the position of doctor has no high rank, the job of computer consultant or entertainer comes with more perks, and salaries are awarded at random. A
doctor my age, shell-shocked by the change, once confided in me, “A
doctor is nothing.”
1 6 6
C H A P T E R 9
A noise outside the room distracted me. I looked at the light coming
from a crack at the bottom of the door to check for any divots of shade
caused by feet, but I saw none. I settled back down once I realized that it was just the cleaning lady, the wheels on her laundry cart squeaking as
they rolled down the corridor, with the woman herself muttering in bad-
tempered irritation about some injustice that had been done to her.
I felt embarrassed. Obviously, the cleaning lady’s life was harder than
my own. So what if doctoring is just any old job? It brings no glory, but it also brings no great misery. “Where’s my gratitude?” I had asked. Well,
there was none. I should be satisfied and at peace, as if I had achieved
everything I had dreamed of. I was living a normal life.
I wanted my beeper to go off at that moment. Time to get up, work,
live. But it didn’t. Inevitably my mind drifted toward other complaints.
Professional medicine calls the doctor a master technician. But I wanted
to talk to someone about culture, about higher things, about the eternal.
Technicians don’t talk about such things. Professional medicine calls the doctor a scientist. That’s a stretch, I thought. As a student I had watched orthopedic surgery residents perform an experiment that involved breaking bunny rabbits’ legs and putting them in slings. When I raised an
eyebrow, the residents said defensively, “Hey, we’re scientists. We’re
MDs.” I replied sarcastically, “So what do the plastic surgery residents
do? Give the bunnies a ‘boob’ job?” Nuclear physicists they were not.
Professional medicine calls the doctor a gentleman. Yet when business
turned medical practice into an assembly line, many doctors no longer
even had time to eat lunch. Some anesthesiologists smuggled food into
their operating rooms as a wretched substitute—not celery or apples,
since the crunching sound might alert the authorities, but candy bars and bananas. The doctor is a gentleman? Even the lowliest animal in a cage
gets lunch.
Professional medicine calls the doctor a professional. But a profes-
sional is in control of his personality. An employed doctor has no such
control. The company owns his smiles, his demeanor, and his language,
for these have commercial significance; they affect doctor-patient rela-
tions. Alone in the call room at night is the only time when a doctor is not pretending for anyone.
Professional medicine calls the doctor a benefactor, someone who
sacrifices himself for the good of others. But I didn’t go into medicine to sacrifice myself. I did think about my happiness: Where’s my happiness?
T H E P R O B L E M O F G O I N G P A R T - T I M E A N D W H E N T O R E T I R E
1 6 7
I asked myself. Something was working against my happiness, and it
made me angry. Nature was rising up within me, seeking to reassert some
universal rule that had been violated. I had read philosophers who said
that all happiness is built on empty space, a feeling that had no basis. I disagreed. Everyone wants to be happy. Can’t they understand? No one
can rid himself of the want, I thought.
Frightened by my own discontent, I switched on the light and picked
up a journal. Then I felt sleepy. I knew that if I put down the journal and turned off the light, the feeling would be gone. I switched on the television. I half-watched a documentary, then decided you either watch a
documentary properly or not all, and turned it off. I lay there and dreamed of dancing and singing. Don’t be impatient, happiness will come, I said to myself. You won’t be in this call room forever. When the time comes,
happiness will come. Happiness is everywhere, in everything.
Then I stood up and looked in the mirror. At first glance I looked like
an anesthetized patient, pale and despairing. Then I studied my face more carefully. I had the pallor of the person whose working day is not regulat-ed and too often goes beyond midnight, of the person who has no time for
indulgence in sports, of the person who eats any old way. I was unshaved; my hair was uncombed. In a word, here was a man who worked too hard,
who no longer cared for anything at all, and who merely continued to
drag out his existence. A tired man—tired of his work, himself, his
thoughts, his doubts. And yet I was only thirty-one years old.
My youth had been lost somewhere in the smoke of time, never to
return, never to come to life again in the green grass and sunshine. Even now, precious minutes were flying. Something turned over inside me, the
last barrier, the last thread attaching me to a conventional medical career.
I decided that very soon I would go part-time.
I met Dr. B while in training. In his early forties, he had gone part-
time at a young age to enjoy life and see the world. A part-time doctor
was a rarity in those days. It was also frowned upon. Many doctors called being part-time childish. Some said it showed a lack of dedication to the profession. A few said it was dangerous. But Dr. B didn’t care. When he
saw some female doctors going part-time to raise their children, he de-
1 6 8
C H A P T E R 9
cided to go part-time for no other purpose than to escape medicine’s
hellish work hours and live a balanced life.
We were paged to the emergency room, where an elderly man was
diagnosed with a leaking abdominal aortic aneurysm. It was the ultimate
vascular emergency. The great vessel leaving the man’s heart had a defect in its wall as it descended through the abdominal cavity. The wall now
had a hole in it. Blood was leaking out. If the aneurysm ruptured, the man would hemorrhage to death in two minutes.
