Intern

by Sandeep Jauhar

  “What’s that?”

  I hesitated. “X-rays of the face?”

  In the middle of the night, hesitation to a radiology technician is a bit like blood to a shark. Suddenly I found myself on the defensive. He hurled questions at me: Why were the X-rays necessary? How were they going to change my management? How badly was he bleeding? Who was going to bring him down? Rajiv had told me that in the hospital, sometimes the best defense is a good offense. “Listen, I’m just covering for the night, but your supervisor’s going to want to know why you refused to do an X-ray on a guy with cancer who just crashed into a window and has a platelet count of zero.”

  That did the trick. “Why didn’t you tell me he had low platelets?” the tech said. “So he should have a CAT scan. Send him down; I’ll do him now.”

  At five in the morning, I put my head down on a pillow in the call room. I popped two more Lodine pills. For the thousandth time during internship, I despaired about how rest doesn’t accumulate. One terrible night and the fatigue drenches over you once again.

  An hour later, as daybreak approached, I found myself in Mr. Fibak’s room. A young Polish man, he too had fallen while getting out of bed. I had seen him once already that night for a fever. Inside his isolation room was a small sink, where I rinsed my hands with scalding hot water before donning gloves and a yellow gown and backing my way through a curtain.

  I took a moment to look over his bedside chart. The vital signs—pulse, temperature, blood pressure, and respiratory rate—were recorded on a graph. Each number was supposed to be charted in a different color, with a different scale for each sign, but someone had recorded all of them in blue. I wasn’t sure whether his pulse was 102, or his blood pressure, or if he had spiked a fever to 102.

  The dawn light was seeping through the window blinds. Looking out onto First Avenue, I could see that taxicabs were moving, but most of Manhattan was still not up. The room was gray, cold, and spare, with a vaguely unwelcoming air, in keeping with the season. Under a terry cloth blanket, Fibak looked like he was sleeping. He was a thin man with sunken cheeks and short, wispy hair standing up on his scalp like young grass in a newly seeded field. Bags of multicolored liquids were hanging on a metal pole at his bedside, emptying slowly into a tightly wound cable of plastic tubes passing into a catheter in his right arm and another in his chest. His skin was pale. His body looked like it would break if I pressed on it.

  I called out his name. He did not stir. Alarmed, I tugged at the blanket and he immediately sat up, appearing embarrassed for having been caught slumbering. “How are you feeling?” I asked as he shook away the sleep. “I was told you fell down.”

  His nose was crusted with blood and there was a small bruise on the side of his face. “You never came back to see me, Doctor!” he exclaimed.

  Evidently I had promised to do so earlier that night, but I had forgotten why. “Well, I’m here now,” I said, pressing gently on the bridge of his nose.

  “That’s because I fell. You were never going to come back to see me.”

  His deep-set eyes looked fearful, like those of a sick child. The inside of his eyelids had a grayish hue, a sign of profound anemia. His breath sounds were coarse, his rib cage almost unbearably bony. Shallow ulcers coated the inside of his mouth. He told me that the pain in his mouth and throat was almost intolerable. He was chronically nauseated, and he could no longer swallow. Nutritive fluids were dripping into his vein through an intravenous catheter. Unopened Tupperware containers filled with prepared foods were strewn on his bedside table. “Who brought these for you?” I asked. “My wife,” he replied. “She wanted me to eat something, but I told her they have to give me morphine and Zofran first.”

  I told him he needed a CAT scan to rule out bleeding in his head. For a moment he was quiet. Then tears came to his eyes. “Come on,” I said. “After what you’ve been through, this will be nothing.”

  “When can I leave this place, Doctor?”

  “I can ask your doctors when they come back in the morning.”

  “I know what they are going to say. ‘When your counts come up. When you stop having fevers.’ I got cytomegalovirus, Doctor. I’ve been on these antibiotics for a month. I just want to know, am I going to leave this hospital?”

