The Intern Blues

by Robert Marion

  Mark Greenberg was a little harder to locate: In contrast to Andy, he does not have a presence on the Internet. In order to find him, I sniffed around our department’s alumni records and came upon a letter of recommendation written by Peter Anderson (our chairman and the man whose lawn was the site of the original meeting between Andy, Mark, Amy, and me) and addressed to a hospital in central New Jersey to which Mark had applied for admitting privileges. Calling information in that town, I was given Mark’s office number. I hesitated before dialing the number.

  I hesitated because Mark and I had not parted on exactly the best of terms. It took me more than a year to transcribe and edit the audio-diaries of the three interns that formed the basis of The Intern Blues. As I completed that work, I sent each of the by-then senior residents a copy of his or her transcript. A few days after sending his out, I got a call from Mark. “You can’t publish this crap,” he yelled at me over the phone. “I never said any of this stuff.”

  “What stuff are you talking about?” I asked, a little surprised by his reaction.

  “All this stuff,” Mark continued yelling. “Almost everything you have coming out of my mouth. Like here, during February, when I was in the NICU. You wrote, ‘And then we walked around and he showed us these so-called patients. My God, those things weren’t patients; they couldn’t have been human; they weren’t anything more than small pockets of pus and protoplasm! These things would have to quadruple their weight in order to be classified as patients. Right now, they’re nothing more than tiny portions of buzzard food.’ Bob, I never would have referred to preemies as ‘small packets of pus and protoplasm’ or ‘tiny portions of buzzard food!’ ”

  “You don’t remember saying those thing?” I asked, surprised.

  “I never said them!” he answered. “How could I remember saying them if I never said them?”

  “You don’t remember your internship very well, do you Mark?”

  “I remember it fine,” he replied. “I agree that things were rough for most of the year. But no matter how bad things got, I always showed respect for my patients. I’m sure of that.”

  “Mark, I hate to burst your bubble, but not only did you say those things, I’ve got you saying them on tape. Would you like me to play them back to you?”

  “You can’t have them on tape, because I never said them,” he reiterated, more angry this time. “If you have someone saying that stuff on tape, then it must have been one of the other interns, because it couldn’t have possibly been me.”

  We argued on like that for a while. Finally, I agreed to let Mark “fix” at least some of what he believed was wrong with his portion of the book. I used his edited transcript to revise the final manuscript, but he still wasn’t happy with the finished product. In the final eighteen months of his training, that unhappiness colored our relationship. So I was less than sure that Mark would react positively to my voice on the phone.

  I called his office at about eleven o’clock on a Monday morning in late January, and when he picked up the phone, I was afraid my worst fears would be realized. “I can’t talk now,” he said bluntly when I told him who it was and why I was calling. “It’s crazy here. Can I call you back sometime after our office closes?” I gave Mark my home number, never expecting to hear from him again.

  But I was wrong; he called me that night. “Sorry about not being able to talk with you earlier in the day, but it’s been really nuts,” he explained, sounding neither angry nor put-out. “It’s flu season here in beautiful New Jersey, and it appears as if everyone with a pulse and a respiratory rate is sick. I was on call this weekend, and I saw seventy patients on Saturday and fifty more on Sunday. A hundred and twenty patients in one weekend! By myself! Can you believe that? It’s a new office record. In recognition, I’m planning on having the shoes I was wearing bronzed so we can display them in our practice’s trophy case. So, sorry I blew you off this morning, but I think it’ll work out better this way.”

  “I thought you were still pissed off about the way you were portrayed in the book,” I said.

  “Was I pissed off about that?” he asked. “I don’t remember. I really don’t remember much about my residency. Except that I hated it as much as anybody can hate anything, and that I’d never want to do it again. Outside of that, I don’t remember the people, the places, the patients, or much of anything else.”

  “You don’t remember making me rewrite your sections?” I asked.

  “The only thing I remember about it is I was afraid people would recognize me and give me a hard time. Remember, I had to go out and look for a job. I thought people in practice were all going to know I was Mark Greenberg in The Intern Blues, and who would want to hire someone who talked about patients the way that guy did? As it turned out, it wasn’t an issue; I don’t think anyone had even heard of the book. Looking back, I might have been a little crazy at the time.”

  I silently agreed. “So what have you been doing since the late eighties?” I asked.

  “Well, as soon as I finished residency, I started working at this practice,” he replied. “I joined in July of 1988, and I’ve been working here ever since. I’ve been here for nearly thirteen years, I’ve been a partner for ten, and I only have eleven more years until I retire.”

  “Until you retire?” I repeated. “You’ve thought about when you’re going to retire?”

  “Sure I know when I’m going to retire. I plan everything. When I started here, I told them I was going to work until I turned 55. The group was fine with that; they all agree with it.”

  “Why 55?” I asked.

  “You’ve obviously never been in practice,” he replied. “You can’t do this kind of work forever. Did you hear what I said before? I saw one hundred and twenty patients over the weekend. One hundred and twenty! By myself! And that doesn’t count doing rounds at the hospital and speaking on the phone to the mother of every one of our patients who didn’t come into the office. You can’t do all that—the hospital, the office visits, the phone calls night and day—when you’re 60 years old. Pediatric practice is for young people. And so I’m going to stop when I turn 55.”

