The Real Doctor Will See You Shortly (23 page)

“I'd be depressed, too,” Don said.

“Really depressed.”

“Any plan to act on it?”

“No interest in talking to a psychiatrist.”

“That's not the question.” He typed a final order and spun toward me. “There's an algorithm,” he said. “If someone is depressed, the follow-up question is: Do you have homicidal or suicidal thoughts? If yes, do you have a plan to act on those thoughts?”

“Got it.”

“There's a big difference between ‘My roommate bums me out' and ‘My roommate bums me out and I'm going to murder him next Tuesday with my new AK-47.' ”

“Obviously.”

Don tapped his index finger on the keyboard. “Suppose he does tell you that he has a plan. Plans to do something bad. Then what?”

“Call the cops, certainly.” I hadn't yet met a patient who was actively planning to harm himself or someone else. I mostly thought of my patients as kind, temporarily debilitated beings in need of help, not deranged monsters capable of harming others.

“What about patient-doctor confidentiality, Matt? If a patient tells you about something devious in confidence—a plan to hurt someone or whatever—can you tell the cops?”

“I suppose I'd consult the hospital ethicist.”

“That's passing the buck, Dr. McCarthy.”

“I'd try to talk him out of it. That goes without saying.”

“You haven't done your outpatient elective yet, have you?” Don asked.

“No.”

“I take it you're not familiar with
Tarasoff
?” I shook my head. “One minute.” He printed out a document and handed it to me. “Read this.”

It was a summary of
Tarasoff v. Regents of the University of California,
a court case that all Columbia residents were eventually exposed to. In the summer of 1969, I read, as Don returned to his
New England Journal of Medicine,
a graduate student at Cal Berkeley told his psychologist that he was going to kill a woman, Tatiana Tarasoff, who had rejected his advances. The graduate student was briefly committed but ultimately set free. Several months later, he murdered Tarasoff
by stabbing her to death. Neither Tarasoff nor her parents were ever given any warning about the threat and sued. The case went before the California Supreme Court, where it was ruled that a physician or mental health professional has a duty not only to a patient but also to individuals who are specifically being threatened by a patient. “The protective privilege ends,” the majority opinion reads, “where the public peril begins.”

“Well?” Don asked after I had put the paper down.

“I'm gonna talk to Darryl later today. See where his head is at. I don't think it's anything like that.” I remembered that I'd promised him no more questions today.

Once again I marveled at all I was expected to master. Beyond the medical knowledge and procedures, beyond writing clear, informative notes and interacting with a wildly diverse hospital staff, I had to understand bioethics. I had to be familiar with court cases and legal precedents. I needed to know what to do in situations I'd never considered. The professional expectations were breathtaking.

“Told me his roommate calls him fat as fuck,” Don said, still staring at the journal.

The words startled me. Don had already gotten Darryl to talk more than I had. How? My residents were always one step ahead of me. Or several. “I'll talk to him.”

“Fine,” Don said, “but don't do it now. We've got a lumbar puncture, two central lines, and a paracentesis that need to get done.”

“Got it. I'll grab the stuff.”

Three hours later, as I was finishing up the lumbar puncture, I caught Darryl Jenkins out of the corner of my eye. He was on a stretcher, wrapped in several blankets, with that plastic bag of clothes on his lap. His asthma had been stabilized and he no longer needed to be in the
ICU. He was being transferred to a general medicine floor and would probably be home in a matter of days.

But I hadn't gone back to talk to him. I had been too busy sticking needles in other patients. I needed to ask him if he'd ever thought of harming himself or another person, like his roommate. It felt like a small betrayal, like I was suggesting that I thought he was capable of something heinous. It just didn't seem right to ask Darryl—a kid who'd almost died because of an asthma exacerbation—if he thought about committing unspeakable acts because he was unhappy.

I dropped my pen and scut list and rushed over to his stretcher. “Hey,” I said. “Congrats on getting out of here.”

Darryl was staring into a cell phone and didn't look up. “Thanks, man.”

