I talked about my interest in psychiatry. Josh asked me what I liked about it, and I told him that, despite the mumbo jumbo, psychiatry at least seemed to be trying to get to the heart of things. While internal medicine dissected, psychiatry synthesized. Internists described disease in a phenomenological way, as a collection of symptoms, as the result of certain chemical excesses or deficits. Psychiatrists, on the other hand, it seemed to me then, were trying to go deeper, into the structure of illness itself. What interested me about psychiatry was what most doctors disparaged: the abstruse theories, the symbolic representations, the weirdness. I had always felt more comfortable with the strange, the grotesque, the questioners of themselves. I often remembered the mentally ill patients I had cared for in medical school. There was Noah Stearns and his dream of traveling “the open road” to California; when the police picked him up, he was wandering around in his hometown, eating weeds. Or Terence Hode, who lost his mind when his wife left him, spending sixteen hours a day watching porn and listening to the Red Hot Chili Peppers. Or Eleanor Wilson, who started telling people that workers at the post office were trying to keep her from “reaching a better life.” Although I had always been reluctant to admit it, I enjoyed these patients so much more than the diabetics or the old ladies with mundane urinary tract infections.
“They talk all the time about supporting you through residency, but really that’s all just lip service,” Josh said. “If you want to switch, go ahead. On the other hand, you might be better off finishing the year.” I had heard this advice before. “Things are going to get better,” he assured me. I had heard that before, too. “You have to ask yourself, Where do I want to be in ten years?” I had heard it all before; I had been working through these issues my entire professional life. After all this time, so many stops and starts, it was dispiriting that I still had no idea what I wanted, and that the insight of an older, supposedly wiser resident left me right where I’d started: knowing the pros and cons but unable to decide.
After dinner, I walked home. The night was clear, the lights bright. The cabs were weaving up the packed avenue like a game of Donkey Kong, their neon taillights randomly blinking at me like a sea of red eyes. There was a void in my life that I didn’t know how to fill. My old career in physics was finished; I couldn’t just pick up where I left off. My new life was all about medicine. Even if I made a big show of never talking about it, at social or family gatherings, it was there, never far from my mind, the dominant motif in my life. How could I just give it up? I had no options, no plans, just complaints.
Becoming a psychiatrist was a romantic notion, driven by a nebulous desire to find creativity within medicine, but I knew it made little sense. Not so long ago I had been experimenting on quantum dots with picosecond laser pulses. Now I wanted to become a psychoanalyst? It sounded flaky, even to me. Psychiatry was fringe, elitist, out of the mainstream—precisely what I had fled by going into medicine in the first place. Did I really want to join another profession I had little faith in? Wasn’t it better to work hard and not have to apologize?
Maybe Josh was right. Internship wasn’t going to last forever. It was already almost a third over. Perhaps my best option was to buckle down and focus. In photography there is a thing called a pinhole camera. It operates on the same principle as squinting: narrow your field of view and you are able to see more clearly. This, I decided, was what I had to do now. Instead of gazing so far into the future, perhaps I should just focus on the path directly ahead of me. Perhaps such an approach would deliver clarity.
Coming up was a rotation at Memorial, the world-famous cancer hospital allied with New York Hospital. Oncology; maybe that was my calling. Somehow I doubted it, but I told myself that I owed it to myself to give residency some more time. If things didn’t improve quickly, then I would march into Dr. Wood’s office and break the news. My father’s injunction kept reverberating in my head: Don’t change horses in the middle of the ocean.
PART II
cracking up
CHAPTER TWELVE
night float
Too few residents emerge from training thankful for the opportunity to practice in a fascinating and intellectually challenging field. Instead, many believe that the world owes them something for what they’ve been through.
