Year of the Intern

by Robin Cook

  "I wouldn't deprive you of the pleasure, Straus. You go ahead and scrub."

  Orthopedic surgery really freaked me. Before med school, I had labored under the delusion that surgery was an accurate and delicate science. Then had come the holocaust of my first orthopedic scrub, where I witnessed the grossest nail pounding, drilling, and bone crunching I could possibly have imagined. Not only that—the mayhem had also been accompanied by comments like "Get X-ray in here so I can see where the hell that nail went"; then, after looking at the X ray, "Damn, missed the hip fragment completely. Let's pound in another one, but this time aim at the belly button instead."

  Such experiences had quickly eliminated orthopedic surgery as a specialty for me. Neurosurgery had fallen away soon after, when I saw the best neurosurgeon in New York pause during a case and peer into the hole he'd dug in a patient's brain to ask, "What is that light gray thing?" No one answered—after all, he was only talking to himself—but that was the end of neurosurgery for me. If he didn't know where he was after twenty years, there was no hope that I'd ever learn.

  With all my medical books packed, I didn't have anything to read to put me to sleep. Then I remembered the drug-firm throwaway I'd crammed into my suitcase. I pulled it out and settled back into the cool white pillow. Appropriately enough, it was titled The Anatomy of Sleep. Flipping to the back of the book, I learned it was a hard sell for a sleeping pill. I cracked open the volume haphazardly and began reading. With so much on my mind, I managed to finish a whole page before my eyes began to droop.

  The harsh ring of the phone came at me even before I had a chance to start a decent dream. In customary panic, I snatched up the receiver as if my life depended on it. By the time the operator connected me to the nurse who had paged me, I was well oriented as to time, place, and person.

  "Dr. Peters, this is Nurse Cranston of F-2. Sorry to wake you, but Mrs. Kimble has fallen out of bed. Would you come over and check her, please?"

  The luminous radium dial of my alarm clock told me I'd been asleep for about an hour.

  "Miss Cranston, we have a new intern tonight. Name's Straus. How about giving him a call on this problem?"

  "The operator already tried," she said. "But Dr. Straus is scrubbed in surgery."

  "Piss."

  "What did you say, Doctor?"

  "Is the patient all right?" I was stalling.

  "Yes, she seems to be. Are you coming, Doctor?"

  I growled something implying the affirmative and hung up. Clearly, I hadn't graduated from internship yet. Until I actually hauled my body out of range, there would always be one more patient to fall out of bed. Lying there thinking about it was a mistake. I drifted back to sleep.

  When the phone rang again, I responded with the usual panic, wondering how long I'd been asleep. The operator enlightened me—twenty minutes, she said—and canny as she was, saved me the effort of making an excuse by suggesting I might have fallen back to sleep. After all, it happened to everyone, even on emergencies. If I didn't put my feet out on the cold floor immediately, my chances of getting up fell precipitously. For a while, my trick had been to place the phone several yards from the bed, out of reach, so that I had to climb out of the warm nest just to answer it. However, with so many laxative calls that I could handle while horizontal, I eventually abolished that ploy and returned the phone next to the bed.

  After the second call, I hauled myself out straightaway and dressed rapidly. With luck, I could be back in bed in twenty minutes. My record was still seventeen.

  The fluorescent lights in the hall, the elevator doors, the stars in the sky—in fact, the whole trip over to Ward F escaped record in my brain. I functioned as an aware creature only when I found myself face to face with Mrs. Kimble.

  "How are you, Mrs. Kimble?" I asked, trying to judge her age by the meager light of the lamp on the night table. I guessed about fifty-five. She was neat and tidy, and gave the impression of being a particularly meticulous individual. Her hair was drawn back in a tight bun that had streaks of gray.

  "I feel terrible, Doctor, just terrible," she said.

  "Where did you hurt yourself? Did you hit your head when you fell?"

  "Heavens, no. I didn't hurt myself at all. I didn't even fall, really. I sat down."

  "You didn't fall out of bed?"

  "No, not at all. I came back from the bathroom, and I was squatting down right there." She pointed to the floor by my feet. "I was trying to get my notebook out of my night table when I lost my balance."

  "Well, now try to get some sleep, Mrs. Kimble."

  "Doctor?"

  "Yes?" I looked back over my shoulder, having already turned toward the door.

  "Could you please give me something for my bowels? I haven't had a decent movement in five days. Here, let me show you."

  With great effort, she reached over and pulled out the night-table drawer, withdrawing a four-inch black notebook. She had to reach so far for the book that I was sure she would topple over, after all. I moved closer to the bed and held my arms under her extended torso.

