I have seen other doctors “turn off” when they feel they can’t help, or they’re getting it wrong. When a clinician misses a diagnosis, or the patient is “failing their treatment,” the unsuccessful doctor’s disgrace turns quickly to derision and dismissiveness. You don’t have anything I can fix turns into You don’t have anything wrong. Or worse, if the patient is a woman and the doctor is a man: It’s all in your head; you’re hysterical. The clinician is afraid, plain and simple. Afraid of his impotence, of the enormity of his failure and what it means to all involved.
Heinz Kohut, a well-known psychoanalyst, writes about empathic failure, that the psychiatrist can’t always succeed at knowing the patient’s pain and helping to ease it. It is best to admit fallibility and apologize for the failure, but most physicians aren’t schooled in the ways of humility. They want to help and heal, to cut, sew, and fix things, and they often get mean and angry if they can’t, like a petulant child. At least I do.
The problem with CPEP is that it is no place for infinitely compassionate clinicians. It’s just not set up for the bleeding hearts. Being malicious is never appropriate—Lord knows I’ve learned that from Mary—but it is crucial to maintain some distance. I’ve known that all along, and Desmond will figure that out too, soon enough. When he eventually gets a job as a CPEP attending, he will last only one year. He will be reluctant to T & R many patients, wanting to admit them and treat them all aggressively, preemptively, no matter how full we are upstairs. Desmond will learn over time that he cannot save everyone, he cannot fix everything, and he will leave CPEP early in the game, telling me he is “crispy,” his term for burnout.
But not me. I will work for a few more years after Desmond comes and goes, my longevity a direct result of my hardened persona, my blessing and my curse.
I’m Only Sleeping
Please don’t wake me.”
Four words that have never come out of my mouth at Bellevue. When it is time for me to leave the CPEP and escape to my office and bed, around one or two in the morning, I always give the same spiel: “I wake up easy; I fall back asleep easy. You should have a low threshold for calling me. If you have a question, pick up the phone; that’s what I get paid for. Just remember, there are no stupid questions … only stupid people.” I pause here for a smile or a laugh, though I’m not always rewarded with one. “And also, this is very important, you CANNOT discharge anyone without my hearing the case.”
When I was a resident, I felt it was important to let my attendings sleep. It was a matter of pride. I wanted to show them I was competent, capable of working all night on my own without their guidance. As an attending, I know that many of my residents likely feel the same way. However, as I am quick to remind them, it is my ass on the line if there is a problem with a discharged patient. I’ll be the one named in a lawsuit if there is what we euphemistically call in medicine “a bad outcome,” so it is not okay for them to fly solo on my watch.
“So,” I conclude, “at some point during the night, call me and give me an update on the area, even if you’re not discharging anyone. If I don’t hear from you, I assume you’re sleeping like I am.”
I always let the residents know that I am available to them all night long, and this is why I take great offense at the faculty meeting when Daniel accuses me of telling the residents not to wake me up.
I immediately deny it and challenge him, “You find one person I said that to.”
“The residents were complaining about you at their last meeting,” he replies.
I know what he’s talking about. A week before, one of the residents had called me to present a case and was giving me a long-winded, meandering case presentation. Since she had woken me up and I was trying not to fully engage, so I could get back to sleep more easily, I asked her to get to the point. She was offended that I had requested the “Reader’s Digest version” of her presentation and processed it as a narcissistic injury, a blow to the ego. She complained at a residents’ meeting where Daniel happened to be. (The irony is, she, too, eventually became a CPEP attending after her residency, and developed a reputation as one of the doctors who makes it clear she does not want to be woken during the night.)
Along with the accusation that I shut out the residents overnight, Daniel adds a few more complaints about me in front of my colleagues. I am working fewer hours than everyone else, and I am whining about doing the moonlighting schedule at every faculty meeting. He singles me out and pummels me verbally. I am defensive and angry as I loudly refute his accusations, and it is not pretty. One of the new attendings sits next to me, her mouth agape. As Daniel and I run out of steam, and the faculty meeting winds down, I notice an interesting coincidence. At this particular meeting when Daniel has chosen to chew me out, his adoring girlfriend, Michelle, and his henchman, Dave, are nowhere in sight. There are many subordinates, but no senior faculty aside from Daniel and me. He has picked a good time to get on my case, making sure his compatriots aren’t there to see the carnage, lest it sully their image of him.
After the meeting, I go straight to Dr. MacKenzie’s office to complain about Daniel, his treatment of me, and all of his recent behavior. I may as well be running to my father to complain that my brother is teasing me: Danny’s picking on me! He started it! I am fuming, rehearsing in my head the litany as I march through the bustling hallways to the other side of the hospital, dodging women wearing saris, men in dashikis, other men in heavy black suits and yarmulkes, their hair curled in front of their ears. I swim upstream toward the entrance as hundreds of Bellevue staffers work their way into the building.