This wasn't the moment to ask him about homicidal or suicidal thoughts, but someone needed to. Someone who was better trained than I was. I motioned to the patient escort to give us a minute. “Darryl,” I said, leaning in close to his face, “can I ask something of you? It's nothing major.”

He was texting and didn't look up. “Me do
you
a favor?”

“Yeah. But I want to run it by you first.” I paused to consider my words. This was my final shot with him. “If we send in a mental health, um, if we send in a psychiatrist or whatever, will you speak with that person?”

He put down the phone and looked up at me. “Why?”

“Because I think it's important.” As he stared me up and down, my pager went off. I quickly silenced it. “I can give you a longer explanation if you'd like, but the short answer is that I think you'd benefit from talking with someone about depression.” He continued to stare, not saying a word. “So would I,” I added. “I'd benefit from talking to someone, too.”

He shrugged.

“It won't take long,” I went on. “And I think it's important.”

He received a text and picked up his phone. “Sure, man.”

“Really?”

“Yeah, it's fine.”

I hadn't expected him to agree so easily. My body had been mildly tensed for a longer bout of convincing, and now I wasn't sure what to do with the extra energy. I fought back a smile. It was a small victory—some might not even call it a victory, but I did. I considered it a tremendous victory.

Darryl might've been placating me—who knows what he'd even say to the psychiatrist?—but I had gotten him to let me create an opportunity for him to get better. And in some ways that was just as valuable as making him better myself. That, I realized, was the long game Jim O'Connell was playing with his patients, the kind I would need to play with people like Darryl and Dre. Their maladies were both immediate problems and symptoms of deeper problems. Convincing Darryl Jenkins to get a flu shot would be a start; it might save him for a year. Convincing him to care enough about himself to do it every year—that was the long-term goal. “Reaching” him, it seemed, might be as simple as pointing him on that path, hoping he'd eventually walk it himself.

“Terrific,” I said. “We'll have someone come by later today.”

Darryl looked over at the escort. “Just get me outta here.”

We shook hands and I gave him a gentle nudge on the shoulder. “You got it.”

A moment later, he was wheeled out of the unit and I never saw him again.

“It's freakin' ridiculous,” Don said as he devoured the last slice of pepperoni pizza. It was mid-March, and more than six weeks had passed since that final exchange with Darryl Jenkins in the ICU. I'd just started a two-week stretch working nights on the general medicine service and had again been randomly paired with Don. He and I were outside of a patient's room on the sixth floor, standing before a large handwritten sign:

Male visitors must be announced

“Our new patient,” Don said, tilting his head at the sign, “from Saudi Arabia. All sorts of nonsense.”

Don shook his head while I was quietly reliving what now qualified as the wildest thing I'd seen in the hospital. A week earlier, during an arrest, a cardiothoracic surgeon had cracked a woman's chest open at the bedside and squeezed her heart. A room of stunned doctors and nurses had looked on in silence as the patient expired, and I'd had two nightmares about it. When it was over, our blood-splattered white coats had looked like a series of Jackson Pollock paintings. There had been an eerie silence as we gently filed out of the room, collectively dazed. Working nights was now a welcome relief—I didn't want to have that dream again. “What's up?” I asked.

“Just tried to examine her,” Don said, “but the husband said I can't
touch her. She's in a burka with just a tiny eye slit. He won't let her speak for herself. It's absurd.”

I thought back to the cultural competency seminar and Marjorie, the student who would recuse herself from treating a Muslim. Would she really just throw up her hands and walk away? Was that what Don was about to do? It was odd seeing him so flustered. I fixated on the tomato sauce that had accumulated at the corners of his mouth.

“How am I supposed to make a diagnosis if I can't lay my hands on the patient?”

I shrugged; the master diagnostician had been stymied. “I'm not sure.”

Behind the door was a young woman with a swollen, throbbing, ruby red knee. She'd been diagnosed with a tumor near the kneecap over New Year's, and it was our job to determine if her new fever was from the cancer, the treatment, or an infection. Don had every reason to be frustrated, but I wondered if he was making a tactical error by letting his emotions get involved. We needed to play the hand we were dealt.

“So what do we do?” I asked.

