The Good Doctor (14 page)

The ob-gyn rotation was an enormous learning experience for me in other ways. I was on call every fourth night. Sleeping, which took place in a tiny, overheated room while the student was wearing paper scrubs, was technically allowed but not exactly encouraged. Deliveries almost always seemed to happen in the middle of the night, and if you were in the call room, no one was going to come and find you. And the residents liked having students around to do the trivial tasks—known as scut work—for them. Some of my fellow students simply said no to scut. Some had the ability to lie down in bed and fall asleep immediately. I could do neither. One day I wrote that things seemed “somewhat out of control” because I had slept for only forty-five minutes the previous night and was still trying to function more than thirty hours after I had arrived at the hospital. If anything, the house staff worked even harder and longer than I did. All of a sudden, some of their behaviors that had bothered me seemed a little less heinous. “I was angry at my patients,” I admitted. “Yes, it’s happened already. And it was directly proportional to my lack of sleep.”

The constant workload was difficult for me for two other reasons. First, there was very little time to read about the diseases that I was encountering. Given the choice between reading and sleeping, I preferred to go to sleep. Second, an eighty- to hundred-hour workweek was cramping my style. I had prided myself on maintaining a diversity of interests during the first two years of medical school. But now there was very little time to read the
New York Times
, much less jog, go to the gym, eat out, or engage in political activities. What did it mean that, this early in my career, I was fighting what I called a “maniacal devotion to medicine”? Was I guarding against my father’s decision to become so immersed in his career that he neglected other aspects of his life, including his family? Perhaps. But how could I become a patient-centered physician like my father and his generation of doctors without completely focusing on my work?

“Twelve days since I last wrote,” I remarked in mid-August, toward the end of the ob-gyn rotation. “I’m afraid the diary has been a casualty to other activities.” And so it was. There were two more entries, both during the next rotation, pediatrics, which I did at Babies Hospital back at Columbia. In contrast to obstetrics, with its unpredictability and fast turnover of patients, inpatient pediatrics featured a large number of ongoing, devastating cases. Not surprisingly, I was drawn to the family dynamics and the ethical issues raised by such sad stories. For example, the mother of a boy dying of a rare cancer learned every little scrap of information as a way to try to maintain control of a terrible situation. I entirely sympathized with her but bristled a little when she told him to stop eating gumdrops.
What the hell is the difference?
I thought. Even though I was not especially good at interacting with children, I came up with some games during the examination, such as giving the boy the stethoscope to listen to my heart. If I was using this dying boy for my education, I later wrote, “I had to give him
something
in return.”

Once again, I struggled with my role. My resident had made me the official blood drawer for one of the boys. Although I was able to obtain the blood, he cringed and screamed whenever I came into the room, making it difficult for me to develop any type of relationship with him. His mother told me that he was starting kindergarten in the fall, but we both knew he would never finish school. Fortunately, many of the pediatric residents and attendings prided themselves on dealing with such profoundly challenging cases. The pediatricians’ egos, I wrote, were smaller than those of other physicians. I learned a great deal from their ease at interacting with both the sick children and their parents.

One Saturday morning, I decided to visit one of my patients, a boy with cystic fibrosis whose parents had gone to New Jersey for the weekend. We had bonded earlier in the week, I wrote, because he was “manic,” full of energy despite his debilitating illness. He had given me a gift of a painted clay pizza. But on Saturday, he was crying. We just sat and talked. My dad surely would have approved of this intervention: no fancy antibiotics, just words. Suddenly it mattered less that I could not always read the
New York Times
.

My next rotation was internal medicine. This was the big one. I enjoyed all my third-year rotations but had little doubt that I would pursue a career in some aspect of internal medicine, like my father. I was no surgeon, and my pediatrics rotation showed me that I did not have the strength to deal with sick children. Besides, medicine, which involved the care of patients with a huge range of fascinating illnesses, had a puzzle-solving aspect that I loved. As of the mid-1980s, the wards at Columbia still had resident labs, in which students and residents performed their own Gram stains, blood counts, and other tests and then used the results to guide their therapeutic decisions. Having grown up with my father, I believed that this type of hands-on medicine was the only way to be a doctor.

