The Real Doctor Will See You Shortly (10 page)

I waited for Jim to say something about persistence or tact, but he didn't say anything. He just stared at the blank sheet of paper. As we sat in silence, I tried to imagine what the last six years of encounters with Sheryl had been like. Had she yelled at him? Politely declined his suggestions? Did he ever get frustrated or upset with her?

“Matt,” he finally said, putting a warm hand on my shoulder, “sometimes things that on the surface can seem like small victories, very small victories…”

His voice trailed off, but I wanted him to continue. I put down my pen. “Yes?”

He stood up and shook his head. “Sometimes those things can actually be tremendous victories.”

I was so taken with Jim and his philosophy that I convinced Harvard Med to give me course credit for schlepping around with him. Instead of making me learn how to efficiently manage a complex primary care
visit with a guy like Sam, the school gave me primary care credit for assisting Health Care for the Homeless one night each week. That's part of the reason I felt so overwhelmed when I started working in Columbia's primary care office; I had watched Jim provide primary care out on the streets, but I hadn't done much of it myself.

Sure, I dispensed clean socks and foot ointment and listened when people wanted to chat, but Jim was the one examining and treating people. He was the one making tough decisions, convincing a reluctant recluse to go to an emergency room or providing reassurance. But it was during those late-night rides that I discovered how important it is to connect with patients. He was the reason, I realized later, that I first went to Benny's room when Baio asked me to introduce myself to the patients in the CCU. I didn't gravitate to the most medically complex patients, I went to the guy on the stationary bike—the guy I could talk to and potentially connect with.

From Jim I learned that through medicine it is possible to reach the unreachable—even the ones who most of us forget about or actively try to ignore. This is the power and beauty of our profession. He spent his evenings with Boston's homeless so they would trust him, so they would come to his clinic when illness struck. And this, I discovered, was no small task for people who lived under bridges or in large boxes near abandoned warehouses—people who were embarrassed by the sores on their legs or the smell of their skin. To walk into a hospital's lobby in shambles and sit in a waiting room was not something most would even consider. But they did it for Jim.

And I wanted them to do it for me.

“Let's start with the basics,” said a woman holding a marker outside of a patient's room. I had completed my month in the cardiac care unit, parted ways with Baio, and moved on to the infectious diseases service. My new assignment—tending to patients with HIV, tuberculosis, or viral hepatitis—was widely considered the most fascinating and emotionally taxing monthlong rotation of intern year, which was hard to imagine given what I'd just gone through. The majority of the patients checked in to the infectious diseases wing of the hospital, we were told, were intravenous drug users or had mental illness. They were the unreachable patients who might yell at you or spit at you, the ones with nothing to lose who would exploit any sign of weakness—emotional, professional, or otherwise.

“If a patient shows up in our emergency room and says they have HIV, what six pieces of information must you obtain without fail?” Dr. Chanel, a junior faculty member in the Division of Infectious Diseases, asked of our small group of residents and medical students. She was in her late thirties and had a gently graying side ponytail. Muffled whispers passed around the half circle. We had just emerged from the room of a young woman who had reluctantly come to our emergency room because of a persistent sore throat; Ariel had been the one to inform her that her symptoms were actually due to acute HIV infection while we all looked on anxiously. As tears streamed down the patient's face, I had been sent out in search of Kleenex. After a few minutes of fruitless searching, I had returned with a handful of paper towels
and toilet paper, which the woman had waved away. Then we'd all shuffled out.

Our group now had a brief moment—a thirty-second huddle—to try to learn something from this encounter before we were sucked back in to the maelstrom of buzzing pages and relentless orders. “One,” Dr. Chanel continued, “what year did they contract HIV? Is this someone who has had it for twenty-five years and been through numerous treatment regimens, or is this someone like our last patient, who contracted it a week ago and is struggling to cope with the diagnosis?”

I wondered if this moment would have been better spent counseling the woman who had just had her world upended.

“Two,” Chanel said, as we took notes, “what is the CD4 count. This is the subset of white blood cells that HIV destroys. Three: viral load. This is the quantity of replicating copies of HIV in the blood. The goal, not surprisingly, is for the viral load to be undetectable. Four: risk factors. How did the patient get HIV?”

I half-raised my hand, and Dr. Chanel nodded at me. “Why does it matter
how
the person contracted HIV?” I asked. “Seems like they've either got it or they don't. Not really our business how they got it.”

She scanned the group. “Can anyone answer Dr. McCarthy's question?”

Meghan cleared her throat, perhaps in an attempt to suppress her twang. “Well,” she said, “patients who get it from IV drug use are more likely to have hepatitis C or endocarditis. Patients who get it through receptive anal intercourse should be screened for anal cancer.”

