Intern

by Sandeep Jauhar

  It was during second year, buried in books and still unsure about whether I even wanted to be a doctor, that I first thought seriously about quitting medical school and doing something completely different. One option I considered was becoming a reporter. Journalism had always been a passion of mine, one that my father, a news junkie, had unwittingly fostered. On Sunday mornings, the voice of David Brinkley was as familiar as my mother’s urging us to come to the table for her potato paranthas. In middle school, my father and I would go to the UC Riverside library to read The New York Times or books and news-magazines on politics and foreign policy, especially nuclear arms control, which was a special interest of mine. For my thirteenth birthday, my father gave me a book of famous front pages from the Los Angeles Times: “Peace,” “Walk on Moon,” “Nixon Quits.” Later, we always watched Nightline together after the rest of the family went to bed. Though he always encouraged his children to keep up with the events of the world, my father made it clear that journalism and writing were never to be considered career options because they offered no security. “Nonscience is nonsense,” he often said.

  At the end of graduate school, I had come across a flyer for a science journalism fellowship sponsored by the American Association for the Advancement of Science. On a whim, I applied, and, to my amazement, was one of 13 people selected out of a pool of about 250 applicants, all doctors and scientists with advanced graduate degrees. I was placed for the summer—the summer before starting medical school—at the Washington, D.C., bureau of Time magazine.

  The summer at Time was perhaps the most exciting of my life. My first week there, I was sent to the U.S. Capitol to get a quote from Bob Dole about the working poor. He spent most of the day on the Senate floor, so my plan was to accost him when he went to the bathroom. When I got my chance, I froze, mumbling what must have been gibberish as he strode past me on the marble floor. Later that afternoon, dejected that I had failed my first journalism assignment, I ran into Dole’s press secretary and asked for an interview with the senator. He was in the midst of dismissing me when the senator walked up. “This is Sandeep Jauhar,” Dole announced. “He’s working on a story about the working poor. Set up a phone interview with him tomorrow morning.” I was speechless. The next day, I got my quote. I had been promised five minutes, but Dole and I ended up talking for fifteen.

  At the end of the summer, before getting a flight back to Berkeley to finish my Ph.D. thesis and pack up to drive to St. Louis, I asked Dan Goodgame, the Time bureau chief, for some names of journalists I could call on in the future. He mentioned a few editors he knew at reputable newspapers: The Tampa Tribune-Times, The Miami Herald, the San Jose Mercury News. “Yes, but what about The New York Times?” I said. My presumptuousness must have amused Dan, but sure enough, he had a contact there, too.

  One afternoon in medical school, then, I called the office of Gerald Boyd, a senior editor at the Times. When his secretary answered, I introduced myself, mentioned Dan’s name, said I was calling from St. Louis, and asked if I could speak with Mr. Boyd about journalism opportunities. Before I knew it, he was on the phone. I’m sure he thought I was a journalist because he started asking me about the St. Louis Post-Dispatch. I explained that I was not a reporter but a medical student interested in writing about science for the Times. He brusquely told me to set up a meeting with him the next time I came to New York.

  When I got off the phone, I did what any aspiring journalist might do. I picked up the phone, dialed American Airlines, and booked a flight to New York. Then I called up Boyd’s assistant and asked her to set up a meeting. “Who are you again?” she asked.

  I told her that I was a medical student.

  “And Mr. Boyd wants to meet with you?” she said.

  In New York a few days later, I took a taxi to the newspaper’s headquarters on Times Square. The security guard called up to Boyd’s office, but there seemed to be some confusion about the purpose of my visit, so I waited in the lobby for half an hour before finally receiving a pass and directions to the third floor. Starry-eyed, I walked through the newsroom where the Pentagon Papers had been published, where Sydney Schanberg had written about the killing fields of the Khmer Rouge, where James Reston and Tom Wicker had tapped out the editorials I’d read as a kid. Boyd’s assistant showed me into his office and went to get him. On the walls were pictures of him with politicians and dignitaries, including an autographed photograph with a former president. I wondered if perhaps I had overreached.

