He directed his final remarks to us graduates. “Don’t be afraid to say ‘I don’t know.’ It gets easier every time you do it. Never be afraid to admit you don’t know something, most especially to your patients, but in doing so make a commitment to do your best to find out. No matter the tongue-lashing you might take from a Socratic superior, don’t be tempted to hide your ignorance—it is an addiction far too rampant in medicine of all ilks today.”
In closing, he offered this thought: “Keep a simple value system. Work out what things in life you care about, the beliefs you hold near and dear, and stick to them. You are about to go through a most tumultuous time. What are you willing to accept? What are you willing to fight for?” I wrote it down in my Palm Pilot: Figure out a value system. Arriving in New York a month later, I still didn’t have a system down, but I did have some vague ideas about the kind of doctor I hoped to become.
CHAPTER FOUR
bogus doctor
Buy a long stethoscope.
—ADVICE FROM A MEDICAL SCHOOL PROFESSOR
I spent the first morning of internship running errands. I picked up a pager from the telecommunications office and a stack of light brown scrubs and short white coats from the hospital laundry. Unlike other teaching hospitals in Manhattan, at New York Hospital only attending physicians and clinical fellows were allowed to wear long coats. This had provoked some grousing during orientation, as my classmates seemed eager to show off their new status as physicians, but it didn’t bother me. I didn’t feel like much of a doctor yet.
Back in my apartment, I tried one on. In medical school I had always felt proud of my short white coat, walking home through the Central West End with my stethoscope jutting out of the waist pocket. Now, as I put on a white coat for the first time as a doctor, a sense of pride washed over me once again. Despite any misgivings I had about medicine, the uniform conferred authority, cachet, membership in an exclusive guild. I stuffed the pockets with useful paraphernalia: a Pocket Pharmacopeia, a Sanford Guide to Antimicrobial Therapy, a Facts and Formulas, a Washington Manual of Medical Therapeutics, a small notebook, my Palm Pilot, a few pens, a stethoscope, a reflex hammer, a tuning fork, a penlight, a small ruler, a pair of EKG calipers, and a handful of alcohol swabs. I could have added more, but my shoulders were starting to sag.
I checked myself out in the mirror. I still looked like a medical student, not a resident, much less a doctor. I poked a Washington University School of Medicine pin through a lapel. I clipped my photo ID onto the chest pocket. Someone had once told me that when you become an intern, nurses treat you better because now you can write orders. But I certainly didn’t feel any different.
Earlier that morning, at 9:00 a.m. in the wood-paneled clinic conference room, Dr. John Bele, a short man with a penchant for pink shirts, yellow ties, and loafers, had distributed orientation packets and quickly gone over the broad outlines of the rotation. As Dr. Wood had promised, there was to be no call. Unlike our colleagues in the main hospital building across the street, we were going to have weekends off because the clinic was closed. Most days we’d be finished by five or six o’clock, he said, except Tuesdays, when there was evening practice. Teaching conferences were held every day at noon in the main hospital. Lunch was usually provided. Grand Rounds were on Thursday mornings; attendance was mandatory.
He had passed out an exam testing our knowledge of primary care. When we were done with it, we could leave; none of us had patients scheduled that first morning. The test questions were straightforward, having more to do with ethics and doctor-patient relations than management of specific clinical conditions. Even as I was taking the test, I wondered how I was doing in comparison to the others. Some habits from medical school die hard.
After lunch, I walked back to the clinic. The air was thick and still. On the sidewalk, blooming tulips rose out of the gated tree plots like hands coming out of a grave. I took off my coat and swung it over my shoulder. Its contents spilled all over the sidewalk.
The clinic was divided into color-coded sections, though the carpet was one long, continuous gray. For the afternoon, I had been assigned to the Red Area. My room was a crowded space with a computer, a small desk, two chairs, and a sink. In the bookcase were a few outdated textbooks. Next to the sink was a box for used needles. From the orientation packet I fished out the temporary password I had been given—“bogus doctor”—and typed it into the computer. Four patients were scheduled to see me that afternoon. One, Jimmie Washington, had already checked in. According to her chart, she was a seventy-one-year-old resident of Harlem who had had a radical mastectomy for a breast tumor that turned out to be benign. Over the years, she had suffered from various intestinal ailments, including chronic diarrhea, but an extensive workup had revealed nothing abnormal. Before going out to the waiting area, I phoned her gastroenterologist to inquire about the results of her most recent colonoscopy. “She’s fine,” he declared, sounding amused. But what did her colonoscopy show? “She’s fine!” he repeated.