  From what Mark was saying and the way he was saying it, I got the impression that he didn’t enjoy his job all that much. “Do you like what you’re doing?” I asked.

  “I love it,” he answered without hesitation. “I’m doing exactly what I wanted to do from the time I started medical school. Of course, back then, I thought I was going to do adult medicine. It wasn’t until my third-year rotations that I realized I liked kids and hated adults. But basically, yes, this is what I thought I’d be doing, having a practice, seeing patients. I get a real thrill out of seeing patients. There’s always something new. Plus, I’m the doctor for the local high-school track team, and, in the summer, I watch over the local Girl Scout camp. It’s a lot of fun.”

  Next I asked Mark about his life away from the office. I reminded him that in the epilogue to The Intern Blues, I had described how he had romantically proposed to his then-girlfriend, Carole, in a rowboat on Candlewood Lake in Connecticut. “Did you two wind up getting married?”

  “We certainly did get married,” he replied, “but not in a rowboat. We got married in a hotel ballroom in Manhattan. We had been living together since we got engaged, and I didn’t think it would be right for me to join the practice without us being married. I mean, what kind of an example would I be setting for my patients? So we tied the knot in May of my senior residency year. Carole wasn’t all that anxious to go ahead with it just then. She was in law school and didn’t have time for anything but studying. But I insisted and told her I’d take care of everything. I planned the whole thing, from the invitations to the honeymoon. All Carole had to do was show up. Afterwards, she told me I did such a good job that if my job didn’t work out, I could always become a wedding planner.”

  “Do you have any kids?”

  “One. A boy named Alex. He’s eight.”

  Remembering what Andy ha
d said about the ways that the experience of being a father had affected his work, I asked if Mark had had a similar experience. “Not really,” he explained. “I don’t think I approached my work any differently before Alex was born than I do now.”

  Also, as with Andy, I asked Mark to think back and consider what effect internship had had on him. “As I said before, Bob,” he answered, “I don’t remember much about my internship, except that it was bad, definitely the worst year of my life. Nothing comes close to how bad it was. And the worst part wasn’t the hours or the sleeplessness, or anything like that, although those things were pretty bad. The worst part was the frustration and the fear that you were going to make a terrible mistake and kill some kid. They were taking people who hadn’t been trained to do things, who never had experience caring for critically ill patients on their own, and forcing them into situations where they were the ones making the decisions. That wasn’t fair to the interns, and it especially wasn’t fair to the patients. I think they’ve done a lot to fix that; I think the new laws that require that interns and residents be better supervised are definitely a good thing. But that wasn’t the case when I was an intern. And because of that, it was by far the worst experience of my life.”

  “Was it worth it?”

  Mark’s response was essentially the same as Andy’s: “Yeah, I think it was worth it. It’s like my running. Since I was in high school, I’ve been a marathon runner. In order to qualify to run in a marathon, you have to prove you’re worthy. In other words, you have to do a lot of shit in order to get to where you want to be. Internship is the shit you have to do in order to practice medicine. I like my job; I like my life. And doing internship and residency was the only way I could get to this point. So definitely, yes, it was worth it. Just don’t tell me I have to do it over again. Boy, that would be bad!”

  When she left the Bronx, Amy Horowitz left virtually no footprints. After all these years, she was by far the most difficult of the three former interns to locate. There were no hits on any Internet search engines, no letters of recommendation, no requests for verification of training. No other information on her whereabouts was revealed during a thorough search through her files in our departmental offices. I even called the Office of Alumni Affairs at the Albert Schweitzer School of Medicine for help; although they had her name listed as a bona fide graduate of the school, they had her listed as “lost,” with no current address available. It looked as if I was stuck.

  I was about to give up when I decided to try one last strategy. Figuring that her father would know where she was (Amy’s mother had passed away while she’d been in college), I called Schweitzer’s admissions office, hoping to get the home address she’d listed when she’d filled out her medical school application twenty years ago. A secretary in the office volunteered to try to retrieve Amy’s application from its microfiche resting place; successful, she called me back in less than an hour with both the phone number and address. Calling the number, I didn’t have a great deal of hope that Amy’s father would still live there; still, I felt I had to give it a shot.

  It turned out that I was correct: Amy’s father no longer lived in New Jersey. The woman who answered the phone, though, had first-hand knowledge of where he was. She turned out to be his niece, the daughter of Amy’s father’s sister, and she and her family had been living in the Horowitz house for the past seven years. Her uncle, she told me, had retired and moved to Boca Raton, Florida. “And Amy’s been living in Israel for more than ten years,” she said. She gave me her uncle’s number, and after a few minutes on the phone with him, explaining who I was and why I wanted to get in touch with his daughter, I finally got the information I’d been searching for. So early the next day, I called Israel. The phone rang three times before Amy picked it up.