Chanel smiled. I wondered if it was the first time that a sentence ending with the words
anal cancer
made someone do that. “That's exactly right.”

I quickly jotted this information down, pausing once to consider how poised Ariel had remained while relaying the devastating diagnosis. I couldn't have done it as easily as she had. I wondered if her time in consulting had prepared her for delivering bad news. Possibly she was used to walking into a room, ruining someone's life, and walking out.

“Good. Point five,” Chanel went on, “what medications are they on? Does their HIV regimen make sense? And six. What opportunistic infections have they had? HIV patients get bizarre infections. That's actually how the virus was discovered. Otherwise healthy gay men in the early nineteen eighties were developing—”

ARREST STAT, SIX GARDEN SOUTH!
the intercom blared, and my knees buckled.
ARREST STAT, SIX GARDEN SOUTH!

I was the only one in our group who visibly flinched. Recently I had resigned myself to the fact that the screeching, electrifying announcement was something I'd never get used to. Two members of the team sprinted away, and I thought of Baio, hustling to revive yet another person. It was strange being separated from him. I wondered where he was and whom he was teaching. The man who'd taught me so much over such a short period of time was now just a guy I passed in the lobby or caught wolfing down a piece of pizza at grand rounds.

“Perhaps we should stop there,” Dr. Chanel said, readjusting her side pony. “Let's reconvene in twenty minutes.”

A few minutes later, the second-year resident I'd been assigned to work with in this portion of my rotation, Ashley—my new Baio—returned from the arrest. She had impossibly high cheekbones and spoke in clipped, overcaffeinated sentences with one thought emerging in the midst of another. In retrospect, she gave the impression of Jennifer Lawrence on speed, perhaps with more sensible shoes.

Ashley had greeted me that morning by saying, “Don't do anything without running it by me first. Are we clear?” Before I could respond, she'd launched into the array of tasks that needed to be completed before rounds—rattling off assignments like wheeling a patient to dialysis and transporting a vial of blood to the chemistry laboratory—faster than I could write, and then withdrew the work delegated to me just as quickly, explaining that it was quicker if she just did everything herself. This was becoming a regular routine, and it made me feel expendable and potentially dangerous. It was clear she considered me a liability, someone who still couldn't enter computer orders related to HIV care
or write notes as proficiently as she could. Our brief exchanges were reminiscent of a naughty child and a frustrated babysitter. Her friends called her Ash, but she'd instructed me to call her Ashley. The intentional distance she put between us made me anxious. Even though we were hardly a personality match, I wanted to click with her. I wanted to click with everyone.

“Where were you?” Ashley asked, running her hands through olive oil hair. “You're supposed to come to these arrests.”

I looked up from my scut. “I didn't realize.”

She flashed a stiletto stare. “Realize.”

“I didn't see any of the other interns going so I—”

“I don't need an explanation. Woman's dead. Dead on arrival.” Ashley shook her head. Baio must not have been there, I thought.

“We're reconvening with the attending in about ten minutes,” I said.

“Good. Here's the deal. Very simple,” she said quickly. “I understand your physical exam skills are quite good, but you, ah, need some work in other areas.”

“Right.” I wondered if the Gladstone episode had reached Ashley.

“So let's play to your strengths. You're the eyes and I'm the brain.”

“Got it.”

“Examine the patients, tell me how they're doing, and I make the plan.”

I scribbled down
Me eyes/Ashley brain
.

“And then, Matt, you carry out that plan. Make sure shit gets done.”

I no longer trusted myself to remember anything unless it was written down. There were literally hundreds of small tasks and new factoids that popped into my brain over the course of the day, and I found it impossible to keep track of them all without committing them to paper. And prioritizing it all required yet another set of skills. “Yes, ma'am,” I said awkwardly. My daily scut list looked like a madman's diary, every inch covered in scrawl. I often thought of Axel, imploring me not to write on my hands.

“And if I can give you one piece of advice, it's this: be efficient.”

“I'll do my best.”

“But efficiency necessitates competency,” she said. “There's too much to know. Information is generated so quickly. And at your stage you're still trying to learn the basics.” Again, Ashley was right. Scores of scientific journals were constantly churning out new and at times contradictory medical information. We would never have time to read it all and were in need of a competent curator. In many ways, Baio had filled that role for me in the CCU. But I needed to do it myself now; Ashley didn't seem like the type who would spoon-feed me information.

A young man wearing just underwear walked by us, demanding to be read his Miranda rights. “To that end,” I said, trying to ignore him, “I've actually started using UpToDate,” referring to a website that summarizes expert medical opinion.

