Doctored

by Sandeep Jauhar

  I see a glimmer that these middle years will make me stronger, that eventually I’ll master my most difficult experiences and look back on them like a vivid dream. Yet it still feels at times as if I am running in place, like one of Chaudhry’s patients trying to keep up with the treadmill. So I will muddle through this period, trying to find peace with the changes that are occurring. I have already mostly forgotten the pain of my internship. All I have now is the memory of that time, and it doesn’t seem so awful. Perhaps all this will blow over, too, and I will be able to revise in my mind how I felt about it.

  What kind of doctor do you want to be? This is a question that all physicians have to answer at various points in their careers. And they have to do it with the knowledge that people often place outsize expectations on our profession. People often think of doctors as either consumedly avaricious or impossibly altruistic. There is a disconnect between how the lay world views medicine and how doctors experience it from the inside.

  One weekend when I was on call in the ICU as a second-year resident, I was on rounds with Abe Sanders, the attending. Dr. Sanders was a portly, avuncular man with a mischievous grin. Despite the miseries of the ICU, he always maintained a relentlessly upbeat manner.

  It was a brilliantly sunny day, perfect weather for sailing. Midway through long, protracted rounds, Sanders called us over to a window. He pointed down at a sailboat on the river. A man was standing on the deck, looking up at the hospital. He looked as if he were about Sanders’s age, though fit and tan. He was holding a drink, and a party with attractive people was being held on board. “See that guy?” Sanders said. “Do you know what he’s thinking?”

  We were standing in a patient’s room. The alarms were going off. No one ventured a guess.

  Sanders said: “He’s thinking, ‘I should have been a doctor!’”

  Of course, I now have a much more nuanced view of medicine than the man on the boat. Having been in medicine for the better part of my professional life, I have seen that there are all types: knights, knaves, and pawns. In fact, most doctors—myself included—are an amalgam of all three. Neither we nor the profession in which we practice is perfect.

  Still, I believe most doctors continue to want to be knights. Most of us went into medicine to help people, not to follow corporate directives or to maximize income. We want to practice medicine the right way, but too many forces today are propelling us away from the bench or the bedside. No one ever goes into medicine to do unnecessary testing. However, this sort of behavior is rampant. The American system too often seems to promote knavery over knighthood.

  But medicine holds the key to its own redemption. A few years ago there was an intern, Jeremy, at my hospital who started his residency when he was forty-six years old. He had gone to medical school in his twenties, but midway through his fourth year he developed lymphoma. He’d been forced to forgo residency. He’d gone into medical education instead, and eventually worked his way to becoming a top-level administrator, the chief operating officer of a large hospital system in Philadelphia, commanding a high six-figure salary and a staff of six assistants. One day I asked him, “What the hell were you thinking when you decided to quit that and become an intern?”

  This is what he said to me. “I hit the big forty-five and asked myself, What is this? What am I doing? I had always just wanted to practice medicine.” So he started going on rounds at 6:00 a.m. daily with an ICU team at one of the hospitals he was overseeing. “I loved being there,” he said. “I just wanted to be taking care of people.”

  In the middle of his second year at LIJ, he suffered another health setback—a new primary bladder cancer for which he had to undergo chemotherapy—and yet he persevered and applied for a fellowship in critical care medicine, eventually going to the Mayo Clinic in Rochester, Minnesota. “I’ve had a great time,” he told me when he graduated. He didn’t seem fazed by his health condition or by the fact that he was going to be fifty-one years old when he finally finished his medical training.

  I believe most people who are drawn to medicine desire a career of tangible purpose, like Jeremy. What redeems the effort? It’s the tender moments helping people in need. In the end, medicine is about taking care of people in their most vulnerable state and making yourself a bit of the same in the process. When I get dispirited, I often think of my eighty-eight-year-old patient Lily Dunhill standing at the doorway to my office. “I’m sorry to bother you, Doctor, but can I share with you a thought? It’s sort of my philosophy on life.” I looked up from my keyboard, where I was tapping out my report on her. “When you get to be my age, you don’t want to take life too seriously. You know the old saying: If you laugh, the whole world will laugh with you. Well, I say, When you cry, your mascara runs.” She smiled warmly. “Thank you for being a good and kind doctor. What you’re doing is so, so important.”

