Intern (39 page)

General internists, my classmates whispered disparagingly, were jacks-of-all-trades, masters of none. There was an appeal to being able to focus on one area of medicine and do it well. I often thought of an experience I had had on the cancer ward. One morning, a nurse paged me during rounds. A patient with leukemia that had transformed into what was called
blast crisis
was in her room screaming. She had been on a morphine drip to control the severe pain in her bones, but her IV had fallen out. Could I come quickly and put in another one?

Her room was on a dingy ward in an old part of the hospital. When I got there, she was writhing, oblivious to my presence. A bag of morphine liquid hung uselessly from a metal pole near her bed. She said her legs felt as if they were going to explode. As a resident, I had
been taught the importance of treating cancer pain aggressively, but until then it had just been a concept.

I told the nurse to give her an intramuscular morphine injection, but she said she already had, twice, with no effect. I grabbed an IV and jabbed it into the woman's arm, but because it was so swollen from cancer and chemotherapy, I couldn't find a vein. I tried repeatedly, in her arms and feet, deep and shallow, this way and that, desperately trying to draw back a red blush, but with no luck. Her shrieks were becoming more piercing as the morphine was running out in her body.

“Call the pain team!” I shouted.

When they arrived, they immediately gave my patient a shot of a very potent narcotic, which calmed her down. Then they put in an IV and started a morphine drip she could adjust for her own comfort. They also started her on a long-acting narcotic that was particularly effective for cancer pain. When I visited my patient a few hours later, she was sitting in a chair, watching television.

The situation was emblematic of ward medicine. So often the key was simply to know whom to call for help. If you couldn't interpret an EKG, you called the cardiology fellow. If he couldn't help you, you called the cardiac electrophysiology fellow. If you didn't know how to administer a cortisol stimulation test, you called the endocrinology fellow. Even for something as commonly encountered as pain, there were specialists who knew what to do. There was always someone, somewhere, who knew more about your problem than you did.

Subspecialty medicine had a kind of glory which I desired for myself, and I wasn't alone. Residents across the country were increasingly forgoing primary care for subspecialty practice, especially lucrative procedure-based ones like cardiology and gastroenterology. In fact, roughly a third of my class was applying for a cardiology fellowship.

“Be sure about what you want,” Dr. Wood said gravely. He didn't seem to think that I was cut out to do a subspecialty. To him, I think, my interest in writing was evidence of my generalist tendencies. I appreciated his frank, forthright manner. He was all too aware of the many detours I had taken so far in my professional life. A cardiology
fellowship was a bit like doing residency all over again. Was this really what I wanted?

I made the decision a few weeks later, when Sonia and I took a vacation to the seaside town of Mystic, Connecticut. I picked the spot randomly out of a
Weekend Getaways
book Sonia had given me after our honeymoon. Mystic is an old whaling and shipbuilding town surrounded by an almost incandescent beauty. That weekend, we went hiking through hills shimmering with the most brilliant colors: oranges and yellows and rust browns and maroon reds. We visited the seaport, where we toured the old sailing boats, tall-masted schooners and sharp-bowed clippers, which were preserved in a sort of museum on the docks. On a wooden deck, an old shipyard hand demonstrated to us the fine art of tying and untying knots.

It was a sorely needed break—our first vacation since our honeymoon, in fact. Internship had been tough on our relationship. During my depression, I had grown impatient, critical of the slightest delay. For a while Sonia and I had stopped talking, except when we were fighting, and even then we weren't talking as much as shouting and maintaining silence. On more than one occasion, I came home to find wet tissues wadded up in a big ball on the coffee table, along with a few half-smoked cigarettes. Sonia had gone to bed, angry and dissatisfied with my apologies.

But, fortunately, we had survived my internship. We were spending more time together, going out to concerts and dinners, talking more. The morning after we arrived, we took a long hike, climbing to the top of a vast clearing where we happened upon a meadow, brilliant with color. We sat down on a large rock, looking out over a valley.

“You're relaxed for the first time in a long time,” Sonia said as we shared a bottle of water. “You're finally smiling.”

I took in a deep breath of cold mountain air. I felt buzzed. Freedom, escape—I had almost forgotten how it felt.