  I was silent. “I will have to ask on rounds,” I said.

  Fibak looked away. “I know I’m never going to leave,” he said, dabbing at his nose. “Just tell them to give me an answer,” he said angrily. “I got a wife and kids, Doctor. It’s been two months.”

  The teams returned to the hospital at seven o’clock. At seven-fifteen, an indignant chief resident paged me to tell me that residents were waiting for me to sign out in the library. I was in with a patient who had just gone into acute congestive heart failure. I had just administered morphine and diuretics and was pretty sure he was going to have to be intubated. Could the group come over to me? I asked. After a few minutes, interns and nurse practitioners started streaming into the room. I wasn’t sure where to begin, so I took out my sign-out lists. They looked like the doodles of a bored high school student, covered with scribbles and arrows and boxes. One page was torn; another had a long streak of blood. “How was your night?” someone asked.

  CHAPTER THIRTEEN

  hole

  And you may find yourself in a beautiful house, with a beautiful wife And you may ask yourself—Well . . . How did I get here?

  —TALKING HEADS, “ONCE IN A LIFETIME”

  In biology, ontogeny recapitulates phylogeny. The fetal heart, through its development, reproduces the single-chambered organ of our gill-bearing ancestors. The education of a doctor similarly replays the travails of physicians of generations past. There are several reasons for this: institutional inertia; a desire for cheap labor; the punitive sensibility of senior physicians. “The brutality of the training is deliberate,” a medical school professor once told me. “It forges loyalty to the profession through shared hardship.” For me, it had done just the opposite. My spirit was broken after four months of toil and compromise. The pain in my neck was unrelenting; my right arm was starting to feel heavy. Midway through my week of night float at Memorial, I informed Dr. Wood that I was going to take a break from residency. I suspect he knew that more than just my neck needed to heal.

  When I called Sonia in Washington to tell her, she started crying. She hadn’t realized how much I had been suffering. I told her the hiatus from residency was going to be temporary, though I had no idea if that was really the case. She said she’d pray for my speedy recovery.

  I was given six days off and then a reduced work schedule—call every fifth night, rather than every third or fourth, and one or two mornings off per week for physical therapy. At first I was elated. Time off! A paid vacation during internship! But my initial exhilaration was quickly replaced with a brooding melancholy when I realized that I was buried again in indecision and purposelessness. Mornings were restless. I’d wake up at dawn, unable to go back to sleep. I’d get out of bed feeling cold, listless, with a queasy, sad feeling, as though my mind had been spinning its discontents in my sleep. There was a heavy weight below my sternum—the weight of a hole—extending down to the pit of my stomach. I lay on the couch, blankly watching television, staring at the window, staring at the walls. So much effort, and now where was I—the bottom of the heap? In my journal I wrote:

  Something is wrong—something. My mind is sluggish; I cannot focus. My mood is low; perhaps I am depressed; or perhaps this is just the way it is. I have felt for months that I am fighting something; I am fighting to stay up. I feel like a marble rolling around in a bowl: back and forth, back and forth, speeding up as it gets to the bottom, desperately trying to avoid what will happen if I stop. How low can I descend? There is a pit visible and perhaps I am bound to fall into it.

  I had gotten so used to the daily grind, to being told what to do and where to be at every moment, that the loss of that routine was queerly unsettling. I found myself peering jealously
through my living room window at my colleagues down on the street scurrying outside the hospital complex. I envied their activity, their health, their sense of purpose and continuing accomplishment. I wondered what they were thinking; did they even know that I was gone? I occupied a sort of netherworld, not sick enough to garner sympathy, but also not healthy enough to function normally.

  Since I couldn’t exercise, I took to walking, especially in the morning, when the fog shrouded the East River like little clouds. I could hardly believe who was out and about: high school kids in hip-hugger jeans; young professionals in James Dean leather coats; middle-aged men pushing expensive strollers with pretty blondes in fur coats and wraparound shawls carrying Louis Vuitton bags. On the promenade, I walked past bums lying on wooden benches or in sleeping bags, their faces blackened, talking to themselves with reverie. I caught their stares and walked on.