The hallway that leads from the outside world to the inner workings of the hospital has the same brisk, bustling feeling as Grand Central Station, but the mix of nationalities is reminiscent of Ellis Island. (The welcome sign for the pediatric emergency room is written in seventeen languages, painted above and alongside the double doors.) Families come in to visit their loved ones; patients arrive for their clinic appointments; concerned mothers, their sick children wrapped in blankets, search for a doctor. I walk in silence, scanning each face, passing the wheelchairs stacked and chained in the corner. (The panhandlers steal them so that they can sit in them and appear crippled, to make their time spent on the corners more lucrative.)
Dodging the bodies, I am lost in thought. It’s not just that Daniel likes to tear me a new one, he likes to do it in front of an audience. Anal sadist exhibitionist. This is how I have described him to Mary.
I stop mid-stride as I stumble upon a startling revelation: I wonder if that’s how Mary thinks of me? Maybe she thinks I’m the sadistic one and I project all my demons onto Daniel. Is it possible that he’s not really the problem, that it’s all just projected self-hatred?
Jesus.
I resume walking, my hand on my forehead. I can’t waver like this when I present my case to MacKenzie, I say to myself. I have to acknowledge to myself that Lucy’s death has further complicated my perceptions of Daniel. I know he was a better friend to Lucy in the end than I was. He sat by her bedside in that hospital, not me; he was fiercely loyal to her, and he loved her as I did. He worked by her side five days a week while I only schmoozed with her on Monday mornings before I went home for the week. In truth, Daniel got a bigger piece of her than I did, and I was jealous. He’s a good doctor, hardworking and generous to a fault. He is charcoal gray, not black, but I can’t paint him as such when I complain to MacKenzie, who can smell ambivalence, who’s a shrink like you, don’t forget, I ramble on in my interior monologue. And don’t cry. You have to learn that it’s okay to be angry. Women at work are always letting their anger make them cry, especially in front of a supervisor. Bosses at work are usually processed as father figures. Don’t make this about your father.
I take a deep breath outside of MacKenzie’s office. He is not my father, I say to myself emphatically, knocking on his door.
“Daniel is totally out of control,” I hit the ground running, barely letting my ass hit the seat
before I begin my screed. “He is being a complete pig. First of all, at the faculty meeting two weeks ago, he makes a disgusting joke about ordering ‘vagina au jus’ at a restaurant.” I make a face, to show I am repulsed by this ribaldry.
MacKenzie is impassive, silent. His fixed gaze and upturned face imply I should continue.
“I have as dirty a mind as the next guy, I’m sure you know, sir, and I can appreciate a good joke, but that was disgusting, misogynistic, and also—honestly—not particularly funny. Then, one Monday morning he says to me, in front of his secretary, ‘You were much more fun to be around when you were pregnant with Molly. You should go home and get yourself knocked up again.’ Do you believe that?”
I stop to see his reaction. Dr. MacKenzie cocks an eyebrow slightly, but doesn’t look too taken aback. Come on, man, at what point will you join me in my outrage?
“And now this morning … he totally humiliates me in front of my colleagues, accusing me of being a slacker and telling the residents not to wake me up, which is completely bogus! I would never say that.” I am steaming mad, lobster-red in the face, fighting back tears while I try to convey to Dr. MacKenzie what an impossible child Daniel is being, without sounding like one myself. I start to imagine a little girl running to her dad for support and coming up empty. This thought makes it infinitely harder to control the tightening in my throat.
Say something, Daddy!
I fill the silence with more whining, “Honestly, I really can’t stand working for him. Under him is more like it. He insists on my subordination, and I have no respect for him anymore. And you know what happened to his hand, right?”
Daniel is wearing a cast on his arm. He punched the employee refrigerator in the nurses’ station during a particularly dramatic exchange at a staff meeting. One of the psych techs was leaving the CPEP to go work upstairs, primarily, I believe, because of issues having to do with Daniel. Daniel had asked something at the staff meeting along the lines of “Who’s with me?” and this particular tech had made a complaint, or implied that he wasn’t on board and was abandoning ship. So Daniel growled and popped the fridge with his fist. There was a dent on that fridge for the longest time. Someone had circled it with a pen, as though to outline the evidence of Daniel’s poor impulse control.
“I know, yes,” Dr. MacKenzie utters casually. His first words of our meeting. He knows, but doesn’t seem to care, that Daniel has assaulted an innocent kitchen appliance. A major appliance.
I was hoping for something more conspiratorial. Perhaps I had fantasies of us dishing the dirt about Daniel and his psychopathology, laughing about him, commiserating together. But MacKenzie remains stone-faced, giving me nothing to go on. He is my boss’s boss, after all, and he’s playing it close to the vest, as usual.
I pull myself together and get ready to leave the office. “All right, then … thanks for listening, I guess. I just needed to unload after this faculty meeting. He is really being an ass lately. One thing I can say, I don’t think he’s acting like a director should.”
“Well, as you know, he is the acting director currently, and the administration is discussing whether to make that permanent.”
“Obviously you know my vote,” I stare into his eyes meaningfully as I stand up. “Thank you for your time, Dr. MacKenzie,” I say faux-politely as I turn to head out the door.