In the waiting room, patients were buzzing around the front desk, which, with its tall mahogany counter flanked by tall ferns, resembled a fortress. Washington was supposed to be an elderly black woman, but there were several out there. Which one was she? I felt shy about calling out her name. I made a first pass, pretending to be going somewhere, and then doubled back after identifying two potential candidates. I tapped one of them on the shoulder. “Ms. Washington?” I said, the words catching in my throat.
A woman bolted out of a nearby chair like a private at boot camp. “That’s Dr. Washington!” she cried. She was a statuesque woman, wearing bright yellow bell-bottoms, a pink floral sweater, and a leopard-skin-print top. Her broad face was adorned with big hanging hoop earrings, large tinted glasses, and a thick smear of rouge. Her hair was tightly spun into a glazed Jheri curl. She looked like a character out of a 1970s blaxploitation film.
She bent down stiffly to pick up her cloth bag. “About time,” she grumbled loudly. “I can’t be waitin’ all day.”
I felt heat rise up to my face. “Please come with me, ma’am . . . I mean, Doctor,” I stammered.
“Hmmph! I been a doctor for fifty years,” she announced, following me. By now other patients were looking on. “Dr. Washington does not want to wait!”
In my room, she hung up her scarf on the door hook and dropped her bag on a chair. With her in it, the room felt even more cramped and confining.
“What kind of doctor are you?” I asked gently.
“Ob-stitian gan-cology,” she replied, mangling the words.
“Oh, so you deliver babies. Where do you practice?”
“In Harlem,” she said, her voice again rising. “Hmmph! I been deliverin’ babies for fifty years. I been a doctor since before you was born.”
I looked over her chart. I asked her why she had had a radical mastectomy. The modified procedure, in which the chest-wall muscles are left largely intact, had been shown to be just as effective for treating breast cancer. “They wasn’t sure it was cancer,” she recalled. “They said, ‘Jimmie, what you want to do?’ and I said, ‘You get rid of it, I don’t need it!’ My friends, they wanted to hold on to their titty, but then they died and lost their titty anyhow. No, uh-uh, I don’t need that!”
And how had she been feeling? “I still be coughin’ some. My leg is swoll, too. What the hell wrong with my foot? It done hurt so bad, I can’t even put a blanket on it. Sometimes I get short-winded. I gots diarrhea, too. That’s why I came up here for.”
“I see . . . And how’s the diarrhea?”
“It ain’t as bad as it was, but it still baaad!”
The diarrhea was intermittent, occurring no more than a few times a week, and was of a normal color. I asked her if she had eaten anything unusual recently. “What you mean?” she asked suspiciously.
“Anything out of the ordinary. Like from a restaurant.”
“I can’t afford no restaurant!” she replied, exasperated.
I pu
lled a fresh sheet of paper onto the brown vinyl examination table and asked her to sit on it. I started to wrap a blood pressure cuff around her left arm, the side of the mastectomy, but she stopped me and told me to put the cuff on the other side. I didn’t know why, but I complied with her request. I quickly inflated the cuff. Then I let the pressure out slowly, listening with my stethoscope at the bend of her arm. One-twenty over eighty. Normal. I put two fingers on her wrist and counted her pulse. Then I counted her breaths, pretending to still count her pulse so as not to make her self-conscious and change her breathing pattern, just as I had been taught in medical school. All vital signs were normal.
An ophthalmoscope was attached to the wall. I tried looking into her eyes, pressing my face against hers—eye to eye, cheek to cheek—but her eyeballs jiggled and I couldn’t get an adequate view. Close up, the topography of her face was rough, scalloped, pitted, like a lunar landscape. There were a few thick gray hairs growing out of her chin. She smelled of cheap perfume and hair oil, but the odor was inoffensive, even slightly pleasant. Her warm breath smelled nice, too, like she had just chewed mint gum. It occurred to me that she might have made herself up just for my benefit.