  In Central Park the leaves were turning color, littering the ground in heavy, sodden piles. Birds circled slowly in the air, like vultures seeking carrion. I had always loved Berkeley in the fall: the crunchy brown leaves under your feet; the long chilly evenings walking down Telegraph Avenue, where the grimy hawkers peddled their fake llama-wool sweaters and the fat ladies sold fruit-shaped candles beside endless stalls of cheap jewelry. Walking without purpose reminded me of that time. I thought how ironic it was that I had gone into medicine to join the real world.

  On my reduced work schedule, I began twice-weekly physical therapy at a nearby orthopedic hospital. Most sessions, my head was put into a traction device, which relieved the pressure from the slipped disk. Standing with my back against a spongy wall, I performed neck-strengthening exercises while young Latino therapists worked on elderly men in wheelchairs to the tunes of salsa and merengue. The goal was to help patients recover “functional status,” so different sections of the treatment room replicated different environments patients might find themselves in: a “deli counter” with a cash register; a “produce department” with plastic fruit; a “dry-goods aisle” with bags of rice and beans; a “frozen-foods section” with fake cartons of ice cream. There was even a tiny space with a single bed and side table. It reminded me of the hospital call rooms I had been sleeping in.

  Over the following weeks, profoundly unsure of my future, I decided to write an essay about my experience on night float. My purpose was to warn hospital administrators and future residents to the dangers of this cross-coverage system. I pitched the idea to Cornelia “Cory” Dean, the science editor of The New York Times, to whom I had been introduced by my journalist-doctor acquaintance Elisabeth Rosenthal. When I spoke with Cory after arriving in New York, she had encouraged me to keep a journal and write about issues related to residency. When I queried her about a piece on night float, she encouraged me to write it up.

  In the essay I criticized a system that left interns in charge of a large number of very sick patients about whom they knew very little. I recounted some of my near-fatal mistakes on the night shift at Memorial, when I’d felt overwhelmed, and had been receiving inadequate supervision. In my opinion, the Bell Commission, which instituted residency work-hour limits, the impetus for the night-float system, seemed to have traded one set of problems for another. Obviously doctors could not assume round-the-clock responsibility for their patients, but having night floats seemed fraught with the kind of risks hospitals were striving to avoid: discontinuity of care, delayed tests, medication errors, or worse. Which was safer: to be cared for by a fatigued resident who knew you, or a rested resident who did not?

  Cory and the Times accepted the essay. In fact, when she paged me to tell me, I was in a flower shop on Lexington Avenue, buying a bouquet for Sonia, who was planning on visiting me that weekend. Cory asked me where she should fax the “playback.” I obviously couldn’t have her fax it to the hospital, so, with the florist’s permission, she faxed it right to the flower shop!

  On the morning the essay was published in the Tuesday science section, I was stopped in the hospital by a medical student I didn’t know, who asked me if I had written “that article” in the Times. I was astounded that a stranger had recognized me. During the day, I spied the newspaper in the hands of several attending physicians, wondering what they were thinking. Of course I felt proud at being published, but I was anxious nevertheless about the reaction the essay could provoke. When I ran into Dr. Carmen, he cryptically told me he had been hearing my name all over the hospital.

  The essay (predictably, in retrospect) caused a firestorm. I was told it was discussed at a meeting of the medical board, which apparently thought that I may have created a liability risk for the hospital. At Memorial, a top-level administrator reportedly instructed the chief residents to draft a press release defending the night-float system and assuring the public that patients were safe. (As far as I know, the press office never released it.) Even Dr. Bertrand Bell, who headed the original work-hours commission in the mid-1980s, sent a letter to the New York State Department of Health, a copy of which was provided to me by the Times:

  The continued scheduling by hospitals of sleep deprivation and chronic fatigue as a feature of residency training in hospitals in New York State . . . is disturbing . . . [Dr. Jauhar’s article] details the most egregious defiance of the law . . . The article is the sentinel event in demonstrating a problem hazardous to health and in need of corrective action. It is quite clear that the department must cite Dr. Jauhar’s hospital for breaking the supervisory requirements of the law.