  Epilogue

  A buzzing on my waist. I pull off my beeper. The teal display lights up in the dark. I reach for the phone. There is perspiration on the back of my neck.

  “Dr. Chaudhry’s service,” a woman says.

  “This is Dr. Jauhar,” I whisper.

  “The ER just paged again, Doctor. About Martha Reed.”

  “How is it they called again? I just talked to them.”

  “I’m sorry, Doctor. Can I connect you?”

  I stare into the dark. Sonia is fast asleep. A soporific buzz rises from the vent.

  “Doctor?”

  “Yes, go ahead.”

  I pull myself up and step out of the bedroom. It is 3:00 a.m. The floorboards creak noisily, as if complaining, too, of being woken. I go downstairs. Through a living room window the moon is shining brightly. Shadows of trees slice across the lawn. The white hydrangeas are glowing like tiny orbs of light.

  “LIJ ER,” a voice announces.

  “Yes, it’s Dr. Jauhar, doc-of-the-day.”

  “Hold on, Dr. Jauhar.” In the darkness of the living room, I stare at the mantelpiece. The nocturnal feeling that the ER is being unfair to me is beginning to take hold. After a minute—maybe more, I don’t know—the receptionist finally comes back on the phone. “Dr. Jauhar, I went round and round, but nobody’s owning up to it. Maybe it’s a page from earlier.”

  “No, the answering service just called me. Can you check again? I don’t know why you guys can’t coordinate your calls. I’ve gotten six phone calls—”

  “I’m sorry, Dr. Jauhar. Hold on.”

  Another minute passes. The room is pretty, though unfinished. Swatches of fabric lie on the rug. Finally a voice says, “Dr. Jauhar, it’s Sabrina, telemetry PA. The family wants to know if they can take Martha Reed home. They say she has a history of infectious colitis, and they’re concerned she’s going to get it again.”

  “Then why did they bring her to the hospital?”

  “I really don’t know, Dr. Jauhar. I wish I could tell you … Dr. Jauhar?”

  I must have dozed off. “Yes, well, I can’t let her leave. I’ll talk to them in the morning.”

  “Okay, Dr. Jauhar. I’ll tell them. While I have you on the phone, can I tell you about this other patient, Rita Roberts? She is forty years old. She’s been having mild chest pain for four months, no relation with exertion, comes and goes. No cardiac risk factors, but her outside attending wants her to have an angiogram. So I’m going to call the fellow for a consult.”

  I try to focus, but my mind is a blur. Perhaps I should intervene, question the rationale of sending a healthy woman with atypical chest pain for cardiac catheterization, protest the risks that we were going to force this young woman to endure. Perhaps I should call her doctor and demand to know why after four months of symptoms he thinks it is warranted to spend thousands of dollars admitting her to the hospital to do an unnecessary procedure—on my watch. But I say nothing. I will deal with it in the morning.

  Notes

  The page numbers for the notes that appear in the print version of this title are not in your e-book. Please use the search fu
nction on your e-reading device to search for the relevant passages documented or discussed.

  2. ODD CONCEPTIONS

  encouraging a kind of shiftwork mentality I have worked in teaching hospitals in New York State for fifteen years, first as a resident and now as an attending physician, mentoring residents and fellows. Over this period I have discerned a gradual decline in the intellectual climate of these institutions. It has been dispiriting to watch. Of all the places one might expect doctors to be curious about medicine, teaching hospitals should be first.

