The Good Doctor (15 page)

It was fitting that my father would invoke this sentiment as I was graduating from medical school, as it had been one of his prime reasons for becoming a doctor. Meanwhile, an award that I received at graduation spoke to my own motivations as a medical student—one who had tried to maintain a broad range of interests while becoming a physician. P&S awarded the annual Joseph Garrison Parker Prize to the graduate “who exemplifies through a continuation of his or her personal interest and activities in art, music, literature or the public interest, the fact that living and learning go together.” I was pleased to receive the award even though I realized that it probably went to the most restless student.

I was, of course, determined to maintain my outside life despite the rigors of internship, which began at the end of June. One of my fellow interns, Eric Stevens, and I planned to go jogging together on mornings when neither of us was on call in the hospital. The jogging lasted for only a few weeks. I started the year with perhaps the two hardest rotations—first oncology and then the medical intensive care unit (MICU)—and things never really eased up. It was a year in which I learned to be a doctor, confronted more intriguing ethical issues, and, truth be told, struggled to keep my patients front and center.

The learning curve for an intern is incredibly steep. I had spent a lot of time on the wards as a medical student but always with close supervision. Not surprisingly, it was not until I had my own patients—and was their primary caretaker—that I developed the skills to practice medicine competently. My oncology patients were incredibly sick. Many of them had neutropenic sepsis, a common complication of chemotherapy in which a patient gets a blood infection because of a low white blood cell count. Others were bleeding, requiring continual transfusions of red blood cells and platelets.

Just as my father recalled specific patients who played seminal roles in his education, so, too, did I. During my first week of internship, I was called to see a previously stable patient with pancreatic cancer whose blood pressure had fallen. When I entered the room, his entire body was shaking. Although I had never seen this before, I knew immediately that he was having rigors, a sign of a bacterial infection in the blood. I later realized that as I was speaking to the patient, I had reflexively opened up his intravenous drip to full speed, something crucial for low blood pressure. It was one of those moments that built my confidence. I called my resident for help. We gave the patient antibiotics and transferred him to the intensive care unit.

The other thing I remember from this case was the patient’s fear. He asked me if he was going to be all right. I had been a doctor for only a few days and I was already encountering an extraordinarily difficult question. I knew that the patient was going to die from his cancer. I was not sure if he would recover from the infection, but there was a good chance. So I focused on that issue and told him I believed the infection was treatable and he would be getting antibiotics momentarily. That the patient was Jewish, roughly my dad’s age, and had a disease similar to my mother’s only made the situation more emotionally charged. But at the same time, perhaps it helped the patient to be cared for by someone who could have been his son. I was getting a better sense of the sort of holistic interventions that my father made at the Mount Sinai.

On call nights, I cross-covered patients who did not have cancer. One of them was an elderly man who seemed to go into severe heart failure every fourth night, just when I was on call. Each time, he looked like he was about to die. The first two times I called the covering resident for help and we administered oxygen, diuretics, and other medications. But the third time I thought to myself,
I know how to do this
—and I did.

At times the decision to strut my stuff was not mine. On one call night in the middle of my internship, I received my fourth and fifth admissions just before midnight, which was the deadline for new cases. They were both incredibly sick; one had severe emphysema and the other a high fever, clouded mental status, and a recent history of heavy alcohol use. The covering resident, who I worked with only on call nights, admitted both cases with me and then announced he was going to sleep.

“But we have to do a spinal tap on the alcoholic,” I reminded him.

“No,
you
have to do it,” he replied.

“But he’s agitated,” I said. “How can I do it by myself?”

“Tie him down with a sheet and have the nurse help you.”

And then he left.

It was one of those
House of God
moments. I knew that I could not complain or I’d be considered a weenie by him and some of my other colleagues. So I did what I had to do with the help of a very sympathetic and capable nurse. Fortunately, the patient did fine. Even better, my regular resident laid into the admitting resident the following morning for having given me two such hard cases so late at night.