Dr. B looked nervous. His eyes darted like a lemur’s. He had just
come off a two-month stint hiking in Europe, and he hadn’t done a surgi-
cal case in all that time. When the patient arrived on the operating table he raced to apply the blood pressure cuff and EKG pads. He was keyed
up, but also distracted and rough. He seemed to want to be done with this operation, to be sitting upstairs in the cafeteria and laughing about the final resolution to this nightmare, which was still open-ended and in the future. It was almost as if he resented the patient for having ruined his afternoon.
Dr. B injected two drugs into the man’s intravenous. Twenty seconds
passed between the moment of injection and the man’s loss of conscious-
ness, during which time the whole room fell quiet and still. Dr. B placed the breathing tube, then listened to the characteristic sound in the man’s chest as he squeezed air into it.
Thirty seconds later an alarm went off on the machine. No blood
pressure was obtainable. Dr. B cycled the machine again, his eyes grow-
ing wider with concern. Again the alarm sounded.
“Everything all right?” asked the surgeon.
“Yeah, just wait a minute,” Dr. B replied impatiently. “I think some-
thing’s wrong with the machine.”
“Should I do anything?” asked the surgeon.
“No, just wait a minute, will you?” Dr. B barked nervously. A shrewd
nurse quietly paged another anesthesiologist to come help.
The patient’s pallor had turned
a ghostly white; his lips were barely
distinguishable from the rest of his skin. A third attempt at getting a blood pressure proved futile. Now terrified, his pupils enormous, Dr. B reached for a drug to artificially raise the man’s pressure. He was about to inject it when another anesthesiologist, Dr. V, burst into the room. When she saw
everyone standing around flummoxed, and then saw the patient’s deathly
pallid face, she instinctively knew what had happened.
T H E P R O B L E M O F G O I N G P A R T - T I M E A N D W H E N T O R E T I R E
1 6 9
“Cut him!” she shouted.
“What?” asked the surgeon.
“Cut him!”
Dr. V saw the patient’s bare, unprepped abdomen.
“Dr. B!”
Dr. B stood still, frozen in place by fear, his eyes fixed attentively on Dr. V, the gaze of a frightened animal. He dared not even to blink.
“Dr. B! Get the iodine solution!” Dr. V raced past him, grabbed the
bottle of orange-brown iodine, and squirted it furiously over the man’s
abdomen. Then she lunged past Dr. B to grab two large-bore intravenous
catheters from the anesthesia cart. Dr. B stood aside, paralyzed, unsure
what to do, although eager to defend his actions to Dr. V.
“I didn’t give that much Pentothal. If his blood pressure dropped from
the Pentothal, it’s not my fault,” Dr. B whispered intensely. He stared at Dr. V with entreaty and hatred in his eyes.
“It wasn’t the Pentothal, you numbskull. He’s hemorrhaging,” whis-
pered Dr. V with equal intensity, making sure no one else could hear.
“You think this guy drove two hours to the hospital, made it to the
emergency room, made it to the elevator, made it to the operating room,
and then, just by coincidence, lost his blood pressure the moment you
started giving anesthesia? No, your muscle relaxant weakened the outside
pressure containing the aneurysm, causing it to explode. The patient
should have been prepped and draped, with blood units already in the
room, before you even started.” Then Dr. V shouted, “Someone, call for
blood!”
“When you grab hold of his aorta, squeeze tight until we get some
blood into him! Just clamp it and pray!” she yelled at the surgeon.
The race began. The surgeon began slicing the patient’s abdomen with
deep strokes, as if he were a butcher hacking meat, the patient’s intestines pouring out of the wound, an intertwined mass still steaming with bodily
heat but abnormally pale, limp, and bloodless, without the usual stirring and swelling motions of the bowel. A tongue of blood spurted out lizard-like from underneath the mass, and then blood began to ooze out all over.
Large dark clots floating in a red current streamed over the sides of the wound onto the surgeon’s feet and beyond onto the floor, leaving puddles
for us to step in.
We placed two more intravenous catheters. Blood spread over my
ungloved hands and fingernails, emitting a sickly sweet smell. As the
1 7 0
C H A P T E R 9
surgeon hacked his way deeper into the man’s belly, blood spattered
everywhere, including onto the uncovered part of my face and neck.
The nurse called out, “The patient has no blood available. The speci-
men sent to the blood bank clotted, and so they couldn’t do the cross-
match.”
“Are you serious?” the surgeon shouted, working furiously. “Come
on! What the hell is going on here? No blood available for a major
vascular case? Who forgot to check . . . ?”
“It doesn’t matter,” Dr. V interrupted, knowing it was probably Dr. B
who had failed to follow up. Perhaps desiring to shield him from another
blow, she told the surgeon, “We’re going to need more blood than they
would have typed for.” Then she told the nurse, “Just send for as much
Type O blood as they can give us.”