I twisted a plastic guard onto my otoscope and looked into her ears. They were waxy but I could still make out the gray eardrums, and as best I could tell, they looked normal. The right side of her chest had been almost totally replaced by scar tissue. I pressed my fingertips on it, and on her neck and armpits, too, feeling for any abnormal lymph nodes, but there were none. I placed my stethoscope on her back, then on her chest, listening to the patter of her heartbeat. It was hypnotic, and as I listened to it, my mind wandered to Berkeley and Lisa and my laser table and the balcony up at Lawrence Berkeley Labs and the International House and my parents, and all this happened in an instant, and then she squirmed and I wondered how long I had been daydreaming, and had she noticed?
When I was done with the exam, I helped her off the table and back into the chair. Then it occurred to me; I had forgotten something: the rectal exam. Was it really necessary? Her most recent colonoscopy had been normal; even her gastroenterologist had said she was fine. But what if my preceptor asked about it? I didn’t want to appear like someone who avoided doing rectal exams. “I’m sorry, ma’am, but I think we will need to do a rectal exam,” I said fearfully. “Whatever you say, Doctor,” she replied, shrugging. Clearly my uniform had conferred an authority upon me that my experience did not warrant. That, or else this lady really liked going to the doctor.
I stepped outside as she undressed. I hated rectals. Just thinking about inserting my finger in someone’s rectum made me nauseated. In medical school I had never been able to do one without gagging. Once, a GI fellow had performed a rectal exam on my moribund patient while I was still in the room. I remembered how incredulous I felt when he started gesturing at me with his stool-smeared finger! Some people were so comfortable with the human body. No wonder they became doctors.
When I went back in, she was lying on the table, buck naked. Evidently I had forgotten to give her a gown. I reached into a drawer and pulled one out, and she put it on. I laid out the materials I was going to use on the counter next to the sink. Stool developer (I unscrewed the top so I wouldn’t contaminate the bottle). Guaiac card. Lubricating gel. I handed her a wad of Kleenex for afterward, something a paid volunteer in medical school had told me was a considerate gesture most doctors forgot.
How to do this? I could have her bend over, but that seemed unseemly, so I asked her to lie on her side, facing the wall. I put on latex gloves and smeared gel on my index finger. Suddenly it felt heavy. Stepping behind her, I paused respectfully. She looked over her shoulder. “Go ahead, help y’self,” she said.
Her generous buttocks, lined with wrinkly stretch marks like water tracks on a dirt road, swallowed up my hand. A fetid odor rose up to my nostrils. I pressed on the spongy wall of her rectum, feeling for masses. Even if one had been there, I probably wouldn’t have known because I had never felt a rectal mass before. Holding my breath, I removed my finger and smeared brown film onto the card. I applied a few drops of developer on the stool but the color didn’t change, meaning there was no blood. I felt relieved; nothing more to do. I stripped off my gloves, trying hard not to look at them. Then it started. My tongue curled up and my eyes started watering. A dry heave welled up in my chest and I felt my legs start to go. I took a deep breath and tried to think of something, anything—dead kittens!—but I heaved and a tear rolled down my cheek. I closed my eyes, and for a moment both she and I were breathing fast. I vigorously shook my head, trying to rid it of the brown, feculent visual. It was all I could do to chuck the gloves into the waste bin before I vomited.
I left Ms. Washington and went to see my preceptor, Dr. Lane, who was talking on the phone in her office. She motioned for me to take a seat under the many framed certificates that adorned the walls. When I described the case, she agreed with my plan, which was basically to use antidiarrheals on an as-needed basis. Back in my room, I gave Ms. Washington a prescription and a follow-up appointment in three months. “Make it two,” she said, retouching her makeup with the aid of a compact mirror. “Okay, two,” I said, changing the appointment. Then she gathered up her things, meticulously tied her scarf, slung her bag over her shoulder, and left.
My first patient, I thought. An “ob-gyn” who could have been invented by Melvin Van Peebles! New York was full of these people, larger-than-life characters who seemed to have walked off the celluloid. It was one of the reasons I had wanted to come here. At the very least, I told myself, this is going to be an interesting year.