“What do
you
suggest we do, Dr. McCarthy? I will defer to you.” Don had gradually been giving me this kind of latitude as we worked through patients. It was a way of pulling back the process and making me, and my fellow interns, more comfortable making decisions. I imagined myself walking a new intern through these scenarios, perhaps as a stall tactic while I gathered my own thoughts. “Take me through your thought process,” he said, running his hands through his floppy hair. “I want to know how you think.”

“Well, I suppose one option is to assume she has an infection and treat her. Give her broad antibiotics. Vancomycin and Zosyn. We haven't identified what might be causing the infection, but those two antibiotics would cover most bacteria.”

“Okay.”

“Another option is to get an MRI and hope that gives us the answer. Progression of the tumor or a new infection.”

“Sure.”

“But the test is expensive and perhaps unnecessary.”

“Right.”

“Or we could get another set of blood tests to see if her white blood cell count is rising.”

“Certainly.”

I folded my arms. “Or we tell the husband to get out of the way so we can actually examine the woman.”

“And then get fired.”

“I doubt that would happen.”

“Fine. All of those suggestions are reasonable. But what would you actually do if I weren't here? What's your move, Doctor?”

I imagined the unknowable woman under the burka and hedged. “I would get an MRI.”

“Then that's what we'll do.”

We walked over to a set of computers and he put in the MRI order. “Is that…is that what you would've done?” I asked as I polished off my Gatorade. “The MRI?”

“No.”

We stared at each other in silence. Then Don looked at his watch and informed me that I was free to take a twenty-minute nap.

“I'm not wrong,” I said defensively.

“I didn't say that you were.”

Moments later, I crawled into a call room bed and thought about what had just transpired. I was comfortable with the choice I had made. I had treated hundreds of patients and was reaching the point where I could reasonably disagree with my superior and not feel bad about it.
I saw doctors disagree all the time. Ours was merely a difference of opinion, two contrasting ways of trying to answer a question that had no obvious answer. A few months earlier, I would have fretted on it for days. This felt like a snapshot moment—one that let me see how much the passage of time had changed me as a doctor.

Before long I drifted off to sleep. Soon my mind had transported me to a beach, far, far away from the hospital. Then I heard a knock at the door.

“Can't sleep,” Don said.

I had been in a deep slumber, dead to the world, about to order a cocktail with an umbrella in it. “Me either.”

“Hypothetical,” he said, crawling onto the top bunk. “Ready?” He was clearly still worked up about the woman with the red knee, but he needed something else to think about.

“You know I love these.”

“Okay,” he said, “they're saying flu season might be bad this year, that we might have to ration ventilators if New York gets hit hard.”

“Sure.”

“We're down to our last ventilator in the ICU and two patients need it: a thirty-two-year-old pregnant woman and a six-year-old boy. Who you gonna give it to?”

I took out my notebook, continuing to add to my list of hypotheticals. I planned to use them on next year's crop of interns. “No other options. I have to pick one?”

“Yes.”

“Which one is more sick?”

“They are both equally sick. Without the ventilator they will each perish in minutes. With it, they'll each live a happy, healthy life on Martha's Vineyard.”

“The Vineyard can be dreary in the winter.”

“That's the scenario. You're stalling.”

“Reflexively I'd pick the mother,” I said. “Save two lives. Wait…how far along in the pregnancy?”

“Four months. She can't deliver the baby.” He sounded surprised. “If I take the baby out of it, would you save the kid?”

These exchanges helped us prepare for unexpected clinical scenarios, but they also helped us get to know each other; it was fascinating to discover how differently colleagues could approach the same ethical quagmire. In this case, however, the answer seemed obvious. “Yes,” I said. “Remove pregnancy from the equation and I'd save the six-year-old before the thirty-two-year-old.”

“Where do you stand on abortion? Pro-choice?”

“Um…why?”

“Just curious when you think life begins. You're not a life-begins-at-conception guy, I take it?”

“Even if I don't consider the unborn child a viable being, I'd save the pregnant mother.”

“Huh, I'd pick the kid.”

“What? Why?”

“I couldn't do that to a kid, Matt. I couldn't.”

“What if the mother was pregnant with twins?”

