Intern (40 page)

The echocardiogram also revealed an abscess, a collection of pus, around the valve. Few conditions in medicine absolutely require surgery, but this is one of them. Antibiotics cannot penetrate into an abscess because there are no blood vessels to deliver the drugs. Left untreated, it is bound to grow, eating away at surrounding tissue. In fact, the abscess had so weakened a portion of Castillo's heart that that part of his heart had turned into a thin-walled aneurysm, bulging out with every heartbeat. If the aneurysm ruptured, he would almost certainly go into congestive heart failure and die.

Surgeons who had been consulted said that Castillo was too sick for surgery. It was going to be a complex operation, involving excision of the infected valve and a portion of the aorta, the major blood vessel emanating from the heart, and replacement with tissue grafts. Besides being a diabetic and a “re-op,” Castillo had had a stroke and a recent bout of congestive heart failure. All that added up to a surgical mortality risk of about 50 percent. “I don't know whether it's ethical or unethical,” the senior surgeon had said in turning down the case, “but in this day and age we are not rewarded for taking care of sick patients.”

At the bedside, I asked Castillo how he was feeling. “I'm breaking up,” he said softly. I took out my stethoscope. “Let's not do this here,” he said. He led me down the hall, past a security guard, to the treatment room. He sat down on the exam table and took off his light blue pajama top. “Angela,” the name of his mother, was tattooed above his left pectoral muscle.

His lungs sounded clear. His heartbeat was fast, but otherwise okay. “What's happening with the surgery?” he asked as I put away my stethoscope. I told him that the surgeons had decided not to operate. “Didn't they tell you?”

“Yes,” he replied, “but it went in one ear and out the other.” I looked away, frustrated.

“Listen, I'm sorry,” he said. “I've had a problem with drugs all my life. It's hard for me to stop.”

I asked him if there was anything he wanted me to do. “Yes, please find out when my mother is coming,” he said. I told him I would ask his nurse to call. But back at the nursing station, the nurse said, “Give me a break. He can walk. He knows how to use the pay phone.”

I sat down to write my progress note. Nearby, a surgical fellow and a second-year resident were having a heated discussion. The fellow was saying he knew Castillo had little chance of surviving without surgery, but that he didn't think an operation was going to change his long-term outcome. The resident replied that he was uncomfortable with doctors playing God.

“Look, we're not doing him again!” the fellow shouted. “He has an
incurable disease. He is always going to shoot up. We don't operate on these people because they reinfect. You're going to expose the staff and the surgeons to this guy's blood, to HIV, for what? To treat an incurable disease?”

“What about people who really do want to stop doing drugs?” the resident countered. “Are you saying you're going to condemn someone to die?”

“This guy had a chance but he failed,” the fellow said angrily. “Why should I take the risk to my family, to my child, because of him?”

“It depends on whether you view drug abuse as a personal failing or a real disease,” the resident said.

“Whatever!” the fellow erupted. “He has himself to blame. I didn't put the needle in his hand.”

The vague outlines of a memory started to form in my mind.

“He says he wants to stop doing drugs,” the resident insisted. “He says he'll enroll in rehab.”

“Look, we've worked with shooters,” the fellow said, obviously frustrated by the resident's stubbornness. “They say whatever they're supposed to when they're in trouble. You can't trust them. Besides, you told me he wanted to go back to that hospital in Staten Island.”

“I spoke to the Staten Island surgeon. His secretary left a message that he would not operate.”

“See!” the fellow cried, throwing up his hands. “You can call anyone you want, but I can tell you right now that no one is going to do this surgery. A valve isn't like popping in a piece of bubble gum. You don't give a new liver to an alcoholic.”

“Valves are not in limited supply. You could say livers are.”

“Yes, but someone who's a recidivist!” the fellow shouted. “It's unfortunate but you reach a point where you have to develop some kind of policy.”

And so it went, back and forth, for several more minutes. The memory I had was of Ira Schneider, the morbidly obese man I had taken care of on Ward 4-North when I was a second-year resident. So
much had changed since I had advocated for Mr. Schneider to receive a bypass operation over the objections of his surgeons. At one time, I too had felt passion like this resident. I too had felt deeply disturbed by a surgeon's refusal to operate. Now, listening to this discussion, I wondered if the resident wasn't just a bit naive. It was a transformation that troubled me.

