick up on them myself. I didn't want to make any more concessions. My progress notes belonged to me.

The hardest part was not having someone to commiserate with me. Sonia was in Washington, busy with her own clinical clerkships. When I told her I was living for the weekends, she thought I was referring to her near-weekly visits to Manhattan, which were nice, but what I really meant was that I was living for the days when I wasn't in the hospital, with or without her. The few interns who complained openly only criticized the backbreaking schedule or an unhelpful resident or a rude attending. No one I spoke with, apart from Cynthia, criticized medicine itself or questioned their commitment to the profession. That
seemingly was off-limits. My parents found it hard to sympathize, too. They (rightly) viewed the decision to go to medical school as my own choice and internship as a temporary phase, a sort of boot camp on the way to a better career. “Who told you to leave physics?” my father would say when he was fed up with my grievances. “You like to grumble. You like to blow on cold milk.” He had never had much patience for “flickering,” and nothing was going to change anyway, and wasn't I just a bit too quick to whine and never see the bright side? “Going into medicine was the best thing that could have happened to you,” he often said. “You had landed into a ditch. Now at least you have some direction.”

When I got to the restaurant, a Hungarian holdover from a previous era, Josh was waiting for me outside. A tall, thin man with a bushy goatee, he always reminded me of a young Vladimir Lenin. He was doing a five-year joint “internal medicine-psychiatry” residency. A few weeks back, Rajiv had suggested that I talk with him about my career issues.

He shook my hand warmly and we went inside. We sat down at a table by a window overlooking a busy street. The waitress brought us bowls of cold cherry soup, and we started talking. Though I had intimated some of my concerns to him over the phone, I took this opportunity to more fully explain my disillusionment. He listened carefully but didn't say much.
This must be what psychiatrists call reflection
, I thought. I felt like a patient sitting on the proverbial couch.

I talked about my interest in psychiatry. Josh asked me what I liked about it, and I told him that, despite the mumbo jumbo, psychiatry at least seemed to be trying to get to the heart of things. While internal medicine dissected, psychiatry synthesized. Internists described disease in a phenomenological way, as a collection of symptoms, as the result of certain chemical excesses or deficits. Psychiatrists, on the other hand, it seemed to me then, were trying to go deeper, into the structure of illness itself. What interested me about psychiatry was what most doctors disparaged: the abstruse theories, the symbolic representations, the weirdness. I had always felt more comfortable with the
strange, the grotesque, the questioners of themselves. I often remembered the mentally ill patients I had cared for in medical school. There was Noah Stearns and his dream of traveling “the open road” to California; when the police picked him up, he was wandering around in his hometown, eating weeds. Or Terence Hode, who lost his mind when his wife left him, spending sixteen hours a day watching porn and listening to the Red Hot Chili Peppers. Or Eleanor Wilson, who started telling people that workers at the post office were trying to keep her from “reaching a better life.” Although I had always been reluctant to admit it, I enjoyed these patients so much more than the diabetics or the old ladies with mundane urinary tract infections.

“They talk all the time about supporting you through residency, but really that's all just lip service,” Josh said. “If you want to switch, go ahead. On the other hand, you might be better off finishing the year.” I had heard this advice before. “Things are going to get better,” he assured me. I had heard that before, too. “You have to ask yourself, Where do I want to be in ten years?” I had heard it all before; I had been working through these issues my entire professional life. After all this time, so many stops and starts, it was dispiriting that I still had no idea what I wanted, and that the insight of an older, supposedly wiser resident left me right where I'd started: knowing the pros and cons but unable to decide.

After dinner, I walked home. The night was clear, the lights bright. The cabs were weaving up the packed avenue like a game of Donkey Kong, their neon taillights randomly blinking at me like a sea of red eyes. There was a void in my life that I didn't know how to fill. My old career in physics was finished; I couldn't just pick up where I left off. My new life was all about medicine. Even if I made a big show of never talking about it, at social or family gatherings, it was there, never far from my mind, the dominant motif in my life. How could I just give it up? I had no options, no plans, just complaints.