“Julie,” he says gently, motioning for me to sit again. “I liked what you had to say at Lucy’s memorial, about how angry she was at having to die. I’m just wondering, how’ve you been feeling lately? I mean, don’t you think it’s possible you and Daniel are just angry that she’s gone? And you’re butting heads in her absence? Because your anger needs to go somewhere.”
Ahh, the psychiatrist in him is emerging. He’s good, actually. He has a smooth, caring delivery. I bet his patients like that. And he knows Daniel well enough to see what even I can see—that there is good and bad in him, as there is in all of us. Nonetheless, I persevere.
“It’s more than that, I think,” I join in on our new empathic level. “Lucy always said she couldn’t trust him. That was something she spoke to me about a lot, when she first brought him down from upstairs. She thought he was smart, and he’s good with the patients. He remembers cases, I’ll give him that; he remembers people’s stories. But there’s something about Daniel that always bothered me.” Here’s my opening. Maybe we will conspiratorially get to dish and gossip after all. I can only speak my mind and see if he’ll follow suit. “The line I usually use when I describe him is ‘There’s no there there.’ He’s all facade. That’s what Lucy couldn’t trust. She never knew what he was thinking, how he was feeling. There’s something missing when you dig for the real him. You know, when I knew him in residency, he called himself Dan. Then he moves here and changes it to Daniel. Now, he’s got the administration calling him Danny. He says it’s his nom de guerre.” Dr. MacKenzie smiles widely at this.
“You’re smiling,” I say, “but I don’t like that he sees it as a war, that it’s him versus the administration. He spends most of our faculty meetings complaining about how hard it is being the boss, how he has to deal with all of these incompetents upstairs. I don’t think it’s appropriate for the rest of the faculty to hear how he has no respect for his superiors. How are we supposed to respect him, then?”
“Well, I appreciate your candor,” says Dr. MacKenzie, wrapping up our meeting. “I’m not sure there’s going to be any happy resolution here. Part of my job in this hospital is to try to satisfy everyone, address their complaints, and find compromises. What I end up doing, primarily, is spreading the misery evenly, thinly, so no one gets too much or too little. That’s pretty much the best I can do.”
“That sounds like a great job,” I sympathize. I have an image of him as an aproned cake decorator smearing shit-brown frosting over a hospital-sized layer cake.
“I’ll see what I can do,” he promises.
“And that sounds like the parting words of a great administrator,” I say as I leave. “I would appreciate your help on this one, Dr. MacKenzie. I’ve always thought of you as one of the good guys.”
I’ve Just Seen a Face
On a Monday morning right before I sign out, I spy a man on a stretcher, lying asleep on his side. The word “Pussy” is tattooed on his right cheek. I am not sure who he is since he came in overnight while I was sleeping. During morning report, the resident signs him out as someone on triage who hasn’t been seen by a doctor yet.
About a week later, I see the guy again as I walk by the coffee shop, on my way to have a meeting with Daniel and Dr. MacKenzie. I run into Daniel waiting for the elevator and mention it to him on the ride up, trying to break the uncomfortable silence. “That guy with the ‘Pussy’ face tattoo is back.”
“It’s an unfortunate word to be wearing, isn’t it?” he asks, his manner arch, ironic. An unfortunate word. Give me a break. His irony only fuels my rage, but I control myself and join in on his level.
“I wonder if it’s how he perceives himself, or if it’s more a case of advertising what he’s hoping to find,” I offer.
We share the remaining time in the elevator in a stony silence; small talk and attempts at humor are useless. Dr. MacKenzie has asked us to come to his office to see if we can hash things out. I’m doubtful we can do more than hammer out the details of a détente. MacKenzie opens the discussion with a bombshell. “Daniel, Julie has made some serious accusations against you, regarding sexual harassment.”
“No I didn’t! I don’t feel sexually harassed by you!” I squeal. “Hardly,” I harrumph. “That is not what I said at all. I just told him about how you chewed me out at that faculty meeting. And how you told me I was a lot more fun when I was pregnant with Molly and I should just go home and get knocked up again. And about how you made that gross joke about vagina au jus.” I stick that last bit in with pleasure, knowing it will infuriate him that I have shared his inane joke with his boss.
“Okay, not sexual harassme
nt, per se, more like sexually inappropriate,” Dr. MacKenzie calmly says. “Can we just agree that there will be no sexual comments, innuendos, or jokes in the workplace?”
“Of course,” we both acquiesce. That’s easy enough.
“Now, I understand you and Julie go back quite a ways, isn’t that right, Daniel?”
“Yes, sir. We did our residency together,” Daniel answers pleasantly. “I was, what, a year ahead of you?” He asks me as if he doesn’t know damn well he was a year ahead of me. Like he doesn’t remember doing a rotation together on the inpatient ward at Sinai, when I pissed him off because I stepped in as his patient visibly deteriorated. Hannah. It was over ten years ago and I can still remember her name. I couldn’t stand by and do nothing when she was so obviously overmedicated, but it sure pissed him off that I broke the chain of command.
“That’s right. We do go back a long way,” I say simply. “But now can we please deal with this scheduling situation? With the moonlighters? It needs to go to someone else.”
Weekends at Bellevue Page 20