—TIMOTHY MCCALL, “THE IMPACT OF LONG WORKING HOURS ON RESIDENT
PHYSICIANS,” THE NEW ENGLAND JOURNAL OF MEDICINE, 1988
At four o’clock in the afternoon, I was struggling to put on my necktie. I draped the silk band around my collar, pulling up and down to adjust the length on each side. Then I curled the wide part around the narrow, making a counterclockwise loop. I fiddled with the short end for a few seconds, trying to remember what to do next, before pulling my hands apart and starting over. On my next attempt, I experienced a faint glimmer of recall. I finally got it on the third try. Procedural memory is the last to go when you are fatigued. It means you are about to collapse. This did not bode well for my first night at Memorial. If I couldn’t put on a tie, how was I going to function in the hospital?
Before heading in for my shift, I stopped by the Hi-Life to see Shannon. “What happened to you?” she said when I sat down at the bar.
I grimaced, taking off my neck brace. “Herniated disk.”
Her expression softened. “How’d that happen?”
I didn’t know. A few weeks earlier, a gnawing pain had developed at the base of my neck and in my right shoulder and elbow. The palm of my right hand, from the thumb to the wrist, felt numb. Josh had diagnosed me with carpal tunnel syndrome, and for a few days I had worn a wrist brace, which only seemed to aggravate the pain. It felt like a fat drill was boring into my shoulder. At first I wondered if perhaps my symptoms were psychosomatic. Interns often develop weird ailments during training, and was it just a coincidence that one of my leukemia patients had been hospitalized with similar complaints? But as the days passed, the pain steadily worsened. When it was almost unbearable, I went to Dr. Bele in the outpatient clinic. He sat me down in a chair, palmed the top of my head, and pressed downward. A hot electrical sensation traveled down my right arm, and I howled in agony. “You have a slipped disk,” he pronounced. He sent me to the office of a sports medicine specialist, who told me that my right biceps reflex was almost absent, indicating significant nerve damage. She gave me a cervical collar and ordered a spine MRI, which was performed the following morning. Rajiv took a few hours off to accompany me to the test. Lying flat on the gantry, I could almost feel my eyelashes scraping against the roof of the scanner, and the loud Schumann opera being piped into the headphones did nothing to quell my anxiety. I thought of wide open spaces. I thought of romantic interludes with Sonia. I thought of the hundreds of MRI scans I had casually ordered for patients over the past few months with nary a second thought.
The MRI showed what by now everyone suspected: a severe herniation of the disk between my fifth and sixth cervical vertebrae. The gelatinous core had ruptured through the fibrous capsule, pinching a nerve root. When the radiologist showed me a sideways view of my spine, it looked like the herniated disk was partially compressing the anterior column of my spinal cord.
I went to a neurologist at my own hospital, who told me there was a slight chance the disk would heal on its own but that it was likely going to require surgery. At the very least, he advised taking a break from internship.
That afternoon on the ward, I was unable to turn my head because of my neck brace. I had to rotate my entire body to look in any particular direction or to perform physical maneuvers. My patients joked that I should see a doctor. My colleagues were mostly reserved, politely inquiring about the injury but not paying it much attention. I remembered how they’d been when a classmate claimed to have a hairline foot fracture back in August: resentful, unsympathetic, whispering that she was faking it. Of course, I was aware that one of them was going to have to cover for me if I left.
A couple of days later, I got a phone call from Dr. Wood. He had jus
t spoken to the neurologist. “So you need some time off?” he said pleasantly.
“That’s what I was told,” I replied, then quickly added, “But I’m not planning on taking any.”
He asked me why. I wasn’t sure what to tell him. I had been contemplating quitting internship before my injury, but now the situation had become more complicated. Leaving now, I feared, would have adverse lasting consequences on my psyche. I didn’t want to be forced out. I wanted to leave on my own terms.
“I’d stay home if I thought it would help,” I said. “But I might need surgery no matter what.”
“Take the time,” Dr. Wood urged. “We all admire the way you’ve handled this, not drawing too much attention to yourself. No one thinks you haven’t been sincere.”