As we sat up on the hill, I told Sonia I had decided to apply for a cardiology fellowship. For the first time in my professional life, I was happy. For as long as I could remember, I had carried a sense of dislocation
—in graduate school, in medical school, in internship. Now, finally, I felt like I was finding my place. Finally, I was using tools that were mine, not borrowed. I had been longing for this moment for four long years. It felt like a release, a rebirth after a long period of internment. The static in my brain was finally clearing. And when Sonia leaned over and said, “You've come a long way. I'm very proud of you,” it felt all the more sweet.

April is the cruellest month, breeding
Lilacs out of the dead land, mixing
Memory and desire, stirring
Dull roots with spring rain.

—
T. S. ELIOT,
THE WASTE LAND
(1922)

 

B
y the time I got to Bellevue Hospital, it was early evening. On the main road, city buses and yellow taxicabs whizzed by as I climbed out of the subway. Tires crackled on the wet street, throwing up a dirty spray. Rainwater splashed out of potholes. I passed by a homeless shelter where, through a grimy window, I spied a line of disheveled men in a dimly lit room being watched over by security guards. The garden in front was overrun with weeds; the only movement was a couple of enormous rats scurrying ravenously through the garbage. This definitely was not the Upper East Side. No manicured lawns here.

The medical center was a vast complex of old brick buildings spanning several city blocks on First Avenue. The hospital itself was a twenty-five-story behemoth garnished with whorls of ivy. I marched down a concrete footpath, past a stone sculpture filled with brackish water, and entered a high-ceilinged atrium. Painted on the tan limestone walls were colorful murals of farmers picking tomatoes, holding rabbits, herding cattle—the agrarian life. The images seemed strangely
out of place in such a hissing urban setting. At the security desk, an officer asked to see my ID. As I fumbled through my cotton scrubs for it, nervously trying to explain why I had come, he good-naturedly waved me in.

I marched down a long tiled hallway stained with footprints from the recent spring rains and got into an elevator going to the CCU. I had been here once before, last month, on a tour of the hospital on my fellowship interview day. That day, a dapper cardiologist with English-butler features had asked me if I was still interested in doing basic research. Since I had been told that Bellevue was looking for research-oriented fellows, I said yes. I said I was fascinated by the electrical properties of cellular ion channels, and I drew similarities between these structures and the quantum dots I had studied in graduate school. Of course, it was a ploy—I had no inclination to return to the research bench—but it was a competitive year, too. My Ph.D. had always been my trump card, and so I decided to play it again for all it was worth.

The cardiology “match list” was due in a week, and I still hadn't decided how I was going to rank the hospitals I had applied to, which is why I had come to Bellevue that evening to take a second look. In the match, applicants and fellowship programs submitted a rank-ordered list of names to the National Residency Matching Program (NRMP) in Washington, D.C., which paired them up by computer. The process was the same for residency, but now the stakes seemed higher because of the increased competition. For weeks my classmates had been discussing the optimal strategy for constructing a match list. Should you take into consideration where programs were going to rank you? Where should you put your “safety hospitals”? The official instruction from the NRMP was to rank programs based on personal preference alone, but lack of a clear understanding of the match process generated considerable anxiety and the sort of paranoia one might expect when neurotic, high achievers compete for a limited number of jobs. My classmates had been having hushed conversations in the corridors
about where people were interviewing, who had received an unofficial offer, who was likely going to match at New York Hospital, and so on. I tried my best to avoid the gossip, but as the deadline for the match drew near, I was starting to get nervous, too.

My family had mostly rallied behind my decision to apply for a fellowship. In fact, Sonia had pushed me whenever my confidence wavered. Now that we were married, she wanted to know that I was on the right track. The ambivalence that had once seemed charming to her was now worrisome. On the phone, whenever I had second thoughts, my mother would say: “Nothing is too difficult for you. Are you saying that everyone can do this, and my son cannot?” My father, though proud, had warned me about the tremendous effort a fellowship was going to require. “I hardly need to repeat that there is no substitute for hard work,” he intoned. “It is work that sustains us.” Rajiv, on the other hand, had seemed underwhelmed, even a bit apprehensive. “You've got to get your act together if you want to do cardiology,” he had lectured. “It's time to stop being immature and focus. You can't live with your head in the clouds your whole life.”

