To prepare for my talk, I had gone through the “administrative files” on ten patients who had been dismissed from the clinic over the past five years. The reasons for expulsion were noncompliance with medical advice, threats, verbal abuse, and physical violence. One patient had punched another in the waiting room. Another patient had forged her doctor’s signature to get painkillers.
After my presentation, the fifteen or so residents and attending physicians in the room weighed in with some of their own tales of difficult patients. A resident told of an obsessed patient who showed up at his clinic every week and even once followed him home. An attending physician said that he had once been conned into prescribing long-acting morphine to a patient with lower back pain. The patient claimed to have had an extensive workup by another doctor, but when the attending checked, he discovered that the other doctor did not exist. “Always do your own workup,” he warned the group. “Set strict rules, and stick to them.” Another physician said that his patients were “hypomanic” and rarely on point. He didn’t agree with the conventional wisdom of letting people talk out what was on their minds. Another attending compared difficult patients to Bloomingdale’s shoppers. “Give me a thousand Kmart shoppers for every Bloomingdale’s shopper,” he said to murmurs of agreement. “Kmart shoppers have their insurance, they don’t pay cash, they’re not going on the Internet, they don’t ask a lot of questions, they don’t have a bunch of doctor friends second-guessing your decisions.”
The atmosphere had the charge of catharsis, as one anecdote led to another. The stories were fascinating in a baroque sort of way, and I felt pleased that my presentation had engendered such a robust discussion. (Evidently, sometimes doctors need to vent, too.) But then a dissenting voice was heard. It was Sheila Jones, a young attending with a slight frame and a wispy voice. A few months back, I had helped care for one of her patients in the hospital, a young woman who had been troubled for years with abdominal pain and a psychologically abusive boyfriend. The patient had been in and out of various hospitals, undergoing X-rays, ultrasounds, CAT scans, and so forth, all of which revealed nothing.
She was angry and afraid, and frequently came to the emergency room demanding hospitalization and painkillers. Doctors who cared for her had grown weary of her constant complaints and started giving her morphine. Then she became addicted, and no one cared about her enough to ensure that she got the psychiatric help she sorely needed, including, in retrospect, me. It was easier to abdicate responsibility than to deal with her.
She was the quintessentially difficult patient. After a while, hers was a room we avoided. Her needs were bottomless, her pain unremitting. In the constant buzz that is ward life, time seemed better spent on other patients. Nothing seemed to be physically wrong with her, at least not anything to explain the severity of her pain. Yet she relentlessly demanded morphine. Try as best we could, it was hard setting limits. A tough approach alienated her. A conciliatory approach simply got her more drugs.
But Dr. Jones knew how to handle her. Though she had been her doctor for only a few months, she had developed an effective style with this patient. She was not afraid to be strict: if the patient yelled, sometimes she yelled back, or she was kind, as the moment required. Though somewhat unconventional, she grasped her patient’s psychology like no one else, and she truly cared for her. She eventually managed to discharge her without morphine.
Jones told the now-silent group that she had several difficult patients in her practice. “Like any doctor, I do not seek them out. But they are not that hard to treat, once you figure out what is bothering them.”
Patients don’t always come right out and say what is wrong, she said. Sometimes they hedge or obfuscate. Often the key to treating them is to look a little deeper.
“Most doctors are reluctant to take on difficult patients,” she acknowledged. When these patients are ready to leave the hospital, “business cards get tucked away and doctors duck into the shadows.” Consciously or not, doctors create hoops for these patients to jump through, marginalizing them even more. “And then we say these patients were ‘lost to follow-up,’ ” she said.
There wasn’t much more discussion after Jones spoke. Soon people filed out of the room. That night, I thought about how different the real doctor-patient relationship is compared with the idealized one that had been presented in medical school. Then the emphasis had been on the heartwarming stories, the enduring intimacy. But in reality the relationship is neither simple nor neat. Every human enterprise has its share of conflict and reconciliation—and medicine is no different. I don’t know what surprised me more: that there was such a divide or that it had taken me so long to see it.
Even now, years later, it remains a mystery to me exactly why one doctor can relate to a difficult patient, and another can alienate her. Another reminder, perhaps, that medicine is a field of specialties. Some doctors are better at treating certain diseases; some at treating certain patients.
CHAPTER SIXTEEN
pride and prejudice
If you are hidebound with prejudice, if your temper is sentimental, you can go through the wards of a hospital and be as ignorant of man at the end as you were at the beginning.
—W. SOMERSET MAUGHAM, THE SUMMING UP, 1938
If internship was about being a secretary, second year on the wards was about being a manager: ignoring the small details, seeing the forest for the trees. During internship, thoughtful reflection had been all but impossible, but being able to delegate changed all that. Now I was the one in charge of my students and interns. At one time I couldn’t have fathomed delegating duties, but on the wards I discovered that I loved having interns around, and it was as easy for me to dump on them as it probably had been for my residents to dump on me. No longer was I the team’s shock absorber—the one who got pimped first, blamed first, thanked last. I had always found it fundamentally unfair that the people who got interrogated on rounds were usually the least equipped to answer questions. That disparity continued, of course, but it was no longer working against me.