  "Look here, Doctor." She opened the notebook and ran her finger down a neatly written list of days. Each day was followed by a graphic and complete description of her bowel activity—form, color, and effort expended. Abruptly her finger halted at one of the days.

  "There, five days ago was the last normal movement I had. Even that wasn't completely normal, because it wasn't brown. It was olive-green, and only this big around." She held up her left hand, with the thumb and index finger defining a circle about a half inch in diameter.

  What could I say to her that would indicate competence and concern, and, most important, would extricate me immediately? I looked from the notebook to her face, groping for a reply and finding none. I passed the buck.

  "I'm sure your private doctor would know far better than I what would be best for you, Mrs. Kimble. Just try to get some sleep for now."

  Back at the nurses' station, I wrote something in her chart about the alleged fall; an entry in the chart was required after all such "falls." Then I set out on my return journey to my waiting bed.

  "Well, Straus," I ruminated. "What would that little episode be worth under your new system? Professional pleasure, bull!"

  My faith in airplanes is not unlimited. In fact, I don't truly believe- in the aeronautical principle. But I had to admit that the Pratt and Whitney engines sounded sturdy and reliable. I could hear them smoothly whining as they did their thing, and the huge, ungainly hulk of the 747 lifted off the ground, leaving Hawaii and my internship behind. I had a window seat on the left side of the aircraft, next to a middle-aged couple dressed in matching flower-print Hawaiian shirts. My carry-on luggage had been a bit of a problem—where to put it all—and I sat now holding my piece of coral, which was not designed by nature to fit neatly into a modern public conveyance.

  The final good-byes had been rather subdued, after all. At the airport, Jan had "leied" me four times, as Hawaiian terminology puts it. Two of the leis were made of pekaki, and their delicate aroma floated in the air around me. There had been no more talk of Jan and me and the future. We would write.

  I had mixed emotions about leaving Hawaii, but no ambivalence about the termination of my internship. Already, though, I was noticing a curious tendency in myself to remember and magnify the high spots, the fun of the year, and to forget the hassle and the hurt that actually had been dominant at the time. The body has a short memory.

  As the plane banked to the left, I looked out the window at the island of Oahu for the last time. Its beauty was undeniable. Rugged ribbed mountains jutted toward the sky, covered by velvetlike vegetation and surrounded by a shining dark blue sea. By pressing my nose against the glass, I could see straight down to where the waves were breaking on the outer reef of Waikiki, forming long ripples of white foam. I would miss those.

  I thought of Straus just starting his internship, with the whole year ahead of him. Right now, he was having one of the experiences I ha
d had. Life was repeating itself. Straus and Hercules—that would be quite a confrontation. I imagined that the sharp edges of Straus's idealism would round off soon enough, after four or five cholecystectomies with Hercules.

  Like a big bird in slow motion, the plane rolled back to a level position on its path toward California. The only evidence that we were moving was an almost imperceptible vibration. The island was gone now, replaced by an indistinct horizon where the broad expanse of ocean merged with the sky. I thought of Mrs. Takura, the baby born in the VW, Roso, and then Straus again. I didn't agree with everything Straus had said, but he had made me realize how little I knew, how little I cared about the system, except, of course, when it affected me directly. Imagine the AMA trying to block my federal low-interest loan for medical school! Impulsively, I rolled slightly to my right, clutching the coral, and extracted my wallet from my pocket. Settling back into the seat, I sorted through my cards and licenses until I came to it. "The physician whose name and signature appear on this card is a member in good standing of the American Medical Association." The words were impressive. They suggested an allegiance with a powerful institution. I had worked for five long years, and now I was there.

  Just then I felt the first jolt, and then another one, sharper, more forceful, as the sign flashed on. "Ladies and gentlemen, please fasten your seat belts. We are expecting some local turbulence," the stewardess droned reassuringly.

  I sat there next to the couple in the flowered shirts, holding my piece of coral and folding the AMA card nervously back and forth, back and forth, until the ragged fold parted and the card tore in half.

  The Last Word

  Dr. Peters has made the troubled journey from medical student through internship to the point at which society will recognize him as a full-fledged doctor. He can apply for, and undoubtedly receive, a license to practice medicine and surgery in any state of the Union. That will signal his readiness to be entrusted with all the responsibilities a medical license confers.

  Thanks to his rigorous training, it can be assumed that he is ready academically. But is Dr. Peters equipped psychologically to practice medicine as a modern humane society has a right to expect?

