Intern (26 page)

ONE FRIDAY AFTERNOON
in the middle of January, a hospital operator paged me to tell me I had an outside call. When she put it through, I heard the uncharacteristically subdued voice of John Davidson, a close acquaintance from medical school who was now in the middle of his fourth year. He had left a couple of messages on my answering machine the night before, but I had neglected to call him back, electing to wait until the weekend, when I had more time. He asked me how I was doing. “Fine,” I replied, though by now I was feeling on edge. After a long pause, he asked me to sit down. “What is it?” I demanded, irritated by the melodrama. And then, voice breaking, he delivered the bad news. Sam Stein, my best friend from medical school, had killed himself.

Feeling dizzy, I sat down. “What?”

Sam had been one of the most beloved students in our class. A Northern California native transplanted to the Midwest, he had an exuberant personality not unlike that of a Labrador retriever, always so full of energy and good cheer. We had spent a lot of time together my final year in St. Louis: marathon studying for exams, bar-hopping to meet women, cruising around town in my red Honda Civic with Radiohead blasting from the stereo. He was the one friend I had invited to my medical school graduation (since I had short-tracked, Sam was going to stay in St. Louis for another year). When I had spoken with him a few weeks earlier, there had been no indication that he was unhappy. His pediatric residency interviews were going well; he had just come back from Boston and was getting ready to fly out to Philadelphia. The residency director at St. Louis Children's Hospital had informally offered him an internship spot, which he was trying to decide whether to accept. He had so much going for him: a beautiful fiancée who was also a doctor, loving parents, a bright future. How could he have killed himself?

John told me that Sam's fiancée Heather had said that Sam had been feeling depressed for the past few weeks. For reasons that were unclear, he seemed to have lost confidence in his academic abilities, though he had always been near the top of his class. He had confessed to Heather that he didn't think he was up to handling residency. “You know Sam,” John said, his voice trembling. “He always was his own worst critic.”

He told me that Sam had started spending a lot of time in the library reading. A fellow classmate had seen him holed up in a cubicle one night, unusual behavior for a fourth-year medical student in the midst of interview season. Heather had made an appointment for him in the student health clinic, where a doctor had given him a prescription for an antidepressant. That was the day before he died. Sam never filled the prescription.

On the day he died, John told me, Sam had gone to the kitchen in the middle of the night. Apparently he had taken out a butcher knife, then climbed onto the counter and opened a small window over the sink. He crawled onto the ledge and jumped, still holding the knife, plunging twelve stories into a pile of garbage cans. Heather had awakened to the wail of police sirens.

My thoughts were swirling. I remembered a party Sam had had on the rooftop of his apartment building in St. Louis a few blocks from where I used to live. At the party, he had impulsively jumped over a four-foot gap onto the roof of the adjoining building, crossing over a chasm that extended down at least three hundred feet. Then, laughing, he jumped back. Livid, I had threatened to leave the party if he repeated the stunt.

“I don't understand,” I finally said, my eyes filling with tears. “He was interviewing at all the best residencies.”

It was an unusually warm winter day in St. Louis when I arrived for the memorial service. John picked me up at the airport, and we drove quietly to his apartment. As we were about to enter Forest Park, he pointed to the reddish brown brick building where Sam had lived. I craned to look back at it. All I could think about was the regret Sam
must have felt after jumping. Twelve stories. I shuddered, imagining what my friend must have been going through.

At the service, which took place in a lecture hall on the medical school campus, friends went up to the podium to talk about Sam. Someone started off his tribute with “Dude!”—and after an uncomfortable silence explained that that was how Sam spoke. John said a few words, too, though I could not bring myself to do so. The doctor who had prescribed the antidepressant showed up. When she saw Heather, they each broke out into horrible wails.

AS WINTER WORE ON
, more light streamed through the window blinds and the hospital became a generally more pleasant place to work. I rotated through various subspecialty wards: cardiology, neurology, pulmonary medicine. The patients on the neurology ward were sick—cruelly sick—and having suffered with my own neurological problem, I felt a special empathy for them. One man had Broca's aphasia. He could compose speech in his head; he just could not talk. Every time he tried to say something, he ended up quitting in tearful frustration. Another man had had a right parietal stroke, causing him to eerily neglect everything on the left side of his body, essentially immobilizing him. A woman with multiple sclerosis had such severe incontinence that she had to catheterize her own bladder to urinate. An elderly woman with Parkinson's disease smacked her lips and flicked her tongue like she was trying to dislodge a seed from between her teeth. She wanted to go home, but a psychiatrist had deemed her without capacity, and social workers had been unable to find a nursing home for her. The state was trying to get guardianship through the courts, but her lawyer was fighting it. Other patients on the ward were paralyzed from brain tumors or had Alzheimer's dementia, including one patient with a type the residents termed “delightful dementia” because it rendered her curiously passive and agreeable. The sentiments I had heard about neurologists seemed close enough to the mark. Master diagnosticians, they had depressingly little to offer their patients.

As the weeks passed and my neck healed, my gloom slowly lifted, allowing me to better judge the pluses and minuses of my situation. In the end, I'm not sure what convinced me to stick with residency, just as I'm not sure exactly what propelled me into the medical profession in the first place. It could have been inertia, my parents' wishes, pragmatism—or perhaps a combination of all three. It could have been the change of season. Fall/winter had always been the most melancholic time of the year for me. I remembered well those tortured months during my junior year in high school ruminating about whether I should believe in God. It could have been the news of Sam's death and the reminder it served that life is tenuous. It could have been the creative outlet provided by
The New York Times
, to which I had started intermittently contributing short essays. Perhaps my neck injury had something to do with it, too. For better or worse, it showed me what it was like to be a patient. Rajiv had said—and I had once believed—that doctors didn't do a whole lot for patients, but now there was refutation of that concept through my own experience. The neurologist and physical therapist provided hope and comfort to me at a vulnerable time in my life. They did for me what I could not do for myself: relieve my suffering. And once I experienced relief, I attributed to my caregivers a kind of omnipotence. It wasn't a stretch for me to realize that perhaps this was how my patients viewed me, too.