  I once met a pulmonologist, a soft-spoken woman who told me that she used to work on the staff of a teaching hospital in New York City but had gone into private practice a few years before. I asked her why. “I loved to teach,” she replied sadly, “but the residents and fellows just didn’t seem to want to learn. They had other things on their minds.

  “I met an intern the other day,” she went on. “He was asking me questions about a case we were managing together. I told him that it was wonderful to see a young doctor so curious about medicine. He said: ‘Thank you for saying so. Now can you tell my chiefs because they are always telling me that I am too inefficient?’”

  In his 1999 book Time to Heal: American Medical Education from the Turn of the Century to the Era of Managed Care, Kenneth Ludmerer, a Washington University physician and historian, bemoans the deteriorating intellectual environment in teaching hospitals.

  He writes: “Most pernicious of all from the standpoint of education, house officers”—interns and residents—“to a considerable extent were reduced to work-up machines and disposition-arrangers: admitting patients and planning their discharge, one after another, with much less time than before to examine them, confer with attending physicians, teach medical students, attend conferences, read the literature and reflect and wonder.”

  5. DO THE RIGHT THING

  and many more lives were at stake A decade ago the Office of the City Comptroller of New York City issued a troubling report that found that volunteer ambulances were apparently biased toward transporting patients to the hospitals that hired them, even if it meant delaying taking patients to the ER or passing other hospitals along the way. At the time, Alan Hevesi, the comptroller, said that volunteer ambulances sometimes “put the financial interest of their hospitals ahead of the health of patients.”

  the models did not account for simple bad luck Any doctor dreads bad luck, but for cardiac surgeons, who generally perform no more than a couple of hundred operations a year, it can be ruinous. A few unexpected outcomes can wreak havoc on a surgeon’s statistics. This point was illustrated in an elegant 1977 article in Scientific American, in which the mathematicians Bradley Efron and Carl Morris studied the batting averages of eighteen Major League baseball players after their first forty-five at bats during the 1970 baseball season. Using statistical arguments, they showed that the batting average of any player converges to the mean batting average of all players if he takes a sufficient number of swings. That is, the true ability of a batter is not what you observe after a small number of at bats because a handful of strikeouts can ruin a batter’s average. The smaller the number of at bats, the greater the potential deviation from that player’s “true” average. This “regression to the mean” can just as well be applied to cardiac surgeons, for whom a few deaths can be statistically ruinous. More important, it calls into question the validity of statistically guided surgical quality-improvement programs.

  8. PACT

  that would be a bad thing A recent study of 250 high-billing physicians found that those doctors did not perform 66 percent of their billed procedures. More troubling, 21 percent of procedures were performed by “unqualified” staff.

  14. DECEPTION

  made fainting seem benign, almost glamorous The common faint—or vasovagal syncope—accounts for roughly three-quarters of the cases of syncope that come through the emergency room. A grab-bag diagnosis, it is probably not a single disease as much as a poorly understood syndrome of standing. The classic physical signs are slow pulse and low blood pressure. A cardiologist once told me how he had diagnosed vasovagal syncope on a plane flight. A passenger in the aisle had started to pass out, and as he was falling, the cardiologist’s fingers somehow had landed on his neck pulse, which was beating slowly. Given the circumstances, it was all he’d needed to make the diagnosis. Rarely fatal, vasovagal syncope can be debilitating to those predisposed. Treatment suggestions reflect the wide spectrum of the disorder, ranging from beta-blocking drugs and salt tablets to pacemakers and Paxil.

  16. FOLLOW THE MONEY

  such “gainsharing” will align physicians’ incentives with cost-cutting goals In 2009, CMS announced a gainsharing demonstration project at twelve New Jersey hospitals that offers doctors financial rewards for helping the hospitals improve efficiency and lower costs by reducing length of stay, improving discharge planning, and so on. There are safeguards in the program to ensure that quality of care does not suffer. This project, one of many piloted under health care reform legislation, is a step in the right direction. Unless doctors view cost-cutting goals as their own, policy makers don’t stand a chance of achieving them.