  When he marched in, a tall man with the build of a football player, any hopes I had had of a relaxed conversation were immediately dashed. “I have five minutes,” he barked, sitting down. “What do you want?”

  “Well, sir—” I stammered, and then I went on to explain my situation.

  “Show me your clips,” he said impatiently.

  “Well, sir—you see, unfortunately, I don’t have any clips.” I explained how at Time magazine interns didn’t usually get the opportunity to write stories. He asked to see my reported pieces. I didn’t have any of those either. But I did have some story ideas. I took out some loose-leaf sheets from my backpack.

  He looked at me like I was crazy. “You can’t work here!”

  A wave of heat washed over my face. “Why not?”

  “You’re not qualified.” He said it like it was the most obvious thing in the world.

  “Well, do you have any internships?”

  “You’re not even qualified for an internship. Our interns usually have several years of newspaper experience.”

  He picked up the phone. “Tell Libby to come in here.” We sat together in awkward silence. After a couple of minutes, a small woman with curly hair and a friendly face entered. It was Elisabeth Rosenthal, a medical writer. “Libby, this is”—he had obviously forgotten my name—“a medical student who wants to be a journalist. Please talk to him.” Then he got up and left.

  Libby Rosenthal and I talked for about half an hour. She told me about her own twisting career journey, going to medical school and finishing a residency in internal medicine before becoming a full-time reporter. “If you want to write for a newspaper,” she said encouragingly, “try the one in St. Louis.” She told me to send her my clips and to keep in touch.

  Back in St. Louis, I got an internship at the Post-Dispatch. Twice a week, when second-year classes were done, I took Highway 40 to a run-down section of downtown and parked in the paper’s weed-strewn parking lot. I wrote stories about wasps, fires, and wild turkeys in Forest Park, and I mailed them to Libby. Though I learned some valuable skills, like writing on deadline—rarely did I get more than four hours to report and write a story—the assignments I received, mostly overflow from the city beat, didn’t much interest me. My mentor at the paper told me that I’d have to write stories like these for years before getting to do what I really wanted. So by the time the internship was finished, I had set aside the idea of becoming a journalist, resolved to focus once again on medical school.

  The hospital off the freeway still beckoned. By the end of second year, I was obsessing about the clinical clerkships coming up, when I would get my first sustained exposure to hospital medicine. I yearned for work, not more scholarship, and I fervently hoped that third year, which had us rotating through all the major medical specialties, would provide fulfillment. There were three months devoted to adult internal medicine, three to surgery, two to obstetrics-gynecology, one to pediatrics, one to psychiatry, and one to neurology, leaving one month for vacation. Whenever I complained about second year to Rajiv, he assured me that things would change drastically once I got to the wards. He said that most of what I was learning in class was useless in clinical practice. He said that the preclinical years were simply a rite of passage. He told me to adopt the medical student mantra: P = MD. It was through practice that one learned what a doctor should do and be.

  WHEN I FINALLY MADE IT to third year, I had narrowed my choice of specialty to internal medicine or psychiatry. Since I was plann
ing on short-tracking, I had to make a decision quickly if I was going to send out residency applications in the fall. Though psychiatry had always appealed to me because of the creativity of its ideas, it quickly became obvious that nurturing my interest at medical school was going to require a thick skin. Many professors openly expressed disdain for psychiatry and psychiatrists. My mentor, a young gastroenterologist with perpetually startled eyes, told me that psychiatry residents came in two types: those from the bottom of the class who could not compete for more prestigious residencies, and those from the top of the class who were mentally ill. “Do internal medicine,” he advised. “It will close the fewest doors.” Rajiv agreed, calling psychiatry “mental masturbation.” After all the effort I had expended to finish a Ph.D. in physics, I couldn’t imagine choosing another career that didn’t meet with my family’s approval.