In some ways, I probably ended up becoming the kind of doctor I never thought I'd be: impatient with alternative hypotheses, strongly wedded to the evidence-based paradigm, sometimes indifferent (hard-edged, emotionless), occasionally paternalistic. Kind of like my brother. Early on in my training, I had unrealistic expectations of other doctors—and also of myself. I thought I was going to make big changes, more of an impact, reform the profession somehow, but in the end I adapted to the culture around me. I came to accept the workings of the hospital and of my colleagues. I became less judgmental—of doctors, not patients (there was a time when it had been the other way around)—and more forgiving of, more faithful to, my guild. Medicine, I learned, is a good profession, not a perfect one—and there are many ways it could change for the better—but most of its practitioners, like my brother, my wife, my classmates, were fundamentally good people trying to do good every day. Sure, there were doctors who were only interested in making a buck, who didn't approach each case thoughtfully, but thankfully they were in the minority. Most doctors really did want to care for their patients in the right way.

I have often thought of the conversation Rajiv and I had when I toured the ICU in San Diego just before I decided to apply to medical school. I had accused him of insensitivity after a remark he made about a dying patient. “So you'll be a different kind of doctor,” he shrugged. “Once you get out of the ivory tower.”

In the end, I probably fell short. Once I embraced my profession, my behavior naturally grew more aligned with that of my colleagues. I wasn't strong enough to change the culture, or even to resist its embrace. For most of internship, I had been tormented by an ideal, which
I had to get rid of in order to survive. All my life, if things weren't perfect, I was apt to dissect, try to find larger meaning; if I wasn't perfect every moment of my life, then I was nothing. I had to let go of that to be free, let go of the past, the missteps, and the false starts. In my weaker moments, I often told Sonia with regret that I had become a different doctor than the one I originally wanted to be. “You're nice, you're caring,” she'd reply sympathetically. “Your patients love you.” Her words, automatic, provided some solace, but I still often wished that I had held on to my earlier ideals.

From the prison ward I walked through the cardiac catheterization suites, where I would spend a lot of time over the next few years, and then I went downstairs and exited the building. It was getting to be dusk. The sidewalk outside Bellevue was like an enormous Jackson Pollock painting, splattered with the most mysterious splotches. The faint light streaming through the cloud formations was an allegory of what my life had been as a resident: bleak, but always with a glimmer of hope to remind me of why I was here.

Near the ER I ran into the CCU fellow, who was waiting for a friend. “How was your tour?” she asked pleasantly. “Good,” I replied. Bellevue was very different from New York Hospital, but I was beginning to wonder if I wouldn't benefit from a change. The fellow invited me out to talk some more about the program, but I politely declined. The evening was temperate, and I wanted to walk home alone.

My shadow stretched long across the concrete squares. The landscape appeared surreal, almost two-dimensional, like it had been painted onto a canvas. I ambled past delicatessens and parking structures, past the UN Building, whose green-tinted face rose to the sky like a giant domino about to topple over, and through midtown, where the office buildings shimmered like black jewels. Each block was like a tableau on a filmstrip, with some unseen force turning the reel. I marveled at the swirl of humanity on the streets: teenagers riding skateboards, young urban professionals carrying briefcases, pretty blondes in wraparound shawls, their designer glasses pushed off their faces
and wedged into their straightened hair. A couple was having dinner at the counter of a gourmet food shop. I stopped to watch them. Did they know how lucky they were for this moment?

Near Fiftieth Street, the neighborhood changed, becoming more residential. Classic walk-ups with rusty fire escapes sat perched atop storefronts with multicolored awnings. Each shop was like an old acquaintance, one that I hadn't seen in a long time and for which I had been longing. I walked under an overpass where homeless men were camped out in sleeping bags. Thoughts flitted through my mind like gnats after the recent rains. What was it, I wondered, that had kept me on this road, through the dark days of an internship winter, through my neck injury and subsequent depression, through the ICU and the CCU and night float? A desire for experience? A sense of service? Pragmatic considerations? Obligation to my parents? The absence of a viable alternative? Or perhaps just the promise that I would make it to this point, when I would finally feel content with the choices I had made. Internship had been a difficult time, but a hopeful one, too—new career, new city, new marriage—and, in the end, it was that hope that had gotten me through it.