Becoming a psychiatrist was a romantic notion, driven by a nebulous desire to find creativity within medicine, but I knew it made little sense. Not so long ago I had been experimenting on quantum dots
with picosecond laser pulses. Now I wanted to become a psychoanalyst? It sounded flaky, even to me. Psychiatry was fringe, elitist, out of the mainstream—precisely what I had fled by going into medicine in the first place. Did I really want to join another profession I had little faith in? Wasn't it better to work hard and not have to apologize?

Maybe Josh was right. Internship wasn't going to last forever. It was already almost a third over. Perhaps my best option was to buckle down and focus. In photography there is a thing called a
pinhole camera
. It operates on the same principle as squinting: narrow your field of view and you are able to see more clearly. This, I decided, was what I had to do now. Instead of gazing so far into the future, perhaps I should just focus on the path directly ahead of me. Perhaps such an approach would deliver clarity.

Coming up was a rotation at Memorial, the world-famous cancer hospital allied with New York Hospital. Oncology; maybe that was my calling. Somehow I doubted it, but I told myself that I owed it to myself to give residency some more time. If things didn't improve quickly, then I would march into Dr. Wood's office and break the news. My father's injunction kept reverberating in my head:
Don't change horses in the middle of the ocean.

Too few residents emerge from training thankful for the opportunity to practice in a fascinating and intellectually challenging field. Instead, many believe that the world owes them something for what they've been through.

—
TIMOTHY MCCALL, “THE IMPACT OF LONG WORKING HOURS ON RESIDENT
PHYSICIANS,”
THE NEW ENGLAND JOURNAL OF MEDICINE
, 1988

 

A
t four o'clock in the afternoon, I was struggling to put on my necktie. I draped the silk band around my collar, pulling up and down to adjust the length on each side. Then I curled the wide part around the narrow, making a counterclockwise loop. I fiddled with the short end for a few seconds, trying to remember what to do next, before pulling my hands apart and starting over. On my next attempt, I experienced a faint glimmer of recall. I finally got it on the third try. Procedural memory is the last to go when you are fatigued. It means you are about to collapse. This did not bode well for my first night at Memorial. If I couldn't put on a tie, how was I going to function in the hospital?

Before heading in for my shift, I stopped by the Hi-Life to see Shannon. “What happened to you?” she said when I sat down at the bar.

I grimaced, taking off my neck brace. “Herniated disk.”

Her expression softened. “How'd that happen?”

I didn't know. A few weeks earlier, a gnawing pain had developed at the base of my neck and in my right shoulder and elbow. The palm of my right hand, from the thumb to the wrist, felt numb. Josh had diagnosed me with carpal tunnel syndrome, and for a few days I had worn a wrist brace, which only seemed to aggravate the pain. It felt like a fat drill was boring into my shoulder. At first I wondered if perhaps my symptoms were psychosomatic. Interns often develop weird ailments during training, and was it just a coincidence that one of my leukemia patients had been hospitalized with similar complaints? But as the days passed, the pain steadily worsened. When it was almost unbearable, I went to Dr. Bele in the outpatient clinic. He sat me down in a chair, palmed the top of my head, and pressed downward. A hot electrical sensation traveled down my right arm, and I howled in agony. “You have a slipped disk,” he pronounced. He sent me to the office of a sports medicine specialist, who told me that my right biceps reflex was almost absent, indicating significant nerve damage. She gave me a cervical collar and ordered a spine MRI, which was performed the following morning. Rajiv took a few hours off to accompany me to the test. Lying flat on the gantry, I could almost feel my eyelashes scraping against the roof of the scanner, and the loud Schumann opera being piped into the headphones did nothing to quell my anxiety. I thought of wide open spaces. I thought of romantic interludes with Sonia. I thought of the hundreds of MRI scans I had casually ordered for patients over the past few months with nary a second thought.