But the rotation at Columbia was not without its drama. On the first day, my very capable intern handed me the scut beeper, the pager used by nurses to reach the doctor assigned to cover a large number of patients in the private Harkness Pavilion. The fact that I was not a doctor mattered little to my intern, who saw this as a tremendous opportunity for me to learn how to draw blood, place intravenous lines, and evaluate patients—and spare himself busywork. If I needed help, I was to page him on his personal beeper. The trouble was that I was in way over my head. I was not especially good at doing procedures and had almost no experience evaluating medical patients with chest pain, headaches, or low blood pressure.

Welcome to medical education circa 1984. In 1978, Stephen Bergman, using the pen name Samuel Shem, had published a book called
The House of God
, an autobiographical account of the experiences of a group of physicians doing their residencies in internal medicine at Boston’s Beth Israel Hospital—the site of my father’s training. My classmates and I had all read it. The book was often cynical, portraying residency as a sort of game that pitted the overworked, dedicated, and nearly all male residents against almost everyone else in the hospital: nurses, administrators, boneheaded senior physicians, and, most notably, patients. Among the terms that
The House of God
popularized was
GOMER
, which stood for “Get Out of My Emergency Room” and described a stereotypical elderly, demented nursing-home patient who supposedly had no business being admitted to an acute-care hospital. There were also a series of laws, which included “Gomers don’t die” and “The only good admission is a dead admission.”

I wish I remembered what I thought of the book when I first read it, probably as a first- or second-year medical student. Bergman, who became a psychiatrist, intended for his book to teach empathy by criticizing the dehumanizing process of training. I understand this now, but that is absolutely not how most of the Columbia house staff viewed
The House of God
. To them, it was more of a how-to manual for getting through residency. Patients, whether gomers or not, were the antagonists, making seemingly endless demands, not following orders, or deteriorating just as we were trying to go to sleep or go home. Our heroes were colleagues who could turf patients to other services. House officers praised as “walls” their fellow residents who sent potential admissions home from the emergency room. The degree to which life imitated art at Columbia was best demonstrated by the fact that one of our residents explicitly imitated the book’s Fat Man, a legendary doctor who dispensed wisdom and sarcasm in equal doses.

It may sound as if I disdained this sort of behavior, but I did not. Medical students generally worship their residents and I was no exception. They were smart, efficient, funny, and—most important—supremely confident. We all wanted to be just like them. And the residents on several rotations worked over a hundred hours a week. Many of their on-call shifts lasted up to thirty-six hours with no opportunity for them to sleep. In such circumstances, who could begrudge them a little name-calling or self-congratulation when they managed to dump a patient onto another service or hospital?

Still, when I wasn’t laughing, I was quite upset by some of these antics. I had been part of a small group of medical students who had gathered during our first year to read an excerpt from the book
Getting Rid of Patients
by Terry Mizrahi, a sociologist who had observed the behavior of overworked house officers and was utterly appalled. At what point did these methods for blowing off steam truly lead to disrespect for—and even inferior care of—sick patients?

The dynamic was much the same during my second five-week internal medicine stint at St. Luke’s, a Columbia affiliate located fifty blocks south, with a few additional ethical issues thrown in. My very capable but busy intern offered me the opportunity to forge his name on orders that I wrote for the patients I was following. It reflected his confidence in my abilities, and, unfortunately, I agreed. In retrospect, I was lucky not to have made some type of egregious error. In another case, I was the only member of the team who argued that an alcoholic patient be given a pass to take care of some business and then return to the hospital. My colleagues all believed that it was a ploy for him to go and drink. My opinion, which did not carry the day, possibly reflected my great naivete. But I was also trying to put into practice some of what I had learned about the limits of paternalism. Was it really so terrible for a perennially sick patient to get a little break from the hospital, or were the doctors merely asserting their power? One of the highlights of my St. Luke’s experience was caring for patients in Scrymser, the last open ward in New York City, a huge hall in which patients’ beds, separated by curtains, were arranged in a semicircle around the nurses’ station. It was like walking into medicine’s past, which I of course loved.

