The Good Doctor (16 page)

Ultimately, it was exhaustion and time pressure that jeopardized the one thing that had made so many of us go into medicine: patient care. Reflecting on medicine in the postwar years, when the average hospitalized patient was much less sick, Paul Beeson recalled having lots of time: “Time to talk and time to think about our patients.” Yet—just as detailed in Shem’s and Mizrahi’s books—I often had to choose between having some free time and doing the best for my patients. Disturbingly, I found myself behaving in ways that I had never thought I would, even occasionally seeing patients as my enemies. One particular case underscored for me how foolish this sort of attitude was.

I was on call. It was about 5:30 a.m. and I had finally finished admitting my patients and doing all the cross coverage. I was in the call room and hoped I could get about ninety minutes of sleep before morning rounds. I was utterly exhausted. I got into the bed and actually fell asleep. Ten minutes later, my beeper went off. It was a nurse calling to report that one of the patients I was covering for another intern was having chest pain. I asked if anyone had done an electrocardiogram (EKG) or gotten vital signs, knowing full well that the answer was likely to be no. “How does the patient look?” I asked. “Okay,” she said, “but I don’t know him very well.”

I looked at the sign-out form I had been given. The patient was a middle-aged Dominican man in his fifties who had been admitted for chest pain but was supposed to go home the following day. The form said that he was on Tylenol for pain. I so wanted to go back to sleep. Couldn’t I just tell the nurse to give him some Tylenol and then go see him at 7 a.m.?

Well, no. I would not have been able to sleep anyway. But I was mad. Mad at the system and mad at the patient for waking me up. When I walked into the patient’s room, however, I must have either said or thought, “Holy shit!” He was sitting bolt upright in bed, breathing forty times a minute, which is an extremely high respiratory rate. A quick examination revealed him to be in flash pulmonary edema: his lungs had filled with fluid. I did what I had to do: I started oxygen, put in an intravenous line, gave him a diuretic by vein, and placed a nitroglycerin pill under his tongue. I also asked the nurses to page the anesthesiologist on call to intubate the patient and put him on a ventilator.

Less than an hour later, things had become much quieter on the ward. The patient had been successfully transferred to the cardiac intensive care unit (CCU). I reminded myself that I had genuinely considered going back to sleep instead of seeing the patient. The patient was lucky, but so was I. By this time, it was nearing 7:00. There was no point in going back to the call room. I just went and got my coffee.

Months later, a man animatedly ran up to me and hugged me. I did not recognize him. “Doctor, Doctor, you saved my life,” he said in broken English. I immediately knew who he was then. Fortunately, he did not know the whole story!

Perhaps the most disturbing event of my internship happened late one Friday afternoon when I was called about another patient with chest pain. I was busy dealing with a different problem, so I sent my medical student to do an electrocardiogram on the patient. I arrived a few minutes later and when I saw the tracing, I’m not sure what looked worse: the patient, who was pale, sweating, and had a very low blood pressure, or the EKG, which had the classic tombstone pattern consistent with an acute heart attack. My student did not look so good either. There were a million things to do, including putting in additional intravenous lines, giving the patient fluid, and getting him to the CCU as soon as possible. I needed help. The medical student, who was quite good, was nearly useless in this emergency, so I had him page my immediate supervisor, a junior resident. But the resident did not answer his beeper. In desperation, I told the student to go to the nurses’ station and ask any doctors there to come and help us. There was only one present: a popular, competent attending cardiologist. The student practically begged him to come, but the attending said no and told him to call his resident. Out of options, I did what I had to do: I called a code, thereby alerting the on-call anesthesiologist and the rest of the medical staff that there was an emergency. Such codes are normally limited to cardiac arrests, when patients’ hearts have actually stopped. My patient was still breathing and had a blood pressure, but I felt that I had no choice. Finally, the help I needed arrived and we transferred the patient to intensive care.