  At one time I might have obsessed about the fallout, but at this point I didn’t much care. Most mornings now I was waking up fantasizing an escape. That I had somehow found the energy while on leave to write the piece and get it published in the most important newspaper in the country only heightened my ambivalence about medicine: Wouldn’t I be better off switching to journalism? In my diary I wrote: “I hate feeling stupid; I clam up and doubt myself. It’s one thing in a field where ignorance is sanctioned, like journalism; quite another in a field where ignorance is vilified, like medicine.”

  I confessed these doubts to my parents when they came to visit me a few weeks later. They had come to New York for a special occasion. Sonia and I were getting “pre-engaged.”

  The view through my window was of a cold late-autumn day: no snow, but no movement on the streets either. My parents were sitting quietly on the couch, expressionless except for their perpetual look of worry, which faded in impact from overuse. Though impressed that I had gotten an article published in the Times, my father was worried about its effects on my medical career. After the battles he had waged at the university over “racialism,” he had become sensitized to professional conflict and advised me to be more accommodating than he had ever been, especially with senior physicians who were going to judge me and perhaps write letters of recommendation on my behalf. “You must remember that medicine is your goal and writing your hobby,” he had written in a letter. “You must never get obsessed with writing at the cost of your profession. We liked reading your article in The New York Times, but nothing will make us happier than seeing you as a great doctor alleviating human suffering.”

  I was sitting at the dining table, absentmindedly looking out onto the street, my head fixed stiffly in a Miami J-collar. I had just taken more Lodine and was waiting for the analgesic effect to kick in.

  “If someone gets sick, I think it’s a reflection on their abilities,” my father declared.

  “Which abilities?” I asked.

  “Abilities as a doctor, as a man. I had neck problems, too. I went to all the bloody doctors. They pumped me with drugs—Celebrex, Vioxx, Fiorinal—but I stopped them all. Now I do my exercises and I feel better. It’s your responsibility to keep yourself healthy. It reflects on your abilities as a doctor. At least that’s my opinion.”

  I said nothing. There was no point arguing when my father was in one of his moods.

  “So what is going on now? We are in the dark.”

  “With what?” I asked.r />
  “With your career, your life!” my father cried. He leaned forward like a lawyer about to make a case he had been preparing for months. “First you wanted to do physics; you said that medicine was for mediocres. Then you wanted to do law. Law has nothing to do with physics, right?” (He did not wait for a reply.) “Then you applied to medical school. We didn’t tell you to apply. I said, ‘Okay, he wants to be a physicist.’ But you said you wanted to do medicine. I didn’t tell you to do it. But I told you, ‘If you do it, you have to stick with it.’ And I’ll tell you, by God, you did the right thing. If you stayed in physics you would be doing post-doc after post-doc: no money, no job security, struggling at the university, like I struggled. Going to medicine was the best thing that could have happened to you. You had landed in a ditch. Now at least you have some direction.”

  I kept quiet. My father was nothing if not persistent. He always believed that one more warning could avert disaster, and right then I was kind of hoping it was true.

  “You can fix this,” my father went on. “Nothing is lost. It is not falling into water but staying there that drowns a man.”

  “What do you want to do?” my mother asked quietly.

  “I don’t know, maybe journalism.”

  “Journalism?” My father’s face filled up with fury. He had barely tolerated this interest when it was an avocation. “What guarantee do you have that you will get a job in journalism?” he demanded. “Do you think they are going to make you an anchorman or hire you at The New York Times?”