  Of all the medical specialties I had been exposed to, internal medicine seemed the most grounded in the fundamental physiology I had learned in class. In some ways, internal medicine was like physics: rigorous, intellectually prestigious, vast (encompassing ten different subspecialties: cardiology, pulmonology, gastroenterology, nephrology, hematology-oncology, endocrinology, rheumatology, allergy-immunology, infectious diseases, and geriatrics). There was something deeply attractive about a field that was so immense and varied. (And popular, too: roughly a third of my class was applying for an internal medicine residency.) But as with everything in my life, I had doubts. Internal medicine was indeed complex, but it seemed to require rote, algorithmic reasoning. Where was the beauty, the creativity? Seventeen thousand medical school graduates every year—roughly a third of them future internists—and all of us trained to treat patients the same way. What was the difference between an internist and the mechanic in La Crosse who diagnosed that whirring sound in my car engine? He used a stethoscope, too. Wasn’t this the cookbook medicine I had always disdained?

  One night at the beginning of my first internal medicine clerkship of third year, a resident, a stocky, cocksure man, admitted a patient from the emergency room. “See if you can figure him out,” he said to me on his way out of the hospital the next morning.

  The patient couldn’t tell me what was wrong, and neither could his eighty-year-old mother. “He’s been lying on the sofa for weeks,” she complained when I went to see him. “He just won’t get up.” Sloth was a sin, but was it a reason to be admitted to the hospital?

  They had been living together in a house in East St. Louis. He was fifty-six and single, working mostly odd jobs until recently, when he started spending his days on the couch, watching television. According to his mother, he seemed sleepy most of the time. He forgot appointments and left chores unfinished. When confronted, he became irritable and withdrawn.

  She suspected he was using drugs, but he never left the house long enough to buy any. Sometimes he seemed to be responding to visual hallucinations. She begged him to see a doctor, but he wouldn’t go. When he stopped bathing, she called 911.

  Though it was my first third year clinical rotation, even I could tell that this wasn’t the usual midsummer lethargy. He was lying in bed, almost expressionless. His movements were slow and listless. When he spoke, he slurred his words.

  He denied using drugs and said he didn’t have any previous medical problems. He vaguely recalled taking a medication, but given his current state, he couldn’t remember what it was. I asked his mother to bring in the bottle.

  Meanwhile, I asked him a few standard questions. He knew where he was and the year, but not the month or the president. I asked him to count backwards from one hundred by seven, a test of attentiveness, but he stopped at ninety-three. I asked him to spell “world” backwards, but he started and stopped at “w.” The mental status tests I had learned in class were useless on a patient with such poor mental status.

  The differential diagnosis of his delirium was almost impossibly long. Some of the usual suspects had already been ruled out. He wasn’t intoxicated or hypoglycemic. A CAT scan of his brain revealed no stroke, tumor, or bleeding. Seizures could explain the lethargy and confusion, but his mother had never seen him shake.

  Of all the diagnostic possibilities, infections were probably the most serious. AIDS could cause a kind of premature dementia, but he didn’t have the usual risk factors. Lyme disease was unlikely; Ixodes ticks weren’t endemic to St. Louis. What about meningitis, I thought, or, worse, syphilis? Untreated syphilis could infect the spinal cord and brain, causing severe nerve damage and dementia. Syphilis was one of the “great masqueraders,” along with tuberculosis and lupus, diseases with such protean manifestations that they could almost never be excluded with certainty. In fact, syphilis was enjoying a resurgence in urban areas like St. Louis. The only way to rule it out was to do a spinal tap.

  With help from another resident, I had the man sit on the side of his bed, leaning forward onto a table. I scrubbed his lower back with antiseptic soap and then injected local anesthetic into the tissue between the third and fourth vertebrae. It was my first spinal tap, and I gingerly pushed the needle and trocar through the soft tissue, worrying that I was going to pierce the spinal cord. My hands shook in a fine tremor; beads of perspiration wet my brow. I advanced the needle in micron-size increments. It must have taken ten minutes to go an inch. When the needle finally perforated the sac around the spinal column, clear fluid bubbled back through the hub. The resident congratulated me on a “champagne tap,” free of blood. We sent the fluid off to the laboratory.