I didn’t say anything, but his kind words lifted my spirits. Though we had little in common, I liked Dr. Wood. I admired his commitment and integrity. And I was glad that he liked something in me, too.
I told him I’d think it over. At the very least, I wanted to complete my upcoming rotation at Memorial Sloan-Kettering. The Memorial rotation was the toughest of the year, and I had been looking forward to it as one might a sickening thrill ride. Cancer was the icon of deathly disease, and as a den of illness, Memorial had a sort of mystique. The patients there were as sick as any we were going to encounter all year. If you overlooked something at Memorial—a rash, a fever—your patient could crump quickly, and no patients were more crump-prone than Memorial patients. I was hoping that taking care of such patients would deliver confidence, courage, a sense of purpose. I felt like a marathoner trying to finish a race even though his legs are collapsing.
The challenge of Memorial was multiplied by the fact that I was going to be doing “night float” there. Night float was a relatively new concept in residency training. Older physicians, like Dr. Wood, had trained under a very different system, when call was every second or third night and residents routinely stayed up for thirty-six hours at a stretch. But things started to change late one spring evening in 1984, when a young woman named Libby Zion entered the emergency room at New York Hospital. She was agitated and running a high fever. Eight hours later, she was dead.
Though the exact cause of her death remains a mystery, her case aroused intense debate over what until then had been little discussed: the way residents are trained in New York State. The residents who cared for Zion the night she died had given her a powerful narcotic, and then had been slow to respond when she developed an adverse reaction. If they had been more rested, medical educators wondered, would they have been able to save her life?
In 1987, a special commission led by Dr. Bertrand M. Bell, a professor of medicine at Albert Einstein College of Medicine in the Bronx, proposed a number of changes in residency training in New York State: closer supervision of residents in emergency rooms, more help with routine tasks like drawing blood, and strict work limits. Residents were prohibited from working more than twenty-four hours at a stretch or more than eighty hours per week. Eventually these changes spread to residency programs throughout the country. Teaching hospitals that had relied on interns and residents as medical staff were forced to grapple with the problem of cross-coverage: providing care to patients when their primary resident was not on duty. As a result, many hospitals created night floats—residents who worked the night shift for specified periods of time, usually a few weeks.
Many in the profession, including most residents, applauded the Bell regulations. Studies have shown that, under the old system, residents after a call night score lower on tests of simple reasoning, response time, concentration, and recall. Many, both inside and outside medicine, argued that residents could not provide proper care for patients if they were chronically fatigued. In an editorial in The New England Journal of Medicine, one educator wrote: “Few would choose to ride in a car driven by a resident coming off a 36-hour shift. It should come as no surprise that the public would question the ability of sleep-deprived residents to make life-and-death decisions.”
However, some educators argued that there was no clear-cut scientific evidence showing that tired residents harm patients, either by increasing mortality rates or complications. One doctor wrote in The New England Journal of Medicine: “My own experience in staffing our intensive care unit both in the traditional manner and with a ‘night float’ suggests that errors due to faulty transfer of information are at least as frequent as those due to fatigue from being on call overnight.” Educators also argued that the work limits that led to the creation of the night-float system were detrimental to a resident’s training because they interrupted learning and created a kind of shift-work mentality. Of course, the shift aspect of night float was precisely the attraction for many interns. After doing night float, Vijay had told me, echoing the sentiments of many of my classmates: “I walk into the hospital empty-handed, and I leave empty-handed, and I like that.”
“Are you sure you can handle it?” Shannon asked me worriedly as I drained my last sip of coffee.
“I think so,” I replied.
Outside, it had started to rain, a late October drizzle that glistened on the tar-black wrought-iron railings guarding the aging brownstones in the neighborhood. Mist pecked at my skin and moistened my hair. The spray cooled my upper body, which felt hot and sweaty because of the neck brace. Under a tree, a water droplet splattered on the bridge of my nose, the intense sensation momentarily dulling the pain in my neck. The pain had been terrible all afternoon. Before leaving the apartment I had popped two pills of Lodine, a painkiller.