Whatever the reason, when the depression finally dissipated, it was like getting the gift of an early spring. I looked forward to going to the hospital each morning. Something was impelling me forward—a sense of discovery, perhaps, or intellectual adventure. Though medical practice might be mundane, even cookbook, I realized (realized again, really) that there were real complexities in it. There was a lot to think about—if you wanted to think. “Things are going to change,” Rajiv constantly assured me when we talked about second year. “You can still become the kind of doctor you want to be.” I was still curious to discover what that would be. (Ironically, my depression was probably the death knell for my interest in psychiatry. I couldn't imagine spending my days talking to people who felt like me.)

In April, Sonia and I got married in a lavish Hindu ceremony at a posh hotel in Woodbridge, New Jersey. At the end of the ceremony we took the traditional seven laps around the holy fire and recited our marriage vows. At the reception afterward, I could see the tremendous relief in her parents' and my parents' eyes. “Come on, darling,” my father cooed as Sonia made her way to the head table in a red
lengha
stitched with gold thread and studded with jewels. Sonia and I made a good, culturally apposite match. It hadn't been easy being engaged during internship, but finding her had been the best thing to happen to me in an otherwise terrible year.

In June, at the end of internship, our class boarded two yellow school buses and went to Tarrytown, in the hills of Westchester County—Washington Irving country—for a daylong retreat. In a building that was a hybrid of a corporate training park and a Gothic Revival estate, we huddled in small groups to talk about the year that had been and the year coming up. We discussed the hardest rotation of internship. Someone said it was the CCU, but the general consensus was that it was night float at Memorial, because of the volume and the constant worry that patients could crump on you at any moment. In the morning, we acted out mock intern-resident encounters and watched staged videos of good and bad residents. As in typical instructional videos, the bad residents were unbelievably bad and the good residents were unbelievably virtuous. In the afternoon we attended classes on how to convey empathy, identify patients' concerns and expectations, and involve patients in shared decision-making. “The fact that we are talking about this touchy-feely stuff is a big change,” Ali, a classmate, said. To me it seemed at best belated. Internship was almost over; it seemed a bit late to start talking about empathy.

At the end of the day, sitting on the grass outside, people recollected memorable moments from internship. David Jennings remembered the time he had forced a patient to go for a procedure. “He said he didn't want it,” David recalled, “but I told him, ‘Shut up, you need it.' I realized then that I was not his friend; I was his doctor. It was an
epiphany.” Cynthia, who, after much back-and-forth, had decided to stick with internal medicine, told of the time a patient had masturbated while she tried to examine him. Rachel recalled how grateful she had been when a resident put in an IV for her without being asked to. That led to a discussion about how we were going to do better by our interns next month. We were going to help out with blood draws and other scutwork; we were going to stay with them through sign-out; we were not going to dump on them the way we had been dumped on. It was a nice sentiment, but I figured that most of what we were pledging would become a distant memory come July 1. Internship had been a brutal initiation to medicine. Somehow we had gotten through it, and now those who would follow us were going to have to go through it, too. I thought about some of the residents I had worked with that year. Some, like Steve in the CCU, had been first-rate, but many others would round quickly and disappear, coming back to the wards for a quick flyby before noon conference and lunch, then off to the residents' lounge in the afternoon. I felt torn between striving to become the kind of resident I had wished for as an intern and getting by like most everyone else.

On the bus ride home, I thought once again about what I had been through over the past twelve months. Had I learned enough to move on? Dr. Wood had assured us during orientation that if we did as we were told, we'd be ready by now to supervise the next batch of interns. That time was at hand, and though I still had doubts, something told me that I was going to make a much better resident than intern. The bus entered a tunnel. I could hear the cars, the rumbling, on the roadway above us. The past twelve months, too, had been a passage through a dark tunnel. Then, suddenly, in the blackness, a shaft of light: second year.

The secret of the care of the patient is in caring for the patient.

—
FRANCIS PEABODY, AMERICAN PHYSICIAN, 1927

 

I
started the second year of residency like my first: in the outpatient clinic, not on the wards, where my classmates were already supervising new interns. Sonia was finishing up her third-year clinical clerkships at George Washington University and was planning on moving in with me next month to do her fourth-year at New York Hospital. Though I missed her, I didn't mind being apart. I felt like I needed time alone to devote myself fully to getting the hang of second year.

One evening, a young man came to see me. Because he had a walk-in appointment, I figured he had a minor problem—maybe a sore throat or a sprained ankle—that I could help him with right away. But when he sat in my examination room, his face was flushed. “I have a lump on my testicle,” he announced.

Jonah was twenty-nine, handsome, with unruly brown hair, hazel eyes, and a nervous earnestness that was instantly likable. He had a kind of California surfer drawl that bespoke nonchalance, but his darting glances and stammer betrayed his anxiety. The lump was about the size of a pea, he said. It didn't hurt. He had noticed it only the night before. “I don't usually examine myself,” he added sheepishly.

I was immediately concerned. A painless testicular mass, if indeed
it originates from the testicle, is almost always cancer. I couldn't remember where I had learned this, but it evidently had diffused into my brain at some point during internship.

A general exam of Jonah turned up nothing out of the ordinary. His right testicle, with the lump, hung a bit lower than his left, but that was normal. He directed me to the mass. It was on the upper pole of the testicle, round, rubbery, about half an inch in diameter. It wasn't tender or mobile. It appeared to arise directly from the testis.