  She and I had last spoken in 1989, and sadness had infused that discussion. In the epilogue of The Intern Blues, I wrote about the birth of Amy’s second child, a son named Eric, who had been born on November 12, 1986. After the two months of maternity leave and one month of an elective without night call, for which she’d fought so hard, she returned to residency full-time. In the last eighteen months of her training, Amy really put herself into her job. She worked hard and became a leader among the residents, and she had a good sense of what needed to be done for her patients and the ability to go ahead and do it.

  In the late winter of her senior residency year, Amy had become pregnant again. This time, she’d planned the pregnancy to the last detail, being due to deliver three months after her training was scheduled finally to come to its end. “I’ve lived through a pregnancy as a resident,” she had told me when she called. “I never want to have to do that again.” She would finish her residency, spend the last trimester of her pregnancy relaxing, give birth, and spend the rest of that academic year being a mother to her three children. “We’ll be like a real family for a while. Then, depending on how things work out, I’ll either go back to work or I’ll spend another year as a mommy. We’re flexible.”

  Right on schedule, on the morning of October 18, 1988, Amy delivered a beautiful baby boy. But within twelve hours, her family’s world was turned upside down. The baby developed perioral and acral cyanosis [blueness around the mouth, hands, and feet, often caused by heart disease]. The pediatric resident on call that night at University Hospital did an arterial blood gas, which showed an oxygen level of only fifty-eight in room air (a normal value would have been in the nineties). When the baby was placed in an environment of 100 percent oxygen, the level increased only to seventy-two (under normal circumstances, the oxygen level in the blood should have risen to more than 200). An emergency cardiology consult was requested. The cardiologist, who made it to the hospital at around 2 A.M., did an echocardiogram, which revealed the terrible problem: Amy’s baby had a hypoplastic left heart.

  Hypoplastic left heart is a catastrophic congenital defect in which, for reasons that are never clear, the left ventricle, the chamber of the heart that pumps oxygenated blood to the rest of the body, doesn’t develop. During fetal life, the defect doesn’t create much of a problem. The fetus has a structure called the ductus arteriosus that shunts blood that would normally go to the lungs to the remainder of the body (fetuses don’t need to use their lungs; they receive oxygenated blood from their mothers through the umbilical cord). Soon after birth, in a transition from fetal to adult circulation, the ductus arteriosus closes, allowing blood to flow through the pulmonary artery to the lungs. In most babies, this change facilitates normal babyhood; in Amy Horowitz’s baby, however, the closure of the ductus arteriosus was a death sentence.

  Amy knew all this. As soon as the cardiologist came into her hospital room and told her what was wrong, she understood completely the implications of the news. She knew that if left untreated, her son would be dead within thirty-six hours. She also knew that there was an option: Surgery could be done essentially to build the baby a left ventricle. The complete surgical repair would involve multiple stages. An initial operation would need to be done as soon as possible; a second operation would have to be performed later in the first year of life; and at least one other operation would be required when the baby was older. And this was not simple surgery: Each operation was fraught with risks. The first one alone had a 50 percent mortality rate. And even in the best case, even if her baby did manage to survive each of the stages of the complex repair, he would have a terrible first few years of life and would face an uncertain future.

  In addition to all of this, Amy had to be concerned about the rest of her family. There were her other two children to think about. Surgery would mean an all-out commitment to this baby, who would spend the better part of his first year of life in the hospital, much of that time in the intensive care unit. Would it be fair to Sarah and Eric to deprive them of the love and attention of their parents during long stretches of time in order to provide for the new baby, whose future, under the best of circumstances, was far from certain?

  On the other
hand, Amy thought, this was her baby, her son. He had grown and developed in her womb for nine months. Knowing that a treatment was available (even though the treatment was not even close to guaranteed to work) and that that treatment might give him a life, could she deprive him of this chance simply because life would be hard for the rest of the family? She was not sure.

  The cardiologist understood her concerns. He started the baby on a Prostaglandin drip, an intravenous medication that would keep the ductus arteriosus open while Amy and Larry made a decision about what to do. Later that morning, from her hospital bed, Amy began calling everyone in the world she trusted and respected, telling her terrible story and asking for advice. I was on the list of people she called. During our conversation, I mostly listened to what she had to say. It seemed clear from her words that she had already made up her mind; she was looking for approval for her decision to stop the Prostaglandin and let nature take its course. I did as she implicitly requested: I agreed with her reasoning and tried my best to offer support.

  By late that afternoon, the decision was finalized. She and Larry met with the neonatologist and told her that they wanted the Prostaglandin drip turned off. After the IV was pulled, the baby was brought to Amy’s room on the maternity floor. He died in his mother’s arms early the next morning.

  In the months after the death of her son, I spoke with Amy every few weeks. On October 20, the family held a private funeral. Not unexpectedly, following this, Amy went through a period of depression. But the demands on her time, caused by the need to care for Sarah, who was then three and a half years old, and Eric, who was nearly two, prevented her from becoming dysfunctional. “I have to get up every morning and get Sarah ready for nursery school,” she told me during one of these conversations. “And Eric needs everything done. The only time I get to myself is when he takes his nap. For me, that’s the worst time of the day. That’s the time I sit and think about exactly what I did.”