My shift was supposed to begin at 5:00 p.m., when residents and nurse practitioners departed for the day, and end at 7:00 a.m., when they returned. Meanwhile, I was going to be responsible for about eighty patients.
At the security desk at the front entrance of the hospital, an officer gave me a quizzical look. I rode up the escalator, passed through a waiting area where families were sprawled on green and orange couches, and turned down a corridor going to the cafeteria. Not wanting to draw attention to myself, I removed the neck brace and stuffed it into my backpack.
It was a typical hospital cafeteria, with grimy brown carpeting, potted plants, and cheap Kandinsky posters. A corkboard on the wall was plastered with announcements from various support groups, invitations to join in research studies, and urgent appeals for bone-marrow donation. Large paneled posters told the storied history of the hospital and predicted the next generation of advances from the Human Genome Project. Two New York Hospital interns were waiting for me at a table reserved for house-staff conferences. One of them, Caitlin, was a very attractive brunette from Georgia. She handed me a list of her patients with their major medical problems, allergies, and a short summary of their hospital course. “Don’t worry about seeing this guy,” she said, pointing to a name with a star next to it. “He’s signing out against medical advice. I told him not to leave. I told him the risks, blah, blah, blah, but he wouldn’t listen, so sayonara,” she concluded with a flick of her hand.
“There is one patient I have to tell you about. This guy Schroeder has been hallucinating all afternoon. We don’t know why; maybe he has brain mets. We gave him some vitamin H”—Haldol—“and he’s quiet now, so he shouldn’t give you any trouble, but if he does, just snow him with more Haldol and Ativan.” I nodded intently; Caitlin had great breasts.
“I’m sorry to dump this on you,” she said, gently caressing my arm.
“No problem,” I replied, affecting nonchalance. “The longer you stay, the longer you stay.”
Six cancer teams—Gastrointestinal (GI), Allogeneic Bone Marrow Transplant, Genitourinary, Head and Neck, Breast, and Melanoma—signed out to me. (The other night-float intern got sign-outs from Leukemia, Lymphoma, Lung, Autologous Bone Marrow Transplant, Hematology, and Multiple Myeloma.) By 6:00 p.m., everyone had left.
The first hour of night float is supposed to be relatively tranquil, the calm before the storm, but not this night. A few minutes after the last inte
rn signed out, I got paged. Beep . . . beep . . . beep. “Are you covering Schroeder on GI?” a voice inquired.
“Hold on, let me check my list.” I sifted through the papers as the voice kept talking. “Okay, here he is,” I said. “Schroeder, patient of Dr. Raymond.” Of course: he was the patient Caitlin had just signed out to me, and whom I’d so smittenly pledged to look after. “Sixty-four. Colon cancer status-post 5-FU and leucovorin. All right, go ahead.”
“I just told you. He’s delirious and his oxygen saturation is dropping.”
There was a long pause.
“Are you coming?”
“Yes, I’ll be right there,” I said.
The GI ward was shaped like a racetrack, with two dimly lit corridors encircled by wooden banisters and painted a dull yellow. The nurses’ station was almost deserted, save for a clerk and two nurses having coffee. In his room, Schroeder was sprawled in bed, his arms and legs tied to the rails. He apparently did not speak English—apart from obscenities—because a German translator was there, a lanky, greasy-faced fellow who was grinning nervously. “He says that things are coming down at him,” the young man said, clenching his teeth to keep from laughing. “He feels that things are crawling on his skin.”
When I attempted to apply my stethoscope to his chest, Schroeder lunged at me with a force that shook the entire bed. His hands turned white as the cloth cuffs cut off his circulation. “What do you want me to do?” the nurse who had paged me demanded. “I can’t keep him tied up all night.” Beep . . . beep . . . beep. I glanced at the beeper on my waist. “What’s his baseline?” I asked, checking the display. About the only thing I had been signed out was that he wasn’t going to give me any trouble.
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