In early March I had received a letter from the chairman of the Department of Medicine at Bellevue. He said that his department was looking to expand its research efforts in cardiology and that he was looking forward to meeting me if I joined the program at his hospital. “He's offering you a spot,” Rajiv declared knowingly when I showed him the letter, but I responded with my usual uncertainty. Though I wanted to stay in Manhattan for further training, I wasn't sure if I was ready to leave New York Hospital.

At the twelfth floor in Bellevue, the elevator doors opened and a teenage girl got on. Tall and pretty, she was whimpering softly, her long, dark eyelashes fluttering over impossibly large, bloodshot eyes and tearstained cheeks. When I asked her what was wrong, she broke down sobbing.
“Mi madre está muerta!”
she cried, as though I (in my green scrubs) were somehow responsible. I remained quiet, unsure how to respond. By the time the doors opened on the sixteenth floor,
she was wailing. She got out of the elevator, turned left, then spun around to stare at me helplessly. Not knowing what to do, I reluctantly stuck out my hand as the doors were closing and stepped out.

The sixteenth floor was quiet, seemingly deserted, except for an elderly man with an IV pole talking on a pay phone. He eyed us suspiciously. The corridor smelled of cigarette smoke and antiseptic. I asked the girl where she was trying to go. “ICU!” she bawled. Apparently she had just learned that her mother had died. I put my hand on her shoulder and told her I would take her there. As we were leaving the elevator bank, a middle-aged man walked up. The girl broke free and ran to him, burying her head in his arms. Another man, about my age, also arrived. His arms were folded across his chest and his face was drawn; he regarded me skeptically. I shifted my weight uncomfortably as they embraced, trying to think of something to say. Nothing came to mind, and by now I had become inured to scenes of grief in the hospital. When the elevator doors opened again, I whispered, “I'm sorry,” and jumped in. The older man raised his hand in gratitude. The family was still weeping in the hallway when the doors clanged shut. ICUs, it seemed, were the same everywhere.

In the elevator, I thought of what an intern had told me about Bellevue. The culture, the patient population, everything was very different than at New York Hospital. “The patients are indigent,” she had said. “Residents perform most of the procedures. You know how it is: high autonomy, low liability.”

The CCU fellow, an Indian woman with a toothy smile, was still writing her daily progress notes at 7:00 p.m. when I arrived—not a propitious sign for a prospective fellow. She flashed a quizzical look when I told her why I had come, but gave me permission to walk around. It was a twelve-bed unit with small sinks and a faintly third-world feel. Office chairs and old respiratory equipment were stacked untidily in a corner. The patients, mostly brown-skinned, were lying in sectioned-off spaces along a main wall. A fair number were intubated, and I was greeted with the familiar ringing of ventilator alarms. The view through the window was of a vast housing project and the slums of Alphabet
City. The flowing waters of the East River had always provided succor on call nights at New York Hospital, and I felt vaguely sad that the view would not be transported with me if I came here.

From the CCU I started wandering around the hospital. I went up two flights to the prison ward. A guard was seated in front of an iron gate under a dingy sign that read
PRISON HEALTH SERVICES, MEDICAL/SURGICAL UNIT
. A group of cops was coming off patrol, stashing their revolvers in a padlocked metal box. Here, several years later, I was going to meet Robert Castillo, a small-time drug dealer, HIV-positive, hospitalized with another bout of endocarditis. The first, from shooting heroin, had destroyed one of his heart valves, requiring open-heart surgery to replace it with a pig valve. Now this pig valve was itself infected.

He was lying in the corner of a four-bedded room, not far from the toilet. The window was slightly open, though it was freezing outside; dried blood and grime stained the sill. The room, as usual, smelled like a pile of dirty socks. Castillo had been living with relatives in Staten Island before his intravenous drug habit landed him in jail. He was a frail man in his fifties with white hair and piercing narrow-set eyes, one of which had stopped moving normally. Doctors thought he had had a stroke but they didn't know why. An echocardiogram, an ultrasound of the heart, provided the answer. Sitting on top of one of his heart valves was an infected mass of tissue—a
vegetation
—that was flapping around wildly, like a flag in the breeze. A portion of it had probably broken off and gone to his brain.