The attending’s refusal to help us, however, always stuck with me. I am certain he was truly busy and perhaps even late to other patient-related commitments. But what kind of physician would not have pitched in to save a possibly dying patient until help arrived? Of course, this doctor is hardly the only one who has acted this way. My wife tells the story of a physician whose children she babysat when she was a teenager. One night, as he was driving her home, they approached a car crash. Rather than stopping to assist, this physician drove back to his house and switched to the car that did not have MD on its license plate.

It was hard not to think about my father—who I could not imagine ignoring a human in distress—when reflecting on these episodes. Once, when I was a teenager, he had pulled a child out of the back seat of a terribly mangled car that had crashed near our house. The child’s mother, who was driving, did not survive, but the girl did. And somehow, my father had always managed, despite a busy consultation service, teaching responsibilities, and clinical research, to keep his primary focus on doing what was best for his patients. Whether I felt burned out or not, the right choice was clear to me.

Another reason I often thought about my dad during my internship and residency was the abrupt appearance of tuberculosis and AIDS. Tuberculosis, which had been the leading cause of death in New York and other cities in the early 1900s, had never actually gone away; it quietly persisted among disadvantaged urban populations. Now it was back with a vengeance, thanks to cutbacks in public health funding, the rise of homelessness in the 1980s, and, it would turn out, the immunosuppression caused by AIDS.

I wish I could say otherwise, but the wise physicians of Columbia (and many other medical centers) were ill prepared for the return of what was once known as the great white plague. Some attending physicians, not having seen a case of the disease in decades, forgot how communicable it could be. On rounds one morning during internship, my attending brought us into the room of a patient with active tuberculosis to excitedly demonstrate the succussion splash, a finding first described by the ancient Greek physician Hippocrates: a characteristic noise heard when one shook a patient who had a large lung cavity containing both air and fluid. The patient coughed the entire time. The masks we wore were woefully inadequate to prevent the transmission of tuberculosis. Indeed, within a few months, my tuberculosis skin test had turned positive, indicating that I had become infected with the bacteria (although not ill from it). Many of my fellow residents also became infected during our three-year tenure. It was not only the medical profession that missed the boat. New York City health officials took far too long to realize that the city’s burgeoning homeless shelters, including an enormous one located across the street from Columbia-Presbyterian, were breeding grounds for tuberculosis, including the drug-resistant types.

We were also insufficiently careful regarding AIDS, which was caused by a virus, eventually called the human immunodeficiency virus (HIV), and led to a series of common and uncommon infections. As my onetime Columbia colleagues Ronald Bayer and Gerald M. Oppenheimer later documented in their excellent book
AIDS Doctors
, physicians across the country—even infectious diseases specialists—downplayed the potential infectivity of the HIV virus. During my pediatrics rotation, one of my fellow medical students drew blood each morning on the hospital’s first AIDS baby without wearing gloves. I remember seeing blood on his hands. It seemed sort of crazy to me, but none of the physicians rebuked him. Interestingly, however, the message that we should protect the privacy of AIDS patients came through loud and clear. Whether due to fears of causing panic among other patients or a sincere effort to prevent AIDS patients from losing their jobs or their health insurance or both, there was an informal edict that we should not actually write
AIDS
or
HIV
in the medical charts. Such efforts, while well-meaning, led us to write some pretty convoluted notes that probably did not enhance the care of our AIDS population.

It was particularly interesting for me that just as I was beginning my medical career, infectious diseases were dominating the wards and the headlines. Doctors like my father and Louis Weinstein, who for years had been preaching about the misuse of antimicrobials and the development of drug-resistant bacteria, would have been the first to say that serious infections had not gone away. But the control of infectious diseases such as polio, rheumatic fever, and diphtheria had indisputably been a public health triumph. Now, once again, infectious diseases specialists were taking care of the sickest patients in the hospital. In the case of AIDS, young previously healthy people, mostly gay men at first, were being admitted with severe infections that often killed them in a few days. Many of these were the rare so-called opportunistic infections seen only in individuals with severely depressed immune systems. I vividly remember admitting to the MICU a man in his late twenties who was a weight lifter and had been in terrific shape. But pneumocystis pneumonia (PCP) had entirely eaten away his lungs; he died almost immediately. It took all the expertise of Glenda Garvey, Harold Neu, and their infectious diseases colleagues at Columbia and across the country to juggle antimicrobial agents and buy time for these unfortunate AIDS victims.