At the same time, individual patients started to fade from view. No longer was I the first doctor paged in a crisis. Part of me missed being more involved in the life of the ward, but I also appreciated having some distance, operating remotely from the workroom, staring at a computer screen, reading through charts one by one, scribbling a short “chart-round” note, a tiny drizzle of ink to show that I had been there. I got very efficient at finding lab results or medical records, minimizing computer time because I knew exactly where everything was. The clerks would still dress me down for hogging the charts or for getting in their way, but for the most part they were much nicer to me, and I was no longer afraid of them. At lunchtime someone would call out, “Anybody want Mexican?” and I would respond, “Count me in!” like I belonged. Fellowship descended on the ranks. As junior residents, we could afford to be congenial because we were no longer carrying the burden of the hospital on our shoulders. Even sign-out wasn’t a frenzied rush to get out of the hospital. In fact, most of the time, we didn’t even attend because our interns took care of it for us.
Not long ago, I had dinner with one of my classmates from residency. He was now a chief resident at a major teaching hospital in the Northeast. Over the meal, we chatted about the transition from internship to second year. “In internship, it’s like, ‘This doesn’t make sense,’ ” he said. “When you think about it, as interns we were making, like, a hundred and fifty decisions a day, and as second-years we were, too, but the difference was that you knew why. As an intern, you didn’t know why, which is why it was so hard. You had to collect the data, process it, massage it, fit it into an existing plan. It was psychologically exhausting.
“Another difference was that second year there was more responsibility. If they criticized you, you took it more personally. You had more invested because you had gone through internship. You were more a part of the community; you worried about what people would say. You wondered, What
will happen if people discover that I’m not as smart, efficient, or competent as they think?”
I nodded. In my case, the constant comparison had been with my brother.
“One time in internship I put a central line into an old woman who was on a ventilator. She needed it for something; I forget what. She had TB or something. It was me and a second-year. We tried a subclavian approach but we couldn’t get it. I tried the internal jugular ten times, and then the resident tried, and he couldn’t get it, so we just kept trying. He finally got it, and we put the line in. I don’t know if at some point he got air back in the syringe, but you can guess what happened. We checked a chest X-ray and we had dropped her lung. It was a big pneumothorax, so the woman ended up needing a chest tube. When the attending came back, he was pissed. He said, ‘I leave and now look! What the fuck! She’s really fucking sick now. I can’t believe that you did this. What were you thinking?’ It stayed with me for a long time—not so much what we had done, as my poor resident. As a second-year, if I had been dressed down like that, I would have been devastated.
“Another time, second year, I took care of this woman whose potassium was low. We were repleting her potassium every day, several times a day even. When I left one evening, I signed out to check her potassium level. For whatever reason—maybe I didn’t impress it hard enough, I don’t know—it didn’t get done, and in the middle of the night, she had a cardiac arrest because of high potassium. Her potassium was off the scale, and then it came to light that she had been getting saline with eighty milliequivalents of potassium chloride at one hundred and twenty-five cc’s an hour. I didn’t know it. I should have known it, but IV fluids weren’t written on the nursing medication sheets, and I had been too lazy to check the computer. I marched straight to Dr. Wood’s office and told him what happened. I said, ‘Dr. Wood, I just killed a patient. I killed her, or at least I didn’t prevent her from being killed.’ ”
“How did he respond?” I asked.
“Of course, he broke it down. He told me it was because of the bad kidney function. He said her kidneys couldn’t excrete potassium properly. He said, ‘If I give you potassium-enriched fluids, will your body be able to handle it? Of course it will,’ and so on and so forth. He broke it down medically, but really what I wanted to talk about wasn’t medical. I had nightmares about that death. As an intern I never felt like that, but as a second-year, you just felt more responsibility.
“So I started this conference for residents to talk about their mistakes, away from Dr. Wood, away from the attendings. Even the chief residents weren’t allowed to sit in. I wanted it to be just house-staff run. Everyone makes mistakes; even if we don’t think we’ve made them, we’ve made them. People would come to the conference and talk about their mistakes in a nonconfrontational way. I saw residents cry at that conference. I talked about the lady with the low potassium. It felt good to get it off my chest. I felt like, if I don’t make this public—not out in public, of course, but just to my colleagues—if I don’t talk about it, then it would become one of those things that never really happened. It would cease to exist.”
AFTER SPENDING JULY in the outpatient clinic, I rotated to 4-North, the cardiac telemetry ward. Ward 4-North at New York Hospital was famous for its high-volume, assembly-line medicine. Each morning, patients would be shipped off for echocardiograms, nuclear stress tests, and cardiac catheterizations by an efficient, well-trained, and highly vocal cadre of nurses whose job it was to ensure everything ran smoothly. As a house officer, if you forgot to do something—fax a requisition, for instance, or write a “nothing-by-mouth-after-midnight” order—your oversight could disrupt the whole enterprise and bring the wrath of the charge nurse down on your head.
