Intern (41 page)

Back in my neighborhood, green scrubs and stethoscope necklaces started to appear. I had walked these streets before starting internship, and now, with the promise of a new life at a new institution, it was as if I was seeing them again for the first time. Outside the hospital, interns were walking with their usual bustle, coupled with that slightly
vacant stare you noticed if you got too close. Not so long ago, I had been one of them, and though internship had been the toughest year of my life, I was glad that I had gone through it. There was so much in store for these interns, and those who would follow them, such a wealth of experience. For a moment I actually envied them. Like me, they had probably been reading Harrison's textbook of internal medicine. I wanted to tell them that it wasn't necessary. The real learning was going to happen someplace else.

x “No one could ever say what exactly . . .” A third of the patients who spend more than five days in the intensive care unit will experience some form of psychotic reaction. Even if they have never had any psychiatric problems before, these patients may experience anxiety, become paranoid, or hear voices and see things. Sometimes they become severely disoriented to time and place. They may get out of bed and grapple with nurses. Occasionally they become very agitated, even violent.

In recent years, progress has been made to reduce the stressors of the ICU. Many units now have visiting hours. Shifts are adjusted to minimize changes in the nursing staff caring for a patient. Lighting is adjusted to synchronize with day-night cycles. When patients leave the ICU, the problem almost always vanishes. Even in the ICU, the psychosis often resolves spontaneously, with the coming of morning or sleep.

39 “Hypothyroid coma has . . .” In 1888, the Clinical Society of London published the first major report on the disorder, calling it
myxedema
and likening it to childhood cretinism. In its most severe form patients can experience a reduced level of consciousness and even florid psychosis with paranoia and hallucinations. Dr. Richard Asher, a British internist and essayist, coined the term
myxedema madness
.

117 “When I looked in the medical literature . . .” In 1998, the American Psychiatric Association commissioned a panel to examine hospital violence. According to a psychiatrist who was a member, the group examined many factors that contributed to the problem, including nursing shortages, HMO frustration, long waiting times in emergency rooms, bad medical outcomes, poor staff training, and tolerance for violent behavior. Most cases of violence are preventable, the
psychiatrist told me, if health care providers learn to recognize the signs and avoid inadvertently provoking patients. Most of his suggestions were common sense: Position yourself between the patient and the door. Practice responding to various situations. But one was more controversial. “We thought that institutions should give physicians permission to defend themselves,” he said. “If a guy's going to hurt you, you've got to hurt him first.”

121 “If internship was . . .” In his book
Time to Heal: American Medical Education from the Turn of the Century to the Era of Managed Care
(Oxford University Press, 1999), Dr. Kenneth M. Ludmerer, an internist and a medical historian, bemoans the deterioration of the learning environment in teaching hospitals. He writes: “Most pernicious of all from the standpoint of education, house officers to a considerable extent were reduced to work-up machines and disposition-arrangers: admitting patients and planning their discharge, one after another, with much less time than before to examine them, confer with attending physicians, teach medical students, attend conferences, read the literature, and reflect and wonder.”

Resident and attending physicians today are running on a treadmill that is moving faster and faster. Attendings are doing briefer consultations. Residents are caring for more and sicker patients, and dealing with quicker patient turnover. This is driven partly by medical advances—only very sick AIDS patients now require hospitalization, for example—but also by the financial bottom line.

It's not just the burgeoning workload, faster patient turnover—the average inpatient length-of-stay has dropped by 50 percent over the past few decades—and a shortage of educational time. There are the protocols. Today, on the wards, there are set standards of treatments for everything: pneumonia, asthma, heart attacks. They serve a useful purpose, employing available data to ensure that all patients receive a basic level of care. But that's not necessarily why they were designed: they cut costs. And they teach residents to follow recipes.

We immediately called a consultation for the man who periodically stopped breathing at night, not just because we didn't know what to do, but because it was the easy way out, passing the problem on to someone who might have more time to deal with it.

180 “. . . must have been going through.” Doctors are more likely than members of the general public to commit suicide. Female doctors are just as likely as male, even though laywomen are four times less likely than laymen. Only 22 percent of depressed medical students seek help. Only 42 percent of those who are considering suicide seek treatment.

223 “Hospitalized patients have . . .” Some doctors argue that obtaining informed consent from patients is a meaningless exercise promoted by ethicists who don't understand the realities of medicine. There are data to support this view. Most studies show that patients recall less than half of what doctors tell them. In one study on informed consent before cataract surgery, for example, only 4 percent of patients recalled more than two out of five risks disclosed to them by their doctors. Only a third remembered later that blindness was a potential risk.

255 “I felt conflicted about this . . .” Swallowing dysfunction is one of the most common problems in the ICU, and it is becoming more prevalent as life spans increase. In 1999, an editorial in
The New England Journal of Medicine
criticized as futile and harmful the routine placement of feeding tubes into patients with advanced dementia who stop eating. “Although the use of feeding tubes is not unequivocally futile in all cases,” wrote Dr. Muriel Gillick of the Hebrew Rehabilitation Center in Boston, “balancing the risks and benefits leads to the conclusion that they are seldom warranted for patients in the final stage of dementia.”

Feeding tubes, she went on, do not prolong life or prevent aspiration, and they inflict considerable pain and suffering by depriving patients of the pleasure of eating and socializing at mealtimes. “Feeding by hand is an act of nurturing that cannot be accomplished by hanging a bag of nutrients on a pole for delivery through a tube,” she concluded.