THAT WEEKEND, I had an invitation to an exhibition of Indian art at the apartment of an acquaintance on the Upper East Side. I asked my classmate Vijay if he wanted to come along, and he gladly said yes. We met in the lobby of my apartment building next to the hospital and walked to the party. It was a warm Saturday night. The leaves of the flowering pear trees were shimmering, as if decorated with tiny Christmas lights. A rich floral bouquet wafted from sidewalk fruit stands. Pretty, fresh-faced women in stylish summer dresses were strolling around the neighborhood in tight-knit groups. Old men were sitting on benches in front of shuttered storefronts spouting off about the Mets or perhaps their medications. Walking along side streets, we encountered young people on brownstone stoops giggling, cuddling, smoking marijuana. The buildings were pale, staggered, seemingly endless. All the movement, the lights, etched tiny scratches in my brain. Just living in New York, I thought, could be a full-time job.
The door was open when we arrived at the party. I poured a drink for myself in the kitchen and maneuvered my way through the packed crowd to the living room, where a red-sari-clad woman in a painting was standing on a balcony similar to the one at my grandfather’s flat in New Delhi. Her hand covered her mouth in an enigmatic expression of shock or perhaps boredom. “What do you think she’s thinking?” I asked the woman standing next to me, who was also staring at the painting. “I think she’s unhappy with her marriage,” the woman replied without missing a beat. Intrigued, I introduced myself and we started talking. Sonia Sharma was a third-year medical student at George Washington University in Washington, D.C., who was spending the summer doing a cardiology elective at St. Luke’s-Roosevelt Hospital Center on the Upper West Side. She was pretty, flirtatiously mirthful, with olive-colored skin, flowing dark brown hair, and dimples that deepened into beautiful trenches when she smiled, which was often. She was wearing a light blue J. Crew dress and brown platform sandals. After chatting for a while, she invited Vijay and me to join her and her sister at a nightclub after the party.
At ten o’clock, Vijay and I paid Shannon a visit at the Hi-Life. As I was telling her about the nice Indian girl I’d just met, I realized I had forgotten to get Sonia’s mobile phone number. Now, I was going to have to find her in a packed Manhattan nightclub on a Saturday night. Though it was getting late, Vijay and I took a cab to midtown, near Times Square. After wait
ing endlessly in a line that weaved halfway around the block and then answering some impertinent questions from the burly bouncer—yes, we were doctors, how did he know?—we got into the club. Miraculously, it seemed, wandering through the smoky haze, we found Sonia and her sister. They seemed glad to see us, and for a couple of hours we smoked cigarettes and shouted at each other over the deafening drumbeat. The alcohol, the hip-hop, the buzz—I felt more free and relaxed than I had in a long time, even a bit reckless; it was like I was in graduate school again. We stayed until the club closed at 2:00 a.m. When we parted, Sonia and I exchanged numbers. Groovy girl, I thought, riding home. Too bad she’s a medical student. I was hoping to date someone Indian, but I was pretty sure I didn’t want to marry a doctor.
THE CLINIC MONTH WENT BY QUICKLY. With controlled hours and no call, the rotation was fairly easy, leaving me to wonder whether it wouldn’t have been better to be thrown into the fire of inpatient medicine earlier. I fell into a comfortable routine, running along the East River in the morning, which helped relieve stress. Since I didn’t have to be in clinic until nine o’clock, some mornings I would turn on the television and watch the CNBC talking heads intone pedantically about how the Internet was going to change the face of business. “Does it justify the stratospheric stock prices?” someone would invariably ask, and the response was almost stereotyped, half smile, expression of tired resignation: “Only time will tell.”
New York patients had an edge, a roughness, an unsavoriness that kept me on my toes. There was the gay man who’d gotten into a fight on the subway and sprained his shoulder; the alcoholic who wanted to get drunk but compromised and sniffed cocaine instead; the old ladies who had more wrinkles on their legs than on their faces. One afternoon, a middle-aged woman came to me with a surprise. The severe lower back and leg pain and numbness that had plagued her for months, making it impossible for her to even sit in a chair, had all but disappeared. She informed me that she had canceled her back surgery scheduled for later in the month.
Intern Page 6