But the place that my colleagues and I really learned medicine was in the medical intensive care unit, both during my first rotation early in internship and several subsequent stints there over the next two years. The patients were incredibly sick with multiple failing organ systems. In managing all of these simultaneous problems, we really learned how the body worked. For example, patients could have far too much fluid in their bodies but not enough in their blood vessels. Low blood pressure required completely different treatment depending on whether it was caused by heart failure or a blood infection. Blood transfusions were the best way to hydrate a patient; sugar water the worst.

All the unit’s attending physicians were excellent, but MICU director Glenda Garvey—whom I had befriended as a student—was, by far, the most memorable. The daughter of two physicians and the granddaughter of another, she had been an English and American literature major at Wellesley College before matriculating at P&S and had stayed on for her residency in internal medicine. There were a smattering of senior women physicians at Columbia, but none quite like Garvey. Despite her gender, Garvey practiced medicine in a manner that was reminiscent of legendary male internists like Paul Beeson, Robert Loeb, and Louis Weinstein. Her knowledge, in her specialty of infectious diseases and in other areas, was immense. Rounds with Garvey were methodical and lengthy, but that was because she insisted on learning every physical finding and laboratory value. “Knowing your stuff,” one of her trainees noted, “was the highest priority.” I suspect that residents who rounded with Garvey in the MICU all had some type of eureka moment in which they suddenly felt confident in caring for the sickest patients imaginable. Such knowledge was fundamental to becoming a great doctor—no matter how committed one was to patient-centered care. As a woman practicing top-notch intensive care medicine at a prestigious medical center, Garvey was a particularly impressive role model for my female colleagues. Her own male medical school classmates had been so perplexed by the presence of a small number of women that they had once sent them all roses on Valentine’s Day. But now Garvey was no longer a curiosity. As one P&S student wrote years later in a blog post, “Dr. Garvey is cool, Dr. Garvey is funny. Dr. Garvey is trim, chic, well-dressed, and looks coolly elegant in a fur coat . . . Dr. Garvey is really,
really
smart. She knows everything.
Everything
, dammit. But unlike many doctors who teach us, she never makes you feel stupid just because you don’t happen to know everything yet. Because she’s chill like that, yo.”

Garvey’s joy when patients improved was palpable. Without any embarrassment, she would proclaim urine made by recovering kidneys “golden goodness.” She insisted that the junior resident on call in the MICU phone her late at night to touch base on the patients. When it was my turn to do so, I felt like one of the residents or fellows my father spoke with during our family vacations. “Now,” Garvey once said to me when she and I finished one of these conversations, “I can go to sleep.”

What was discussed less in the unit, however, was how a patient’s prognosis should affect medical decisions; even patients who did not seem likely to pull through were treated aggressively. Perhaps because her approach to medicine was so old school, Garvey immersed herself in the medical details of patients rather than scrutinizing the possible ethical ramifications of our interventions. Typical was the very first patient we rounded on in late July of my internship. He was an intravenous drug user in his forties who had been on a ventilator for many weeks with failure of multiple organs. He had just about every tube possible stuck into his body and was massively swollen and unresponsive. There were several other similar patients in the fourteen-bed ward.

To be sure, I was no expert in clinical medicine, let alone intensive care medicine. Nevertheless, having learned about the debates over end-of-life care in the Society and Medicine course, I was surprised to observe Garvey’s daily focus on treating the patient’s infections, fluid balance, and breathing status, seemingly without her paying any attention to whether such interventions were actually going to help the patient to recover. Other residents noticed this seeming imbalance as well.