  Acknowledgments

  There are many people I wish to thank for their help and support during the writing of this book.

  First and foremost, I am deeply indebted to the patients I’ve had the privilege of caring for and learning from during my years as an attending physician. My relationships with you have enriched my life in more ways than I can enumerate.

  My agent, Todd Shuster, has been a friend and advocate for fifteen years. I am grateful for his perseverance and faith.

  Most authors would be lucky to have one great editor. I had three. Paul Elie, a brilliant writer himself, had a clear vision for this book and urged me to write it. His successor, Courtney Hodell, astutely shepherded the manuscript through a first draft. And finally, the preternaturally smart Alex Star helped me mold the book into its current form. Alex’s fine editorial touches are present on nearly every page. I feel so incredibly fortunate to have had the opportunity to work with him.

  I am also thankful for the assistance of several other colleagues at Farrar, Straus, and Giroux: Laird Gallagher, who attended to so many important details during the course of this enterprise; Taylor Sperry, who read through the first draft and made numerous helpful suggestions; Susan Goldfarb, my wonderful production editor; and Katie Kurtzman, my publicist.

  And of course I am indebted to Jonathan Galassi for giving me the chance to write the book in the first place.

  I have had the enormous privilege of writing for The New York Times for almost two decades. I am grateful to the many editors who have helped shape me into a writer, but I owe a special thanks to David Corcoran, who edited some of the journalism that made its way into the book.

  Medicine and writing are distinct but complementary spheres in my professional life. I am extraordinarily lucky to have such a tremendous group of colleagues at Long Island Jewish Medical Center, where I work. John Meister has been a loyal comrade for nearly a decade. Janine Sandy, my assistant, keeps my workday running smoothly. I owe a special thanks to Stacey Rosen, my chief during the years I was writing this book, as well as to my current bosses, Stanley Katz and Barry Kaplan, for their ongoing support. I am also grateful for the extraordinarily industrious cardiology fellows I work with. You make my job easy.

  I also wish to acknowledge several in the leadership of the North Shore–LIJ Health System who have been encouraging of my work, including Michael Dowling, David Battinelli, and Lawrence Smith, Dean of the Hofstra North Shore–LIJ School of Medicine, who offered me one of my most rewarding roles: teaching cardiology to first-year medical students.

  Several other colleagues have earned my heartfelt appreciation, including David Slotwiner, Maya Frankfurt, Jacob Moore, and Danielle Ofri, who all critiqued early drafts of the manuscript, and Sheena Gupta, who assisted me with the research.

  Of cou
rse, the narrative has relied on my memory of events that in some cases occurred a decade ago. If my memory has failed me, the fault is mine and mine alone.

  I save my deepest gratitude for my family: my parents, Prem and Raj, and my sister, Suneeta. My brother, Rajiv, stands out for special recognition. He read through many drafts of the manuscript and generally was an unflagging reservoir of support throughout the entire enterprise. No words can repay my debt to him. I am also obliged to my father-in-law, Madho Sharma, for his generosity and backing.

  Parenthood is the best part of my existence. I want to recognize the twin lights of my life: my son, Mohan, my best friend and right-hand man, and my darling little girl, Pia, who was just a baby as this project was taking off and provided the hugs and kisses that helped to pull me away from it. I hope one day they will read this book and be as proud of me as I am of them.

  Finally, I am so grateful to my wife, Sonia, for being my life partner and gracing me with all the things that add up to a special life. This book would not exist without her, and so it is only fitting that I end it with her.

  ALSO BY SANDEEP JAUHAR

  Intern: A Doctor’s Initiation

  A NOTE ABOUT THE AUTHOR

  Sandeep Jauhar, M.D., Ph.D., is the director of the Heart Failure Program at Long Island Jewish Medical Center. He writes regularly for The New York Times. He lives with his wife and their son and daughter on Long Island.