As the head of the MICU, Garvey probably saw most of these patients before they died. Over time, there were fewer gay men and many more homeless people with histories of psychiatric problems and intravenous drug use. The notion that these patients somehow deserved to get AIDS due to their aberrant lifestyles was rampant in the media. Some of my coworkers on the wards of our hospital, I must confess, felt the same.

But Garvey would have none of this. Although she rivaled any of her colleagues in her knowledge of medicine, Garvey was profoundly affected by these dying souls. Was it because she was a senior woman physician in a hospital that had too few others? Perhaps. We residents were overtired and often cynical, but we took notice and hoped that we would one day care as much. As one of Garvey’s students, Steve Miller, later wrote, “I saw her holding the hands of dying AIDS patients, in comas, when most others were afraid to touch them.”

Well after several Columbia colleagues and I had finished our training, we continued to organize periodic reunion dinners with Garvey. Unfortunately, she developed colon cancer in the late 1990s and eventually died of it in 2004 at the age of sixty-one. I’d like to think that Garvey, who had no children of her own, saw this group of mentees—trained by her to provide consummate care to their patients—as her surrogate kids. After her death, Columbia wisely began a teaching academy in her name.

If tuberculosis and AIDS represented enormous challenges even for experienced clinicians, the two diseases provided a boon for medical historians and bioethicists, who were called upon to revisit past epidemic infectious diseases and discuss such tricky issues as quarantining the sick. In fact, tuberculosis would become the main focus of my own research once I became a fellow and graduate student.

CHAPTER FIVE

Forging My Own Path

Students and house officers interested in careers in bioethics, medical history, or the medical humanities often ask me how I became an MD-PhD. I tell them it was mostly good luck and good timing. Just as my father had taken advantage of an opening in Louis Weinstein’s infectious diseases fellowship program, I applied to the Robert Wood Johnson Foundation’s Clinical Scholars Program at a time when it was supporting researchers interested in history and bioethics.

I had been exposed to these fields as a medical student and resident, but as a Clinical Scholar at the University of Washington in Seattle, I began formal study and met leading researchers. I had not particularly planned to focus my research on the years after World War II, but exploring the transition from medical paternalism to patient autonomy made a lot of sense for someone interested in the history of medicine and bioethics. The postwar era was when the ground began to shake under the comfortable model of physician-dominated medical practice that had existed for centuries. My research into the triumph of autonomy meant that I would also explore a series of ethical issues—including human experimentation, conflict of interest, and truth-telling—that directly called into question the behaviors of my father and his generation of physicians. Our competing perspectives led to spirited arguments and, at times, genuine tension between us. The world of medicine had split apart over the previous twenty years and my dad and I seemed to be on opposite sides.

I never heard of the Clinical Scholars Program during my days as a house officer. The Department of Medicine at Columbia was a very traditional place and the vast majority of residents subspecialized in fields like cardiology, gastrointestinal diseases, and infectious diseases. Only rarely did a graduate choose to go into general internal medicine, even though all the residents maintained a general medicine clinic throughout their three years in the program. I knew that I did not want to subspecialize, but I had no idea what I wanted to do. Like several of my other indecisive peers, I began a stint as an attending physician in Columbia-Presbyterian’s emergency department, actually earning a reasonable salary for the first time.

When I learned about the Robert Wood Johnson program, I was immediately intrigued. Clinical Scholars spent two years at one of six sites across the country, learning research skills, being mentored, and usually earning advanced degrees. Most of the scholars, I would learn, were studying epidemiology or health services research, but several others were interested in history or bioethics.