He leaned his head over the edge of the bed. “You just opened a whole other can of worms, my friend. In that case I'd pick the mother.”

Neither of us could know that a swine flu pandemic was mere weeks away and that we would be called to very real emergency meetings dealing with the possible issue of ventilator rationing. Some of the most contentious arguments I witnessed as an intern dealt with the hypothetical methods for allocating resources in the face of uncertainty. Those clashes about ventilators—which occasionally bubbled over into shouting matches—invariably drew me back to Benny, who was still languishing because of the UNOS organ-sharing algorithm. When you're advocating for your patient, you don't care about the wisdom of a construct that benefits someone who is not your patient.

“Okay, I've got one,” I said. “Guy spends a year living in the CCU waiting for an organ transplant that never arrives. How much is his hospital bill?”

“That's not”—Don, still peering over the edge of the bed, trailed off and contorted his face like he was staring into a bright light—“really a hypothetical.”

Like nearly all of my colleagues, Don had taken care of Benny during the last year, but I couldn't tell if Benny's saga had affected him (or anyone else, for that matter) the way it had me. “I suppose it's not.”

“Probably a million bucks,” Don said. “Maybe two. With all the nursing costs and food and specialists, it's probably closer to two.” He shook his head. “It's kinda mind-boggling.”

Mind-boggling
was an understatement. A slew of more appropriate adjectives came to mind:
incredible, outrageous, ridiculous
. And who was paying for it all? His insurance company? Taxpayers? I never asked him; I didn't want to know. “You think he's getting that heart?” I asked.

Benny's fate had truly become an obsession with me. I now saw so much of the healthcare system—particularly the inefficiency and the excess—through the lens of his situation. Was it really that bad to order an extraneous test or two when millions were being spent on just one guy? Did it really matter if someone's discharge was held up by a single day when he'd been held hostage for months?

“Honestly?” Don asked. “No, Matt, I don't think he's getting the heart.”

I shook my head and picked up an EKG book. “I'd like to disagree with you. But I'm not sure I can.”

“I think one of these times,” Don went on, “he's gonna need to be intubated and something happens, maybe it takes too long, maybe the tube goes in the wrong spot, and he's gonna have a cardiac arrest and that'll be it.”

The thought made me shudder. Who would tell his family? Who would run the cardiac arrest? I hoped it would be Baio.

“You're bumming me out,” Don said, returning to his pillow. “Okay, I got another. Would you rather marry Madonna or an adult film actress?”

I was happy to change the subject. “Porn star?”

“Yes.”

“Madonna now or—”

“Yeah,” he said, “now.”

“Is the porn star still, ah, active in the industry?”

“Yes.”

“And is she performing to pay off my loans or because she loves the work?”

“Loves the work.”

“And what phase is Madonna in?”

“Chiseled cougar in need of a boy toy.”

“Has the porn star ever won any awards for her work?”

“Several.”

I wondered if Lalitha and Ariel and Meghan talked about this kind of nonsense with their supervising residents. I knew they talked about silly stuff with me, but I was curious if it extended beyond our pod. Were other doctors in other call rooms trying to make each other laugh? “This is a tough one,” I said. “I imagine holidays would be difficult with the porn star. How does my mother feel about the starlet?”

“At your wedding she wrestled the microphone away from the emcee and said, ‘I can't believe my son is marrying a fucking porn star.' ”

“Yikes.”

“Otherwise, the relationship has been cordial.”

“Where do we live?”

“Scottsdale, Arizona.”

“Naturally. How do my friends feel about the porn gal?”

“Friends from college think she's really cool. Friends from med school do not.”

“And does Madonna treat me as her intellectual equal?”

“No.”

“Am I allowed to make eye contact with her?”

“Madonna allows you to look directly at her three times a day.”

“My sister would be pumped if—”

“Your sister thinks you're gay.”

I took a deep breath. “I think I gotta go with Madonna.”

He rubbed my shoulder and fought off a smile. “Dr. McCarthy, I have posed that hypothetical to perhaps a dozen interns this year and no one, no one, has taken that long to conclude that Madonna is the preferable life partner.”