“Wonderful,” she said. “It should be your bible.”

“It's incredible.”

“Just don't reference it on rounds—attendings think it's lazy.”

Two nurses escorted the hallucinating man back to his room.

“Use it for everything but anatomy,” Ashley said. “Netter for anatomy.”

Netter referred to Frank Netter, the physician-artist whose medical illustrations are the standard for human anatomy. Ashley tapped her pen to her cheek and fought back a smile. “Being from Harvard, your anatomy skills must be, ahem, disastrous.” She was referring to the worst-kept secret among top medical schools: a paucity of corpses meant Harvard students had to choose to dissect either an upper or a lower extremity but not both. I'd been a leg man.

“Guilty.” I smiled. “I've actually been trying to read at home when I can.”

“Don't,” she commanded. “Reset your brain at home.”

“Okay.”

“Bust it here. But when you're home, you're home.”

I thought of the mindless hours I'd logged at home since starting internship watching reality television and reading tabloids in the name of mental health. Our generation of physicians was undoubtedly different—it was hard to imagine the Badass doing something similar. Did he take a look at Baio and think
Happy Days
? Or
Joanie Loves Chachi
? Doubtful. Maybe he played golf or flew single-engine planes.

Ashley looked at her pager as she took a large gulp from her latte.

“You know,” I said, feeling momentarily unguarded, “I continue to feel overwhelmed. Trying to wrap my head around everything and learn how to do procedures.” I wasn't entirely sure why I was opening up to her, but chronic sleep deprivation led most of us to behave in unusual ways. I found myself more willing to confide in my colleagues; others burst into tears when the cafeteria was out of ketchup.

She frowned. “That's not something you should go around advertising.”

“Just being honest.”

“No one wants to hear that you're struggling. I certainly don't.”

I flinched. “True.”

“Be confident. You know more than you think. But enough with the teeth grinding.” She held up an EKG. “Anyway, would you rather have a doctor who's right or who's certain?”

A moment later, a medical student named Carleton joined us. He was from Princeton. Or an Abercrombie & Fitch ad. Possibly both.

“Just spoke to Ms. Sarancha for an hour!” he said with a mix of enthusiasm and frustration. Medical students were first against the wall when a demented patient requested to chat with a doctor. At Mass General, an intern once sent me in to talk with a patient but neglected to mention that the man was capable of saying only one word: “Why?” After exhausting my meager explanatory skills, I picked up the patient's chart and realized he wasn't overly inquisitive; rather, he'd suffered a massive stroke that impaired the part of the brain responsible
for producing language. As pranks went it was relatively harmless and ultimately built camaraderie between the intern and me. It was the kind of thing Baio would do.

“Thank you for doing that,” I said to Carleton. “Morning's going to be busy, but let's spend a few minutes this afternoon talking about shock.”

Ashley shot an unsparing look. “Why are you discussing shock?”

It was one of the few topics I had mastered, that was why. And because Baio told me I should teach. “Fundamental topic to discuss,” I offered.

“To cover in the ICU,” she said, “but not here. We should focus on learning all we can about HIV.” In that case, I thought, Carleton was out of luck. I knew little about the virus, certainly not enough to teach. “That's how things stick with you,” she said. “See the condition, read about it, and associate the patient's face with the condition.”

“I just think it's—”

“This isn't a dialogue,” she said, her distaste palpable. “That's the way to do it.”

Ashley's approach was reminiscent of a drill sergeant. Even on our most hellacious days, it had never felt like Baio was crowbarring a teaching session into our dialogue; it just flowed naturally as we hopped from one patient to the next. But though their styles may have differed—Ashley seemed to talk down to me while Baio propped me up—both wanted to impart vivid images that I would never forget. Teaching points and patient scenarios that would stick in my brain for decades.

“Okay, Carleton,” I said as Ashley picked up her phone, “if things calm down this afternoon we can talk a bit about HIV.”

ARREST STAT, EIGHT HUDSON NORTH! ARREST STAT, EIGHT HUDSON NORTH!

Ashley and I shot out of our chairs and sprinted toward the stairs.

ABC, ABC

In the hallway, I darted past a bewildered Peter Lundquist, nearly
colliding with the Tupperware container in his hand. Peter brought in cookies and cakes for the CCU staff day after day, even after Denise had been transferred out of the unit. They had been a delightful change from the pungent Filipino ginger desserts we were accustomed to.

When I reached the arrest, two dozen physicians and nurses were already at the bedside.

“Too many people,” one of the nurses said. “People out now.”

Intern orientation had introduced me to the concept that more physicians equals more chaos. I backed away from the lifeless body. A few steps past the door, someone grabbed my arm.