I enjoyed the rest of the third-year rotations and my fourth-year electives. Direct patient care was enormously rewarding and made me want to read all about the diseases I encountered. One rotation that I unexpectedly enjoyed was surgery. I knew I was too clumsy to become a surgeon and did not have the traditional gung-ho mentality. But for someone interested in the history of medicine, the specialty was fertile. Surgeons had particular reverence for brethren who had taught them particular techniques or invented specific operations. So when I held clamps in the operating room, I was quizzed on legendary nineteenth-century surgeons such as Theodor Billroth, who pioneered partial stomach removal for ulcers, and Charles McBurney, who pinpointed the best place to make an incision when an inflamed appendix needed to be removed. I scrubbed in with the well-spoken patrician surgeon Philip Wiedel, who performed a similar type of meticulous mastectomy—in which every individual blood vessel was tied off—that the famous William Halsted himself had advocated. The operation took many hours but was a chapter in the history of medicine that would disappear within a decade as Wiedel’s generation of surgeons retired.

I also greatly appreciated my rotation on neurology, in part because the long length of stays for patients with strokes allowed time for more meaningful interactions. In addition, the neurologists seemed to be the last physicians who viewed the proliferation of CT scans and other sophisticated diagnostic imaging as threatening to the intellectual nature of medicine. Several of the neurology attendings even forbade the students to give the results of head CT scans until after the team, revisiting the brain’s anatomy and function, attempted to determine where the patient’s lesion was likely to be. This was my father’s medicine, pure and simple. The patient, as opposed to the disease, was front and center. But within a few years, as more and more X-rays and scans were routinely obtained in the emergency room prior to admission, most senior physicians—in neurology and other fields—simply allowed the answer to the case to be revealed. The traditional exercise of diagnosing challenging diseases, which required prolonged contact with patients and had fostered the careers of many great physicians, was becoming a dying art.

By this time, I had decided that I wanted to stay in New York City for my internal medicine residency—preferably at Columbia, where I had grown quite comfortable. During my fourth year, I was able to return to several of my outside interests, including helping to write the annual comedy show and serving as the musical director for the Bard Hall Players’ production of
Pippin
. What my classmates and I were really waiting for, however, was Match Day, the day on which fourth-year medical students learn where they will be doing their residencies. Students list their preferred choices, and residency programs create lists of their preferred students. A computer does the rest. I had listed Columbia first, but it was far from clear that I would match there, in part due to my lackluster performance during the first two years of medical school. But my third- and fourth-year rotations had gone very well, and I had bonded with several attendings in the Department of Medicine. When I opened my envelope on Match Day, I received good news. Plus, many close medical school classmates would become my fellow interns and residents.

Although my dad had not dropped me off at medical school, he was surely not going to miss my graduation in May 1986, twenty-eight years after his own medical school graduation. In addition to him, my mother, my sister, and both grandmothers—Pearl and Jessie—attended. My father noted the absence of Mannie and Meyer with great regret. Regarding the two of us, he wrote in his journals that he was “drawing ever closer to me as a friend and colleague, not just as a son.”

At this time, my father was abuzz not only with my graduation from medical school but with news of his recent humanitarian trip with his brother, Allan, to the Soviet Union, where they had met with a large number of “courageous and resolute” Jewish refuseniks, individuals prohibited from emigrating out of the country. The two brothers had brought with them forbidden reading materials, gifts, and emotional support for the cause. They had also helped a few refuseniks get permission to come to the United States for medical treatment. Like his year of sitting shivah for my grandfather, this was another one of my father’s episodic, but highly intense, interactions with his faith. Throughout these years, my father had also remained engrossed with the Holocaust, reading Elie Wiesel and collecting stories from relatives, colleagues, and patients. Coincidentally, during an airport layover on their trip home, Phil and Allan had met and chatted with the famed Nazi hunter Simon Wiesenthal, who had devoted his life to avenging the deaths of his fellow Jews. My dad characterized helping the refuseniks as a way for him and his brother—who had avoided the Holocaust—to repay their “Jewish debt.”