263 “ ‘Do you think he'd . . .' ” Up to 20 percent of patients in a teaching hospital have DNR orders written. A third of patients who had been resuscitated and left the hospital stated unequivocally that they wished they had not been resuscitated and would not consent to resuscitation in the future.

272 “Our apathy seemed . . .” In fact, the decline may already have begun. For example, in a 1992 study at Duke University Medical Center, one of the country's best teaching hospitals, 63 residents in internal medicine were asked to listen to three common heart murmurs programmed into a mannequin. The results were troubling to medical educators. Roughly half of the residents couldn't identify two of the murmurs, despite being tested in a quiet room and having all the time they needed—hardly conditions encountered in real practice—and approximately two-thirds missed the third. Performance had not improved later in the year, when the residents were retested.

In a later study at thirty-one internal medicine and family practice residency programs on the East Coast, 453 residents and 88 medical students were tested on twelve different heart sounds taped directly from patients. On average the residents got only 20 percent of the sounds right, not much better than the medical students.

275 “With decreasing reimbursement and . . .” Primary care, particularly preventive medicine, is looking more and more untenable in the era of fifteen-minute office visits. A study published recently in the
American Journal of Public Health
estimated that it would take over four hours a day for a general internist to provide the preventive care currently recommended for an average-size panel of adult patients. “The amount of time required is overwhelming,” the authors wrote.

In a recent study of family practices in Michigan, only 3 percent of female and 5 percent of male patients over fifty had fully completed age-appropriate cancer screening tests. Nationwide, less than a third of older adults have had their stool tested within the past two years for occult blood, one of the first signs of colon cancer. Only 33 percent have ever had a flexible sigmoidoscopy, even though recent research suggests that performing this test more frequently could detect more intestinal cancers.

276 “. . . roughly a third of my class was . . .” In 2003, 12 percent fewer medical school graduates decided to specialize in internal medicine than in 1998, the year I started internship. That year, fewer seniors chose internal medicine residencies than at any other time in the previous decade. Though I couldn't have known it at the time, our year marked the beginning of a demographic shift.

One of the reasons, of course, is money. The average medical school debt is now $104,000, and internal medicine subspecialties, especially procedure-based ones like cardiology, are more lucrative than primary care. But a more important reason, I think, is that medical students increasingly view primary care physicians as harried and overworked.

T
here are many people I wish to thank for their help and support during the writing of this book.

First and foremost, I am deeply indebted to the patients I had the privilege to care for—and learn from—during internship and residency. Knowing you, if only briefly, has made all the difference.

My agent, Todd Shuster, knew I should write a book well before I did. I am grateful for his perseverance and faith.

I owe a tremendous debt of gratitude to my brilliant editor, Paul Elie, who had a clear vision for this book. I will never forget what he told me after the first round of editing. “That's a lot to do,” he wrote, “but it's what's needed if the book is to be what it is meant to be.” I also want to thank Paul's assistant, Cara Spitalewitz, for attending to so many important details during the course of this enterprise. And I am very grateful to Jonathan Galassi and John Glusman for giving me the opportunity to write the book in the first place.

Writing became a big part of my life during residency. For their contributions to my peculiar career path, I owe a special thanks to the writers and editors of the science section of
The New York Times
: Larry Altman, Laura Chang, David Corcoran, Erica Goode, Denise Grady, Gina Kolata, Barbara Strauch, and the late John Wilson. I am especially grateful to Cory Dean for encouraging me to write about residency and for reading an early draft of the manuscript.

My classmates at New York Hospital lived through the experience of internship and residency with me. I wish to recognize them for their
hard work and dedication during that exciting and trying period in our lives. I am especially thankful to Sameer Rohatgi and Sung Lee for their friendship. I also want to thank my present colleagues at Long Island Jewish Medical Center, especially nurse practitioner John Meister, my assistants, Naidra Wilson and Karen Hinds, and my chiefs, Dr. Stacey E. Rosen and Dr. Stanley Katz. I am also grateful for the excellent and extraordinarily industrious cardiology fellows I work with. You make my job easy.

My writing group—Thomas Estler, Bara Swain, and Danielle Ofri—was instrumental in motivating me to complete this book. I am especially indebted to Danielle, an accomplished physician-writer, for her innumerable helpful suggestions during the course of writing and for being such a wonderful role model. Two good friends also stand out for recognition: Ivan Oransky, a physician-editor who read an early draft of the manuscript, and Michael Berry, who proposed titles.

Of course, the narrative has relied on my memory of events that occurred almost a decade ago. If my memory has failed me, the fault is mine and mine alone.

I save my deepest gratitude for my family: my sister, Suneeta, and my mother, for their constant love and support; my brother, Rajiv, for his unflinching determination and for showing me the way; and my father, for all his pushing and prodding throughout my life. He was my first example of an author, and as much as I might not want to admit it, for good or bad, and in so many different ways, I am him. I also want to thank my wife Sonia's family for their advice and support, especially my father-in-law, Madho Sharma, and my sister-in-law, Nina, a writer herself, who lovingly read through the manuscript and made countless helpful suggestions.

Being married to a doctor isn't easy, but being married to an ambivalent doctor can be particularly trying. I am grateful to my wife, Sonia, for being my life partner, for gracing me with a beautiful home, and for sticking by me through the difficult times. The book would not be what it is without her essential advice and support.

Finally, I want to recognize the sunshine of my life, my son, Mohan, who arrived as this project was taking off and provided the necessary pull away from it. He is my angel, a king, the court jester—all in one. I hope one day when he reads this book he'll be proud of his dadda.
Why do I love you so much? Just because!