What a strange experiment I had conducted! Bailing out of a promising physics career in my mid-twenties to go to medical school. And then a clinical residency in internal medicine when I wasn't even sure I wanted to be a doctor. It had been a foolhardy mission, and yet it occurred to me that I would do it all over again. Becoming a doctor had strengthened me in all the ways I had hoped for. I discovered a physical hardiness I didn't know I possessed. I learned how to cope with—and inflict—pain. (Residency had toughened me, but it had coarsened me, too.) I learned how to withstand pressures—mental, physical, and moral. I learned to become passably competent with my hands. I learned how to think in schemata and to simplify—perhaps oversimplify. And finally I learned how to make big decisions—and not always after ponderous reflection. At one time I had worried that my ruminative nature would impair me as a physician, and no doubt it hurt me
when I was an intern. But in the end, my unwillingness to act reflexively probably made me a better doctor. The very characteristic that had been least adaptive when I was an intern probably helped me the most afterward.

There had been other benefits, too, of a more personal nature. I'd met and married a doctor, and though our mutual interests extended well beyond medicine, our common profession served as a comforting backdrop to our relationship. Rajiv and I had gotten closer, too. Being in the same profession as him had helped me become more accepting of his brash behavior. (For better or worse, I had become more like him than I ever expected.) Finally, it was good to see Mom and Dad so proud. I was “on the right track.” I had climbed “out of the ditch.” I had fulfilled their dream for me, and though they could never know what I had been through, I embraced their pride. Though I still thought they were hopelessly naive about medicine, I also believed that they probably had been right all along in encouraging me to become a doctor.

I had seen so much in the past year and a half. I had learned so much about a profession that had once been inscrutable and intimidating to me. I learned that patients will almost always tell you what is wrong with them, if you're willing to listen. I learned that the most important thing in clinical practice is common sense. And I discovered to my surprise that the practice of medicine is its own ivory tower. Whenever you delve into something deeply, it achieves its own fortified, rarefied status. And as in academia, the ivory tower of medicine is loaded with mystery. Most things we don't understand; much of our knowledge is incomplete. I often thought of what an attending physician once said to me on the geriatrics ward. I had been caring for an elderly woman who had fallen at home and could not get up, so, as part of the workup, I ordered telemetry monitoring, an EKG, and a head CT scan, all of which were unrevealing. I told the physician I was planning on getting an echocardiogram and maybe a tilt-table test. Far from being impressed with my thoroughness, he shrugged. “Sometimes
elderly people just fall,” he said. But what was the reason, I asked: an arrhythmia, a transient ischemic attack? Was it a shutdown of signaling from the brain to the limbs? He shrugged again. “Sometimes they just fall.”

I had learned so many lessons these past twenty months, and perhaps the biggest one of all was that medicine was a lot more complex than I had ever imagined. It was a glorious, quirky, inescapably human enterprise, with contentious debates, successes and failures, villains and heroes, oddities, mysteries, absurdities, and profundities. It was a testament to the power of my profession that now I could not imagine a life without it.

Was the pain, the ordeal, of residency worth it? When I was buried in internship, depressed and hopeless, I didn't think so. But once I got through the first year of residency, I came to realize that there probably isn't a better way to learn medicine. Internship is a classic apprenticeship of immersion. Some of the suffering may be gratuitous—thirty-six-hour shifts and hundred-hour weeks endanger patients and doctors alike—but there is only so much you can ease away and still preserve the core of the experience. In learning to become a doctor you have to work hard and stay late and devote yourself to medicine to the near exclusion of everything else in your life. You have to see a patient's illness through its course—observe the arc—to get a grip on the dynamics of disease. In my work at a teaching hospital, I often worry that the current crop of interns, mandated to leave the hospital after a twenty-four shift, is missing out on valuable lessons and is learning a mentality of moderation that is incompatible with the highest ideals of doctoring. Residency may not need to be as painful as it used to be—as it perhaps still is—but it probably has to retain a certain degree of wretchedness to serve its purpose.