The patients on 4-North were mostly archetypes: middle-aged businessman who developed crushing chest pain sitting at his mid-town desk; elderly woman who forgot to take her medications and went into congestive heart failure; diabetic with diffuse vascular disease who needed bypass surgery. One morning, I had to present three cases of unstable angina from the night before but couldn’t remember which was which. The only differences were the patients’ ages and the small details, the social history, which we so often ignored. The same clinical narrative could apply just as well to my eighty-five-year-old widowed patient with Alzheimer’s as to the fifty-five-year-old dentist with a family. Stuck, my mind a blank, I fumbled until Mira, the intern assigned to work with me, whispered something into my ear. “The father of two disabled children?” I said out loud. “Oh yes, now I remember.”
Mira was a fast-talking, wisecracking Jewish girl from Long Island with a pretty freckled face who barreled through the unit as if she was on twenty cups of coffee. She showed up at 6:00 a.m. to preround, finished her notes before I even arrived on the ward, inserted central lines, drew blood, and generally did whatever was necessary to get the job done. She had a wonderful mix of directness, chutzpah, and easygoing charm. With Mira around, I never worried about the “July phenomenon,” where patients supposedly did worse at the beginning of each academic year because inexperienced interns were caring for them. She seemed to have mastered her patients much better than I ever had.
Rounds started at eight o’clock, when we sat down with David Klein, the attending physician, to discuss admissions from the night before. Klein was a short, graying man with a supercilious air and a perpetually exasperated expression that conveyed haughtiness. He spoke with a sneer, and he seemed to relish cutting into patients and house staff alike. One morning Mira presented a case. “The patient came to the emergency room in the middle of the night—” she began.
Klein groaned loudly. He often said that coming to the hospital in the middle of the night was a sign of irresponsibility.
“—after doing cocaine—” Mira continued. Klein groaned again.
“He was in his usual state of health until three a.m.—”
“Yeah, yeah, I get the point,” Klein snapped. “Is he a scumbag?”
Mira stopped, looking flustered. Klein threw up his hands, as if he had asked the most natural question in the world. “Is he a scumbag or a solid citizen?” he demanded. Mira seemed to draw a blank. I had never seen her hesitate before.
“I’m not sure,” she finally replied.
“Well, he snorts cocaine! Where does he live?”
“Manhattan.”
“Where in Manhattan?”
“I’m not sure.”
“Well, you can bet he’s not from the Upper East Side.” Some residents laughed at this remark.
“You mean people on the Upper East Side don’t use cocaine?” I interjected. I despised Dr. Klein, and he didn’t like me much either. He had once warned our team to watch what they said lest I quote them in a newspaper column.
“No, not most of them,” Klein replied dismissively. There was an awkward pause as he uncrossed and recrossed his legs. Then he let Mira finish.
Rounds with Klein were exercises in division—making distinctions, pointing out the differences between people, the haves and the have-nots, and in fact he was quite open about it, as if his openness somehow absolved him of his prejudices. If patients on 4-North were archetypes, then Klein, too, was an archetype: overbearing, arrogant cardiologist.
Most days on the telemetry ward, we had to obtain informed consent from patients going for cardiac procedures. We were supposed to tell them the risks and benefits and answer their questions, but the process didn’t always go smoothly. Sometimes we were forced to apply “gentle coercion” for the good of the patient.
José Villegas was a middle-aged man with kidney failure who had suffered a small heart-attack. One morning, he was scheduled to go for a coronary angiogram, but apparently no one had discussed it with him. When he was told that the dye used in the angiogram could damage his already weakened kidneys, he balked. He said he didn’t want the procedure; he was unwilling to accept even the slightest risk of dialysis. That much was clear, even in his broken English, but Klein and the fellow had a
lready decided that the benefits of the procedure outweighed the risks. “You could have a severe blockage in your heart,” the fellow warned.
Villegas said he would take his chances.
“You could have another heart attack,” the fellow intoned gravely. Villegas’s resolve appeared to crack. “You could drop dead!” Klein shouted. Few patients can resist that kind of pressure, and Villegas wasn’t one of them. “I guess I have no choice,” he said resignedly, signing the consent form. We filed out of the room. In the hallway, barely out of earshot, Klein chuckled. “We can make them do whatever we want,” he said. “As long as they agree with us, they’re not crazy.”
Though I detested such strong-arm tactics, I was aware that my own conduct as a physician was hardly blameless. I thought back to Jonah and his testicular mass. When he had asked me if it was cancer, I had lied and said that I did not know. I too was learning that deliberate half-truths are a part of the doctor’s armamentarium.
Chest pain was the most common reason for admission to 4-North. Some of it was benign, like the hysterical Mexican women who screamed “Ay, ay, ay.” (Residents termed this “status hispanicus.”) But most of it was serious, and sometimes quite mysterious, too. One night I admitted a burly Russian man with a thick accent who was lying in bed, clutching his chest, looking very uncomfortable. He told me he had been experiencing chest pain at home that frequently got worse when he exerted himself and sometimes was relieved by nitroglycerin tablets under the tongue. Although his EKG and blood tests were normal, with no signs of heart damage, his story was too good, too characteristic of angina, to dismiss. I told him he was going to need a coronary angiogram. “Have you had one before?” I asked.
Intern Page 22