Dr. B seemed to understand what Dr. V had done on his behalf. He
slightly resented his weakness and Dr. V’s reminder of it but said noth-
ing, for he knew he had made another mistake.
Several minutes later the orderly lugged into the room a large box
containing blood units. We transfused each unit as fast as we could.
Fifteen minutes later the patient’s blood pressure returned to measur-
able levels, although his color still hovered menacingly between white
and ash-gray. The surgeon held on to the patient’s aorta as if it were a
wriggling snake, waiting for more transfused blood to fill up the patient’s vascular system. Still, the suction canisters roared, inhaling blood into their gaping maws. The blood pressure disappeared again—this time for
good. The patient bled to death. We could not resuscitate him.
Part-time doctors are a new phenomenon in medicine. Before the
1990s, they were rare. By 2005, 7 percent of male doctors and 29 percent
of female doctors were part-time. In 2011, 22 percent of male doctors and 44 percent of female doctors were part-time. 1 A doctor’s desire to go part-time today is understandable. Medical training is longer than ever.
Subspecialties such as cardiology and orthopedic surgery now need as
many as eight years of postgraduate work, up from five years in 1970. 2
Many doctors today don’t start living adult lives, with real salaries, until their late thirties. Naturally they feel impatience and regret, as I had in my call room. They want another life, and so they go part-time.
Other statistics hint at what is happening: In a 2014 survey, 60 percent
of physicians older than forty-five had negative views toward being a
doctor; yet almost 50 percent of physicians younger than forty-five
T H E P R O B L E M O F G O I N G P A R T - T I M E A N D W H E N T O R E T I R E
1 7 1
shared the same negative views. 3 Young doctors today are surprisingly cynical and jaded about their profession. Their inward cursing and brood-ing inevitably leads many of them to go part-time; it’s as if they want to remedy the mistake they made by going into medicine in the first place.
Indeed, many older full-time doctors have left independent practice to
become hospital employees, not because they like being employed, but
because they are unable to find young doctors willing to join their prac-
tices and take night and weekend call, so determined are young doctors
these days to live their lives.
Professional medicine remains quiet on this issue. It shouldn’t. Part-
time doctoring has the potential to increase the risk of catastrophes, as it affects a doctor’s ability to retain vital instincts. Dr. B was a case in point.
Being a creature of habit is a bad thing in a physician. A doctor who
follows rules and protocols unthinkingly can make bad decisions. Yet
being a creature of habit is also a good thing in a physician. It helps turn conscious decision making into instinct. This makes a doctor safe.
A surgeon, for example, is often a creature of habit. He will often eat
the same breakfast at the same time every morning and stand on the same
side of the operating table every day because he prefers to work reflexive-ly, almost without thinking, with no new feeling in his mind, his hands,
his stomach, or his bladder to perturb him. It is why a surgeon can work
after being awake for forty hours; too tired to think, he works by habit, which is how he works best. Even a surgeon’s lashing out in anger is
more of a habit than an action, as a rude surgeon is typ
ically rude to
everyone.
When the surgeon cuts, the choice of where and how to cut is some-
times not even conscious. The surgeon thinks with his fingers and his
scalpel. This is vital to being a good surgeon. It is analogous to the boxer who thinks with his body. The boxer never has time to say to himself,
“Since my opponent is doing this, I will do that.” Instead, the boxer
thinks with his arms and his gloves. If there is the smallest break in the motion, if it pauses only slightly while the boxer hesitates and reasons, the rhythm breaks down and the exercise becomes impossible. It is the
same with a surgeon, who establishes a direct communication between
his eyes fixed on the patient and his fingers holding the knife.
In medicine, the art of thinking is often the art of making thought
instinctive. Instinctive thoughts have narrow limits, but they can be infallible—and lifesaving. It is through instinct, born of the thousands of cases
1 7 2
C H A P T E R 9
he or she has observed, that a doctor acquires the flashing rapidity of
decision that medical events sometimes require.
Part-time doctoring threatens such instincts. In Dr. B, principles that
would have percolated quickly and naturally to the surface of conscious-
ness in a full-time doctor were repressed. Had he been given time, he
might have been able to conjure them up—for example, the need to prep
and drape a patient with a leaking aneurysm before inducing anesthesia.
But conjuring takes time, and he had none. Knowledge is a doctor’s only
if, at the moment of need, it offers itself to the mind without the need for long meditation, for which there is no time.
Anesthesiologists are also creatures of habit. When shown a new drug,
an anesthesiologist sometimes thinks, “Let me not know about it; then I
will be happy.” This is a bad habit, as it prevents the anesthesiologist
from learning new things. Yet vigilance to the point of suspicion is also a habit, and a good one. In the surgical theater every funny-looking face
suggests to the anesthesiologist a difficult intubation, every operating
Medical Catastrophe Page 24