  Later that evening, test results started coming back. Blood tests for kidney and liver disease were negative. The spinal fluid was clean, ruling out an infection. But when the level of thyroid-stimulating hormone came back, it was off the scale. My patient had the worst case of hypothyroidism the doctors had ever seen.

  The next day, his mother brought in a brown bag. Inside it was an empty prescription bottle. Sure enough, it was for thyroid hormone; he had been taking the medicine at home but had stopped six months earlier after it ran out, slowly sinking into an amnesiac delirium that made him forget he needed it, a lapse that almost cost him his life. Hypothyroid coma has a 20 percent mortality rate even if diagnosed and treated appropriately.

  As in physics, everything fit together nicely. His condition had been a puzzle, but through logic and judicious testing, I had solved it. I felt proud of myself.

  The next morning I ran into my resident and told him I had made the diagnosis. “Let me guess,” he said.

  “Hypothyroidism.”

  “How did you know?” I asked in disbelief.

  “I tapped on his knee,” he replied; the tap had elicited the slow reflex that is a classic sign of the disease. I had been taught this clinical pearl in class, but as with most of what I learned during the first two years of medical school, I had forgotten it. The lapse had caused my patient to undergo a painful procedure he probably didn’t need.

  I often felt intimidated by the clinical acumen of my internal medicine superiors. On morning rounds, their eyes would turn to me and my throat would tighten and my mind seize, like an engine low on oil. I admired their snappy, confident style. I wasn’t sure how much I had in common with them, but fundamentally I knew I wanted to be like them. One afternoon, I watched a resident struggle to reinsert a breathing tube into a morbidly obese man with severe emphysema who, in a fit of delirium, had yanked it out. The patient was choking, grabbing his neck with one hand as he fought off the resident with the other. A pulmonologist suddenly appeared. He strode up to the bedside, pulled out a metal laryngoscope from his coat pocket, violently pulled the man’s head back and inserted a new breathing tube in one seemingly continuous motion. The whole thing took less than thirty seconds. “Carry on,” he said, strutting out of the room in a theatrical flourish. I must have looked awestruck. “That’s Hoffman,” the resident said. “He likes to intubate people.” I remembered him from a lecture he had given on respiratory physiology. In the lecture hall he seemed pedantic and disorganized, h
is handouts poorly written and pedagogically unsound, but in the hospital he was the man, powerful and in command. I envied his confidence, his swaggering style. It was what I yearned for in my new profession.

  So, in the end, I decided on internal medicine. In internal medicine, there was more to know, more to do, more potential to help people, and more potential to impress. It was, it seemed, doctoring in its essence.

  Medical school graduation fell on my parents’ thirty-third wedding anniversary, an unplanned but perfect gift. They beamed with pride as I strode into the auditorium in my cap and flowing blue gown. The commencement address was delivered by Dean Dowton, a pediatrician who spoke eloquently about his early dreams of becoming a doctor while growing up in the outback of Australia. “From that limited horizon,” he said, “I knew nothing of the world at large, let alone the world of medicine.” His words resonated with me. Not so long ago, ensconced in academia in a college town overloaded with knowledge and ambition, I had felt the same way.

  “Here today,” he went on, “we watch the best and brightest transit from an environment which is familiar to one which is new and exciting, even if a little anxiety-provoking. The world these new physicians enter will be one of contrasts: savoring success on the one hand, demanding duty on the other; exalted expectation, followed by endless effort. Are you, new medical graduates, entering a world beyond reach, away from the rest of society?”

  He went on to talk about what could be done to bridge the gap between the world of medicine and the world at large. “There are tangible things we all can do to make certain medicine is not a world beyond. You, parents and partners, will be a window through which these new doctors will look into the real world. You will serve this role many times over. We need those who care about us to provide a mirror for our actions as we step out into the brave new world.” To me, his comments seemed ironic at the very least. From the ivory tower of the university, the world of medicine and the real world had seemed one and the same. That was why I had decided to become a doctor in the first place. But evidently for someone who had spent enough time in the world of medicine, it was its own ivory tower, removed from the world at large.