  "Old-line" doctors will be satisfied that he is. To the greater number of them, his personality aberrations are merely assurance that the "hazing" he got during his internship initiated him into the fraternity. Internship was rugged for them, and it should be just as rugged for the next generation. Toughen them up—these youngsters are too soft. Does such logic suggest that the older men may possibly be suffering from the same psychological problems as Dr. Peters, and for the same reasons? And what happens to the patient during these juvenile exercises?

  The physician's traditional—indeed, antique—lofty standing on the world's scale of social values and, in the United States, the current awe of technological achievement have led to an attitude of increased veneration for the medical practitioner. As a direct corollary of this worship of all things medical, it has become unthinkable to question the medical profession's control over the education of the embryonic physician. Medical schools and medical training programs have been relatively free to do as they please. No one asks why.

  Yet it has not always been so. The training of doctors in the United States was seriously challenged once, early in this century, when an extramedical group was appointed to study American medical education. This group—in the landmark Flexner report—mercilessly exposed the abominable conditions that then existed. Most medical schools, it said, were mere diploma mills totally lacking in academic controls. Indirectly, the report indicted the medical profession itself for having made such poor use of the carte-blanche charter given it by an adoring public.

  This document had far-reaching effects. It began a gradual and relentless improvement in academic standards at medical schools. But its effects were not wholly beneficial. For one thing, the report made it possible for the medical profession—in the person of the American Medical Association—further to tighten its grip on medical education by actually decreasing the number of medical schools and training facilities—a move that was necessary, it was alleged, in order to raise the quality of instruction.

  And the improvement and standardization of the curriculum that the report instigated caused the pendulum to swing toward the inclusion of more laboratory and science courses in the study of medicine. But the pendulum did not stop swinging until it had reached the point of infringing on clinical medicine. (Did anyone stop to think about the patient?) One result is that today's medical graduates are amply equipped with the latest hypotheses on the more bizarre diseases and rare metabolic processes, but they often do not know the simple clinical facts necessary to treat the common cold or how to deal humanely with a dying man who is beyond strictly medical help.

  A feeling grows in America that another "Flexner report" may be needed to bring about reforms in medical training. There has never been an objective examination of the psychological education of physicians. Any mature, honest, and forward-looking analysis would have to consider it with the same seriousness given to academic excellence.

  The public is distantly aware that some physicians are prone to personal peculiarities—the surgeon's childish tantrums, for example. Most people are more likely to be aware that when a student enters medical school his head is usually full of idealistic visions about relieving suffering, aiding the poor, and doing good for society. However, few have noted the discrepancy between the number of idealists who enter and the tiny percentage who come out on the other side with their ideals still intact. And hardly anyone makes the connection between lost ideals and the surgeon's silly antics. Or between lost ideals and the preoccupation of many emerging doctors, at the end of their long training, with "staking out a claim" to a financially and socially rewarding group of patients, and with buying luxury houses and cars to repay themselves for the deprivations of their years of preparation.

  Obviously, the possibility that a doctor's ideals could change between medical school and medical practice is diametrically opposed to what people want to believe—and to what is presented to them in the mass media. Movies, television, and "doctor" novels have all tended to reinforce the myth of the inherent psychological health and goodness of doctors—especially young doctors.

  Thus we return to the credibility of Dr. Peters as the representative of interns in general. Once more I state my belief that he is representative. He is not one of a few aberrant individuals. He is the typical young fledgling who began with relatively idealistic goals. He is the typical student and intern, whose personality gradually undergoes certain modifications that turn him into the whining, complaining, and selfish person we have come to know—understandable, but not admirable.

  The contention that the medical world is full of Dr. Peterses is a large mouthful to swallow. If, in addition, it can be accepted that almost everyone who goes through medical school will suffer similar personality wounds, the suspicion might arise that the fault rests with the system, not the people entering it. And doesn't this, in turn, suggest that the system needs to be studied for its psychological effects, and altered toward a direction that would nourish, rather than extinguish, the idealism and sensitivity of its students?

  Change is inevitable, and it is the hope of men and women of good will that change will be for the better—better for society and for each individual. Voluntary reform is a saner and healthier form of change than explosive measures taken as a result of abuse. It is time for analysis and reform in our medical schools and in the medical centers where interns and residents are trained if medicine—as both a science and an art—is to meet the needs of our time. Even the most thoughtful and probing analysis will be imperfect. Even the most earnestly pursued remedies will not be wholly successful. But if we cannot reach the ideal, we can move toward it. At the very least we will have had the sense and courage to try.