Part of the problem was that, while medical schools like P&S were beginning to teach bioethics, there was nothing remotely close to an ethics or professionalism curriculum in most residency training programs—and Columbia’s was no exception. Interestingly, however, there was a particularly enlightened pair of eyes and ears present in the MICU: Robert Zussman, a sociologist working with the Center for the Study of Society and Medicine who was doing fieldwork for a book on the ethics of intensive care medicine. Zussman, who wore a herringbone sports jacket in the MICU, symbolized what David Rothman had termed a “stranger at the bedside,” a nonphysician who had come to exert a growing influence over medical decision making. Garvey had given Zussman permission to attend MICU rounds, but he made her uncomfortable, which we knew from how she raised her eyebrows when he offered an opinion. In
Intensive Care
, Zussman ultimately concluded that “moral education” in the unit was “hit or miss,” as opposed to systematic. And he believed that the Columbia-Presbyterian MICU (called Outerboro in the book) was particularly “insistent” on “pursuing every therapeutic possibility, even for patients in apparently terminal stages of illness.”

What was going on here? It is not surprising that practice lagged behind theory. It was easy to talk about the medical profession’s ethical blind spots in the classroom but much harder to effect change on the wards. At the same time, patient care in the MICU exemplified the style of medicine that doctors of Garvey’s generation had learned and with which they were comfortable: one where physicians made the tough decisions for patients. The increasingly important concept of informed consent, in which patients and families made educated choices using information provided by doctors, played only a small role at Columbia, Zussman found. During the course of his research in the MICU, only eight patients declined a procedure, and seven of the eight either changed their minds or were overruled. Paternalism still ruled the day. Until the attending physicians said otherwise, the treatment of my first MICU patient that July would remain a full-court press.

I had encountered a similar mind-set during my previous month on the oncology service. Many of the patients who were deteriorating did not seem to know that they had terminal cancer. Thus, when the house staff raised questions with them about how aggressive their care should be and whether a transfer to the MICU would be appropriate, patients were often confused or even angry. Whereas some of these patients probably knew their prognoses and were in denial, it was clear that some of the senior Columbia oncologists were purposely avoiding these types of discussions, something that the social scientist Nicholas A. Christakis would later confirm in a series of studies on doctor-patient communication at the end of life. When I began to study bioethics and the history of medicine formally in succeeding years, I would learn why autonomy and other patient-centered strategies had become so crucial and why so many physicians continued to resist them. One of those physicians was my father.

Although I tried to incorporate bioethical teachings into the care of my patients, it was not easy. In addition to our relative inexperience on the wards, my colleagues and I were always exhausted. If we had a choice between raising ethical concerns and going home to sleep, we almost always found the latter more appealing. Fatigue remained a particular problem for me, given my inability to grab an hour of sleep whenever the opportunity arose. Overnight call on the wards was only one out of every four nights, but there was not yet a night-float system, in which doctors covered patients at night in order to ease the burden of the daytime staff. As a result, I was generally up all night dealing with my own patients and those I was covering. That meant that every four days, I worked a thirty-six-hour shift, from roughly 7 a.m. to 7 p.m. the following day. I had not previously been much of a coffee drinker, but that changed. By the afternoon I was post-call, I simply poured it down the hatch in order to stay awake and—frankly—try not to kill someone due to my exhaustion.

Twenty years later, for my book on famous patients, I wrote about the well-known Libby Zion case, in which an eighteen-year-old girl died at New York Hospital in 1984. Zion, who had been admitted for fever and agitation, underwent an abrupt deterioration for unclear reasons and died within twelve hours of her arrival at the hospital. As was the custom at the time, the physicians who admitted Zion were house officers covering dozens of patients and working two-day shifts. I interviewed her father, Sidney Zion, a journalist and former prosecutor who, in the wake of Libby’s death, had successfully carried out a passionate and often harsh crusade to force the medical establishment to implement shorter resident work hours and better attending-level supervision. There were some physicians who objected to the night-float shifts that Zion and other reformers advocated, arguing that doctors in training could achieve mastery of diseases only by watching patients for the first two days of their admissions, but I did not share that view. What we were doing was crazy.